Robotic Orthotopic Neobladder: The Two Chimney Technique

*Panagiotis Pardalidis, Nikolaos Andriopoulos and Nikolaos Pardalidis*

### **Abstract**

Bladder substitution following radical cystectomy for urothelial cancer (transitional cell carcinoma) has become increasingly common and in many centers has evolved to become the standard method of urinary diversion. Orthotopic neobladder has been a commonly used option for urinary diversion since the 1980s. Advantages of this type of diversion are the ability to avoid an ostomy, voiding function similar to the native bladder, and improved cosmesis. Robotic intracorporeal neobladder creation has demonstrated similar outcomes to open technique and represents a promising minimally invasive diversion for the future. The Studer pouch is widely used nowadays, yet there are still some drawbacks. Therefore, we designed a technique that would offer an orthotopic ureteroileal anastomosis by using a two chimney modification. This modification is simple to handle, safe and free of ureteric stricture or reflux. With low stricture rates, this modified procedure of ureterointestinal anastomosis, is worthy of further promotion.

**Keywords:** urothelial bladder cancer, urinary diversion, bladder substitution, robotic orthotopic neobladder, ureteroileal anastomosis

#### **1. Introduction**

Indications for orthotopic diversion are: absence of malignancy of the prostatic urethra in men or the bladder neck in women, adequate renal function (GFR >35– 40), normal liver function, absence of severe urethral stricture disease, absence of inflammatory bowel disease (IBD) and a reliable patient with good mental status and dexterity. Drawbacks unique to a neobladder include urinary incontinence, incomplete emptying, need for self-intermittent catheterization (SIC) and longer operative times. Many viable surgical techniques exist and offer good functional and oncological outcomes. In determining the best type of urinary diversion for a specific patient, consideration must be given to both the morbidity associated with surgery and the potential positive impact on the patient's quality of life.

Kock demonstrated the importance of complete detubularization of the bowel segment and the double-folding technique that creates the most spheric shape possible (Kock, 1982). These concepts are the cornerstone of current cutaneous and orthotopic reservoirs [1].

In 1979, Camey and Le Duc reported their pioneering clinical experience with orthotopic substitution to the native urethra in male bladder cancer patients (Camey and Le Duc, 1979). The initial Camey diversion used an intact segment of ileum,

resulting in a high-pressure reservoir. Subsequently the Camey II detubularized reservoir (Camey, 1990); Hautmann W-neobladder (Hautmann, 1988); "hemi-Kock" neobladder (Skinner, 1991); Studer pouch (Studer, 1989); extraserosal-lined ureteral tunnel (Abol-Enein and Ghoneim, 1993); T pouch (Stein, 1998); stomach neobladder (Hauri, 1998); cecal and ileocecal neobladders (Light and Engelmann, 1986; Mansson and Colleen, 1990); and sigmoid reservoir (Reddy and Lange, 1987) have all been described [1]. All those techniques of urinary diversion have been evaluated through time, providing good renal preservation as well as functional and oncologic outcomes. Orthotopic diversion quickly surpassed continent cutaneous diversion in popularity for both patients and physicians because it allows natural voiding, is simpler to construct and is less likely to require revision surgery at a later date.

Although the ideal bladder substitute remains to be developed, the orthotopic neobladder most closely resembles the original bladder in both location and function. This form of lower urinary tract reconstruction relies on the intact external rhabdosphincter continence mechanism, seldom requires intermittent catheterization and avoids the difficulties associated with the efferent continence mechanism of continent cutaneous reservoirs. Voiding is accomplished by relaxation of the pelvic floor musculature (as in normal voiding) along with a concomitant increase in intra-abdominal pressure (Valsalva maneuver).

It is estimated that approximately 80–90% of male patients and 75% of female patients undergoing cystectomy are potential candidates for neobladder construction from a purely medical standpoint.
