Robotic cross-folded U-configuration intracorporeal ileal neobladder for muscle-invasive bladder cancer: Initial experience and functional outcomes

The incidence and risk factor for febrile urinary tract infection after robot-assisted laparoscopic radical cystectomy in bladder cancer patients

INTRODUCTION

Febrile urinary tract infections are major complications of radical cystectomy; however, their characteristics after robot-assisted radical cystectomy remain unclear. Thus, we investigated the rate, severity, pathogens, and risk factors of febrile urinary tract infections after robot-assisted radical cystectomy.

PATIENTS AND METHODS

Patients who underwent robot-assisted radical cystectomy at three institutions between April 2018 and March 2022 were retrospectively analyzed. The febrile urinary tract infections occurring within 90 days of surgery were evaluated.

RESULTS

Overall, 191 patients were included. Of the 157 patients with ileal urinary diversions, 138 and 19 received ileal conduit and ileal neobladder, respectively; 42 febrile urinary tract infections were observed in 36 patients (22.9 %). Of the 32 patients who underwent cutaneous ureterostomy, four patients had febrile urinary tract infections (12.5 %). The incidence of postoperative febrile urinary tract infections was significantly higher in patients with ileal neobladder (52.9 %) than in those with an ileal conduit (18.8 %) (p < 0.05, log-rank test). Gram-positive strains were the dominant pathogen (60.0 %), followed by gram-negative strains (37.1 %) and fungi (2.9 %). The blood culture was positive in 28.6 % for febrile urinary tract infections. The primarily isolated strains were Enterococcus faecalis, Staphylococcus aureus, and Staphylococcus epidermidis, Escherichia coli and Pseudomonas aeruginosa. Female was the only risk factor for febrile urinary tract infections in those with an ileal conduit.

CONCLUSIONS

Gram-positive strains account for 60 % of pathogens causing febrile urinary tract infections after robot-assisted radical cystectomy, that may cause severe complications, rendering management of febrile urinary tract infections paramount.

Postoperative complications and determinant of selecting non intracorporeal urinary diversion in patients undergoing robot-assisted radical cystectomy: an initial experience

Background

Robot-assisted radical cystectomy (RARC) with urinary diversion has become a standard surgical procedure because of its three-dimensional high-definition surgical field of view, flexibility, and stability. However, because of the highly complex steps of surgery, postoperative complications cannot be ignored.

Methods

This retrospective, single-center, observational cohort study investigated the postoperative complications following RARC at a non-high-volume center in Japan. From August 2019 to March 2023, 50 consecutive patients who underwent RARC for histologically proven muscle-invasive bladder cancer (MIBC) or high-risk non-MIBC with an indication for radical cystectomy according to the Japanese Urological Association Guideline 2019 were included. Factors correlated with the selection of extracorporeal urinary diversion (ECUD) or cutaneous ureterostomy rather than intracorporeal urinary diversion (ICUD) for urinary diversion were also investigated.

Results

In total, 33 (66%) and 31 (62%) patients experienced complications during the first 90 and 30 days after RARC, respectively. Among them, 19 (38%) and 18 (36%) patients developed Clavien-Dindo classification G2 complications, and 12 (24%) and 11 (22%) developed G3 or higher (major) complications during the first 90 and 30 days after RARC, respectively. The most common complications were gastrointestinal complications (26%) and urinary tract infections (22%). Nine patients (18%) underwent surgical intervention within 90 days of undergoing RARC. Higher infusion volume during the operations was significantly correlated with the occurrence of major complications within 90 days (P=0.025) and 30 days (P=0.0158) after RARC. Nineteen patients (38%) underwent non-ICUD. Twelve patients received ECUD as an ileal conduit or neobladder, and among them, three patients received ECUD due to intraabdominal adhesion for previous abdominal surgery or radiation, while four patients received ECUD ileal conduit due to comorbidities and advanced cases (palliative surgery) to shorten the surgery time.

Conclusions

Surgical complications related to the initial experience with RARC at a non-high-volume center in Japan cannot be ignored. Although this complicated surgical procedure requires a learning curve to achieve a stable rate of much fewer major complications after RARC, careful assessment of patients' status before surgery and critical postoperative management may reduce complication rates more quickly, even at non-high-volume centers.

