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Name:
Atlas - Intracorporeal Neobladder
Description:
Atlas - Intracorporeal Neobladder
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https://cadmoremediastorage.blob.core.windows.net/2df9a6f6-4405-4a3e-b921-8d28ad4cc627/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=p2kuvSQxRwP9ZWtt07Fz6%2BjQozUExn%2BW6jXY6uaklUY%3D&st=2025-05-05T05%3A04%3A09Z&se=2025-05-05T09%3A09%3A09Z&sp=r
Duration:
T00H18M32S
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https://stream.cadmore.media/player/2df9a6f6-4405-4a3e-b921-8d28ad4cc627
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https://cadmoreoriginalmedia.blob.core.windows.net/2df9a6f6-4405-4a3e-b921-8d28ad4cc627/Video Atlas.m4v?sv=2019-02-02&sr=c&sig=Orup3wx8VeckuGIDv1mK83vhrOBH17UiOUyVCy9HeY8%3D&st=2025-05-05T05%3A04%3A09Z&se=2025-05-05T07%3A09%3A09Z&sp=r
Upload Date:
2023-12-06T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 Introduction.
SPEAKER 1: In this video, we will present detailed surgical steps of the Karolinska technique for intracorporeal Studer neobladder reconstruction. We will refer to this diagram that has been published in the accompanying article in the Journal of [INAUDIBLE] neurology illustrating the surgical steps of the procedure. We will also point out tips and tricks to make the reconstruction faster and more efficient. The first step before starting the reconstructive part of the surgery is to pass the left ureter underneath the mesentery of the sigmoid colon.
SPEAKER 1: Note the tag clips are used to facilitate manipulation of the ureters and are then clipped together.
Segment:2 Urethral anastomosis.
SPEAKER 1: The first step of the reconstruction is to perform the posterior reconstruction and the urethral enteric anastomosis. The distal ilium and ileocecal valve are first identified. Using the small grasping retractor in the right hand and the Cartier forceps in the fourth hand, the mesentery of the distal ileum is gently grasped and brought down into the pelvis.
SPEAKER 1: Once in position, the Cartier forceps is used to maintain the intestine in place. A 3-0 double arm barbed suture is then used to first perform a posterior reconstruction re-approximating the Denonvilliers' fascia and the posterior urethral tissue.
SPEAKER 1: After performing two passes with each needle, the stitch is cinched down to approximate the tissue. The same needle is then used to anchor the posterior aspect of the ilium. This allows to remove tension from the urethral anastomosis. At this stage, care is taken to avoid taking the urethra.
SPEAKER 1: Once again, two passes are made with each needle before cinching it down. Using the monopolar scissor, A one to two centimeter incision is made on the anterior aspect of the ilium in line with the urethra. This will become the bladder neck of the new bladder.
SPEAKER 1: We then use the same barbed suture to perform the ureteroileal anastomosis first passing out on the ilium and then out on the urethra. This technique is analogous to the technique most commonly used in prostatectomy. We ensure to take full thickness back on the ilium side and to take the urothelium on the urethra side to ensure a watertight anastomosis.
SPEAKER 1: Asking the assistant to bring the tip of the catheter in and out of the urethra can be used at this step to make identification of the urethral mucosa easier. The urethral enteric anastomosis is then performed in the running fashion circumferentially. It is then important to pass the catheter to make sure it goes through the anastomosis smoothly before tying the two stitched together anteriorly.
SPEAKER 1:
Segment:3 Bowel stapling and anastomosis.
SPEAKER 1: The next step is the stapling of the bowel. For this step, we use the small grasping retractor in the right hand and the cardio grasper in the left hand. The fourth robotic arm is deducted to allow introduction of the laparoscopic stapler. A 60 millimeter stapler load is applied perpendicular to the ilium approximately 10 centimeters distal to reestablish anastomosis.
SPEAKER 1: The next step is to re-establish intestinal continuity. A one to two centimeter incision is made on the antimesenteric side of both limbs to be anastomosed. The jaws of a 60 millimeter stapling load are then introduced in each of the limbs. During this step, it's critical to have a good communication with your assistant to make sure the stapler comes in at the right angle.
