Robot assisted radical cystectomy with Florence robotic intracorporeal neobladder (FloRIN): Analysis of survival and functional outcomes after first 100 consecutive patients upon accomplishment of phase 3 IDEAL framework

Stapled W-shaped (Hautmann) Orthotopic Ileal Neobladder. Functional Results and Complications over a 13-year Period

BACKGROUND AND OBJECTIVE

The preferable technique for orthotopic bladder substitution after radical cystectomy is debated. The aim of this study was to describe our technique of a stapled W-shaped ileal neobladder and assess the complications and functional results in 100 patients. treated from December 2009 to July 2022.

METHODS

The W-shaped ileal neobladder is created with lateral arms of 15 cm and central arms of 10 cm. Following an incision of the lower part of the two medial arms, a 10-cm GIA titanium stapler is used to detubularize the medial arms first and then the laterals to the medial arms. Urethral-neobladder anastomosis and end-to-end ureteroileal anastomosis are finally carried out. We reported on clinical data, complications, and urinary function outcomes assessed by the International Consultation on Incontinence Questionnaire (ICIQ)-Short Form and daytime/24-h pad test. Full urinary continence (UC) was defined as pad tests yielding 0 g.

KEY FINDINGS AND LIMITATIONS

The median surgical time was 210 min. The early (up to 90 d) and late (>90 d) complication rates were 18% (2% grade ≥4) and 11.7% (2% grade ≥4), respectively. Two patients had "late" bladder stones due to chronic urinary retention, whereas none developed calcifications in the neobladder along the stapling lines. Daytime and 24-h UC rates were 74.7% and 72.4% at 12 mo, 82.7% and 72.4% at 36 mo, respectively. Median ICIQ scores were in line with pad test results, being 0 in patients with full UC.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our stapled W-shaped ileal neobladder technique was found to be simple and fast to shape, with a low complication rate, and yielded favorable long-term functional outcomes.

PATIENT SUMMARY

This study details the surgical technique, complications, and functional outcomes of patients who underwent open cystectomy with a stapled W-shaped ileal neobladder. Our results indicate that this approach is safe and provides favorable long-term functional outcomes.

Step by step technique of Stentless Florence Robotic Intracorporeal Neobladder (FloRIN), does the ureteral management influence functional outcomes?

INTRODUCTION

Benefits and harms of avoid the sent placement during IntraCorporeal Neobladder configuration are still debated. Our objective was to describe the step-by-step technique of Florence intracorporeal neobladder (FloRIN) configuration performed with stentless procedure focusing on perioperative and mid-term functional outcomes.

MATERIALS AND METHODS

In this single institution prospective randomized 1:1 series all consecutive patients underwent Robot-Assisted Radical Cystectomy (RARC) and FloRIN reconfiguration from January 2021 to March 2021 were enrolled. Functional perioperative and mid-term outcomes were gathered. Postoperative complications were graded according to Clavien-Dindo classification and divided in early (<30 days from discharge) and delayed (>30 days).

RESULTS

Overall, 10 patients were included in the analysis. Of these, the 50.0% was treated with Stentless FloRIN. In terms of baseline features, no differences were recorded between the two groups. Median age was 65 and 66 years while median BMI was 27 and 25 in the stentless and in the stent group, respectively. Concerning intraoperative variables, no intraoperative complications as well as open conversion occurred among both groups. As regard introperative features, a shorter console time was associated with stentless procedure (331 min vs 365 min). In terms of perioperative outcomes, canalization and time to drainage removal didn't differ between groups while length of hospital stay was significantly lower in stentless group 10 days versus 14 days. Early and delayed postoperative complication rate was not influenced by the ureteral management at a preliminary assessment with comparable rates of Clavien Dindo ⩾ 3a between the two groups. Mid-term functional outcomes did not differ between groups in terms of kidney function loss.

CONCLUSIONS

FloRIN with Stentless technique showed functional and perioperative preliminary outcomes comparable with the standard ureteral management strategy. Further series with longer functional follow-up assessment will be needed to confirm our preliminary results.

Atlas of Intracorporeal Orthotopic Neobladder Techniques After Robot-assisted Radical Cystectomy and Systematic Review of Clinical Outcomes

BACKGROUND

Multiple and heterogeneous techniques have been described for orthotopic neobladder (ONB) reconstruction after robot-assisted radical cystectomy. Nonetheless, a systematic assessment of all the available options is lacking.

OBJECTIVE

To provide the first comprehensive step-by-step description of all the available techniques for robotic intracorporeal ONB together with individual intraoperative, perioperative and functional outcomes based on a systematic review of the literature.

DESIGN, SETTING, AND PARTICIPANTS

We performed a systematic review of the literature, and MEDLINE/PubMed, Embase, Scopus, and Web of Science databases were searched to identify original articles describing different robotic intracorporeal ONB techniques and reporting intra- and perioperative outcomes. Studies were categorized according to ONB type, providing a synthesis of the current evidence. Video material was provided by experts in the field to illustrate the surgical technique of each intracorporeal ONB.

SURGICAL PROCEDURE

Nine different ONB types were identified: Studer, Hautmann, Y shape, U shape, Bordeaux, Pyramid, Shell, Florence Robotic Intracorporeal Neobladder, and Padua Ileal Neobladder.

MEASUREMENTS

Continuous and categorical variables are presented as mean ± standard deviation and as frequencies and proportions, respectively.

RESULTS AND LIMITATIONS

Of 2587 studies identified, 19 met our inclusion criteria. No cohort studies or randomized control trials comparing different neobladder types are available. Available techniques for intracorporeal robotic ONB reconstruction have similar operative time, estimated blood loss, intraoperative complications, and length of stay. Major variability exists concerning postoperative complications and functional outcomes, likely related to reporting bias.

