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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 32  |  Issue : 2  |  Page : 46-51

Key steps in performing robotic-assisted radical cystectomy with intracorporeal urinary diversion and the evidence that we have so far


1 Department of Surgery, S.H. Ho Urology Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
2 School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, England, UK

Date of Submission29-Jul-2020
Date of Decision30-Oct-2020
Date of Acceptance25-Nov-2020
Date of Web Publication22-Jun-2021

Correspondence Address:
Jeremy Yuen-Chun Teoh
Department of Surgery, S.H. Ho Urology Centre, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_108_20

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  Abstract 


Robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) has been proposed as the most minimally invasive surgical approach in performing radical cystectomy for patients with bladder cancer. However, iRARC is a highly technical and complex procedure with a steep learning curve. Without appropriate training and adequate experiences, iRARC may become a lengthy procedure and may lead to significant morbidities with a prolonged hospital stay. Essentially, the robotic approach in performing RARC is to replicate what is being done in the open approach, and the key steps in performing iRARC were described in this article. There were five randomized controlled trials (RCTs) comparing between RARC and open radical cystectomy (ORC). RARC has been shown to have a lower blood transfusion rate and short hospital stay than ORC. When compared to ORC, RARC had a similar positive surgical margin rate and time of recurrence. Given such potential benefits, a decision-analytic model has shown that RARC might be a more cost-effective treatment approach than ORC. On the other hand, previous RCTs focused mainly on RARC with extracorporeal urinary diversion; high-quality studies on the total intracorporeal approach are lacking. The iROC trial is a multicenter study comparing between iRARC and ORC. Preliminary results showed that iRARC is well tolerated by patients. The iROC trial has completed patient recruitment and the final results are eagerly awaited. By then, hopefully, we will be able to understand the true value of iRARC in managing patients with bladder cancer.

Keywords: Bladder cancer, intracorporeal, radical cystectomy, robot-assisted radical cystectomy, robotic


How to cite this article:
Teoh JY, Yee CH, Chiu PK, Chan VW, Chan EO, Ng CF, Chan ES. Key steps in performing robotic-assisted radical cystectomy with intracorporeal urinary diversion and the evidence that we have so far. Urol Sci 2021;32:46-51

How to cite this URL:
Teoh JY, Yee CH, Chiu PK, Chan VW, Chan EO, Ng CF, Chan ES. Key steps in performing robotic-assisted radical cystectomy with intracorporeal urinary diversion and the evidence that we have so far. Urol Sci [serial online] 2021 [cited 2021 Sep 22];32:46-51. Available from: https://www.e-urol-sci.com/text.asp?2021/32/2/46/318993




  Introduction Top


Radical cystectomy is the first-line treatment of muscle-invasive bladder cancer,[1] and it is one of the most complex surgeries in urology. Apart from removing the bladder, pelvic lymph node dissection is needed for staging purposes and optimizing cancer control. In addition, a urinary diversion is mandatory and this involves the use of bowels to reconstruct and resume continuity of the urinary tract. This often results in a lengthy procedure and it is easily complicated with postoperative ileus, and hence, the hospital stay may be excessively prolonged.[2],[3]

Although open radical cystectomy (ORC) is considered the standard surgical approach in many urological centers, minimally invasive approaches (i.e., laparoscopic or robotic-assisted) have gained increasing interest in the hope of reducing trauma and enhancing recovery after the operation.[4] Robotics in particular allows a high degree of flexibility and dexterity, and this complex procedure becomes much easier to perform. Intracorporeal bowel anastomosis and reconstruction of the urinary tract also become a feasible option within a reasonable operative time.[5] Hence, robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) has become the standard of care in a number of expert centers worldwide.[6] In this review article, tips and tricks in performing iRARC are discussed, and the current evidence in this surgical approach is summarized.


