Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion

Long-Term Outcomes of Orthotopic Neobladder Versus Ileal Conduit Urinary Diversion in Robot-Assisted Radical Cystectomy (RARC): Multicenter Results from the Asian RARC Consortium

PURPOSE

Robot-assisted radical cystectomy (RARC) has gained traction in the management of muscle invasive bladder cancer. Urinary diversion for RARC was achieved with orthotopic neobladder and ileal conduit. Evidence on the optimal method of urinary diversion was limited. Long-term outcomes were not reported before. This study was designed to compare the perioperative and oncological outcomes of ileal conduit versus orthotopic neobladder cases of nonmetastatic bladder cancer treated with RARC.

PATIENTS AND METHODS

The Asian RARC consortium was a multicenter registry involving nine Asian centers. Consecutive patients receiving RARC were included. Cases were divided into the ileal conduit and neobladder groups. Background characteristics, operative details, perioperative outcomes, recurrence information, and survival outcomes were reviewed and compared. Primary outcomes include disease-free and overall survival. Secondary outcomes were perioperative results. Multivariate regression analyses were performed.

RESULTS

From 2007 to 2020, 521 patients who underwent radical cystectomy were analyzed. Overall, 314 (60.3%) had ileal conduit and 207 (39.7%) had neobladder. The use of neobladder was found to be protective in terms of disease-free survival [Hazard ratio (HR) = 0.870, p = 0.037] and overall survival (HR = 0.670, p = 0.044) compared with ileal conduit. The difference became statistically nonsignificant after being adjusted in multivariate cox-regression analysis. Moreover, neobladder reconstruction was not associated with increased blood loss, nor additional risk of major complications.

CONCLUSIONS

Orthotopic neobladder urinary diversion is not inferior to ileal conduit in terms of perioperative safety profile and long-term oncological outcomes. Further prospective studies are warranted for further investigation.

Association between bladder cancer treatment and female sexual function

INTRODUCTION

Bladder cancer ranks 17th in prevalence of cancer types among women, and the trend is rising. The increased risk of female sexual dysfunction (FSD) after radical cystectomy (RC) underscores the need for greater focus on preserving and mitigating FSD.

OBJECTIVES

To place greater emphasis on the importance of female sexual function (FSF) in the treatment of bladder cancer and stimulate additional research to discover more effective solutions for enhancing the overall quality of life.

METHODS

This review used a narrative approach. Previous reviews on FSF after RC have provided limited and 1-sided solutions due to the lack of research. What makes this review unique is its innovative approach: it includes all available measures curing FSD as well as comparative analyses based on experimental data, thus making the findings more comprehensive. A detailed perspective of treatments for female bladder cancer is provided, including nerve- and organ-sparing RC, robot-assisted RC, and radiotherapy. We also analyze the impact of treatments for female bladder cancer on postoperative FSD. Additionally, solutions for addressing or alleviating postoperative FSD are summarized, such as urinary diversion, vaginal reconstruction, and drug and nondrug treatment.

RESULTS

Research has suggested that robot-assisted nerve- and organ-sparing RC is promising. Moreover, orthotopic neobladder among urinary diversions without a stoma helps to maintain a positive female body image. If part of the anterior vaginal wall must be removed during RC, vaginal reconstruction can restore the dimensions with synthetic grafts and biologic scaffolds. Additionally, postoperative measures, such as vaginal laser and hormone therapy, and use of vaginal dilators and lubricants have a significant role in reducing distress caused by FSD to provide maximum relief.

CONCLUSIONS

To support FSF after RC, various interventions are needed, and urologists must focus on patient recovery while minimizing treatment impact on FSF as much as possible.

Surgical outcomes and predictive value for major complications of robot-assisted radical cystectomy of real-world data in a single institution in Japan

OBJECTIVE

The objective of the study was to describe the surgical outcome of robot-assisted radical cystectomy and predictive factors for major complications in real-world clinical practice at a single institution in Japan.

METHODS

We retrospectively analyzed 208 consecutive patients undergoing robot-assisted radical cystectomy at our institution between 2019 and 2023. Patient and disease characteristics, intraoperative details, and perioperative outcomes were reviewed. Postoperative complications were defined as minor complications (Clavien-Dindo grades 1-2) or major complications (grades 3-5). Predictors of complications were examined using multivariable logistic analysis.

RESULTS

Overall, 147 men and 61 women, median age 70 years (interquartile range, 62-77), were included in this study. Median operative time and estimated blood loss were 8.4 h and 185 mL, respectively; 11 patients (5%) received intraoperative blood transfusions. For urinary diversions, ileal conduit, neobladder, and cutaneous ureterostomy were performed in 153 (74%), 49 (24%), and 6 (3%) patients, respectively. Urinary diversions were primarily performed with extracorporeal urinary diversion. In total, 140 complications occurred in 111 patients (53%) within 30 days. Of these patients, 31 major complications occurred in 28 patients, and one perioperative death (0.5%) with a postoperative cardiovascular event. Multivariable analysis showed only prolonged operative time (odds ratio: 4.34, 95% confidence interval: 1.82-10.35, p < 0.01) was the independent risk factor for major complications.

CONCLUSIONS

This study reports surgical outcomes at our single institution. Prolonged operative time was a significant prognostic factor for major complications. As far as we know, this study reports the largest number of robot-assisted radical cystectomy cases at a single center in Japan.

Postoperative Outcomes and Analgesic Requirements of Single-Port vs Multiport Robotic-Assisted Radical Cystectomy

Objective: To compare outcomes in patients undergoing robotic-assisted radical cystectomy (RARC) with urinary diversion for bladder cancer with either the single-port (SP) or multiport (MP) robotic platform. Methods: All patients who underwent SP and MP RARC at our institution between January 2018 and January 2023 were retrospectively reviewed. Postoperative analgesia was administered by a departmentwide narcotic stewardship protocol, and inpatient and outpatient narcotic use was tracked. The available preoperative clinical, operative, and postoperative outcomes were analyzed using t-test, chi-square, and Fischer exact statistical measures. Kaplan-Meier analysis with log-rank testing was used to determine the freedom from high-grade (Clavien-Dindo grade ≥3) postoperative complications stratified by SP or MP robotic use. Results: Overall, 96 patients underwent RARC with urinary diversion at our institution, with 49 MP and 47 SP procedures performed. Preoperative clinical parameters including age, body mass index, prior abdominal surgery, and use of neoadjuvant chemotherapy were similar between the two groups. Patients undergoing SP RARC had a shorter operative time (386.0 ± 90.9 minutes vs 453.6 ± 94.8 minutes, p < 0.01) and faster return of bowel function (3.4 ± 1.4 days vs 4.5 ± 2.2 days, p < 0.01). However, both cohorts had similar length of hospitalization, postoperative narcotic use, pathologic staging, and rate of positive surgical margin. Within 3 months postoperatively, both cohorts had a similar high-grade complication, hospital readmission, and cancer recurrence rate. Conclusions: The SP robot allows a safe alternative surgical approach for RARC and offers similar postoperative outcomes compared to the MP robot.

Peri- and post-operative outcomes of robot-assisted radical cystectomy after the implementation of the EAU guidelines recommendations for collecting and reporting complications at a high-volume referral center

PURPOSE

No studies relied on a standardized methodology to collect postoperative complications after robot-assisted radical cystectomy (RARC). The aim of our study was to evaluate peri- and post-operative outcomes of patients undergoing RARC adhering to the European Association of Urology (EAU) recommendations for reporting surgical outcomes and using a long postoperative follow-up.

MATERIALS AND METHODS

246 patients who underwent RARC with intracorporal urinary diversion at a single tertiary referral center with a postoperative follow-up ≥ 1 year for survivors. Postoperative outcomes were collected prospectively by interviews done by medical doctors. Complications were scored using the Clavien-Dindo classification (CD), grouped by type and severity (severe: CD score ≥ 3). We described peri- and post-operative outcomes and complication chronological distribution.

RESULTS

Overall, 16 (6.5%) and 225 patients (91%) experienced intraoperative and postoperative complications, respectively. Moreover, 139 (57%) experienced severe complications. The most common any-grade and severe complications were infectious (72%) and genitourinary (35%), respectively. Overall, 52% of complications (358/682) occurred within 10 days from surgery, and 51% of severe complications (106/207) occurred within 35 days. However, 13% of complications (90/682) and 28% of severe complications (59/207) occurred 3 months after surgery. The earliest complications were fever of unknown origins and paralytic ileus (median time-to-complication [mTTC]: 4 days), the latest complications were urinary tract infection (mTTC: 40 days) and hydronephrosis/ureteral obstruction (mTTC: 70 days).

