Posterior reconstruction during robotic-assisted radical cystectomy with intracorporeal orthotopic ileal neobladder: description and outcomes of a simple step

A posterior reconstruction (PR) might improve the fluidity and delicacy of the maneuvers related to the neovesico-urethral anastomosis during robotic-assisted radical cystectomy (RARC). Our objective is to describe in detail the surgical steps of PR and to assess its feasibility and functional outcomes. The data regarding patients undergoing a totally intracorporeal RARC with neobladder and PR for high-grade and/or muscle-invasive urothelial cancer of the bladder at Karolinska University Hospital between October 2015 and November 2016 by a single surgeon (PW) were reviewed. Prior to the anastomosis, a modified posterior Rocco’s repair involving the Denonvillier’s fascia, the rhabdosphincter, and the posterior side of the ileal neobladder neck was performed. The steps are shown in a video at https://doi.org/10.1089/vid.2019.0029. The primary outcome was urinary continence; the secondary outcomes were urinary leakage, intermittent catheterization, and complications related to the reconstructive steps. Eleven male patients with a median age and BMI of 67 years and 24, respectively, underwent RARC with PR associated to the neovesico-urethral anastomosis. Overall and posterior reconstruction time were 300′ (195–320) and 6′ (4–7), respectively. The daytime and nighttime continence rates were 100% and 44% at 12 months, respectively; the median pad weight was 3.5 g and 108 g at daytime and nighttime, respectively. One urinary leakage from the urethrovesical anastomosis was treated conservatively. Two patients perform intermittent catheterization. The posterior reconstruction during RARC is safe and feasible, providing good continence rates. It supported a careful suturing of the anastomosis as well as an uncomplicated catheter placement.


Purpose
Robot-assisted laparoscopic radical cystectomy (RARC) is a viable alternative to open radical cystectomy for the treatment of patients with bladder cancer, with acceptable periand postoperative outcomes [1].
Incontinence is one of the drawbacks of radical cystectomy with neobladder and significantly impairs quality of life. Posterior reconstruction (PR) during radical prostatectomy was initially proposed in order to facilitate anastomosis and to possibly improve early continence rates [2].
Although the influence of PR on post-prostatectomy continence has been questioned [3], many surgeons around the world included this step in robotic-assisted radical prostatectomy (RARP) because of an improved hemostasis and a greater support for a delicate anastomosis.

3
The ileum of the neobladder is a relatively weaker tissue as compared to the bladder wall in radical prostatectomy. The early and late complications related to the ileourethral anastomosis of neobladder account for 10% in open cystectomy even in experienced hands [4], making of PR a very attractive approach in order to reduce undue tractions on the tissues involved in the anastomosis.
We describe a simple technique of PR which can be incorporated into the neovesico-urethral anastomosis of the neobladder during RARC. The early and intermediate functional results of the cohort of patients treated with RARC and PR are reported.

Study design
Between October 2015 and November 2016, 33 consecutive patients underwent a totally intracorporeal RARC with a modified Studer neobladder at Karolinska University Hospital by three different surgeons (PW, AH, CA), for high-grade and/or muscle-invasive urothelial cancer of the bladder. During this time interval, all male patients operated by one surgeon (PW) received a posterior reconstruction (PR) associated to the neovesico-urethral anastomosis. Preoperative clinical characteristics, intra-and postoperative data were prospectively collected in an ethically approved database and reviewed. A detailed informed consent was obtained in all cases. The outcomes of the study included: continence rates and urinary leakage. RARCs with PR were performed by a surgeon (PW) with extensive experience in robotics (> 200 RARCs).

Preoperative evaluation and data collection
For each patient, we prospectively collected preoperative (age, BMI, American Society of Anaesthesiologists-ASAscore), perioperative (overall and PR operative time, blood loss, complications related to the PR and to anastomosis, peri-and postoperative complications within 30 days), and pathologic data (tumor staging, surgical margin status). Cystoprostatectomy for advanced prostate cancer and cystectomies for bladder cancer in the female were excluded. None of the patients had undergone preoperative radiotherapy. Medical and surgical complications were collected for all patients through a combination of institutional electronic medical records and operative notes.

