title: Management of Challenging Urethro-ileal Anastomosis During Robotic Assisted Radical Cystectomy with Intracorporeal Neobladder Formation.
abstract: BACKGROUND
  Robotic assisted radical cystectomy (RARC) is increasingly being adopted, but intracorporeal neobladder formation remains a challenging procedure limited to selected centers. Common challenges with intracorporeal neobladder formation relate to fashioning a tension-free urethro-ileal anastomosis. In this paper, we describe a series of maneuvers to overcome these challenges that we believe will be of great utility to surgeons performing intracorporeal neobladder.
  
  
  OBJECTIVE
  To describe maneuvers to overcome challenges during intracorporeal urethro-ileal anastomosis formation and to report postoperative outcomes for patients in whom these maneuvers were used.
  
  
  METHODS
  A retrospective review of medical records of patients who underwent RARC with intracorporeal neobladder performed by one surgeon (G.-P.H.) at our tertiary center from January 2012 to February 2015 in which at least one additional maneuver was required beyond preservation of urethral length, removal of the sigmoid colon from the pelvis, and careful ileal loop selection. The primary end point was 90-d complications. Follow-up ranged from 6 to 36 mo, and 16 patients had at least 1-yr follow-up.
  
  
  METHODS
  RARC with intracorporeal neobladder formation.
  
  
  METHODS
  Clinical and operative data collected from a prospectively maintained, institutional review board-approved database. Maneuvers used during intracorporeal urethro-ileal anastomosis were recorded. Descriptive statistics were used to evaluate postoperative outcomes.
  
  
  CONCLUSIONS
  Nineteen patients met the inclusion criteria. Mean operative time was 486 min (standard deviation: 112 min) with median hospitalization of 7 d (interquartile range: 7-9 d). Seven patients (36.8%) experienced a complication, with one (5.3%) major complication thought to be unrelated to surgery. No open conversions were required. There was no 90-d mortality.
  
  
  CONCLUSIONS
  Our stepwise approach can help overcome challenges of urethro-ileal anastomosis during intracorporeal neobladder formation.
  
  
  RESULTS
  When performing intracorporeal neobladder formation, challenges are often encountered in fashioning the urethro-ileal anastomosis. We describe a series of maneuvers that, when used in a stepwise manner, help overcome these challenges.
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Nima
authors.initials: N
authors.lastname: Almassi
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Homayoun
authors.initials: H
authors.lastname: Zargar
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Vishnu
authors.initials: V
authors.lastname: Ganesan
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Amr
authors.initials: A
authors.lastname: Fergany
authors.affiliation: Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address: haberg2@ccf.org.
authors.forename: Georges-Pascal
authors.initials: GP
authors.lastname: Haber
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D015653:Cystectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D007082:Ileum / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009820:Ohio; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D065287:Robotic Surgical Procedures / Q000009:adverse effects; D019738:Surgically-Created Structures / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome; D014521:Urethra / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery*; D014547:Urinary Diversion / Q000009:adverse effects / Q000379:methods*
keywords: Intracorporeal neobladder; Robotic cystectomy; Urethro-ileal anastomosis