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Robot-assisted Radical Cystectomy: Description of an Evolved Approach to Radical Cystectomy
Although open radical cystectomy (ORC) remains the gold standard of care for muscle-invasive bladder cancer, robot-assisted radical cystectomy (RARC) continues to gain wider acceptance. In this article, we focus on the steps of RARC, describing our approach, which has been developed over the past 10 yr. Totally intracorporeal RARC aims to offer the benefits of a complete minimally invasive approach while replicating the oncologic outcomes of open surgery.
We report our outcomes of a totally intracorporeal RARC procedure, describing step by step our technique and highlighting the variations on this standard template of nerve-sparing and female organ–preserving approaches in men and women.
Design, setting, and participants
Between December 2003 and October 2012, a total of 113 patients (94 male and 19 female) underwent totally intracorporeal RARC.
We performed RARC, extended pelvic lymph node dissection, and a totally intracorporeal urinary diversion (UD) in all patients. In the accompanying video, we focus on the standard template for RARC, also describing nerve-sparing and female organ–preserving approaches.
Outcome measurements and statistical analysis
Complications and oncologic outcomes are reported, including overall survival (OS) and cancer-specific survival (CSS) using Kaplan-Meier analysis.
Results and limitations
RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37–84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. On surgical pathology, 48% of patients had ≤pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0–57). Twenty percent of patients had lymph node–positive disease. Positive surgical margins occurred in six cases (5.3%). Median follow-up was 25 mo (range: 3–107). We recorded a total of 70 early complications (0–30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥3. Thirty-six late complications (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥3. One patient (0.9%) died within 90 days of operation from pulmonary embolism. Using Kaplan-Meier analysis, CSS was 81% at 3 yr and 67% at 5 yr.
Our structured approach to RARC has enabled us to develop this complex service while maintaining patient outcomes and complication rates comparable with ORC series. Our results demonstrate acceptable oncologic outcomes and encouraging long-term CSS rates.
Keywords: Urinary bladder neoplasms, Radical cystectomy, Robotics, RARC, Surgical technique.
Robot-assisted surgery has seen remarkable growth in urology, mainly driven by robot-assisted radical prostatectomy (RARP). Although the change from open to robotic cystectomy seen with RARP has not yet been replicated, there are signs that this is now changing. In the last decade, robot-assisted radical cystectomy (RARC) has been gradually adopted as a surgical option in both the United States and Europe. As recently as 2010, the number of centres performing this surgery appeared limited, with only about 500 cases being reported in the worldwide literature  . Limiting factors to the uptake of this approach have included the lack of both long-term outcome data and prospective randomised trials. In recent years, the number of publications on RARC has increased, including large series  , reflecting the growing acceptance of this approach , , and .
RC with urinary diversion (UD) remains one of the most complex and morbid operations performed in urology. It is associated with high complication rates even in the hands of experienced surgical teams  . Complication rates have been shown to decrease with experience, although they still remain high, even in high-volume specialist centres , , , , and . Although open RC (ORC) remains the gold standard for muscle-invasive and high-risk non–muscle-invasive bladder cancer (BCa), minimally invasive approaches are continually being refined and reassessed. As technology develops and the technique evolves, it is likely that more surgeons will adopt this approach to BCa.
In this article, we focus on our standard template for RARC, additionally describing two variations: nerve-sparing RARC in men and organ-preserving surgery in women. We have previously described our approach to the stages of pelvic lymph node dissection (PLND) and intracorporeal UD  and  as well as published our outcome data from Karolinska on 113 RARC procedures completed with a totally intracorporeal approach, performed between December 2003 and October 2012.
