VM79 - Colon Cancer in Patient with Ileal Conduit - Robotic Right Colectomy

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Purpose/Background: An ileal conduit is commonly created for urinary diversion after cystectomy. This establishes unique future operative challenges should the patient require oncologic resection for colorectal cancer.

Methods/Interventions: This video displays a robotic right colectomy for an ascending colon adenocarcinoma in a patient with previous radical cystectomy and ileal conduit.

Results/Outcomes: A review of anatomic considerations is presented. The patient underwent an uneventful surgical recovery. Final surgical pathology demonstrated T3N0 adenocarcinoma with appropriate oncologic resection margins, no tumor in 0/34 lymph nodes.

Conclusion/Discussion: Oncologic surgical principles for colon cancer require resection of the tumor site with at least 5cm margins including high ligation of the named primary vascular pedicle for removal of the draining lymph nodes. Post surgical anatomy with an ileal conduit presents unique technical considerations secondary to aberrant ureteral location. During creation of the ileal conduit the left ureter is passed behind the mesentery of the sigmoid colon and right ureter reflected cephalad. The conduit is created using a 15-20cm segment of ileum approximately 15-20cm from the ileocecal junction. This is oriented with the ureters anastomosed to the proximal portion of bowel and distal portion of conduit matured through the abdominal wall to serve as the ostomy for isoperistaltic urine expulsion. Exclusive to this patient population, cystoscopy with stent placement and instillation of indocyanine green (ICG) is not possible to facilitate ureteral location. Placement of stents for instillation of ICG would require nephrostomy tubes and antegrade stenting which would be a considerable morbidity to the patient. Preoperative imaging should be reviewed to delineate the trajectory of each ureter, location of conduit and small bowel anastomosis from conduit creation, and vascular pedicle supplying the tumor. A CT urogram with delayed contrast images may be ordered if anatomy is not clear on staging imaging. A foley catheter can be placed into the urostomy for drainage of urine during the case. The foley tubing can also facilitate localization of the conduit if small bowel anatomy is not clear by moving the tubing while simultaneously observing within the peritoneal cavity. For a minimally invasive surgical approach staggering the ports as lateral as possible will create more working space around the conduit.