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Identification and Fixation of the Bowel and left troughs. Each trough has a descending and an
Using a fenestrated robotic forceps, a 45–50 cm bowel ascending loop with a chimney. Six stay sutures (Tags 1–6) 1
third throw. The same process is then repeated for the left trough. The right and left troughs are then sutured together to create the posterior plate (Fig. 3B).
are used to fix the ‘W’ configuration. The first stay suture
τόχρονα καλύτερα ποσοστά εγκράτειας κυρίως κατά τη βρα-
δυνή κατάκλυση.
orea
7-Suprapubic reanastomosis port
ve e
Μετά από τη διενέργεια της ρομποτικής ριζικής κυστεκτομής, η δημιουργία νεοκύστης ενδοσωματικά-ρομποτικά είναι τε- χνικά πολύ δύσκολη. Γι’ αυτόν τον λόγο ορισμένοι ρομπο- τικοί χειρουργοί μετά το πέρας της ρομποτικής ριζικής κυ- στεκτομής επιλέγουν να κάνουν την νεοκύστη ανοιχτά. Έτσι όμως χάνονται όλα τα πλεονεκτήματα της ελάχιστα επεμβα- τικής-τραυματικής μεθόδου αφού το ρομποτικό χειρουργείο έχει μετατραπεί σε ανοιχτό. Άλλοι Ρομποτικοί Χειρουργοί
επιλέγουν να κάνουν απλοποιημένες μορφές νεοκύστη
suction tube is gently advanced through the 15-m
ς
σκοπό να διευκολυνθούν ρομποτικά στα δύσκολα βήματα Η.
2 3
segment is chosen for the neobladder and divided into right
and left troughs. Each trough has a descending and an
Fi
g. 5
Ure
anter2-stesuc τουρομποτικούχειρουργείου.Όμωςαυτέςοιαπλοποιημέ-anenechsing
ταλειφθεί η χρήση ακόμη και στο ανοιχτό χειρουργείο. Δεν
(Fig.Aient th the F
Divis
είναι λογικό να γίνεται ρομποτικά μία νεοκύστη η οποία δεν Separ mesenitate
είναιλειτουργικήκαιτεχνικά-χειρουργικάανήκειπλέονστοstretclad.Th
παρελθόν και μόνο κριτήριο διενέργειας της να είναι η τεχνι-
κή ευκολία του χειρουργού και όχι η διευκόλυνση της ζωής 154
του ασθενούς.
Ο συνδυασμός της ρομποτικής χειρουργικής με την απαιτού-
part of the distal ureter is transected and sent for permanent papthaortloogfictahleedxaismtailnuartieotner. Tishteraanstecrtieodr ahnaldf soefntthfeourrpeetermroa–nent ilepalatahnoalsotgoimcaolseisxaims cinoamtipolnet.eTdh.eThanetaenriaosrtohmalofsoisfothfethuereleteftro– sidieleaisl panerafsotormeodsisinisacsoimiplalertefdas.hTiohne.anastomosis of the left
postoperative day 1 in elderly patients. Sips of clear liquids weproesitnoiptieartaetdiv,eanddayd1ietinisealdevralyncpeadtigeunitds.edSipbsyoreftculrenarolfiqbuoiwd funwcetrioeninaintidatetodl,earanndcedioetf itsheadpvaatniecnetd. Pgautiideendtsbwyeretucronvoefrbte tofournacltipoaninanmdedtoicleartaionnceonofcethaeblpeatoientot.lePrateienotrsalwienrteakceo.nve Eatrolyoarmalbpualiantiomnedanicdatciohnesotnpcheysaiboltehetoratpoylewraetreeoirnasltiitnutaekde.in
allEpaartlyienatms.bGuleantitolen paonudchchierrsitgpathiyosniowthaesrsatpayrtwederoenindsatyitu1ted
traction on the bowel using the fourth arm. To speed-up tocreatethepostesruituorirng,pthlaetcoenti(nFuoiugs.su3tuBre)li.necanbetightenedatevery
ascending loop with a chimney. SiNx steayosubturleas (dTadgs e1–6r)–urethral Anastomosis
ύχος 05 | Μάιος - Ιούνιος 2020 (Tag 1) should be at the most dependent portairoe unsedotof fitxhthee ‘rWig’ chontfiguration. The first stay su Neobladder–urethral Anastomosis
4
e (Tag 1) should be at the most dependent portion of the right
trough. The second stay suture (Tag 2) is placed 12–15 cm The robotic instruments are then removed and the robot is econd stay suture (Tag 2) is placed 12–15 cm The robotic instruments are then removed and the robot is
he first and marks the upper end of the chimney undocked. The position of the patient is changed from steep proximal to the first and marks the uppe chimney undocked. The position of the patient is changed from steep
7
escending limb. The third stay suture (Tag 3) is Trendlenberg to flat, thereby facilitating the neobladder– oftherightdescendinglimb.ThethirdsTcamgfro3m)thiesTag1oTnrtheenasdcelnedninbgleoorpgoftofluartet,hrtahlaenrasetobmyosifs.aAcftielritrealetaisneogfthtehsetaynsuetuorebsl(aTadgsd1er–
μ
ε
154
tero–ileal anastomosis.