Patient selection, preoperative preparation, patient positioning, and equipment required have previously been described  . Potential complications and strategies to avoid them have been summarised in Table 1 .
|Stage of operation||Complications to avoid||Evolved technique|
|Patient selection||Inappropriate case selection for RARC||Avoid patients with decreased pulmonary compliance who cannot tolerate the Trendelenburg position. Avoid previous extensive abdominal surgery and patients with bulky disease.|
|1: Port placement||Trauma to bowel adhesions||First port placed with Hasson technique. Camera port secured with purse string suture to prevent air leakage.|
|Leakage from port sites|
|2: Dissection of ureters||Ureteric strictures||Maintain adequate periureteral tissue on the mobilized ureters.|
|3. Development of anterior rectal space||Rectal injury||Good surgical planes; stay anterior to rectal fat.|
|4. Development of lateral pelvic space||Injury to the obturator nerve In elderly patients, atherosclerotic external iliac vessels may be tortuous in the pelvis.||Avoid injury to the obturator nerve by identifying it early in the dissection. If transected, it should be repaired with tension-free end-to-end anastomosis using 9.0 Prolene interrupted sutures.|
|Tortuous vessels should be identified.|
|5b (male). Nerve-sparing dissection||PSM on the prostate||Review imaging prior to operation. Intrafascial dissection can be used for T2 prostate tumours.|
|5 (female). Mobilisation of bladder and transection of urethra||Urethrovaginal or vesicovaginal fistula||With both organ-sparing and non–organ-sparing approaches, to avoid the potential of a vesicovaginal fistula, make sure that the vaginal closure is not aligned with the cut urethra when an orthotopic neobladder is planned.|
|6. Bladder take-down||Injury to the inferior epigastric vessels.||Avoid inferior epigastric vessels.|
|Bleeding from the DVC||Increase pneumoperitoneum to 20 mmHg prior to dissection. Then, oversew with 3.0 V-Loc or Biosyn suture.|
|7. PLND||Damage to collapsed walls of the iliac and hypogastric veins||Careful dissection. If veins are damaged, a small cut is often controlled with pressure with or without Surgicel. Suturing a cut vein may result in a tear and a larger hole in the vein.|
|8a. Removing the specimen||Ruptured specimen bag||Specimen is removed through an extended camera port in men, vagina in women. Make sure the incision is large enough. The specimen can be removed under direct vision, with the camera placed in a 15-mm hybrid port.|
|Damage to the mesentery of the ileal conduit|
|8b. Formation of the ileal conduit||Leakage from uretero-ileal anastomoses||The camera can be placed through a 15-mm hybrid port after removal of the specimen to verify that the mesentery is not malrotated and anastomoses are not under tension.|
|Single J stents, with the end of the stent brought through the stoma, prevents temporary occlusion at the level of the abdominal wall caused by postoperative oedema.|
|The ileal stoma should be formed after removal of the specimen and decompression of pneumoperitoneum.|
RARC = robot-assisted radical cystectomy; PSM = positive surgical margin; DVC = dorsal vein complex; PLND = pelvic lymph node dissection.
2.1. Patient selection
The selection process included preoperative investigation to ensure fitness for surgery as well as specific counselling about robotic surgery. Patients with decreased pulmonary compliance who cannot tolerate the Trendelenburg position are not candidates for the robot-assisted technique. Furthermore, if the patient has a history of previous extensive abdominal surgery, RARC may be contraindicated. Patients with bulky disease should also be avoided.
2.2. Template for standard robot-assisted radical cystectomy and nerve-sparing robot-assisted radical cystectomy in men
2.2.1. Stage 1: Port placement and lysis of adhesions, if required
Appropriate port placement is critical for successful surgery. A six-port technique is used, with the camera port placed 5 cm above the umbilicus in the midline. The camera port is placed by a small mini-laparotomy, as described by Hasson, and the other ports are placed in view of the camera. Pneumoperitoneum between 10 and 12 mmHg is desirable during the procedure, but during port placement, a pressure of 18 mmHg is advantageous. Two robotic ports are placed level with the umbilicus on the left and right sides, lateral to the rectus sheath. The left port is placed 8 cm from the midline, and the right port is placed 10–11 cm from the midline to enable more space for the assistant's port. A third robotic instrument port is placed 2 cm above and medial to the left anterior superior iliac spine through a 15-mm port, enabling laparoscopic stapling by the assistant when the third robotic port is temporarily disconnected. Two assistant ports are placed on either side of the right robotic instrument port, with the right lateral port 2 cm above and medial to the anterior superior iliac spine (see Fig. 1 ).
