Robot-Assisted Radical Cystoprostatectomy

Abstract

Open radical cystectomy remains the gold standard for treatment of muscle-invasive bladder cancer. However, efforts to reduce the operative morbidity of open radical cystectomy have fostered interest in minimally invasive approaches. Both laparoscopic and robot-assisted laparoscopic approaches have been reported (Turk I, DeGer S, Winkelman B, Schoberger B, Loening SA, J Urol 165:1863–1866, 2001; Gill IS, Kaouk JH, Meraney AM et al., J Urol 168:13–18, 2002; Xavier C, Arroyo C, Rozet F, Barret E, Vallancien G, Eur Urol 47:780–784, 2005; Menon M, Hemal AK, Tewari A, et al., BJU Int 92:232–236, 2003; Hemal AK, Abdol-Enein H, Tewari A et al., Urol Clin N Am 31:719–729, 2004; Pruthi RS, Wallen EM, J Urol 178:814–818, 2007; Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). Advantages of minimally invasive approaches are well documented, including decreased blood loss, less postoperative pain, faster recovery and return of bowel function, and shorter hospital stay (Xavier C, Arroyo C, Rozet F, Barret E, Vallancien G, Eur Urol 47:780–784, 2005; Hemal AK, Abdol-Enein H, Tewari A et al., Urol Clin N Am 31:719–729, 2004; Pruthi RS, Wallen EM, J Urol 178:814–818, 2007; Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). However, long-term oncologic and functional outcomes are yet to be reported. Nevertheless, we and others have reported on pathologic outcomes of early oncologic significance such as surgical margin status and number of lymph nodes removed during pelvic lymphadenectomy (Pruthi RS, Wallen EM, J Urol 178:814–818, 2007; Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). Our findings suggest that the robotic approach can yield pathologic measures of early oncologic efficacy equivalent to that of open radical cystectomy (Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). We also show that the robotic approach allows for a lymph node dissection up to and beyond the level of the common iliac artery, and that the total number of lymph nodes removed is not diminished compared to the open technique (Wang GJ, Barocas DA, Raman JD, Scherr DS, BJU Int 101:89–93, 2007). Nevertheless, larger, randomized studies with long-term functional and oncologic outcomes are required to better define the role and oncologic safety of robot-assisted radical cystectomy in the surgical management of bladder cancer. Herein, we describe our technique of robot-assisted laparoscopic radical cystectomy. A governing theme in our technique is a strict adherence to the oncologic principles underlying open radical cystectomy. We have divided our technique into 16 steps and include a complete description of our operating room setup, patient positioning, trocar placement, and instrument list. We provide specific details of our step-by-step procedure, including our process of redocking the robot after extracorporeal orthotopic neobladder creation for the urethral-neobladder anastomosis. Each step is illustrated with an intraoperative photo and an accompanying line drawing. Extracorporeal urinary diversion in our series includes ileal conduit, continent cutaneous diversion, and orthotopic ileal neobladder (W-pouch with afferent limb). Our technique of urinary diversion has been described elsewhere (Rowland RG, Mitchell ME, Bihrle R, Kahnoski RJ, Piser JE, J Urol 137:1136–1139, 1987; Hautmann RE, Egghart G, Frohneberg D, Miller K, J Urol 139:39–42, 1988) and is beyond the scope of this chapter. We conclude with a list of special considerations for robotic cystectomy in female patients.

This chapter contains a video segment which can be found at the URL: http://www.springerimages.com/Su