Robotic Cystectomy Research Articles

The Role of Robotic Cystectomy in the Salvage and Palliative Setting: A Retrospective, Single-Center, Cohort Study

Introduction: This article compares surgical and survival outcomes of robot-assisted and open radical cystectomy with cutaneous ureterostomy for the treatment of frail bladder cancer patients with limited life expectancy. Methods: The institutional database was searched for cystectomy cases with cutaneous ureterostomy, from 1 June 2016 to 31 August 2022. The study population was split into two groups, according to the surgical approach. The baseline characteristics and surgical outcomes were compared. Logistic regression analyses identified predictors of major bleeding events (hemoglobin loss ≥ 3.5 g/dL or blood transfusion) and re-operation within 30 days from surgery. The Kaplan–Meier method estimated the impact of the robotic approach on overall survival and Cox regression analysis assessed its predictors. Results: A total of 145 patients were included: 30% (n = 43) underwent robotic cystectomy. Patients’ characteristics and tumor stages distribution were comparable in the two groups but those receiving a minimally invasive treatment showed significantly reduced times to flatus, bowel and hospital discharge (all p < 0.001). Although operation times were longer in this cohort, major bleeding events (60% vs. 89%) and postoperative severe complications (0 vs. 8%) (both p < 0.001) were less frequent compared to the open approach. A logistic regression showed that robotic surgery independently predicted major bleeding events (OR: 0.26; 95%CI 0.09–0.72; p = 0.02) but not the need for re-intervention. A Kaplan–Meier analysis showed that robotic cystectomy was associated with a significant advantage in terms of overall survival (LogRank = 0.03), and this result was confirmed by Cox regression analysis (HR: 0.39; 95%CI 0.14–0.94; p = 0.04). Conclusions: Robotic cystectomy with cutaneous ureterostomy may represent a viable option to treat frail bladder cancer patients, as the minimally invasive approach reduces the risk of bleeding and serious complications and provides a prompt restoration of bowel function and a shorter hospital stay compared to open surgery.

PJY01 Robotic cystectomy for benign disease: Does indication matter?

PJY01 Robotic cystectomy for benign disease: Does indication matter?

PJY20 Pfannenstiel extraction sites for robotic cystectomies: Can we reduce the rates of incisional hernias?

PJY20 Pfannenstiel extraction sites for robotic cystectomies: Can we reduce the rates of incisional hernias?

Robot-assisted resection of choledochal cyst in neonates

ObjectiveLaparoscopic choledochectomy and hepatojejunostomy have been reported in children since 1995, but this procedure is technically demanding. Robotic surgical systems can simplify complex minimally invasive procedures. Currently, few reports have been made on neonates. We present the experience of 6 cases of neonatal CC(choledochal cysts).Study designBetween January 2022 and December 2023, 6 neonates underwent robotic resection of choledochal cyst and hepaticojejunostomy using the Da Vinci surgical system at Children’s Hospital, Zhejiang University School of Medicine, a high-volume hepatobiliary disease center. demographic data of the patients and surgical outcomes were collected and analyzed.ResultsAll 6 patients were successfully treated by robotic cystectomy and hepaticojejunostomy. The mean age was 17.3 days (range 4–25) and the mean weight was 3.6 kg (range 2.55–4.4). 5 cysts were type Ia and 1 was type Iva. The mean diameter of the cysts was 3.8 cm (range 1.25-5). The mean time to establish feeding was 4.83 days (range 4–6), and patients were discharged after a median time of 16.83 days (range 7–42) without postoperative complications.ConclusionsThis procedure is safe and effective for neonates. The authors found that the use of robot-assisted surgery has ergonomic advantages in this delicate, minimally invasive procedure.

Urinary Bladder Melanosis Diagnosed Simultaneously With Urothelial Carcinoma: A Case Report and Literature Review

Melanosis is a rare entity described as brown-black tissue pigmentation secondary to melanin deposition. Presented here is the third reported case of melanosis diagnosed simultaneously with urothelial carcinoma of the bladder. This is only the sixth case associating melanosis with malignancy. The patient is a 78-year-old man who presented with lower urinary tract symptoms and on cystoscopy, was noted to have diffused brown-black bladder pigmentation. Initial pathology showed squamous cell carcinoma with melanosis present. The patient underwent robotic cystectomy with ileal conduit and on final pathology, had urothelial carcinoma with squamous differentiation. A literature review was performed for both benign-associated and malignant-associated melanosis. The review elucidated that melanosis may herald malignancy in 16% of available reported cases, suggesting even a patient with benign melanosis should undergo surveillance.