5
T
B
mak The fourth arm is used to steadily retract the cu
tur
ε
op of urethral anastomosis. After release of the stay sutures (Tags 1
figuration. Fig. 2 Identification and fixation of the bowel.
Fig.1Portsconfiguration.nandfixnstructionoftheposterior
ht robot arm;
ght Assistant porHt;ussein et al. 6-Suction 5 mm port; and
BJU Internationa
A 45- or 60-mm Endo GIA stapler that is passe 15-mm assistant port is used to divide the bowe ld b pos djac nipu wing
s no
ved yl)] f th
pro
on
ngth
omosis port
Fig. 3 (A) Bowel detubularisation; (B) Construction of the posterior plate.
1-Camera port; 2-Right robot arm; 3-Left robot arm; 4-Right Assistant port;
μώξεις, πυελονεφρίτιδες, μετεγχειρητικά στενώματα και ταυ-
5-Fourth robotic arm; 6-Suction 5 mm port; and
Fig. 4 (A) Neobladder–urethral anastomosis; (B) Closure of lower half of the anterior wall.
and 4), the mocsltipdeepnedndaetntthepadritstoafl tuhretpero.stTehrieorurpeltaetre iosfptahretial
d
m
Fig. 4 ( Fig.e
n
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a o m
BJU International © 2017 BJU International
Fig. 6poCrlto,stuhrerooufgthethaentoeprieonr wparlltooffthteheneanotbelaridodrewr.all
© 2017 The Authors
completed, the ureteric stent is placed. A metal
Fig. 5 Uretero–ileal anastomosis.
and 4), the most dependent part of the posterior plate of the neobladder. The metal suction tip is held in plac
Fig. 5 Uretero–ileal anastomosis. Fig. 6 Closure of the anterior wall of the neobladder. neobladderisanastomosedtotheposteriorurethralplateinroesten
Fig. 6 Closure of the anterior wall of the neobladder.
Θ.
anter w hold νεςμορφέςνεοκύστηςδενείναιλειτουργικέςκαιέχειεγκα-Fsilifentisp
A stent nnothe bee-Js
σματα για τον ασθενή τόσο ογκολογικά όσο και σε επίπεδο
The remaining anterior neobladder wall is closed using 3/0
A
function and tolerance of the patient. Patients
ποιότητας ζωής. Στο κέντρο μας, έχοντας πραγματοποιήσει thrcoauthgehteerxtisenussieodn fofr tihrerig1a5t-imonm. Spoerctiminecnisbioangsocr
ved
τα τελευταία χρόνια περισσότερες από 300 ρομποτικές κυ-
all patients. Gentle pouch irrigation was started dratriannisvalegfitnianllysitiun.female patients. A Jackson-Pratt or Blake RoRboets-ausslitssted RC (RARC), ePLND (up to the aortic
pathway. The nasogastric
στης Hautmann, επιβεβαιώσαμε την ανωτερότητα αυτήςthrτouηghςextension of the 15-mm port incision or
τικά με άλλες μεθόδους. Αν θέλουμε να περάσουμε ένα μήνυ-
tis
T
3
τεχνικής με πραγματικά ελάχιστο αριθμό επιπλοκών συdγrκainρiιs -left in situ.