2.2.2. Stage 2: Development of the periureteral space, clipping, and division of ureters
The ureters are identified and the peritoneum covering them is carefully opened. The ureters are dissected out towards the bladder, holding them by and maintaining adequate periureteral tissue. Close to the ureterovesical junction, they are divided between two Hem-o-Lok clips (see Fig. 2 ). A stay suture is placed on both proximal clips for easier identification and manipulation of the ureters during construction of the UD. The distal ureteric margins may be sent for frozen section.
2.2.3. Stage 3: Development of the anterior rectal space—identifying the seminal vesicle, vas deferens, Denonvilliers fascia, and prerectal space
Orientate yourself by identifying the level of the vas deferens before commencing the posterior dissection. The assistant retracts on the peritoneum, and an incision is made in the peritoneum, with the tips of the scissors above the seminal vesicles, exposing the vesicles and vas deferens. Further dissection behind the seminal vesicles exposes the Denonvilliers fascia, which is then opened, and a surgical plane is developed between the Denonvilliers fascia (attached to the prostate) and the rectum. Retroprostatic dissection should proceed anterior to the yellow prerectal fat to avoid rectal injury. In non–nerve-sparing cases, the seminal vesicles are left intact on the bladder; in cases of nerve sparing, the seminal vesicles are divided close to the prostate, thereby avoiding undue damage to the erectile nerves that are in close proximity lateral to the seminal vesicles.
2.2.4. Stage 4: Development of lateral pelvic space—lateral to the umbilical ligament down to the endopelvic fascia.
The medial umbilical ligaments are identified close to the abdominal inguinal ring. The peritoneum is incised lateral to the ligaments, extending it to the medial aspect of the external iliac artery and developing the space of Retzius (see Fig. 3 ). Using a combination of sharp and blunt dissection, the space between the lateral wall of the bladder and the pelvic sidewall is developed until the endopelvic fascia is reached. It is important that the umbilical ligaments and urachus are left intact at this point of the dissection, ensuring that the bladder does not fall down into the operating field. The endopelvic fascia is then opened, the lateral surface of the prostate can be separated from the elevator ani muscle and the prostatic apex, and the dorsal vein complex (DVC) can be isolated. Take care to avoid injury to the obturator nerve.
2.2.5. Stage 5a: Control of the vascular pedicle with a LigaSure seal to the tips of the seminal vesicles
The vas deferens is divided to open the space medial to the external iliac vessels, and the lateral dissection is continued (see Fig. 4 ). Using the fourth arm, retract the bladder towards the umbilicus. With good retraction, the lateral pedicles can be identified for division with the LigaSure or Hem-o-Lok clips. The superior vesicle artery is divided at its origin. Then, the inferior vesicle artery and the vesicoprostatic artery are divided. The division of the pedicles is stopped at the upper lateral aspect of the prostate, level with the seminal vesicles, if you want to preserve the neurovascular bundles (NVBs). In a non–nerve-sparing procedure, the dissection is continued with the LigaSure seal. The NVBs on the posterolateral aspect of the prostate are easily transected in this fashion all the way down to the apex of the prostate.
188.8.131.52. Stage 5b: Nerve-sparing dissection
If nerve sparing is planned following preoperative staging, a high intrafascial release of the NVB is performed with a strict athermal technique using Hem-o-Lok clips and 5-mm metal clips for haemostasis (see Fig. 5 ). The nerve-sparing procedure is similar to RP. It is important not to accidentally transect the NVBs during dissection close to the vesicles and the base of the prostate, where the dissection is in close proximity to the NVBs. The lateral aspect of the prostate is exposed, and an incision laterally down to the capsule along the lateral aspect of the prostate is performed. The rectum is then pushed downward with the suction cannula, and the Denonvilliers fascia is transected close to the prostatic capsule. The vesicoprostatic pedicles are then taken down from the prostate using Hem-o-Lok clips to avoid cautery. An intrafascial dissection plane can be used to facilitate a nerve-sparing procedure.
