Extracorporeal Urinary Diversion Research Articles

Long-term oncologic outcomes and complications of robot-assisted radical cystectomy for the treatment of urothelial carcinoma of the bladder

IntroductionTo report the long-term outcomes of robot-assisted radical cystectomy (RARC) for the treatment of muscle invasive and high-risk non-muscle invasive bladder cancer. MethodsWe reviewed a single tertiary center database of RARC from 2004 to 2020. Concomitant extended pelvic lymph node dissection and extracorporeal urinary diversion were performed. Cox regression analysis and the Kaplan-Meier method were used to identify factors associated with and report time-to-event estimations of recurrence-free survival and overall survival. Clavien-Dindo complications were identified, categorized, and substratified by time from surgery within 90-days and between 90-days and >5-years postoperatively. ResultsA total of 510 patients with median follow-up of 57.1 months (IQR 21.8–103.6) were included. Continent diversion was performed in 259 (51%) patients. Of the 340 (67%) ≥cT2 patients, 153 (45%) received cisplatin-based neoadjuvant chemotherapy. Recurrence was identified in 157 (31%) patients, and 118 (23%) died from bladder cancer. The overall complication rate was 52% with 267 (41%) major grade ≥ III events. Infectious (25%) and genitourinary (22%) complications were the most common irrespective of the time interval beyond 90-days. The risk of recurrence or death were increased by extravesical disease (HR 1.91 and 1.97, respectively) and lymph node positivity (HR 4.58 and 2.42, respectively) in multivariable analysis (all, P < 0.001). The estimated 5-, and 10-year recurrence-free and overall survival rates were 69% and 64% and 61% and 44%, respectively. ConclusionsRARC is a durable treatment that optimizes the probability of cure for patients requiring extirpation for bladder cancer. Targeting the modifiable complications of radical surgery may further improve the risk/benefit ratio of RARC.

Intracorporeal urinary diversion offers the advantage of delaying postoperative renal function injury in patients undergoing robot-assisted radical cystectomy.

To analyze changes in renal function and associated risk factors in patients with bladder cancer undergoing robot-assisted radical cystectomy (RARC) with intracorporeal or extracorporeal urinary diversion (ICUD or ECUD). Clinical-pathological data was extracted from electronic medical records of 266 patients with bladder cancer who underwent RARC at our institution between August 2015 and August 2022. Postoperative renal function was assessed using the estimated glomerular filtration rate (eGFR). Patients were classified into ECUD and ICUD groups based on the surgical approach. Significant differences in eGFR were observed between the two groups at 1, 2, and 3 years postoperatively. Moreover, 112 patients (42.1%) experienced long-term renal function injury. Independent risk factors for long-term renal function injury included the type of surgical approach, ureteroenteric anastomotic strictures, and pathological stage T3 or above. In terms of short-term renal function, 30 cases of acute kidney injury (AKI) were observed, with an incidence rate of 11.3%. No difference in AKI incidence was found between the groups. Postoperative AKI and chronic kidney injury are prevalent complications following RC. This study highlights that pathological stage, ureteroenteric anastomotic strictures, and ECUD significantly impact long-term renal function, but the type of urinary diversion (ileal conduit or orthotopic neobladder) had no effect on renal function, and ICUD was superior in terms of long-term renal injury rate. Therefore, precise preoperative assessment and the selection of appropriate surgical approach are crucial for preserving renal function in patients with bladder cancer.

Comparison of Extracorporeal and Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy for Bladder Cancer: A Meta-Analysis.

