Robotic and laparoscopic radical cystectomy in the management of bladder cancer

Comparing surgical site wound infection after laparoscopic and open radical cystectomies in patients with bladder cancer

This study comprehensively compared the effects of laparoscopic and open radical cystectomies on postoperative wound infections and complications in patients with bladder cancer. We conducted a systematic search for relevant studies in PubMed, Embase, Google Scholar, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases, from database inception to October 2023. Two researchers independently screened the literature, extracted data, and assessed the quality based on the inclusion and exclusion criteria. Data analysis was performed using Stata 17.0 software. Overall, 16 studies involving 1427 patients with bladder cancer were included. The analysis revealed that, compared with open radical cystectomy, laparoscopic radical cystectomy significantly reduced the incidence of wound infections (odds ratio [OR] = 0.38, 95% confidence interval [CI]: 0.23-0.64, p < 0.001) and complications (OR = 0.35, 95%CI: 0.26-0.47, p < 0.001) and significantly shortened the hospital stay duration (standardised mean difference [SMD] = -1.85, 95%CI: -2.34 to -1.36, p < 0.001). Thus, this study determined that laparoscopic radical cystectomy for the treatment of bladder cancer effectively reduced the occurrence of wound infections and complications, and significantly shortened the patient's hospital stay, demonstrating notable therapeutic effectiveness worthy of clinical application.

Effect of Radical Laparoscopic Surgery and Conventional Open Surgery on Surgical Outcomes, Complications, and Prognosis in Elderly Patients with Bladder Cancer

Background

Bladder cancer is a common malignant tumor of the urinary system in the clinic. It has multiple lesions, easy recurrence, easy metastasis, poor prognosis, and high mortality.

Objective

The aim of this study is to investigate the impact of laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC) on the surgical outcome, complications, and prognosis of elderly patients with bladder cancer.

Materials and Methods

One hundred elderly bladder cancer patients who underwent surgery in our hospital from June 2019 to June 2021 were selected for the retrospective study and were divided into 50 cases each in the ORC group and the LRC group according to the different surgical methods. The ORC group was treated with ORC, and the LRC group implemented LRC treatment. The differences in surgery, immune function, recent clinical outcomes, and complications between the two groups were observed and compared.

Results

The mean operative time, mean intraoperative bleeding, intraoperative and postoperative transfusion rate, and transfusion volume of patients in the LRC group were statistically significant when compared to the ORC group. The differences in the meantime to resume eating, time to get out of bed, mean number of days in hospital after surgery, and the amount of postoperative numbing analgesics used by patients in the LRC group after surgery were statistically significant compared to the ORC group (P < 0.05). There was no statistically significant difference in the comparison of immune function between the two groups before surgery (P > 0.05), while the comparison of CD8⁺ and B cells 1 week after surgery of the LRC group was significantly better than that of the ORC group (P < 0.05), and the operation time of the LRC group was longer than that of the ORC group (P < 0.05). Statistical analysis of postoperative complications showed that the overall incidence of postoperative complications in the LRC group was significantly lower than that in the ORC group (16.67% vs. 46.67%) (P < 0.05).

Conclusion

LRC has less surgical trauma and intraoperative bleeding, faster postoperative recovery, and fewer postoperative complications, providing some reference for clinical surgery for elderly bladder cancer patients.

[Oncological results of a series of 93 laparoscopic radical cystectomies: 5 years of follow-up]

OBJECTIVE

To report oncological results at 5 years after laparoscopic radical cystectomy (LRC) with lymph node dissection for bladder cancer (BC).

PATIENTS AND METHODS

This is a retrospective single-center study of all patients who underwent LRC for BC by the same surgeon from February 2007 to March 2016. Demographic, perioperative and oncologic data were collected. We reported overall survival rate (OS), cancer specific (CSS) and recurrence-free survival (SSR), as primary indicators of oncologycal outcomes. These survival rates were estimated according to the Kaplan-Meier method. Log-rank tests were used to explore overall survival according tumor stage, lymph node involvement and surgical margins status.

