Robot-assisted Laparoscopic Radical Cystoprostatectomy Research Articles

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

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

Perioperative Outcomes and Oncologic Efficacy from a Pilot Prospective Randomized Clinical Trial of Open Versus Robotic Assisted Radical Cystectomy

Robotic assisted laparoscopic radical cystectomy for bladder cancer has been reported with potential for improvement in perioperative morbidity compared to the open approach. However, most studies are retrospective with significant selection bias. A pilot prospective randomized trial evaluating perioperative outcomes and oncologic efficacy of open vs robotic assisted laparoscopic radical cystectomy for consecutive patients was performed from July 2009 to June 2011. To date 47 patients have been randomized with data available on 40 patients for analysis. Each group was similar with regard to age, gender, race, body mass index and comorbidities, as well as previous surgeries, operative time, postoperative complications and final pathological stage. We observed no significant differences between oncologic outcomes of positive margins (5% each, p = 0.50) or number of lymph nodes removed for open radical cystectomy (23, IQR 15-28) vs robotic assisted laparoscopic radical cystectomy (11, IQR 8.75-21.5) groups (p = 0.135). The robotic assisted laparoscopic radical cystectomy group (400 ml, IQR 300-762.5) was noted to have decreased estimated blood loss compared to the open radical cystectomy group (800 ml, IQR 400-1,100) and trended toward a decreased rate of excessive length of stay (greater than 5 days) (65% vs 90%, p = 0.11) compared to the open radical cystectomy group. The robotic group also trended toward fewer transfusions (40% vs 50%, p = 0.26). Our study validates the concept of randomizing patients with bladder cancer undergoing radical cystectomy to an open or robotic approach. Our results suggest no significant differences in surrogates of oncologic efficacy. Robotic assisted laparoscopic radical cystectomy demonstrates potential benefits of decreased estimated blood loss and decreased hospital stay compared to open radical cystectomy. Our results need to be validated in a larger multicenter prospective randomized clinical trial.

Robot-Assisted Laparoscopic Bilateral Nerve-Sparing Radical Cystoprostatectomy for Bladder Cancer

Introduction: We present an 8-minute video of bilateral nerve-sparing (NS) robot-assisted laparoscopic radical cystoprostatectomy (RALC) performed for invasive bladder cancer. Materials and Methods: Between December 2009 and April 2010, we performed 12 NS-RALC procedures with intracorporeal Studer pouch formation and bilateral extended pelvic lymph node dissection for muscle invasive bladder cancer.1,2 Trocars: six ports were used (a 12-mm camera, three 8-mm robotic, 12- and 15-mm assistant ports). NS radical cystoprostatectomy: a zero-degree lens is used. Patient position: maximum trendelenburg (30°). Peritoneum overlying the ureters is incised. Ureters are dissected off until entering the bladder, clipped from their most distal part. Distal ends are sent for frozen analysis. Peritoneum overlying the anterior wall of the Douglas' pouch is incised; vasa and seminal vesicles (SV) are exposed. Fascial leaflet of Denonvilliers' fascia is opened over the SV and dissected off until membraneous urethra is reached. Neurovascular bundles (NVB) are dissected laterally from prostatic base to apex with blunt dissection on each side. Extensions from NVB at the level of the tips of SV is clipped with hem-o-lock and used as a landmark for the future part of NVB dissection. Peritoneum lateral to the medial umblical ligaments is incised; pubic bones are exposed. Endopelvic fascia is opened after removal of overlying fatty tissue. The levator ani muscle fibers are dissected off. Prostatic fascia is released bilaterally to make a high anterior release and NVB dissection continued. Ligation of the lateral bladder pedicle is accomplished with the use of Ligasure® starting from medial to external iliac artery until the hem-o-lock clip at the level of ipsilateral SV tip is reached. Distal to this level, NVB is dissected off of the SV wall and posterolateral prostate with sharp and blunt dissection and hem-o-lock clips when necessary. No energy is used around NVB. Transection of the urachus at the level of umblicus and attacments between anterior bladder wall with the abdomen completes bladder dissection. Puboprostatic ligaments are cut and dorsal venous complex is suture tied with 2/0-vicryl and severed with bipolar and monopolar scissors. Urethral catheter is withdrawn, and a 0/0-vicrly suture is passed across urethra at the level of prostatic apex. Free end of this suture is then passed underneath the urethra, and tied on the apex. Urethra is cut flush with the apex and specimen is placed in an endobag. A 12-mm rim from the most proximal urethral remnant is sent for frozen analysis. Results and Conclusions: Mean console time (whole procedure) was 10 hours (8.1–11.5); mean intraoperative blood loss was 455 mL (100–700); mean lymph node yield was 21.3 (8–38). Surgical margins were negative in all patients. Perioperative death rate was zero. Right external iliac vein injury occurred in one patient during performing lymph node dissection whom we converted to open surgery and repaired. RALC is a safe procedure and can be learned and performed with excellent short-term surgical results and satisfactory pathological outcomes. No competing financial interests exist. Presented during the 28th World Congress of Endourology and SWL, September 1–4, 2010, Chicago, IIlinois. Runtime of video: 8 mins

