title: Totally laparoscopic creation of a novel stapled orthotopic neobladder in the porcine model.
abstract: OBJECTIVE
  Laparoscopic urinary diversion remains difficult and time consuming even when performed by experienced laparoscopists. Here we describe a novel procedure that quickly creates an ileal orthotopic neobladder with an afferent tubular segment using a laparoscopic stapling device.
  
  
  METHODS
  Laparoscopic cystectomy and stapled ileal neobladder were performed in five domestic juvenile pigs. Following cystectomy, 30 to 40 cm of terminal ileum was harvested, and ileal continuity restored. The harvested ileum was made into a J configuration, and three to seven laparoscopic staple firings were used to create a spherical pouch with an afferent limb modeled after the Studer-type neobladder. An aperture was created in the dependent portion of the neobladder, and urethral anastomosis was performed using six interrupted absorbable sutures. Ureterointestinal anastomosis was performed using a Wallace technique. Postoperative cystography and intravenous pyelography were performed. A 1-month survival study was completed in one pig.
  
  
  RESULTS
  All five procedures were completed successfully without conversion to open surgery. The majority of the steps of the procedures were performed by second- and third-year urology residents (PGY 3-4). Neobladder stapling, ureterointestinal anastomosis, and the first three urethral sutures were performed by an endourology fellow. Average time for neobladder creation and entire procedure was 78 and 355 minutes, respectively. Postoperative cystography revealed spherical orthotopic neobladder with minimal or no leakage in all animals. Average neobladder capacity was 100 mL, and no obstruction was visualized on intravenous pyelography immediately after the procedures. One pig successfully survived the 1-month study period. There was excellent neobladder storage, no clinically apparent renal obstruction, and no postoperative complications.
  
  
  CONCLUSIONS
  Total laparoscopic urinary diversion and specifically orthotopic neobladder remains one of the frontiers of minimally invasive urologic surgery. Our technique for stapled ileal neobladder provides substantial advantages in terms of the operative time required for orthotopic neobladder reconstruction. This may offer an avenue to foster the development of more feasible techniques for laparoscopic urinary tract reconstructive surgery.
authors.affiliation: The Brady Institute of Urology, John Hopkins Medical Institutions, Baltimore, MD, USA. awagner@bidmc.harvard.edu
authors.forename: Andrew
authors.initials: A
authors.lastname: Wagner
authors.forename: Michael
authors.initials: M
authors.lastname: Munter
authors.forename: Danil
authors.initials: D
authors.lastname: Makarov
authors.forename: Matthew
authors.initials: M
authors.lastname: Nielsen
authors.forename: Diana
authors.initials: D
authors.lastname: Scorpio
authors.forename: Louis R
authors.initials: LR
authors.lastname: Kavoussi
mesh_terms: D000818:Animals; D015653:Cystectomy; D007082:Ileum; D010535:Laparoscopy; D017792:Surgical Stapling; D034421:Sus scrofa; D016476:Urinary Reservoirs, Continent; D013520:Urologic Surgical Procedures / Q000379:methods*