RESULTS

In all, 93 patients (82 men and 11 women) underwent LRC. Mean age was 59 years. Minor complications (Clavien I-II) occurred in 24.7%. Major complications (Clavien IIIa-V) were observed in 8.6%. No patients received neoadjuvant chemotherapy. Median lymph node (LN) yield was 15 and 26.5% patients had positive LN. The positive surgical margins (SMs) rate was 5.3%. Median follow-up for the entire patients was 50 months (19-84 months). Forty-three patients (46.2%) were followed for at least 71 months. Five year RFS, CSS and OS were 67%, 85% and 79%, respectively. Non organ confined desease, positive LN and positive SMs were associated with poorer OS (P<0.039, P<0.016 and P<0.001).

CONCLUSION

LRC was associated with acceptable long-term oncologic outcomes, similar to those currently reported after open cystectomy for BC.

LEVEL OF EVIDENCE

3.

Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion vs. open mini-laparotomy cystectomy: evaluation of surgical inflammatory response and immunosuppressive ability of CO2-pneumoperitoneum in an experimental porcine study

OBJECTS

To compare surgical inflammatory response (SIR) after radical cystectomy (RC) in a porcine model using minimal invasive techniques. Additionally we aimed to investigate the potential immunosuppressive ability of preoperative CO₂-pneumoperitoneum (CO₂P).

MATERIALS AND METHODS

Forty female landrace pigs were randomized to five groups: Three intervention groups all having a cystectomy and an ileal conduit either done by robot-assisted laparoscopic technique with intracorporeal urinary diversion (RALC) or an open mini-laparotomy with or without prior CO₂P (OMC ± CO₂P). Two control sham groups with or without prior CO₂P (S ± CO₂P). Serum samples were obtained preoperatively, immediately postoperative, 24, 48 and 72 hours postoperatively, and the inflammatory mediators CRP, Haptoglobin, Ceruloplasmin, Albumin, Cortisol, IL-4, IL-6, IL-12 and IFN-α were measured.

RESULTS

Operative time was significantly longer in RALC compared to open groups (OMC ± CO₂P) (p's < .0001). CRP and Haptoglobin levels were significantly higher for surgical intervention groups (SIG) compared to controls 24, 48 and 72 hours postoperatively (p's < .001). At 48 hours, CRP was higher for RALC vs OMC + CO₂P (p = .029). At 72 hours, Haptoglobin was higher for RALC vs open groups (p's < .024). Ceruloplasmin, cortisol, albumin, IL-4, IL-6, IL-12 and IFN-α, revealed no significant differences between SIG.

CONCLUSIONS

No major differences were found between RALC and OMC regarding the degree of tissue trauma quantified by inflammatory markers. Thirty minutes of CO_2-insufflation preoperative appears to have a transient immunosuppressive effect of the innate postoperative SIR, whereas prolonged CO₂P apparently diminishes this effect.

Robotic radical cystectomy for the management of bladder cancer: Analysis of operative and pathological outcomes of eighteen patient

OBJECTIVE

To present the surgical and pathological results of robotic radical cystectomy (RRC) operations performed in our clinic.

MATERIAL AND METHODS

A total of 18 patients, who underwent RRC and intracorporeal urinary diversion between October 2016 and September 2017 for clinically localized bladder cancer in our clinic, were included in the study. The results were evaluated under three headings. 1. operative outcomes (total operation time, perioperative blood loss, postoperative hematocrit decrease) 2. recovery period (pull-off drain day, hospitalization time) 3. oncological results (pathologic stage, surgical margin, number, and characteristics of lymph nodes removed). Complications within the postoperative 30-day period, were evaluated and the Clavien classification system was used to classify the complications.

RESULTS

The mean age of the patients was 64.4 (52-80) years. Seventeen male patients and one female patient underwent robotic cystectomy. At the operative outcomes, the mean blood loss was 325 mL, and the mean hematocrit decrease was 3.15%. The mean duration of the surgery was 471 minutes (330-630), while the median operative time was 450 minutes. Complications occured in 6 patients during the early postoperative period. Six of them (75%) had minor complications (Clavien grade 1), two patients (25%) had major complications (Clavien grade 4).

CONCLUSION

Our initial experience with RRC is that, this surgical technique has acceptable operative, oncological and short-term clinical outcomes. However, prospective randomized studies are needed to assess whether there is a clear advantage compared to open surgery.