CONCLUSIONS

The rate of postoperative complications after RARC is > 90% when a standardized collection method and a long follow-up is implemented. These results should be used to identify potential areas of improvement and for preoperative patient counseling.

Perioperative and Complication Related Outcomes for Robotic-Assisted vs Open Radical Cystectomy: A Comparative National Surgical Quality Improvement Project Analysis

Background: Radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer, but it comes with significant perioperative risk, with half of the patients experiencing major postoperative complications. Robot-assisted radical cystectomies (RARCs) have aimed to decrease patient morbidity and been increasingly adopted in North America. Currently, both open radical cystectomies (ORCs) and RARCs are frequently performed. The aim of this study is to contribute to the existing literature using newly available data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP), representing one of the most recent, largest multi-institutional studies, while uniquely accounting for a variety of factors, including type of urinary diversion, cancer staging, and neoadjuvant chemotherapy. Methods: RC procedures performed between 2019 and 2021 were identified in NSQIP and the corresponding cystectomy-targeted database. Cases in the ORC group were planned open procedures, and cases in the RARC group were robot assisted, including unplanned conversion to open cases for intention to treat. Chi-square and t-tests were performed to compare baseline demographics and operative parameters. Multivariate analysis was performed for outcomes, including major complications, minor complications, and 30-day mortality rates, while adjusting for baseline differences significant on univariate analysis. Results: Five thousand three hundred forty-three RC cases were identified. Of these, 70% underwent planned ORC, while 30% received RARC. RARC was associated with longer operative times and shorter hospital length of stay compared with ORC. On multivariate analysis, there was no difference between the cohorts in 30-day rates of major complications, hospital readmissions, need for reoperation, or mortality. ORC was, however, associated with higher rates of minor complications, bleeding, superficial surgical site infections, and anastomotic leak. Conclusions: In the NSQIP database, ORC is associated with higher rates of 30-day minor complications, most notably bleeding, compared with RARC. However, there is no difference in regard to perioperative major morbidity or mortality rates. This study is unique in the size of the cohorts compared, timeliness of data (2019-2021), applicability to a variety of different practice settings across the country, and ability to control for factors, such as type of urinary diversion and pathological bladder cancer staging, as well as use of neoadjuvant chemotherapy. This study was approved by the Institutional Review Board (IRB) specific to Thomas Jefferson University.

Impact of lymph node dissection on surgical and oncological outcomes in patients undergoing robot-assisted radical cystectomy for bladder cancer: a multicenter retrospective study

This study was performed to clarify the therapeutic and diagnostic roles of lymph node dissection (LND) by examining the impact of LND and lymph node yield (LNY) on oncological outcomes in patients undergoing robot-assisted radical cystectomy (RARC). Between 2014 and 2021, 216 patients underwent LND during RARC at Tokushima University Hospital and affiliated hospitals. Among the 216 patients, we compared 115 patients with an LNY of ≥ 20 and 101 with an LNY of < 20 to investigate the impact of LNY on surgical and oncological outcomes. Furthermore, we investigated the impact of LNY and the extent of LND on oncological outcomes by dividing the extent of LND into two groups (standard and extended). The 3-year rates of overall survival (OS) (p = 0.256), cancer-specific survival (CSS) (p = 0.791), and recurrence-free survival (RFS) (p = 0.953) did not differ between the two groups divided by the LNY. A higher LNY was associated with a significantly higher lymph node positivity rate (p = 0.020). The incidence of LND-related major complications was not significantly different between the two groups (p = 0.910). The 3-year survival rates did not differ between the two groups divided by the extent of LND: OS (p = 0.366), CSS (p = 0.814), and RFS (p = 0.689). The LNY and extent of LND were not associated with oncological outcomes in patients undergoing LND during RARC, whereas a higher LNY was associated with lymph node positivity. In the era of adjuvant therapy with immune checkpoint inhibitors, LND during RARC has an important diagnostic role in the detection of pathological node positivity.

Long-term outcomes of pelvic-fascia sparing robotic-assisted radical prostatectomy versus standard technique: Superior urinary function and quality of life without compromising oncologic efficacy in a single-surgeon series

BACKGROUND

Prostatic fascia-sparing robotic-assisted radical prostatectomy (PFS-RARP) has improved short-term postoperative continence compared to standard prostatectomy (S-RARP) but long-term differences remain unclear.

MATERIALS AND METHODS

One hundred two S-RARP followed by 239 PFS-RARPs were performed by a single surgeon. Univariate analyses were performed with t-test, χ2, Wilcoxon rank sum, Fisher exact, and analysis of variance (ANOVA). Regression models analyzed associates of EPIC-CP scores and oncologic outcomes. Cox proportional hazards modeling assessed postoperative continence. Primary outcomes included patient-reported urinary incontinence (UI) via EPIC-CP and continence rates. Secondary outcomes included EPIC-CP scores, positive surgical margins (PSM), and biochemical recurrence (BCR). Perioperative outcomes and time to continence were measured.

RESULTS

Median follow-up for PFS-RARP vs. S-RARP was 26 vs. 65 months. PFS-RARP demonstrated improved EPIC-CP UI and total scores at 24 months. On multivariate analysis, PFS-RARP was associated with improved EPIC-CP UI and total scores through 18 months, but not with PSM or BCR. PFS-RARP had a 39% and 66% reduced risk of incontinence using 0 and 0 to 1 pad-use definitions (HR 0.61, 95% CI 0.39 - 0.95; HR:0.34, 95% CI 0.16 - 0.76). Continence returned faster with PFS-RARP (0 PPD: 91.0 days vs. 261 days, P < 0.001; 0-1 PPD: 32.7 days vs. 171 days, P < 0.001). There were no differences in PSM (35% vs. 25%, P = 0.064). There were more anterior PSM in PFS-RARP vs. S-RARP (47% vs. 26% P = 0.035), but no differences in BCR (16% vs. 22% P = 0.241).

CONCLUSIONS

PFS-RARP improves continence and patient-reported QOL up to 24 months postoperatively without compromising oncologic outcomes.

Systematic review comparing uretero-enteric stricture rates between open cystectomy with ileal conduit, robotic cystectomy with extra-corporeal ileal conduit and robotic cystectomy with intra corporeal ileal conduit formation

Cystectomy is the gold standard treatment for muscle invasive bladder cancer. Robotic cystectomy has become increasingly popular owing to quicker post- operative recovery, less blood loss and less post-operative pain. Urinary diversion is increasingly being performed with an intracorporeal technique. Uretero-enteric strictures (UES) cause significant morbidity for patients. UES for open cystectomy is 3-10%, but the range is much wider (0-25%) for robotic surgery. We aim to perform systematic review for studies comparing all 3 techniques, to assess for ureteric stricture rates. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (Page et al. in BMJ 29, 2021). PubMed, Scopus and Embase databases were searched for the period January 2003 to June 2023 inclusive for relevant publications.The primary outcome was to identify ureteric stricture rates for studies comparing open cystectomy and urinary diversion, robotic cystectomy with extracorporeal urinary diversion (ECUD) and robotic cystectomy with intracorporeal urinary diversion (ICUD). Three studies were identified and included 2185 patients in total. The open operation had the lowest stricture rate (9.6%), compared to ECUD (12.4%) and ICUD (15%). ICUD had the longest time to stricture (7.55 months), ECUD (4.85 months) and the open operation (4.75 months). Open operation had the shortest operating time. The Bricker anastomoses was the most popular technique. Open surgery has the lowest rates of UES compared to both robotic operations. There is a learning curve involved with performing robotic cystectomy and urinary diversion, this may need to be considered to decide whether the technique is comparable with open cystectomy UES rates. Further research, including Randomised Control Trials (RCT), needs to be undertaken to determine the best surgical option for patients to minimise risks of UES.

Single incision robotic cystectomy and urinary diversion

PURPOSE

In this review, we aim to provide readers with a balanced understanding of all aspects of single incision robotic cystectomy (SIRC) and urinary diversion using the single-port (SP) robot. The review will trace the historical progression from open surgery to the introduction of minimally invasive approaches and present an in-depth description of the SIRC technique, offering a step-by-step guide for reference. Emphasis will be placed on indications and patient selection criteria to equip surgeons with well-rounded insights for decision-making.

METHODS

The review analyzes preliminary surgical outcomes by drawing from existing literature and clinical experiences, endeavoring to present a balanced view of the potential benefits and limitations. Addressing the learning curve and training prerequisites is paramount, and this review explores strategies and challenges in preparing surgeons for proficiency. Finally, the focus shifts to current challenges and future directions, identifying key issues and potential advancements in the field.

