Robot-assisted radical cystectomy with intracorporeal diversion – Bordeaux neobladder, technique and first results

Overview

Introduction: Robotic-assisted radical cystectomy (RA-RACE) has emerged as a viable alternative to traditional open surgery. However, the complete intracorporeal creation of the neobladder presents significant technical challenges. This paper reports on a series of intracorporeal RA-RACE procedures utilizing the Bordeaux neobladder (modified Y reconstruction), which has recently gained popularity as an alternative to the classic Studer diversion (Wiklund, Karolinska neobladder). One of the key advantages of the Bordeaux neobladder is that it is technically more simple to perform, as it does not require ureteral transposition, making reimplantation easier. Additionally, the shape of the neobladder is more favorable, as it is designed to create a low-pressure reservoir with a larger volume, thus better meeting the requirements for neobladders. In this paper, we evaluate the outcomes of the first five patients who underwent this procedure. Population: From February to June 2025, we performed five robot-assisted radical cystectomy (RA-RACE) procedures using a Bordeaux neobladder. The average age of the patients was 63.2 (48–72) years, all patients were male. The mean body mass index (BMI) was 27 kg/sqm, with values ranging from 22.3 to 36.7. Three patients received neoadjuvant chemotherapy, specifically two patients treated with Gemcitabine and cisplatin, and one patient who underwent dose-dense MVAC (methotrexate, vinblastine, doxorubicin, cisplatin). The preoperative clinical stages for these patients included two with cT3 cN0 G3 urothelial carcinoma and one with cT3 cN1 G3. Additionally, there was one patient who did not receive neoadjuvant chemotherapy and had a very high-risk cT1 urothelial carcinoma of the bladder, along with another patient who presented with a cT2 high-grade urothelial carcinoma featuring squamous differentiation. Video: The reconstruction phase of the operation begins after completing the RA-RACE ablation phase. The Trendelenburg position is adjusted to an angle of 10–15°. Then, 40 cm of preterminal ileum is isolated and brought into the pelvis using a loop, where it is fixed suburethrally with V-Loc®, size 3-0 sutures according to the Rocco technique. The anastomosis is constructed using two Monocryl, size 3-0 sutures (Van Velthoven technique). The ileum is divided with scissors, and an entero-entero anastomosis is performed using two 60mm blue robotic staplers. The excluded loop is detubulated sharply with scissors. In constructing the neobladder, the posterior wall is formed first. All sutures for this step are done with V-Loc®, size 4-0. Next, the cranial portion of the posterior wall is flipped toward the urethra, which is ventrally reconstructed to approximately 2 cm. The anterior reconstruction of the neobladder is completed by suturing its edges together. The spatulated ureters are then directly connected to the open edges of the neobladder using two Monocryl, size 5-0 sutures. Before closure, a mono-J ureteral stent, attached to the Safil Quick, size 4-0 neovesicle, is percutaneously inserted into each ureter. The integrity of the neobladder is verified by filling it with 120 ml of saline. A drain is placed in the pelvis, and a Ch 20 urinary catheter with holes located beneath the balloon is positioned inside the neobladder. Finally, the specimen is extracted through a short upper midline laparotomy into a bag. Results: The average total operation time was 313 (298–334) minutes, and the average console time was 272 (249–302) minutes. The average blood loss was 340 (150–600) ml, and the postoperative course was uncomplicated in all. The average length of hospital stay was 14 (12–17) days; the length of intensive care stay was 2 days in all; mono-J ureteral catheters were extracted on average 12 (9–14) days. The urinary catheter was left in place for 3–4 weeks. Within 90 days after surgery, one patient was hospitalized for a febrile urinary tract infection (Clavien II complication). Within 120 days of RA-RACE, another patient was hospitalized for a urinary tract infection requiring DJ stent placement (Clavien IIIa complication). Conclusion: The Bordeaux neobladder is an appealing alternative to commonly used urinary derivations, such as the Studer technique. One of its advantages is that it does not require ureteral transposition or the creation of a „Wallace plate“. Additionally, the construction process is relatively quick. However, the outcomes of this technique should be evaluated with a longer follow-up period for patients. This method has now become standard and has been successfully implemented in six additional patients.

Keywords:

bladder cancer – radical cystectomy – neobladder – robotic surgery