Robot-assisted laparoscopic radical cystectomy with extracorporeal urinary diversion: Initial experience and outcomes

INTRODUCTION

Open radical cystectomy (ORC) is the most common surgical approach for invasive carcinoma of the urinary bladder, but robot-assisted radical cystectomy (RARC) has recently gained popularity. There is limited data from the Indian subcontinent on RARC. The aim of this study was to assess the perioperative, pathological, and oncological outcomes of RARC and follow-up in our initial 63 cases.

MATERIALS AND METHODS

A retrospective analysis of prospectively maintained data of 63 RARC procedures performed in our tertiary care institute from July 2006 to January 2016 was done. All patients underwent RARC with extracorporeal urinary diversion. We analyzed perioperative parameters, length of hospital stay, pathological and oncological outcomes, and rate of complications. Follow-up data were analyzed for disease recurrence and survival.

RESULTS

The mean age of the patients was 58 years. The mean American Society of Anesthesiologists (ASA) score was 1.66. Mean operative time was 348.6 min and mean blood loss was 868.2 ml. Mean hospital stay was 10.4 days (±5.4 days). 42.8% patients had pT2 disease, 49.2% pT3, 1.58% pT1, and 6.34% had pT4 disease. Mean lymph node yield was 12.4 (3-25). One patient had positive surgical margins. Twenty-four patients had postoperative complications of which four were major complications (Clavien-Dindo 3 or higher). At a median follow-up of 60 months (range: 3-108 months), 11 patients were lost to follow-up 10 patients developed metastasis, out of which 4 died. Four had recurrence, two died and two are receiving chemotherapy.

CONCLUSION

This study shows the feasibility and safety of RARC. The operative time, blood loss, return of bowel activity and hospital stay were higher than those reported in the literature but may reflect the learning curve.

Oncological Outcomes in Patients Treated with Radical Cystectomy for Bladder Cancer: Comparison Between Open, Laparoscopic, and Robot-Assisted Approaches

PURPOSE

To investigate oncological outcomes in patients with muscle-invasive bladder cancer who underwent open radical cystectomy (ORC), laparoscopic radical cystectomy (LRC), or robot-assisted radical cystectomy (RARC).

PATIENTS AND METHODS

A retrospective analysis was performed on 230 patients who underwent ORC (n = 150), LRC (n = 22), or RARC (n = 58) between September 2009 and June 2012. Perioperative outcomes were compared between the three surgical approaches. The influence of the type of surgical approach on recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) was analyzed using the Kaplan-Meier method, and differences were assessed with the log-rank test. Predictors of RFS, CSS, and OS were also analyzed with a Cox regression model.

RESULTS

The median patient age for ORC, LRC, and RARC groups was 68.0 (interquartile range [IQR]: 60.0-73.0), 65.0 (IQR: 62.8-74.0), and 61.5 (IQR: 54.8-72.0) years, respectively (p = 0.017), and the median follow-up duration was 27.9 (IQR: 14.7-47.9), 28.8 (IQR: 15.7-41.8), and 32.0 (IQR: 15.5-45.4) months, respectively (p = 0.955). There was no significant difference in RFS, CSS, and OS according to the surgical approach (p = 0.253, p = 0.431, and p = 0.527, respectively). Subgroup analysis revealed that RFS, CSS, and OS were not significantly different in both subgroups with stage ≤pT2 or ≥pT3. Multivariable Cox regression analyses showed that the surgical approach was not a significant predictor of RFS, CSS, and OS.

CONCLUSION

Our findings indicate that the type of surgical approach is not associated with RFS, CSS, and OS in patients with bladder cancer.

A comparative study between open and laparoscopic approach in radical cystectomy with orthotopic ileal neobladder

OBJECTIVE

Probably, laparoscopic radical cystectomy with ileal neobladder and neovesicourethral anastomosis is one of the most complex procedures in minimally invasive surgery.

MATERIAL AND METHODS

Prospective study carried out in 72 patients surgically treated for invasive bladder neoplasia between January 2008 and October 2013. Patients were undergone to radical cystectomy with ileal neobladder (open approach in 33 patients and laparoscopic approach in 39). The study assessed comparatively surgical outcomes, continence rate and postoperative complications.

