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Surgery
in
Motion
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles
Giovanni
E.
Cacciamani
a,b,
*,
Vincenzo
De
Marco
a
,
Marco
Sebben
a
,
Riccardo
Rizzetto
a
,
Maria
A.
Cerruto
a
,
Antonio
B.
Porcaro
a
,
Inderbir
S.
Gill
b
,
Walter
Artibani
a
a
Department
of
Urology,
University
of
Verona,
Verona,
Italy;
b
Urology
Institute,
University
of
Southern
California,
Los
Angeles,
CA,
USA
E
U
R
O
P
E
A
N
U
R
O
L
O
G
Y
X
X
X
(
2
0
18
)
X
X
X
–
X
X
X
ava
ilable
at
www.sciencedirect.com
journa
l
homepage:
www.europea
nurology.com
Article
info
Article
history:
Accepted
November
16,
2018
Associate
Editor:
Alexandre
Mottrie
Keywords:
Robot-assisted
radical
cystectomy
Robotic
urinary
diversion
Intracorporeal
urinary
diversion
Vescica
Ileale
Padovana
Paduan
ileal
pouch
Please
visit
www.europeanurology.com
and
www.urosource.com
to
view
the
accompanying
video.
Abstract
Background:
The
Vescica
Ileale
Padovana
(VIP)
was
first
described
in
1989
as
a
tech-
nique
for
total
bladder
replacement,
and
gained
popularity
due
to
technical
simplicity
and
functional
advantages.
Objective:
To
report
preliminary
results
and
a
detailed
step-by-step
surgical
technique
description
of
robot-assisted
VIP
(ra-VIP)
that
replicates
the
open
technique
principles.
Design,
setting,
and
participants:
We
report
the
data
of
15
consecutive
patients
who
underwent
robot-assisted
radical
cystectomy
(RARC)
and
totally
intracorporeal
ra-VIP
at
our
institution
from
April
2015
to
March
2017.
Surgical
procedure:
RARC,
extende d
pelvic
lymph-node
dissection,
and
totally
intracorpo-
real
ra-VIP.
An
enhanced
recovery
after
surgery
(ERAS)
protocol
was
adopted
in
most
cases.
Measurements:
Perioperative
outcomes
(operating
time,
blood
loss,
transfusion
rate,
and
hospital
stay),
readmission
for
early
(30
d)
and
late
(90
d)
postoperative
complica-
tions,
pathological
and
oncological
outcomes,
and
overall/cancer-specific
survival
were
reported.
Results
and
limitations:
The
median
(interquartile
range)
age
was
60
(54–66)
yr.
The
median
body
mass
index
was
24
(24–25).
The
median
American
Society
of
Anesthesiol-
ogists
score
was
2
(2–2).
The
operative
time
was
390
(284–470)
min
and
the
estimated
blood
loss
was
300
(50–900)
ml.
No
conversion
to
open
technique
was
reported.
The
median
hospital
stay
was
17
(12–23)
d.
Three
patients
received
postoperative
transfu-
sions.
Six
patients
had
90-d
major
complications.
One
patient
was
readmitted
after
discharge
and
reported
a
long-term
sequela.
One
positive
margin
was
reported.
At
a
mean
follow-up
of
17
(13–25)
mo,
14
(93%)
patients
were
alive:
one
patient
died
from
disease
progression.
Daytime
continence
rate
at
12
mo
was
62%.
Conclusions:
Our
preliminary
results
showed
that
ra-VIP
appears
to
be
a
feasible
technique
for
robot-assisted
totally
intracorporeal
bladder
replacement
following
ro-
botic
radical
cystectomy.
Patient
summary:
Vescica
Ileale
Padovana
(VIP)
was
first
described
almost
30
yr
ago
for
bladder
replacement
after
radical
cystectomy.
We
report
a
step-by-step
technique
of
robot-assisted
VIP
that
follows
the
open
surgical
principles
of
detubularization
and
double
folding,
mixing
the
advantages
of
VIP
with
the
benefits
of
the
robotic
approach.
©
2018
European
Association
of
Urology.
Published
by
Elsevier
B.V.
All
rights
reserved.
*
Corresponding
author.
Department
of
Urology,
University
of
Verona,
Polo
Chirurgico
Confortini
–
5th
floor,
Piazzale
S.
Stefani
1,
Verona
37100,
Italy.
Tel.
+39
340/2491750;
Fax.
+39
045/8127715.
E-mail
address:
giovanni.cacciamani@gmail.com
(Giovanni
E..E.
Cacciamani).
EURURO-8153;
No.
of
Pages
10
Please
cite
this
article
in
press
as:
Cacciamani
GE,
et
al.
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles.
Eur
Urol
(2018),
https://doi.org/10.1016/j.
eururo.2018.11.037
https://doi.org/10.1016/j.eururo.2018.11.037
0302-2838/©
2018
European
Association
of
Urology.
Published
by
Elsevier
B.V.
All
rights
reserved.
1.
Introduction
Radical
cystectomy
(RC)
is
the
gold-standard
treatment
for
muscle-invasive
bladder
cancer;
however,
it
is
a
complex
procedure
that
frequently
involves
complications,
resulting
in
increased
hospital
stay
and
readmission
[1].
RC
with
urinary
diversion
(UD)
is
considered
one
of
the
most
challenging
procedures
due
to
technical
complexity
[2,3].
The
type
of
UD
performed
depends
on
patient's
factors,
disease
staging
[4],
and
surgeon
preferences.
The
Vescica
Ileale
Padovana
(VIP)
was
first
described
in
1989
as
a
technique
for
total
bladder
replacement
[5].
It
represents
the
second
most
commonly
performed
neobladder
tech-
nique
in
Italy
[6],
and
it
has
gained
popularity
also
in
Poland,
Spain,
and
elsewhere
due
to
its
simplicity,
technical
advantages,
and
functional
outcomes.
The
use
of
robot-
assisted
RC
(RARC)
is
rapidly
increasing;
it
can
result
in
decreased
postoperative
pain,
reduced
incisional
morbidity,
reduced
blood
loss
and
transfusion
rate,
reduced
ileus,
and
decreased
hospital
stay
with
rapid
postoperative
convales-
cence
[7–9].
Intracorporeal,
extracorporeal,
and
hybrid
techniques
of
UD
after
RARC
have
been
reported
for
both
continent
and
incontinent
diversion
[10].
Despite
the
rise
of
RARC
cases
from
0.6%
in
2004
to
31.3%
in
2017
[9],
only
few
centers
perform
intracorporeal
orthotopic
neobladder
(ICONB)
techniques
[11–13 ].
