Robotic-assisted radical cystectomy for men and women

Background

The treatment for muscle invasive bladder cancer (MIBC) and some high-risk superficial bladder cancers (in patients who may or may not have had intravesical immunotherapy) is radical cystectomy (RC), customarily through an open lower midline abdominal incision. This is a major physiological insult causing high morbidity and a clearly defined mortality. There is an accepted complication rate of up to 60%, a 25% readmission rate, and a transfusion rate of over 40%, the latter of which is connected to increased bladder cancer specific mortality. ^,

Seeking to reduce the trauma and morbidity of some open procedures across different specialties, the concept of “Minimally Invasive Surgery” (MIS) started to become mainstream in the 1980s. Menon and team have travelled to Egypt to work alongside some of the world’s highest-volume cystectomists for the purpose of developing robotic-assisted radical cystectomy (RARC), and over the past 15 years, high-volume Robotic Urology Centers have been further advancing the procedure and investigating its comparative outcomes in order for it to gain global acceptance. Despite this concerted effort, there is still some controversy over the suggested inferiority of the open over the robotic approach. The evidence for RARC will be dealt with in more detail in one of the sections below, but first this chapter will outline patient preparation and patient selection as well as a detailed technical description of this challenging urological procedure.

Patient preparation

Patient selection is an important part of the preoperative process and will to some degree depend on surgeon experience. The ideal patient is slim (body mass index [BMI] <30), with a T2 tumor (without extravesical spread), lacking in comorbidities, without any history of abdominal surgery or radiation and an Eastern Cooperative Oncology Group (ECOG) status of 0. As surgeons gain experience and climb their learning curves (LCs), with improved operative technique and an ability to overcome intraoperative difficulties, their operative time will come down and the breadth of patients they can confidently take on will increase. Nevertheless, even for the experienced surgeon, there will be certain red flags that indicate caution when offering patients RARC. This includes BMI greater than 35, locally advanced disease on preoperative staging, prior pelvic bowel surgery or radiation, prior pelvic trauma, history of vascular surgery, or medical comorbidities such as cardiac or pulmonary disease that may compromise anesthetic safety, especially given the physiological effect of prolonged Trendelenburg. Once selected for RARC, patients should be operated on as soon as is reasonably possible, regardless of gender. An analysis of US SEER database bladder cancer patients undergoing RC between 1992 and 2001 (although not specifically RARC) found a delay of over 3 months from diagnosis had a detrimental effect on survival outcomes. This was supported by a more recent metanalysis that demonstrated delays beyond the same 3-month cutoff resulted in poorer long-term survival.

Positioning, port placement, and instrumentation

Patient positioning and port placement are the same for both male and female cystectomy and are crucial to ensure smooth progress of the surgery and minimize any technical difficulties. Thirty degrees of Trendelenburg brings the small bowel out of the pelvis into the upper abdominal cavity but necessitates foam cushions on the table beneath the patient to prevent cephalad sliding, and sometimes the addition of padded fixed shoulder supports. The legs are held in stirrups and spread to allow the robotic system to be brought up to the pelvis, with the hips only minimally flexed and knees flexed to approximately 30 degrees. The arms may be adducted or abducted on boards, with the hands carefully protected by foam sponge. It is essential that the patient is checked for any pressure points at the time of positioning to avoid soft tissue damage or compartment syndrome during the procedure. The port placement is similar in configuration to a robotic-assisted radical prostatectomy (RARP) although more cephalad, higher on the abdomen. The preferred method of placement is the one used by the Karolinska group, measuring the camera port placement 5 cm above the umbilicus in the midline, with additional robotic ports at the level of and 8 to 10 cm either side of the umbilicus, lateral to the rectus sheath. Most centers will prefer an open Hasson approach to placing the camera port to avoid bowel injury. Although pressure of the pneumoperitoneum for the operation is generally 12 mm Hg, for port insertion most will prefer 18 mm Hg to increase the intrabdominal space. The first assistant port is at the same level on the anterior axillary line, two to three fingerbreadths above the anterior superior iliac spine, and the final assistant port triangulates between the camera port and the right robotic instrument port, high enough on the abdomen to allow the assistant to move without clashing. Camera and assistant ports are 12 mm trocars, left and right robotic instrument ports are 8 mm trocars, and the far-left robotic instrument port is a 15 mm trocar, which allows the robotic instrument to be removed so that a gastrointestinal (GI) stapler can be inserted during the bowel reconstruction. The cephalad placement of ports facilitates the presacral part of the extended lymph node dissection (ELND), as well as the uretero-ileal anastomosis on the afferent limb of the urinary diversion. Some groups find reducing the Trendelenburg once the cystectomy and lymph node dissection (LND) are accomplished makes the bowel work easier, although this requires dedocking, so may lengthen operative time.