An Unexpected Resident in the Ileum Detected During Robot-Assisted Laparoscopic Radical Cystoprostatectomy and Intracorporeal Studer Pouch Formation: Taenia Saginata Parasite

A case of moving ileal Taenia saginata parasites is presented with demonstrative images. We came across the parasites surprisingly while performing robot-assisted laparoscopic radical cystoprostatectomy with intracorporeal Studer pouch urinary diversion. We recommend stool sample evaluation in the preoperative period for possible presence of intestinal parasitic diseases, particularly in patients with bladder cancer who are admitted from areas with an increased incidence of intestinal parasitic diseases, before opening the bowel segments during surgery to perform radical cystectomy and urinary diversion.

Ureteric Duplication is not a Contraindication for Robot-Assisted Laparoscopic Radical Cystoprostatectomy and Intracorporeal Studer Pouch Formation

Ureteric duplication is a rarely seen malformation of the urinary tract more commonly seen in females. We report 2 cases of robot-assisted laparoscopic radical cystoprostatectomy (RALRCP) with bilateral extended pelvic lymph node dissection and intracorporeal Studer pouch formation in patients with duplicated right ureters. Two male patients (53 and 68 years old) underwent transurethral resection of a bladder tumor that revealed high-grade muscle invasive transitional cell carcinoma, with no metastases. We performed RALRCP and intracorporeal Studer pouch formation. A duplicated right ureter was observed during the procedures in both patients. Left ureter distal segment was spatulated 2cm long and anastomosed using running 4/0 Vicryl to the right ureter at its bifurcation where it forms a single lumen without spatulation. All 3 ureters were catheterized individually. A Wallace type uretero-ileal anastomosis was performed between the ureters and the proximal part of the Studer pouch chimney. Although ureteric frozen section analysis suggested ureteric carcinoma in situ in patient 1, postoperative pathologic evaluation was normal. Frozen section and final postoperative pathologic evaluations were normal in patient 2. Duplicated ureters might be underdiagnosed on CT. The presence of a duplicated ureter is not a contraindication to RALRCP and intracorporeal Studer pouch formation. The da Vinci-S surgical robot is very safe for performing this complicated procedure. Frozen section analysis of ureters during radical cystectomy for bladder cancer might not reliably diagnose the pathologic condition and might overestimate the disease in the ureters.