© 2017 The Authors
μα, αυτό θα ήταν ότι η τεχνική δυσκολία μιας μεθόδου δεν θα
πρέπει να αποτελεί για τον χειρουργό και ‘’αντένδειξη’’ πραγ- ματοποίησης της, όταν η μέθοδος αυτή υπερέχει και προσφέ- ρει τα καλύτερα αποτελέσματα για τον ασθενή.
side is performed in a similar fashion.
part of the distCalousurereteorfitshetraAnstecritoerdWanlldofsethnet Nfoerobpelardmdaenrent
Παρακολουθήστε εδώ postoperative day 1 in elderly patients. Sips of
μενη χειρουργική εμπειρία, αποφέρει τα βέλτιστα αποτελέ-
(evaellrypa8tihen).tsT.hGeeanbtldeopmoiuncahl dirraiignatisonremwaosvestdarwtehdenonthdeay 1
το vide
Closure of the Anterior Wall of the Neobladder were initiated, and diet is advanced guided by pathological examination. The anterior half of the uretero– ou(tepvuetryis8<1h5).0TmheL/adbadyoamnidnaflludidrabinioicshreemisotvreydexwchluendetshuerin
50w catVh-eLteorcisuutuserdeifnorairTr-igshataipoend.Smpaencinmeren(Fbiagg.s6)c.aTnhbeeFroetleriyeved thoeAocpartoahulecthperoagairnadmmstweandstsitcawaketerineoanrtem3oonwvceedk.sa.bIflenotoleatkolwearsatoebsoer
ileal anastomosVis-TLhiosec crseuomtmuariepnilnegtaeadTn.-tesThriaohprendeamonbalnasdntdeoremr(Fwoigasl.ils6i)so. cTflohtsehedFeoulseiyfntg 3/0
opuotupcuh toigs
a/dkae
ueied
cfhneomliesatrkyweaxscloubdseesrvue
side is performed in a similar fashion.
ς κυστεκτομής σε
ρ
ι
an
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r
ι
κ
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ή
Closure of the Anterior Wall of the Neobladdάerνδρα(evκerαy 8ι hγ). υThνe αabdίoκmαinal drain is removed w
et
rie
Early ambulation and chest physiotherapy wer tratnhsrvoaugihnaellxyteinsifoenmaolfetphaeti1e5n-tms.mA pJaocrktsionnc-isPiroanttoorr Blake Results
drain is left in situ. bifRuorcbaotti-oans)siwstietdh RICN(BRAwRaCs )p,eerPfoLrNmDed(uinp fitovethpeataieonrtisc. The
The remainingPaonstoeprieorratniveoCblardeder wall is closed using 3/0
Postoperative Care A pouchogram was taken at 3 weeks. If no lea
στεκτομέςμεενδοσωματικήδημιουργίαορθότοπηςνεVο-Lκocύsu-tureinAllapaTti-esnhtsawperdemaannagnederus(iFngigo.u6r)in.sTtithuetioFnoalleclyinicalcare reswidausa2l0di(s8e)asaendaftneornReAoRfCth,eanpdatiaelnltpsahtiaedntasnhyadevnideegnactieveofso
as
transvaginally in female patients. A Jackson-Pratt or Blake
SD) overall
Postoperative Care
BJU International © 2017 BJU International 1 © 2017 The Authors Robot-assisted RC (RARC), ePLND (up to the BJU International © 2017 BJU International
bifurcation) with ICNB was performed in five mean age was 57 years. The mean (SD) lymph was 20 (8) and none of the patients had any e residual disease after RARC, and all patients h tissue surgical margins (Table 1). The mean (S
© 2017 BJU International © 2017 BJU
All patients were managed using our institutional clinical care pathway. The nasogastric tube was typically removed on
tu
be w
typic
ally removed on
Results
o
ε
π
ε
μ
β
yn an
the catheter and stents were removed.
ra<m1
amsLt
td3 flw
kbs.ioI
ά
σ
mouebatinfpuuracgtaetiwsona<s)1w575it0hyeImaCrsNL.B/Tdhwaeaymspaeaenrnfdo(rSflmDue)dildyimnbpfiihovecnhpoadetemieyniteslt.drTyh wamse2a0n(8ag)eanwdasn5o7neyeoafrtsh.eThpeatmieneatsnh(aSdDa)nlymevpihdenocdeeoyfield
ε
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ν
the catheter and stents were removed. catheterisusedpafAtohlwlrpaiyar.triTeinghtaestnwioaesnroe.gamSstaprniecacgtieumdbeusnwinabgsatoygupsriciacnlaslytnitruebtmieoonvraeldtcrloinenivcaeldcaretisrseuseidsuarlgidciasleamsearagfitnesr(RTAabRlCe,1a)n.dThaellmpaetaienn(tSsDh)adovneergaalltive
P
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1
PA
R
sue
surg
T
2
P
ical margins (Table
1).