Assessment of continence and complications
The primary outcome of interest was urinary continence, defined as no leakage or use of a safety pad for minimal leakage during a given time (day or night). Continence rates as assessed by third-party personnel with self-administrated questions 1 and 5 of the EPIC questionnaire at 6, and 12 months after catheter removal were recorded. Additional data on mucous leakage, and pad size, timing (daytime or nighttime) and wetness were also gathered. The secondary outcomes measured were (1) urinary leakage, (2) intermittent catherization, and (3) overall complications and those directly related to the reconstructive steps (anastomosis and posterior reconstruction) of RARC, as assessed by the Clavien-Dindo classification [5].

Cystectomy and neobladder
The surgical technique combining RARC, pelvic lymph node dissection, and intracorporeal urinary diversion has been previously described [6,7]. A modified Studer ileal neobladder is fashioned; the anastomosis between the ureters and the afferent limb of the pouch is performed using the Wallace technique. Special attempt was made to preserve the maximal urethral length and the neurovascular bundles to various degrees at the surgeon's discretion, and directed by preoperative clinical and functional assessment. Figure 1 depicts the main steps of the posterior reconstruction in a sagittal view (Fig. 1). After the ileum is brought down to the urethra by placing two vessel loops around the intestine through the mesenterium, the posterior reconstruction is started. The technique includes a modified posterior Rocco's repair with a bidirectional barbed suture (Quill 3-0) suturing the rhabdosphincter and the median fibrous raphe to the remaining Denonvillier's fascia in a running fashion; thus reconstructed plane is then fixed to the posterior side of the selected tubularized bowel segment 1 cm dorsocephalad (Fig. 2). On tying this suture, the ileum segment descends close to the urethral stump ( Fig. 3). At the tip of the U-shaped ileal loop, a 1.5 cm incision is made with the robotic scissors at the level of the urethral anastomosis (Fig. 4). The urethroneovesical anastomosis is then performed according to the Van Velthoven technique [8], using a second bidirectional 3-0 Quill needle. The running suture is started by placing both needles outside-in through the intestine opening, which will act as the neobladder neck, and inside-out through the urethra at corresponding sites (Fig. 5). After passing the catheter through the urethra, the anterior side of the suture is completed and the distal ends tied together (Fig. 6). The surgical steps of the PR during RARC with neobladder are also illustrated in a recently published video (see at https ://doi.org/10.1089/ vid.2019.0029) [9].

Postoperative management
In case of uneventful postoperative course, the drain is removed on day 1, the ureteral stents on day 10, and the catheter on postoperative day 21. In case of persistent drain output, a urine sample is taken from the catheter and analyzed for creatinine level. A cystogram is performed only if urinary leakage is suspected. Leakage of the anastomosis is possibly managed conservatively by maintaining an indwelling catheter for an additional period, according to the degree of leakage.

Results
Eleven male patients with a median age and BMI of 67 years (range 55-76) and 24 (21-33), respectively, underwent RARC with posterior reconstruction associated to the neovesico-urethral anastomosis in the study interval. Seven patients had an ASA score of 3. Overall and posterior reconstruction time were 300′ (195-320) and 6′ (4-7), respectively. Eight patients underwent a nerve-sparing RARC. No positive surgical margins were reported. Operative and functional results are reported in Table 1. Table 2a reports the complications according to the Clavien-Dindo system, including a urinary leakage from the ureteroenteric anastomosis in two cases, treated with bilateral nephrostomy. One urinary leakage from the urethrovesical anastomosis was treated conservatively with an indwelling catheter for 2 months. Two patients perform clean intermittent catheterization (CIC) due to increased residual volume; one of them experiences night incontinence as well. Table 2b reports the continence rates and pad weight. The daytime continence rates were 100% at 6 and 12 months. The nighttime continence rates were 42% and 44% at 6 and 12 months, respectively. The 12-month follow-up was unavailable in two cases, due to the insufficient time lapse from surgery.