To explore the therapeutic efficacy of intracorporeal urinary diversion (ICUD) and extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy for bladder cancer through systematic review. This study systematically retrieved electronic databases of PubMed, Web of Science, Cochrane Library, CNKI, and Wanfang to include peer-reviewed studies comparing ICUD and ECUD after robot-assisted radical cystectomy for bladder cancer. Relative risk (RR) and mean difference (MD) were used to represent the pooled effect size and estimate its 95% confidence interval (CI). This study included 15 studies with good quality, involving 5,370 patients undergoing robot-assisted radical cystectomy for bladder cancer. Meta-analysis showed that ICUD reduced intraoperative bleeding volume by 64.12 ml (95% confidence interval [CI]: [-100.95, -27.29]), significantly decreased the risk of blood transfusion (RR: 0.40; 95% CI: [0.24, 0.68]) and gastrointestinal complications (odds ratio [OR]: 0.61; 95% CI: [0.47, 0.80]), with shorter postoperative time of exhaust (MD: -9.27; 95% CI: [-18.47, -0.08]) and oral intake (MD: -0.92; 95% CI: [-1.30, -0.54]). However, ICUD had a relatively longer surgical duration (MD: 30.84 min, 95% CI: [5.03, 56.66]). In addition, there was no statistically significant difference concerning the impact of ICUD and ECUD on the length of stay in the hospital (MD: -0.68d; 95% CI: [-1.79, 0.42]), overall complications (30-day: RR: 1.16; 95% CI: [0.93, 1.46]; and 90-day, RR: 0.85; 95% CI: [0.69, 1.04]) and readmission rate (30-day: RR: 0.96; 95% CI: [0.72, 1.27]; and 90-day: RR: 1.15; 95% CI: [0.80, 1.64]). ICUD after robot-assisted laparoscopic radical cystectomy for bladder cancer exhibits obvious positive effects, especially in reducing the risk of blood transfusion and gastrointestinal complications, and shortening postoperative time of exhaust and oral intake. The findings in this meta-analysis should be confirmed by multiple high-quality studies in the future.

Evaluating the Differences of Wound Related Complications in Robotically Assisted Radical Cystectomy vs Open Radical Cystectomy

ObjectiveTo determine whether robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) compared to open radical cystectomy (ORC) or RARC with extracorporeal urinary diversion (ECUD) would result in a decreased rate of surgical site complications. RARC has been shown to be non-inferior to ORC. Both RARC and ORC are complicated by a high rate of perioperative morbidity, including wound related complications, which may be decreased by a robotic approach with intracorporeal diversion. MethodsA retrospective review of our bladder cancer database for patients undergoing radical cystectomy from 2013 to 2021. Patients were stratified by surgical technique as RARC with ICUD vs. ORC vs. RARC with ECUD. Surgical site complications were measured at both 30 and 90-day intervals. ResultsOf the 269 patients, 127 (47.2%) had RARC with ICUD, 118 (43.7%) had ORC, and 24 (8.9%) had RARC with ECUD (mean ages 71.0, 69.5, 67.5 respectively). A comparison of the three groups demonstrated statistical significance at both the 30-day (p<0.001) and 90-day (p<0.001) timeframes for total surgical site complications, with RARC with ICUD having the fewest amount of patients experience a surgical site complication (0.8%) followed by ORC (25.4%) and RARC with ECUD (29.2%). ConclusionOverall, we observed lower surgical site complication rates among patients undergoing RARC with ICUD compared to patients who underwent ORC or RARC with ECUD. This study suggests that decreased surgical site complications may be one benefit of the minimally invasive approach particularly in patients at high risk for surgical site complications after radical cystectomy.

Comparative Outcomes of Open Radical Cystectomy vs. Robot-Assisted Approaches with Intracorporeal and Extracorporeal Urinary Diversion: A Meta-Analysis and Network Meta-Analysis of Perioperative and Quality of Life Outcomes.

Background: To conduct a comprehensive systematic review and network meta-analysis of RCTs that compare outcomes of robot-assisted radical cystectomy (RARC) with intra- or extracorporeal urinary diversion (ICUD or ECUD) and the standard open approach (oRC). Methods: A systematic review identified RCTs including patients aged >18 years with non-metastatic bladder cancer treated with RARC (ICUD or ECUD) vs. oRC and reporting peri- and post-operative outcomes and quality of life (QoL) assessment. Standard and network metanalyses were performed. Results: Data from 1024 patients included in eight RCTs were analyzed. The standard meta-analysis found that RARC had longer OT, lower EBL, and a lower transfusion rate compared to oRC (all p < 0.001). No significant differences in terms of LOS between the ICUD vs. ECUD vs. ORC were recorded. RARC patients demonstrated better scores in fatigue, insomnia, pain, physical functioning, and role functioning-according to QoL assessment-compared to ORC at early follow-up, despite no difference at baselines. Finally, at network metanalysis, ICUD (OR = 0.74, p < 0.001) but not ECUD (OR = 0.92, p < 0.08) yielded a lower rate of high-grade 90-day complications compared to ORC despite longer OT (MD = 89.56, p = 0.0351). Conclusions: RARC represents a safe and feasible option to reduce perioperative bleeding with no definitive impact on LOS compared to ORC. Interestingly, ICUD may reduce the burden of 90-day complications to a greater extent than ECUD. Nonetheless, surgeons should be aware of the extended OT and steep learning curve of ICUD. Finally, RARC may provide some short-term benefits in terms of QoL, but more research is needed to determine its long-term effects.