  Tips and Tricks in Performing Robotic-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion Top


Essentially, the robotic approach in performing radical cystectomy and pelvic lymphadenectomy is to replicate what is being done in the open approach. Split leg position is usually adequate, but the lithotomy position is necessary for female cystectomy or when concomitant urethrectomy is indicated. The patient is placed in a Trendelenburg position to prevent the bowels from dropping to the pelvic area, but a balance has to be made when you are planning for a neobladder reconstruction to avoid excessive tension to the urethra. In order to facilitate subsequent bowel manipulation and anastomosis, the ports should be inserted higher up with reference to the level of the umbilicus, and the 12 mm assistant port that allows insertion of bowel stapler should be placed on the left side of the abdomen [Figure 1]. While some surgeons may prefer a 30° lens for the procedure except during posterior dissection, the authors find that a 0° lens can serve the purpose throughout the surgery. Bilateral ureters should be isolated and traced to the bladder; they serve as landmarks in your subsequent dissection and you should always get below them in order to avoid inadvertent opening of the bladder. Posterior dissection of the prostate is usually straight forward as this organ is usually spared from bladder cancer invasion. Bilateral lateral dissection and opening of the endopelvic fascia are important to facilitate subsequent clipping and division of the vascular pedicles.
Figure 1: Port placement for robotic-assisted radical cystectomy

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The major challenge in tackling the posterior aspect of the bladder and the prostate is how you can optimize the exposure of the operative field by maximizing the utility of the fourth arm and guiding your assistant to assist you during the whole procedure. Especially when the bladder tumor is bulky, the bladder may constantly drop and obscure your view. Always try to retract the bladder upward using your robotic fourth arm. During female cystectomy, bilateral ovaries and fallopian tubes can be clipped or sutured to the respective median umbilical fold after mobilization in order to facilitate subsequent retraction. Depending on the situation, you can consider additional maneuvers to further optimize exposure. For example, you can ask your assistant to retract the rectosigmoid colon away with his/her right-hand instrument (e.g., sucker), and tackle the vascular pedicles using his/her left-hand instrument (e.g., energy device or clipping). When retraction of the bladder is particularly difficult, you can ask your assistant to use his/her left-hand instrument (e.g., Maryland or grasper) to retract the bladder upward together with your robotic fourth arm, and tackle the vascular pedicles using his/her right-hand instrument by (e.g., energy device). In a certain situation when the plane between the specimen and the rectum is not clearly defined, retrograde dissection after transection of the urethra would make dissection more efficient. After completing posterior dissection, the whole bladder, together with the prostate in male patients, can be dropped for subsequent urethral dissection. The deep venous complex can be controlled early, though suturing of the venous complex after bladder removal is also possible. In bladder cancer surgery, urine spillage must be avoided to prevent tumor seeding. Therefore, one must get very familiar with how to encircle and clip the urethra before division. Once the urethra is divided, the specimen should be placed inside an endobag immediately. The specimen can be retrieved transvaginally for female patients; otherwise, the specimen can be retrieved through a mini-laparotomy wound at the end of the procedure. Bilateral pelvic lymph node dissection template can be completed as in its open counterpart. However, the lymph node packet behind the common iliac bifurcation is best approached from the lateral angle in the robotic technique, instead of the anterocephalad angle in the open technique. The left ureter as well as the sigmoid mesenteric window must be dissected cephalad enough to avoid tension while bringing the ureter through the sigmoid mesentery to the right side of the abdomen. The right ureter usually has sufficient length and trimming may be necessary.

The most technically demanding part of the surgery (both to the console surgeon and the assistant) is the intracorporeal bowel reconstruction. Positioning the bowel in a natural curvature is crucial to maintain orientation and to facilitate subsequent anastomosis and reconstruction [Figure 2]a and [Figure 2]b. The ileal segment can be isolated using a 60 mm bowel stapler, and the length of the stapler can be used as a ruler to estimate the length of the ileal segment. Before firing your stapler, always be aware of the location of the ureters and avoid trapping them inadvertently. Side-to-side bowel anastomosis can then be performed using bowel staplers [Figure 2]c and [Figure 2]d. For the ileal conduit, 15 cm of the ileal segment is utilized. Our center usually performs the uretero-ileal anastomosis using the Wallace method [Figure 3], though Bricker anastomosis is also possible. Ureteric catheters are brought through the ileal segment and inserted into the ureters until resistance is felt. The stoma is then fashioned at the right lower quadrant of the abdomen. For neobladder reconstruction, our center usually performs a Studer pouch with 55 cm of the ileal segment. Different from an open approach, urethral anastomosis is usually performed early on as an anchoring point using STRATAFIX™ in a continuous manner [Figure 4]a. The positioning of the bowels in a natural curvature is again extremely crucial to maintain orientation. Stay sutures can be applied between the bowels as a form of fixation and bowel orientation can be maintained [Figure 4]b. The bowels are then incised at the anti-mesenteric border, and this can be facilitated by retracting the bowel longitudinally using your robotic fourth arm, and by asking your assistant to tense up the bowel lumen using a sucker [Figure 4]c. The subsequent neobladder reconstruction will follow the usual Studer's approach[7] and this will require extensive suturing using barbed sutures [Figure 4]d and [Figure 4]e. Bilateral ureters are anastomosed to the chimney of the Studer pouch using 4/0 PDS in a continuous manner; bilateral ureteric catheters were inserted and brought out through the abdominal wall. Suprapubic catheter and urethral Foley catheter should be placed before the completion of the neobladder reconstruction [Figure 4]f.
Figure 2: Key steps in preparing the ileal segment and performing bowel anastomosis intracorporeally; (a) Staple the distal end of the planned ileal segment about 20 cm from the cecum, (b) Staple the proximal end of the planned ileal segment, (c) Side-to-side bowel anastomosis, and (d) Completion of bowel anastomosis

