SIU 2018: Robotic Assisted Radical Cystectomy: Present and Future

Seoul, South-Korea (UroToday.com) An encompassing overview of robotic radical cystectomy was given in this talk, by Dr. Rodriguez. Radical cystectomy remains the standard of care for muscle invasive bladder cancer and some types of non-muscle invasive bladder cancer. However, it is a procedure that still has significant morbidity, with transfusion required in 40% of the patients, complications endured by 31% of the patients, and readmission rates as high as 21%.1

The usage of robotic radical cystectomy has increased in the US since its first description in 2003. 2 According to contemporary studies, approximately 28.9%-39.4% of all cystectomies are currently performed robotically.3,4 Some institutions perform all cystectomies robotically.5 Robotic radical cystectomy has demonstrated similar oncological outcomes when compared to the open procedure with respect to surgical margins,6 number of lymph nodes resected6, 5-year cancer specific survival 7, and local and distant metastases.8 Patients undergoing robotic radical cystectomy have longer operating times, but have less estimated blood loss, less risk of blood transfusion, and less hospital length of stay.

In a meta-analysis of 4 randomized controlled trials with 239 patients, the complications rate and health related quality of life was compared between robotic and open cases.9 This found no difference in the 30-day complications, 90-day complications, overall grade 3-5 complications, and health related quality of life. However, in all these randomized controlled trials that were analyzed, the urinary diversion was extracorporeal. Therefore, the comparison was not purely of robotic vs. open cases, but more of different “open” cases.

Intracorporeal urinary diversion has demonstrated in retrospective studies to have less complications (Gastrointestinal 23% vs 10%, infectious 18% to 10%), and less readmissions at 30 days (15% to 5%) and 90 days (19% to 12%).10 In general, intracorporeal diversion is a safe procedure, and is gaining more attention from various institutions. 

In this next section, Dr. Rodriguez showed several videos of the procedure, and gave some important surgical hints. He began with the positioning of the patient. This should be done with the patient in the supine low lithotomy position, arms are tucked to the body, nasogastric tube is used only during the procedure. Next, the patient is placed in steep Trendelenburg position. Using the handheld camera, we fully visualize the full retraction of the bowel toward the upper abdomen. Reverse Trendelenburg is applied until bowel holds in the upper abdomen.

In the next phase, steps pertaining the ureter were discussed. It is critical to preserve the adventitia of the ureter, so that ischemia and strictures are prevented. Clipping the ureter before cutting it is also important for several reasons. First, it enables to dilate the ureter to make the anastomosis easier, it prevents urine spillage in the surgical field, and might prevent tumor seeding. It also enables to correctly calculate the estimated blood loss during the procedure.

Pedicle control is managed with articulating Endo GIA instruments for fast and safe pedicle dissection. The anterior bladder attachments are fulgurated and resected. The dorsal vein complex is ligated with a 0 vicryl in a CT 1 needle cut to 6 inches. This allows a quick dissection and removal of the bladder. If needed, nerve sparing can be performed at this stage as well, using hemolocks and meticulous dissection. Lastly, the urethra must be clipped before being cut. An extended pelvic lymph node dissection is performed like in open procedures, to maximize the oncological outcomes. The boundaries include that of the standard lymph node dissection, the common iliac vessels medial to the crossing of the ureters, and up to the region of aortic bifurcation.

When finally performing the urinary diversion, injury of major mesenteric arcades can be prevented using indocyanine green to better assess the vasculature, or with white light transillumination. Handling the bowel can be done with a special bowel grasper (graptor) or by using the Marionette technique, whereby the bowel is grasped using specifically placed stitches only.

Dr. Rodriguez concluded his talk, stating the robotic radical cystectomy is going to continue to grow worldwide, and intracorporeal diversion is going to get easier to be performed by the next generation of robotic surgeons. Robotic radical cystectomy will be attempted using the new single port system, with new approaches in the abdomen and perineum. The oncological results of the robotic radical cystectomy can be improved by complete knowledge of the pelvic anatomy, and by adhering to the oncological principles.

Presented by: Alejandro Rodriguez, United States 

References: 
  1. Johnson SC et al. Urologic Oncology 2017
  2. Menon M, et al. BJU Int 2003
  3. Bachman AG et al. Urology 2017
  4. Pak JS et al. Urology 2017
  5. Brassetti A et al. BJU Int  2017
  6. Matulewicz RS et al. Url Oncol 2016
  7. Raza SJ et al. Eur Urol 2015
  8. Nguyen DP ,et al Eur Urol 2015
  9. Lauridsen SV et al. Systematic Reviews 2017
  10. Ahmed K et al. Eur Urol 2014
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre  Twitter: @GoldbergHanan at the 38th Congress of the Society of International Urology - October 4- 7, 2018 - Seoul, South Korea
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