Contemporary morbidity and mortality of open versus robotic cystectomy for bladder cancer: An analysis of the National Surgical Quality Improvement Program (NSQIP) procedure targeted cystectomy database

ObjectivesTo evaluate the association between surgical modality (RARC vs. ORC) and the risk of 30-day complications. Materials and MethodsWe utilized the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Cystectomy-Targeted database from 2019 to 2021. The primary outcome was a composite of major complications including 30-day mortality, reoperation, cardiac events, and stroke. Secondary outcomes included individual major and cystectomy-specific complications. Propensity score matching (PSM) was employed to minimize inherent differences within our cohort. We performed logistic regression to assess the association between outcomes of interest and operative modality. ResultsWe found no difference between operative modality and the primary outcome, however, RARC was associated with a 70% lower risk of 30-day mortality (OR 0.30, 95% CI 0.13-0.70) and had favorable outcomes with respect to respiratory, deep venous thrombosis, wound complications, and length of stay. Limitations are related to residual confounding given the observational methodology. ConclusionsRARC was associated with reduced risk of multiple 30-day complications, including mortality, as well as organ system and cystectomy-specific outcomes. These data support the clinical benefit of increased adoption of RARC.

The role of neoadjuvant chemotherapy for patients with variant histology muscle invasive bladder cancer undergoing robotic cystectomy: Data from the International Robotic Cystectomy Consortium

ObjectiveTo assess the role of neoadjuvant chemotherapy (NAC) before robot-assisted radical cystectomy (RARC) for patients with variant histology (VH) muscle-invasive bladder cancer (MIBC). MethodsRetrospective review of 988 patients who underwent RARC (2004–2023) for MIBC. Primary outcomes included the utilization of NAC among this cohort of patients, frequency of downstaging, and discordance between preoperative and final pathology in terms of the presence of VH. Secondary outcomes included disease-specific (DSS), recurrence-free (RFS), and overall survival (OS). ResultsA total of 349 (35%) had VH on transurethral resection or at RARC. The 4 most common VH subgroups were squamous (n = 94), adenocarcinoma (n = 64), micropapillary (n = 34), and sarcomatoid (n = 21). There was no difference in OS (log-rank: P = 0.43 for adenocarcinoma, P = 0.12 for micropapillary, P = 0.55 for sarcomatoid, P = 0.29 for squamous), RFS (log-rank: P = 0.25 for adenocarcinoma, P = 0.35 for micropapillary, P = 0.83 for sarcomatoid, P = 0.79 for squamous), or DSS (log-rank P = 0.91 for adenocarcinoma, P = 0.15 for micropapillary, 0.28 for sarcomatoid, P = 0.92 for squamous) among any of the VH based on receipt of NAC. Patients with squamous histology who received NAC were more likely to be downstaged on final pathology compared to those who did not (P < 0.01). ConclusionOur data showed no significant difference in OS, RFS, or DSS for patients with VH MIBC cancer who received NAC before RARC. Patients with the squamous variant who received NAC had more pathologic downstaging compared to those who did not. The role of NAC among patients with VH is yet to be defined. Results were limited by small number in each individual group and lack of exact proportion of VH.

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.

Robotic simple cystectomy as a last resort for antibiotic-recalcitrant recurrent urinary tract infections in women

To report a series of women with antibiotic-recalcitrant recurrent urinary tract infections (rUTI) managed with robotic simple cystectomy and ileal conduit urinary diversion. Following Institutional Review Board approval, all female patients who underwent robotic cystectomy for rUTI between 2011-2021 were identified from a prospectively-maintained internal database at a tertiary care center. Exclusion criteria included interstitial cystitis, neurogenic bladder, urinary tract neoplasm, or congenital abnormality. Electronic medical records were reviewed by an independent researcher. Patients were also administered the Quality of Life Questionnaire-C30 (QLQ-C30). Twenty-four patients met inclusion criteria. Median age was 75 years (range 53-87). Median rUTI duration was 6 (interquartile range (IQR) 2-10) years. Median UTI count in the 12 months preceding cystectomy was 5 (IQR 3-9). Infections with multidrug resistant organisms were found in 21 patients (88%). The 30-day postoperative complication rate was 79% (19/24), of which 11% were Clavien-Dindo grade ≥III. The main late complication was parastomal hernia, with 17% requiring repair or revision. At a median of 36 months (range 12-61) post-operatively, the median QLQ-C30 global health status score was 50 (range 33-83). Cystectomy is a last-resort management option for women with severely symptomatic end-stage bladders in the setting of antibiotic-recalcitrant rUTI. Patients should be counseled thoroughly regarding possible acute and long-term postoperative complications. Select patients, managed in high-volume referral centers, can benefit from robotic simple cystectomy with ileal conduit urinary diversion.