2.2.6. Stage 6: Anterior bladder, take down, dorsal vein complex control, apical dissection, and clip or suture the urethra
The urachus and the median umbilical ligaments are coagulated with bipolar cautery and cut. The bladder is then taken down, staying in the correct plane by following the areolar tissue. The DVC is divided with cold scissors, and then a continuous haemostatic suture with a V-Loc suture is placed. Maximum sparing of the urethra is performed, and prior to cutting, a suture or Hem-o-Lok clip is placed on the prostatic apex to avoid spilling tumour cells. When the specimen is totally freed, it is immediately placed in an Endocatch retrieval bag.
2.3. Template for standard robot-assisted radical cystectomy and organ-sparing robot-assisted radical cystectomy in women
2.3.1. Stage 3a: Posterior dissection—non–organ-sparing technique
The posterior dissection of the cul-de-sac is performed with an inverted “U” incision, which is extended a few centimetres above the common iliac vessels bilaterally. The uterus is anteverted with the fourth robotic arm. The infundibulo-pelvic suspensory ligaments along with the ovarian pedicle are identified and divided using either Hem-o-Lok clips or a LigaSure suture. The uterine artery pedicle is identified, skeletonised, then clipped or divided with the LigaSure suture. When mobilised and with adequate haemostasis achieved, the fourth robotic arm is used for retraction of the freely mobile uterus and the surrounding adnexa. The uterus is retracted proximally so that it is under tension, and the junction between the vagina and uterus is identified. Identification is further helped by manipulating a sponge in the vagina. After incision, the sponge is identified and the anterior wall of the vagina is taken with the specimen. For good functional outcomes, it is important to take care to preserve the autonomic nerves that run along the vagina's lateral walls, as they are responsible for sexual function.
2.3.2. Stage 3b: Posterior dissection—organ-sparing technique
In cases where no suspicion of tumour invasion towards the uterus exists and vaginal-sparing dissection is planned, the uterus can be dissected separately and preserved. The infundibulo-pelvic suspensory ligaments, the ovarian pedicle, and the uterine pedicle are preserved. The space between the uterus and the bladder is developed using a sponge placed in the vagina. The anterior vagina is opened close to the cervix, and the plane between the vagina and the bladder is developed. Dissection in the plane between the vagina and the posterior aspect of the bladder towards the bladder neck commences.
2.3.3. Stage 4: Lateral dissection and control of the vascular pedicle
The dissection of the bladder lateral to the umbilical ligaments is performed, thereby helping to isolate and identify the vascular pedicles. After transecting the round ligament, the superior vesicle pedicle is clipped and divided using Hem-o-Lok clips or a LigaSure suture. The bladder is gently retracted using the fourth arm, putting the vascular pedicle on stretch and identifying the pedicle safely away from the external iliac vessels and the rectum, which can then be clipped or cut with a LigaSure suture. Alternatively, the anterior trunk of the internal iliac artery is dissected and the individual branches, including the inferior vesical artery, are identified and clipped or cut with a LigaSure suture.
2.3.4. Stage 5: Mobilisation of the bladder and dissection of the urethra
The lateral dissection is carried down to the perirectal space and followed along the curve of the pubic bone. The endopelvic fascia is opened. The bladder is then dissected off the anterior abdominal wall, as described above. The urethra is identified, and a dorsal venous stitch or bipolar cautery is used to secure the venous complex. In non–organ-sparing surgery, the periurethral tissue, with the help of proximal traction and manually manipulating the Foley catheter, and dissection of the urethra and the anterior vagina are carried out to complete the urethrectomy, avoiding the need to undock the robot. When an orthotopic neobladder is planned, the urethra is transacted just below (∼5 mm) the bladder neck to ensure a functional urethral closure mechanism.
