Robot-Assisted Radical Cystectomy and Urinary

Diversion in Female Patients: Technique with

Preservation of the Uterus and Vagina
Mani Menon, MD, FACS, Ashok K Hemal, MD, MCH, FACS, Ashutosh Tewari, MD, Alok Shrivastava, MD,
Ahmed M Shoma, MD, Hassan Abol-Ein, MD, Mohamed A Ghoneim, MD

BACKGROUND: After performing more than 500 robotic radical prostatectomy and robotic radical cystopros-
tatectomy in men, we attempted to develop the technique of robot-assisted radical cystectomy
in women. This article describes two techniques of robot-assisted radical cystectomy for
women, conventional and with preservation of the uterus and vagina. To the best of our
knowledge, this is the first case series of robot-assisted radical cystectomy and urinary diversion
in women.
STUDY DESIGN: Robot-assisted radical cystectomy was undertaken in three female patients with transitional cell
carcinoma of the urinary bladder. The operation was performed with the conventional anterior
approach in one patient and with a new technique in two patients, which allows preservation of
urethra, uterus, vagina, and both ovaries. As planned, the radical cystectomy was done roboti-
cally, using the da Vinci Surgical System (Intuitive Surgical). The bladder was entrapped in an
Endocatch bag and removed through a small subumbilical incision. Urinary reconstruction was
performed extracorporeally after exteriorizing the bowel through the incision used for retrieving
the specimen. In two patients, the reconstructed pouch was placed in the pelvis and the
abdominal incision was closed. Urethroneovesical anastomosis was done robotically, using a
technique described previously for men.
RESULTS: The average operating time for the robotic radical cystectomy was 160 minutes and the mean
operating times for ileal conduit and orthotopic neobladder were 130 minutes and 180 min-
utes, respectively. The mean blood loss was less than 100 mL. The mean number of lymph nodes
removed was 12 (range 3 to 21). Surgical margins were free of tumor in all three patients.
CONCLUSIONS: This approach incorporates advantages of minimally invasive and open surgery. Performing the
radical cystectomy with the robot allows precise and rapid removal of the bladder with minimal
blood loss. Extracorporeal reconstruction of the urinary tract reduces operative time at this stage
of evolution of laparoscopic and robotic instrumentation. In the future, with the development
of technology, instrumentation, and with additional refinement of our technique, the entire
procedure may be done completely intracorporeally with equal efficiency. ( J Am Coll Surg
2004;198:386–393. © 2004 by the American College of Surgeons)

The classic operation for invasive bladder cancer in
women is anterior exenteration with removal of the
bladder, urethra, uterus, vagina, and both ovaries.1 Ad-
vances in surgical technique have allowed urethral and
vaginal-sparing operations in female patients with
No competing interests declared.
Received May 7, 2003; Revised November 3, 2003; Accepted November 3,
2003.
From the Vattikuti Urology Institute, Detroit, MI, and Urology Nephrology
Center, Mansoura, Egypt.
Correspondence address: Mani Menon, MD, FACS, Vattikuti Urology Insti-
tute, 2799 West Grand Boulevard, K-9, Detroit, MI 48202.
muscle-invasive bladder cancer because urethral, vagi-
nal, or cervical involvement is unusual.2 Although lapa-
roscopic radical cystectomy in women has been reported
by various authors, robotic radical cystectomy in women
has not.3-10 We have previously reported our experience
with both laparoscopic radical prostatectomy and ro-
botic radical cystoprostatectomy in men.11-14 The en-
couraging results from this experience led us to develop
a robotic approach to radical cystectomy in women. Af-
ter performing one anterior pelvic exenteration, we felt
that the precision offered by robotic technology would
allow us to preserve the uterus and the vagina in most

© 2004 by the American College of Surgeons ISSN 1072-7515/04/$30.00

Published by Elsevier Inc. 386 doi:10.1016/j.jamcollsurg.2003.11.010
Vol. 198, No. 3, March 2004 Menon et al Robot-Assisted Radical Cystectomy in Women 387

Table 1. Patient Characteristics, Intraoperative, and Postoperative Data

Patient no.

