LAUSR

OBJECTIVE To describe our technique for robotic total pelvic exenteration with intracorporeal sigmoid conduit and colostomy using the da Vinci Si robot. METHODS Three 8-mm robotic ports and two 12-mm laparoscopic ports are placed in a "W" configuration, approximately 2-3 cm more cephalad than for radical prostatectomy (Fig. 1). The robot is docked between the legs with the patient in steep Trendelenburg. The ureters are dissected out from the iliac vessels to the rectovesical pouch, where they are clipped and transected. The sigmoid colon is stapled across at the rectosigmoid junction and reflected into the abdomen. A posterior plane is developed below the rectum (Fig. 2A), if space allows, or through the rectum. The endopelvic fascia is exposed and incised bilaterally. After sequentially controlling the bladder and prostatic pedicles (Fig. 2B) using the Harmonic scalpel, the urethra is transected at the prostatic apex, and the anterior rectal wall is incised (Fig. 2C). Any remaining attachments are divided, the rectal remnant is excised, and the specimen is bagged and extracted (Fig. 2D). Adjacent segments of left and sigmoid colon are harvested for the conduit and colostomy, avoiding a bowel anastomosis. The ureters are anastomosed to the conduit, maintaining separation between the gastrointestinal and the urinary systems. The conduit and left end colostomy are matured (Fig. 3). The technique is performed entirely intracorporeally with specimen extraction through the anus, avoiding a large open incision. RESULTS We present the case of a high-functioning (Eastern Cooperative Oncology Group performance status 1) 73-year-old man with metastatic castrate-resistant prostate cancer following failed primary brachytherapy. Despite a good systemic response to chemotherapy and complete androgen blockade, his prostate-specific antigen level continued to rise (to 33 ng/mL) because of an enlarging prostatic pelvic mass. He suffered from progressive local symptoms, including intractable pelvic pain, obstructive uropathy, and impending rectal obstruction. The indication for pelvic exenteration was local palliation. Total robotic time was 5.4 hours. The perioperative course was complicated by disseminated intravascular coagulation secondary to metastatic prostate cancer, which resulted in a transient ischemic attack. The disseminated intravascular coagulation resolved with blood product transfusion, and the patient recovered well without permanent disability. In-patient length of stay was 8 days. Complete local palliation was achieved until the patient's death from prostate cancer 5 months later. CONCLUSION We demonstrate our step-by-step technique for robotic total pelvic exenteration with intracorporeal sigmoid conduit.