Surgical outcomes and predictive value for major complications of robot-assisted radical cystectomy of real-world data in a single institution in Japan.

The objective of the study was to describe the surgical outcome of robot-assisted radical cystectomy and predictive factors for major complications in real-world clinical practice at a single institution in Japan. We retrospectively analyzed 208 consecutive patients undergoing robot-assisted radical cystectomy at our institution between 2019 and 2023. Patient and disease characteristics, intraoperative details, and perioperative outcomes were reviewed. Postoperative complications were defined as minor complications (Clavien-Dindo grades 1-2) or major complications (grades 3-5). Predictors of complications were examined using multivariable logistic analysis. Overall, 147 men and 61 women, median age 70 years (interquartile range, 62-77), were included in this study. Median operative time and estimated blood loss were 8.4 h and 185 mL, respectively; 11 patients (5%) received intraoperative blood transfusions. For urinary diversions, ileal conduit, neobladder, and cutaneous ureterostomy were performed in 153 (74%), 49 (24%), and 6 (3%) patients, respectively. Urinary diversions were primarily performed with extracorporeal urinary diversion. In total, 140 complications occurred in 111 patients (53%) within 30 days. Of these patients, 31 major complications occurred in 28 patients, and one perioperative death (0.5%) with a postoperative cardiovascular event. Multivariable analysis showed only prolonged operative time (odds ratio: 4.34, 95% confidence interval: 1.82-10.35, p < 0.01) was the independent risk factor for major complications. This study reports surgical outcomes at our single institution. Prolonged operative time was a significant prognostic factor for major complications. As far as we know, this study reports the largest number of robot-assisted radical cystectomy cases at a single center in Japan.

Efficacy of the Addition of Robot-assisted Radical Cystectomy with Extracorporeal Urinary Diversion after an Enhanced Recovery Protocol.

It is unclear if robotic radical cystectomy with extracorporeal urinary diversion (eRARC) provides additional benefit when performed along with enhanced recovery after surgery (ERAS). We assessed the additional efficacy of eRARC in terms of perioperative outcomes. We retrospectively assessed 143 patients undergoing radical cystectomy with urinary diversion between June 2010 and December 2021 at a single center. The patients were assigned to three groups: open radical cystectomy (ORC) with conventional recovery after surgery (CRAS) [Group A], ORC with ERAS [Group B], and eRARC with ERAS [Group C]. A propensity score-matched analysis was performed to evaluate how ERAS and eRARC affected outcomes respectively. Meanwhile, multivariable analysis was used to detect the predictors of prolonged length of hospital stay (LOS). The median LOS was shorter after ERAS and eRARC. In the propensity score-matched analysis, ERAS was linked to a significantly shorter median LOS (28.0 vs. 20.0 days, P < .001), but eRARC was not associated with a shorter LOS (19.0 vs. 17.5 days, P = .21). Neither ERAS nor eRARC were connected with a reduce in complication rate. Following multivariable analysis, ERAS was found to be independently associated with shorter LOS (OR=0.23, P < .001), but eRARC demonstrated no such correlation (OR=0.29, P = .096). ERAS had strong association with shorter LOS, although eRARC did not contribute to additional efficacy. Neither ERAS nor eRARC decreased the complication rate.

Identify risk factors for perioperative outcomes in Intracorporeal Urinary Diversion and Extracorporeal Urinary Diversion with Robotic Cystectomy.