Utility and safety of robot-assisted radical cystectomy in older patients with bladder cancer

Introduction: This study aimed to investigate the efficacy and safety of robot-assisted radical cystectomy (RARC) in older patients with bladder cancer (BCa).Material and methods: We reviewed the clinical and pathological records of 110 patients with BCa who underwent RARC at Gifu University Hospital between February 2019 and January 2023. Older patients were defined as those with BCa aged ≥ 75 years. The enrolled patients were divided into two groups: those aged < 75 years (Group I) and those aged ≥ 75 years (Group II). Oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS), were the primary endpoints of the study; the secondary endpoints were the surgical and pathological outcomes.Results: A shorter console time, less blood loss, and reduced time to postoperative fluid and food intake in Group II may be attributed to the fact that more patients opted for ureterocutaneostomy in Group II than in Group I. In all patients, the three-year OS and RFS rates were 84.7% and 88.5%, respectively. There were no significant differences in OS or RFS between the two groups. (p = .403, p = .963, respectively).Conclusions: RARC appears to be a safe and useful treatment option for older patients with BCa.

Robot-Assisted Radical Cystectomy with Modified Vesica Ileale Padovana (VIP) Neobladder Configuration Using a Hybrid Approach: Initial Experience

PURPOSE

We developed a new technique to fold a neobladder (NB) simply by using a modified Vesica Ileale Padovana (VIP) with a hybrid approach. We provide a step-by-step description of our technique as it was used in this initial experience.

METHODS

A total of 10 male patients with a median age of 66 years underwent robot-assisted radical cystectomy (RARC) with an orthotopic NB via a hybrid approach from March 2022 to February 2023. After the isolation of the bladder and bilateral pelvic lymphadenectomy, Wallace plate creation was performed, and the robot was undocked. We extracorporeally performed the removal of the specimen and a side-to-side ileoileal anastomosis, and then the VIP NB posterior plate was rotated 90 degrees counterclockwise using a 45 cm detubularized ileum. The robot was redocked; then, circumferential urethra-ileal anastomosis, side-to-middle anterior wall closure, and ureteric afferent limb anastomosis were performed.

RESULTS

The median estimated blood loss was 524 mL, and the mean operative time was 496 min. Patients had a high continence rate, and no high-grade complications were observed.

CONCLUSION

The NB configuration using the modified VIP method for a hybrid approach is a feasible surgical technique to minimize the movement of robotic forceps. In particular, it may be more useful in Asian individuals with narrow pelvises.

"Bordeaux Neobladder": First Evaluation of the Urodynamic Outcomes

Background

The intracorporeal orthotopic modified-Y "Bordeaux" neobladder (iYNB) was first described in 2016. No urodynamic evaluation of this neobladder has yet been performed.

Objective

To present the urodynamic features of the iYNB and incontinence-specific health-related quality of life (HRQoL) outcomes.

Design setting and participants

We prospectively assessed 26 patients operated between September 2018 and November 2020.

Surgical procedure

Robotic radical cystectomy for malignant disease of the bladder and iYNB, performed by a single surgeon, were used.

Measurements

Three months after surgery and in November 2021, consenting patients underwent clinical evaluation and multichannel urodynamic study (UDS). The incontinence quality of life (I-QoL) questionnaire was used to evaluate HRQoL. Continence was classified into day- and nighttime, and clinically defined as the use of zero pads. A descriptive statistical analysis was performed.

Results and limitations

The mean age at surgery was 65.4 yr. The mean follow-up period was 27 mo (12-38). The mean time for the neobladder reconstruction was 192 min (110-340). The mean maximum capacity was 431 cm3 (range 200-553). The mean postvoid residual was 101.6 ml (0-310), and the rate of clean intermittent catheterization was 17.6%. With the exception of a significant reduction in the volume of the first sensation of bladder fullness, no other statistically significant changes in the UDS parameters of both the storage and the voiding phase were observed over time. Day- and nighttime continence rates were 58.8% and 23.5%, respectively. The mean postoperative I-QoL score was 103.3 (89-110). Limitations include the small number of patients and short follow-up.