Characteristic 1 2 3
Age (y) 59 60 66
Preoperative diagnosis,
tumor stage (clinical) T3b T3b T3b
Body mass index 31 30 28
Number of ports 6 6 6
Operative time (min)
Radical cystectomy 150 160 170
Urinary diversion 130 190 170
Blood loss (cc) 150 250 100
Type of urinary diversion Ileal conduit W-Pouch, neobladder T-Pouch
Surgical margins Negative Negative Negative
Number of lymph nodes
removed, pathologic
status 13, negative 21, negative 3, negative
PT2, Grade 2, transitional PT1, Grade 2, transitional PT3a, Grade 3, transitional
Final histopathology cell carcinoma cell carcinoma cell carcinoma
Complications or conversion None None None
Hospital stay (d) 5 7 8

women with bladder cancer. This report of robotic rad- pression stockings are applied. Under general, intubated
ical cystectomy and continent urinary diversion (ortho- anesthesia a nasogastric tube and perurethral Foley cath-
topic neobladder) in women with carcinoma of bladder eter are inserted at the beginning of the operation. The
is the first report in the world literature to the best of our patient is positioned (Fig. 1) in lithotomy with both
knowledge. arms adducted, tucked, and padded, and the table
flexed, which opens the area between umbilicus and the
METHODS pubis. The table is tilted in steep Trendelenburg’s
Radical cystectomy with robot-assistance was performed position.
in three women (Table 1) with muscle-invasive transi-
Creation of pneumoperitoneum, peritoneoscopy,
tional cell carcinoma of the bladder. In one woman, a
and port placement
conventional anterior pelvic exenteration was done,
A six-port transperitoneal approach is used. Pneumo-
whereas in two, a nerve-sparing technique that preserved
peritoneum is created with a Veress needle (Ethicon
the vagina and uterus was used. Urinary diversion was
Endo-Surgery) introduced at the proposed site of the
achieved by orthotopic neobladder in two patients and
ileal conduit in one patient.
The operation was performed using the da Vinci Sur-
gical System (Intuitive Surgical). All robot-assisted rad-
ical cystectomies and the ileal conduit were performed
by a single surgeon (MM), experienced in robotic tech-
niques, but a second surgical team created the urinary
diversion (ileal conduit and orthotopic neobladder).

Preoperative preparation and position

Bowel preparation with antibiotic coverage is initiated 1
day before the procedure. On the morning of the oper-
ation, a broad-spectrum antibiotic and 5,000 U of sub-
cutaneous heparin are administered. Bilateral leg com-
Figure 1. Patient’s position (table is tilted in to the Trendelenburg
position) for radical cystectomy and placement of ports (three ports
for robotic arms: 12-mm port for robotic camera, and two 8-mm port
for robotic instruments and 2–3 ports for laparoscopic assistance).
388 Menon et al Robot-Assisted Radical Cystectomy in Women
Figure 2. Robotic installation.
primary port in the umbilical region. A 12-mm port
with a 30-degree laparoscope is inserted to perform the
initial inspection of the entire peritoneal cavity and vis-
cera for metastatic disease. The second and third 8-mm
ports are placed 2 cm lateral to the left and right rectus
muscle and about 5 cm below the level of umbilicus. The
fourth 12-mm port is placed 5 cm above the iliac crest in
midaxillary line on the right side for the purpose of
retraction, countertraction, and insertion of needle with
suture and application of clip by the patient side assis-
tant. A fifth, 5-mm port is placed in between and about
2.5 cm above the right side ports for the purpose of
suction. After all ports are placed, the robot is wheeled in
between the legs and installed by hooking up its three
arms to designated ports (Fig. 2).
Posterior dissection
Our previous experience in performing robot-assisted
radical cystectomy in men14 convinced us that a poste-
rior approach, through the cul-de-sac, allowed for easier
mobilization of the bladder. We reasoned that the angled
lenses, combined with the wristed instrumentation
would allow us to develop the rectovesical or uterovesical
plane and begin the preservation of the neurovascular
bundles even before the anterior and lateral bladder dis-
section was performed. The posterior dissection is done
with the 30-degree lens, looking downward. Using the
wristed da Vinci hook, an inverted U-shaped incision is
made in the peritoneum of the cul-de-sac between the
bladder and the uterus. In many patients, the course of
the lower ureters can be seen as a peritoneal fold that
extends from the iliac bifurcation to the posterior blad-
J Am Coll Surg
der wall. When this is seen, the vertical limbs of the U
follow this course, extending to a point roughly 1-in
proximal to the bifurcation of the common iliac artery.
The horizontal part of the U is made anterior to the
ovaries and the corpus of the uterus. The laparoscopic
assistants provide equal countertraction on the
transected peritoneal folds and the surgeon dissects all
fatty and fibrovascular tissue off the posterior peritoneal
fold. The plane between the uterus and the bladder is
developed as far inferiorly as is easily possible, maintain-
ing a broad dissection front. This plane can usually be
separated at this point down to the junction of the cor-
pus uteri and the cervix. Developing the plane between
the vagina and the urethra is done at a later stage. The
superior portion of the uterosacral ligaments has to be
transected to connect the vertical and the horizontal
limbs of the U. The cardinal ligaments that attach the
lateral margins of the cervix and the vagina to the pelvic
walls, are left intact. The ureters are dissected to the
bifurcation of the iliac vessels proximally and the uret-
erovesical junction (Fig. 3) distally. The inferior vesicle
pedicle is secured and divided during this phase of the
dissection. The ureter is then clipped, transected, and
the margins sent for frozen section.
Bilateral pelvic lymphadenectomy
We use the 30-degree lens looking upward and down-
ward for different steps of this part of the operation. The
peritoneum is incised in the line of the external iliac
artery from the apex of the U, proximally, to the inguinal
Figure 3. Depicting ureterovesical junction, obturator nerve (ob.N.),
and bladder.
Vol. 198, No. 3, March 2004 Menon et al Robot-Assisted Radical Cystectomy in Women 389