The increasing adoption of robotic-assisted cystectomy with intracorporeal urinary diversion (ICUD), despite its complexity, prompts a detailed comparison with extracorporeal urinary diversion (ECUD). Our study at a single institution investigates perioperative outcomes and identifies risk factors impacting the success of these surgical approaches. In this retrospective analysis, 174 patients who underwent robotic-assisted cystectomy at the University of Louisville from June 2016 to August 2021 were reviewed. The cohort was divided into two groups based on the urinary diversion method: 30 patients underwent ECUD and 144 underwent ICUD. Data on demographics, complication rates, length of hospital stay, and readmission rates were meticulously collected and analyzed. Operative times were comparable between the ICUD and ECUD groups. However, the ICUD group had a significantly lower intraoperative transfusion rate (0.5 vs. 1.0, p=0.02) and shorter hospital stay (7.8 vs. 12.3 days, p<0.001). Factors such as male sex, smoking history, diabetes mellitus, intravesical therapy, higher ASA, and ACCI scores were associated with increased Clavien-Dindo Grade 3 or higher complications. Age over 70 was the sole factor linked to a higher 90-day readmission rate, with no specific characteristics influencing the 30-day rate. Robotic cystectomy with ICUD results in shorter hospitalizations and lower intraoperative transfusion rates compared to ECUD, without differences in operative time, high-grade postoperative complications, or readmission rates. These findings can inform clinical decision-making, highlighting ICUD as a potentially more favorable option in appropriate settings.

Infections After Adoption of Antibiogram-directed Prophylaxis and Intracorporeal Urinary Diversion for Robot-assisted Radical Cystectomy

BackgroundEnhanced recovery after surgery (ERAS) has significantly decreased the morbidity associated with radical cystectomy. However, infectious complications including sepsis, urinary tract (UTIs), wound (WIs), and intra-abdominal (AIs) infections remain common. ObjectiveTo assess whether intracorporeal urinary diversion (ICUD) and antibiogram-directed antimicrobial prophylaxis would decrease infections after robotic-assisted radical cystectomy (RARC). Design, setting, and participantsA retrospective analysis was performed of a prospectively maintained database of patients undergoing RARC between 2014 and 2022 at a tertiary care institution, identifying two groups based on adherence to a prospectively implemented modified ERAS protocol for RARC: modified-ERAS—ICUD and antibiogram-directed ampicillin-sulbactam, gentamicin, and fluconazole prophylaxis were utilized (from January 2019 to present time), and unmodified-ERAS—extracorporeal urinary diversion (UD) and guideline-recommended cephalosporin-based prophylaxis regimen were utilized (from November 2014 to June 2018). Patients receiving other prophylaxis regimens were excluded. InterventionICUD and antibiogram-directed infectious prophylaxis. Outcome measurements and statistical analysisThe primary outcome was UTIs within 30 and 90 d postoperatively. The secondary outcomes were WIs, AIs, and sepsis within 30 and 90 d postoperatively, and Clostridioides difficile infection (CDI) within 90 d postoperatively. Results and limitationsA total of 396 patients were studied (modified-ERAS: 258 [65.2%], unmodified-ERAS: 138 [34.8%]). UD via a neobladder was more common in the modified-ERAS cohort; all other intercohort demographic differences were not statistically different. Comparing cohorts, modified-ERAS had significantly reduced rates of 30-d (7.8% vs 15.9%, p = 0.027) and 90-d UTIs (11.2% vs 25.4%, p = 0.001), and 30-d WIs (1.2% vs. 8.7%, p < 0.001); neither group had a WI after 30 d. Rates of AIs, sepsis, and CDI did not differ between groups. On multivariate regression, the modified-ERAS protocol correlated with a reduced risk of UTIs and WIs (all p < 0.01). The primary limitation is the retrospective study design. ConclusionsUtilization of ICUD and antibiogram-based prophylaxis correlates with significantly decreased UTIs and WIs after RARC. Patient summaryIn this study of infections after robotic radical cystectomy for bladder cancer, we found that intracorporeal (performed entirely inside the body) urinary diversion and an institution-specific antibiogram-directed antibiotic prophylaxis regimen led to fewer urinary tract infections and wound infections at our institution.

Robot-assisted radical cystectomy with intracorporeal urinary diversion: a Danish 11-year series.