CONCLUSIONS

By presenting historical context, technical insights, clinical evidence, and strategic foresight, the review aims to provide a comprehensive resource that engages surgeons, researchers, and trainees from diverse perspectives.

Advancements in robotic surgery: innovations, challenges and future prospects

The use of robots has revolutionized healthcare, wherein further innovations have led to improved precision and accuracy. Conceived in the late 1960s, robot-assisted surgeries have evolved to become an integral part of various surgical specialties. Modern robotic surgical systems are equipped with highly dexterous arms and miniaturized instruments that reduce tremors and enable delicate maneuvers. Implementation of advanced materials and designs along with the integration of imaging and visualization technologies have enhanced surgical accuracy and made robots safer and more adaptable to various procedures. Further, the haptic feedback system allows surgeons to determine the consistency of the tissues they are operating upon, without physical contact, thereby preventing injuries due to the application of excess force. With the implementation of teleoperation, surgeons can now overcome geographical limitations and provide specialized healthcare remotely. The use of artificial intelligence (AI) and machine learning (ML) aids in surgical decision-making by improving the recognition of minute and complex anatomical structures. All these advancements have led to faster recovery and fewer complications in patients. However, the substantial cost of robotic systems, their maintenance, the size of the systems and proper surgeon training pose major challenges. Nevertheless, with future advancements such as AI-driven automation, nanorobots, microscopic incision surgeries, semi-automated telerobotic systems, and the impact of 5G connectivity on remote surgery, the growth curve of robotic surgery points to innovation and stands as a testament to the persistent pursuit of progress in healthcare.

Robot-assisted Radical Cystectomy with Orthotopic Neobladder Reconstruction: Techniques and Functional Outcomes in Males

BACKGROUND

Little is known regarding functional outcomes after robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction.

OBJECTIVE

To report on urinary continence (UC) and erectile function (EF) at 12 mo after RARC and ICNB reconstruction and investigate predictors of these outcomes.

DESIGN, SETTING, AND PARTICIPANTS

We used data from a multi-institutional database of patients who underwent RARC and ICNB reconstruction for bladder cancer.

SURGICAL PROCEDURE

The cystoprostatectomy sensu stricto followed the conventional steps. ICNB reconstruction was performed at the physician's discretion according to the Studer/Wiklund, S pouch, Gaston, vescica ileale Padovana, or Hautmann technique. The techniques are detailed in the video accompanying the article.

MEASUREMENTS

The outcomes measured were UC and EF at 12 mo.

RESULTS AND LIMITATIONS

A total of 732 male patients were identified with a median age at diagnosis of 64 yr (interquartile range 58-70). The ICNB reconstruction technique was Studer/Wiklund in 74%, S pouch in 1.5%, Gaston in 19%, vescica ileale Padovana in 1.5%, and Hautmann in 4% of cases. The 12-mo UC rate was 86% for daytime and 66% for nighttime continence, including patients who reported the use of a safety pad (20% and 32%, respectively). The 12-mo EF rate was 55%, including men who reported potency with the aid of phosphodiesterase type 5 inhibitors (24%). After adjusting for potential confounders, neobladder type was not associated with UC. Unilateral nerve-sparing (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.88-7.85; p < 0.001) and bilateral nerve-sparing (OR 6.25, 95% CI 3.55-11.0; p < 0.001), were positively associated with EF, whereas age (OR 0.93, 95% CI 0.91-0.95; p < 0.001) and an American Society of Anesthesiologists score of 3 (OR 0.46, 95% CI 0.25-0.89; p < 0.02) were inversely associated with EF.

CONCLUSIONS

RARC and ICNB reconstruction are generally associated with good functional outcomes in terms of UC. EF is highly affected by the degree of nerve preservation, age, and comorbidities.

PATIENT SUMMARY

We investigated functional outcomes after robot-assisted removal of the bladder in terms of urinary continence and erectile function. We found that, in general, patients have relatively good functional outcomes at 12 months after surgery.

Bladder cancer

Bladder cancer is a global health issue with sex differences in incidence and prognosis. Bladder cancer has distinct molecular subtypes with multiple pathogenic pathways depending on whether the disease is non-muscle invasive or muscle invasive. The mutational burden is higher in muscle-invasive than in non-muscle-invasive disease. Commonly mutated genes include TERT, FGFR3, TP53, PIK3CA, STAG2 and genes involved in chromatin modification. Subtyping of both forms of bladder cancer is likely to change considerably with the advent of single-cell analysis methods. Early detection signifies a better disease prognosis; thus, minimally invasive diagnostic options are needed to improve patient outcomes. Urine-based tests are available for disease diagnosis and surveillance, and analysis of blood-based cell-free DNA is a promising tool for the detection of minimal residual disease and metastatic relapse. Transurethral resection is the cornerstone treatment for non-muscle-invasive bladder cancer and intravesical therapy can further improve oncological outcomes. For muscle-invasive bladder cancer, radical cystectomy with neoadjuvant chemotherapy is the standard of care with evidence supporting trimodality therapy. Immune-checkpoint inhibitors have demonstrated benefit in non-muscle-invasive, muscle-invasive and metastatic bladder cancer. Effective management requires a multidisciplinary approach that considers patient characteristics and molecular disease characteristics.

Lymph node dissection during radical cystectomy for bladder cancer: A two-center comparative study of robotic versus open surgery

INTRODUCTION

This study was performed to evaluate the safety and efficacy of lymph node dissection (LND) during robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC).

METHODS

From October 2003 to December 2021, 122 patients underwent LND during RARC and 103 patients underwent LND during ORC at Tokushima University Hospital and Tokushima Prefectural Central Hospital. We investigated the safety and efficacy of LND during RARC by comparing the surgical and oncological outcomes between the two groups.

RESULTS

The patients were significantly older in the RARC than the ORC group. The operative time was significantly shorter and the estimated blood loss was significantly lower in the RARC than the ORC group. Although the lymph node yield was significantly higher in the RARC than the ORC group, there was no significant difference in lymph node positivity between the groups. There was no significant difference in the incidence of local recurrence or distant metastasis between the two groups. The 5-year survival rates (overall survival, cancer-specific survival, and recurrence-free survival) were not different between the RARC and ORC groups.

CONCLUSION

This study suggests that the surgical and oncological safety and efficacy of LND during RARC are greater than those of LND during ORC. We believe that LND during RARC is a higher-quality procedure than LND during ORC.

Robot-assisted radical cystectomy with intracorporeal urinary diversion: a Danish 11-year series

OBJECTIVES

To evaluate the oncological and perioperative outcomes from a large, single-centre, robot-assisted radical cystectomy (RARC) cohort performed with intracorporeal urinary diversion (ICUD).

PATIENTS AND METHODS

Patients who underwent RARC because of bladder cancer or recurrent carcinoma in situ from June 2009 until August 2020 at Herlev and Gentofte Hospital were prospectively and consecutively included. Kaplan-Meier survival analysis was used to estimate recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). A Cox proportional hazards model was used to identify individual predictors of outcomes. Multiple logistic regression analysis was used to identify predictors of high-grade complications (Clavien-Dindo Grade ≥III).

RESULTS

A total of 542 patients were included. The median (interquartile range) follow-up was 5.3 (2.73-8.06) years. In all, 78 patients (14%) were converted to open surgery; 15 (3%) during cystectomy and 63 patients (12%) were converted from ICUD to extracorporeal urinary diversion. The 5-year RFS, CSS and OS rates were 63% (95% confidence interval [CI] 59%-68%), 75% (95% CI 72%-80%) and 67% (95% CI 63%-72%), respectively. Pathological non-organ-confined disease (tumour stage >T2 or positive lymph nodes) predicted poorer RFS, CSS and OS. Reconstruction with a neobladder (20% of cases) compared to an ileal conduit was the only predictor of high-grade complications (odds ratio 2.54, 95% CI 1.46-4.43; P < 0.001).

CONCLUSION

A RARC with ICUD is feasible as a standard surgical procedure for bladder cancer with only a few patients converted to open surgery. In our hands reconstruction with a neobladder was a strong predictor for high-grade complications.

First case report of robot-assisted radical cystectomy for bladder cancer that developed after salvage radiotherapy following radical prostatectomy for prostate cancer

Introduction

Robot-assisted radical cystectomy for bladder cancer that develops after curative treatment for prostate cancer has not yet been reported.