Herein,
we
report
the
step-by-step
detailed
surgical
technique
description
of
totally
intracorporeal
orthotopic
robot-assisted
(ra-)VIP
that
replicates
open
technique
principles
and
initial
experience.
2.
Patients
and
methods
From
April
2015
to
March
2017,
a
total
of
15
consecutive
patients
were
identified
from
our
collated
database,
who
underwent
RARC,
extended
pelvic
lymph
node
dissection
(ePLND),
and
intracorporeal
orthotopic
ra-
VIP
for
the
intent
to
cure
bladder
cancer.
Exclusion
criteria
were
prostatic
stromal
tumor
invasion,
urethral
tumor,
inflammatory
bowel
disease,
impaired
renal
(serum
creatinine
>2.0
mg/dl)
and
liver
functions,
poor
physical
condition,
salvage
cystectomy,
extensive
local
tumor
burden,
cognitive
incapability,
and
lack
of
motivation
or
physical
inability
to
perform
intermittent
catheterization
[4].
An
enhanced
recovery
after
surgery
(ERAS)
protocol
was
followed
in
most
patients,
when
applicable.
Exclusion
from
the
ERAS
protocol
were
an
American
Society
of
Anesthesiologists
(ASA)
score
of
>3,
presence
of
malnutrition
according
to
the
Mini
Nutritional
Assessment-Short
Form
criteria,
and
presence
of
inflammatory
bowel
diseases
[14,15].
All
data
were
entered
consecu-
tively
into
an
institutional
review
board–approved
database
and
queried
retrospectively.
Each
patient
signed
an
informed
consent
form.
The
IDEAL
Collaboration
guidelines
were
followed,
and
the
present
study
shows
the
results
of
the
phase
IIb
trial
[16]
(see
Figs.
1
and
2,
Table
1,
and
the
Supplementary
material
for
more
details).
All
patients
were
followed
for
12
mo.
Preoperative
data
collected
included
age,
gender,
body
mass
index
(BMI),
ASA
score,
Charlson
comorbidity
index,
prior
pelvic
surgery,
and
administration
of
neoadju-
vant
chemotherapy.
Perioperative
data
comprised
operative
times,
estimated
blood
loss
(EBL),
perioperative
transfusions
rate,
intraoper-
ative
complications,
total
number
of
lymph
nodes
removed,
length
of
hospital
stay,
30-
and
90-d
postoperative
complications
classified
according
to
the
Clavien-Dindo
classification
[17]
and
reported
according
to
the
European
Association
of
Urology
Complication
Panel
recommen-
dations
[18],
and
readmission
rate.
Oncological
outcomes
recorded
were
urothelial
(urethral
and
ureteral)
and
soft
tissue
positive
margins,
histology,
pathological
tumor
stage
(TNM),
positive
lymph
nodes,
and
clinical
recurrence.
Local
and
distal
recurrences
were
defined
as
clinical
relapse
in
soft
tissue
or
presence
of
lymph
nodes
confirmed
by
imaging
[19].
Cancer-specific
survival
and
overall
survival
were
recorded.
Daytime
continence
was
defined
as
the
complete
absence
of
involuntary
loss
of
urine,
of
any
entity,
both
at
rest
and
under
stress,
and
the
lack
of
a
need
for
sanitary
pads
for
protection.
Nocturnal
continence
was
defined
as
the
absence
of
involuntary
losses
of
urine
during
sleep
with
a
maximum
of
two
micturitions
per
night
(either
with
spontaneous
awakening
due
to
voiding
desire
or
at
scheduled
wakening
hours),
considering
dry
sleep
for
6–7
h.
The
dataset
includes
the
entire
learning
Fig.
1
–
Trocar
configuration
for
robot-assisted
radical
cystectomy
and
ra-VIP.
(A)
Trocar
Placement:
the
12-mm
camera
port
is
placed
3
cm
above
the
umbilicus.
Two
8-mm
robotic
ports
are
placed
1
cm
cranially
to
the
midline
between
umbilicus
and
anterior
superior
iliac
spine,
laterally
to
the
camera
port.
The
other
8-mm
robotic
port
is
placed
2
cm
cranially
to
the
right
anterior
superior
iliac
spine.
A
12-mm
assistant
port
is
placed
2
cm
cranially
to
the
left
anterior
superior
iliac
spine.
A
5-mm
assistant
port
for
suction
is
placed
at
the
left
between
the
camera
and
the
robotic
art
port,
above
the
umbilicus
line.
The
Air
Seal
insufflation
system
is
routinely
used.
(B)
Ileal
loop
positioning:
the
40-cm
ileal
loop
is
now
ready
for
reconstruction.
For
better
understanding,
you
can
ideally
divide
the
loop
into
20
cm
distal
and
20
cm
proximal.
The
distal
loop
is
anchored
in
the
middle,
as
already
described,
to
the
fibrous
tissue
posterior
to
the
urethra.
Two
anchorage
stitches
are
placed:
one
on
the
right
side
(point
“0”)
at
the
proximal
end
of
the
ileal
loop
to
the
right
psoas
and
one
on
the
left
side,
10
cm
caudally
from
the
UIA
site
(point
“20”)
to
the
left
psoas.
The
goal
of
these
lateral
anchorage
stitches
together
with
the
anchorage
in
the
deep
pelvis
is
to
maintain
the
distal
loop
in
a
fixed
position
during
detubularization
and
reconstruction.
ra-VIP
=
robot-assisted
Vescica
Ileale
Padovana;
UIA
=
urethroileal
anastomosis.
E
U
R
O
P
E
A
N
U
R
O
L
O
G
Y
X
X
X
(
2
0
18
)
X
X
X
–
X
X
X
2
EURURO-8153;
No.
of
Pages
10
Please
cite
this
article
in
press
as:
Cacciamani
GE,
et
al.
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles.
Eur
Urol
(2018),
https://doi.org/10.1016/j.
eururo.2018.11.037
curve
of
the
participating
surgeon
(W.A.)
who
has
previous
experience
in
robotic
surgery
(>150 0
robotic
procedures)
and
open
VIP
technique
(>700
cases).
No
patient
was
excluded.
2.1.
Preoperative
recommendations
and
patient
positioning
Antibiotic
prophylaxis
using
Augmentin
(amoxicillin)
4
g
was
adminis-
tered
2
h
before
surgery.
The
patient
is
positioned
in
the
Trendelenburg
position
with
30
inclination.
