Techniques of Robot Assisted Extracorporeal Urinary Diversion

The purpose of this chapter is to provide a step-by-step approach to the different extracorporeal urinary diversions (ECUD) that may be performed in the setting of robot-assisted laparoscopic radical cystectomy (RARC). Recent multi-institutional prospective trials have been completed demonstrating non-inferiority of RARC compared to open surgery with regard to surgical quality measures and importantly, oncologic outcomes. To further capitalize on the benefits of minimally invasive surgery, intracorporeal urinary diversion (ICUD) is growing in popularity with proposed benefits of faster convalescence, decreased blood loss, and decreased post-operative ileus. However, most surgeons still consider ECUD a safer option, especially for continent diversions, and carry out the hybrid approach of RARC with ECUD. As urinary reconstruction contributes more to post-operative morbidity than the radical cystectomy itself, it is imperative to be proficient in urinary diversion techniques whichever approach one chooses. We will discuss in detail the extracorporeal techniques of a Studer orthotopic neobladder which includes re-docking the robot for the urethral anastomosis, the Indiana pouch continent cutaneous urinary diversion, and the ileal conduit urinary diversion. Our technique follows a common template which can be applied to all types of urinary diversion.