Conclusions

The UDS evaluation of iYNB demonstrates that both the volumetric and the pressure characteristics are acceptable and may enhance quality of life. Prospective studies with larger numbers of patients and longer follow-up are needed to further evaluate the iYNB.

Patient summary

The "Bordeaux" neobladder provides acceptable urodynamic outcomes. It is associated with high levels of health-related quality of life and good rates of continence in patients.

Efficacy and Safety of the "Trisection Method" Training System for Robot-Assisted Radical Cystectomy at a Single Institution in Japan

To maintain a surgeon's concentration, reduce fatigue, and train young surgeons, surgical procedures for bladder cancer are divided into the following parts: robot-assisted radical cystectomy (RARC), bowel reconstruction, and totally intracorporeal urinary diversion (ICUD) (RARC+ICUD). Each part is performed by a different surgeon (Trisection method). We retrospectively evaluated the efficacy and safety of this approach at a single institution in Japan. One hundred consecutive patients who underwent RARC+ICUD at Gifu University Hospital between November 2018 and August 2022 were included in this study. The patient background, surgical outcomes, and postoperative complications were compared between surgeries by first-, second-, and third-generation surgeons. The overall survival (OS) and recurrence-free survival (RFS) were compared between surgeries by each generation. Of the 100 patients, 19, 38, and 43 RARCs were performed by first-, second-, and third-generation surgeons, respectively. There were 35, 25, and 39 patients who underwent ileal conduit, neobladder, and ureterocutaneostomy, respectively. No significant differences were found among the patients respective to the type of ICUDs. Although the first-generation surgeon had a significantly shorter operative time with RARC, the surgical time for bowel reconstruction, length of hospital stays, and incidence of postoperative complications were not significantly different among the groups. Additionally, OS and RFS did not differ significantly among the generations. The "Trisection method" is an effective and safe concept with no difference in outcomes between the generations of surgeons.

Urodynamic assessment and quality of life outcomes of robot-assisted totally intracorporeal radical cystectomy and orthotopic neobladder for bladder cancer: a preliminary study

PURPOSE

Few data exist regarding the functional outcomes of robot-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder. The aim of this study was to evaluate the urodynamic and functional outcomes in patients undergoing RARC and totally intracorporeal orthotopic neobladder for bladder cancer.

METHODS

In this monocentric, observational study carried out between 2016 and 2020, consecutive patients undergoing RARC and intracorporeal orthotopic neobladder in the Department of Urology, Pitié-Salpêtrière Hospital, were included. Reconstruction was totally intracorporeal Y-shaped neobladder. Main outcomes were urodynamic findings 6 months post-surgery, continence and quality of life (QoL). Continence was defined by no pad or one safety pad. International Consultation on Incontinence Questionnaire (ICIQ), International Index of Erectile Function questionnaire (IIEF-5) and Bladder Cancer Index (BCI) scores were recorded.

RESULTS

Fourteen male patients were included (median age: 64 years [IQR 54-67]. Median maximal neobladder cystometric capacity was 495 ml [IQR 410-606] and median compliance was 35.5 ml/cm H₂O [IQR 28-62]. All patients had post-void residual volume < 30 ml, except for three (22%) who required clean intermittent-self catheterisation. Daytime continence was achieved in 10 patients (71%) and night-time continence in two (14.3%). Median ICIQ score was 7 [IQR 5-11]. Postoperative erectile function was present in 7% of patients (mean IIEF-5 = 5 [IQR 2-7]). Thirteen patients (93%) were satisfied with their choice of neobladder.

CONCLUSION

RARC with totally intracorporeal orthotopic neobladder for bladder cancer provides satisfactory urodynamic results and good QoL. These findings should be confirmed long-term.

Predicting perioperative outcomes of robot-assisted radical cystectomy: Data from the Asian Robot-Assisted Radical Cystectomy Consortium

OBJECTIVES

To report the perioperative outcomes of robot-assisted radical cystectomy and elucidate their risk factors.