CONCLUSIONS

Several techniques are described for intracorporeal ONB during robot-assisted radical cystectomy with comparable perioperative outcomes. We provide the first step-by-step surgical atlas for robot-assisted ONB reconstruction. Further comparative studies are needed to assess any advantage of one technique over others.

PATIENT SUMMARY

Patients elected for radical cystectomy should be aware that multiple techniques for robotic orthotopic neobladder are available, but that current evidence does not favor one type over the others.

Replicating Florence Intracorporeal Neobladder Technique in Laparoscopic Radical Cystectomy: A Retrospective Study

OBJECTIVE

To evaluate retrospectively the feasibility of Florence robotic intracorporeal neobladder technique in laparoscopic radical cystectomy.

METHODS

Fourteen patients with muscle-invasive bladder cancer underwent laparoscopic radical cystectomy and Florence robotic intracorporeal neobladder between September 2021 and February 2023. Patients' characteristics, pathology data, perioperative outcomes, postoperative complications, and follow-up data were collected.

RESULTS

All operations were successfully completed laparoscopically. The median total operative time was 343 minutes, and the median estimated blood loss was 169.5 mL. No intraoperative complications were observed. The median hospitalization time was 7days, while the median time to regular diet was 3days. Clavien Dindo Grade < III complications appeared in five patients within 30days postoperation. No other complications were noted over the 90days follow-up. Organ-confined disease was confirmed in 11 patients and locally advanced disease in three patients. At 3months follow-up, eight and four patients were daytime and night-time continent, respectively.

CONCLUSION

Replicating Florence robotic intracorporeal neobladder in laparoscopic radical cystectomy is safe, feasible, and repeatable, based on the encouraging perioperative, oncological, and functional outcomes of our study. However, further prospective studies on a larger scale are required to prove its long-term results.

Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023

Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).

Gender and cystectomy for bladder cancer: A high-volume tertiary urologic care center experience

BACKGROUND

Differences have often been reported in the outcomes of bladder cancer (BC) patients according to gender.

OBJECTIVE

This study aims to provide data on patients undergoing radical cystectomy (RC) in a high-volume tertiary urologic center and to assess whether gender discrepancies do exist in terms of surgical options and clinical outcomes.

MATERIALS AND METHODS

Consecutive BC patients treated between 2016 and 2020 at a single center (Careggi University Hospital, Florence, Italy) were included in the study. The impact of gender on disease stage at diagnosis, overall survival (OS), and type of surgery was analyzed.

RESULTS

The study series comprised 447 patients (85 females and 362 males). At a median follow-up of 28.3 months (IQR: 33.5), OS was 52.6% and cancer-specific survival was 67.6%. Significant differences in OS emerged for age, acute myocardial infarction (AMI), Charlson Comorbidity Index (CCI), pT, and pN. OS rates were higher in patients undergoing robot-assisted surgery and in those receiving open orthotopic neobladder (ONB) (p = 0.0001). No statistically significant differences were found between male and female patients regarding surgical offer in any age group, surgical time, early postoperative complications, pathologic stage, and OS.

CONCLUSIONS

After adjustment for pathologic tumor stage and treatment modalities, female and male patients showed similar oncologic outcomes. Further studies should be undertaken to evaluate functional results in women subjected to RC.

Comparison of the Y-pouch orthotopic neobladder and the Studer technique after radical cystectomy: surgical and functional outcomes from a single-center series

BACKGROUND

To explore a method of constructing an orthotopic ileal neobladder (ONB) in the Y-pouch configuration. We describe the steps followed to create the Y-pouch ileal orthotopic neobladder (ONB) and compared the perioperative, functional, and urodynamics outcomes with the Studer neobladder technique.

METHODS

A retrospective cohort study of 90 bladder cancer patients, who received open radical cystectomy with the ONB performed at a hospital from June 2009 to May 2020. These patients were divided into two groups-the Y-pouch and the Studer neobladder groups. Perioperative, functional outcome, complication, renal function data outcomes, and pressure-volume study were used to evaluate the treatment outcomes after a radical cystectomy.

RESULTS

Ninety patients (54 Studer and 36 Y-pouch neobladder) were enrolled. The median patient age was 62.6 (± 11) years. The mean operative time for the Studer technique was 290 (242.5-350) min, and the Y-pouch technique was 300 (271.2-335) min) (p = 0.826). At 30 days postoperatively, the Clavien-Dindo classification of surgical complications revealed grade-2 urinary infections in two patients (5.6%) and six patients (11.1%) for the Y-pouch and Studer techniques, respectively. Intermediate complications (30-90 days) were reported in 4 (11.1%) and 18 patients (44.4%) in the Y-pouch and the Studer techniques, respectively (p = 0.062). In the urodynamics study (UDS), the Y-pouch group had a mean postvoid residual volume of 20 mL and Studer of 40 ml (p = 0.06). A mean capacity of 462 (380-600) mL compares to the Studer neobladder group with 495 (400-628) mL. The average mean compliance of the Studer group was 35.5 (28-52) ml/cm H₂O and 33 (30-43) ml/cm H₂O for Y pouch, and most patients had > 30 ml/cm H₂O compliance (80/90 patients).

CONCLUSIONS

The Y-pouch neobladder technique in an RC with an orthotopic neobladder provides perioperative and functional outcomes compared to those of the Studer orthotopic neobladder resulting in similar intermediate-term. Therefore, the Y-pouch ileal neobladder is both feasible and safe to be used as a standard neobladder technique for urinary diversion in patients with bladder cancer undergoing radical cystectomy and needs confirmation with long-term results.

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.

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.

Update on robotic cystectomy

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.