SPEAKER 1: Notice that we use cartier to either old staple line or the mesentery in order to avoid direct manipulation of the bowel with the cartier grasper. Once the first stapling load is fired, we hold the intestine in a similar angle and the assistant comes in with a second load of 45 millimeter. Notice all the stapler is first introduced in the closed position before being opened and slid all the way up both limbs of ilium.
SPEAKER 1: Using two staple loads in this fashion allows us to make sure we obtain a widely patent anastomosis. Finally, a 60-millimeter load of staple is fired transversely to close the open end of both ilium limb.
SPEAKER 1: Next, the intestinal segment is detubularized as depicted on this diagram. The fourth arm is used to put the intestinal limb on traction and an incision is made on the entire mesenteric border of the intestine. At this point, the assistant can introduce a suction in the intestinal lumen to give light counter traction and facilitate the dissection.
SPEAKER 1: On the proximal limb, a 10 centimeter segment of intestine is preserved and will serve as the chimney for the neobladder. The rest of the segment is then incised and opened in a similar fashion, The next step is to place stay sutures in order to align the intestinal segment for the neobladder creation.
Segment:4 Neobladder formation.
SPEAKER 1: For the first stay suture we take several muscular bites of the distal end of the right limb and at the base of the chimney on the left limb.
SPEAKER 1: The second stay suture is placed as depicted on this diagram. The suture is placed in a way to align both sides of the intestine and obtain similar length on the left and on the right side. Notice how the seromuscular stitch help to avert the serosa and will facilitate the suture of the bladder in the next step.
SPEAKER 1: Finally, the third stay suture is placed in a similar fashion at the apex of the intestinal segment. The next step is to use a 3-0 Barb suture to close the posterior plate of the neobladder. The fourth robotic arm and the assistant grasper are used to hold the stay sutures. It is at this stage that we reap the benefit of adequately placed stay sutures.
SPEAKER 1: Notice all the serosal border of each limb is nicely aligned. This makes for a fast and efficient closure of the neobladder. When we reach the midpoint of the posterior plate, the fourth arm and the assistant are repositioned. Once again, by using the stay suture, this helps to expose the serosal border and to expedite the suturing.
SPEAKER 1: We now proceed with the folding of the neobladder. We use a 3-0 barbed suture to fold the neobladder in a way to obtain similar length of intestine on each side.
SPEAKER 1: The anterior aspect of neobladder is then closed distally using the same barbed suture. Once again, we make sure to take the serosa on each bite as this is what gives the strength to the closure. As we reach the most distal part of the closure, it is often necessary to change the angle of the needle to close a small [INAUDIBLE] that may form close to the urethra.
SPEAKER 1: When the closure is complete, we introduce the final catheter. We use a large bore catheter to ensure adequate drainage of the neobladder. We then inflate the balloon and place the catheter in its final position. The next step in the reconstruction is to perform the ureteral Wallace plate and to prepare the proximal end of the chimney for the ureterointestinal anastomosis.
SPEAKER 1: The ureters are held up using the fourth arm and the wide spatulation is made on each of the ureter. The spatulation should be made as proximal as possible to limit the risk of ischemic complication and ureteral-enteric anastomosis stricture. The mesentery theory is dissected off the proximal part of the chimney on approximately 1 centimeter. This will facilitate visualization of the serosa for the ureterointestinal anastomosis.
SPEAKER 1: The staple line is excised. We also excised the excess mucosa in order to facilitate the anastomosis.
Segment:5 Ureteroileal anastomosis.
SPEAKER 1: We used a 5-0 resorbable monofilament suture on the RB-1 needle to create the Wallace plate. Notice the needle is introduced on the medial aspect of the ureter. When tied, the sensors and nice exposure of the medial aspect of the ureters to be stitched together for the Wallace plate.
SPEAKER 1: The needle is then brought from out to in and the suture is carried out distally in the running fashion.