RESULTS

Mean age was 63.5±9 years (64.3 open vs. 62.7 laparoscopic, P=.46) mean surgery time 323.6±78.7 minutes (321.3 vs. 326.5, P=.77), average hospital stay 14.8 days±8,1 (16.2 vs. 13.6, P=.2), transfusion rate 40.3% (66.7% vs. 17.9%, P<.0001) and complications rate 47.2% (63.6% vs. 33.3%, P=.01). Major complications were reported in 29.1% of cases (39.4% open vs. 20,5% laparoscopic, P=.07). With a mean follow-up rate of 42.5±19.2 months (range 15-70), 50 (69.4%) patients remain alive and free of disease. Continence was evaluated in these patients: total continence rate was 38% (50% vs. 27%, P=.09) and diurnal continence rate 58% (70.8% vs. 46.1%, P=.07). Self-catheterization rate was 8% (4.2% vs. 11.5%, P=.67). Total incontinence rate was 34% (25% vs. 42.3%, P=.19).

CONCLUSION

According to our experience, transfusion rate, number and severity of complications are lower in laparoscopic cystectomy with ileal neobladder. No statistically significant impact on operative time and on hospital stay was observed. In patients undergone to laparoscopic approach, continence rate is lower but not statistically significant.

Robotics in uro-oncologic surgery

In urology, the main use for the robotic technique has been in radical prostatectomy for prostate cancer. Robotic surgery for other organs, such as the kidneys and bladder, has been less explored. However, partial nephrectomy or radical nephroureterectomy can be difficult for inexperienced laparoscopic surgeons. The advent of the da Vinci robot, with multijointed endowristed instruments and stereoscopic vision, decreases the technical difficulty of intracorporeal suturing and improves the reconstructive steps. The objective of this article is to offer an overview of all robotic procedures recently developed in the field of urology. We evaluate the feasibility of these procedures and their potential advantages and disadvantages. We also describe perioperative, postoperative, and oncologic outcomes of robot-assisted surgery as well as perform a comparison with open and laparoscopic techniques. Comparative data and an adequate follow-up are needed to demonstrate equivalent oncologic outcomes in comparison with traditional open or laparoscopic procedures.

Evaluation of open and laparoscopic radical cystoprostatectomy combined with orthotopic neobladder: a single-surgeon experience

AIM

To compare the outcomes of laparoscopic (LRCP) and open radical cystoprostatectomy (ORCP) with orthotopic urinary diversion for muscle-invasive organ-confined bladder cancer by a single surgeon.

PATIENTS AND METHODS

Prospectively documented 15 LRCP and 15 ORCP patients, followed for at least 3 years, were included in our study. The demographic parameters of patients, preoperative radiologic staging, previous operations, surgical outcomes, complications, oncologic results and intermediate-term follow-up, postoperative chemotherapy and follow-up periods were recorded and evaluated.

RESULTS

The mean oncologic follow-up was 3 years. Transfusion rate, estimated blood loss, oral intake and narcotic analgesic requirement were statistically less in the LRCP group (p < 0.05). However, operation time and hospital stay were similar in both groups. The complication rates were not significantly different between the two groups. The mean number of dissected lymph nodes was 20.0 ± 1.7 in the ORCP and 22.6 ± 2.0 in the LRCP group. One patient in each group had a margin positive for bladder cancer.

CONCLUSIONS

The laparoscopic approach may be feasible for muscle-invasive organ-confined bladder cancer. Furthermore, LRCP provides less blood loss, early oral intake and postoperative pain management. Additionally, continence and sexual function may be provided by LRCP as with ORCP.

Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy

PURPOSE

Robotic assisted laparoscopic radical cystectomy for bladder cancer has been reported with potential for improvement in perioperative morbidity compared to the open approach. However, most studies are retrospective with significant selection bias.

MATERIALS AND METHODS

A pilot prospective randomized trial evaluating perioperative outcomes and oncologic efficacy of open vs robotic assisted laparoscopic radical cystectomy for consecutive patients was performed from July 2009 to June 2011.