Single incision robotic cystectomy and urinary diversion.

In this review, we aim to provide readers with a balanced understanding of all aspects of single incision robotic cystectomy (SIRC) and urinary diversion using the single-port (SP) robot. The review will trace the historical progression from open surgery to the introduction of minimally invasive approaches and present an in-depth description of the SIRC technique, offering a step-by-step guide for reference. Emphasis will be placed on indications and patient selection criteria to equip surgeons with well-rounded insights for decision-making. The review analyzes preliminary surgical outcomes by drawing from existing literature and clinical experiences, endeavoring to present a balanced view of the potential benefits and limitations. Addressing the learning curve and training prerequisites is paramount, and this review explores strategies and challenges in preparing surgeons for proficiency. Finally, the focus shifts to current challenges and future directions, identifying key issues and potential advancements in the field. By presenting historical context, technical insights, clinical evidence, and strategic foresight, the review aims to provide a comprehensive resource that engages surgeons, researchers, and trainees from diverse perspectives.

PE087 - Initial experience in robotic cystectomy. Descriptive comparative study between laparoscopic and robotic-assisted cystectomies

PE087 - Initial experience in robotic cystectomy. Descriptive comparative study between laparoscopic and robotic-assisted cystectomies

PE089 - Defining the quality of robotic cystectomy – how to C the way forward

PE089 - Defining the quality of robotic cystectomy – how to C the way forward

PE085 - Learning curve for robotic cystectomy and outcomes

PE085 - Learning curve for robotic cystectomy and outcomes

Retrospective Evaluation of a Single Surgeon's Learning Curve of Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion via Ileal Conduit.

Robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) is increasingly being performed instead of open surgery. A criticism of this technique is the long learning curve, but limited data are available on this topic. At our center, the transition from open radical cystectomy (ORC) to iRARC began in May 2017. A retrospective analysis was conducted on the initial 53 cases of robot-assisted cystectomy with intracorporeal urinary diversion via ileal conduit, which were performed by one single surgeon. The patients were divided into four consecutive groups according to the surgeon's increasing experience, and perioperative parameters were analyzed as a surrogate for the learning curve. Over the course of the learning curve, a decline in median operation time from 415 to 361 min (p = 0.02), blood loss from 400 to 200 mL (p = 0.01), and minor complications from 71% to 15% (p = 0.02) was observed. No significant difference in overall and major complications, length of hospital stay, and total lymph node yield was shown. During the initial period of the learning curve, only the less complex cases were operated on using robotic surgery, while the more challenging ones were handled through open surgery. After experience with 28 cases, no more cystectomies were performed through open surgery. This led to an increase in operation time and length of hospital stay, as well as a higher incidence of both minor and overall complications among cases 28-40. After 40 cases, a significant decrease in these parameters was observed again. Our analysis demonstrated that operation time, blood loss, and minor complications decrease with increasing surgical experience in iRARC, while suggesting that technically challenging cases should be operated on after experience with 40 robotic cystectomies.

The impact of neoadjuvant chemotherapy on 30-day radical cystectomy outcomes.