SPEAKER 1: The next step is to bring the ureteral catheter through the chimney and up the ureters. To do this, we pass the guidewire through a 14 gauge angiocatheter at the lower part of the abdomen. The needle driver in the right end is passed through the chimney. It then serves to all the guidewire in order to give a counter tension so the stent can be passed on the wire.
SPEAKER 1: The stent and the guidewire are then pulled through the chimney and placed up the first ureter. The wire is removed and this step is repeated for the second ureter. While the stents are held by the right hand, the assistant gently pulls them to align the chimney and the urethral opening.
SPEAKER 1: We then perform a Wallace type ureteroileal anastomosis. Using a double arm 3-0 barbed suture, we start the ends the most is out-in on the ileum. We then go in-out on the lateral aspect of the left ureter. We do this because this part of the anastomosis is going to become harder to visualize as the anastomosis progresses. It is really important here to always pass the needle beneath the stent in order to avoid entangling them in the suture.
SPEAKER 1: After having done two passes with each needle, the suture is cinched down. Notice that our previous preparation of the proximal chimney makes the serosa much easier to identify at this step of the surgery.
SPEAKER 1: The anastomosis continues in a running fashion towards the right ureter. When the top of the spatulation is reached on the ureter, the excess ureter is excised sharply. During this step, we try and preserve as much as possible of the periureteral tissue as this provides support to the anastomosis and helps in the exposure.
SPEAKER 1: When the right side of the anastomosis is completed, the fourth arm is repositioned in order to expose the lateral aspect of the left ureter. The other needle is used to complete the left side of the anastomosis. Care must be taken to identify the edge of the left ureter to ensure watertight closure.
SPEAKER 1: When the top of the ureteral spatulation is reached, the fourth arm is once again repositioned and the excess of the left ureter is excised sharply.
SPEAKER 1: Once again, the periureteral tissue is preserved as this provides support during the completion of the anastomosis.
SPEAKER 1: The distal end of each ureter is sent for definitive pathology.
Segment:6 Leak test.
SPEAKER 1: The final step of the reconstruction is to close the proximal part of the anterior wall of the neobladder. Here the, fourth arm is used to maintain the counter traction.
SPEAKER 1: As the closure progresses, we make sure to tightly encircle each of the ureteral stent in order to prevent them from getting dislodged and also to limit the risk of urinary leak after the stent removal.
SPEAKER 1: Finally, we perform a leak test by filling the neobladder with approximately 100 milliliters of saline. We make sure to inspect the urethral the ureteral anastomosis. The catheter is then flushed a few times to remove any remaining bowel content and make sure the catheter drains properly.
SPEAKER 1: Thanks for watching this video. For more details, please refer to the accompanying article in Journal of Endourology.
Segment:1 Introduction.
SPEAKER 1: In this video, we will present detailed surgical steps of the Karolinska technique for intracorporeal Studer neobladder reconstruction. We will refer to this diagram that has been published in the accompanying article in the Journal of [INAUDIBLE] neurology illustrating the surgical steps of the procedure. We will also point out tips and tricks to make the reconstruction faster and more efficient. The first step before starting the reconstructive part of the surgery is to pass the left ureter underneath the mesentery of the sigmoid colon.
SPEAKER 1: Note the tag clips are used to facilitate manipulation of the ureters and are then clipped together.
Segment:2 Urethral anastomosis.
SPEAKER 1: The first step of the reconstruction is to perform the posterior reconstruction and the urethral enteric anastomosis. The distal ilium and ileocecal valve are first identified. Using the small grasping retractor in the right hand and the Cartier forceps in the fourth hand, the mesentery of the distal ileum is gently grasped and brought down into the pelvis.
SPEAKER 1: Once in position, the Cartier forceps is used to maintain the intestine in place. A 3-0 double arm barbed suture is then used to first perform a posterior reconstruction re-approximating the Denonvilliers' fascia and the posterior urethral tissue.
SPEAKER 1: After performing two passes with each needle, the stitch is cinched down to approximate the tissue. The same needle is then used to anchor the posterior aspect of the ilium. This allows to remove tension from the urethral anastomosis. At this stage, care is taken to avoid taking the urethra.