METHODS

A review of the Asian Robot-Assisted Radical Cystectomy Consortium database from 2007 to 2020 was performed. The perioperative outcomes studied included complication rates, time to solid food intake, estimated blood loss, length of hospital stay, and 30-day readmission rates.

RESULTS

Of 568 patients, the overall complication rate was 49.2%, comprising major complications in 15.6%. Preoperative hydronephrosis was associated with an increased risk of major complications (odds ratio 3.27, 95% confidence interval 1.48-7.26, P = 0.004) while neoadjuvant chemotherapy was protective (odds ratio 0.46, 95% confidence interval 0.25-0.84, P = 0.012). The median time to solid food intake was 4 days (interquartile range 3-7) and smoking was a risk factor (odds ratio 4.28, 95% confidence interval 2.36-7.79, P < 0.001) for prolonged time to solid food intake. Median length of hospital stay was 13 days (interquartile range 9-19), and diabetes mellitus (odds ratio 1.66, 95% confidence interval 1.08-2.56, P = 0.021), neoadjuvant chemotherapy (odds ratio 2.21, 95% confidence interval 1.46-3.33, P < 0.001), and orthotopic bladder substitute creation (odds ratio 2.82, 95% confidence interval 1.90-4.18, P < 0.001) were independent risk factors for prolonged length of hospital stay. The 30-day readmission rate was 23.4% and higher in those with bilateral hydronephrosis (odds ratio 4.58, 95% confidence interval 1.97-10.65, P < 0.001) and orthotopic bladder substitute creation (odds ratio 1.87, 95% confidence interval 1.16-3.02, P = 0.010).

CONCLUSIONS

There are preoperative conditions which are significant risk factors for adverse perioperative outcomes in robot-assisted radical cystectomy. Most are potentially modifiable and can direct strategies to reduce surgical morbidity related to this major oncological procedure.

Robot-assisted-radical-cystectomy with total intracorporeal Y neobladder: Analysis of postoperative complications and functional outcomes with urodynamics findings

OBJECTIVES

To describe our robotic Y intracorporeal neobladder (ICNB) technique and to report its post-operative complications and urodynamics (UD) findings.

SUBJECTS

and Methods: In this prospective study we enrolled patients affected by MIBC (T1-T4N0-N1M0) from 01/2017 to 06/2021 at our Centers. All the patients underwent robotic radical cystectomy (RARC) with Y-ICNB reconfiguration. Early and late complications were collected and classified according to Clavien-Dindo. Continence and potency at 1, 3, 6 and 12 months were evaluated. At the 3rd month of follow-up patients underwent UD. Finally, in a retrospective match paired analysis the functional outcomes of Y RARC patients were compared with a cohort of open Y radical cystectomy.

RESULTS

45 patients were enrolled. Overall 30-day complications were observed in 25 (55,5%) patients and 30 to 90-days complications in 4 (8,9%). 9 patients (20%) had Clavien ≥3 complications. UDs revealed median neobladder capacity of 268 cc, with a median compliance of 13 ml/cm H20; the voiding phase showed a voiding volume and a post void residual (PVR) of 154 cc and 105 cc respectively. At 12 months of follow-up 4.4%, 15.5% and 4.4% of the patients experienced urge, stress and mix urinary incontinence respectively. The comparison between Y RARC and Y open RC revealed a higher neobladder capacity with open approach (p = 0.049) with subsequent better findings during the voiding phase in terms of maximum flow (p = 0.002), voiding volume (p = 0.001) and PVR (p = 0.01). Focusing on continence recovery, a slight trend in favor of RARC was shown without reaching the statistical significance.

CONCLUSIONS

Robotic Y-ICNB is feasible and safe as shown by the low rate of postoperative complications. Satisfying UD functional outcomes are achievable, both during filling and voiding phase.

