Robot-assisted radical cystectomy and urinary diversion in female patients: Technique with preservation of the uterus and vagina

BACKGROUND: After performing more than 500 robotic radical prostatectomy and robotic radical cystoprostatectomy in men, we attempted to develop the technique of robot-assisted radical cystectomy in women. This article describes two techniques of robot-assisted radical cystectomy for women, conventional and with preservation of the uterus and vagina. To the best of our knowledge, this is the first case series of robot-assisted radical cystectomy and urinary diversion in women. STUDY DESIGN: Robot-assisted radical cystectomy was undertaken in three female patients with transitional cell carcinoma of the urinary bladder. The operation was performed with the conventional anterior approach in one patient and with a new technique in two patients, which allows preservation of urethra, uterus, vagina, and both ovaries. As planned, the radical cystectomy was done robotically, using the da Vinci Surgical System (Intuitive Surgical). The bladder was entrapped in an Endocatch bag and removed through a small subumbilical incision. Urinary reconstruction was performed extracorporeally after exteriorizing the bowel through the incision used for retrieving the specimen. In two patients, the reconstructed pouch was placed in the pelvis and the abdominal incision was closed. Urethroneovesical anastomosis was done robotically, using a technique described previously for men. RESULTS: The average operating time for the robotic radical cystectomy was 160 minutes and the mean operating times for ileal conduit and orthotopic neobladder were 130 minutes and 180 minutes, respectively. The mean blood loss was less than 100 mL. The mean number of lymph nodes removed was 12 (range 3 to 21). Surgical margins were free of tumor in all three patients. CONCLUSIONS: This approach incorporates advantages of minimally invasive and open surgery. Performing the radical cystectomy with the robot allows precise and rapid removal of the bladder with minimal blood loss. Extracorporeal reconstruction of the urinary tract reduces operative time at this stage of evolution of laparoscopic and robotic instrumentation. In the future, with the development of technology, instrumentation, and with additional refinement of our technique, the entire procedure may be done completely intracorporeally with equal efficiency.