SPEAKER 1: Once again, two passes are made with each needle before cinching it down. Using the monopolar scissor, A one to two centimeter incision is made on the anterior aspect of the ilium in line with the urethra. This will become the bladder neck of the new bladder.
SPEAKER 1: We then use the same barbed suture to perform the ureteroileal anastomosis first passing out on the ilium and then out on the urethra. This technique is analogous to the technique most commonly used in prostatectomy. We ensure to take full thickness back on the ilium side and to take the urothelium on the urethra side to ensure a watertight anastomosis.
SPEAKER 1: Asking the assistant to bring the tip of the catheter in and out of the urethra can be used at this step to make identification of the urethral mucosa easier. The urethral enteric anastomosis is then performed in the running fashion circumferentially. It is then important to pass the catheter to make sure it goes through the anastomosis smoothly before tying the two stitched together anteriorly.
SPEAKER 1:
Segment:3 Bowel stapling and anastomosis.
SPEAKER 1: The next step is the stapling of the bowel. For this step, we use the small grasping retractor in the right hand and the cardio grasper in the left hand. The fourth robotic arm is deducted to allow introduction of the laparoscopic stapler. A 60 millimeter stapler load is applied perpendicular to the ilium approximately 10 centimeters distal to reestablish anastomosis.
SPEAKER 1: The next step is to re-establish intestinal continuity. A one to two centimeter incision is made on the antimesenteric side of both limbs to be anastomosed. The jaws of a 60 millimeter stapling load are then introduced in each of the limbs. During this step, it's critical to have a good communication with your assistant to make sure the stapler comes in at the right angle.
SPEAKER 1: Notice that we use cartier to either old staple line or the mesentery in order to avoid direct manipulation of the bowel with the cartier grasper. Once the first stapling load is fired, we hold the intestine in a similar angle and the assistant comes in with a second load of 45 millimeter. Notice all the stapler is first introduced in the closed position before being opened and slid all the way up both limbs of ilium.
SPEAKER 1: Using two staple loads in this fashion allows us to make sure we obtain a widely patent anastomosis. Finally, a 60-millimeter load of staple is fired transversely to close the open end of both ilium limb.
SPEAKER 1: Next, the intestinal segment is detubularized as depicted on this diagram. The fourth arm is used to put the intestinal limb on traction and an incision is made on the entire mesenteric border of the intestine. At this point, the assistant can introduce a suction in the intestinal lumen to give light counter traction and facilitate the dissection.
SPEAKER 1: On the proximal limb, a 10 centimeter segment of intestine is preserved and will serve as the chimney for the neobladder. The rest of the segment is then incised and opened in a similar fashion, The next step is to place stay sutures in order to align the intestinal segment for the neobladder creation.
Segment:4 Neobladder formation.
SPEAKER 1: For the first stay suture we take several muscular bites of the distal end of the right limb and at the base of the chimney on the left limb.
SPEAKER 1: The second stay suture is placed as depicted on this diagram. The suture is placed in a way to align both sides of the intestine and obtain similar length on the left and on the right side. Notice how the seromuscular stitch help to avert the serosa and will facilitate the suture of the bladder in the next step.
SPEAKER 1: Finally, the third stay suture is placed in a similar fashion at the apex of the intestinal segment. The next step is to use a 3-0 Barb suture to close the posterior plate of the neobladder. The fourth robotic arm and the assistant grasper are used to hold the stay sutures. It is at this stage that we reap the benefit of adequately placed stay sutures.
SPEAKER 1: Notice all the serosal border of each limb is nicely aligned. This makes for a fast and efficient closure of the neobladder. When we reach the midpoint of the posterior plate, the fourth arm and the assistant are repositioned. Once again, by using the stay suture, this helps to expose the serosal border and to expedite the suturing.
SPEAKER 1: We now proceed with the folding of the neobladder. We use a 3-0 barbed suture to fold the neobladder in a way to obtain similar length of intestine on each side.
SPEAKER 1: The anterior aspect of neobladder is then closed distally using the same barbed suture. Once again, we make sure to take the serosa on each bite as this is what gives the strength to the closure. As we reach the most distal part of the closure, it is often necessary to change the angle of the needle to close a small [INAUDIBLE] that may form close to the urethra.
