Combined robotic and cystoscopic surgery for rectal cancer invading urinary bladder

Abstract

Although the application of laparoscopic rectal surgery has been widely accepted by accumulated evidence, it remains technically difficult in some cases of obesity, narrow male pelvis, bulky tumors, or involvement of adjacent organs. After robotic rectal surgery has been covered by the health insurance system in Japan since April 2018, we have employed robotic rectal surgery for an increasing number of cases by taking advantages of its 3D vision and wrist function. When a colorectal cancer involves the urinary bladder, the surgical treatment of choice is an anterior resection with en bloc (partial or total) bladder resection, depending on the site and extent of bladder involvement. In the attached video, robotic surgery was conducted with the aid of intraoperative cystoscopy, which resulted in curative resection with negative margin. Given that the robotic system provides excellent stability and dexterity for bladder reconstruction, the robotic approach can be technically suitable for locally advanced T4 colorectal cancer with urinary involvement.

Electronic supplementary material

The online version of this article (10.1007/s13691-020-00413-7) contains supplementary material, which is available to authorized users.

Introduction

Although the application of laparoscopic rectal surgery has been widely accepted by accumulated evidence [1], it remains technically difficult in some cases of obesity, narrow male pelvis, bulky tumors, or involvement of adjacent organs. Bony structure surrounding the rectum can cause a restriction in forceps motion within the narrow pelvic space. In Japan, robotic rectal surgery has been covered by the health insurance system since April 2018. Accordingly, we have also employed robotic rectal surgery for an increasing number of cases by taking advantages of its 3D vision and wrist function.

When a rectosigmoid cancer involves the urinary bladder, the surgical treatment of choice is an anterior resection with en bloc (partial or total) bladder resection, depending on the site and extent of bladder involvement. Recently, some studies reported the usefulness of the robotic surgery in multivisceral resection for rectal cancer [2, 3]. In the attached video, we demonstrate the novel use of intraoperative cystoscopy during da Vinci Xi robotic rectal surgery for rectosigmoid cancer invading the urinary bladder (Supplementary Video 1).

Case presentation

A 64-year-old woman was admitted to our hospital for the treatment of rectosigmoid cancer. Due to the colonic stenosis caused by the tumor, she had undergone creation of a temporary transverse colostomy at another hospital. The pathological and genetic analyses of the biopsy sample revealed that the tumor was a moderately differentiated adenocarcinoma without RAS mutation. Abdominal computed tomography (CT), magnetic resonance imaging (MRI), and colonoscopy indicated that the rectosigmoid cancer with multiple regional lymph node swelling invaded into the urinary bladder, although distant metastasis was not observed (cT4bN2M0) (Fig. 1a, c). Cystoscopy showed that the rectosigmoid cancer spread within the lumen of the urinary bladder (Fig. 1b), and the biopsy of the bladder tumor suggested a moderately differentiated adenocarcinoma. According to the recommendation of our multidisciplinary team, neoadjuvant chemotherapy (NAC) was performed: seven cycles of modified FOLFOX6 plus panitumumab. After NAC, CT and MRI showed that the main tumor decreased in size, although cystoscopy showed that the tumor on the bladder side still remained to some extent (Fig. 1d–f). To achieve curative resection with a negative margin, robotic surgery was conducted with the aid of intraoperative cystoscopy.

Fig. 1.

Pre- and post-NAC images. a–c Pre-NAC images. a Colonoscopy. b Cystoscopy. c MRI, coronal plane. Note that the rectosigmoid cancer invaded into the urinary bladder (white arrow). d–f Post-NAC images. d Colonoscopy. e Cystoscopy. f CT, coronal plane. Note that the rectosigmoid cancer still invaded into the urinary bladder to some extent (white arrow)

Technique

First, the transverse colostomy was reversed by hand-sewn end-to-end anastomosis; the defect of the abdominal wall was then closed. Next, robotic surgery was performed using the da Vinci Xi system. The port placement is shown in Fig. 2, as we previously described [4, 5]. The operator employed two-left-one-right arm setting: two fenestrated forceps connected to #1 and #2 arms on the left hand and one monopolar scissors connected to #4 arm on the right hand. The camera port connected to #3 arm was placed through the E–Z access. After abdominal exploration, the takedown of the sigmoid colon adherent to the bladder was done with 23° head-down and 7° right-tilt. After mobilizing the left-sided colon, ligation of the inferior mesenteric artery with D3 lymph node dissection was performed. Posterior dissection of the rectum was continued until the sacral promontory was reached, followed by extension of the dissection procedures toward the lateral sides. After the rectosigmoid colon was carefully separated from the bladder by blunt dissection, only the fistulous tract was left between the bladder and rectosigmoid colon. Intraoperative cystoscopy revealed that the tumor on the bladder side spread about 2 cm from the fistulous tract. While the extent of the tumor spread and the location of ureteral orifice were checked using a cystoscopy, partial bladder resection was performed with an appropriate safety margin. Both ureteral orifices were preserved. The bladder defect was closed in two layers using 4–0 vicryl (for the mucosal layer) and 3–0 V-Loc (for the seromuscular layer). The bladder was filled with saline via a urethral catheter and checked for leakage. After the mesorectum was dissected at the point of distal transection as a tumor-specific mesorectal excision, the rectum was divided using EndoWrist staplers. After the resected specimen was extracted, double-stapling technique anastomosis was performed.