4594 Background: Neoadjuvant chemotherapy (NAC), often a cisplatin-based regimen, is recommended before radical cystectomy (RC), as studies have shown a modest survival benefit. However, NAC may confer toxicity and augment preoperative frailty, affecting perioperative outcomes. We investigated the relationship between NAC and 30-day RC outcomes using the National Surgical Quality Improvement Program (NSQIP). Methods: RCs performed between 2019-2020 were identified in NSQIP and the corresponding cystectomy-targeted database. Baseline demographics, comorbidities, and operative parameters were compared via Pearson’s chi-square and t-tests between patients who received NAC before RC and RC alone (RCA) groups. Patient frailty was compared using the NSQIP frailty index (mFI-5), a validated 5-item score including points for diabetes, functional status, chronic obstructive pulmonary disease, heart failure, and hypertension. Multivariable logistic regression was used to compare outcomes, adjusting for age, race, robotic or open approach, urinary diversion type, comorbidities, ASA classification, and functional status. Minor complications included superficial SSI, pneumonia, UTI, bleeding requiring transfusion, AKI, or C. diff infection. Major 30-day complications included sepsis, DVT, stroke, reintubation, renal failure, MI, PE, septic shock, wound dehiscence, deep wound infection, cardiac arrest, readmission, reoperation, or mortality. All statistical tests were two tailed, p&lt;0.05 considered significant. Results: 4,482 RCs were identified. Of these, 1889 (42%) patients received NAC. Compared to RCA, NAC patients were younger (66.9 years vs 70.4 years, p&lt;0.001), had higher rates of white race, being functionally independent, preoperative weight loss, and cigarette use. NAC also had lower ASA class, fewer comorbidities, and lower frailty (mFI-5 0.8 vs 0.9, p&lt;0.001). Compared to RCA, NAC patients had more robotic cystectomies (23% vs 19%, p=0.0003), received more continent diversions, had a shorter length of stay (7.1 vs 7.8 days, p&lt;0.001), and more commonly had pT0 tumors compared to RCA (18.4% vs 5.9%, p&lt;0.001). On MVA, NAC patients had higher rates of minor complications, most notably increased bleeding requiring transfusion [OR 1.8; 95%CI 1.6-2.1; p&lt;0.001]. There was no difference in major complications between NAC and RCA, except NAC was associated with higher rates of sepsis [OR 1.4; 95%CI 1.1-1.8; p=0.003]. There was no difference in 30-day need for reoperation, readmission, or mortality. Conclusions: In the largest study to date on this topic, we found that NAC for RC is often given to younger, healthier patients, and is not associated with higher rates of major complications or mortality. NAC is associated with higher rates of bleeding and sepsis, which may be related to the immunosuppressive effects of chemotherapeutics. Providers should discuss with patients the benefits and risks of NAC before RC.

Comparing different pneumoperitoneum (12 vs. 15 mmHg) pressures with cytokine analysis to evaluate clinical outcomes in patients undergoing robotic-assisted laparoscopic radical cystectomy and intracorporeal robotic urinary diversion.

Robotic cystectomy is the mainstay surgical intervention for treatment-refractory nonmuscle-invasive and muscle-invasive bladder cancer. However, paralytic ileus may complicate the postoperative recovery and may be a consequence of an inflammatory response associated with transient gut ischaemia. We have therefore investigated clinical, operative and inflammatory biomarker associations between paralytic ileus in the context of robotic cystectomy and intracorporeal ileal conduit urinary diversion. Prospective consective patients referred for robotic cystectomy were consented and included in the study, while patients >75 years old and converted to open procedure were excluded. The pneumoperitoneum pressure (PP) for carbon dioxide insufflation required to perform the procedure efficiently and safely was recorded (12 or 15 mmHg). We also recorded the postoperative days patients passed flatus and stools, whether they developed ileus, as well as other standard clinical and demographic data. The expression of select proinflammatory and anti-inflammatory cytokines was determined by multiplex analysis using a cytometric bead array with changes in profiles correlated with the pressures applied and with the existence of an ileus. Twenty-seven patients were recruited, but only 20 were used in the study with 10 patients in each PP group. Seven patients were excluded all of whom had an extracorporeal ileal conduit formation. There were differences in the 40-min shorter operative time and 1day shorter length of stay, as well as passing flatus 1day and stools 1.5days earlier in the 12 mmHg compared with the 15 mmHg group. More patients had ileus in the 15 mmHg group vs 12 mmHg group (30% vs. 10.0%). These were not statistically significant. Similarly, there were no statistical differences in the expression of proinflammatory cytokines at the two different pressures or between patient groups, but there were outliers, with the median indicating nonsymmetrical distribution. By comparison, anti-inflammatory cytokines showed some significant differences between groups, with IL-6 and IL-10 showing elevated levels postsurgery. No statistical difference was observed between pressures or the existence of an ileus, but the maximum levels of IL-6 and IL-10 detected in some patients reflect a pressure difference. The initial findings of this novel scientific study indicated a higher risk of paralytic ileus postrobotic cystectomy and robotic intracorporeal urinary diversion when a higher pressure of 15 mmHg is used compared with 12 mmHg. Although further studies are required to establish the linkage between cytokine profile expression, pressure and ileus, our initial data reinforces the advantages of lower pressure robotic cystectomy and intracorporeal urinary diversion in patient outcomes.

