Lighting from the urethral cystoscope side: A novel technique to safely manage bowel division during intracorporeal robotic urinary diversion

RC and UD represent the “gold standard” treatment for muscle-invasive BC. Laparoscopic RC and RARC are emerging techniques; in comparison with open RC, these approaches are characterized by reduced blood loss and postoperative pain, and improvement in recovery of intestinal function. The robotic creation of an intracorporeal neobladder has gradually been adopted as part of complete RARC procedures, but it does remain subject to controversy. Technological advances could further improve the ease and efficiency of robotic intracorporeal diversion. One of the most critical points in intracorporeal reconfiguration is the manipulation of the bowel. As the recent Pasadena Consensus Panel noted,[1] there are various ways of facilitating safe manipulation of the ileum, one of which is the Marionette technique.[2] However, no mention was made in the final Pasadena document about the problem of incising the mesentery to avoid major injury to ileal vascularization. In our opinion, this maneuver represents one of the most dangerous steps in intracorporeal UD. An anastomotic leakage, especially that resulting from ileal–ileal anastomosis, is a dangerous and sometimes life-threating complication. Meticulous preservation of the bowel mesenteric vascularization could help avoid bowel ischemia and might decrease the risk of such complications. The literature describes a technique to isolate the bowel segment, using fluorescence imaging to confirm vascular anatomy: indocyanine green solution, given intravenously for mesenteric angiography, can successfully identify the mesenteric arcades.[3] Identification of bowel vascularization was one of the earliest and most frequently studied applications of indocyanine green, and this efficacious and well-known method has already been tested during nephron-sparing surgery. However, it is expensive and requires expert use of a special robotic camera. Nevertheless, the majority of intracorporeal reconstructions are carried out without strict visualization of the arcades, and some robotic surgeons use a stapler and apply this parallel with the direction of the vessels with no problem. Starting from personal experience, we would like to suggest a novel method, which is inexpensive and easy to carry out.