Prior
to
the
start
of
the
robotic
procedure,
a
16-Ch
Foley
urethral
catheter
is
placed
in
order
to
drain
the
bladder.
The
equipment
used
during
RARC
and
ra-VIP
is
given
in
Table
1.
Port
placement
is
presented
in
Fig.
1A.
2.2.
Robot-assisted
RC
All
RARC
procedures
with
ra-VIP
were
performed
on
the
Da
Vinci
Robotic
System
SI
(Intuitive
Surgical,
Sunnyvale,
CA,
USA).
Bilateral
ePLND
is
performed
according
to
a
template
including
routine
external
iliac,
Cloquet's
nodes,
obturator
fossa,
Marcille's
fossa,
internal
and
common
iliac
nodes,
and
presacral
nodes.
Specimens
are
sent
as
separate
packets.
Posterior
dissection
is
performed
to
identify
the
seminal
vesicles
in
the
male
and
vault
of
vagina
in
the
female.
Ureters
are
sectioned
at
the
level
of
their
juxtavesical
portion.
A
distal
ureteral
segment,
1–2
cm
long,
is
usually
sent
for
a
frozen
section.
Mobilization
of
the
ureter
is
then
extended
to
the
entire
iliac
segment,
by
lifting
the
peritoneal
edge.
Ureters
are
left
in
their
natural
position
without
any
modification
of
their
normal
anatomy.
In
more
detail,
the
left
ureter
is
not
passed
behind
the
sigmoid
colon
but
maintains
its
position
lateral
to
the
colon.
The
lateral
pedicles
are
then
ligated
and
divided
with
the
aid
of
hem-o-lok
clips
and
a
vessel-sealing
device.
The
dissection
is
continued
posteriorly
to
the
apex
of
the
prostate
in
male
and
to
the
urethra/proximal
anterior
vaginal
wall
in
female.
The
bladder
is
then
dropped,
endopelvic
fascia
incised,
and
urethra
divided
after
careful
clipping
to
avoid
urine
spill.
The
specimen
is
positioned
in
an
Endocatch
bag
(removed
vaginally
in
the
female
case).
Prior
to
the
start
of
the
reconstructive
part
of
the
procedure,
the
patient
is
positioned
in
a
lesser
Trendelenburg
position
with
20–15
inclination,
in
order
to
allow
the
bowel
to
descend
into
the
pelvis
and
facilitate
bringing
the
ileal
loop
down
to
the
urethral
stump.
Fig.
2
–
Bladder
neck
construction
and
urethroileal
anastomosis
(UIA).
(A)
Using
Endowrist
scissors,
a
10-cm
antimesenteric
opening
of
the
distal
ileal
segment
is
performed.
A
5-cm
distal
funnel
is
created
using
an
anterior
3-0
Quill
running
suture.
(B)
The
ileal
anastomotic
orifice
is
created
at
the
inferior
apex
of
the
funnel's
anterior
suture.
(C)
The
UIA
is
performed
according
to
the
Van
Velthoven
technique
using
3-0
Quill
barbed
sutures.
Running
suture
is
started
by
placing
both
needles
outside
in
through
the
anastomotic
ileal
orifice
made
on
the
distal
funnel,
which
will
be
the
neobladder
neck.
One
needle
is
placed
at
the
5:30
o’clock
position
and
the
other
needle
at
the
6:30
o’clock
position,
and
in
doing
so,
the
middle
knot
sits
at
the
6
o’clock
position
on
the
posterior
neobladder
neck.
The
urethral
“bites”
are
made
inside
out,
at
the
corresponding
sites.
The
right
suture
is
run
counterclockwise
back
to
the
1
o’clock
position,
passing
the
needle
from
outside
in
at
the
neobladder
neck
to
inside
out
at
the
urethra
side.
The
same
procedure
is
completed
for
the
left
running
suture
from
the
7
to
12
o’
clock
position.
As
UIA
was
performed
as
one
of
the
first
step
of
the
procedure,
the
ileal
loop
is
secured
deep
in
the
pelvis,
making
the
detubularization
of
the
intestinal
segment
easier
and
maintaining
its
fixed
position
during
the
posterior
plate
reconstruction.
Table
1
–
Equipment
for
RARC
and
ra-VIP
Robotic
equipment
(Da
Vinci,
Intuitive
Surgical
System)
Three
8-mm
trocars
0
and
30
laparoscopic
3D
optics
Endowrist
monopolar
curved
scissors
Endowrist
Bipolar
Maryland
Endowrist
Cadiere
grasp
Endowrist
needle
holder
Endowrist
proGrasps
Laparoscopic
equipment
Two
12-mm
trocars
One
5-mm
trocar
One
long
suction
irrigator
(45
mm)
One
5-mm
endoscopic
grasper
One
10-mm
Endobag
Clipper
10
mm
Hem-O-lok
(Weck
closure
system)
Laparoscopic
staplers
(60
mm
3
mm)
Endo
GIA
Sources
of
energy
and
cautery
Monopolar
and
bipolar
electrocautery
Hem-O-lok
10
mm
Sutures
3-0
Quill
barbed
suture
4-0
Monocryl
suture
RARC
=
robot-assisted
radical
cystectomy;
ra-VIP
=
robot-assisted
Vescica
Ileale
Padovana.
E
U
R
O
P
E
A
N
U
R
O
L
O
G
Y
X
X
X
(
2
0
18
)
X
X
X
–
X
X
X
3
EURURO-8153;
No.
of
Pages
10
Please
cite
this
article
in
press
as:
Cacciamani
GE,
et
al.
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles.
Eur
Urol
(2018),
https://doi.org/10.1016/j.
eururo.2018.11.037
2.3.
Ileal
loop
isolation
and
re-establishment
of
intestinal
continuity
Grasping
gently
with
robotic
Cadiere,
an
ileal
loop
of
40
cm
in
length,
at
least
20
cm
away
from
the
ileal-cecum
valve
is
selected
and
brought
down
to
the
urethra.
Eventual
adhesions
that
make
ileal
mobilization
challenging
are
recognized
and
dissected
sharply.
The
ileum
is
adequately
mobilized
to
accomplish
a
tension-free
urethroileal
anasto-
mosis
(UIA).
The
posterior
wall
of
the
lower
part
of
the
ileal
loop
where
the
UIA
will
be
performed
is
now
fixed
with
a
3-0
Quill
(Angiotech
Pharmaceuticals,
Inc.,
Vancouver,
BC,
Canada)
deep
in
the
pelvis
to
the
fibrous
tissue
posterior
to
the
urethral
stump
to
establish
a
fixed
point,
facilitating
the
performance
of
enteral
resection
and
the
following
steps
till
the
anastomosis.