The
m
A
R
ean (
33
placed 10–12 cm from the Tag 1 on the ΧΈΙΡΟΥΡΓΙΚΗ ΤΈΧΝΙΚΗ
trough. The s
proximal to t r end of the of the right d
tay suplatcuedr1e0–(12
ascending lo
Fig. 1 Ports con
Fig. 2 Identificatio 1-Camera port; 2-Right robot arm;
3-Left robot arm; 4-Right Assistant port; 213
5 5-Fourth robotic a4rm; 6-Suction 5 mm port; and
7-Suprapubic reanastomosis port 7
6
4
6
213
5
7
1-Camera port; 2-Rig 3-Left robot arm; 4-Ri 5-Fourth robotic arm; 7-Suprapubic reanast
A.
A BJU Intern Γ.
© 2017 The Authors
B mesentery proximally and distally. Care shou ational © 2017 BJU International 153
Δ. to inadvertently injure any structure located isolated segment, e.g. the mesentery of the a Additionally, care should be taken while ma mesentery to avoid stretch injury and narro supply of the neobladder. Bowel continuity i established at this point.
Uretero–ileal Anastomosis
The staple line of the right chimney is remo
opening is sutured [3/0 polyglactin 910 (Vicr
enterotomy is made on the anterior aspect o
an end-to-side uretero–ileal anastomosis. Ap
of the ureters needs to be used to avoid tensi
anastomosis. Selecting the proper ureteric le
by aligning the ureteric end with its respecti
Any redundant length can be excised, while the ureteric end is viable.
Intracorp
neobladderisaannads©tospma2otus0elad1te7tdoutThshienegporsoAtberouIintoitcrhauscocoriersrptshsorreasallfpoWlra-ntaeowibniladde Έ. Ζ.
AB
anend-to-endAfasshiniognleuasrimnged3/40/0V-pLoolycgslauctIntuitrnraec9(o1Fr0pigos.rue4atAulrW)e.-nT(e5hoebcla BJU International © 2017 BJU International 153
anterior part oftothmeakneasatnomanoassistoims tohseisnwciotmhpinletteerdruopvtedr asu2t2u-re
A) Neobladder–urethral anastomosis; (B) Closure of loweFr hsaillfiocfothneeacnatetrhioeratwreamrll.eCdlofosurraecoofnotinluyotuhsealonwasetromhaolfsiso)f.tEhiether wa
4 (A) Neobladder–urethral anastomosis; (B) Closure of loawnertehrailfoorf twheaallntoefraiontrhcwehaolln.reinobglasudtduereishsouublsdeqbueepnltalycepderinforamne‘odutsid AB
A (Fig. 4B). B on the ureter side at the angle of the spatulatio on the neobladder side is placed ‘inside–out’. Af the first suture, the fourth arm is manipulated t
Division and Restoration of Bowel Continuity
ureteric end close to the enterotomy before tyin
to achieve a tension-free anastomosis. This initi Separation of the neobladder starts by creating two
ensures proper alignment and placement of the mesenteric windows. The bowel and its mesentery are
sutures. Once the first suture is placed, the rem stretched just proximal to Tag 2 and just distal to Tag 6.
anastomosis can be completed in a continuous manner (Fig. 5). Once the posterior wall anasto
d-to-end fashion using 3/0 V-Loc suture (Fig. 4A). Th ior part of the anastomosis is then completed over a 2 cone catheter. Closure of only the lower half of the
ior wall of the neobladder is subsequently performed 4B).
ion and Restoration of Bowel Continuity
ation of the neobladder starts by creating two nteric windows. The bowel and its mesentery are hed just proximal to Tag 2 and just distal to Tag 6.
© 2017 The Authors
BJU International © 2017 BJU International
Hussein et al.
ation of theFigb. 3o(Aw) Beowl.el detubularisation; (B) Co
plate.
B.
A
botic needle driver to allow passage of th imney and then into the ureter. An 8.5-F ent with a guidewire is passed through th
d into the ureteric opening. Once the ste ay, the suction tip is withdrawn while the single-J stent is preferred to have a suffic e stent distally near the neourethra or to 3/0 chromic suture is used to secure the eobladder to prevent dislodgement, and a used to secure the distal end of the singl eourethra or to the Foley catheter (to facil ter on). Both sutures should be loosely tie
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