V06-03 SURGICAL TECHNIQUE FOR SINGLE INCISION ROBOTIC RADICAL CYSTECTOMY WITH ORTHOTOPIC NEOBLADDER

You have accessJournal of UrologyCME1 Apr 2023V06-03 SURGICAL TECHNIQUE FOR SINGLE INCISION ROBOTIC RADICAL CYSTECTOMY WITH ORTHOTOPIC NEOBLADDER Justin Campagna, Adri Durant, and Mark Tyson Justin CampagnaJustin Campagna More articles by this author , Adri DurantAdri Durant More articles by this author , and Mark TysonMark Tyson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003274.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic cystectomy is associated with low utilization rates of orthotopic neobladder reconstruction due to challenges related to intracorporeal sewing and configuration. A new technique that shortens the learning curve may lead to greater utilization of neobladders and improve outcomes. In this video, we present a new technique for single incision robotic cystectomy (SIRC) with orthotopic Studer-type ileal neobladder using the da Vinci Single Port (SP) robotic platform. METHODS: A single 5 cm periumbilical incision is utilized to perform a robotic cystectomy in standard fashion, preserving neurovascular bundles when indicated. The robot is undocked, the specimen is removed and the Studer neobladder is constructed extracorporeally through the 5 cm incision. Enterotomies are made for the urethral and ureteral anastomoses, with pre-placement of anastomotic sutures to facilitate intracorporeal anastomosis. The neobladder is returned to the abdomen, the robot is redocked and the anastomoses are completed intracorporeally. RESULTS: Forty-one patients have undergone SIRC, with 50% of these patients undergoing orthotopic neobladder reconstruction. Seventeen (41%) of all single-port cases were converted to open. The median operative time was 480 minutes and the median length of hospitalization was seven days. 17% required readmission to the hospital, 17% developed small bowel obstruction or ileus, and 13% required a blood transfusion. There were no differences noted in pain (morphine milligram equivalents) between the patients who underwent SIRC and those that were converted to open. CONCLUSIONS: SIRC with orthotopic neobladder reconstruction using the da Vinci Single Port (SP) robotic platform is a safe and feasible minimally invasive approach. With this hybrid intracorporeal/extracorporeal technique, incisional burden is limited to what would otherwise be required for extraction while simultaneously adhering to long-standing principles of neobladder reconstruction. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e509 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin Campagna More articles by this author Adri Durant More articles by this author Mark Tyson More articles by this author Expand All Advertisement PDF downloadLoading ...

PD36-12 MEASURING OBJECTIVE RECOVERY OF ACTIVITY LEVELS USING WEARABLE DEVICES FOLLOWING OPEN VS INTRACORPOREAL ROBOTIC CYSTECTOMY: SECONDARY OUTCOMES ANALYSIS OF THE IROC RANDOMIZED TRIAL

PD36-12 MEASURING OBJECTIVE RECOVERY OF ACTIVITY LEVELS USING WEARABLE DEVICES FOLLOWING OPEN VS INTRACORPOREAL ROBOTIC CYSTECTOMY: SECONDARY OUTCOMES ANALYSIS OF THE IROC RANDOMIZED TRIAL

Teaching robotic cystectomy: prospective pilot clinical validation of the ERUS training curriculum.

To provide the first clinical validation of the European Association of Urology Robotic Urology Section (ERUS) curriculum for training in robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC). The ERUS proposed a structured curriculum, divided into 11 steps, to train novice surgeons and help overcome the steep learning curve associated with iRARC. In this study, one trainee completed the curriculum under the mentorship of an expert. Twenty-one patients were operated on by the trainee following the proposed iRARC curriculum [(t)iRARC group] and were compared with 42 patients treated with the standard of care by the mentor [(m)iRARC group]. To evaluate curriculum safety, peri-operative outcomes, surgical margins and complications were assessed. Propensity-score matching (1:2) was used to identify comparable (t)iRARC and (m)iRARC cases. Matched variables included age, body mass index, neoadjuvant therapy, American Society of Anesthesiologists score and cT stage. Mann-Whitney and chi-squared tests were used to compare peri- and postoperative outcomes between the two cohorts. To evaluate curriculum efficacy, steps attempted and completed by the trainee were assessed and studied as a function of growing surgical experience of the trainee. The trainee progressed in proficiency-based training through steps of increasing difficulty. No differences in estimated blood loss, positive soft tissue margins, number of resected lymph nodes, overall and high-grade complications, or 90-day readmissions between the (t)iRARC and (m)iRARC groups were observed (all P> 0.05). However, operating time was significantly longer in the (t)iRARC group (P= 0.01). Of the 209 available steps, the trainee attempted 168 (80%) and successfully performed 125 (60%). Increasing experience was associated with more steps being successfully performed (P< 0.001). The proposed ERUS curriculum assists naïve surgeons during the learning curve for iRARC and should be encouraged in order to guarantee optimal outcomes during the learning phase of this procedure.

Interview: Timothy Clinton

Interview: Timothy Clinton