To evaluate the oncological and perioperative outcomes from a large, single-centre, robot-assisted radical cystectomy (RARC) cohort performed with intracorporeal urinary diversion (ICUD). Patients who underwent RARC because of bladder cancer or recurrent carcinoma in situ from June 2009 until August 2020 at Herlev and Gentofte Hospital were prospectively and consecutively included. Kaplan-Meier survival analysis was used to estimate recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). A Cox proportional hazards model was used to identify individual predictors of outcomes. Multiple logistic regression analysis was used to identify predictors of high-grade complications (Clavien-Dindo Grade ≥III). A total of 542 patients were included. The median (interquartile range) follow-up was 5.3 (2.73-8.06) years. In all, 78 patients (14%) were converted to open surgery; 15 (3%) during cystectomy and 63 patients (12%) were converted from ICUD to extracorporeal urinary diversion. The 5-year RFS, CSS and OS rates were 63% (95% confidence interval [CI] 59%-68%), 75% (95% CI 72%-80%) and 67% (95% CI 63%-72%), respectively. Pathological non-organ-confined disease (tumour stage >T2 or positive lymph nodes) predicted poorer RFS, CSS and OS. Reconstruction with a neobladder (20% of cases) compared to an ileal conduit was the only predictor of high-grade complications (odds ratio 2.54, 95% CI 1.46-4.43; P < 0.001). A RARC with ICUD is feasible as a standard surgical procedure for bladder cancer with only a few patients converted to open surgery. In our hands reconstruction with a neobladder was a strong predictor for high-grade complications.

Assistent guide: A novel device for ureteral stent placement in robot-assisted intracorporeal ileal conduit.

Ureteral stent placement in robot-assisted intracorporeal ileal conduit formation (RICIC) is more challenging than extracorporeal urinary diversion. We developed a novel dedicated device called the Assistent guide for safe and smooth performance of ureteral stent placement by the patient-side surgeon (PSS). This study reviewed the clinical records of 59 patients underwent RICIC with a total of 110 ureteral stent placements: 59 stents were placed using the Assistent guide, and 51 stents were placed using a suction tip. The stenting time was significantly shorter in the Assistent guide group than in the suction tip group. Even for beginners, the stenting time was significantly shorter. The PSSs' satisfaction score was significantly higher in the Assistent guide group. No complications associated with ureteral stent placement occurred. We showed the safety and efficacy of the Assistent guide for ureteral stent placement in RICIC.

Robot-Assisted Radical Cystectomy: A Single-Center Experience and a Narrative Review of Recent Evidence

Radical cystectomy represents one of the most challenging surgical procedures, exhibiting a high morbidity rate. The transition to minimally invasive surgery in the field has been steep, due to either the technical complexity and prior concerns of atypical recurrences and/or peritoneal spread. More recently, a larger series of RCTs has proven the oncological safety of robot-assisted radical cystectomy (RARC). Beyond survival outcomes, the comparison between RARC and open surgery in terms of peri-operative morbidity is still ongoing. We present a single-center experience of RARC with intracorporeal urinary diversion. Overall, 50% of patients had an intracorporeal neobladder reconstruction. The series confirms a low rate of complications (Clavien Dindo ≥ IIIa 7.5%) and wound infections (2.5%) and the absence of thromboembolic events. No atypical recurrences were found. To discuss these outcomes, we reviewed the literature related to RARC including level-1 evidence. PubMed and Web of Science searches were performed using the medical subject terms "robotic radical cystectomy" and "randomized controlled trial (RCT)". Six unique RCTs comparing robot and open surgery were found. Two clinical trials dealt with RARC with an intracorporeal reconstruction of UD. Pertinent clinical outcomes are summarized and discussed. In conclusion, RARC is a complex but feasible procedure. The transition from extracorporeal urinary diversion (UD) to a complete intracorporeal reconstruction could be the key to improving peri-operative outcomes and reducing the whole morbidity of the procedure.

Robotic Cystectomy with Intracorporeal Urinary Diversion is Associated with Decreased Narcotic Consumption

Introduction: Improvements in robotic technology and surgeon experience have made intracorporeal ileal conduit urinary diversion (ICUD) following robot-assisted radical cystectomy (RARC) a reality. Thus, it is essential to understand the benefits and drawbacks to this technically challenging approach. This study investigates surgical and pain-related perioperative outcomes in patients who underwent ICUD compared to extracorporeal urinary diversion (ECUD) at a tertiary care center. Methods: We reviewed a prospectively maintained database of 198 patients who underwent robot-assisted radical cystectomy between January 2015 and October 2020. Surgical, functional, and pain-related perioperative outcomes were compared between 177 patients who received either ICUD or ECUD. Results and Conclusion: Among 177 patients, 107 (60.4%) patients underwent ECUD and 70 (39.6%) underwent ICUD. Patients who received ICUD had significantly lower narcotic consumption (P=.031). There were no significant differences across cohorts in operative time (P=.10), estimated blood loss (P=.958), blood transfusion rate (P=.267), overall survival (P=.485), LOS (P=.652), or 30-day readmissions (P=.080). Our study suggests that RARC with intracorporeal ileal conduit reduces post-operative narcotic use as compared to extracorporeal diversion. Further validation across multiple institutions will be required to elucidate the full advantage and/or disadvantage to this approach.