artery then terminates in several vaginal branches, which

run along the lateral sulcus of the vagina.
The bladder is dropped off the anterior abdominal
wall (Fig. 5). Endopelvic fascia is now opened lateral to
the urethra and the urethrovesical junction is identified.
The anterior dissection is performed very carefully as
specimen is now left with only its anterior attachments.
The pubourethral suspensory ligaments are preserved;
we also avoid extensive dissection for better preservation
of urethral sphincter complex and its nerve supply. The
dorsal vein complex is secured using a suture of 0 Vicryl
on a CT1 needle, as previously described in men for
robot-assisted radical prostatectomy and cystectomy.11-14
Figure 4. Exposure of the iliac vessels. EIV, external iliac vein; EIA,
external iliac artery; LN, lymph node; PM, psoas muscle.
The apex of the urethra is freed from the anterior vaginal
wall using blunt and sharp dissection. The superior ves-
ligament distally. This incision is lateral to the medial ical pedicle is clipped and transected at its origin (Fig. 6).
umbilical ligament and transects the round ligament.
The incision then curves medially under the rectus ab- Dissection of the vesicovaginal space and
preservation of the neurovascular bundles
dominis, transecting the medial umbilical ligaments and
The lateral sulci of the vagina and the lateral wall of the
the urachus. A standard pelvic lymphadenectomy is
urethra are used as operative landmarks to avoid injury
done using the 30-degree lens directed downward. Us-
to neurovascular bundles. Dissection is performed in the
ing this lens is essential if the common iliac lymph nodes
plane between these two structures, preserving the vag-
are being sampled. All nodal tissue is cleared from the
inal arteries, and the nerve supply to the vagina and the
genitofemoral nerve laterally, to the bladder wall medi-
clitoris (The pudendal nerve arises from the sacral plexus
ally, and from the distal common iliac artery superiorly,
[S2-S4] and gives three branches: the clitoral, perineal,
to the lateral circumflex iliac vein and the node of Clo-
and inferior hemorrhoidal. The clitoral branch lies on
quet inferiorly. The obturator fossa is cleared of nodal
the perineal membrane along its path to supply the cli-
tissue, preserving the obturator nerve, but sacrificing the
toris. The perineal branch [the largest of the three
obturator vessels if necessary. The nodal tissue (Fig. 4)
branches] enters the subcutaneous tissues of the vulva
seems to form two natural packages, one attached to the
behind the perineal membrane).
bladder wall and one lateral to this. In our opinion,
Monopolar coagulation is avoided, and the da Vinci
lymphadenectomy is the most difficult part of the oper-
ation because the tissue contains multiple small blood
vessels that have to be meticulously coagulated. Other-
wise, they retract into the tissues and give rise to hemo-
dynamically insignificant but visually annoying oozing.
This impairs visibility and may obscure the detection of
precise tissue planes. Leaving perivesical fat and nodal
tissue attached to the bladder may decrease the oozing
and allow a more anatomic operation.