Cost Analysis of Robotic Versus Open Radical Cystectomy for Bladder Cancer

Recently robotic approaches to cystectomy have been reported, and while clinical and oncological efficacy continues to be evaluated, potential financial costs have not been clearly evaluated. In this study we present a financial analysis using current cost structures and clinical outcomes for robotic and open cystectomy for bladder cancer. The financial costs of robotic and open radical cystectomy were categorized into operating room and hospital components, and further divided into fixed and variable costs for each. Fixed operating room costs for open cases involved base cost as well as disposable equipment costs while robotic fixed costs included the amortized machine cost as well as equipment and maintenance. Variable operating room costs were directly related to length of surgery. Variable hospital costs were directly related to transfusion requirement and length of stay. The means of the prior 20 cases of robotic and open cystectomy were used to perform a comparative cost analysis. Mean fixed operating room costs for robotic cases were $1,634 higher than for open cases. Operating room variable costs were also higher by a difference of $570, directly related to increased operating room time. Hospital costs were nearly identical for the fixed component while variable costs were $564 higher for the open approach secondary to higher transfusion costs and longer mean length of stay. Based on these findings robotic cystectomy is associated with an overall higher financial cost of $1,640 (robotic $16,248 vs open $14,608). Cost calculators were constructed based on these fixed and variable costs for each surgical approach to demonstrate the expected total costs based on varying operating room time and length of stay. Robotic assisted laparoscopic radical cystectomy is associated with a higher financial cost (+$1,640) than the open approach in the perioperative setting. However, this analysis is limited by its single institution design and a multicenter followup study is required to provide a more comprehensive analysis.

Robot-Assisted Laparoscopic Radical Cystoprostatectomy with Ileal Conduit Urinary Diversion: Initial Experience in Korea

In this paper, we report our initial experience of robot-assisted laparoscopic radical cystoprostatectomy (RLRC) with an ileal conduit urinary diversion (ICUD). Our patient was a 59-year-old man presenting with a clinical T4 invasive transitional cell carcinoma of the bladder and prostate. A RLRC was performed with the da Vinci() robot system (Intuitive Surgical, Mountain View, CA), which has a total of seven degrees of motion (six degrees of freedom and grip), and EndoWrist (Intuitive Surgical) instrumentation. The specimen was extracted through the 8-cm-sized incision in the umbilical trocar site. The ICUD was achieved through a removal site of a specimen by an extracorporeal technique. The total operative time was 340 minutes and the estimated blood loss was 600 mL. The pathologic examination showed a stage T4a, with negative surgical margins. A RLRC can be an alternative to the open technique. We are the first group to perform RLRC in Korea and to report on our technique and outcome.

Robotic assisted laparoscopic radical cystoprostatectomy: Operative and pathologic outcomes: Pruthi RS, Wallen EM, Division of Urologic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC

Recent small case series have now been reported for robotic assisted laparoscopic radical cystoprostatectomy. We report our initial experience with robotic assisted laparoscopic radical cystoprostatectomy, evaluating the perioperative and pathological outcomes of this novel procedure. A total of 20 men underwent robotic assisted laparoscopic radical cystoprostatectomy and extracorporeal urinary diversion for clinically localized bladder cancer. Outcome measures evaluated in this series were operative variables, hospital recovery, pathological outcomes, and complication rate. Comparisons were made to 24 gender matched men who underwent an open procedure during the same period. Mean patient age was 62.3 years (range 54–76). Ten patients underwent ileal conduit diversion and 10 received an orthotopic neobladder. In all cases, urinary diversion was performed extracorporeally. Mean operative time for robotic cases was 6.1 hours, including 5.2 hours in the most recent 10 cases. This was longer than in patients undergoing an open procedure (3.8 hours). Mean surgical blood loss was 313 ml, which was significantly less than in those undergoing open cystectomy (588 ml). On surgical pathology, 14 cases were pT2 or less, 4 were pT3, and 2 were N+. In no case was there inadvertent entry into the bladder or positive surgical margins. A mean of 19 lymph nodes was removed. Mean time to flatus was 2.1 days and mean time to bowel movement was 2.8 days, which was significantly shorter than in men undergoing an open procedure. Of the patients 16, 3, and 1 were discharged on postoperative days 4, 5, and 8, respectively. There were a total of 6 postoperative complications (30%) in 5 patients. Our initial experience with robotic assisted laparoscopic radical cystoprostatectomy appears to be favorable with acceptable operative, pathological, and short-term clinical outcomes. As our experience increases, we expect to continue to refine our surgical technique and decrease operative time.