The
Endo
GIA
60-mm
stapler
is
inserted
through
the
left
12-mm
trocar.
In
order
to
cut
the
ileum
properly,
once
the
designated
point
is
established,
the
bowel
is
grasped
by
the
robotic
Cadiere
forceps
and
pushed
against
the
Endo
GIA
60-mm
stapler.
After
performing
the
distal
and
proximal
ileal
sections,
the
isolated
ileal
segment
is
placed
downward.
Subsequently,
the
ileal-ileal
latero-lateral
anastomosis
and
an
accurate
mesenteric
suture
are
carried
out.
Monopolar
Endowrist
scissors
are
used
to
excise
the
staple
line
of
both
the
edges
of
the
sectioned
ileum,
and
the
continuity
of
the
ileum
is
restored
by
stapling
the
proximal
and
distal
ends
of
the
ileal
loop
side
to
side
on
their
antimesenteric
border.
A
transverse
Endo
GIA
60-mm
stapler
is
used
to
close
the
open
ends
of
the
ileal
extremities.
2.4.
Robot-assisted
VIP
configuration
After
ileal
loop
isolation
(Fig.
1B),
the
reconstruction
takes
place
as
follows.
A
10-cm
antimesenteric
opening
of
the
distal
ileal
segment
is
performed
(Fig.
2A),
and
a
5
cm
distal
funnel
is
created
(Fig.
2B).
The
ileal
orifice
is
created
at
the
inferior
apex
of
the
funnel,
and
the
UIA
is
performed
(Fig.
2C).
The
ileal
segment
is
totally
open
on
the
antimesenteric
border
to
obtain
full
detubularization.
The
posterior
plate
configuration
is
carried
out
by
folding
the
proximal
ileal
loop
medially
in
a
“U
shape”
(Fig.
3A–C).
To
perform
the
anterior
plate,
the
superior
margin
of
the
posterior
plate
is
folded
up-down
with
the
first
stitch
in
the
middle
of
the
anterior
wall
of
the
distal
funnel
(Fig.
4A–
C).
The
right
and
left
ureters
are
generously
spatulated
and
then
separately
anastomosed
directly
to
the
lateral
horns
of
the
reservoir,
previous
ureteral
catheter
positioning
(Fig.
5A–C).
A
watertight
test
is
performed
with
150
ml
of
saline
solution.
Ureteral
stents
are
brought
outside
the
abdominal
wall
through
a
single
small
incision.
A
drain
is
placed
in
the
front
of
the
reservoir.
Detailed
descriptions
of
the
aforementioned
steps
are
provided
in
the
figure
legends.
2.5.
Postdischarge
patient
care
The
drain
is
removed
as
soon
as
possible
(24–48
h).
Ureteral
catheters
are
removed
during
the
hospital
stay
between
8
and
12
d
after
the
procedure.
At
2
wk,
a
retrograde
radiological
control
of
the
reservoir
is
performed
and,
if
no
leakage
is
seen,
the
indwelling
catheter
is
removed
(Fig.
6).
Otherwise,
patients
are
discharged
with
an
indwelling
catheter
for
additional
10
d.
2.6.
Statistical
analysis
Demographic
data,
operative
and
postoperative
clinical
variables
were
collected
in
a
database.
Continuous
variables
were
shown
as
median
and
interquartile
ranges
(IQRs).
Categorical
variables
were
shown
in
frequencies
and
percentages.
Fig.
3
–
Posterior
configuration
of
ra-VIP.
The
ileal
segment
is
now
totally
open
on
the
antimesenteric
border
to
achieve
full
detubularization.
The
monopolar
Endowrist
scissor
is
used
to
excise
the
staple
line
of
both
the
edges
of
the
ileal
loop.
The
first
step
of
posterior
reconfiguration
is
represented
by
the
medial
folding
“U”
shape
of
the
proximal
ileal
loop.
(A)
Barbed
sutures
are
used
to
approximate
the
internal
margin
of
point
“10”
cited
on
the
opposite
side
of
the
UIA
with
the
medial
margin
of
the
distal
edge
of
the
proximal
ileal
segment.
A
second
stitch
approximates
the
medial
margin
of
the
proximal
20
cm
of
the
loop.
This
“tension”
stitch
is
grasped
by
the
bed
assistant
with
Joan
forceps.
The
suture
previously
placed
at
the
internal
point
“10”
is
held
using
the
Prograsp
on
the
fourth
robotic
arm.
By
softly
pulling
these
stitches,
the
medial
margins
of
the
proximal
medially
folded
loop
are
brought
together
and
exposed,
in
order
to
allow
an
easier
and
more
precise
running
suture
between
the
internal
point
“10”
and
the
cranial
tension
stitch.
(B)
Lock-stitch
sutures
are
placed
with
a
3-mm
interval
between
contiguous
stitches,
biting
the
ileal
wall
at
full
thickness,
and
a
running
suture
is
completed.
A
“tension”
stitch
is
placed
to
bring
the
apex
of
the
medially
folded
proximal
loop
to
the
right
edge
of
the
distal
loop.
This
“tension”
stitch
is
grasped
and
gently
pulled
cranially
by
the
bed
assistant
with
a
Joan
forceps
in
order
to
expose
the
margins
of
the
right
suture
of
the
posterior
plate.
(C)
A
running
suture
is
performed.
The
posterior
plate
is
now
completed.
ra-VIP
=
robot-assisted
Vescica
Ileale
Padovana;
UIA
=
urethroileal
anastomosis.
E
U
R
O
P
E
A
N
U
R
O
L
O
G
Y
X
X
X
(
2
0
18
)
X
X
X
–
X
X
X
4
EURURO-8153;
No.
of
Pages
10
Please
cite
this
article
in
press
as:
Cacciamani
GE,
et
al.
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles.
Eur
Urol
(2018),
https://doi.org/10.1016/j.
eururo.2018.11.037
Fig.
4
–
Anterior
plate
construction
of
ra-VIP
and
ureteroileal
anastomosis.
(A)
The
superior
margin
of
the
posterior
plate
is
folded
up-down
with
a
first
stitch
in
the
middle
to
the
anterior
wall
of
the
distal
funnel.
(B)
Running
sutures
are
placed
from
the
center
to
the
left
and
the
right
lateral
horn,
leaving
the
most
lateral
segments
uncompleted.
After
completion
of
the
ureteroileal
anastomosis
(for
more
details,
please
see
Fig.