Case presentation

A 65-year-old man underwent radical prostatectomy and received salvage radiotherapy after his postoperative prostate-specific antigen level failed to decrease. Nine years after radiotherapy, local recurrence and lung/bone metastases were observed, and he was started on androgen deprivation therapy. In the following year, he was diagnosed with nonmuscle invasive bladder cancer. He underwent transurethral resection of the bladder tumor once but had multiple recurrences within 3 months. As hematuria could not be controlled by transurethral surgery, he underwent robot-assisted radical cystectomy without rectal injury. Since then, there has been no recurrence of either bladder or prostate cancer.

Conclusion

This is the first report of a successful robot-assisted radical cystectomy for bladder cancer that developed after local salvage radiotherapy following radical prostatectomy for prostate cancer.

Robot-assisted radical cystectomy vs open radical cystectomy in patients with bladder cancer: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Even though there isn't enough clinical evidence to demonstrate that robot-assisted radical cystectomy (RARC) is preferable to open radical cystectomy (ORC), RARC has become a widely used alternative. We performed the present study of RARC vs ORC with a focus on oncologic, pathological, perioperative, and complication-related outcomes and health-related quality of life (QOL).

METHODS

We conducted a literature review up to August 2022. The search included PubMed, EMBASE and Cochrane controlled trials register databases. We classified the studies according to version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). The data was assessed by Review Manager 5.4.0.

RESULTS

8 RCTs comparing 1024 patients were analyzed in our study. RARC was related to lower estimated blood loss (weighted mean difference (WMD): -328.2; 95% CI -463.49--192.92; p < 0.00001), lower blood transfusion rates (OR: 0.45; 95% CI 0.32 - 0.65; p < 0.0001) but longer operation time (WMD: 84.21; 95% CI 46.20 -121.72; p < 0.0001). And we found no significant difference in terms of positive surgical margins (P = 0.97), lymph node yield (P = 0.30) and length of stay (P = 0.99). Moreover, no significant difference was found between the two groups in terms of survival outcomes, pathological outcomes, postoperative complication outcomes and health-related QOL.

CONCLUSION

Based on the present evidence, we demonstrated that RARC and ORC have similar cancer control results. RARC is related to less blood loss and lower transfusion rate. We found no difference in postoperative complications and health-related QOL between robotic and open approaches. RARC procedures could be used as an alternate treatment for bladder cancer patients. Additional RCTs with long-term follow-up are needed to validate this observation.

Perioperative outcomes of open versus robot-assisted radical cystectomy in octogenarians: a population based analysis

Octogenarians undergoing cystectomy experience higher morbidity and mortality compared to younger patients. Though the non-inferiority of robot-assisted radical cystectomy (RARC) compared to open radical cystectomy (ORC) has been established in a generalized population, the benefits of the robotic approach have not been well studied in an aged population. The National Cancer Database (NCDB) was queried for all patients who underwent cystectomy for bladder cancer from 2010 to 2016. Of these, 2527 were performed in patients age 80 or older; 1988 and 539 underwent ORC and RARC, respectively. On Cox regression analysis, RARC was associated with significantly reduced odds for both 30- and 90-day mortality (HR 0.404, p = 0.004; HR 0.694, p = 0.031, respectively), though the association with overall mortality was not significant (HR 0.877, p = 0.061). The robotic group had a significantly shorter length of stay (LOS) compared to open surgery (10.3 days ORC vs. 9.3 days RARC, p = 0.028). The proportion of cases performed robotically increased over the study period from 12.2% in 2010 to 28.4% in 2016 (p = 0.009, R² = 0.774). The study is limited by a retrospective design and a section bias, which was not completely control for in the analysis. In conclusion, RARC provides improved perioperative outcomes in aged patients compared to ORC and a trend toward greater utilization of this technique was observed.

Robot-assisted vs. open radical cystectomy: systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Several randomized controlled trials (RCTs) have been launched in the last decade to examine the surgical safety and oncological efficacy of robot-assisted (RARC) vs open radical cystectomy (ORC) for patients with bladder cancer. The aim of the study was to perform a systematic review and meta-analysis of RCTs to compare the perioperative and oncological outcomes of RARC vs ORC.

METHODS

A literature search was conducted through July 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The outcomes were intraoperative, postoperative, and oncological outcomes of RARC vs ORC.

RESULTS

A total of eight RCTs comprising 1,024 patients met our inclusion criteria. RARC was associated with longer operative time (mean 92.34 min, 95% CI 83.83-100.84, p < 0.001) and lower blood transfusion rate (Odds ratio [OR] 0.43, 95% CI 0.30-0.61, p < 0.001). No differences emerged in terms of 90-day overall (p = 0.28) and major (p = 0.57) complications, length of stay (p = 0.18), bowel recovery (p = 0.67), health-related quality of life (p = 0.86), disease recurrence (p = 0.77) and progression (p = 0.49) between the two approaches. The main limitation is represented by the low number of patients included in half of RCTs included.

CONCLUSIONS

This study supports that RARC is not inferior to ORC in terms of surgical safety and oncological outcomes. The benefit of RARC in terms of lower blood transfusion rate need to be balanced with the cost related to the procedure.

The feasibility of robot-assisted radical cystectomy: an experimental study

PURPOSE

To investigate the feasibility of the avatera system for performing robot-assisted radical cystectomy (RARC) followed by intracorporeal reconstruction of ileal neobladder.

METHODS

Six anesthetized female pigs were used to perform RARC and formation of the intracorporeal orthotopic ileal neobladder. Three surgeons with different level of expertise in the use of robotic systems performed RARC after a short instructional lecture and a 2-h hands-on training. The urinary diversion phase was performed only by the experienced surgeon. The successful completion of the procedure, operative time for demolitive and reconstructive phases, intraoperative blood loss and malfunction of the robotic system were evaluated.

RESULTS

An improvement of the operative time was observed for each surgeon. The experienced surgeon, the fellow and the resident improved their time by 11, 15, and 22 min, respectively, between the first and the second RARC performed. The most significant time difference was demonstrated by the resident, who had no previous experience in using robotic systems. The time difference between the first and the last orthotopic ileal neobladder creation for the experienced surgeon was 51 min.

CONCLUSION

The feasibility of avatera system for performing complex surgical procedure such as RARC with intracorporeal neobladder formation was demonstrated by this experimental study. No major bleeding or severe malfunctions were observed during the procedures. Significant improvement in operative time was demonstrated with the increasing experience from 1st to 6th case.

Peri-operative, Functional, Quality of Life, and Oncological Outcomes After Robot-Assisted Radical Cystectomy and Intra-corporeal Orthotopic Ileal Neobladder-Our Experience

Robot-assisted radical cystectomy (RARC) and intracorporeal orthotopic neobladder (OINB) is technically a challenging surgery due to the involvement of prolonged console time and higher level of surgical skills. Therefore, standardizing technique and testament of good functional and oncological outcomes is required to increase its acceptance among surgeons. We report our experience of RARC with OINB and analyze the perioperative, functional, quality of life, and survival outcomes. Single surgeon experience of over 22 OINB after RARC is done, which includes 21 male and one female patients, was done retrospectively. Modified Karolinska Studer technique of neobladder creation was followed. Intraoperative findings, post-operative complications, and follow-up information were recorded for analysis. The patients' median age was 50.5 years (IQR, 41.25-55.50), and the median follow-up period was 45.5 months (IQR, 26.75-68). Median console time was 447.5 min (IQR, 347.5-500), blood loss was 225 ml (IQR, 200-250), and hospital stay was 12 days (IQR, 11-15). Most of the complications were Clavien-Dindo grades I and II. Longer surgery time and more complications were noted in the first 10 cases compared to the next 12 cases. Day and night-time urinary continence is 95% and 77% at 12 months, respectively. Two patients died of disease, and overall survival at 5 years was 84%. Our experience supports OINB as a feasible option after RCIC with acceptable complications, good functional and survival outcomes, with better quality of life. With experience, surgical morbidity and operative time decrease. This surgery should be undertaken after gaining experience with an intracorporeal ileal conduit and has a steep learning curve.

Global trends and hotspots in research of robotic surgery in oncology: A bibliometric and visual analysis from 2002 to 2021

BACKGROUND

With the development of robotic surgery in the field of oncology, an increasing number of relevant research papers have been published. In order to explore the research hotspots and trends in this field, a bibliometric and visual analysis was performed for the first time.

METHODS

The literature records related to oncology robotic surgery were obtained from the Web of Science Core Collection database and imported into the software VOSviewer 1.6.18, CiteSpace 6.1.R3, and the Bibliometric Online Analysis Platform for analysis.

