Functional outcomes after robot-assisted radical cystectomy: A review of literature

[Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]

Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.

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.

Lower Detrusor Apron-sparing Robot-assisted Radical Cystectomy and Intracorporeal Neobladder Reconstruction: Technique and Preliminary Outcomes

BACKGROUND

Prior studies on robot-assisted laparoscopic prostatectomy (RALP) have shown that preservation of the anterior periprostatic structures is associated with good functional outcomes in terms of urinary continence and erectile function. With this in mind, we developed a technique for preservation of the lower part of the detrusor apron (LDA) and anterior periprostatic structures at the time of robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction.

OBJECTIVE

To describe our LDA-sparing RARC technique and to assess its safety and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively evaluated 11 patients who underwent LDA-sparing RARC and ICNB reconstruction at our centre from January 2017 to May 2021.

SURGICAL PROCEDURE

In brief, after developing the plane posterior to the bladder and prostate, the dissection proceeds laterally on both sides of the prostate in an effort to identify the prostatic pedicle. At this point, the bladder pedicles are sectioned in an antegrade fashion. Once the prostate is reached, the dissection is continued laterally by developing the plane that was previously identified. The neurovascular bundles and the lateral and anterior periprostatic structures are conserved in toto. Neobladder reconstruction is performed intracorporeally.

OUTCOME MEASUREMENTS

Postoperative complications, urinary continence (UC), and erectile function (EF).

RESULTS AND LIMITATIONS

The median console time was 290 min. The 30-d complication rate was 36%, with two Clavien-Dindo grade II and two grade III complications that were not attributable to the novel surgical technique. At 12 mo, all patients reported daytime UC or use of a safety pad; at night, seven patients were continent or used a safety pad. Regarding 12-mo EF, four patients were potent without a need for medications, while six were potent with the use of oral phosphodiesterase type 5 inhibitors and one with the use of intracavernosal injections. Limitations include the small number of cases.

CONCLUSIONS

LDA-sparing RARC is an applicable and reproducible procedure. Our results suggest that this approach is associated with good functional outcomes in terms of UC and EF.

PATIENT SUMMARY

We describe a novel approach for robot-assisted removal of the bladder that allows greater preservation of nerve bundles and other structures. Our study shows that the technique is safe and associated with good outcomes for urinary function and erectile function for patients eligible for this surgical procedure.

Late-onset enteric fistula following radical cystectomy for bladder cancer: A case report

Enteric fistula is a rare early onset complication following radical cystectomy with urinary diversion for bladder cancer. We present the case of a 55-year-old woman presenting with an insidious fistula between the ileum and the ileal conduit, diagnosed 20-months after the initial surgery. A single surgical intervention was sufficient for treating this rare etiology. We herein present the case and discuss the available literature on the diagnosis and treatment of such complication.

Robot-assisted radical cystectomy with intracorporeal reconstruction of urinary diversion by mechanical stapler: prospective evaluation of early and late complications

Introduction

Radical cystectomy with pelvic lymph node dissection is the gold standard treatment for non-metastatic muscle-invasive bladder cancer and high-risk non-muscle-invasive bladder cancer. For years, the traditional open surgery approach was the only viable option. The widespread of robotic surgery led to its employment also in radical cystectomy to reduce complication rates and improve functional outcomes. Regardless of the type of approach, radical cystectomy is a procedure with high morbidity and not negligible mortality. Data available in the literature show how the use of staplers can offer valid functional outcomes, with an acceptable rate of complications shortening the operative time. The aim of our study was to describe the perioperative outcomes and complications associated with robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) using a mechanical stapler.

Material and methods

From January 2015 to May 2021, we enrolled patients who underwent RARC with pelvic node dissection and stapled ICUD (ileal conduit or ileal Y-shaped neobladder according to the Perugia ileal neobladder) in our high-volume center. Demographic features, perioperative outcomes and early (≤30 days) and late (>90 days) post-operative complications according to the Clavien-Dindo classification, were recorded for each patient. We also analyzed the potential linear correlation between demographic, pre-operative as well as operative features and the risk of post-operative complications.

Results

Overall, 112 patients who underwent RARC with ICUD were included with a minimum follow-up of 12 months. Intracorporeal Perugia ileal neobladder was performed in 74.1% of cases while ileal conduit was performed in 25.9%. The mean operative time, estimated intraoperative blood loss, and LOS were 289.1 ± 59.7 min, 390.6 ± 186.2 ml, and 17.5 ± 9.8 days, respectively. Early minor and major complications accounted for 26.7% and 10.8%, respectively. Overall late complications were 40.2%. The late most common complications were hydronephrosis (11.6%) and urinary tract infections (20.5%). Stone reservoir formation occurred in 2.7% of patients. Major complications occurred in 5.4%. In the sub-analysis, the mean operative time and the estimated blood loss improved significantly from the first 56 procedures to the last ones.

Conclusion

RARC with ICUD performed by mechanical stapler is a safe and effective technique. Stapled Y-shaped neobladder did not increase the complication rate.

Erectile Dysfunction in Pelvic Cancer Survivors and Current Management Options

Pelvic malignancies, including prostate, rectal, and bladder cancers, are among the most frequent malignancies found in the male population. These issues are most effectively and commonly treated with radiotherapy and/or surgery. However, these treatments can cause collateral damage, resulting in significant impacts on quality of life, with erectile dysfunction being one of the most frequent postoperative complications. Currently, there are several treatment options for erectile dysfunction, including oral phosphodiesterase type 5 inhibitors, vacuum erection devices, intracorporeal injections, and penile prosthesis. The latter has shown to be an effective and safe technique, with results comparable to those obtained by patients without pelvic surgery or radiotherapy. The results of early penile rehabilitation programs are promising and they have been incorporated into a greater proportion of treatment plans more recently, with varying degrees of success. In this narrative review, we summarize the literature on erectile dysfunction after pelvic cancer treatments and its management.

Oncological and functional outcomes of female reproductive organ-sparing radical cystectomy and ileal neobladder construction

OBJECTIVES

To examine the oncological and urinary functional outcomes of reproductive organ-sparing radical cystectomy (ROS-RC) and U-shaped ileal neobladder construction in females compared with male patients.

METHODS

We retrospectively examined 357 patients (281 male and 76 female) with muscle-invasive bladder cancer who were treated with RC plus U-shaped ileal neobladder construction between May 1996 and July 2021. All female patients were treated with ROS-RC. We compared disease-free survival (DFS), cancer-specific survival (CSS), overall survival (OS), and urinary functional outcomes between male and female patients. We evaluated the effect of gender on DFS, CSS, and OS. Furthermore, urinary functional outcomes were evaluated in 140 males and 48 females using a pressure-flow study at 3, 6, 9, and 12 months postoperatively.

RESULTS

Female patients were considerably older than male patients at the time of radical cystectomy. No significant difference was noted in the tumor stage preoperatively. The multivariable Cox regression analysis with an inverse probability treatment weighted model revealed that the female gender was not significantly related to DFS, CSS, and OS. Moreover, urinary functions at 12 months were not markedly different between males and females, except for the capacity of the neobladder, detrusor pressure, and maximum urethral closure pressure.

CONCLUSIONS

This study demonstrates that female patients with ROS-RC and U-shaped ileal neobladder construction did not significantly correlate with worse oncological outcomes. The combination of ROS-RC and U-shaped ileal neobladder construction might attain adequate urinary function without sacrificing oncologic outcomes.