5),
ureteral
stents
are
crossed
and
brought
outside
the
neobladder.
(C)
The
suture
of
lateral
segments
of
the
anterior
plate
is
completed.
The
final
shape
of
the
reservoir
results
in
a
geometric
cardioid.
The
14
Ch
catheter
is
placed
into
the
neobladder
with
the
balloon
filled
with
7
cc
of
saline.
A
watertight
test
is
performed
with
150
ml
of
saline
solution.
Ureteral
stents
are
brought
outside
the
abdominal
wall
through
a
single
small
incision.
A
single
drain
is
placed
in
front
of
the
reservoir.
ra-VIP
=
robot-assisted
Vescica
Ileale
Padovana.
Fig.
5
–
Ureteral-ileal
anastomoses.
(A)
A
5-mm
opening
is
made
on
the
left
and
right
sides
of
the
neobladder
dome.
(B)
The
right
and
left
ureters
are
generously
spatulated
and
(C)
then
separately
anastomosed
directly
to
the
lateral
horns
of
the
reservoir
by
means
of
two
running
4-0
monofilament
sutures.
Two
8
Ch
ureteral
stents
are
used.
Both
ureters
maintain
the
normal
anatomical
position.
A
rotation
of
the
ureter
on
its
axis
must
be
carefully
avoided.
During
the
isolation
of
the
distal
ureter,
particular
attention
is
given
to
not
damage
its
blood
supply,
accurately
preserving
the
adventitia.
ra-
VIP
=
robot-assisted
Vescica
Ileale
Padovana.
Fig.
6
–
Postoperative
cystogram
showing
the
spherical
double-folded
shape
of
ra-VIP.
No
extravasation
or
ureteral
reflux
is
demonstrated.
ra-
VIP
=
robot-assisted
Vescica
Ileale
Padovana.
E
U
R
O
P
E
A
N
U
R
O
L
O
G
Y
X
X
X
(
2
0
18
)
X
X
X
–
X
X
X
5
EURURO-8153;
No.
of
Pages
10
Please
cite
this
article
in
press
as:
Cacciamani
GE,
et
al.
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles.
Eur
Urol
(2018),
https://doi.org/10.1016/j.
eururo.2018.11.037
3.
Results
Baseline
characteristics
are
shown
in
Table
2.
The
median
(IQR)
age
was
60
(54–66)
yr
and
median
BMI
was
24
(24–
25)
kg/m
2
.
ASA
scores
II
and
III
were
reported
in
13
(87%)
and
two
(13%)
patients,
respectively.
One
patient
was
female
and
one
(7%)
underwent
prior
pelvic
surgery.
Peri-
and
postoperative
data
are
summarized
in
Table
3.
The
median
(IQR)
operative
time
was
390
(284–
470)
min
and
EBL
was
300
(50–900)
ml.
The
median
(IQR)
number
of
yielded
lymph
nodes
was
30
(26–34).
No
intraoperative
complications,
transfusion,
and
conversion
to
open
technique
were
reported.
A
total
of
three
(20%)
patients
received
transfusion
during
the
hospital
stay.
No
postoperative
active
bleeding
was
reported.
Early
compli-
cations
were
reported
in
seven
(47%)
patients.
Late
complications
(within
90
d)
were
reported
in
one
(7%)
patient
who
was
readmitted
for
sepsis
and
lymphocele
that
required
surgical
drainage.
One
patient
reported
long-term
sequela
due
to
loss
of
the
right
kidney
secondary
to
ureteral
benign
stricture.
At
a
median
(IQR)
follow-up
of
17
(13–25)
mo,
one
patient
died
from
disease
progression
due
to
tumor
seeding
(intestinal
metastases).
One
patient
was
lost
to
12-
mo
follow-up.
Pathological
outcomes
are
shown
in
Table
4.
Pathology
confirmed
organ-confined
disease
in
nine
(60%)
patients
and
locally
advanced
disease
in
six
(40%).
Three
patients
had
lymph-node
disease.
Regarding
pathological
outcomes,
only
one
(7%)
patient
reported
left
ureteral
positive
margin
(focal
nests
of
carcinoma
in
situ).
At
3-yr
follow-up,
no
ureteral
recurrence
was
noted.
Functional
outcomes
are
reported
in
Table
5.
Continence
status
was
assessed
as
previously
indicated.
At
3-mo
follow-
up,
nine
(60%)
and
one
(7%)
of
the
patients
reported
day-
and
night-time
continence,
respectively;
however,
eight
(62%)
and
five
(38%)
patients,
respectively,
reported
day-
and
night-time
continence
12
mo
after
the
procedure.
Evaluating
the
median
(range)
number
of
pads
worn
at
3-
and
12-mo
follow-up,
daytime
usage
decreased
from
1.6
(1–
3)
to
0.42
(0–1),
while
the
use
of
night-time
pads
reduced
from
1.3
(1–2)
to
0.72
(0–2).
One
patient
developed
chronic
urinary
retention
and
clean
intermittent
catheterization
was
needed.
Table
2
–
Preoperative
characteristics
Patients,
n
15
Age
(yr),
median
(range)
60
(54–66)
BMI
(kg/m
2
),
median
(range)
24
(24–25)
Gender
Male,
n
(%)
14
(93)
Female,
n
(%)
1
(7)
ASA
score,
median
(range)
2
(2–2)
II,
n
(%)
13
(87)
III,
n
(%)
2
(13)
CCI,
median
(IQR)
5
(3–6)
<4,
n
(%)
9
(60)
4,
n
(%)
6
(40)
NACH,
n
(%)
1
(7)
Prior
pelvic
surgery,
n
(%)
1
(7)
ASA
=
American
Society
of
Anesthesiologists
(classification);
BMI
=
body
mass
index;
CCI
=
Charlson
Comorbidity
Index;
IQR
=
interquartile
range;
NACH
=
neoadjuvant
chemotherapy.