Robot-Assisted Intracorporeal Orthotopic Ileal Neobladder: Description of the "Shell" Technique

Background: Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder (ICNB) remains a very complicated, technically demanding and time-consuming surgical procedure. In the current study we describe our robot-assisted intracorporeal “Shell” neobladder reconstruction. Methods: From January 2017 to December 2019, we performed 30 intracorporeal ileal neobladder “Shell” reconstructions. We prospectively collected demographics and clinical and pathological data and retrospectively analysed perioperative, functional and oncological outcomes. Results: No conversion to open surgery or intraoperative blood transfusion was necessary. The median whole operative time was 493 min (IQR 433–530 min), ranging from 514 min (IQR 502–554 min) recorded during the first ten procedures to 470 min (IQR 442–503 min) of the last ten. The median estimated blood loss was 400 mL (IQR 350–700 mL). The median length of stay was 11 days (IQR 10–17). Both early and late complication rates were 46.7%. The high-grade early complication rate accounted for 20%, while the high-grade late complication rate was 30%. The daytime continence rate registered was 73.3%, while night-time continence rate was 60%. Conclusions: Our results demonstrated “Shell” neobladder reconstruction as a technically feasible procedure, with good functional outcomes in tertiary referral centre. Longer follow-up and larger populations are needed to validate these preliminary results.

Intracorporeal versus extracorporeal urinary diversion following robot-assisted radical cystectomy: a meta-analysis, cumulative analysis, and systematic review

Over the last decade, the increased utilization of robot-assisted radical cystectomy (RARC) in the surgical treatment of muscle-invasive bladder cancer has led to an uptrend in intracorporeal urinary diversions (ICUD). However, the operative results comparing ICUD to extracorporeal urinary diversion (ECUD) have varied widely. We performed a meta-analysis to analyze perioperative outcomes and complications of ICUD compared to ECUD following RARC. This study is registered at International Prospective Register of Systematic Reviews (PROSPERO) CRD42020164074. A systematic literature review was conducted using PubMed, EMBASE, and Cochrane databases in August 2019. A total of six studies comparing ICUD vs ECUD were identified and meta-analysis was conducted on these studies. In addition, a cumulative analysis was also performed on 83 studies that reported perioperative outcomes after RARC and ICUD or ECUD. The Weighed Mean Difference of operative time and blood loss between ICUD and ECUD group was (16; 95% confidence interval - 34 to 66) and (- 86; 95% confidence interval - 124 to - 48), respectively. ICUD and ECUD had comparable early (30-day) and mid-term (30-90-day) complication rate (RR 1.19; 95% confidence interval 0.71-2.0; p = 0.5) and (RR 0.91; 95% confidence interval 0.71-1.15 p = 0.4) respectively. In the 83 studies that were included in the cumulative analysis, the mean operative time for ileal conduit and neobladders by ICUD were 307 and 428 min, respectively, compared to ECUD 428 and 426 min, respectively. ICUD and ECUD have comparable short- and mid-term complication rate. The ICUD group has lower blood loss and lower rate of blood transfusion compared to ECUD.

Long-term chronological changes in urination status of patients who underwent ileal neobladder reconstruction at a single institution

PURPOSE

This study aimed to investigate the long-term chronological changes in urination status of patients who underwent radical cystectomy (RC) followed by orthotopic ileal neobladder (ONB) reconstruction using the International Prostatic Symptoms Score (IPSS) and the Overactive Bladder Symptoms Score (OABSS).

METHODS

This retrospective study focused on patients who underwent RC followed by ONB reconstruction and those who consented for IPSS, quality of life (QOL) based on urinary symptoms (IPSS-QOL), and OABSS assessments in the follow-up period. The patients were divided according to gender into the male group (M-group) and female group (F-group). All patients were evaluated using IPSS, IPSS-QOL, and OABSS every 3 months. The primary endpoint was to assess chronological changes in the urination status of patients who underwent ONB reconstruction after RC.

RESULTS

The median age of the enrolled patients (n = 122) was 65 years and the median follow-up period was 92.0 months. The median voiding symptom score in IPSS after 10 years of surgery was significantly higher in the M-group than in the F-group. Contrarily, the F-group demonstrated a significantly higher median storage symptom score at 60-66 and 102-114 months than the M-group. The median OABSS scores were relatively higher in the F-group than in the M-group.

