Minimally invasive techniques in radical cystectomy
Open radical cystectomy (ORC) is the current gold-standard treatment for MIBC and for high-risk recurrent NMIBC. Ideally, all patients with MIBC should receive platinum-based neo-adjuvant chemotherapy [
38,
39]. ORC has a peri-operative complication rate of 25 to 62% [
40]. Therefore, minimally invasive techniques in radical cystectomy have been explored.
The majority of the existing data comprises cohort studies. The advantages of laparoscopic radical cystectomy (LRC) include decreased blood loss, reduced postoperative pain, early return of bowel function, and shorter hospital stay [
6,
41]. However, the data should be interpreted with caution, given the problem of selection bias in most series. Overall, current evidence suggests that LRC has good early oncologic outcomes with low morbidity in large cohorts with up to 5 years follow-up [
42]. Nevertheless, LRC is considered an advanced laparoscopic procedure, because it has multiple difficult steps and fewer degrees of freedom of movement compared with ORC.
In 2001, the da Vinci
® robot (Intuitive Surgical Inc., CA, USA) was introduced as an innovative system for minimally invasive surgery. The view of the operative field is improved by binocular three-dimensional high-definition endoscopic vision. 'Endowrists' on the tip of each instrument can reproduce the movements of the human hand. A small RCT by Nix
et al. of robot-assisted radical cystectomy (RARC) versus ORC showed that RARC produced a reduction in operative blood loss, time for return of bowel function, and analgesic requirements, compared with ORC, with equivalent lymph-node (LN) yields [
7]. A prospective cohort study showed fewer major complication rates at 30 and 90 days post- RARC compared with ORC [
43]. The short-term outcomes of RARC are promising, with an OS rate of 70 to 90% during 2 to 3 years of follow-up [
44‐
47]. The International Robotic Cystectomy Consortium comprises 18 institutions, which have reported comparable rates to ORC for LN yields and positive surgical margin rates [
48,
49]. To date, 1,200 cystectomies have been recorded on their collaborative database [
50].
Most urologists performing LRC or RARC advocate performing the cystectomy and LN dissection intracorporeally, with subsequent extracorporeal urinary diversion via a lower midline incision. Increasing experience has enabled intra-corporeal reconstruction of urinary diversion, whether this be by ileal conduit or orthotopic neobladder formation. Clearly, the learning curve is steep. Operative times are longer, although patients have lower inpatient narcotic requirements and comparable short-term clinical outcomes to extra-corporeal diversion [
51‐
53].
However, there is a distinct lack of RCTs comparing RARC with ORC. Several that are currently under way, including the randomized CORAL (Randomised Control Trial of Open, Robotic and Laparoscopic Radical Cystectomy) trial [
54], a trial in the University of Texas Health Science Centre, USA (Open Versus Robotic-Assisted Radical Cystectomy: A Randomised Trial) [
55], and the BOLERO (Bladder Cancer: Open Versus Laparoscopic or Robotic Cystectomy) trial at Cardiff University, UK [
56]. The long-term outcomes of the first cohort of patients who underwent RARC should be available in the next 1 to 2 years.
Bladder preservation
Strategies for bladder preservation have also been investigated. A phase III trial of chemotherapy (fluorouracil plus mitomycin) combined with radiotherapy was shown to improve the 2-year DFS rate compared with radiotherapy alone, and it also decreased the salvage cystectomy rate, with good long-term bladder function [
8]. Long-term data from Massachusetts General Hospital, USA, has shown that combined multi-modal therapy in the form of concurrent cisplatin-based chemotherapy and radiotherapy after maximal TURBT achieves complete response and preserves the native bladder in more than 70% of patients, while offering long-term survival rates comparable with contemporary cystectomy series [
57]. However, a number of different protocols were used in this centre, and so the optimal therapy regimen is still uncertain. However, these studies suggest that this approach could be a real alternative to radical surgery in select patients with muscle-invasive disease.