SPEAKER 1: When the closure is complete, we introduce the final catheter. We use a large bore catheter to ensure adequate drainage of the neobladder. We then inflate the balloon and place the catheter in its final position. The next step in the reconstruction is to perform the ureteral Wallace plate and to prepare the proximal end of the chimney for the ureterointestinal anastomosis.
SPEAKER 1: The ureters are held up using the fourth arm and the wide spatulation is made on each of the ureter. The spatulation should be made as proximal as possible to limit the risk of ischemic complication and ureteral-enteric anastomosis stricture. The mesentery theory is dissected off the proximal part of the chimney on approximately 1 centimeter. This will facilitate visualization of the serosa for the ureterointestinal anastomosis.
SPEAKER 1: The staple line is excised. We also excised the excess mucosa in order to facilitate the anastomosis.
Segment:5 Ureteroileal anastomosis.
SPEAKER 1: We used a 5-0 resorbable monofilament suture on the RB-1 needle to create the Wallace plate. Notice the needle is introduced on the medial aspect of the ureter. When tied, the sensors and nice exposure of the medial aspect of the ureters to be stitched together for the Wallace plate.
SPEAKER 1: The needle is then brought from out to in and the suture is carried out distally in the running fashion.
SPEAKER 1: The next step is to bring the ureteral catheter through the chimney and up the ureters. To do this, we pass the guidewire through a 14 gauge angiocatheter at the lower part of the abdomen. The needle driver in the right end is passed through the chimney. It then serves to all the guidewire in order to give a counter tension so the stent can be passed on the wire.
SPEAKER 1: The stent and the guidewire are then pulled through the chimney and placed up the first ureter. The wire is removed and this step is repeated for the second ureter. While the stents are held by the right hand, the assistant gently pulls them to align the chimney and the urethral opening.
SPEAKER 1: We then perform a Wallace type ureteroileal anastomosis. Using a double arm 3-0 barbed suture, we start the ends the most is out-in on the ileum. We then go in-out on the lateral aspect of the left ureter. We do this because this part of the anastomosis is going to become harder to visualize as the anastomosis progresses. It is really important here to always pass the needle beneath the stent in order to avoid entangling them in the suture.
SPEAKER 1: After having done two passes with each needle, the suture is cinched down. Notice that our previous preparation of the proximal chimney makes the serosa much easier to identify at this step of the surgery.
SPEAKER 1: The anastomosis continues in a running fashion towards the right ureter. When the top of the spatulation is reached on the ureter, the excess ureter is excised sharply. During this step, we try and preserve as much as possible of the periureteral tissue as this provides support to the anastomosis and helps in the exposure.
SPEAKER 1: When the right side of the anastomosis is completed, the fourth arm is repositioned in order to expose the lateral aspect of the left ureter. The other needle is used to complete the left side of the anastomosis. Care must be taken to identify the edge of the left ureter to ensure watertight closure.
SPEAKER 1: When the top of the ureteral spatulation is reached, the fourth arm is once again repositioned and the excess of the left ureter is excised sharply.
SPEAKER 1: Once again, the periureteral tissue is preserved as this provides support during the completion of the anastomosis.
SPEAKER 1: The distal end of each ureter is sent for definitive pathology.
Segment:6 Leak test.
SPEAKER 1: The final step of the reconstruction is to close the proximal part of the anterior wall of the neobladder. Here the, fourth arm is used to maintain the counter traction.
SPEAKER 1: As the closure progresses, we make sure to tightly encircle each of the ureteral stent in order to prevent them from getting dislodged and also to limit the risk of urinary leak after the stent removal.
SPEAKER 1: Finally, we perform a leak test by filling the neobladder with approximately 100 milliliters of saline. We make sure to inspect the urethral the ureteral anastomosis. The catheter is then flushed a few times to remove any remaining bowel content and make sure the catheter drains properly.
SPEAKER 1: Thanks for watching this video. For more details, please refer to the accompanying article in Journal of Endourology.
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