CONCLUSIONS

Although long-term urinary function with ONB demonstrated acceptable results, dysfunctional voiding was observed > 10 years after surgery. Thus, the changes in long-term urinary function should be considered when deciding ONB.

The Utility and Efficacy of Laparoscopic Radical Cystectomy in Patients with Muscle-Invasive Bladder Cancer at a Single Institution

BACKGROUND

The aim of this study was to compare the surgical and oncological outcomes and complications of laparoscopic radical cystectomy (LRC) to those of open radical cystectomy (ORC) in patients with muscle-invasive bladder cancer (MIBC).

METHODS

Our study focused on patients with histologically confirmed stage T2-T4a urothelial carcinoma of the bladder without distant metastases, who underwent LRC (LRC group) or ORC (ORC group). The primary endpoints in this study were the overall survival (OS) and recurrence-free survival (RFS) rates.

RESULTS

In this study, 59 patients, 17 underwent LRC and 42 underwent ORC, were enrolled. The 2-year OS rate was 100% in the LRC group and 88.0% in the ORC group (p = 0.85). The 2-year RFS rate was 63.5% in the LRC group and 69.5% in the ORC group (p = 0.321). On multivariate analysis, the histological type, positive lymph node, and positive resection margin were significantly associated with the OS rates.

CONCLUSIONS

This study suggested that LRC may achieve similar oncological outcomes and fewer perioperative complications and less blood loss compared to ORC. Therefore, LRC should be considered as one of the treatment options for patients with MIBC.

Totally intracorporeal robot-assisted urinary diversion for bladder cancer (part 2). Review and detailed characterization of the existing intracorporeal orthotopic ileal neobladder

Abstract

To review the most used intracorporeal orthotopic ileal neobladder (ICONB) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new consistent images.

Methods

We performed a non-systematic review of the literature with the keywords “bladder cancer”, “urinary diversion”, “radical cystectomy”, and “neobladder”.

Results

Forty studies were included in the analysis. The most frequent type of ICONB was the modified Studer “U” neobladder (70%) followed by the Hautmann “W” modified neobladder (7.5%), the “Y” neobladder (5%), and the Padua neobladder (5%). The operative time to perform a urinary diversion ranged from 124 to 553 min. The total estimated blood loss ranged from 200 to 900 mL. The rate of positive surgical margins ranged from 0% to 8.1%. Early minor and major complication rates ranged from 0% to 100% and from 0% to 33%, respectively. Late minor and major complication rates ranged from 0% to 70% and from 0% to 25%, respectively.

Conclusion

The most frequent types of ICONB are Studer “U” neobladder, Hautmann “W” neobladder, “Y” neobladder, and the Padua neobladder. Randomized studies comparing the performance of the different types of ICONB, the performance in an intra or extracorporeal manner, or the performance of an ICONB versus ICIC are lacking in the literature. To this day, there are not sufficient quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used ICONB with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images of each technique.

Robot-assisted intracorporeal orthotopic bladder substitution after radical cystectomy: perioperative morbidity and oncological outcomes - a single-institution experience

OBJECTIVE

To report a single-institution experience with totally intracorporeal neobladder urinary diversion (UD) after robot-assisted laparoscopic radical cystectomy (RARC).

PATIENTS AND METHODS

A total of 158 patients underwent totally intracorporeal neobladder UD after RARC between 2003 and 2016. Patient demographics, intraoperative and pathological data, 30- and 90-day perioperative mortality and complications were recorded. Complications were classified according to the modified Clavien-Dindo classification. The 5-year overall (OS) and cancer-specific survival (CSS) rates were estimated by Kaplan-Meier plots.

RESULTS

Most of the patients were male (84%) and had clinical T Stage ≤2 (87%). The mean operation time was 359 (SD ±98) min, with a median (range) estimated blood loss of 300 (50-2200) mL. Most of the men (86%) received a nerve-sparing procedure and 38% of the females an organ-sparing approach. A lymph node dissection was performed in 156 (99%) patients, with a median (range) yield of 23 (7-48) nodes. Conversion to open surgery occurred in five patients (3%). We recorded negative margins in 156 patients (99%). The median (range) follow-up was 34 (1-170) months, with 30- and 90-day mortality rates of 0%. Clavien-Dindo Grade III-IV complications occurred in 29 of 158 (18%) patients at 30-days and in eight of 158 (5%) between 30-90 days, resulting into a 90-day overall high-grade complication rate of 23%. The unadjusted estimated 5-years recurrence-free survival, CSS and OS rates were 70%, 72%, and 71%, respectively.