RESULTS

To date 47 patients have been randomized with data available on 40 patients for analysis. Each group was similar with regard to age, gender, race, body mass index and comorbidities, as well as previous surgeries, operative time, postoperative complications and final pathological stage. We observed no significant differences between oncologic outcomes of positive margins (5% each, p = 0.50) or number of lymph nodes removed for open radical cystectomy (23, IQR 15-28) vs robotic assisted laparoscopic radical cystectomy (11, IQR 8.75-21.5) groups (p = 0.135). The robotic assisted laparoscopic radical cystectomy group (400 ml, IQR 300-762.5) was noted to have decreased estimated blood loss compared to the open radical cystectomy group (800 ml, IQR 400-1,100) and trended toward a decreased rate of excessive length of stay (greater than 5 days) (65% vs 90%, p = 0.11) compared to the open radical cystectomy group. The robotic group also trended toward fewer transfusions (40% vs 50%, p = 0.26).

CONCLUSIONS

Our study validates the concept of randomizing patients with bladder cancer undergoing radical cystectomy to an open or robotic approach. Our results suggest no significant differences in surrogates of oncologic efficacy. Robotic assisted laparoscopic radical cystectomy demonstrates potential benefits of decreased estimated blood loss and decreased hospital stay compared to open radical cystectomy. Our results need to be validated in a larger multicenter prospective randomized clinical trial.

Quality of lymphadenectomy is equivalent with robotic and open cystectomy using an extended template

PURPOSE

Extended lymph node dissection for bladder cancer provides better staging, cancerous node removal and potentially survival. Minimally invasive techniques have been criticized about the ability to adequately perform extended lymph node dissection. We compared the extended lymph node dissection quality of robotic and open cystectomy by assessing node yield and positivity.

MATERIALS AND METHODS

We compared extended lymph node dissection in 120 open and 35 robotic cystectomy cases. Extended lymph node dissection included skeletonization of structures in each nodal group below the aortic bifurcation (common iliac, external iliac, obturator, hypogastric and presacral nodes). Nodes were processed identically but submitted as 1 or 2 packets for robotic cases and as 10 or more packets for open surgery cases.

RESULTS

The mean±SD node count in the open group was 36.9±14.8 (range 11 to 87) and in the robotic group the mean yield was 37.5±13.2 (range 18 to 64). Only 12 of 120 open (10%) and 2 of 35 robotic (6%) cases had fewer than 20 nodes. A total of 36 open (30%) and 12 robotic (34%) cases were node positive. Open extended lymph node dissection identified 80% and 90% confidence of accurate staging as pN0 when obtaining 23 and 27 nodes, respectively. A node count of 23 or 27 was achieved in 87% and 77% of open cases, and in 91% and 83% of robotic cases, respectively. Of patients with open surgery 36% received neoadjuvant chemotherapy compared to 31% of those with robotic surgery.

CONCLUSIONS

No difference was identified in the lymph node yield or the positive node rate when comparing open and robotic extended lymph node dissection. Local recurrence and survival data are needed to confirm whether the 2 techniques are oncologically equivalent.

The emergence of surgeon-controlled robotic surgery in urologic oncology

The rise of robotic surgery is transforming medicine. In many ways, urology has taken charge in pioneering a new era of minimally invasive surgery with the emergence of the robot. The unprecedented dissecting precision and the dynamic three-dimensional, high definition view of the surgical field are undoubtedly revolutionizing the field of urology. These unique attributes of robotic surgery confer enormous advantages in dealing with uro-oncological surgery. The robotic revolution began nearly a decade ago with surgeon-controlled robotic radical prostatectomy and has since expanded to include radical cystectomies and partial nephrectomies. There have been numerous landmark studies published showing that robotic surgery provides comparable oncological and functional outcomes against traditional open or laparoscopic surgery. As a result, it becomes exceedingly imperative that urologists and the oncological community remain up-to-date regarding these developments and appreciate the oncological outcomes of surgeon-controlled robotic surgery. This review will assess the impact surgeon-controlled robotic surgery has had in the field of urologic oncology.

Improving selection of appropriate urinary diversion following radical cystectomy for bladder cancer

Radical cystectomy represents the gold-standard of treatment for invasive bladder cancer. Following cystectomy, various options for urinary diversion may be offered to patients. This article represents an overview of the history of urinary diversion, explains the current selection criteria used at one of the most experienced bladder cancer centers worldwide, and provides an update on the current understanding of continence mechanisms. Furthermore, we review the current literature on quality of life for patients with different forms of urinary diversion. Excellent functional results can be achieved with continent forms of urinary diversion. It is important to consider the relative and absolute contraindications when choosing any form of urinary diversion. Proper patient selection and thorough standardized preoperative counseling is critical in achieving optimal results.