RESULTS

A total of 6,964 publications, including 5,635 articles and 1,329 reviews, were included in this study. Over the past 20 years, annual publications and citations have experienced rapid growth, particularly in the last two years. The United States was the country with the most publications, while Yonsei University in South Korea was the most productive institution. The Journal of Robotic Surgery and the Journal of Urology were the journals with the most publications and citations, respectively. Mottrie A from Belgium and Ficarra V from Italy were the authors with the highest number of publications and citations, respectively. The keywords "robotic surgical procedure", "laparoscopic surgery", "prostate cancer", "colorectal cancer", "gastric cancer", "resection", "complications classification", "open surgery", "transoral robotic surgery", "pathological outcomes", and "robot-assisted surgery" reflect the research hotspots and trends of oncology robotic surgery.

CONCLUSION

The therapeutic advantages of robotic surgery in oncology are not yet prominent, and further randomized controlled trials with multicenter and large samples are needed to evaluate the advantages of robotic surgery compared with laparoscopic surgery and open surgery in the treatment of tumors from multiple outcome indicators.

Robotic-assisted versus standard laparoscopic radical cystectomy in bladder cancer: A systematic review and meta-analysis

Background

This study aimed to evaluate the efficacy and safety of robotic-assisted radical cystectomy (RARC) versus laparoscopic radical cystectomy (LRC) in the treatment of bladder cancer.

Methods

Two researchers independently searched PubMed, Embase, Cochrane, and CBM using the index words to identify the qualified studies which included randomized controlled trials (RCTs) and non-randomized controlled trials (prospective and retrospective studies), and the investigators scanned references of these articles to prevent missing articles. Differences in clinical outcomes between the two procedures were analyzed by calculating odds risk (OR) and mean difference (MD) with an associated 95% confidence interval (CI).

Results

Sixteen comparative studies were included in the meta-analysis with 1467 patients in the RARC group and 897 patients in the LRC group. The results indicated that RARC could significantly decrease blood loss (P = 0.01; MD: -82.56, 95% CI: -145.04 to -20.08), and complications 90 days or more after surgery, regardless of whether patients were Grade ≤ II (P = 0.0008; OR: 0.63, 95% CI: 0.48 to 0.82) or Grade ≥ III (P = 0.006; OR: 0.59, 95% CI: 0.40 to 0.86), as well as overall complications (P: 0.01; OR = 0.52; 95% CI: 0.32 to 0.85). However, there was no statistical difference between the two groups at total operative time, intraoperative complications, transfusion rate, short-term recovery, hospital stay, complications within 30 days of surgery, and bladder cancer-related mortality.

Conclusions

The meta-analysis demonstrates that RARC is a safe and effective treatment for bladder cancer, like LRC, and patients with RARC benefit from less blood loss and fewer long-term complications related to surgery, and should be considered a viable alternative to LRC. There still need high-quality, larger sample, multi-centric, long-term follow-up RCTs to confirm our conclusion.

A propensity score matching study on robot-assisted radical cystectomy for older patients: comparison of intracorporeal ileal conduit and cutaneous ureterostomy

BACKGROUND

Robot-assisted radical cystectomy (RARC) and intracorporeal urinary diversion are less invasive than conventional procedures. However, for older patients, cutaneous ureterostomy (CUS) may be preferred because urinary diversion using the intestine has a high incidence of perioperative complications and is highly invasive. The purpose of this study was to demonstrate the safety and efficacy of intracorporeal ileal conduit (ICIC) compared with CUS in patients aged 75 years or older who underwent RARC.

METHODS

From October 2014 to December 2021, 82 patients aged 75 years or older who underwent RARC at Tokushima University Hospital, Tokushima Prefectural Central Hospital, or Ehime Prefectural Central Hospital were retrospectively reviewed. Of these, 52 and 25 patients who underwent ICIC and CUS, respectively, were included. After adjusting the patients' characteristics using propensity score-matching, surgical results and prognoses were retrospectively compared. The propensity score was based on age, Eastern Cooperative Oncology Group Performance Status Scale (ECOG-PS), American Society of Anesthesiologists physical status classification (ASA-PS), clinical tumor stage, and neoadjuvant chemotherapy.

RESULTS

The median age was lower in the ICIC group compared with the CUS group, and the proportion of high-risk cases (ECOG-PS ≥ 2 or ASA-PS ≥ 3) did not differ. The median operation time was longer in the ICIC group, and estimated blood loss was higher, compared with the CUS group. There were no significant differences in the incidence of complications within the first 30 postoperative days, incidence of complications 30-90 days after surgery, 2-year overall survival, 2-year cancer-specific survival, and 2-year recurrence-free survival. The stent-free rate was significantly lower in the CUS group than that in the ICIC group.

CONCLUSION

In older patients, the ICIC group showed non-inferior surgical and oncological outcomes compared with the CUS group. Urinary diversion following RARC in older patients should be carefully selected by considering not only the age but also the general condition (including comorbidities) of the patient.

Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).

Endopelvic Fascia Sparing Robotic Radical Cystectomy with Intracorporeal Studer Pouch with Balbay's Technique

Background and Objectives

Robotic radical cystectomy (RARC) with intracorporeal urinary diversion is a technically complicated, time-consuming procedure. The aim of this study was to present the operative, pathological, oncological, and functional outcomes of patients who underwent endopelvic fascia sparing (EPFS) RARC with intracorporeal Studer pouch formation. To the best of our knowledge, this is first series in the literature that includes EPFS RARC.

Methods

Between October 1, 2019 and April 30, 2022, 10 bladder cancer patients underwent EPFS RARC, bilateral extended pelvic lymph node dissection with intracorporeal Studer pouch reconstruction with Balbay's technique. Patient demographics, operative, and post-operative parameters were recorded.

Results

Among 10 patients, 8 were male and 2 were female. Mean operative time, median estimated blood loss, and median duration of hospital stay was 530 minutes, 316 ml, and 8 days, respectively. One month postoperatively, the mean maximum flow, average flow rate, mean voided, and post-voided urine volume were 20.2 ml/sec, 4.4 ml/sec, 273.6 ml, and 3.5 ml, respectively. All of the patients were fully continent during day-time, three had mild night-time incontinence requiring pad use (both patients 1 pad per night). During a mean 11.5 months of follow up, zero patients died. One patient with a pathological, stage 4 tumor, had nodal recurrence at six months postoperatively. No distant metastasis were detected.

Conclusion

Endopelvic fascia sparing RARC has very promising early functional results with safe oncological outcomes and low complication rates.

Technique of en bloc resection of the membranous urethra and bladder during robot-assisted radical cystectomy in patients without simultaneous urethrectomy

INTRODUCTION

Prophylactic urethrectomy is often performed simultaneously with radical cystectomy (RC) in patients who are not selected for neobladder creation for urinary diversion. However, the indications for prophylactic urethrectomy are still controversial. Here, we introduce the ideal urethral dissection technique during robot-assisted radical cystectomy (RARC) in patients without simultaneous prophylactic urethrectomy.

MATERIALS AND SURGICAL TECHNIQUE

At our hospital, RARC is performed using a da Vinci surgical system with the operating table tilted to 20°. After lymph node dissection and bladder mobilization, periurethral dissection is commenced. A notable point of our technique is en bloc resection of the bladder and membranous urethra using a continuous intracorporeal approach. First, while applying traction on the isolated bladder in the cranial direction, we carefully and gradually dissect the urethral smooth muscle from the external urethral sphincter with electrocautery scissors. Next, we ligate the membranous urethra with suture material as far from the prostate as possible. Then, we cut the urethra as far from the prostate as possible after ligation of the urethra with a Hem-o-lok clip just beyond the apex of the prostate. Using this method, we are able to remove at least 1.0 cm of the membranous urethra en bloc with the bladder. Finally, we suture the pelvic floor, including the levator ani muscle, in two layers using 3-0 V-Loc and 2-0 V-Loc sutures.

DISCUSSION

We believe this technique allows separation of the residual urethra from the abdominal cavity and enables safe performance of secondary urethrectomy.