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Figure 3: Uretero-ileal anastomosis in Wallace fashion, suturing in progress

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Figure 4: Key steps in performing intracorporeal neobladder reconstruction (Studer pouch); (a) Urethral anastomosis early on as anchoring point, (b) Orientate bowel and fix with stay sutures. (c) Incise on the antimesenteric border of the ileal segment, (d) Posterior reconstruction of the neobladder, (e) Anterior reconstruction of the neobladder, and (f) Completion of neobladder reconstruction

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  Robotic-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Is it Justified? Top


RARC is a minimally invasive approach in treating bladder cancer, yet it is a highly technical surgery with a steep learning curve. An international multicenter study showed that at least 30 cases are needed to achieve a positive surgical margin of <5%.[8] On the other hand, an annual surgical volume of 30 cases of radical cystectomy is already considered a high-volume center and it may not be easy to achieve.[9],[10] As radical cystectomy is a highly complex surgery, a robotic approach may lead to an excessively prolonged operative time.[11] There is a real concern whether the robotic approach is too technical which may, in turn, lead to increased complication rates and prolonged hospital stay. Intracorporeal urinary diversion further complicates the surgery, and it may be difficult to generalize to every oncology center. The use of a robotic system and stapler devices is also expensive, and iRARC may not be a cost-effective approach. Does the current evidence justify the robotic approach in performing RARC?

Up to date, there are five randomized controlled trials (RCTs) comparing between RARC and ORC [Table 1]. The RAZOR trial is the largest RCT conducted in 15 academic centers, which randomized 312 patients to receive either RARC or ORC.[12] The other four studies were single-center RCT with relatively small sample sizes ranging from 40 to 118.[13],[14],[15],[16],[17] The results were summarized in a recent Cochrane review.[18] All five RCTs reported the perioperative complication rates; RARC and ORC had similar rates of major (Clavien Grades 3–5) and minor (Clavien Grades 1 and 2) complications. Two RCTs reported on blood transfusion rates; RARC had a lower rate of blood transfusion than ORC (relative risk 0.58, 95% confidence interval [CI] 0.43–0.80). Five RCTs reported on hospital stay; RARC resulted in a shorter hospital stay than ORC (mean difference - 0.67 days, 95% CI −1.22–−0.12). Five trials reported on positive surgical margin rates; RARC and ORC had similar positive margin rates. Two trials reported on time of recurrence; RARC and ORC had a similar time of recurrence. Among the five RCTs, four of them performed extracorporeal urinary diversion, and the remaining study performed urinary diversion at the discretion of the surgeon. Hence, these results are mainly reflecting the comparison between RARC with extracorporeal urinary diversion and ORC.
Table 1: Randomized controlled trials comparing between robotic-assisted radical cystectomy and open radical cystectomy

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A decision-analytic model was developed to investigate the cost-effectiveness of RARC and ORC based on propensity-matched cohort.[19] Although RARC is more expensive than ORC, RARC had fewer transfusions, fewer complications, and better health-related quality of life. RARC cost $2969 less per quality-adjusted life years when compared to ORC. Two-way sensitivity analysis showed that RARC is the preferred treatment approach as long as it can prevent complications and transfusions. Together with the results from the Cochrane review,[18] it is possible that RARC may be a more cost-effective treatment approach than ORC.

