FOIU 2018: Robotic Assisted Radical Cystectomy

Tel-Aviv, Israel ( Alejandro Rodriguez, MD gave a presentation on the usage of robotic radical cystectomy. Although open radical cystectomy is the standard of care for muscle-invasive bladder cancer (MIBC) and some non-MIBC (NMIBC), it is still a procedure that is associated with high morbidity. Recent publications demonstrate a complication rate of 31.5%, with 40.7% requiring blood transfusions. The average length of stay decreased from 10.6 days to 9.2 days, but readmission increased to 21.4% in 2015. 1

Robotic-Assisted Radical Cystectomy (RARC) has increased in the USA since its first description in 2003. Currently, 28.9-39.4% of RC cases are performed robotically in contemporary studies. 2 In some select institutions, 100% of cases are performed robotically. 3 RARC has demonstrated similar oncological outcomes compared to open surgery with respect to:

  • Surgical margins 4
  • Number of lymph nodes resected 4
  • 5-year cancer specific and overall survival 5
  • Local and distant recurrences 6
Patients undergoing RARC have longer operating times, however, they have less estimated blood loss, a risk of blood transfusion, and length of hospital stay. 7

In a review comparing complications and health-related quality of life between open RC and RARC, 273 articles were analyzed, of which only 4 were randomized controlled trials, including 239 patients. Overall, no difference was noted in the 30 and 90-day complication rate, and overall grade 3-5 complications at 30- and 90 days. 8

Intra-corporeal urinary diversion has been demonstrated in retrospective studies to have less complication, including gastrointestinal (23% to 10%) and infectious (18% to 10%), and less readmission at 30 and 90-days (15% to 5%, and 19% to 12%, respectively). 9 This procedure can be done safely, and therefore, more institutions need to perform it and spread the surgical technique. 

Rodriguez moved on to discuss some technical aspects of the procedure.

  1. Patient positioning – the patient should be placed in steep Trendelenburg
  2. Periureteral and lateral pelvic space – always preserve the adventitia of the ureter, and clip the ureters to prevent urine spillage, prevent seeding of tumor cells, have an accurately estimated blood loss, and create ureteral dilatation to facilitate ureteral – intestinal anastomosis
  3. Pedicle control – Use articulating Endo GIA, and fulgurate and resect anterior bladder attachments (urachus)
  4. Ligate the dorsal vein complex with 0 vicryl in a CT 1 needle cut to 6 inches.
  5. Perform extended lymph node dissection
  6. Prevent injury to major mesenteric arcades with indocyanine green and white light transillumination.
Rodriguez concluded his talk by stating that RARC will continue to increase worldwide. The next generation of robotic surgeons will be comfortable in performing intracorporeal urinary diversions. More institutions will only use the robotic-assisted approach for performing radical cystectomies and urinary diversions.

1. Johnson SC et al. Urologic Oncology 2017
2. Bachman AG et al. Urology 2017
3. Brassetti A, et al. BJU Int 2017
4. Matulewicz rs, ET AL. Urol Oncol 2016
5. Raza SJ et al. Eur Urol 2015
6. Nguyen DP, et al. Eur Urol 2015
7. Xia L, et al. Plos One, 2015
8. Lauridsen SV. Et al. Systematic reviews, 2017
9. Dason S et al. Curr Opin Urol 2018

Presented by: Alejandro Rodriguez, MD, Watertown, New York, USA

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan  at the 2018 FOIU 4th Friends of Israel Urological Symposium, July 3-5. 2018, Tel-Aviv, Israel