In an organ-sparing approach, the vagina is opened between the cervical insertion and the urethra to retrieve the specimen through the opening in the anterior vaginal wall (see Fig. 6 ). The specimen is also removed via the opening in the vagina in a non–organ-sparing approach. The edges of the vagina are closed by continuous suture using the “clam shell” technique  with a V-Loc suture.
|No. of patients||113||43||70|
|Age, yr, mean ± SD (range)||63.7 ± 9.5 (37–84)||69.9 ± 6.7 (55–84)||59.8 ± 9.0 (37–76)|
|Male age, yr, mean ± SD, yr (range)||65.3 ± 11.8 (37–80)||69.3 ± 6.1 (58–80)||60.3 ± 8.8 (37–76)|
|Female age,yr, mean ± SD (range)||63.4 ± 9.0 (40–84)||71.5 ± 8.3 (55–84)||55.6 ± 10.8 (40–66)|
|BMI, mean ± SD (range)||25.6 ± 3.3||24.8 ± 3.1 (21–35)||26.1 ± 3.4 (18–34)|
|Preoperative T stage, no. (%)|
|Tis||5 (4.5)||1 (2.3)||4 (5.8)|
|Ta||4 (3.6)||1 (2.3)||3 (4.3)|
|T1||33 (29.5)||11 (25.6)||22 (31.9)|
|T2||60 (53.6)||24 (55.8)||36 (52.2)|
|T3||8 (7.1)||5 (11.6)||3 (4.3)|
|T4||1 (0.9)||1 (2.3||0 (0)|
|Squamous cell carcinoma (missing = 1)||1 (0.9)||0 (0)||1 (1.5)|
|Preoperative grade, no. (%)|
|G1||1 (0.9)||0 (0)||1 (1.5)|
|G2||10 (9.1)||3 (7.0)||7 (10.3)|
|G3 (missing = 2)||100 (90.9)||40 (93.0)||60 (88.2)|
|Concomitant CIS, no. (%)||27 (24.0)||10 (23.3)||17 (24.3)|
|BCG therapy, no. (%)||13 (11.5)||8 (18.6)||5 (7.1)|
|Neoadjuvant chemotherapy, no. (%)||35 (31.0)||18 (41.9)||17 (24.3)|
SD = standard deviation; BMI = body mass index; CIS = carcinoma in situ; BCG = bacillus Calmette-Guérin.
|Diversion, no. (%)||113 (100)||43 (38)||70 (62)|
|Nerve sparing in men, no. (%) (missing = 2)||46 (50.5)||5 (15.6)||41 (69.5)|
|Organ sparing in women, no.||2||0||2|
|Operating time, min, median (range)||390 (190–760)||292 (190–561)||420 (265–760)|
|Conversion, no. (%)||5 (4)||1 (2.3)||4 (5.7)|
|EBL, ml, median (range)||350 (50–2200)||200 (50–2000)||500 (100–2200)|
|Hospitalisation time, d, median (range)||9 (4–142)||9 (6–142)||9 (4–78)|
|Follow-up time, mo, median (range)||25.4 (3–107.8)||11.0 (3–106.1)||30.3 (3–107.8)|
EBL = estimated blood loss.
|Postoperative pT stage, no. (%)|
|T0||27 (24.5)||10 (23.3)||17 (25.4)|
|Ta||8 (7.3)||1 (2.3)||7 (10.3)|
|Tis||7 (6.4)||1 (2.3)||6 (8.8)|
|T1||11 (10.0)||4 (9.3)||7 (10.3)|
|T2||30 (27.3)||10 (23.3)||20 (29.4)|
|T3||14 (12.7)||6 (14.0)||8 (11.8)|
|T4 (missing = 3)||13 (11.8)||11 (25.6)||2 (2.9)|
|Postoperative grade, no. (%)|
|Squamous cell||1 (0.9)||1 (2.4)||0 (0)|
|Dysplasia||1 (0.9)||0 (0)||1 (1.5)|
|N/A (pT0)||26 (23.9)||9 (21.4)||17 (25.4)|
|G1||0 (0)||0 (0)||0 (0)|
|G2||8 (7.3)||1 (2.4)||7 (10.4)|
|G3 (missing = 4)||73 (67.0)||31 (73.8)||42 (62.7)|
|Concomitant CIS, no. (%)||26 (23.0)||10 (23.3)||16 (22.9)|
|PSM, no. (%)||6 (5.3)||5 (11.6) (T3/4 bladder)||1 (1.5) (ureter)|
|Concomitant PCa, no. (%)|
|≤6||39 (43.3)||15 (46.9)||24 (41.8)|
|7||5 (5.6)||4 (12.5)||1 (1.7)|
|≥8 (missing = 4)||2 (2.2)||1 (3.1)||1 (1.7)|
|PLND, no. (%)|
|None||5 (4.5)||4 (9.3)||1 (1.5)|
|Limited (obturator + external iliac)||5 (4.5)||0 (0)||5 (7.5)|
|Standard (obturator + external iliac + internal iliac)||38 (34.5)||9 (20.9)||29 (43.3)|
|Extended (obturator + external iliac + internal iliac + common iliac) (missing = 3)||62 (56.4)||30 (69.8)||32 (47.8)|
|Lymph node counts, mean No. ± SD, (range)|
|Overall||20.7 ± 10.5 (0–57)||20.9 ± 11.6 (0–57)||20.6 ± 9.6 (0–52)|
|Limited||10.6 ± 0.9 (10–12)||None carried out||10.6 ± 0.9 (10–12)|
|Standard||18.7 ± 7.7 (7–43)||17.2 ± 3.9 (11–23)||19.1 ± 8.6 (7–43)|
|Extended||24.5 ± 10.4 (10–57)||24.5 ± 11.5 (11–57)||24.4 ± 9.2 (10–52)|
|pN stage, no. (%)|
|N0||82 (72.6)||26 (60.5)||56 (80.0)|
|N1||12 (10.6)||5 (11.6)||7 (10.0)|
|N2||11 (9.7)||8 (18.6)||3 (4.3)|
|N/A (no PLND performed) (missing = 3)||5 (4.4)||4 (9.3)||1 (1.5)|
|Recurrences, no. (%)||20 (17.7)||7 (16.3)||13 (18.6)|
|Location of recurrences, no.|
N/A = not applicable; CIS = carcinoma in situ; PSM = positive surgical margin; PCa = prostate cancer; PLND = pelvic lymph node dissection; SD = standard deviation.
|Early (0–30 d)|
|Ileal conduit (n = 43)||Neobladder (n = 70)|
|Complication||No. (%)||No. (%)||Treatment||Clavien grade|
|Paralytic ileus||3 (7.0)||2 (2.9)||Conservative||1|
|Abdominal hernia||1 (2.3)||–||Conservative||1|
|Paralytic ileus||2 (4.6)||1 (1.4)||Small intestine enema–neostigmine||2|
|PUO||2 (4.6)||1 (1.4)||Antibiotics||2|
|Fungal infection||2 (4.6)||–||Antibiotics||2|
|Anaemia||2 (4.6)||1 (1.4)||Transfusion||2|
|Wound infection||–||1 (1.4)||Antibiotics||2|
|Abdominal abscess||2 (4.6)||3 (4.3)||Drainage + antibiotics||3a|
|Lymphocele||1 (2.3)||4 (5.7)||Drainage||3a|
|Ureteroileal leakage||9 (20.9)||3 (4.3)||Nephrostomy||3a|
|Bleeding||1 (2.3)||–||Selective embolisation||3a|
|Bleeding from major vessels||2 (4.6)||2 (2.9)||Reoperation||3b|
|Obstructive ileus||1 (2.3)||1 (1.4)||Reoperation||3b|
|Reservoir perforation||N/A||1 (1.4)||Reoperation||3b|
|Wound rupture||1 (2.3)||–||Reoperation||3b|
|Renal insufficiency||2 (4.6)||–||Haemodialysis||4a|
|Urosepsis||2 (4.6)||6 (8.6)||Antibiotics||4b|
|Late (>30 d)|
|Ileal conduit (n = 43)||Neobladder (n = 70)|
|Complication||No. (%)||No. (%)||Treatment||Clavien grade|
|Increased urine residual||N/A||1 (1.4)||CISC||2|
|Metabolic acidosis||–||1 (1.4)||Medication||2|
|Pyelonephritis||–||2 (2.8)||Nephrostomy + antibiotics||3a|
|Incisional hernia||1 (2.3)||–||Reoperation||3b|
|Parastomal hernia||3 (6.9)||N/A||Reoperation||3b|
|Reservoir stones||–||2 (2.8)||Cystolitholapaxy||3b|
|Ureteroileal stricture||1 (2.3)||3 (4.3)||Balloon dilatation||3b|
|Obstructive ileus||–||1 (1.4)||Reoperation||3b|
|Urethrovaginal fistula||–||1 (1.4)||Martius flap||3b|
|Ureteroileal fistula||1 (2.3)||–||Reoperation||3b|
|Death||1 (2.3)||1 (1.4)||N/A||5|
PUO = pyrexia of unknown origin; UTI = urinary tract infection; N/A = not applicable; DVT = deep vein thrombosis; PE = pulmonary embolism; MI = myocardial infarction; ICU = intensive care unit
UTI = urinary tract infection; N/A = not applicable; CISC = clean intermittent self-catheterisation; ICU = intensive care unit.
RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37–84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. Median operating time for totally intracorporeal RARC with ileal conduit was 292 min (range: 190–561) and 420 min for totally intracorporeal RARC with neobladder (range: 265–760). On surgical pathology, 48% of patients had ≤pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0–57). Twenty percent of patients had lymph node–positive disease. Positive surgical margins (PSM) occurred in six cases (5.3%)—five patients with T3/4 disease and one having a positive ureteric margin that was misreported at the time of surgery. Median follow-up was 25 mo (range: 3–107). We recorded a total of 70 early complications (0–30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥3 complications. Thirty-six late events (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥3 complications. One patient (0.9%) died within 90 days from pulmonary embolism, another patient died after 90 days from aorto-ileal fistula. It is not clear if this was related to the surgery. Using Kaplan-Meier analysis, overall survival (OS) was 80.3% at 36 mo, and cancer-specific survival (CSS) was 81.1% at 36 mo. At 60 mo, OS was 66.6% and CSS was 67.3% (see Fig 7 and Fig 8).
In developing our RARC technique over the past 10 yr, we have aspired to realise the benefits of a minimally invasive approach while avoiding the recognised steep learning curve with high associated complication rates experienced in laparoscopic RC  . An optimised RARC approach should offer lower blood loss, lower perioperative morbidity and complication rates, better functional outcomes, and at least equivocal oncologic prognosis to ORC as well as shorter recovery time, as reflected in length of stay.
The complexity of RC is exacerbated by the comorbidities of the patients, who are often elderly. RC is a long operation incorporating three defined stages, namely, RC, PLND, and UD. We have aimed to simplify the operation by breaking each stage into smaller steps, developing an approach in which each step is completed systematically before the next step commences. In this article, we have concentrated on the RC stage, including adaptations to the standard approach.
We believe that three main advantages exist to this structured approach. Primarily, the aim is to simplify the technique and improve outcomes. Working in one defined area before moving onto the next focuses the surgeon's attention on the single task at hand. The smaller movements required when operating concisely in one anatomical area combined with correct instrument choice contribute to gentle tissue handling. It is important that completing the steps includes achieving adequate haemostasis. In this article, we have also highlighted common complications that can occur during each step ( Table 1 ). We believe that by being aware of when they are most likely to occur, they can more readily be avoided. In our experience, by completing each step systematically, we have witnessed reduced operating times. Although it is accepted that not all fast surgeons are good surgeons, it is recognised that most experienced surgeons with good outcomes have a tendency to be faster, because they are progressive in their operating and decisive in their actions.
Second, by systematically describing the individual steps of the surgery, it is easier to teach and monitor learning. A standard template also enables mentorship shared among several trainers. Third, our process facilitates the ability to appropriately adapt the technique with new steps, such as nerve-sparing approaches in men or organ preservation in women. The natural evolution of RARC has incorporated proven aspects of RARP that improve functional outcomes, such as nerve-sparing surgery and avoiding cautery  and . The template, when learned, can also be adapted with the advent of new technologies or instruments  .
Robotic surgery's role in the management of BCa continues to evolve with its growing popularity and is supported by encouraging short- and intermediate-term outcomes  and . To date, most oncologic data have been on surrogate markers of oncologic outcome, namely, lymph node yields and PSM rates , , , , and . Our lymph node yields were satisfactory compared with other series, with a mean number of 24 lymph nodes in the extended PLND  and . Our overall PSM rate of 5.3% is comparable to ORC and RARC series, and PSM is related to preoperative staging , , , , and .
ORC with extended PLND remains the gold-standard treatment, providing excellent local cancer control with 50–70% 5-yr CSS  . RC is an oncologic procedure, and any approach will be judged by the long-term survival outcomes, which because of the time since introduction have not yet been available. As our RARC series commenced in 2003, we have been able to contribute to the growing long-term outcome data for RARC, publishing the first Kaplan-Meyer analysis at 36 and 60 mo, with encouraging results comparable to open series. The results from our series found a CSS of 67% at 5 yr.
RC by any approach is associated with significant perioperative complication and mortality rates  . Recent publications reported perioperative complication rates from ORC ranging from 49% to 64%, high-grade complication rates ranging from 13% to 40%, and 90-d mortality ranging from 0% to 4.5% , , and . RARC is also associated with a high rate of complications  and , but a robotic approach has been shown to reduce the complication rates compared to ORC  as well as being better tolerated in these susceptible patient groups  and . In our series, we recorded a total of 71 early complications (0–30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥3 complications. We also recorded 40 late events (>30 d) in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥3 complications. Within 90 d of operation, one patient (0.9%) died from pulmonary embolism.
As RARC has been performed since 2003, we are now starting to see both long-term outcome data and early randomised controlled trial (RCT) outcomes, which have until now been lacking  and . A recent meta-analysis concluded that RARC compared to ORC is associated with lower overall perioperative complications, higher lymph node yields, longer operation time, reduced blood loss, and reduced transfusion rates as well as a shorter length of stay. In addition, the two surgical techniques appeared equivalent in terms of PSM rates  . Future large-volume, well-designed RCTs with long-term follow-up are awaited to confirm the findings of this analysis.
We have presented our template for standard RARC, which can be adapted at the relevant stages to incorporate a nerve-sparing approach in men and organ preservation in females. By adopting a standardised approach to this complex surgery, we have successfully developed a robotic cystectomy service with acceptable short-term and long-term patient outcomes.
RARC is primarily an oncologic procedure, and we have demonstrated good oncologic outcomes and encouraging long-term CSS rates. We have also shown acceptable complication rates, both within 30 d and long term, while delivering a minimally invasive approach. In our series, RARC appears to be a viable alternative to ORC.
Author contributions: J.W. Collins had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Wiklund, Hosseini, Collins, Tyritzis.
Acquisition of data: Hosseini, Schumacher, Laurin, Khazaeli.
Analysis and interpretation of data: Wiklund, Hosseini, Collins, Tyritzis.
Drafting of the manuscript: Wiklund, Collins, Tyritzis.
Critical revision of the manuscript for important intellectual content: Wiklund.
Statistical analysis: Nyberg.
Obtaining funding: None.
Administrative, technical, or material support: Adding, Jonsson.
Other (specify): None.
Financial disclosures: J.W. Collins certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
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Karolinska University Hospital, Stockholm, Sweden
The authors are joint first author.
© 2013 Published by Elsevier B.V.