Tips and Tricks for Robot-Assisted Laparoscopic Radical Cystoprostatectomy and Pelvic Lymph Node Dissection

Abstract

Introduction: Radical cystoprostatectomy and bilateral pelvic lymph node dissection remain the standard therapy for muscle-invasive urothelial carcinoma of the bladder. A minimally invasive robotic approach to the extirpative portion of radical cystectomy has become increasingly prevalent. We sought to develop a step-by-step video to share the lessons learned in our initial series of robotic cystectomy cases. Materials and Methods: Eighty-one patients underwent robot-assisted laparoscopic radical cystectomy by a single surgeon from March 2011 to June 2017. Patient demographics, pathologic analysis, and outcomes were obtained. Surgical Technique: We begin with a posterior dissection developing a plane between the rectum and prostate. We then proceed with a unilateral approach taking the lymph nodes and pedicles on one side, then replicate a similar procedure on the contralateral side. The left ureter is passed under the mesocolon and the presacral nodes are removed. We then complete the cystoprostatectomy with anterior dissection of the prostate apex. Although urinary diversion was not demonstrated in this video, extracorporeal urinary diversion was completed for ileal conduits and continent diversions, whereas a hybrid approach was performed for ileal neobladders. Results: The mean age at surgery was 70 years (range 51–89) and 76% were men. Thirty-eight percent underwent neoadjuvant chemotherapy, and 62% ileal conduit, 32% ileal neobladder, and 5% continent urinary diversions were created. Overall 90 day Clavien I-II complication rates were 27% and Clavien III-V complication rates were 11%. Final pathology report included T0-T2 (40%), T2 (14%), and T3-T4 (46%), and 31% were positive lymph nodes. There was one positive surgical margin and mean lymph node counts were 29 (range 3–87). Overall survival was 74% with a mean follow-up of 44 months (range 1–78). Conclusions: Robot-assisted laparoscopic radical cystoprostatectomy and extended pelvic lymph node dissection can be performed safely with favorable pathologic outcomes in surrogates of surgical margins and a number of lymph nodes were removed. Long-term outcomes will need to mature. With increasing experience, our results have suggested that this procedure can be performed expeditiously without sacrificing pathologic and clinical outcomes. No competing financial interests exist. The authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure. Runtime of video: 10 mins