Transition from da Vinci to Versius robotic surgical system: initial experience and outcomes of over 100 consecutive procedures

We sought to describe the development of the robotic urology program at Sindh Institute of Urology and Transplantation (SIUT) and the feasibility of transitioning from the da Vinci to Versius robotic systems. The SIUT robotics program began in 2017 utilizing the da Vinci Si robotic system, transitioning to the Versius system in 2021. Retrospective review of our quality assurance database was performed. All procedures performed utilizing the two systems were identified, analyzed, and compared. Data were described with descriptive statistics. Matched procedures (by type of procedure) performed by the same surgeons utilizing the da Vinci and Versius were compared. All tests were double-sided with statistical significance set at p < 0.05.106 cases were performed by the Versius robotic surgical system in 2021. Median age was 42 years (IQR 26-56), and 69 (65%) were males. Procedures included both benign (83%) and malignant disorders (17%), several upper tract (75%), and pelvic/lower tract (25%). No major intraoperative complications were observed. Conversion to open occurred in six procedures. Malfunction of the robotic arms occurred in two procedures: the erroneous bedside units (BSU) were replaced. Eight patients developed postoperative high-grade complications. Matched analysis of various procedures (pyeloplasty, stone surgery, radical, partial, and simple nephrectomy) showed no significant difference in perioperative outcomes. To our knowledge, this is the first and largest series of urologic procedures performed by the Versius robotic surgical system.

A Historical Perspective of The Evolution of Laparoscopic Surgeries in Urology

Recent decades have seen the rapid progression of minimally invasive surgery in urology with continuing developments in robotic technology paving ways into a new era. In addition to these technological innovations, interests from urologists in developing and embracing new techniques have become a forefront in the ongoing evolution of the field allowing for improvement intraoperative experience as well as morbidity and mortality outcomes. This article aims to provide an overview of the historical development of laparoscopic surgery in urology whilst also providing a brief look into its future.

A comparative population-based analysis of peritoneal carcinomatosis in patients undergoing robotic-assisted and open radical cystectomy

PURPOSE

To compare the population-based incidence of peritoneal carcinomatosis following open (ORC) vs. robotic-assisted radical cystectomy (RARC).

METHODS

Using the Surveillance, Epidemiology and End Results Program (SEER)-Medicare linked data, we identified 1,621 patients who underwent radical cystectomy for bladder cancer during 2009 and 2014; 18.1% (n = 294) and 81.9% (n = 1327) underwent RARC and ORC, respectively. We subsequently evaluated the rates of peritoneal carcinomatosis at 6, 12, and 24 months following surgery. Multivariable proportional hazards regression was performed to determine factors associated with development of peritoneal carcinomatosis.

RESULTS

Patients who underwent RARC vs. ORC were more likely to be male (p = 0.04); however, age at diagnosis, race, comorbidities, education, and marital status (all p > 0.05) did not differ by surgical approaches. Our findings showed that there were no significant differences in the rates of peritoneal carcinomatosis between ORC and RARC at 6, 12, and 24 months. In adjusted analyses, factors associated with peritoneal carcinomatosis were advanced N stage (N0 versus N2/3: HR 0.30, 95% CI 0.16-0.55, p < 0.01), preoperative hydronephrosis (HR 1.70, 95% CI 1.09-2.65, p = 0.04), higher T stage (T1 versus T4: HR 0.34, 95% CI 0.15-0.79, p < 0.01; T2 versus T4: HR 0.39, 95% CI 0.20-0.76, p < 0.01), and use of neoadjuvant chemotherapy (HR 1.78, 95% CI 1.11-2.84, p < 0.01). However, RARC was not associated with peritoneal carcinomatosis (HR 1.36, 95% CI 0.78-2.35).

CONCLUSION

In this population-based analysis, we found no difference in peritoneal carcinomatosis between robotic or open approaches to radical cystectomy. These data should be reassuring to those utilizing robotic cystectomy.

Robot-Assisted Totally Intracorporeal Resection of Cutaneous Ureterostomy Tumor and Ileal Conduit Surgery: A Rare Case Report

BACKGROUND

Radical cystectomy (RC) is the standard treatment for muscular invasive bladder cancer (MIBC) and some high-risk non-muscular invasive bladder cancer (NMIBC). Cutaneous ureterostomy is a common form of urinary diversion. However, after radical cystectomy, recurrence of upper urinary tract malignancies is possible. There is no relevant report on how to improve this situation's management.

CASE PRESENTATION

This case is a 56-year-old male patient hospitalized due to the development of a new tumor in the ureteral cutaneous stoma following radical cystectomy for more than five years. A biopsy of the tumor revealed high-grade urothelial carcinoma. Computed tomography (CT) revealed that the local soft tissue around the cutaneous stoma was thickened, but no other lesions were visible. After evaluating the case, we chose robot-assisted completely intracorporeal resection of cutaneous ureterostomy tumor and ileal conduit surgery. The total time for the operation and the blood loss were 400 minutes and 150 ml, respectively. Following surgery, the patient got standard chemotherapy in combination with immunotherapy. Additionally, ten months following the surgery, the patient did not experience disease progression or complications.

CONCLUSION

The robot-assisted operation is safe and feasible for upper urinary tract tumor recurrence following radical cystectomy with cutaneous ureterostomy.

Diffusion of robot-assisted radical cystectomy: Nationwide trends, predictors, and association with continent urinary diversion

Objectives

To assess the utilisation trends of robot-assisted radical cystectomy (RARC), rates of performing continent urinary diversions (CUDs), and impact of diffusion of RARC on CUD rates.

Methods

We investigated the National Cancer Database for patients with muscle-invasive bladder cancer (MIBC) who underwent RC between 2004 and 2015. Patients were stratified by surgical technique into open (ORC) and RARC groups, and by type of urinary diversion into continent (CUD) and ileal conduit (ICUD) groups. Linear regression models were fitted to evaluate time trends for surgery and conversion techniques. Multivariate logistic regression models were utilised to identify independent predictors of RARC and CUD.

Results

A total of 14466 patients underwent RC for MIBC, of which 4914 (34%) underwent RARC. There was a significant increase in adoption of RARC from 22% in 2010 to 40% in 2015 (R2 = 0.96, P < 0.001), this was not associated with a change in the rates of CUD over the same period (P = 0.22). Across all years, ICUD was the primary type of urinary diversion, CUD was only offered in 12% in 2010 compared to 9.9% in 2015 (R2 = 0.33, P = 0.22). Multivariate analysis identified male gender (odds ratio [OR] 1.18, P = 0.03), academic centres (OR 1.74, P = 0.001), and lower T stage (T4 vs T2; OR 0.78, P = 0.03) as independent predictors of CUD, while surgical technique was not associated with odds of receiving CUD (P = 0.8).

Conclusions

There is significant nationwide increasing trend of adoption of RARC. This diffusion was not associated with a decline in CUD, which remains significantly underutilised in both ORC and RARC groups. Abbreviations CUD: continent urinary diversion; ICD-O: International Classification of Diseases for Oncology; ICUD: ileal conduit urinary diversion; (N)MIBC: (non-)muscle-invasive bladder cancer; NAC, neoadjuvant chemotherapy; NCDB: National Cancer Database; OR: odds ratio;(O)(RA)RC: (open) (robot-assisted) radical cystectomy.

Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion

INTRODUCTION

Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD.

MATERIAL AND METHODS

Retrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon.

RESULTS

The 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60 min between G1-G3 (p = 0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (p = 0.6) or the number of lymph nodes removed (p = 0.061). The postoperative complication rate was 77% and did not change during the LC (p = 0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (p = 0.217).

CONCLUSIONS

The inclusion of junior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.

Three-port approach vs standard laparoscopic radical cystectomy with an ileal conduit: a single-centre retrospective study

BACKGROUND

This study aimed to evaluate the effect of the three-port approach and conventional five-port laparoscopic radical cystectomy (LRC) with an ileal conduit.

METHODS

Eighty-four patients, who were diagnosed with high-risk non-muscle-invasive and muscle-invasive bladder carcinoma and underwent LRC with an ileal conduit between January 2018 and April 2020, were retrospectively evaluated. Thirty and fifty-four patients respectively underwent the three-port approach and five-port LRC. Clinical characteristics, pathological data, perioperative outcomes, and follow-up data were analysed.

RESULTS

There were no differences in perioperatively surgical outcome, including pathology type, prostate adenocarcinoma incidence, tumour staging, and postoperative creatinine levels between the two groups. The operative time (271.3 ± 24.03 vs. 279.57 ± 48.47 min, P = 0.299), estimated blood loss (65 vs. 90 mL, P = 0.352), time to passage of flatus (8 vs. 10 days, P = 0.084), and duration of hospitalisation post-surgery (11 vs. 12 days, P = 0.922) were no clear difference between both groups. Compared with the five-port group, the three-port LRC group was related to lower inpatient costs (12 453 vs. 14 134 $, P = 0.021). Our follow-up results indicated that the rate of postoperative complications, 90-day mortality, and the oncological outcome did not show meaningful differences between these two groups.

CONCLUSIONS

Three-port LRC with an ileal conduit is technically safe and feasible for the treatment of bladder cancer. On comparing the three-port LRC with the five-port LRC, our technique does not increase the rate of short-term and long-term complications and tumour recurrence, but the treatment costs of the former were reduced.

