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NARUS 2018: Development of a robotic cystectomy program

Las Vegas, NV (UroToday.com) Dr. Delworth gave an overview on the creating of a robotic urologic cystectomy program. Despite the fact that this is time consuming, with low reimbursement, a high learning curve and significant bowel work, there are still several reasons why such a program needs to be developed. This includes the fact that it is a challenging project, providing a unique service, and most importantly, expanding lifesaving surgery to a population that would not have had access to it.

In order to develop a robotic cystectomy program there are certain must haves:

  1. The surgeon must be proficient
  2. There must be a proficient interventional radiology unit
  3. Good general surgery support
  4. Engaged team
  5. Support including residents/fellows/partners, hospitalists and medical specialists.
It would be most helpful if the hospital also has an Xi robot with advanced instrumentation (including stapler, vessel sealer, firefly, and air-seal), routine utilization of ERAS protocol, and a surgical home.

Additionally, it is important to have guardrails, such as when to convert to open surgery (blood loss of over 1000 cc), dogmatic positioning, be strict with your oncological outcomes, make sure anesthesia prevents hypercarbia from developing, and have a timeline of different steps of the procedure (2 hours for bladder removal, 2 hours for lymphadenectomy, reconstruction 2-4 hours).

It is prudent to watch for challenging cases and make sure there are not the first cases you operate on. These include high BMI, T4 disease, hostile abdomen, prior radiation, coexisting ostomy, prior bladder perforation, and history of extensive BCG therapy.

In summary, in the first steps of creating a robotic cystectomy program, make sure that you are a proficient surgeon, do your first cases with extracorporeal diversion, avoid difficult patients, setup guardrails, track your data, and make sure you get support from your hospital.

Speaker: Mark G. Delworth, Cincinnati, Ohio, USA

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV