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Zennami K, Sumitomo M, Nukaya T, Takenaka M, Ichino M, Takahara K, Sasaki H, Kusaka M, Shiroki R. Impact of Urethra-Preserving Surgery During Radical Cystectomy: An Optimal Urethral Management in the Robotic Era. Clin Genitourin Cancer 2024:102146. [PMID: 39043553 DOI: 10.1016/j.clgc.2024.102146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/07/2024] [Accepted: 06/23/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVES The optimal indication and survival benefits of prophylactic urethrectomy (PU) during radical cystectomy remain unclear. Therefore, this study aims to evaluate the impact of urethra-preserving surgery (UPS) on oncological outcome including its recurrence patterns, and to establish an optimal urethral management strategy with a novel UPS technique in the robotic era. PATIENTS AND METHODS We retrospectively analyzed 281 male patients with bladder cancer who received radical cystectomy (RC) (115 with and 166 without PU) at our institutions between 2010 and 2023. Subsequently, perioperative and oncological outcomes were assessed between propensity score-matched cohorts. RESULTS Urethral recurrence (UR) occurred in 5 patients (5/166, 3.0%), all of whom underwent open-RC. Three among those (1.8%) with concomitant metastasis were died of cancer. There were no statistically significant differences between the PU and UPS groups in urethral-recurrence free survival (urethral-RFS) (P = .14), local-RFS (P = .59) and overall survival (OS) (P = .84) in the entire cohort. However, the UPS group showed significantly worse urethral-RFS (P = .008), local-RFS (P = .005) and OS (P = .03) in patients with high-risk of UR. Analysis of recurrence patterns revealed that UPS in high-risk patients significantly increased local recurrence (25.8% vs. 5.0%, P = .02). Conversely, a novel robotic-UPS technique demonstrated significantly favorable perioperative outcomes, comparable local-RFS (P = .79) and OS (P = .16) without UR (0/134, 0%) when compared to robotic-PU. Robotic-UPS also exhibited significantly better local-RFS (P =.007) and OS (P < .001) than open-UPS. CONCLUSIONS UR-related death was rare and PU did not show a survival benefit for the entire cohort. However, inappropriate UPS in patients at high-risk of UR may increase local recurrence which might be responsible for poor survival after UPS rather than disease progression derived from UR. The robotic-UPS has the potential to reduce unnecessary PU, urethral and local recurrence without compromising survival.
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Affiliation(s)
- Kenji Zennami
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan.
| | - Makoto Sumitomo
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takuhisa Nukaya
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masashi Takenaka
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Manabu Ichino
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kiyoshi Takahara
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hitomi Sasaki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Mamoru Kusaka
- Department of Urology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Ryoichi Shiroki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
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Sowanthip D, Zennami K, Bejrananda T, Nukaya T, Takenaka M, Ichino M, Takahara K, Sasaki H, Kusaka M, Sumitomo M, Shiroki R. Older versus younger patients in robot-assisted radical cystectomy with intracorporeal ileal conduit comparing safety and clinical outcomes. Int J Urol 2024; 31:370-378. [PMID: 38180102 DOI: 10.1111/iju.15377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE To evaluate the safety and efficacy of robot-assisted radical cystectomy using an intracorporeal ileal conduit in older compared to younger patients. METHODS We retrospectively analyzed 122 patients who underwent robot-assisted radical cystectomy with an intracorporeal ileal conduit at Fujita Health University Hospital and Fujita Health University Okazaki Medical Center between 2012 and 2022. Patients were categorized into two groups: older (age ≥ 75 years; n = 53) and younger (age < 75 years; n = 69). Perioperative outcomes, complications, recurrence-free survival, cancer-specific survival, and overall survival were compared between the cohorts. RESULTS The groups had no significant differences in perioperative outcomes, such as estimated blood loss, operative time, and blood transfusion rate. However, hospital stay was longer in the older patients than in the younger group (19 vs. 16 days; p < 0.001). The 30-day minor and major complication rates were 33.3% and 13.0%, respectively, for the younger group and 50.9% and 9.4% for the older group (p = 0.11). Urinary tract infection and bowel ileus were the most common complications in both groups. No significant differences were observed in recurrence-free survival, cancer-specific survival, and overall survival between the groups (p = 0.58, p = 0.75, and p = 0.78), and subgroup analysis in ≥cT3 revealed the older group tended to have poorer cancer-specific survival and overall survival (p = 0.07 and p = 0.01). Multivariate analysis indicated that older age was not associated with high-grade complications and cancer-specific survival. CONCLUSIONS Robot-assisted radical cystectomy with an intracorporeal ileal conduit is a safe and effective treatment option for older patients.
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Affiliation(s)
- Dutsadee Sowanthip
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
- Division of Urology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, The Thai Red Cross Society, Bangkok, Thailand
| | - Kenji Zennami
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tanan Bejrananda
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
- Division of Urology, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Takuhisa Nukaya
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masashi Takenaka
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Manabu Ichino
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kiyoshi Takahara
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hitomi Sasaki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Mamoru Kusaka
- Department of Urology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Makoto Sumitomo
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Ryoichi Shiroki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
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Zennami K, Kusaka M, Tomozawa S, Toda F, Ito K, Kawai A, Nakamura W, Muto Y, Saruta M, Motonaga T, Takahara K, Sumitomo M, Shiroki R. Impact of an enhanced recovery protocol in frail patients after intracorporeal urinary diversion. BJU Int 2024. [PMID: 38500447 DOI: 10.1111/bju.16340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
OBJECTIVE To determine whether an enhanced recovery after surgery (ERAS) protocol enhances bowel recovery and reduces postoperative ileus (POI) in both non-frail and frail patients after robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC). PATIENTS AND METHODS This retrospective cohort study included 186 patients (104 with and 82 without ERAS) who underwent iRARC between 2012 and 2023. 'Frail' patients was defined as those with a low Geriatric-8 questionnaire score (≤13). The primary outcomes were postoperative bowel recovery and the incidence of POI. Secondary outcomes included length of stay (LOS), 30- and 90-day complications, 90-day readmission rate, and POI predictors. RESULTS The ERAS group exhibited a significantly shorter LOS, early bowel recovery, a lower POI rate, fewer 90-day high-grade complications, and fewer 90-day readmissions than the non-ERAS group in the entire cohort. Non-frail patients in the ERAS group had a lower rate of POI (7.1% vs. 22.1%; P = 0.008), whereas ERAS did not reduce POI in frail patients (44.1% vs. 36.6%; P = 0.50). In the multivariate analysis, ERAS was associated with a reduced risk of POI in both the entire cohort (odds ratio [OR] 0.39, P = 0.01) and in non-frail patients (OR 0.24, P = 0.01), whereas ERAS was not likely to reduce POI (OR 1.14, P = 0.70) in frail patients. Prehabilitation was identified as a favourable predictor of POI. CONCLUSIONS The ERAS protocol did not reduce POI in frail patients after iRARC, although it enhanced bowel recovery and reduced POI in non-frail patients. Prehabilitation for frail patients might reduce POI.
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Affiliation(s)
- Kenji Zennami
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Mamoru Kusaka
- Department of Urology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Shuhei Tomozawa
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Fumi Toda
- Department of Rehabilitation Medicine I, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kazuki Ito
- Department of Rehabilitation, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Akihiro Kawai
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Wataru Nakamura
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoshinari Muto
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masanobu Saruta
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tomonari Motonaga
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kiyoshi Takahara
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Makoto Sumitomo
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Ryoichi Shiroki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
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Fu S, Shi H, Fan Z, Li J, Luan T, Dong H, Wang J, Chen S, Zhang J, Wang J, Ding M, Wang H. Robot-assisted radical cystectomy with intracorporeal urinary diversion: an updated systematic review and meta-analysis of its differential effect on effectiveness and safety. Int J Surg 2024; 110:01279778-990000000-00948. [PMID: 38260944 PMCID: PMC11020008 DOI: 10.1097/js9.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/24/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion (iRARC) is increasingly being used in recent years. Whether iRARC offers advantages over open radical cystectomy (ORC) remains controversial. This study aimed to compare the difference of perioperative outcomes, oncological outcomes and complications between iRARC and ORC. METHODS The PubMed, Embase, Cochrane Library, Web of Science and CNKI databases were searched in July 2023 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement. Studies were identified to be eligible if they compared perioperative outcomes, oncological outcomes and complications in patients who underwent iRARC with ORC. RESULTS Twenty-two studies involving 7,020 patients were included. Compared to ORC, iRARC was superior for estimated blood loss [EBL WMD: -555.52; 95% CI, -681.64 to -429.39; P<0.001], blood transfusion rate [OR: 0.16; 95% CI, 0.09 to 0.28; P<0.001], length of hospital stay [LOS WMD: -2.05; 95% CI, -2.93 to -1.17; P<0.001], Clavien-Dindo grades ≥III complication rate [30d: OR: 0.57; 95% CI 0.44 to 0.75; P<0.001; 90d: OR: 0.71; 95% CI 0.60 to 0.84; P<0.001], and positive surgical margin [PSM OR: 0.65; 95% CI 0.49 to 0.85; P=0.002]. However, iRARC had a longer operative time [OT WMD: 68.54; 95%CI 47.41 to 89.67; P<0.001] and a higher rate of ureteroenteric stricture [ UES OR: 1.56; 95% CI 1.16 to 2.11; P=0.003]. Time to flatus, time to bowel, time to regular diet, readmission rate, Clavien-Dindo grades CONCLUSION Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion appears to be superior to open radical cystectomy in terms of effectiveness and safety. However, attention should be paid to the occurrence of ureteroenteric stricture during follow-up.
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Affiliation(s)
- Shi Fu
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - HongJin Shi
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhinan Fan
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
- Department of Urology, Meishan People's Hospital, Meishan, China
| | - Jinze Li
- Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Luan
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Haonan Dong
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jincheng Wang
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shuwen Chen
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jinsong Zhang
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jiansong Wang
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Mingxia Ding
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Haifeng Wang
- Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
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Courboin E, Mathieu R, Panetta V, Mjaess G, Diamand R, Verhoest G, Roumiguié M, Bajeot AS, Soria F, Lonati C, Simeone C, Simone G, Anceschi U, Umari P, Sridhar A, Kelly J, Mertens LS, Sanchez-Salas R, Colomer A, Cerruto MA, Antonelli A, Krajewski W, Quackels T, Peltier A, Montorsi F, Briganti A, Teoh JYC, Pradere B, Moschini M, Roumeguère T, Albisinni S. Comparing Robotic-Assisted to Open Radical Cystectomy in the Management of Non-Muscle-Invasive Bladder Cancer: A Propensity Score Matched-Pair Analysis. Cancers (Basel) 2023; 15:4732. [PMID: 37835425 PMCID: PMC10571883 DOI: 10.3390/cancers15194732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/22/2023] [Accepted: 09/03/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND For non-muscle-invasive bladder cancer (NMIBC) requiring radical surgery, limited data are available comparing robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) to open radical cystectomy (ORC). The objective of this study was to compare the two surgical techniques. METHODS A multicentric cohort of 593 patients with NMIBC undergoing iRARC or ORC between 2015 and 2020 was prospectively gathered. Perioperative and pathologic outcomes were compared. RESULTS A total of 143 patients operated on via iRARC were matched to 143 ORC patients. Operative time was longer in the iRARC group (p = 0.034). Blood loss was higher in the ORC group (p < 0.001), with a consequent increased post-operative transfusion rate in the ORC group (p = 0.003). Length of stay was longer in the ORC group (p = 0.007). Post-operative complications did not differ significantly (all p > 0.05). DFS at 60 months was 55.9% in ORC and 75.2% in iRARC with a statistically significant difference (p = 0.033) found in the univariate analysis. CONCLUSION We found that iRARC for patients with NMIBC is safe, associated with a lower blood loss, a lower transfusion rate and a shorter hospital stay compared to ORC. Complication rates were similar. No significant differences in survival analyses emerged across the two techniques.
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Affiliation(s)
- Etienne Courboin
- Department of Urology, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium; (G.M.); (T.Q.); (T.R.); (S.A.)
- Department of Urology, CHU Rennes, 35000 Rennes, France; (R.M.); (G.V.)
| | - Romain Mathieu
- Department of Urology, CHU Rennes, 35000 Rennes, France; (R.M.); (G.V.)
| | - Valentina Panetta
- L’altrastatistica S.R.L., Consultancy & Training, Biostatistics Office, 00100 Rome, Italy;
| | - Georges Mjaess
- Department of Urology, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium; (G.M.); (T.Q.); (T.R.); (S.A.)
| | - Romain Diamand
- Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, 1070 Brussels, Belgium; (R.D.); (A.P.)
| | - Gregory Verhoest
- Department of Urology, CHU Rennes, 35000 Rennes, France; (R.M.); (G.V.)
| | - Mathieu Roumiguié
- Department of Urology, Andrology and Renal Transplantation, CHU Rangueil, Paul-Sabatier University, 31000 Toulouse, France; (M.R.); (A.S.B.)
| | - Anne Sophie Bajeot
- Department of Urology, Andrology and Renal Transplantation, CHU Rangueil, Paul-Sabatier University, 31000 Toulouse, France; (M.R.); (A.S.B.)
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, 10024 Turin, Italy;
| | - Chiara Lonati
- Department of Urology, Spedali Civili di Brescia, 25123 Brescia, Italy; (C.L.); (C.S.)
| | - Claudio Simeone
- Department of Urology, Spedali Civili di Brescia, 25123 Brescia, Italy; (C.L.); (C.S.)
| | - Giuseppe Simone
- Department of Urology, Regina Elena National Cancer Institute, 00100 Rome, Italy; (G.S.); (U.A.)
| | - Umberto Anceschi
- Department of Urology, Regina Elena National Cancer Institute, 00100 Rome, Italy; (G.S.); (U.A.)
| | - Paolo Umari
- Departement of Urology, Ospedale Maggiore della Caritá di Novara, Universitá del Piemonte Orientale, 28100 Novarra, Italy;
| | - Ashwin Sridhar
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK; (A.S.); (J.K.)
| | - John Kelly
- Division of Surgery and Interventional Sciences, University College London, London WC1E 6BT, UK; (A.S.); (J.K.)
| | - Laura S. Mertens
- Department of Urology, Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Rafael Sanchez-Salas
- Department of Urology, Institut Mutualiste Montsouris, 70123 Paris, France; (R.S.-S.); (A.C.)
| | - Anna Colomer
- Department of Urology, Institut Mutualiste Montsouris, 70123 Paris, France; (R.S.-S.); (A.C.)
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37100 Verona, Italy; (M.A.C.); (A.A.)
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, 37100 Verona, Italy; (M.A.C.); (A.A.)
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, 50-556 Wroclaw, Poland;
| | - Thierry Quackels
- Department of Urology, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium; (G.M.); (T.Q.); (T.R.); (S.A.)
| | - Alexandre Peltier
- Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, 1070 Brussels, Belgium; (R.D.); (A.P.)
| | - Francesco Montorsi
- Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.M.); (A.B.); (M.M.)
| | - Alberto Briganti
- Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.M.); (A.B.); (M.M.)
| | - Jeremy Y. C. Teoh
- S.H. Ho Urology Centre, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China;
| | - Benjamin Pradere
- Department of Urology, University of Vienna, 1010 Vienna, Austria;
- Department of Urology, Hopital La Croix du Sud, 31000 Toulouse, France
| | - Marco Moschini
- Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, 20132 Milan, Italy; (F.M.); (A.B.); (M.M.)
| | - Thierry Roumeguère
- Department of Urology, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium; (G.M.); (T.Q.); (T.R.); (S.A.)
- Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, 1070 Brussels, Belgium; (R.D.); (A.P.)
| | - Simone Albisinni
- Department of Urology, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium; (G.M.); (T.Q.); (T.R.); (S.A.)
- Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, 00100 Rome, Italy
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Walz S, Aslani V, Sawodny O, Stenzl A. Robotic radical cystectomy - more precision needed? Curr Opin Urol 2023; 33:157-162. [PMID: 36710596 DOI: 10.1097/mou.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Recently, several trials as well as registry-data analyses investigating the role of robot-assisted radical cystectomy with extra or intracorporal urinary diversion were completed and follow up matured. This review aims to comment on the current evidence-based findings and interpret the future role of the robotic approach as a part of the treatment of bladder cancer. RECENT FINDINGS Numerous trials and registry-data analyses revealed no significant differences in progression-free and overall survival after open radical cystectomy or robot-assisted radical cystectomy irrespective of urinary diversion. Perioperative parameters, especially intraoperative blood loss, transfusions, thromboembolic events, wound infections and hospitalization were significantly increased in open radical cystectomy. Patients' convalescence, and especially early postsurgical quality of life, was improved by the robotic approach. The highly demanding surgery itself displayed by a flat learning curve required more than 130 surgeries per institution to reach a stable plateau of complications. The performance of high-quality radical cystectomy irrespective of the approach was significantly increased in high-volume centres. Local recurrence occurs in 11% after radical cystectomy. Current research focuses on intraoperatively usable detection methods and instruments to minimize the risk of residual tumour cells. SUMMARY Taken together, the total intracorporal approach in radical cystectomy holds the potential to improve perioperative parameters and reduces hospitalization without impairing oncological performance of the procedure. To provide best results for the patient radical cystectomy and especially the technically challenging total intracorporal procedure will gain importance in bladder cancer treatment but should be limited to high-volume centres.
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Affiliation(s)
- Simon Walz
- Department of Urology, University Hospital Tuebingen, Tuebingen
| | | | - Oliver Sawodny
- Institute for System Dynamics, University of Stuttgart, Stuttgart, Germany
| | - Arnulf Stenzl
- Department of Urology, University Hospital Tuebingen, Tuebingen
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Han JH, Ku JH. Robot-assisted radical cystectomy: Where we are in 2023. Investig Clin Urol 2023; 64:107-117. [PMID: 36882169 PMCID: PMC9995950 DOI: 10.4111/icu.20220384] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/08/2023] [Accepted: 02/01/2023] [Indexed: 03/02/2023] Open
Abstract
Open radical cystectomy (ORC) is associated with high rates of perioperative morbidity and mortality, owing to its extensive surgical nature and the high frequency of multiple co-morbidities among patients. As an alternative, robot-assisted radical cystectomy (RARC) has been increasingly adopted worldwide, being a reliable treatment option that utilizes minimally invasive surgery. Seventeen years have passed since the advent of the RARC, and comprehensive long-term follow-up data are now becoming available. The present review focuses on the current knowledge of RARC in 2023, and analyzes various aspects, including oncological outcomes, peri/post-operative complications, post-operative quality of life (QoL) change, and cost-effectiveness. Oncologically, RARC showed comparable oncological outcomes to ORC. With regard to complications, RARC was associated with lower estimated blood loss, lower intraoperative transfusion rates, shorter length of stay, lower risk of Clavien-Dindo grade III-V complications, and lower 90-day rehospitalization rates than ORC. In particular, RARC with intracorporeal urinary diversion (ICUD) performed by high-volume centers significantly reduced the risk of post-operative major complications. In terms of post-operative QoL, RARC with extracorporeal urinary diversion (ECUD) showed comparable results to ORC, while RARC with ICUD was superior in some respects. As the RARC implementation rate increases and the learning curve is overcome, more prospective studies and randomized controlled trials with large-scale patients are expected to be conducted in the future. Accordingly, sub-group analysis in various groups such as ECUD, ICUD, continent and non-continent urinary diversion, etc. is considered to be possible.
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Affiliation(s)
- Jang Hee Han
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University Hospital, Seoul, Korea.,Department of Urology, Seoul National University College of Medicine, Seoul, Korea.
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Grauer R, Wiklund NP. Update on robotic cystectomy. Curr Opin Urol 2021; 31:537-541. [PMID: 34506337 DOI: 10.1097/mou.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This article aims to discuss recently published (2019-2021) studies on robot-assisted radical cystectomy (RARC) with attention to evidence comparing intracorporeal (ICUD) and extracorporeal urinary diversion (ECUD) in terms of intraoperative and perioperative metrics. RECENT FINDINGS RARC produces equivalent oncological outcomes compared to open radical cystectomy (ORC). The benefits of RARC are most pronounced perioperatively. ICUD has been increasingly used at centers of excellence as it reduces intestinal exposure, which may incrementally minimize morbidity compared to ECUD or ORC. As the learning curve for ICUD diversion has flattened, retrospective analyses have emerged that suggest this technique may hold benefit over both ORC and RARC with ECUD, though current data is conflicting, and a randomized controlled study is forthcoming. SUMMARY ORC is the current 'gold standard' management for muscle-invasive bladder cancer. Based on the premise of the minimization of perioperative morbidity, the development of RARC, most recently with ICUD, seeks to improve patient outcomes. Despite a protracted learning curve, many expert bladder cancer centers have adopted an intracorporeal approach. As more centers adopt, refine, and climb the learning curve for ICUD, a clearer insight of its effect on morbidity will be revealed-informing further adoption of the technique.
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Affiliation(s)
- Ralph Grauer
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Urinary diversions for benign and oncologic indications: what did we learn about short term complications in the last 24 months? Curr Opin Urol 2021; 31:556-561. [PMID: 34265842 DOI: 10.1097/mou.0000000000000927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF THE REVIEW Urinary diversion (UD) with or without cystectomy is a procedure with high short term complication rates. In this review, we summarize the most relevant findings of the last 2 years. RECENT FINDINGS The use of a prophylactic mesh decreases the risk of parastomal hernia after ileal conduit (IC) surgery without adding mesh-related complications according to a recent randomized multicentre trial. Robot-assisted surgery is increasingly applied for UD and is evolving from extra- to intra-corporeal reconstruction in both continent and incontinent diversions, but there is still a need for appropriately designed studies assessing both short- and long-term complications. Promising techniques to decrease ureterointestinal stricture rates have been reported from small series, such as retrosigmoid placement of the proximal IC to avoid transpositioning of the left ureter, or in robot-assisted surgery the use of indocyanine green with near-infrared light to improve visualisation of distal ureteral viability. SUMMARY Most recent reports derive from observational data. Appropriate randomized studies are warranted for the evaluation of new techniques to be implemented in a surgical area that still is associated with high complication rates.
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