**6. The robotic cystectomy and two chimney approach**

The robot-assisted surgical approach for pelvic urologic oncology has existed since the mid-2000s and the technique for robot-assisted radical cystectomy (RARC) with lymph node dissection has been established. Early oncologic outcomes after RARC and lymph node dissection are safe and efficacious (Hellenthal, 2011) [1]. Moreover, we observed decreased robotic surgery-related complications and improved outcomes over time in our early series (Pardalidis 2011) [3]. Several perceived advantages of robot-assisted approaches for bladder cancer include less pain, minimal blood loss and earlier return of bowel function, which ultimately help in a quicker return to previous quality of life (Challacombe et al., 2011) [1]. Despite smaller incisions and advances in extirpation, recovery has relied mainly on return of bowel function. More than 1700 cases of RARC have been registered in the International Robotic Cystectomy Consortium database (IRCC). Based on data published in 2013 from the IRCC, approximately 18% of procedures have been performed with the complete intracorporeal approach (Ahmed, 2014) [1]. Two commonly performed procedures with the complete intracorporeal approach include the ileal conduit and a modified Studer neobladder.

When constructing orthotopic bladder substitution, a design with features similar to that of a normal bladder must be adopted, including creating a low pressure pouch with adequate capacity and effective preservation of renal function. Controversy still remains regarding the optimal mode of ureteroileal anastomosis. Anti-reflux techniques can be harmful to renal function due to the development of anastomotic strictures at a higher rate than with refluxing techniques (9–20% vs. 1–6%). Refluxing techniques, are easier to perform with a lower stenosis rate in the long-term follow-up period; but these techniques also have drawbacks for renal function, including recurrent pyelonephritis and hydronephrosis caused by vesicoureteral reflux, especially during voiding due to increasing bladder luminal pressure.

ICUD-EAU International Consultation on Bladder Cancer 2012 does not recommend applying antireflux anastomosis in orthotopic bladder substitutions. Studer

**Figure 2.** *Two chimney neobladder formation before ureteroneobladder anastomosis.*

and Timmer recommend antireflux techniques only in cases where urine diversion can generate great intraluminal pressure and/or when there is a risk of permanent bacterial colonization [2]. Hence, we designed a technique that would resolve these problems by using a two chimney method of ureteroileal anastomosis in an ilealmodified orthotopic bladder substitution.

The Studer pouch is widely used these days, yet there are still some drawbacks. The afferent limb of the Studer pouch is anastomosed with the bilateral ureters together, either in a Wallace I or II fashion so as the left ureter should be tunneled under the mesosigmoid for anastomosis with the afferent ileal segment. This maneuver may be the cause of increased left stenosis occurred twice as frequently as on the right side because of extensive dissection and possible tension creating ischemia of the distal ureteral end. Our technique by formation of two chimneys on each neobladder lateral side and end to end ureteroileal anastomosis, effectively avoids these drawbacks because of the separate bilateral ureteroileal anastomosis. Each ureter is spatulated and anastomosed without tension and less ischemia, so the risk of stenosis is decreased (**Figures 2**–**11**).

This surgical modification seems to preserve ureteral vascularization, resulting to low stricture rate (4%). Additionally, in case of reintervention it is easier

#### **Figure 3.**

*Spatulation of the left ureter before ureteroneobladder anastomosis.*

**Figure 4.** *Left end-to-end ureteroneobladder anastomosis.*

*Robotic Orthotopic Neobladder: The Two Chimney Technique DOI: http://dx.doi.org/10.5772/intechopen.100114*

**Figure 5.** *Ureteral stent catheterization of the left ureter.*

**Figure 6.** *Right chimney end-to-end ureteroneobladder anastomosis.*

**Figure 7.** *Final two chimney neobladder formation with ureteral external stents.*

#### **Figure 8.**

*Isolation of final ileal segment of 75 cm. A 12,5 cm part chimney is preserved in each side and the rest is detubularized.*

#### **Figure 9.** *The posterior part is anastomosed with 3.0 continuous sutures.*

to access each anastomosis without damaging the other one [4]. We are using ureteral catheters on each side which are exteriorized to the skin and removed a week postoperatively. An ERAS protocol for quick recovery is a standard

*Robotic Orthotopic Neobladder: The Two Chimney Technique DOI: http://dx.doi.org/10.5772/intechopen.100114*

#### **Figure 10.**

*The right upper part of the ileum is approached to the left lower part with continuous 3.0 sutures, creating a spheric neobladder.*

#### **Figure 11.** *The ureters are anastomosed with 4.0 sutures to each chimney seperately.*

approach for the robotic cystectomy patients. In our last 5 patients we are performing a stentless watertight anastomosis with no stricture presence or hydronephrosis after a short of 18 months follow up time. These are very promising results.

**Figure 12.** *CT urography follow up 2 years.*

**Figure 13.** *CT urography follow up 10 years.*

*Robotic Orthotopic Neobladder: The Two Chimney Technique DOI: http://dx.doi.org/10.5772/intechopen.100114*

Urographic studies demonstrate no reflux or stricture in either of the implanted ureters (36 renal units in total), after 10 years of follow up (**Figures 12** and **13**) [5].

This modification of Studer neobladder with two chimneys 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 [6].
