In this video, our technique of robotic intracorporeal Studer pouch construction specifically punctuating our suturing and stenting techniques are presented. A 63 year-old female patient with muscle invasive bladder cancer was referred to our hospital for robotic radical cystectomy and intracorporeal Studer-pouch construction. Her pathological stage prior to radical cystectomy was T1GIII, and the tumor was spread out all over the bladder mucosa in the endoscopic examination. Her past medical history revealed a laparoscopic cholecystectomy 20 years ago and a cesarean section 30 years ago.

Surgical Technique

Having completed the genitalia preserving female cystectomy and extended pelvic lymphadenectomy, intracorporeal neobladder construction is started. Identifying the ileo ceacal junction, stay sutures are placed on the antimesenteric border of the ileum 20 cm apart. Most dependent region of the ileal segment to be used for the pouch approximately 35 cm from the ileaceal junction is determined by bringing the ileal wall down to the membranous urethra. A 2 cm opening at this site is made and membranous urethra is sutured to the ileum at this opening. Intestinal staplers are applied at 20 cm and 50 cm from the ileoceal junction. Sparing the most proximal 10 cm of ileum as afferent loop, ileal segment is opened at its antimesenteric border. Posterior wall of the pouch is brought together with interrupted sutures placed 5 cm apart and a running 3/0 monocryl. Running suturing is performed by passing 3-5 throws forming loose loops before pulling it up and tightening the suture line. Foley catheter is exchanged with a nelatone tube. Anterior wall of the pouch is folded downwards from its mid and a transvers anastomosis is accomplished using a running 3/0 monocryl. A Wallace type ureteroureterostomy is done between the spatulated ends of the ureters. Silk tie is pulled up bringing the nelatone tube through the opening at the level of ureterointestinal anastomosis. Two DJS (double J stent) are introduced into the nelatone outside the body and guided to both ureters. Additionally another guide wire is sent and the nelatone tube is removed. Finally a 20F Foley catheter with a slit at its tip is inserted into the pouch over this guide wire after distal ends of the DJS are tied together and to the Foley catheter outside. Tightening the suture line after passing -5 throws so that string makes big loops prevents using laparoscopic hooks and shortens the procedure. Internalizing DJS prevents bridging of the intestinal elements around them intraabdominally outside the pouch. It may also reduce infectious complications and decrease the amount of mucus clogs due to the diversion of produced urine into the pouch which result in low pressure continuous irrigation with patients own urine.

Patient has full daytime continence at 3rd postoperative month. CT shows a near natural looking neobladder and well preserved internal genitalia. In conclusion, our robotic suturing and internal stenting techniques reported for the first time in the English literature are useful adjuncts to a complicated robotic surgical procedure which we believe decrease perioperative complication rates.