Control of the bladder pedicles and dorsal

vein complex
The anterior trunk of the internal iliac artery gives off
the uterine and the inferior vesical arteries. The uterine
artery is clipped (if conventional anterior approach is
Figure 5. View of tumor and transverse incision is in process across
performed), and dissection is terminated when the pre- both medial umbilical ligaments, while the anterior peritoneum is
viously clipped inferior vesical artery is identified. The retracted with the help of tip suction.
390 Menon et al Robot-Assisted Radical Cystectomy in Women J Am Coll Surg

Figure 6. Dissection of the right lateral pedicle of the bladder after

division of the ureter, and the tented superior vesical artery (Sup.
V.A.) is shown.

articulated scissors and bipolar forceps are used for this

step. Development of the vesicovaginal space is difficult
and often bloody in open operations, and sometimes
even with traditional laparoscopy. It is easier with robot-
ics. We believe that this is because of the three- Figure 7. Radical cystectomy specimen being retrieved from limited
supra-pubic incision.
dimensional visualization, the wristed instrumentation
and the earlier control of the vesical and uterine pedicles. gether the ends of two 5-in sutures of 30 polydioxane, one
When the vesicovaginal space has been fully devel- dyed and one undyed, which helps in identification), as
oped, the previously developed plane behind the urethra previously described for robotic radical prostatectomy, ro-
will be encountered. At this point, the lens is switched to botic radical cystectomy, and urinary diversion.11-14 This
the 0 degree lens and the urethra is transected.