Robotic Assisted Laparoscopic Radical Cystoprostatectomy: Operative and Pathological Outcomes

Recent small case series have now been reported for robotic assisted laparoscopic radical cystoprostatectomy. We report our initial experience with robotic assisted laparoscopic radical cystoprostatectomy, evaluating the perioperative and pathological outcomes of this novel procedure. A total of 20 men underwent robotic assisted laparoscopic radical cystoprostatectomy and extracorporeal urinary diversion for clinically localized bladder cancer. Outcome measures evaluated in this series were operative variables, hospital recovery, pathological outcomes and complication rate. Comparisons were made to 24 gender matched men who underwent an open procedure during the same period. Mean patient age was 62.3 years (range 54 to 76). Ten patients underwent ileal conduit diversion and 10 received an orthotopic neobladder. In all cases urinary diversion was performed extracorporeally. Mean operative time for robotic cases was 6.1 hours, including 5.2 hours in the most recent 10 cases. This was longer than in patients undergoing an open procedure (3.8 hours). Mean surgical blood loss was 313 ml, which was significantly less than in those undergoing open cystectomy (588 ml). On surgical pathology 14 cases were pT2 or less, 4 were pT3 and 2 were N+. In no case was there inadvertent entry into the bladder or positive surgical margins. A mean of 19 lymph nodes was removed. Mean time to flatus was 2.1 days and mean time to bowel movement was 2.8 days, which was significantly shorter than in men undergoing an open procedure. Of the patients 16, 3 and 1 were discharged home on postoperative days 4, 5 and 8, respectively. There were a total of 6 postoperative complications (30%) in 5 patients. Our initial experience with robotic assisted laparoscopic radical cystoprostatectomy appears to be favorable with acceptable operative, pathological and short-term clinical outcomes. As our experience increases, we expect to continue to refine our surgical technique and decrease operative time.

Robotic-Assisted Laparoscopic Radical Cystoprostatectomy

ObjectivesRecent small case series have been reported for robotic-assisted laparoscopic radical cystoprostatectomy. The present literature includes 34 patients who have undergone robotic-assisted cystectomy procedures. We report our initial experience with robotic-assisted laparoscopic radical cystoprostatectomy, describing stepwise the surgical procedure and evaluating perioperative and pathologic outcomes of this novel procedure. MethodsTwenty men underwent robotic-assisted laparoscopic radical cystoprostatectomy and extracorporeal urinary diversion for clinically localized bladder cancer. The stepwise operative procedure is described in detail. Outcome measures evaluated included operative variables, hospital recovery, pathologic outcomes, and complication rate. Comparisons were made to these gender-matched 24 men who underwent an open procedure during this same period. ResultsMean age was 62.3 yr (range: 54–76 yr). Ten patients underwent ileal conduit diversion and 10 patients underwent an orthotopic neobladder. In all cases the urinary diversion was performed extracorporeally. Mean operating room time of all patients was 6.1h (most recent 10 cases, 5.2h). Mean surgical blood loss was 313ml. On surgical pathology, 14 patients were ≤pT2, 4 patients pT3, and 2 patients N+. In no case was there inadvertent entry into the bladder or positive surgical margins. Mean number of lymph nodes removed was 19 (range: 6–29). Mean time to flatus was 2.1 d and bowel movement 2.8 d. Sixteen patients were discharged on postoperative day (POD) 4, three patients on POD 5, and one on POD 8. There were six postoperative complications (30%) in five patients. ConclusionsOur initial experience with robotic-assisted laparoscopic radical cystoprostatectomy appears to be favorable with acceptable operative, pathologic, and short-term clinical outcomes. As our experience increases, we should expect to continue to refine our surgical technique and reduce operating room times. Larger experiences are required to adequately evaluate and validate this procedure as an appropriate surgical and oncologic option for the bladder cancer patient.

Robot-Assisted Laparoscopic Radical Cystoprostatectomy and Totally Intracorporeal Ileal Neobladder

To describe robot-assisted laparoscopic radical cystoprostatectomy and intracorporeal orthotopic ileal neobladder construction. With the use of the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA), we performed laparoscopic radical cystectomy and intracorporeal construction of an orthotopic ileal neobladder (modified W pouch). The total operative time was 12 hours, and the estimated blood loss was 100 mL. There were no intraoperative or postoperative complications, and the patient?s hospital stay was 5 days. At early follow-up, oncologic and functional results are good. Robot-assisted laparoscopic radical cystoprostatectomy with intracorporeal ileal neobladder construction is technically feasible. However, its role in the management of invasive bladder cancer remains to be defined.