Robot-assisted Radical Cystectomy: Description of an Evolved Approach to Radical Cystectomy

doi:10.1016/j.eururo.2013.05.020

European Urology

Volume 64, Issue 4, October 2013, Pages 654-663

https://doi.org/10.1016/j.eururo.2013.05.020 Get rights and content

Abstract

Background

Although open radical cystectomy (ORC) remains the gold standard of care for muscle-invasive bladder cancer, robot-assisted radical cystectomy (RARC) continues to gain wider acceptance. In this article, we focus on the steps of RARC, describing our approach, which has been developed over the past 10 yr. Totally intracorporeal RARC aims to offer the benefits of a complete minimally invasive approach while replicating the oncologic outcomes of open surgery.

Objective

We report our outcomes of a totally intracorporeal RARC procedure, describing step by step our technique and highlighting the variations on this standard template of nerve-sparing and female organ–preserving approaches in men and women.

Design, setting, and participants

Between December 2003 and October 2012, a total of 113 patients (94 male and 19 female) underwent totally intracorporeal RARC.

Surgical procedure

We performed RARC, extended pelvic lymph node dissection, and a totally intracorporeal urinary diversion (UD) in all patients. In the accompanying video, we focus on the standard template for RARC, also describing nerve-sparing and female organ–preserving approaches.

Outcome measurements and statistical analysis

Complications and oncologic outcomes are reported, including overall survival (OS) and cancer-specific survival (CSS) using Kaplan-Meier analysis.

Results and limitations

RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37–84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. On surgical pathology, 48% of patients had ≤pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0–57). Twenty percent of patients had lymph node–positive disease. Positive surgical margins occurred in six cases (5.3%). Median follow-up was 25 mo (range: 3–107). We recorded a total of 70 early complications (0–30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥3. Thirty-six late complications (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥3. One patient (0.9%) died within 90 days of operation from pulmonary embolism. Using Kaplan-Meier analysis, CSS was 81% at 3 yr and 67% at 5 yr.

Conclusions

Our structured approach to RARC has enabled us to develop this complex service while maintaining patient outcomes and complication rates comparable with ORC series. Our results demonstrate acceptable oncologic outcomes and encouraging long-term CSS rates.

Introduction

Robot-assisted surgery has seen remarkable growth in urology, mainly driven by robot-assisted radical prostatectomy (RARP). Although the change from open to robotic cystectomy seen with RARP has not yet been replicated, there are signs that this is now changing. In the last decade, robot-assisted radical cystectomy (RARC) has been gradually adopted as a surgical option in both the United States and Europe. As recently as 2010, the number of centres performing this surgery appeared limited, with only about 500 cases being reported in the worldwide literature [1]. Limiting factors to the uptake of this approach have included the lack of both long-term outcome data and prospective randomised trials. In recent years, the number of publications on RARC has increased, including large series [2], reflecting the growing acceptance of this approach [3], [4], [5].

RC with urinary diversion (UD) remains one of the most complex and morbid operations performed in urology. It is associated with high complication rates even in the hands of experienced surgical teams [6]. Complication rates have been shown to decrease with experience, although they still remain high, even in high-volume specialist centres [6], [7], [8], [9], [10]. Although open RC (ORC) remains the gold standard for muscle-invasive and high-risk non–muscle-invasive bladder cancer (BCa), minimally invasive approaches are continually being refined and reassessed. As technology develops and the technique evolves, it is likely that more surgeons will adopt this approach to BCa.

In this article, we focus on our standard template for RARC, additionally describing two variations: nerve-sparing RARC in men and organ-preserving surgery in women. We have previously described our approach to the stages of pelvic lymph node dissection (PLND) and intracorporeal UD [3], [5] as well as published our outcome data from Karolinska on 113 RARC procedures completed with a totally intracorporeal approach, performed between December 2003 and October 2012.

Section snippets

Methods

Patient selection, preoperative preparation, patient positioning, and equipment required have previously been described [5]. Potential complications and strategies to avoid them have been summarised in Table 1.