Intracorporeal Urinary Diversion versus Extracorporeal Urinary Diversion during Robot-Assisted Radical Cystectomy

Abstract Background/Aim: Radical cystectomy (RC) is a fundamental step in the therapeutic plan of nonmuscle and muscle-invasive urinary bladder cancer. Open RC is a surgical procedure with high morbidity and as such robot-assisted RC (RARC) has been established as an efficient alternative. Although in the beginning, the urinary diversion step during RARC was mostly performed extracorporeally nowadays a preference of the intracorporeal approach is yearly increasing. The aim of this review is to compare these two techniques of urinary diversion and depict the latest trends of current research on this field. Materials and Methods: A literature search of MEDLINE database (March 26, 2022) was performed to retrieve the articles published in English that are dated between January 1, 2010 and February 28, 2022. The search strategy included terms: “intracorporeal,” “vs,” “extracorporeal,” “urinary,” “diversion,” “comparison,” “after,” “RARC” and “or”. Results: Intracorporeal urinary diversion (ICUD) is strongly associated with lower perioperative blood loss and blood transfusion needs compared with the extracorporeal urinary diversion (ECUD). ICUD prolongs the operative duration. However, when ICUD is performed by experienced surgeons or in high volume centers, operative duration is comparable for ICUD and ECUD. The two approaches are assessed as equal in respect of postoperative complications. Conclusion: The debate as to whether ICUD must replace ECUD and become the standard of care does not end with this review. Intracorporeal approach in most of the studies seems to be associated with prolonged operative duration, lower transfusion needs, and equal complication rates when compared with ECUD. However, the contradiction of the results and the low quality of the available data demand the conduction of randomized prospective studies comparing ICUD and ECUD in order to offer the best available treatment to the patient.

MP03-01 ROBOT-ASSISTED RADICAL CYSTECTOMY WITH EXTRACORPOREAL URINARY DIVERSION DOES NOT INCREASE URETEROENTERIC STRICTURE RATE: OUTCOMES FROM A RANDOMIZED TRIAL COMPARING OPEN VERSUS ROBOTIC CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022MP03-01 ROBOT-ASSISTED RADICAL CYSTECTOMY WITH EXTRACORPOREAL URINARY DIVERSION DOES NOT INCREASE URETEROENTERIC STRICTURE RATE: OUTCOMES FROM A RANDOMIZED TRIAL COMPARING OPEN VERSUS ROBOTIC CYSTECTOMY Chun Huang, Melissa Assel, Benjamin Beech, Nicole Benfante, Daniel Sjoberg, Jonathan Coleman, Guido Dalbagni, Harry Herr, S. Machele Donat, Vincent Laudone, Andrew Vickers, Bernard Bochner, and Alvin Goh Chun HuangChun Huang More articles by this author , Melissa AsselMelissa Assel More articles by this author , Benjamin BeechBenjamin Beech More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Daniel SjobergDaniel Sjoberg More articles by this author , Jonathan ColemanJonathan Coleman More articles by this author , Guido DalbagniGuido Dalbagni More articles by this author , Harry HerrHarry Herr More articles by this author , S. Machele DonatS. Machele Donat More articles by this author , Vincent LaudoneVincent Laudone More articles by this author , Andrew VickersAndrew Vickers More articles by this author , Bernard BochnerBernard Bochner More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002515.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robot-assisted radical cystectomy is increasingly used to treat bladder cancer. There have been reports of higher stricture risks compared to open cystectomy. We analyzed stricture risk in patients randomized to open or robotic cystectomy with extracorporeal urinary diversion. METHODS: We included 118 patients randomized to robotic (n=60) or open (n=58) cystectomy at a single, high-volume institution. Urinary diversion was performed by experienced open surgeons. Stricture was defined as non-malignant obstruction on imaging, corroborated by clinical status, and requiring procedural intervention. The risk of stricture within 1 year was compared between groups using Fisher’s exact test. RESULTS: Fifty-eight and 60 patients were randomized to robotic and open cystectomy, respectively. We identified 5 strictures, all in the open group. In patients with at least 1 year of follow-up, the increase in risk of stricture from open surgery was 9.3% (95% CI 1.5%, 17%). Of the 5 strictures, 3 were managed endoscopically while 2 required open revision. There was no evidence that perioperative grade 3-5 complication were associated with development of a stricture (p=1) and no evidence of a difference in 24-month estimated glomerular filtration rate between arms (p=0.15). CONCLUSIONS: In this study at a high volume center, robotic cystectomy with extracorporeal urinary diversion achieved excellent ureteral anastomotic outcomes. Although stricture risk was higher in the open group, risk was low in both arms. Purported increased risk of stricture is not a reason to avoid the robot-assisted radical cystectomy. Future research should examine the impact of different surgical techniques and operator experience on the risk of stricture, especially as more intracorporeal diversions are performed. Source of Funding: This study was supported in part by the Sidney Kimmel Center for Prostate and Urologic Cancers at Memorial Sloan Kettering Cancer Center (MSK), Pin Down Bladder Cancer, the Michael and Zena Wiener Research and Therapeutics Program in Bladder Cancer, and a Cancer Center Support Grant (P30 CA008748) to MSK from the National Institutes of Health/National Cancer Institute © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e19 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chun Huang More articles by this author Melissa Assel More articles by this author Benjamin Beech More articles by this author Nicole Benfante More articles by this author Daniel Sjoberg More articles by this author Jonathan Coleman More articles by this author Guido Dalbagni More articles by this author Harry Herr More articles by this author S. Machele Donat More articles by this author Vincent Laudone More articles by this author Andrew Vickers More articles by this author Bernard Bochner More articles by this author Alvin Goh More articles by this author Expand All Advertisement PDF DownloadLoading ...

