Robot-Assisted Radical Cystectomy in a Context of Budget Constraints: Description of a Technique with Reduced Economic Impact

Abstract

Background: Robot-assisted radical cystectomy (RARC) is increasingly being implemented in urologic surgical departments. However, its unclear clinical advantage has to be weighed against its rather increased cost compared with open radical cystectomy. We herein describe a technique reducing the number of robotic surgical instruments and staplers for RARC with intracorporeal urinary diversion, presenting preliminary results of our technique in a prospective cohort of patients. Patients and Methods: Eight patients underwent RARC with intracorporeal urinary diversion using a “low-cost” technique between October 2018 and October 2019. RARC is performed with a DaVinci Xi robot. The demolitive part is completed with three robotic instruments: hot shear scissors, Maryland bipolar grasper, and a Cadiere forceps for retraction; Hem-o-lock clips are used for vascular pedicles, avoiding energy dissection devices. For the reconstructive phase, a robotic needle holder is used for suturing in the right hand, whereas the left hand uses the previously employed Maryland. Bowel manipulation is performed with the Cadiere forceps in the right hand and the Maryland in the left hand. For bowel suturing, an omega-shaped configuration is used to avoid wasting staple lines on bowel isolation. Thus, one first staple line (60 mm laparoscopic EndoGIA) completes the anastomosis itself, and a second throw allows the closure of the access enterotomies in the bowel, isolating the intestinal segment for urinary diversion. The omega-shaped bowel destined for ileal conduit is almost 20 cm in length and is measured visually using the robotic cadiere as reference. For neoladder, the diversion begins with the ileo-urethral anastomosis, then two 20 cm limbs are isolated proximally and distally from the anastomosis. The entire procedure is completed with only four instruments, no energy dissector and two throws of 60 mm laparoscopic staplers. The attached video displays the technique. Results: All eight procedures were completed using only four robotic instruments and two staple lines. Seven of eight patients underwent ileal loop diversion and one of eight orthotopic neobladder. Mean operating room time was 400 minutes with a standard deviation (SD) of 89 and a median of 375 minutes (interquartile range [IQR] 338–435). Mean blood loss was 393 mL (SD 136) with a median of 375 mL (IQR 312–537). No intraoperative complications or conversions to open surgery occurred. Mean lymph node yield was 26 (SD 7.4) with a median of 28 (IQR 17–32). Mean hospital stay was 10 (SD 2.6) with a median of 9 days (IQR 7–11). Three of eight patients experienced complications, of which one Clavien I (paralytic ileus) and two Clavien II (urinary tract infection). We estimated, compared with currently diffused RARC techniques, a reduction in cost of 2500€ based on single use instruments and using Belgian prices as reference (−1000€ robotic instruments, −500€ dissection device, −1000€ staple lines). Conclusions: RARC is feasible using a “low-cost” approach, which includes avoiding energy dissection devices, clever use of robotic instruments, and minimizing bowel staple lines. Our results are encouraging and in line with reported large RARC series. A thorough economic analysis is required to define the impact of our technique on hospitalization costs for RARC in Europe. No competing financial interests exist. Runtime of video: 6 mins