Results

RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37–84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. Median operating time for totally intracorporeal RARC with ileal conduit was 292 min (range: 190–561) and 420 min for totally intracorporeal RARC with neobladder (range: 265–760). On surgical pathology, 48% of patients had ≤pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The

Discussion

In developing our RARC technique over the past 10 yr, we have aspired to realise the benefits of a minimally invasive approach while avoiding the recognised steep learning curve with high associated complication rates experienced in laparoscopic RC [12]. An optimised RARC approach should offer lower blood loss, lower perioperative morbidity and complication rates, better functional outcomes, and at least equivocal oncologic prognosis to ORC as well as shorter recovery time, as reflected in

Conclusions

We have presented our template for standard RARC, which can be adapted at the relevant stages to incorporate a nerve-sparing approach in men and organ preservation in females. By adopting a standardised approach to this complex surgery, we have successfully developed a robotic cystectomy service with acceptable short-term and long-term patient outcomes.

RARC is primarily an oncologic procedure, and we have demonstrated good oncologic outcomes and encouraging long-term CSS rates. We have also

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Perioperative and Functional Results for Robot-assisted Radical Cystectomy with Totally Intracorporeal Neobladder in Male Patients via the Vesica Patavina (Ves.Pa.) Technique: IDEAL Stage 2a Report
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Robot-assisted radical cystectomy (RARC) offers several advantages over open surgery, but intracorporeal neobladder construction (INC) is a challenging procedure. The vesica patavina (Ves.Pa.) refinement is a modification of the original technique that simplifies the neobladder configuration and reduces the risk of complications.
To present a stage 2a IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up) report on RARC with INC using the Ves.Pa. technique.
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RARC with the refined Ves.Pa. technique for INC is safe, feasible, and replicable. The technique simplifies the procedure and reduces the risk of complications. The study results suggest acceptable oncological and functional outcomes over short-term follow-up.
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To report perioperative outcomes, early (≤90 d) and late (>90 d) complications among patients undergoing RAC for UAEs after RT.
We retrospectively evaluated 32 patients undergoing RAC with ICUD for UAEs in a single tertiary centre.
Surgery was performed using a da Vinci Xi system with adaptation for the primary treatment.
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The median age-adjusted Charlson comorbidity index (ACCI) was 6 (IQR 5–7). The indication for RAC was hemorrhagic radiation cystitis in 29 cases (91%), contracted bladder in two cases (6.2%), and urinary fistula in one case (3.1%). The median EBL, OT, and LOS were 250 ml, 330 min, and 10 d, respectively. A total of 31 (97%) patients received an ileal conduit. The 90-d rate of Clavien-Dindo grade ≥IIIa complications was 28%. The late complication rate was 46% and the perioperative mortality rate was 0%. On univariate analyses, ACCI was the only parameter correlated with the risk of early complications (odds ratio 1.75, 95% confidence interval 1.05–2.9; p = 0.03). The median follow-up was 30 mo (IQR 15–40). The lack of comparison with open cystectomy represents the main limitation.
RAC for UAEs in patients with a history of pelvic irradiation is a feasible option in high-volume centers. The use of new technologies can help to overcome some of the technical difficulties and reduce the risk of perioperative and late complications.
We report our experience with robot-assisted surgery for removal of the bladder in the management of urinary problems after radiation therapy for prostate cancer. When performed by highly experienced surgeons, this is a feasible procedure with outcomes and early and late complication rates that are acceptable.
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Intracorporeal Urinary Diversion in Robotic Radical Cystectomy
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Average LOS has varied from 5 to 14 days, though most reports found medians in the 7-day to 9- day range.24,25,42–45 Median or mean lymph node yields range from 19 to 25 and positive surgical margin rates are 0% to 3.7%.24,25,28,40,45,46 An initial series from the Karolinska Institute of 36 patients receiving ICN demonstrated continence rates of 97% and 83% for daytime and nighttime, respectively with a mean follow-up time of 25 months.28
Totally intracorporeal robot-assisted urinary diversion for bladder cancer (Part 1). Review and detailed characterization of ileal conduit and modified Indiana pouch
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¹: The authors are joint first author.

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Surgery in MotionRobot-assisted Radical Cystectomy: Description of an Evolved Approach to Radical Cystectomy

Abstract

Background

Objective

Design, setting, and participants

Surgical procedure

Outcome measurements and statistical analysis

Results and limitations

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Urol Oncol

Eur Urol

Eur Urol

J Urol

Eur Urol

Eur Urol

J Urol

Clin Genitourin Cancer

Urology

Eur Urol

Eur Urol

Eur Urol

Eur Urol

J Urol

Eur Urol

Surgery in Motion
Robot-assisted Radical Cystectomy: Description of an Evolved Approach to Radical Cystectomy