CONCLUSION

In our present series the complication and oncological results were similar to open RC series, suggesting that RARC followed by totally intracorporeal neobladder UD is a safe and feasible alternative.

Current status and future perspective of robot-assisted radical cystectomy for invasive bladder cancer

The current status of robot-assisted radical cystectomy was reviewed 16 years after the initial robot-assisted radical cystectomy for the treatment of invasive bladder cancer. Articles associated with robot-assisted radical cystectomy and written in English were selected from the PubMed database from January 2003 to February 2019. The present review article focused on the distribution of robot-assisted radical cystectomy, patient selection, preoperative management, surgical technique, lymph node dissection, urinary diversion, recurrence pattern, oncological outcomes, cost, learning curve, complications and educational programs. A total of 400 articles were divided according to the country of the first author's affiliation. The USA was the most dominant at 198 (50%), whereas the number of articles from the countries belonging to the Urological Association of Asia was 15 (3.8%) for China, 17 (4.3%) for South Korea, 10 (2.5%) for Japan, eight (2%) for Taiwan, eight (2%) for Turkey and one (0.2%) for Iran. The percentage of robot-assisted radical cystectomy carried out is increasing, and intracorporeal urinary diversion and ileal neobladder are also frequently carried out. With a refined technique being performed in high-volume centers, robot-assisted radical cystectomy has contributed to the reduction in transfusion rate, length of stay and severe complications; however, it has not yet shown any cancer-specific survival benefits. Robot-assisted radical cystectomy is not fully spread throughout the Urological Association of Asia. Further investigation with respect to worldwide results is needed to prove the real benefit of robot-assisted radical cystectomy regarding low morbidity, reduced total medical cost, and survival benefit. In the era of precision medicine, appropriate drug and surgery will be given based on each genetic profile.

Robot-assisted radical cystectomy in a patient with muscle-invasive bladder cancer following radiotherapy for prostate cancer

INTRODUCTION

Muscle-invasive bladder cancer following radiotherapy for prostate cancer is rare. We reported a case of muscle-invasive bladder cancer who underwent robot-assisted radical cystectomy following radiotherapy for prostate cancer.

CASE PRESENTATION

A 72-year-old man was referred to our division with a muscle-invasive bladder cancer. He had a history of intensity-modulated radiation therapy for localized prostate cancer. After three courses of platinum-based neoadjuvant chemotherapy, he obtained a radiologic complete response. He elected for robot-assisted radical cystectomy, standard lymph node dissection, and intracorporeal ileal conduit urinary diversion. Pathological findings revealed no residual tumor within the bladder and residual tumor in the prostate. He had discharged without any complications; and quality of life had improved.

CONCLUSION

A robot-assisted approach might be a potential option for well-selected patients with muscle-invasive bladder cancer who have previously received radiotherapy for localized prostate cancer.

Current role of robotic bladder cancer surgery

INTRODUCTION

Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in urology, that is not devoid of postoperative complications. Minimally invasive surgery, and especially robot-assisted RC (RARC) has emerged as an alternative to open RC (ORC) in an attempt to minimize surgical morbidity and facilitate the surgical approach. The aim of this paper was to present the current knowledge on the oncological efficacy and complication outcomes of RARC.

EVIDENCE ACQUISITION

A non-systematic review on all relevant studies with the keywords "Radical cystectomy," "Open," "Robot-assisted," "Complications," "Recurrence," "Survival," "Neobladder," "Potency," "Continence" and "Intracorporeal" was performed using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) Guidelines.

EVIDENCE SYNTHESIS

RARC shows similar lymph node yields and positive surgical margin rates as well as perioperative complication outcomes compared with ORC. RARC exhibits significantly less blood loss and less intra- and postoperative blood transfusion. Moreover, survival and recurrence rates are not related to the surgical approach. Finally, RARC seems to be more expensive and has a longer operating time compared to the open technique.