Urinary diversion and urethroneovesicostomy

The freed specimen is entrapped in a laparoscopic Endo-
catch II bag (US Surgical) and retrieved (Fig. 7) through a
5- to 6-cm incision placed midway between the umbilicus
and pubic symphysis. Through the same incision, a seg-
ment of ileum is extracted, isolated, detubularized, and re-
configured extracorporeally (Fig. 8). The pouch (neoblad-
der) is placed in the pelvis and a Foley catheter is passed per
urethrum into the pouch, through the neobladder neck.
The pouch is pulled down to the urethra; the previously
placed Foley catheter with inflated balloon helps in this
maneuver. The abdominal incision is closed and the robot
is redocked. The technique for laparoscopic running ure-
throvesical anastomosis, described by Van Velthoven and
colleagues13-15 for laparoscopic and robotic radical prosta-
tectomy, was modified by us for the robotic radical prosta-
tectomy and urethroneovesicostomy. It is performed ro- Figure 8. An extracorporeally created orthotopic neobladder
(40 cm–long segment of distal ileum is isolated and arranged in
botically with a continuous running double-armed W-shaped configuration) from site of retrieval of specimen, being
3-polydioxane suture (this suture is prepared by tying to- inserted into the pelvis for anastomosis.
Vol. 198, No. 3, March 2004 Menon et al
allows us to accomplish watertight, running (clockwise and
counterclockwise) urethroneovesicostomy.
RESULTS
The average operating time for the robotic radical cys-
tectomy was 160 minutes, and the mean operating times
for ileal conduit and orthotopic neobladder were 130
minutes and 180 minutes, respectively. The mean blood
loss was less than 100 mL. The bilateral pelvic lymph-
adenectomy was performed as described earlier in all
cases and mean number of lymph nodes removed was 12
(range 3 to 21). The histopathologic examination of
these nodes was negative in all cases. The surgical mar-
gins of the specimen were free of tumor in all patients.
DISCUSSION
Radical cystectomy and urinary diversion are among the
most difficult procedures being performed in laparo-
scopic urology. The complexity of the procedure in-
creases with the number of suture lines and reaches its
apotheosis when an orthotopic bladder is constructed.
Laparoscopic surgeons appear to have taken a staged
approach to its evolution, starting with simple cystec-
tomy, and progressing through radical cystectomy to
complete intracorporeal neobladder reconstruction.3-10,16,17
Every group has raised concerns that these procedures are
technically demanding, take a long operating time, and
require great laparoscopic skills.
The first case reports of laparoscopic simple and rad-
ical cystectomy were described by Parra and colleagues
in 19923 and by Sanchez de Badajaz and colleagues6 in
1993 respectively. From 1995 onward, various authors
have reported small series of laparoscopic radical cystec-
tomies with extracorporeal reconstruction of ileal con-
duit and urinary diversion in women.4-6,10 In 2000, Gill
and colleagues8 first described the technique of laparo-
scopic radical cystoprostatectomy and intracorporeal il-
eal conduit in two cases. From Europe, Turk and col-
leagues7 reported first series of laparoscopic radical
cystectomy and continent diversion (rectosigmoid
pouch) with extraction of the bladder through a recto-
tomy, avoiding an abdominal incision in 2001. Later,
Gill and colleagues9 also described laparoscopic cystec-
tomy with intracorporal construction of a continent or-
thotopic urinary diversion in another two patients. The
case series of laparoscopic cystectomy and urinary diver-
sion (ileal conduit, continent, or orthotopic neobladder)
fall into two categories—those in which the diversion
Robot-Assisted Radical Cystectomy in Women 391
was done extracorporeally and those in which the diver-
sion (ileal conduit or orthotopic neobladder) was done
intracorporeally. The operating time with extracorporeal
ileal conduit and neobladder diversion has ranged from
6 to 9 hours and 6.5 to 12 hours, respectively, and for
completely intracorporeal ileal conduit and neobladder
diversion has ranged from 10 to 11.5 hours and 7.4 to 12
hours, respectively (Table 2). The blood loss has ranged
from 300 to 1,200 mL.
We have stated previously the reasons behind using
robotic technology for complex oncologic cases and
have reported our extensive experience with laparo-
scopic radical prostatectomy and more modest experi-
ence with robotic cystoprostatectomy and urinary diver-
sion in men.11-14 Although laparoscopic radical
cystectomy and urinary diversion has been reported by
various authors in women, robotic cystectomy has
not.3-10 In attempting to develop this procedure in
women with less operative time and blood loss, we es-
chewed the urge to perform the entire procedure intra-
corporeally. Although most individuals find suturing
much easier with the robot than with conventional lapa-
roscopy, it still is not as easy as with open operations. The
major advantage of a completely intracorporeal proce-
dure appears to be the avoidance of a small abdominal
incision of 5 to 8 cm and the surgical specimen can and
has been removed transvaginally, transanally, and by
small abdominal incision; the cost is an additional 2 to 3
hours in the operating room. Additionally, no one has
examined the impact of vaginal operations on female
sexual dysfunction. Given this, we preferred to remove
the bladder through a small subumbilical incision. This
incision has allowed us to do the urinary reconstruction
extracorporeally. Even the Mansoura group, with a sur-
gical experience of more than 700 orthotopic bladders,
found it impossible to perform the urethroneovesicoc-
tomy without extending the incision to the pubis. This is
why we did this final portion robotically after closing the
incision.
Definitive treatment of bladder cancer in women
conventionally includes removal of the uterus, the ova-
ries, and much of the vagina. The reasons for this are not
clear because bladder cancer rarely extends into these
organs. Additionally, there is no evidence that excision of
the female reproductive tract results in a greater cure rate
than for men, in whom such a wide excision is not pos-
sible (Ghoneim and Abol-Enein, unpublished data).
The major reason for removing the uterus and the upper
392 Menon et al Robot-Assisted Radical Cystectomy in Women J Am Coll Surg

