Robotic Radical Cystectomy and Urinary Diversion

Building on the clinical experience with da Vinci-assisted laparoscopic radical prostatectomy, the use of robotics has expanded to include extended pelvic lymph node dissections and radical cystectomy with urinary diversion. The current indications for robotic cystectomy are the same as those reported for laparoscopic radical cystectomy. Patients with large bulky tumors and obvious extravesical disease are not ideal candidates. Robotic cystectomy has now been reported in both men and women with or without a concurrent nerve-sparing technique using either an ileal conduit or an ileal neobladder urinary diversion (20-23).

Although minor variations have been reported among institutions, the technique of robotic cystectomy closely follows the operative steps of conventional laparoscopic radical cystectomy. After the patient is placed in dorsal lithotomy position and then steep Trendelenburg, five or six transabdominal ports are placed in similar fashion as for robotic prostatectomy. All steps of extended bilateral lymph node dissection and radical cystectomy can be performed solely with the da Vinci robotic system. The urinary diversion can then be performed entirely in an open fashion via the specimen extraction incision, entirely intracorporeally using only the da Vinci robot, or in combination with open and minimally invasive techniques (20-23).

Beecken et al. reported the first case of da Vinci-assisted laparoscopic cystectomy with intracorporeal formation of the ileal neobladder (20). The procedure was performed with an overall operative time of 510 minutes and an estimated blood loss was <200 cc. The da Vinci robot facilitated intracorporeal suturing for the urethral anastomosis, construction of the neobladder, and the ureteroileal anastomosis (20). Bowel continuity was reestablished after a minilaparotomy was performed for specimen removal. Yohannes et al. reported some of the first cases of laparoscopy-assisted robotic cystoprostatectomy with ileal conduit urinary diversion for organ-confined urothelial carcinoma (21). The da Vinci robot was employed to perform bilateral lymph node dissection, cystoprostatectomy, and ileoureteral anastomosis. Total operative times were 600 and 720 minutes with blood loss of 435 and 1800 mL, respectively (21).

With a larger clinical experience, operative times and estimated blood loss have improved. Menon et al. reported a series of 14 nerve-sparing robot-assisted radical cystoprostatectomies with urinary diversion (22). The da Vinci system was utilized to perform all aspects of the surgery except for the urinary diversion, which was performed extracorporeally. For those undergoing an orthotopic neobladder, the da Vinci was also utilized to perform the urethroneovesical anastomosis. Mean operative time for the nerve-sparing cystoprostatectomy was 140 minutes and average blood loss for the entire procedure less than 150 mL. One complication of unexplained blood loss requiring exploration was reported (22). Results are currently not available in regard to postoperative continence and erectile function.

Robot-assisted female cystectomy with preservation of the uterus and vagina has been recently reported (23). Menon et al. published their series of three patients, for which the da Vinci robot was utilized to perform the cystectomy and urethroneovesical anastomosis. Posterior mobilization of the bladder via the cul-de-sac of Douglas facilitated preservation of the uterus and vagina. Urinary reconstruction was performed extracorporeally through a small midline incision. Average operating time for the cystectomy was 160 minutes with mean blood loss of less than 100 mL (23). It is known that the pneumoperitoneum created during laparoscopic and robotic procedures helps to reduce vascular bleeding. The group reasoned that the superior hemostasis afforded by the robotic system allowed them to avoid the significant vaginal bleeding that often accompanies reproductive sparing female cystectomies (23).

Although the procedure has yet to demonstrate a decrease in length of hospital-ization or length of overall procedure time, robot-assisted cystectomy appears to have a favorable clinical future. Those that perform this procedure have sited it to be technically much simpler than laparoscopic cystectomy or even robot-assisted radical prostatectomy. Additionally, the benefits of limited patient morbidity, cosmesis, and superb hemostasis as well as visualization provided by the robotic system cannot be ignored. We anticipate robot-assisted cystectomy to become more widely performed now that a standard technique has been described and demonstrated to be safe and effective.

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