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

Biochemical implications of robotic surgery: a new frontier in the operating room

Robotic surgery represents a milestone in surgical procedures, offering advantages such as less invasive methods, elimination of tremors, scaled motion, and 3D visualization. This in-depth analysis explores the complex biochemical effects of robotic methods. The use of pneumoperitoneum and steep Trendelenburg positioning can decrease pulmonary compliance and splanchnic perfusion while increasing hypercarbia. However, robotic surgery reduces surgical stress and inflammation by minimizing tissue trauma. This contributes to faster recovery but may limit immune function. Robotic procedures also limit ischemia-reperfusion injury and oxidative damage compared to open surgery. They also help preserve native antioxidant defenses and coagulation. In a clinical setting, robotic procedures reduce blood loss, pain, complications, and length of stay compared to traditional procedures. However, risks remain, including device failure, the need for conversion to open surgery and increased costs. On the oncology side, there is still debate about margins, recurrence, and long-term survival. The advent of advanced technologies, such as intraoperative biosensors, localized drug delivery systems, and the incorporation of artificial intelligence, may further improve the efficiency of robotic surgery. However, ethical dilemmas regarding patient consent, privacy, access, and regulation of this disruptive innovation need to be addressed. Overall, this review sheds light on the complex biochemical implications of robotic surgery and highlights areas that require additional mechanistic investigation. It presents a comprehensive approach to responsibly maximize the potential of robotic surgery to improve patient outcomes, integrating technical skill with careful consideration of physiological and ethical issues.

Comparative study between the use of double J ureteric stents vs bander ureteric stents during robotic-assisted radical cystectomy with intra corporeal ileal conduit urinary diversion

Robotic-assisted radical cystectomy (RARC) is fast becoming the standard of care with comparable oncological outcomes to open surgery for patients with muscle-invasive bladder cancer. Ileal conduit is by far the most popular means of urinary diversion following a cystectomy. Use of stents is common practice to reduce uretero-enteric anastomosis-related complications. In the current study, practice was changed from the use of Double J (DJ) stents to bander stent intraoperatively. The potential advantages of using bander stent are avoiding second surgery for stent removal and easier change under local anaesthetic in the interventional radiology department. To compare the incidence of blocked, slipped stents and rate of ureteroileal anastomotic stricture after RARC with intracorporeal ileal conduit between practices of using DJ stents and bander stents. Retrospective analysis of all the patients undergoing Robotic radical cystectomy and intracorporeal ileal conduit between June 2014 and August 2023 was done. Initially, all intracorporeal anastomosis were covered with DJ stents. The practice was changed to cover the anastomosis with bander stent in November 2020. Number of patients needing re-surgery for blocked, slipped stents and ureteroileal anastomotic stricture were analyzed and compared using Chi-square analysis and Fisher's exact test (P < 0.05). A total of 168 patients underwent RARC with intracorporeal ileal conduit between June 2014 and August 2023 of which 128 patents were diverted with DJ stents and 40 with bander stent. The mean age and the patient demographics between the two groups were comparable. Of the 128 patients who were diverted with DJ stents, 6 (4.7%) had blocked stents, 3 (2.3%) had slipped stents, and 3 (2.3%) developed ureteroileal stricture needing readmission and urgent invasive intervention to exchange the stent or nephrostomy tube, whereas only 1 (2.5%) of the 40 patients with bander stent had blocked stent which was changed under local anaesthetic in the interventional radiology suite with no slipped stents reported and 2 (5%) had ureteroileal stricture who needed nephrostomies. Intraoperative ureteric stenting using bander stent has the potential to reduce the incidence of stent-related complications, such as blockage, slippage, and ureteroileal anastomotic stricture, following RARC with intracorporeal ileal conduit urinary diversion. Additionally, managing bander stent-related complications is less invasive with lower rate of readmission postoperatively compared to managing DJ stent-related ones.

New technology in prostate cancer and financial toxicity

The management of prostate cancer has significantly evolved over the last few decades with the emergence of new diagnostic and treatment technologies, which are typically more expensive than the previous alternatives. However, decision-making regarding which diagnostics and treatment to pursue is often influenced by perceived benefits, adverse effects, and physician recommendations, without considering the financial liability borne by patients. New technologies may exacerbate financial toxicity by replacing less costly alternatives, promoting unrealistic expectations, and expanding treatment to those who would have previously gone untreated. More judicious use of technologies with an understanding of the contexts in which they are most beneficial may help prevent avoidable financial toxicity to patients.