Intracorporeal Urinary Diversion After Robot-assisted Cystectomy: Time to Climb the Next Learning Curve?

Abstract

The initial series of robot-assisted radical cystectomies (RARCs) was reported byMenon et al., 10 yr ago, in 2003 [1], but widespread adoption of this approach has been significantly slower than for robot-assisted radical prostatectomy. The reason may be the technically demanding nature of the procedure, limitations on prolonged operative times in patients with multiple comorbidities, the substantial cost of RARC relative to open surgery [2], uncertainty about the morbidity of RARC compared with open cystectomy [3], and a paucity of mature oncologic data [4]. Given the technical demands of RARC and early reports indicating long operative times and high complication rates with intracorporeal diversion [5], extracorporeal urinary diversion (ECUD) was initially the preferred approach for most centres [6]. One criticism of ECUD is that it requires a similar incision and comparable bowel manipulation and exposure as open cystectomy/diversion, which removes some of the benefits of a minimally invasive approach. Perhaps with those issues in mind and with increasing data showing acceptable operating times and morbidity with intracorporeal diversion, several centres have begun to adopt intracorporeal urinary diversion (ICUD), at least for ileal conduit [7]. In this month’s European Urology, the impressive International Robotic Cystectomy Consortium (IRCC) strengthens the impetus for a broader adoption of ICUD, reporting fewer complications compared with ECUD and comparable operative times [8]. The IRCC study is a retrospective analysis of 935 patients who underwent radical cystectomy and pelvic node dissection across 18 international centres. Within that cohort, 768 patients who underwent ECUD were compared with 167 patients who had ICUD with respect to operative time, hospital stay, reoperation rate, readmission rate, oncologic