The iROC study is the first RCT investigating the role of RARC with total intracorporeal urinary diversion.[20] This multicenter RCT aims to randomize 320 patients undergoing radical cystectomy to receive either iRARC or ORC. The primary outcome is the days alive and out of hospital within the first 90 days from surgery. The investigators previously reported the recovery of the first 30 patients undergoing iRARC.[21] Recovery was quantified using multiple domains including personal activity trackers, the 30-s chair stand test, qualitative questionnaires of disability (WHODAS 2.0), health-related quality of life (EORTC QLQ-C30 and QLQ-BLM30), and health economics (EQ-5D-5 L). Each domain deteriorates after surgery but then recovers with time. The authors concluded that iROC appears to be well tolerated by patients. The iROC study has already completed patient recruitment and the study results are eagerly awaited. By then, hopefully, we will have a much better idea of whether iRARC has any benefit in terms of patient recovery as well as its cost-effectiveness when compared to ORC.


  Conclusions Top


iRARC is currently the most minimally invasive approach in performing radical cystectomy in patients with bladder cancer, with the aim of minimizing surgical trauma and optimizing recovery postoperatively. Although it is a highly technical procedure, the authors believe that this procedure can be generalized with appropriate training and adequate surgical experiences. RARC has been shown to have a lower blood transfusion rate and shorter hospital stay than ORC, while achieving equivalent rates of peri-operative complications and oncological outcomes. The iROC study results on iRARC are eagerly awaited; by then, we may understand its true value in the management of bladder cancer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Witjes JA, Bruins HM, Cathomas R, Compérat E, Cowan NC, Gakis G, et al. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. Available from: https://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastati. [Last accessed on 2020 Jul 22].  Back to cited text no. 1
    
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Nutt M, Scaief S, Dynda D, Alanee S. Ileus and small bowel obstruction after radical cystectomy for bladder cancer: Analysis from the nationwide inpatient sample. Surg Oncol 2018;27:341-5.  Back to cited text no. 2
    
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Hirobe M, Tanaka T, Shindo T, Ichihara K, Hotta H, Takahashi A, et al. Complications within 90 days after radical cystectomy for bladder cancer: Results of a multicenter prospective study in Japan. Int J Clin Oncol 2018;23:734-41.  Back to cited text no. 3
    
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Mazzone E, D'Hondt F, Beato S, Andras I, Lambert E, Vollemaere J, et al. Robot-assisted radical cystectomy with intracorporeal urinary diversion decreases postoperative complications only in highly comorbid patients: Findings that rely on a standardized methodology recommended by the European Association of Urology Guidelines. World J Urol 2020. https://pubmed.ncbi.nlm.nih.gov/32419055/.  Back to cited text no. 5
    
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Hayn MH, Hussain A, Mansour AM, Andrews PE, Carpentier P, Castle E, et al. The learning curve of robot-assisted radical cystectomy: Results from the International Robotic Cystectomy Consortium. Eur Urol 2010;58:197-202.  Back to cited text no. 8
    
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Patel MI, Bang A, Gillatt D, Smith DP. Contemporary radical cystectomy outcomes in patients with invasive bladder cancer: A population-based study. BJU Int 2015;116 Suppl 3:18-25.  Back to cited text no. 9
    
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Scarberry K, Berger NG, Scarberry KB, Agrawal S, Francis JJ, Yih JM, et al. Improved surgical outcomes following radical cystectomy at high-volume centers influence over all survival. Urol Oncol 2018;36:308 e11-7.  Back to cited text no. 10
    
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Parekh DJ, Reis IM, Castle EP, Gonzalgo ML, Woods ME, Svatek RS, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): An open-label, randomised, phase 3, non-inferiority trial. Lancet 2018;391:2525-36.  Back to cited text no. 12
    
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Bochner BH, Dalbagni G, Marzouk KH, Sjoberg DD, Lee J, Donat SM, et al. Randomized trial comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: Oncologic outcomes. Eur Urol 2018;74:465-71.  Back to cited text no. 13
    
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20.
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21.
Catto JW, Khetrapal P, Ambler G, Sarpong R, Potyka I, Khan MS, et al. Multidomain quantitative recovery following radical cystectomy for patients within the robot-assisted radical cystectomy with intracorporeal urinary diversion versus open radical cystectomy randomised controlled trial: The first 30 patients. Eur Urol 2018;74:531-4.  Back to cited text no. 21
    


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