Table
3
–
Perioperative
characteristics
Operative
time
(min),
median
(range)
390
(284–470)
EBL
(ml),
median
(range)
300
(50–900)
Conversion
rate,
n
(%)
0
(0)
Intraoperative
complications,
n
(%)
0
(0)
Perioperative
transfusions,
n
(%)
3
(20)
Intraoperative
transfusions,
n
(%)
0
(0)
Postoperative
transfusion,
n
(%)
3
(20)
Hospitalization
time
(d),
median
(range)
17
(12–23)
30-d
postoperative
complications,
n
(%)
7
(47)
Minor
(Clavien-Dindo
<III),
n
(%)
2
(13)
Fever
1
(7)
Ileus
1
(7)
Major
(Clavien-Dindo
III),
n
(%)
5
(33)
Anemia
requiring
transfusion
3
(20)
Urinary
Leak
edge
2
(13)
90-d
postoperative
complications,
n
(%)
1
(7)
Minor
(Clavien-Dindo
<III),
n
(%)
0
(0)
Major
(Clavien-Dindo
III),
n
(%)
1
(7)
Right
ureteric
benign
stricture
1
(7)
90-d
readmission,
n
(%)
1
(7)
Late
sequelae,
n
(%)
1
(7)
Follow-up
(mo),
median
(range)
17
(13–25)
Recurrence-free
survival,
n
(%)
14
(93)
Overall
survival,
n
(%)
14
(93)
EBL
=
estimated
blood
loss.
Table
4
–
Pathological
characteristics
pT
stage,
n
(%)
pT0
2
(13)
pTIS
2
(13)
pTa
0
(0)
pT1
3
(20)
pT2a
2
(13)
pT3a
2
(13)
pT4a
4
(27)
pN
stage,
n
(%)
pN0
12
(80)
pN1
1
(7)
pN2
2
(13)
pM
stage,
n
(%)
pM0
0
(0)
Positive
margins
1
(7)
Urethral
margins
0
(0)
Soft
tissue
margins
0
(0)
Ureteral
margins
1
(7)
Table
5
–
Functional
outcomes
3
mo
6
mo
12
mo
No.
of
patients
at
F-U
15
(100)
15
(100)
13
(82)
Daytime
continence
9
(60)
8
(53)
8
(62)
Night-time
continence
1
(7)
3
(20)
5
(38)
CIC
0
(0)
1
(7)
1
(7)
Pad/die
(daytime)
1.6
(1–3)
0.85
(0–3)
0.42
(0–1)
Pad/die
(night-time)
1.3
(1–2)
1
(1–2)
0.72
(0–2)
CIC
=
clean
intermittent
catheterization;
F-U
=
follow
up.
E
U
R
O
P
E
A
N
U
R
O
L
O
G
Y
X
X
X
(
2
0
18
)
X
X
X
–
X
X
X
6
EURURO-8153;
No.
of
Pages
10
Please
cite
this
article
in
press
as:
Cacciamani
GE,
et
al.
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles.
Eur
Urol
(2018),
https://doi.org/10.1016/j.
eururo.2018.11.037
4.
Discussion
The
robotic
approach
to
RC
has
risen
from
0.6%
in
2004
to
31.3%
in
2017
in
the
USA
[9].
It
is
gaining
popularity
as
a
feasible
alternative
to
the
open
procedure
and
is
beginning
to
be
considered
a
“new
reality”
in
the
treatment
of
bladder
cancer.
Although
functional
and
oncological
out-
comes
are
in
line
with
contemporary
open
series
[9,20,21],
a
recent
systematic
review
and
meta-analysis
showed
that
RARC
is
a
safe
surgical
procedure
with
acceptable
perioperative
outcomes,
shorter
length
of
hospital
stay,
and
advantages
in
terms
of
blood
loss,
transfusion
rates,
and
possibly
postoperative
complications
[9].
Creation
of
the
UD
after
RARC
may
represent
a
challenging
step
of
the
surgical
procedure
and
the
use
of
extracorporeal
(ECUD),
totally
intracorporeal
(ICUD),
and
hybrid
UD
has
been
described
in
the
literature
for
both
continent
and
inconti-
nent
diversion
[10].
Despite
the
increasing
use
of
RARC,
a
majority
of
centers
perform
ECUD
due
the
difficulties
with
bowel
reconfiguration
and
concerns
about
the
time
efficiency
compared
with
the
open
approach
[11,22].
Reser-
vations
regarding
the
use
of
ICUD
approach
include
longer
surgical
times
and
increased
complexity
[7],
but
consider-
ing
the
advantages
of
the
robotic
surgery
(wristed
instrument,
three-dimensional
[3D]
visualization,
superior
high-definition
image
quality,
and
ergonomic
position),
performing
the
entire
procedure
totally
intracorporeally
could
lead
to
decreased
bowel
manipulation
and
exposure
to
the
external
environment,
reducing
fluid
loss
with
consequently
shorter
time
to
oral
intake
and
faster
bowel
function
recovery
[22,23].
The
choice
of
the
UD
creation
approach
also
influences
the
perioperative
out-
comes
in
open
surgery
[4]
as
well
as
in
robotic
approach.
A
broad
range
of
ICONB
techniques
and
different
shapes
have
been
proposed
(Table
6),
and
the
use
of
IDEAL
guidelines
during
the
experimental
protocol
has
been
reported
[24].
However,
only
few
followed
a
double-folding
reconfiguration
that
represents
ideal
geometric
and
functional
properties
leading
to
a
good-capacity
low-
pressure
reservoir
[22,25].
Herein,
we
present
the
surgical
technique
and
prelimi-
nary
results
of
ra-VIP,
a
robotic
surgical
technique
replicat-
ing
the
open
surgical
principle.
VIP
was
first
described
in
the
early
1990s
as
a
cardioid-shaped
double-folded
neobladder
developed
by
mixing
principles
from
the
Camey
reservoir,
the
clam
cystoplasty,
and
the
Kock
pouch
[5].
In
consider-
ation
of
its
advantages
[5],
it
became
a
broadly
used
orthotopic
reservoir
[6]
in
Italy
and
other
European
countries.
Perioperative
and
functional
outcomes
have
widely
been
evaluated,
showing
that
VIP
is
a
feasible
and
safe
procedure
[15,26,27].
The
use
of
the
robotic
approach
to
perform
the
VIP
has
previously
been
described
by
Simone
et
al.
[25].
Although
several
steps
are
common,
the
main
difference
is
based
upon
the
generous
use
of
endoscopic
staplers
in
order
to
save
time
to
perform
the
posterior
plate.
Despite
the
authors
reporting
a
low
stone
formation
rate,
albeit
the
application
of
an
endoscopic
stapler
simplifies
the
surgical
procedure
[25,28],
our
and
others’
experience
in
using
staplers
in
bowel
urinary
reservoirs
is
that
the
risk
of
reservoir
stone
development
can
increase
signifi-
cantly
[29].
Moreover,
the
use
of
“tension
stitches”
makes
it
easier
to
perform
posterior
plate
sutures,
making
the
suturing
times
competitive.