Fig. 2.

Port placement in the da Vinci Xi system. Five da Vinci ports (four 8-mm ports and one 12-mm port) were placed on an umbilical horizontal line symmetrically with 7 cm interval. A 5-mm AirSeal port was placed on the right quadrant. The operator employed two-left-one-right arm setting

Result

The total operative time was 575 min, and the blood loss was 26 mL. The urinary balloon catheter was placed for 7 days postoperatively. Two weeks postoperatively, the patient was discharged without any adverse event. Macroscopic findings of the resected rectum showed a 30 × 12-mm type II tumor, while that of the resected bladder showed a solid tumor, 18 × 18 mm in size (Fig. 3a). Histopathological analysis showed that the tumor stage was Stage IIB (ypT4aN0M0 according to the 8th edition of the UICC) (Fig. 3b) and that the invasion depth of the tumor on the bladder side was limited to the muscle layer of the bladder (Fig. 3c). Tumor cells were not observed within the fistulous tract between the bladder and rectosigmoid colon (Fig. 3d). Immunohistochemical analysis showed that the tumor cells on the rectum side were positive for CDX2 and cytokeratin 20, but negative for cytokeratin 7 (Fig. 3e), which was completely consistent with the tumor cells on the bladder side (Fig. 3f). At 13 months after surgery, no recurrence or clinical symptoms were observed.

Fig. 3.

Macroscopic and histopathological findings of the specimen. a Macroscopic finding. The rectosigmoid colon (bottom) and urinary bladder (top) were shown. b Histopathological findings of the tumor on the rectum side. H&E, scale bar: 500 µm. c Histopathological findings of the tumor on the bladder side. H&E, scale bar: 500 µm. d Histopathological findings of the fistulous tract. H&E, scale bar: 500 µm. e Immunohistochemical analysis of the tumor on the rectum side. H&E, CDX2, CK20, and CK7 staining. f Immunohistochemical analysis of the tumor on the bladder side. H&E, CDX2, CK20, and CK7 staining

Discussion

Approximately 5% of primary colorectal cancer invades the urinary system [6, 7]. In such cases, several studies reported that en bloc resection of the involved urinary system is needed for patients’ favorable prognoses [8, 9]. For locally advanced colorectal cancer with suspected involvement of adjacent organs (sT4b), laparoscopic surgery with multivisceral resection was safe and feasible, except in cases with urinary tract invasion [10]. Given that the robotic system provides excellent stability and dexterity for the surgical maneuver in the narrow pelvis, the robotic da Vinci approach can be technically suitable for surgery for rectal cancer with multivisceral resection.

In this case, only the fistulous tract was left between the bladder and rectosigmoid colon in the middle of conducting blunt dissection, which was an unexpected event for us. We might have introduced an intraoperative cystoscopy a little earlier. To prevent the thin fistulous tract from tearing during surgery, the fistulous tract was clipped by hemolock and then divided. Intraoperative cystoscopy was very useful for obtaining an adequate safety margin and preventing excessive resection of the urinary bladder. Using the tile pro function of the da Vinci Xi system, the surgeon could see both the intraabdominal view and cystoscopic view in the surgeon console simultaneously. We assume that this point is an important advantage of the robotic da Vinci Xi system. Histopathological analysis indicated that the tumor on the bladder side spread outward within the muscle layer of the bladder (Fig. 3c) and that tumor cells were not observed within the fistulous tract (Fig. 3d), which was thought to be due to the therapeutic effect of NAC. To rule out the possibility of double cancer, we conducted the immunohistochemical staining for CDX2, cytokeratin 20, and cytokeratin 7, and found that the character of the tumor cells on the rectum side was consistent with that of the tumor cells on the bladder (Fig. 3e, f).

In conclusion, combined robotic and cystoscopic surgery is a safe and useful approach for visualizing the tumor spread and the ureteral orifice intraoperatively. We have recently reported the usefulness of intraoperative cystoscopy during laparoscopic surgery for colovesical fistula due to colonic diverticulitis [11]. To the best of our knowledge, this is the first report of combined robotic and cystoscopic surgery for the management of rectal cancer.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Research involving human participants and/or animals

For this type of study, formal consent is not required.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the documents is available for review by the Editor-in-Chief of the journal.