Open Radical Cystectomy versus Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Early Outcomes of a Single-Center Randomized Controlled Trial.

Radical cystectomy (RC) with urinary diversion (UD) is still considered a complex surgery associated with significant morbidity. Open RC (ORC) remains the reference option of treatment, even if adoption of robot-assisted RC (RARC) is rapidly increasing. To date, all the available randomized controlled trials were characterized by an extracorporeal approach in performing UD, undermining potential benefits of a totally minimally invasive procedure. In this study, we aimed to report perioperative and 6-month outcomes from the first RCT comparing ORC and RARC with totally intracorporeal UD. Patients were eligible for randomization if they had a diagnostic transurethral resection of bladder tumor with cT2-4, cN0, cM0 or recurrent high-grade nonmuscle-invasive bladder cancer and no anesthesiological contraindications to robotic surgery. Patients were enrolled with a covariate adaptive randomization process based on the following variables: body mass index, American Society of Anesthesiologists® score, baseline hemoglobin, planned UD, neoadjuvant chemotherapy and cT stage. The primary end point was to demonstrate the superiority of RARC with intracorporeal UD in terms of a 50% transfusion rate reduction. Overall, 116 consecutive patients (58 RARC, 58 ORC) were enrolled. Among primary endpoint, overall perioperative transfusion rates were significantly lower in the RARC cohort (RARC: 22% vs ORC: 41%; p=0.046). This prospective randomized trial observed 22% and 41% overall perioperative transfusion rates in patients treated by RARC and ORC, respectively, confirming a significant benefit in favor of RARC with intracorporeal UD. However, perioperative complications, hospital stay and 6-month health-related quality of life were largely comparable between groups. Oncologic and functional outcomes will be assessed at longer followup to observe potential differences between arms.

Utility of the HYBRID Method Incorporating the Advantages of Both Extracorporeal and Intracorporeal Urinary Diversion in Robotic-Assisted Radical Cystectomy.