In
addition,
exposure
of
the
edges
allows
safer
sewing
and
may
help
the
surgeon
to
include
in
the
suture
the
entire
thinness
of
the
bowel
wall.
Further
investigations
are
needed
in
order
to
compare
the
two
techniques
in
terms
of
perioperative
outcomes.
In
the
described
technique,
replicating
the
open
technique,
staplers
are
avoided,
and
every
suture
is
accomplished
with
reabsorbable
sutures
(barbed
or
non-
barbed).
Specific
tricks
were
developed
in
order
to
facilitate
suturing
by
means
of
putting
stay
sutures
in
axis
and
applying
tension
to
the
segment
to
be
sutured.
Up
to
the
present
time,
no
patient
developed
neobladder
stones.
Performing
the
UIA
at
the
beginning
of
the
reconstruction
allows
stabilization
of
the
neobladder
in
the
small
pelvis,
helping
in
subsequent
reconfiguration
steps.
It
may
be
interesting
to
mention
and
compare
the
step
sequence
of
the
open
versus
robotic
procedure.
Steps
in
the
open
procedure
are
the
following:
complete
detubulariza-
tion,
construction
of
the
lower
funnel
and
the
anastomotic
hole,
posterior
plate
reconstruction,
ureteroileal
anastomo-
ses,
subcomplete
anterior
plate
reconstruction,
UIA,
and
completion
of
the
anterior
plate
suture.
Robot-assisted
VIP
steps
are
as
follows:
anchorage
to
perineum
of
the
lowest
part
of
the
distal
20-cm
loop,
partial
detubularization,
construction
of
the
lower
funnel,
UIA,
posterior
plate
reconstruction,
ureteroileal
anastomoses,
and
anterior
plate
reconstruction.
In
addition
to
the
magnification,
3D
visualization
and
manipulation
using
Endowrist
permitted
by
the
robotic
technology,
the
advantages
of
our
technique
are
the
following.
Compared
with
the
other
techniques
described,
we
use
a
shorter
ileal
segment
(40
vs
55–65
cm).
This
allows
a
reduction
of
the
absorption
surface
and
leads
to
a
lesser
postvoiding
residual.
The
principles
of
detubular-
ization
and
a
double-folding
reconfiguration
are
followed
in
order
to
create
a
low-pressure,
good-capacity,
and
compliance
reservoir.
The
“cardioid”
shape
of
VIP
is
similar
to
that
of
the
natural
bladder,
allowing
it
to
fit
perfectly
in
the
small
pelvis,
becoming
a
real
orthotopic
neobladder.
The
lower
funnel
directs
the
voiding
pressure
toward
the
urethral
conduit
during
abdominal
straining.
The
anasto-
motic
hole
at
the
very
end
of
the
anterior
suture
constructing
the
lower
funnel
allows
a
perfect
ileal-
urethral
anastomosis,
without
tension
and
with
a
well-
vascularized
ileal
wall.
Moreover,
maintaining
the
left
ureter
in
its
anatomic
native
position,
without
the
need
of
crossing
from
left
to
right
side,
the
risk
of
stricture
due
to
the
left
ureter
isolation
and
devascularization
is
at
least
theoretically
decreased.
E
U
R
O
P
E
A
N
U
R
O
L
O
G
Y
X
X
X
(
2
0
18
)
X
X
X
–
X
X
X
7
EURURO-8153;
No.
of
Pages
10
Please
cite
this
article
in
press
as:
Cacciamani
GE,
et
al.
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles.
Eur
Urol
(2018),
https://doi.org/10.1016/j.
eururo.2018.11.037
Table 6 –Literature review
Study Neobladder
shape
No of
patients
Patient
positioning
Ileum
length
(cm)
Ileum
length
for NB
(cm)
Bowel resection Bowel
reapproximation
ONB sutures Urethroileal
anastomosis
(timing)
Urethroileal
anastomosis
(technique)
Left ureter Ureteral stenting
insertion
Ureteral
stenting
technique
Ureteroileal
anastomosis
Case series
Pruthi et al. [28] Studer “U”3 Flat NR NR Endo GIA 60-mm
stapler
Side–to-side fashion Stapler + Vicryl 2-
0, SH
End of
reconstruction
2 running
sutures
Transposed Per urethra,
internalized
Seldinger Bricker
Jonsson et al.
[30]
Studer “U”36 Trendelenburg
(10–15
0
)
50 40 Endo GIA 60-mm
stapler
Side-to-side fashion Biosyn 3-0 Beginning of
reconstruction
Van Velthoven Transposed Per urethra,
externalized
Seldinger Wallace
Schumacher
et al. [31]
Studer “U”45 Trendelenburg
(10–15
0
)
50 40 Endo GIA 60-mm
stapler
Side-to-side fashion Biosyn 3-0 Beginning of
reconstruction
Van Velthoven Transposed Per urethra,
internalized
Seldinger Wallace
Canda et al. [32] Studer “U”23 Trendelenburg
(5
0
)
50 40 Endo GIA 60-mm
stapler
Side-to-side fashion Polyglactin 2-0 RB
and 3-0
poliglecaprone RB
Beginning of
reconstruction
Van Velthoven Transposed Per urethra,
internalized
Seldinger Wallace
Goh et al. [22] Studer “U”8 Trendelenburg 60 44 Echlon 60-mm
laparoscopic
stapler
Side-to-side fashion 2.0 V-loc suture After posterior
wall completion
Van Velthoven Transposed Percutaneous,
internalized
Seldinger Bricker
Kang et al. [33] Camey pouch 4 Trendelenburg 60 60 Endo GIA 60-mm
stapler
Side-to-side fashion Vicryl 3-0 Beginning of
reconstruction
Van Velthoven –Percutaneous,
internalized
–Bricker
Tyritzis et al.
[20]
Studer “U”70 Trendelenburg
(10–15
0
)
50 40 Endo GIA 60-mm
stapler
Side-to-side fashion Biosyn 3-0 Beginning of
reconstruction
Van Velthoven Transposed Per urethra,
externalized
Seldinger Wallace
Desai et al
a
[34] Studer “U”132 –50/60 40/44 –– –After/beginning of
reconstruction
Van Velthoven Transposed ––Wallace/
Bricker
Collins et al.
[35]
Studer “U”80 Trendelenburg
(10–15
0
)
50 40 Endo GIA 60-mm
stapler
Side-to-side fashion 3-0 V-Loc Beginning of
reconstruction
Van Velthoven Transposed Percutaneous,
externalized
Seldinger Wallace
Atmaca et al.