Single-Port Robotic Radical Cystectomy with Intracorporeal Bowel Diversion: Initial Experience and Review of Surgical Outcomes

INTRODUCTION & OBJECTIVE

Scant literature is available on surgical outcomes of radical cystectomies on the new single-port (SP) system. This study compares short term outcomes in patients undergoing radical cystectomy with intracorporeal urinary diversion (ICUD) on the multi-port (MP) vs. SP platform.

METHODS

This IRB approved study used a prospective cystectomy database and non-parametric testing including Chi-Squared, Mann-Whitney U, and Fisher Exact tests to analyze all variables stratified by surgical approach.

RESULTS

34 patients underwent radical cystectomy with ICUD from 9/1/2019 to 2/8/2021. 20 patients were in the MP cohort, while 14 were in the SP group. Table 1 presents the demographics of both groups and shows no statistically significant differences. Intra- and post-operative as well as pathology data is shown in Table 2. Patients in the SP group had less narcotic use (MP: 25 MME vs. SP: 11.5 MME, p=0.047) and shorter return of bowel function (MP: 3 days vs. SP: 2 days, p=0.032). Operative times were similar between both groups despite having fewer patients undergoing ileal conduit (MP: 85% vs. SP: 50%, p=0.027) in the SP group. In table 3, we list the early short term post-operative follow up data for each group which showed no significant differences between the two groups with an average follow up of 4.9 months for MP and 4.4 months for SP.

CONCLUSIONS

Our initial experience with SP robotic cystectomy and ICUD appears to be safe and an effective alternative to MP cystectomies. A learning curve was involved but the overall transition from MP to SP was smooth. Operative times were similar despite fewer patients undergoing ileal diversion, shorter return of bowel function, and less narcotic use in the SP group. Further studies including longer follow ups with multi-institutional data are underway.

Radical Cystectomy in England from 2013 to 2019 on 12,644 patients: An analysis of national trends and comparison of surgical approaches using Hospital Episode Statistics data

Introduction

We evaluate the data of 12,644 Radical Cystectomies in England (Open, Robotic and Laparoscopic) with trends in the adaption of techniques and post-operative complications.

Methods

This analysis utilised national Hospital Episode Statistics (HES) from NHS England.

Results

There was a statistically significant increase (P < .001) in the number of Robotic assisted radical cystectomies from 10.8% in 2013-2014 and 39.5% in 2018-2019.The average LOS reduced from 12.3 to 10.8 days for RARC from 2013 to 2019 similarly the LOS reduced from 16.2 to 14.3 for ORC. The rate of sepsis (0-90 days) did rise from 5% to 14.5% between 2013-2014 and 2017-2018 for the entire cohort (P < .001). Acute renal failure (ARF) increased over the years from 9.5% to 17% (P < .001). The rate for fever, UTI, critical care activity and ARF were higher for ORC than RARC (P < .001).The comparison of all episodes within 90 days for conduit versus non-conduit diversions showed significantly higher rates of sepsis, infections, UTI and fever in non-conduit group .Overall complications were significantly higher in non-conduit group throughout the duration except was year 2016-17(P < .001).The robotic approach has increased in last 5 years with nearly 40% of the cystectomies now being robotically in 2018-19 from the initial percentage of 10.8% in 2013-14.

Conclusion

This evaluation of the HES data from NHS England for 12,644 RC confirms an increase in the adoption of Robotic Cystectomy. Our data confirms the need to develop strategies with enhanced recovery protocols and post-operative close monitoring following Radical Cystectomy in order to reduce post-operative complications.

Complication Rate after Radical Cystectomy Depends on the Surgical Technique and Patient's Clinical Status

PURPOSE

This study aimed to explore the complication rates of radical cystectomy in patients with muscle-invasive bladder cancer and identify potential risk factors.

METHODS

A total of 553 patients were included: 131 were operated on via an open approach (ORC), 242 patients via a laparoscopic method (LRC), and 180 by a robot-assisted procedure (RARC). Patient age, gender, American Society of Anesthesiologists (ASA) score, urinary diversion type, preoperative albumin level, body mass index (BMI), pathological (TNM) stage, and surgical times were collected. The severity of complications was classified according to the Clavien-Dindo scale (Grades 1-5).

RESULTS

The surgical technique was significantly related to the number of complications (p < 0.00005). Grade 1 complications were observed most frequently following LRC (52.5%) and RARC (51.1%), whereas mostly Grade 2 complications were detected after ORC (78.6%). Those with less severe complications had significantly higher albumin levels than those with more severe complications (p < 0.05). Patients with an elevated BMI had fewer complications if a minimally invasive approach was used rather than ORC. The patient's general condition (ASA score) did not impact the number of complications, and urinary diversion type did not affect the severity of the complications. Mean surgical time differed according to the urinary diversion type in patients with a similar TNM stage (p < 0.005); however, no difference was found in those with more locally advanced disease. Longer operation time and lower protein concentration were associated with higher probability of complication rate, that is, Clavien-Dindo score 3-5.

CONCLUSIONS

The risk of complications after RC is not related to the type of urinary diversion, and can be reduced by using a minimally invasive surgical technique, especially in patients with high BMI.

Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion

INTRODUCTION

Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD.

MATERIAL AND METHODS

Retrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon.

RESULTS

The 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60minutes between G1-G3 (P=0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (P=0.6) or the number of lymph nodes removed (P=0.061). The postoperative complication rate was 77% and did not change during the LC (P=0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (P=0.217).

CONCLUSIONS

The inclusion of júnior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.

Perioperative Outcomes of Robot-Assisted Radical Cystectomy with Intracorporeal Versus Extracorporeal Urinary Diversion

PURPOSE

This study was designed to investigate and compare the perioperative outcomes of intracorporeal urinary diversion (ICUD) versus extracorporeal urinary diversion (ECUD) following robotic-assisted radical cystectomy (RARC) in patients with localized bladder cancer from the Asian Robot-Assisted Radical Cystectomy (RARC) Consortium.

METHODS

The Asian RARC registry was a multicenter registry involving nine centers in Asia. Consecutive patients who underwent RARC were included. Patient and disease characteristics, intraoperative details, and perioperative outcomes were reviewed and compared between the ICUD and ECUD groups. Postoperative complications were the primary outcomes, whereas secondary outcomes were the estimated blood loss and the duration of hospitalization. Multivariate regression analyses were performed to adjust potential confounders.

RESULTS

From 2007 to 2020, 556 patients underwent RARC; 55.2% and 44.8% had ICUD and ECUD, respectively. ICUD group had less estimated blood loss (423.1 ± 361.1 vs. 541.3 ± 474.3 mL, p = 0.002) and a shorter hospital stay (15.7 ± 12.3 vs 17.8 ± 11.6 days, p = 0.042) than the ECUD group. Overall complication rates were similar between the two groups. Upon multivariate analysis, ICUD was associated with less estimated blood loss (Regression coefficient: - 143.06, 95% confidence interval [CI]: - 229.60 to - 56.52, p = 0.001) and a shorter hospital stay (Regression coefficient: - 2.37, 95% CI: - 4.69 to - 0.05, p = 0.046). In addition, ICUD was not associated with any increased risks of minor, major, and overall complications.

CONCLUSIONS

RARC with ICUD was safe and technically feasible with similar postoperative complication rates as ECUD, with additional benefits of reduced blood loss and a shorter hospitalization.

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

This systematic review and meta-analysis aimed to assess and compare the perioperative and oncological outcomes of intracorporeal (ICUD) and extracorporeal (ECUD) urinary diversion following robot-assisted radical cystectomy (RARC). A systematic literature search of articles was performed in PubMed^®, Web of Science^®, and Scopus^® databases according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. We included studies that compared patients who underwent RARC with ICUD to those with ECUD. Twelve studies including 3067 patients met the eligibility criteria. There were no significant differences between ICUD and ECUD in overall and major complications, regardless of the period (short-term [≤ 30 days] or mid-term [> 30 days]). Subgroup analyses demonstrated that ICUD performed by high-volume centers exhibited a significantly reduced risk of major complications (short-term: OR 0.57, 95% CI 0.37–0.86, p = 0.008, mid-term: OR 0.66, 95% CI 0.46–0.94, p = 0.02). Patients who underwent ICUD had lower estimated blood loss (MD -102.3 ml, 95% CI − 132.8 to − 71.8, p < 0.00001), less likely to receive blood transfusion rates (OR 0.36, 95% CI 0.20–0.62, p = 0.00003); and these findings were consistent in subgroup analyses by low-volume centers (MD-121.6 ml, 95% CI − 160.9 to − 82.3, p < 0.00001 and OR 0.36, 95% CI 0.20–0.62, p = 0.00003, respectively). ICUD had a higher lymph node yield (MD 3.68, 95% CI 0.80–6.56, p = 0.01). Patients receiving ICUD provided comparable complications, superior perioperative outcomes, and similar oncological outcomes compared with ECUD. Centralization of patients may contribute to a reduction of postoperative complications, while maintaining the advantages.