Robotic-assisted radical cystectomy (RARC) is a well-known standard procedure for muscle-invasive bladder cancer. However, it remains controversial whether extracorporeal urinary diversion (ECUD) or intracorporeal urinary diversion (ICUD) is superior in this technique. We have developed a HYBRID method that combines ECUD and ICUD to retain the advantages of each. The purpose of this study was to compare perioperative outcomes between HYBRID and ECUD in RARC and to evaluate the usefulness of the HYBRID method. We retrospectively analyzed the perioperative outcomes of 36 consecutive bladder cancer patients who underwent RARC with ileal conduit at our institution between March 2013 and December 2021. Propensity-score matching was used to align patient backgrounds between the HYBRID and ECUD groups. After matching, 12 cases were selected for each group. There was no significant difference in patient demographics between the groups except for the rate of neoadjuvant chemotherapy. Mean console time was significantly longer in the HYBRID group due to intracorporeal manipulation; however, a relatively favorable trend of mean blood loss was observed in this group. There was no significant difference between the groups in terms of positive surgical margin, mean number of lymph node removed, or positive lymph node. The incidences of complications associated and non-associated with the urinary tract and grade ≥III complications at postoperative day (POD) 0-30 and 31-90 were similar between the groups. In the HYBRID group, no complications non-associated with the urinary tract or grade ≥III complications were observed at POD 31-90. The HYBRID method takes advantage of the benefits of both ICUD and ECUD and is a highly applicable technique that can be used in a variety of patient backgrounds.

Robot-assisted radical cystectomy: Where we are in 2023.

Open radical cystectomy (ORC) is associated with high rates of perioperative morbidity and mortality, owing to its extensive surgical nature and the high frequency of multiple co-morbidities among patients. As an alternative, robot-assisted radical cystectomy (RARC) has been increasingly adopted worldwide, being a reliable treatment option that utilizes minimally invasive surgery. Seventeen years have passed since the advent of the RARC, and comprehensive long-term follow-up data are now becoming available. The present review focuses on the current knowledge of RARC in 2023, and analyzes various aspects, including oncological outcomes, peri/post-operative complications, post-operative quality of life (QoL) change, and cost-effectiveness. Oncologically, RARC showed comparable oncological outcomes to ORC. With regard to complications, RARC was associated with lower estimated blood loss, lower intraoperative transfusion rates, shorter length of stay, lower risk of Clavien-Dindo grade III-V complications, and lower 90-day rehospitalization rates than ORC. In particular, RARC with intracorporeal urinary diversion (ICUD) performed by high-volume centers significantly reduced the risk of post-operative major complications. In terms of post-operative QoL, RARC with extracorporeal urinary diversion (ECUD) showed comparable results to ORC, while RARC with ICUD was superior in some respects. As the RARC implementation rate increases and the learning curve is overcome, more prospective studies and randomized controlled trials with large-scale patients are expected to be conducted in the future. Accordingly, sub-group analysis in various groups such as ECUD, ICUD, continent and non-continent urinary diversion, etc. is considered to be possible.

Novel Antibiotic-Irrigating Wound Protector Reduces Infectious Complications in Robot-Assisted Radical Cystectomy with Extracorporeal Urinary Diversion

ObjectiveTo determine whether use of an antibiotic-irrigating wound protector (AWP) reduces infectious complications after robotic radical cystectomy with extracorporeal urinary diversion (RCUD). MethodsA prospectively maintained bladder cancer database was queried for patients undergoing robotic RCUD at a tertiary referral center one year prior to implementing an AWP and one year after (2018–2020). All diversions were performed extra-corporally. 92 patients total. 46 consecutive patients using a traditional wound protector (TWP) and 46 consecutive with an AWP. Infections were classified as symptomatic urinary tract infection, blood stream infection, and surgical site infection. The incidence of infectious complications at 30- and 90-days were compared. ResultsBaseline patient characteristics between the 2 groups showed no statistically significant differences. The overall complication rate was 65.2% in the TWP group and 26.1% in the AWP group at 30-days, and 67.4% vs 30.4% at 90-days. Focusing on infections, the 30-day complication rate was 30.4% in the TWP group compared to 6.5% in the AWP group (P =.003). This pattern persisted at 90-days with 37.0% in the TWP group compared to 6.5% in the AWP group (P =.004). Most complications were symptomatic UTI and blood stream infections, 14/24 (58%), requiring parenteral antibiotic treatment. ConclusionWe provide preliminary data showing use of an AWP can reduce infectious complications after RCUD. While larger prospective studies are warranted, our findings are a significant step towards decreasing morbidity of an already highly morbid procedure.

Robotic surgery in Asia

The percentage of robot-assisted radical cystectomy (RARC) is comparatively low in Asia compared to other continents [11]. Few studies showed, RARC with intracorporeal urinary diversion causes less bleeding and hospital stay compared with extracorporeal urinary diversion.