[Robotic-assisted laparoscopic radical cystectomy: evaluation of functional and oncological results]

PURPOSE

radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. We report our experience with 84 consecutive cases of robotic assisted laparoscopic radical cystectomy with regard to perioperative results, pathological outcomes and surgical complications.

MATERIALS AND METHODS

a total of 84 consecutive patients (70 male and 14 female) underwent robotic radical cystectomy and urinary diversion at our institution from January 2007 to August 2010 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes and complication rate.

RESULTS

mean age of this cohort was 65.5 years (range 28 to 82). Of the patients 62 underwent ileal conduit diversion, 22 received a neobladder. Mean operating room time for all patients was 261min. (range: 243-618min.) and mean surgical blood loss was 298ml (range: 50-2000ml). 29% of the cases were pT1 or less disease, 38% were pT2, 26% and 7% were pT3 and T4 disease respectively, 15% were node positive. Mean number of lymph nodes removed was 15 (range 1 to 33). In 2 cases (2.4%) there was a positive surgical margin. Mean days to flatus were 2.12, bowel movement 2.87 and discharge home 17.7 (range: 10-33). There were 45 postoperative complications with 11.9% having a major complication (Clavien grade 3 or higher). At a mean followup of 16.7 months 10 patients (11%) had disease recurrence and 2 died of disease.

CONCLUSIONS

our experience with robotic radical cystectomy for the treatment of bladder cancer suggests that in proper hands this procedure provides acceptable surgical and pathological outcomes.

Comparison of surgical stress response to laparoscopic and open radical cystectomy

OBJECTIVES

To prospectively compare stress response to laparoscopic and open radical cystectomy by the measurement of humoral mediators and the incidence of systemic inflammatory response syndrome (SIRS).

METHODS

Thirty-eight patients undergoing radical cystectomy were prospectively assessed. Blood samples were obtained from all patients before surgery, during surgery, 72 h after surgery. Serum levels of interleukin (IL)-6 and interferon (IFN)-gamma were measured using an enzyme-linked immunosorbent assay. We also investigated the incidence and duration of SIRS in the two groups.

RESULTS

The two groups had comparable perioperative variables except for less estimated blood loss in the laparoscopic group. The IL-6 levels increased during and after surgery in the two groups (P < 0.001). However, the IL-6 levels in the laparoscopic group were significantly lower than those in the open group during and after surgery (P = 0.006, P < 0.001). The incidence of SIRS was 57.1% in the laparoscopic group and 79.2% in the open group (P = 0.149). The mean duration of SIRS was 1.4 days in the laparoscopic group and 2.8 days in the open group (P = 0.032). The IFN-gamma levels decreased, but there was no difference in the two groups over the entire period assessed. Multivariate analysis demonstrated that the group (laparoscopic versus open) was the only influencing factor on the levels of IL-6 and the duration of SIRS.

CONCLUSIONS

Our study suggests that the laparoscopic group is markedly less stressful and it has a shorter duration of SIRS than the open group.

Robotic-assisted laparoscopic intracorporeal urinary diversion

BACKGROUND

Recent small case series have now been reported for robotic-assisted laparoscopic radical cystectomy (RALRC). In most of these series, the urinary diversion has been performed in an extracorporeal fashion. There have been few case reports of an intracorporeal diversion and little description of the technique of such a procedure.

OBJECTIVE

In this paper, we report our initial experience with robotic-assisted laparoscopic intracorporeal urinary diversion, describing stepwise the surgical procedure itself and evaluating perioperative and pathologic outcomes of this novel procedure.

DESIGN, SETTING, AND PARTICIPANTS

We studied a single-institution case series of patients undergoing robotic-assisted cystectomy and intracorporeal urinary diversion for clinically localized urothelial carcinoma of the bladder (n=10) or for a noncompliant dysfunctional bladder refractory to more conservative management (n=2). Historical comparisons are also made to a consecutive case series of 20 patients undergoing robotic radical cystectomy and extracorporeal urinary diversion.

SURGICAL PROCEDURE

RALRC and intracorporeal urinary diversion, including ileal conduit (n=9) and orthotopic ileal neobladder (n=3).