Discussion
Urinary diversion with orthotopic ileal neobladder involves inherent changes in continence mechanisms, due to the loss of bladder stretch reflexes and filling sensation. Although continence rates for most patients continue to improve over   After passing the catheter through the urethra, the anterior side of the suture is completed and the distal ends tied together time as the neobladder capacity increases, reporting of combined daytime and nighttime continence was still as high as 49% by more than 18-36 months [10]. Although incontinence is regarded as one of the most important keys to patient satisfaction, therapeutic options in men have been limited up until now and include pelvic floor training [11], pharmacological agents [12], retrourethral slings [13], and artificial sphincter placement [14]. However, these studies comprise a very limited number of patients and often report only moderate amelioration of the symptoms or unacceptable side effects.
The PR technique was first reported by Rocco in 2001 [1] and this technical modification has since become a common practice during RARP [15]. The rationale is that it restores the anatomical and functional length of the rhabdosphincter, possibly increasing the early continence rates. According to this theory, the PR reestablishes the continuity of the musculofascial plate, which is disrupted during pelvic radical surgery [16]. Accordingly, some authors consider the median dorsal raphe as a fulcrum for the contraction of the sphincter that, combined with the activity of the puboperinealis muscle, results in a double-sling mechanism for closure of the urethra [17]. Of note, autoptic studies have shown that the rhabdosphincter has more connective and smooth muscle and less striated muscle, partly accounting for greater difficulty in recovery of urinary control following pelvic surgery in older patients, who are often the object of pelvic oncologic surgery [16].
Although the role of the PR during radical prostatectomy is still controversial [15], the PR might prove particularly useful in case of radical cystectomy with ileal neobladder. A strong argument for undertaking a PR is the greater support that it can provide to the neovesico-urethral anastomosis. Both the ileal wall and the urethra are soft tissues with some   degree of elasticity. However, they can be easily disrupted during a complex and delicate surgical step such as the robotic suturing of the neovesico-urethral anastomosis, due to instruments conflict or traction by the ileal mesenterium. Another advantage of PR is that it facilitates the placement of the catheter during the neovesico-urethral anastomosis: this easy step can become extremely useful, especially in case a difficult catherization of the neobladder neck is experienced during a RARC. The functional results presented in this study are very promising. The 6-and 12-month continence rates were 100% during daytime, including a patient performing CIC. As expected, the results improved over time and compare very favorably with the results of open and robotic cystectomy with neobladder reconstruction. The analysis of the historical functional outcomes of 70 RARCs with neobladder without posterior reconstruction at Karolinska showed that 19 males (90.5%) and 2 out of 3 (66.7%) females were continent (0-1 pad/day) at 12 months [18]. Hautmann found a "good" or "satisfactory" level of continence in 95.9% of patients within 5 years [4]. Clifford et al. reported a daytime continence rate of 92% at more than 12-18 months in a more recent large cohort of patients undergoing open radical cystectomy and Studer pouch [10]. Yuh reported a daytime continence rate ranging from 83 to 100% in men in a systematic review on functional results after RARC [19]. However, there is a high variability in terms of definition of continence. According to Yuh, only three of six studies reported a distinct definition of continence; these studies generally lack reporting of pad weight and rely mostly on the number of pads [20]. At 12 months, the daytime pad weight was only 3.5 g in our series. It might be argued that this is the result of the meticulousness reachable by robotic cystectomy per se and not of the posterior reconstruction. Of course, this is a very reasonable argument: only a parallel study with a larger sample size will clarify this issue. Still, the present cohort includes a limited number of patients but it has been closely followed up with an objective methodology and the results are promising. The only complications reported in our series which might be directly associated to the PR were one case of a urinary leakage from the neovesico-urethral anastomosis, treated with an indwelling catheter for 2 months, and two cases of increased residual volume requiring intermittent catheterization. These results are in line with those of open and robotic series of radical cystectomy with neobladder without posterior reconstruction [4,20,21].
We recognize several limitations in our study. First, a small number of cases is presented. Initially, the operations were performed with the standard approach but, with increasing experience, anatomic restoration was preferred. Second, our study was retrospective in design. We believe a prospective controlled multi-institutional study would be the most successful. Third, the continence criteria were not strict. We accepted minimal leakage as continent, and that definition may have improved our outcomes for all groups. By design and practicality, we did not measure the entire urinary function domain nor the entire realm of the EPIC questionnaire. We selected the EPIC questions that we considered most appropriate for the study hypothesis together with the pad weight.
In conclusion, we continue to include the posterior muscolofascial plate reconstruction in our technique, because this step is simple, reproducible, with a very limited increase in operative time, and with only a negligible risk of potential harm to the patient.

Conclusions
Posterior reconstruction incorporated into the neovesicourethral anastomosis during RARC is a safe and feasible procedure, which can be performed in a few minutes. Although the sample size of this study limits definitive conclusions, the overall continence rates were promising. In general, it supported a careful suturing of the delicate tissues of the neovesico-urethral anastomosis as well as an uncomplicated catheter placement, suggesting that this easy step should be included into the RARC procedure.

Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of interest.
Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual participants included in the study.