Principles of RARC

Developing a modular approach to RARC, similar to RARP, facilitates education, but also provides the operating surgeon with a methodical structure allowing smooth progress through what can be a lengthy procedure. Using this modular approach has other benefits, including providing the operating surgeon with a clear step by step path through the procedure, allowing a systematic focus on each task and instrument movement in relation to the anatomical area, and how this relates to potential complications and relevant technical difficulties. As the surgeon gains experience, this will inevitably reduce the operating time (OT), so limiting the physiological stress of 30 degrees of Trendelenburg as well as reducing the risk of complications. Moreover, a structured approach contributes to muscle memory and helps anatomical learning as well as mentoring trainee surgeons. Finally, as RARC develops and new techniques emerge, these can be introduced more effectively into a well-established structure. The following “modules” are the fundamental building blocks for RARC common to both men and women, where their anatomical structures have similarity. These will be discussed individually before discussing the specific details of male and female RARC. For some modules, there is inevitable crossover.

Dissection of the ureters

See Figs. 25.1 and 25.2 .

The position of the ureters beneath the peritoneum is variable, but entering the pelvis over the pelvic brim, they generally cross the bifurcation of the common iliac arteries. Incising the peritoneum over this point is a reasonable first step. Their localization may be more challenging on the left side than the right, due to adhesions from diverticular disease, requiring adhesiolysis, which may distort the underlying anatomy. Using the fourth arm to retract the sigmoid colon may be helpful, and once the peritoneum is opened, dissecting inferiorly medial to the pelvic side wall may also reveal their location. Once found, they are dissected distally toward the uretero-vesical junction, taking care not to dissect off the periureteral tissue which may cause devascularization, and increase the risk of subsequent ureteric stricture. To reduce direct ureteric manipulation, some surgeons will pass a silicone loop around the ureters, which can be pulled by the robotic instrument during dissection, rather than grasping the ureter itself. Once the uretero-vesical junction is reached, the ureters are divided between two Hem-o-loks, each with an attached stay suture. This makes their manipulation easier during the later conduit or neobladder reconstruction and uretero-ileal anastomosis. Routinely, the distal ureteric margins are sent for frozen section.

Bladder mobilization and urethral transection

See Figs. 25.24–25.34 .

The lateral dissection is continued on either side of the bladder, down to the pelvic floor, following the pubic bones and opening the endopelvic fascia if it remains intact. This will allow further definition of the prostate and prostatic urethra in men, and the vesicourethral junction in women. Nerve- or organ-sparing technical variations are discussed below. The dorsal vein complex, more developed in men, can be ligated and divided with the pneumoperitoneum increased to 20 mm Hg to minimize bleeding. The dorsal venous complex (DVC) can be oversewn, especially for men, before completing the urethral transection by applying the largest Hem-o-lok with the catheter in place, which is then divided at the same time, to prevent spillage of tumor cells. At the time of urethral transection generally as much urethra is spared as possible.

Bladder drop

See Figs. 25.35 and 25.36 .

The urachus and median umbilical ligaments are divided last, and the bladder is dropped completely from the under surface of the anterior abdominal wall distally down to the pubic symphysis. Most of this dissection may have already been done to facilitate the urethral transection. During the bladder drop, it is important to avoid injury to the inferior epigastric vessels.

Specimen removal

See Figs. 25.37 and 25.38 .

The bladder specimen is placed into a large bag when it has been freed. Similarly right and left lymph node packets are placed in individual bags, and a method such as tying a knot in the string allows differentiation of right and left. All three bags are clipped, and depending on the need for biobanking, can be removed at the same time mid operation which requires dedocking, or upon completion of the procedure. When removing the specimen, care should be taken not to rupture the bags or injure the mesentery of the conduit which may be close by.