[36]
Studer “U”32 Trendelenburg
(5
0
)
50 40 Endo GIA 60-mm
stapler
Side-to-side fashion Polyglactin 2-0 RB
and 3-0
poliglecaprone RB
Beginning of
reconstruction
Van Velthoven Transposed Per urethra,
internalized
Seldinger Wallace
Butt et al. [37] Hautmann “W”4 Trendelenburg 65 60 Endo GIA 60-mm
stapler
Side-to-side fashion Vicryl 3-0 End of
reconstruction
–Nontransposed Percutaneous,
externalized
Seldinger Bricker
Koupparis et al.
[38]
Studer “U”11 ––––– ––––––Bricker
Schwentner
et al
a
[39]
Studer “U”62 Trendelenburg
(5
0
)
50 40 Endo GIA 60-mm
stapler
Side-to-side fashion Polyglactin 2-0 RB
and 3-0
poliglecaprone RB
Beginning of
reconstruction
Van Velthoven Transposed Per urethra,
externalized
Seldinger Wallace
Sim et al
a
[40] Studer “U”73 Trendelenburg 50 40 Endo GIA 60-mm
stapler
Side-to-side fashion 3-0 absorbable
suture
Beginning of
reconstruction
Van Velthoven Transposed Percutaneous,
externalized
–Wallace
Tan et al. [41] Pyramid neobladder 20 Trendelenburg
(10
0
)
50 50 Endo GIA 60-mm
stapler
Side-to-side fashion 3-0 V-Loc and 2-0
Polyglactin
Beginning of
reconstruction
–Transposed Percutaneous,
externalized
–Bricker
Almassi et al.
[42]
Studer “U”19 flat 45 30 Endo GIA 60-mm
stapler
Side-to-side fashion 3-0 V-Loc and 2-0
Monocryl
After posterior
wall completion
–Transposed Percutaneous,
externalized
–Wallace
Asimakopoulos
et al. [43]
“Y”40 Trendelenburg 40 40 –– –––––––
Collins et al.
[44]
Studer “U”86 Trendelenburg
(10–15
0
)
50 40 Endo GIA 60-mm
stapler
Side-to-side fashion 3-0 V-Loc Beginning of
reconstruction
Van Velthoven Transposed Percutaneous,
externalized
Seldinger Wallace
Lamb et al. [45] Pyramid neobladder 31 Trendelenburg
(10
0
)
50 50 Endo GIA 60-mm
stapler
Side-to-side fashion 3-0 V-Loc and 2-0
Polyglactin
Beginning of
reconstruction
–Transposed Percutaneous,
externalized
–Bricker
Pyun et al. [46] Camey pouch 11 Trendelenburg 60 60 Endo GIA 60-mm
stapler
Side-to-side fashion Vicryl 3-0 Beginning of
reconstruction
Van Velthoven –Percutaneous,
internalized
–Bricker
Simone et al.
[25]
PIB 45 Trendelenburg
(20
0
)
42 42 Endo GIA 60-mm
stapler
Side-to-side fashion Staplers
+ absorbable
suture
Beginning of
reconstruction
2 running
sutures
Nontransposed ––Split-nipple
technique
Minervini et al.
[24]
Florin 18 Trendelenburg
(20
0
)
50 50 Endo GIA 60-mm
stapler
Side-to-side fashion V-loc 3-0 Beginning of
reconstruction
Van Velthoven Nontransposed ––Bricker
Current Series
b
ra-VIP 15 Trendelenburg
(30
0
)
40 40 Endo GIA 60-mm
stapler
Side-to-side fashion Quill 3-0 Beginning of
reconstruction
Van Velthoven Nontransposed Percutaneous,
externalized
Seldinger Directc
NR = not reported; ra-VIP = robot-assisted Vescica Ileale Padovana.
a
Data from multicenter study.
b
Values of heterogenic group.
E
U
R
O
P
E
A
N
U
R
O
L
O
G
Y
X
X
X
(
2
0
18
)
X
X
X
–
X
X
X
8
EURURO-8153;
No.
of
Pages
10
Please
cite
this
article
in
press
as:
Cacciamani
GE,
et
al.
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles.
Eur
Urol
(2018),
https://doi.org/10.1016/j.
eururo.2018.11.037
5.
Conclusions
These
preliminary
results
showed
that
totally
intracorpo-
real
ra-VIP
is
feasible,
reproducing
the
same
advantages
as
those
of
open
procedure.
A
wider
series
beyond
the
learning
curve
and
with
longer
follow-up
is
needed
to
better
evaluate
long-term
functional
and
oncological
outcomes
and
to
reduce
operative
time.
Author
contributions:
Giovanni
E.
Cacciamani
had
full
access
to
all
the
data
in
the
study
and
takes
responsibility
for
the
integrity
of
the
data
and
the
accuracy
of
the
data
analysis.
Study
concept
and
design:
Artibani,
Cacciamani.
Acquisition
of
data:
Sebben,
Rizzetto.
Analysis
and
interpretation
of
data:
Artibani,
Cacciamani,
Porcaro.
Drafting
of
the
manuscript:
Artibani,
Cacciamani.
Critical
revision
of
the
manuscript
for
important
intellectual
content:
Artibani,
Cacciamani,
Cerruto,
De
Marco,
Gill.
Statistical
analysis:
Porcaro.
Obtaining
funding:
None.
Administrative,
technical,
or
material
support:
Sebben.
Supervision:
Artibani.
Other:
None.
Financial
disclosures:
Giovanni
E.
Cacciamani
certifies
that
all
conflicts
of
interest,
including
specific
financial
interests
and
relationships
and
affiliations
relevant
to
the
subject
matter
or
materials
discussed
in
the
manuscript
(eg,
employment/affiliation,
grants
or
funding,
consultan-
cies,
honoraria,
stock
ownership
or
options,
expert
testimony,
royalties,
or
patents
filed,
received,
or
pending),
are
the
following:
None.
Funding/Support
and
role
of
the
sponsor:
None.
Appendix
A.
Supplementary
data
The
Surgery
in
Motion
video
accompanying
this
article
can
be
found
in
the
online
version
at
https://doi.org/10.1016/j.
eururo.2018.11.037
and
via
www.europeanurology.com.
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No.
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10
Please
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article
in
press
as:
Cacciamani
GE,
et
al.
Robot-assisted
Vescica
Ileale
Padovana:
A
New
Technique
for
Intracorporeal
Bladder
Replacement
Reproducing
Open
Surgical
Principles.
Eur
Urol
(2018),
https://doi.org/10.1016/j.
eururo.2018.11.037