CONCLUSIONS

As current evidence shows, RARC seems as a technically feasible and safe procedure, providing equivalent perioperative and oncological results compared to ORC. More prospective, randomized-controlled trials are necessary to draw definitive conclusions on all comparative aspects.

Utility of robot-assisted radical cystectomy with intracorporeal urinary diversion for muscle-invasive bladder cancer

Radical cystectomy remains the gold standard for treatment of muscle‐invasive bladder cancer. Robot‐assisted radical cystectomy has technical advantages over laparoscopic radical cystectomy and has emerged as an alternative to open radical cystectomy. Despite the advancements in robotic surgery, experience with total intracorporeal reconstruction of urinary diversion remains limited. Most surgeons have carried out the hybrid approach of robot‐assisted radical cystectomy and extracorporeal reconstruction of urinary diversion, as intracorporeal reconstruction of urinary diversion remains technically challenging. However, intracorporeal reconstruction of urinary diversion might potentially proffer additional benefits, such as decreased fluid loss, reduction in estimated blood loss and a quicker return of bowel function. The adoption of intracorporeal ileal neobladder reconstruction has hitherto been limited to high‐volume academic institutions. In the present review, we compare the totally intracorporeal robot‐assisted radical cystectomy approach with open radical cystectomy and robot‐assisted radical cystectomy + extracorporeal reconstruction of urinary diversion in muscle‐invasive bladder cancer patients.

Postoperative weight loss followed by radical cystectomy predicts poor prognosis in patients with muscle-invasive bladder cancer

We aimed to investigate the impact of postoperative weight loss following radical cystectomy (RC) on patients' prognoses. RC and urinary diversion were performed in 512 consecutive patients with muscle-invasive bladder cancer at our hospitals between May 1996 and July 2018. Demographic clinical information, pre- and postoperative serum albumin, hemoglobin, and weight were evaluated retrospectively at 1 month. We also evaluated the association of weight loss with complications and overall survival (OS) as estimated using the Kaplan-Meier method and compared using the log-rank test. Risk factors for poor OS were determined by Inverse Probability of Treatment Weighted (IPTW)-adjusted Cox regression analysis. In 385 patients who met the study search criteria, median postoperative weight loss from baseline at 1 week and 1 month was 1.1 (- 1.8%) and 3.2 (- 5.4%) kg, respectively. Patients with significant weight loss (defined as ≥ 7.5% at 1 month) had higher-grade complications within 1 month and had significantly shorter OS than those with weight loss of < 7.5%. Type of urinary diversion, loss of serum albumin, and loss of hemoglobin were not significantly associated with weight loss. IPTW-adjusted Cox regression analysis showed that such significant weight loss was an independent risk factor for poor OS. Weight loss followed by radical cystectomy was significantly associated with poor prognosis in patients with muscle-invasive bladder cancer.

Robotic cross-folded U-configuration intracorporeal ileal neobladder for muscle-invasive bladder cancer: Initial experience and functional outcomes

BACKGROUND

This study compared the surgical and urinary functional outcomes in patients with muscle-invasive bladder cancer (MIBC) who underwent robot-assisted radical cystectomy (RARC) followed by intracorporeal ileal neobladder reconstruction (ICNB) to those in patients who underwent minimum incision endoscopic radical cystectomy (MIE-RC) followed by extracorporeal ileal neobladder reconstruction (ECNB).

MATERIALS AND METHODS

This study reviewed the clinical records of 153 consecutive MIBC patients who underwent neoadjuvant chemotherapy followed by radical cystectomy and ileal neobladder reconstruction.

RESULTS

The operative time in the ICNB group was significantly longer than that in the ECNB group. The median estimated blood loss was significantly less in the ICNB group than in the ECNB group. The neobladder capacity gradually increased in both groups. The maximum neobladder pressure and urethral closure pressure gradually improved in both groups.

CONCLUSION

Our initial experience with ICNB was favourable, with acceptable surgical and urinary functional outcomes.