Erik P. Castle and Raj S. Pruthi (eds.)Robotic Surgery of the Bladder201410.1007/978-1-4614-4906-5_1© Springer Science+Business Media New York 2014
1. History of Minimally Invasive Techniques for Radical Cystectomy with Urinary Diversion
(1)
Department of Urology, Tulane University Health Sciences Center, 1430 Tulane Avenue, SL-42, New Orleans, LA 70112, USA
Abstract
This chapter looks to briefly educate the reader on the history of minimally invasive techniques for the treatment of muscle invasive bladder cancer. It will discuss the evolution of both purely laparoscopic and robotic approaches. The authors will go on to discuss briefly where the various procedures stand today in terms of feasibility (operative times, physical demand on the surgeon, etc.), complications (including but not limited to ureteral stricture formation, blood loss, and length of stay), and oncological outcomes (positive margin rates, pelvic lymphadenectomy, and overall survival).
Introduction
Radical cystectomy with urinary diversion is the most effective treatment for non-metastatic, muscle-invasive bladder cancer [1]. Most cystectomies are performed via open surgical technique; however, laparoscopic and robotic cystectomies have recently gained popularity at various centers. Minimally invasive techniques are well established in the field of urology and are increasingly being used for a variety of indications ranging from benign to malignant urologic diseases [2].
Even in skilled and experienced hands, open radical cystectomy is associated with complication rates as high as 30–60 % [3]. Laparoscopic and robotic cystectomies have the advantage of smaller incisions, lower pain scores, and potentially shorter hospital stays, quicker recoveries, and lower overall morbidities, lower blood loss, while at the same time aiming to achieve similar oncologic outcomes as open surgical techniques [4].
Few studies have reported on the long-term efficacy of minimally invasive techniques in the treatment of muscle-invasive bladder cancer. In this chapter, we will outline the history of laparoscopic and robot-assisted radical cystectomy as having a growing role in the management of muscle-invasive bladder cancer. In addition, we will also present an overview of the literature regarding outcomes for laparoscopic and robotic cystectomies.
History of Laparoscopic Radical Cystectomy
Laparoscopic radical cystectomy preceded the robotic era and the first laparoscopic radical cystectomy (LRC) with ileal conduit was performed in 1993 in Malaga, Spain [5]. This was duplicated at other centers and in 2000, Gill et al. [6] reported on two patients who underwent LRC with intracorporeal ileal conduit. And, in 2002, Gill et al. [7] published his series on LRC with continent orthotopic ileal neobladder performed completely intracorporeally. Following that, two groups reported their series on LRC with laparoscopic continent reconstruction of rectosigmoid pouch [8, 9]. Currently, the largest series of patients (N = 171) who underwent LRC with intracorporeal orthotopic ileal neobladder, is from China, with a median follow-up of 3 years [10]. LRC, however, did not gain traction except in select centers because of the physically demanding nature of the procedure and skills needed.
History of Robot-Assisted Radical Cystectomy
After the formal approval of the Robotic surgical device in 2001, many hospitals gained access to the Da Vinci™ Robotic System (Intuitive Surgical Inc., Sunnyvale, CA). Though approved for radical prostatectomy, robot-assisted radical cystectomies (RARC) were performed, using the Da Vinci™, with the first series of robot-assisted radical cystectomies with extracorporeal ileal conduit published in 2003 by Menon et al. [11] Centers, which were well versed in Robotic Radical prostatectomy, ventured into RARC, and soon this procedure was increasingly used and is now an acceptable treatment option. With increased experience, surgeons started performing the urinary diversion intracorporeally and thus another milestone in advancing MIS in bladder cancer was reached. The first reported case of RARC with intracorporeal neobladder was performed in Germany in 2003 [12]. Since that time, several robot-assisted radical cystectomy series have been reported, some with intracorporeal [13] and others with extracorporeal urinary diversion [14]. To date, outcomes studies comparing intracorporeal versus extracorporeal urinary diversion have been sparingly reported, and surgeon experience largely guides the decision for patient selection and which urinary diversion is performed. Thus, over the past decade, there has been a slow but steady trend towards applying RARC techniques for bladder cancer. The acceptance rate for RARC has been slower and limited, compared to robotic radical prostatectomy for prostate cancer.
Outcomes for Laparoscopic and Robot-Assisted Radical Cystectomy
Complications
Radical cystectomy is known to have a high rate of morbidity and relative mortality. Rates of complications in LRC range between 10 and 40 % in recent LRC series [15–17], which is slightly lower than the reported complication rates (30–60 %) found for open radical cystectomies (ORC) [3].
Prior studies have revealed an 8 % incidence of uretero–ileal anastomotic strictures in RARC, which is generally higher than the ureteral stricture rates seen in ORC [18]. This may be because of challenges in performing an extracorporeal urinary diversion if there are tension or exposure problems, especially at the left uretero-enteric anastomosis. In a series of robot-assisted radical cystectomies, Ng et al. [19] found decreased blood loss, lower transfusion rates, shorter hospital stays, and decreased complications compared to open radical cystectomies. However, many patients who undergo radical cystectomy were not found to be candidates for minimally invasive techniques, which may lead to selection bias in many of these comparative studies. For example, severe cardiopulmonary compromise is a relative contraindication to undergo minimal invasive radical cystectomy, because patients who undergo LRC and RARC need to be able to withstand steep Trendelenburg position with pneumoperitoneum, and some patients with cardiopulmonary disease may not be healthy enough to tolerate CO2 pneumoperitonium [20].
Oncological Control
Extended pelvic lymphadenectomy during minimally invasive surgery is safe and equivalent to the open lymph node dissection technique in most series [21]. A nonrandomized study by Richards et al. found equivalent lymph node counts between ORC and RARC (15 versus 16) [22]. A small-randomized prospective trial found equal node counts, with a mean of 18 removed in the open group and 19 in the robotic group [23].
The rates of local tumor recurrence after open cystectomy are approximately 10 % [1]. Overall the 5-year survival for patients with organ-confined, lymph-node negative disease approaches 89 % [1]. LRC and RARC appears equivalent, however, follow-up data have been limited with the majority RARC series reporting less than 2-year follow-up of outcomes [4].
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
