Is experience with extracorporeal urinary diversion following robotic assisted radical cystectomy necessary before transitioning to intracorporeal urinary diversion?

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.

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

INTRODUCTION

Aim of the study was to evaluate the Florence intracorporeal neobladder (FloRIN) oncological and functional outcomes at the end of assessment phase (phase 3) IDEAL-Guidelines.

MATERIALS AND METHODS

This single-institution prospective series included consecutive patients treated with robot-assisted radical cystectomy (RARC) and FloRIN reconfiguration technique from February 2016 to June 2020. Functional features were evaluated six months after surgery. Patients were grouped into four quartiles according to time of radical cystectomy and impact of learning curve improvement was evaluated.

RESULTS

One-hundred FloRIN were completed with a median console time of 373 (IQR: 312-415) minutes. Two cases were converted to open surgery. No intraoperative complications occurred. At pathological examination, 30% of patients were staged as pT ≤ 1 and 47% as pT ≥ 3. Transitional cell carcinoma was present in 87% of cases. Carcinoma in situ (CIS) and nodal involvement were observed in 38% and 29% of patients, respectively. At a median follow-up time of 17 (IQR: 7-28) months, 20 clinically relevant events (Clavien-Dindo≥3) occurred. Operative time significantly decreased throughout the series (median minutes 435; 395; 365 and 330 in the four quartiles, respectively; p < 0.001). Similarly, early Clavien-Dindo≥3 postoperative complications rate significantly decreased across the series (number of events: 1; 4; 0; 0; p = 0.03). Overall, 75% and 65% of patients achieved day-time and nigh-time continence, respectively. Twenty-seven patients experienced disease recurrence. Cancer-specific and overall survival were equal to 80%.

CONCLUSIONS

RARC with FloRIN reconfiguration showed worthy functional and survival outcomes, with learning curve improvement significantly influencing operative time and early complications rate across series.

Intracorporeal versus extracorporeal urinary diversion after robotic-assisted radical cystectomy: evidence from a systematic review and pooled analysis of observational studies

INTRODUCTION

We aimed to compare the perioperative, pathological and oncological outcomes of patients undergoing extracorporeal urinary diversion (EUD) and intracorporeal urinary diversion (IUD) following robot-assisted radical cystectomy (RARC).

EVIDENCE ACQUISITION

Multiple scientific databases were searched up to January 2020 for comparative studies comparing IUD and EUD. The data was analyzed by Review Manager 5.3.

EVIDENCE SYNTHESIS

A total of 9 observational studies comprising 3582 patients were included in the final analysis. We observed that IUD approach were significantly associated with lower estimated blood loss (EBL) (MD: -90.50, 95% CI: -131.26 to -49.74, P<0.0001), fewer gastrointestinal complications (RR: 0.65; 95% CI: 0.45 to 0.93; P=0.02), and lower risk of uretero-ileal anastomotic stricture (RR: 0.36; 95% CI: 0.14 to 0.91; P=0.03). We did not detect significant difference in terms of length of stay (P=0.14), operative time (P=0.55), blood transfusion (P=0.10), 30-day complication (P=0.50), 90-day complication (P=0.40), 30-day readmission (P=0.12), 90-day readmission (P=0.95), positive surgical margins (P=0.42), lymph node yield (P=0.13), 30-day reoperation (P=0.11) and 90-day mortality (0.27) between IUD and EUD.

CONCLUSIONS

The approach of urinary diversion does not have a considerable impact on pathological, perioperative and oncological outcomes in patients undergoing RARC. The benefits conferred by IUD are lower EBL, lower risk of gastrointestinal complications, and uretero-ileal anastomotic stricture. Subgroup analysis of patients with ileal conduit showed similar results on perioperative and complication outcomes. Well-designed trials conducted by large volumes and experienced surgeons, and reporting complications based on standardized methodology are still warranted.

Robotic radical cystectomy with intracorporeal urinary diversion: beyond the initial experience

Robotic assisted radical cystectomy (RARC) has gained popularity within minimally-invasive urologic surgery, and has been shown to be a safe procedure with similar oncologic outcomes when compared to the conventional open standard. While initial RARC feasibility and outcomes studies were performed with extracorporeal urinary diversion, intracorporeal urinary diversion (ICUD) is becoming increasingly utilized. Reported benefits of an intracorporeal approach include decreased blood loss and a lower incidence of ureteral strictures. While ICUD is technically challenging, many have overcome the learning curve associated with this procedure via a mentorship model and a dedicated operative team. Techniques vary between institutions, and ileal conduit, continent cutaneous and orthotopic continent (neobladder) diversions have all been performed. Herein, we describe the learning curve, technical points, and unique complications associated with ICUD.