Robot-assisted versus open radical cystectomy: A cohort study on perioperative outcomes accounting for stage selection bias and surgical experience

BACKGROUND

Most comparisons of robot-assisted (RARC) versus open radical cystectomy (ORC) for urothelial carcinoma do not factor the inherent stage selection bias or surgical experience.

METHODS

We compared the perioperative outcomes of 229 RARC and 335 ORC at a single tertiary referral centre with propensity score matching and multiple regression models, when controlling for tumour and patient characteristics, surgeon's experience and type of urinary diversion.

RESULTS

RARC had less major complications (19.8% vs. 34.1%) and ICU admissions (6.6% vs. 19.8%), with lower blood loss (400 vs. 500 ml) and transfusion rates. The operating time was longer (336 vs. 286 min), but decreased with surgeon's experience. RARC had less positive surgical margins (3% vs. 8.4%) and a higher lymph node count (14 vs. 11).

CONCLUSIONS

In this large single centre series comparing RARC with ORC controlling for stage selection bias and surgical experience, RARC proved significantly better outcomes, especially with intracorporeal urinary diversion.

Diffusion and adoption of the surgical robot in urology

Over the last two decades, robotic surgery has become a mainstay in hospital systems around the world. Leading this charge has been Intuitive Surgical Inc.’s da Vinci robotic system (Sunnyvale, CA, USA). Through its innovative technology and unique revenue model, Intuitive has installed 4,986 robotic surgical systems worldwide in the last two decades. The rapid rate of adoption and diffusion of the surgical robot has been propelled by many important industry-specific factors. In this review, we propose a model that explains the successful adoption of robotic surgery due to its three core groups: the surgeon, the hospital administrator, and the patient.

Robotic assisted radical cystectomy versus open radical cystectomy: a review of what we do and don't know

Radical cystectomy (RC) is the gold standard treatment for muscle-invasive and high-risk, noninvasive bladder cancer. Since 2003, robot-assisted radical cystectomy (RARC) has been gaining popularity. Metanalyses show that the primary advantage of RARC is less blood loss and the primary advantage of open radical cystectomy (ORC) is shorter operative times. There do not appear to be significant differences in complications, cancer-related outcomes or survival between the two approaches. Cost analyses comparing RARC and ORC are complicated by the often-ill-defined distinction between the cost to the hospital versus the cost to payors. However, it is likely that for both hospitals and payors, RARC is cost effective at high-volume centers. It is feasible that in the future, increased experience with RARC will lead to improved outcomes and justify the use of RARC over ORC.

A Novel Neobladder-Urethral Drag-and-Bond Anastomosis Technique During Laparoscopic Radical Cystectomy for Ileal Orthotopic Neobladder: Surgical Technique and Initial Research

Purpose

To explore the application of the neobladder-urethral drag-and-bond anastomosis technique in laparoscopic radical cystectomy (LRC) with ileal orthotopic neobladder (IONB) reconstruction.

Patients and Methods

This is a retrospective cohort study on a procedure performed by a single surgeon. From January 2014 to December 2018, we identified 43 male bladder cancer patients who received LRC with IONB reconstruction. These patients were divided into two groups, with 22 patients undergoing neobladder-urethral drag-and-bond anastomosis (NUDA) and 21 patients undergoing neobladder-urethral anastomosis under laparoscopy (NUAL). Anastomosis time, catheter removal time, postvoid residual (PVR), maximum urinary flow rate (Q-max), urine leakage and anastomotic stenosis were used to evaluate the simplicity and surgical effect of the two groups.

Results

Both groups demonstrated similar tumor characteristics. A significant difference in neobladder-urethral anastomosis time was found between the NUDA group and the NUAL group (14.6 ± 0.4 vs 70 ± 2.5 min, P<0.0001), and there was no significant difference in other characteristics.

Conclusion

The neobladder-urethral drag-and-bond anastomosis technique in LRC and IONB reconstruction, with its shorter learning curve, was easier and more convenient than neobladder-urethral anastomosis under laparoscopy.

Effect of intracorporeal urinary diversion on the incidence of benign ureteroenteric stricture after cystectomy

OBJECTIVES

To compare ureteroenteric stricture rates after radical cystectomy in patients who undergo an intracorporeal urinary diversion versus other surgical approaches.

METHODS

We retrospectively reviewed health records of all patients who underwent cystectomy with urinary diversion at Mayo Clinic Hospital (Phoenix, AZ, USA) from 1 January 2007 through 1 January 2018. Ureteroenteric stricture was identified by surveillance imaging. Patients were stratified by surgical approach: open radical cystectomy, robot-assisted radical cystectomy with extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion. A Cox proportional hazards model was fitted that included independent predictors of stricture development.

RESULTS

Of the 573 cystectomies assessed, 236 (41.2%) were carried out robotically. In the robot-assisted radical cystectomy cohort, 39 patients (16.5%) underwent intracorporeal urinary diversion. The median follow-up period was 55, 70 and 71 months for the open radical cystectomy, robot-assisted radical cystectomy-extracorporeal urinary diversion and robot-assisted radical cystectomy-intracorporeal urinary diversion groups, respectively. Subgroup stricture rates were as follows: open radical cystectomy, 8.0%; robot-assisted radical cystectomy-extracorporeal urinary diversion, 9.6%; and robot-assisted radical cystectomy-intracorporeal urinary diversion, 2.6% (P = 0.33). The median time to stricture was 5 months (interquartile range 3.3-11.5 months). In the bivariable analysis, factors that were associated with the development of ureteroenteric stricture were postoperative urinary leak (hazard ratio 3.177, 95% confidence interval 1.129-8.935; P = 0.03) and body mass index (hazard ratio 1.078, 95% confidence interval 1.027-1.132; P = 0.002). On multivariable logistic regression analysis, intracorporeal urinary diversion approach was not associated with the development of ureteroenteric stricture (hazard ratio 0.272, 95% confidence interval 0.036-2.066; P = 0.21).

CONCLUSIONS

Ureteroenteric stricture is a complication that typically occurs within the first postoperative year. Although our results did not support major differences in outcomes between intracorporeal urinary diversion and extracorporeal urinary diversion, the small sample size did not exclude the possibility of a type 2 statistical error.

Well leg compartment syndrome following robot-assisted radical cystectomy in the lithotomy position: a case report

Background

The indications for robot-assisted urologic surgeries have expanded due to their low invasiveness. However, complicated surgical procedures lead to prolonged surgical duration, requiring patients to remain in the lithotomy position for an extended time. Well leg compartment syndrome (WLCS) is a known severe postoperative complication related to the lithotomy position.

Case presentation

We report a case of WLCS after robot-assisted radical cystectomy (RARC), in which the patient recovered without neurological sequelae. A 55-year-old, obese male who underwent RARC complained of right leg pain and paresthesia 3 h after the surgery that lasted for 481 min. Emergency evaluation revealed unilateral WLCS in the anterior and lateral compartments. Urgent fasciotomy was performed 4 h after symptom onset. He thereafter recovered completely and was discharged without any neuromuscular dysfunction.

Conclusions

Early detection of WLCS, surgical treatment, and additional measures are crucial to prevent its life-threatening and/or disabling outcomes.

Role of laparoscopy in the era of robotic surgery in urology in developing countries

With the rapid expansion of robotic platforms in urology, there is an urgent and unmet need to review its cost and benefits in comparison to the traditional laparoscopy, especially in reference to a developing country. A nonsystematic review of the literature was conducted to compare the outcomes of pure laparoscopic and robot-assisted urologic procedures. Available literature over the past 30 years was reviewed. Robot-assisted surgery and laparoscopy were found to have similar outcomes in the areas of radical prostatectomy, partial and radical nephrectomy, radical cystectomy, retroperitoneal lymph node (LN) dissection, inguinal LN dissection, donor nephrectomy, and kidney transplantation. Robot-assisted surgery was found to be significantly costlier than pure laparoscopy. In the absence of a clear advantage of robot-assisted surgery over pure laparoscopy, lack of widespread availability and the currently prohibitive cost of robotic technology, laparoscopic urological surgery has a definite role in the developing world.