Table 2. Important Series of Laparoscopic, Robotic Radical Cystectomy, and Urinary Diversion
First Operation, Retrieval of Operation No. of Hospital
author Case profile n urinary diversion specimen time (h) ports stay (d)
Parra3 Pyocystis 1 Lap. simple cystectomy — 2.2 — 5
Puppo5 Lap. assisted transvaginal
Transitional cancer 5 radical cystectomy Mini-lap 6–9 — 7–18
Badajoz6 Lap. radical cystectomy Enlarged port
⫹ extracorporeal ileal site and flank
Transitional cancer 1 conduit incision — — —
Hemal10 Transitional cell Lap. radical cystectomy
cancer (9) and ⫹ extracorporeal ileal Infraumbilical
squamous (1) cancer 10 conduit incision 6.48 5–6 10.88
Gill8 Lap. radical cystectomy
Transitional cell ⫹ intracorporeal ileal Abdominal
cancer 2 conduit incision 11.5, 10 6 6
Gill9 Lap. radical cystectomy
⫹ continent orthotopic
neobladder, 1 case
Transitional cell extracorporeal Indiana Abdominal
cancer 2⫹1 pouch incision 8.5, 10.5, 7 6–7 5, 12, 6
Turk7 Lap. radical cystectomy
Transitional cell ⫹ intracorporeal rectal
cancer 5 sigmoid pouch None 7.4 6 10
Abdel-Hakim16 Transitional cell
cancer (men) (8) and Lap. radical cystectomy
squamous cancer ⫹ extracorporeal
(women) (1) 9 reconstruction of pouch Minilaparotomy 6.5–12 (median 8.3) 5–6 —
Gaboardi17 Lap. radical cystectomy
Transitional ⫹ extracorporeal
cell cancer reconstruction ileal Supraumbilical
(T1-Grade 3) 1 ONB incision 7.5 5–6 7
Menon14 Nerve-sparing robotic
radical cystopros-
tatectomy with urinary
diversion in male (ileal
conduit, 2; T-pouch, 2; 5-6 cm RRC, 140 min; ileal
W-pouch, 9; T-pouch, suprapubic conduit, 120 min;
— 14 1) incision ONB, 168 min 6 —
Present study Roboticradical
cystectomy with urinary
diversion in women (ileal RRC, 160 min; ileal
Transitional cell conduit, 1; W-pouch, 1; Subumbilical conduit, 130 min;
cancer 3 T-pouch, 1) incision ONB, 180 min 5 6.7
Lap., laparoscopic; ONB, orthotopic neobladder; RRC, robotic radical cystoprostatectomy.

vagina appears to be to enter a better dissection plane,
avoiding troublesome vaginal bleeding. We reasoned
that the superior hemostasis that accompanies robotic
operations would afford us the opportunity of leaving
the female reproductive structures intact. We saw several
advantages with this approach—the specimen is smaller,
and can be removed through a smaller incision, the
uterus and vagina provide backing to the neobladder and
prevent kinking of the urethraneovesical anastomosis,
reducing, in theory at least, the likelihood of urinary
hypercontinence, and, last, it allows maintenance of sex-
ual function in women who want it. These are the rea-
sons behind our developing the technique of uterus-
sparing radical cystectomy.
The technique of robotic radical cystectomy in
women reported in this article reflects our current ap-
proach. An additional benefit of this technique is its
surgical accuracy because of the remarkably stable and
precise movement of the “endowrist” instruments (Intu-
itive Surgical), which allow the surgeon to dissect, di-
vide, suture, and anastomose. Incorporation of these
steps has resulted in improvement in our own perfor-
Vol. 198, No. 3, March 2004 Menon et al
mance of this operation (ie, decreased blood loss, oper-
ative time, and incontinence). We believe that a careful
detailing of our approach would be of some value to
individuals who are first embarking on robotic radical
cystectomy in women, and that this will translate into
decreased operative time and complications for their pa-
tients. It will also help to overcome the obstacles of the
learning associated with this.
We have developed an original technique for per-
forming robotic radical cystectomy (standard and
uterus-preserving) in women using the da Vinci system
(Intuitive Surgical) and for constructing an ileal and
orthotopic neobladder. This technique allows precise
and rapid removal of the bladder with minimal blood
loss and combines the advantages of the minimally in-
vasive approach with those of open operations. We were
able to exteriorize the bowel segment and construct the
urinary pouch through the small incision necessary to
extract the surgical specimen from the abdomen. Per-
forming this part of the operation extracorporeally re-
duces operative time.
Author Contributions
Study conception and design: Menon, Hemal, Tewari,
Ghoneim
Acquisition of data: Tewari, Shrivastava, Shoma
Analysis and interpretation of data: Hemal, Tewari,
Abol-Ein
Drafting of manuscript: Menon, Hemal
Critical revision: Menon, Hemal
Supervision: Menon
Surgical team: Menon, Hemal, Tewari, Shoma, Abol-
Ein, Ghoneim
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