MEASUREMENTS

The stepwise operative procedure is described in detail. Outcome measures evaluated in this series included operative variables, hospital recovery, and complication rate. Comparisons were made to a contemporaneous series of 20 patients who underwent a robotic cystectomy with extracorporeal diversion during this time period (from an experience of >100 robotic cystectomy patients since 2005).

RESULTS AND LIMITATIONS

Twelve patients (mean age: 60.9 yr) underwent an intracorporeal diversion. Mean operating-room time of all patients was 5.3h, and mean surgical blood loss was 221ml. Mean time to flatus, bowel movement, and hospital discharge was 2.2 d, 3.2 d, and 4.5 d, respectively. Eleven of the 12 patients were discharged on or before postoperative day 5. There were six postoperative complications in five patients (42%), with one complication being Clavien grade 3 or higher. The major limitations of the study are the small sample size and the nonrandomized nature of the compared treatment groups (intracorporeal vs extracorporeal), which limits the ability to directly compare the techniques at a high level of scientific confidence.

CONCLUSIONS

Our initial experience with robotic-assisted laparoscopic intracorporeal diversion appears to be favorable with acceptable operative and short-term clinical outcomes.

Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results

BACKGROUND

In recent years, surgeons have begun to report case series of minimally invasive approaches to radical cystectomy, including robotic-assisted techniques demonstrating the surgical feasibility of this procedure with the potential of lower blood loss and more rapid return of bowel function and hospital discharge. Despite these experiences and observations, at this point high levels of clinical evidence with regard to the benefits of robotic cystectomy are absent, and the current experiences represent case series with limited comparisons to historical controls at best.

OBJECTIVE

We report our results on a prospective randomized trial of open versus robotic-assisted laparoscopic radical cystectomy with regard to perioperative outcomes, complications, and short-term narcotic usage.

DESIGN, SETTING, AND PARTICIPANTS

A prospective randomized single-center noninferiority study comparing open versus robotic approaches to cystectomy in patients who are candidates for radical cystectomy for urothelial carcinoma of the bladder. Of the 41 patients who underwent surgery, 21 were randomized to the robotic approach and 20 to the open technique.

INTERVENTION

Radical cystectomy, bilateral pelvic lymphadenectomy, and urinary diversion by either an open approach or by a robotic-assisted laparoscopic technique.

MEASUREMENTS

The primary end point was lymph node (LN) yield with a noninferiority margin of four LNs. Secondary end points included demographic characteristics, perioperative outcomes, pathologic results, and short-term narcotic use.

RESULTS AND LIMITATIONS

On univariate analysis, no significant differences were found between the two groups with regard to age, sex, body mass index, American Society of Anesthesiologists classification, anticoagulation regimen of aspirin, clinical stage, or diversion type. Significant differences were noted in operating room time, estimated blood loss, time to flatus, time to bowel movement, and use of inpatient morphine sulfate equivalents. There was no significant difference in regard to overall complication rate or hospital stay. On surgical pathology, in the robotic group 14 patients had pT2 disease or higher; 3 patients had pT3/T4 disease; and 4 patients had node-positive disease. In the open group, eight patients had pT2 disease or higher; five patients had pT3/T4 disease; and seven patients had node-positive disease. The mean number of LNs removed was 19 in the robotic group versus18 in the open group. Potential study limitations include the limited clinical and oncologic follow-up and the relatively small and single-institution nature of the study.

CONCLUSIONS

We present the results of a prospective randomized controlled noninferiority study with a primary end point of LN yield, demonstrating the robotic approach to be noninferior to the open approach. The robotic approach also compares favorably with the open approach in several perioperative parameters.

Robotic salvage cystectomy in the nonagenarian

Radical cystectomy with pelvic lymphadenectomy remains the standard treatment for muscle-invasive bladder cancer. However, bladder preservation with radiotherapy, with or without chemotherapy, represents an alternative treatment strategy. In patients that fail this bladder conservation treatment, salvage cystectomy is then indicated to treat persistent or recurrent cancer. We report our experience with robotic-assisted laparoscopic salvage radical cystoprostatectomy with pelvic lymph node dissection in a 91-year-old man. This minimally invasive approach for treatment of persistent bladder cancer refractory to chemoradiation, even in the nonagenarian, is a safe and viable alternative to traditional open surgery.