Laparoscopic and Robotic Radical Cystectomy in Males and Females

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Laparoscopic and Robotic Radical Cystectomy in Males and Females

Douglas S. Scherr,¹ David M. Golombos,² & Abimbola Ayangbesan³

¹ Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA

² Department of Urology, Stony Brook School of Medicine, Stony Brook, NY, USA

³ Vanderbilt University Medical Center, Nashville, TN, USA

Introduction

Bladder cancer is largely a disease of the elderly, presenting with a median age of 73 years in men and 74 years in women [1]. It is the fourth most common cancer in the United States; in 2016, an estimated 76 960 new diagnoses and 16 390 deaths were predicted [2]. Bladder cancer is also the fourth leading cause of cancer death in men aged 80 and older [2]. In managing patients with bladder cancer, the primary therapy relies on initial staging from transurethral resection of bladder tumor (TURBT) [1]. For patients with muscle‐invasive bladder cancer and for those with high‐risk recurrent non‐muscle‐invasive disease, open radical cystectomy (ORC) remains the gold standard of treatment [1]. Attempts at a minimally invasive approach were first made in the early 1990s with the introduction of laparoscopic cystectomy [3, 4], followed by the introduction of robot‐assisted radical cystectomy in 2003 [5]. When compared to ORC, recent studies have shown laparoscopic radical cystectomy (LRC) to be a safe, feasible, and reliable alternative with lower morbidity and perioperative complications [6–10]. Furthermore, robot‐assisted radical cystectomy (RARC) has also been shown to be a safe alternative, presenting with reduced perioperative complications, less estimated blood loss with lower need for perioperative blood transfusion, hastened gastrointestinal recovery, lower narcotic requirement, and shorter length of stay [11–19]. Given the technical similarities between LRC and RARC, both approaches will be addressed collectively; however, given its growth in popularity, a greater focus will be placed on robotic cystectomy.

Indications and patient selection

LRC and RARC are usually indicated for patients with organ‐confined, nonbulky bladder cancer [20] with the goal of surgical cure of disease. On rare occasions, palliative cystectomy is performed in patients with severe symptoms from disease as an adjunct to chemotherapy. Contraindications to robot‐assisted cystectomy generally vary from patient to patient and should be assessed on a case‐by‐case basis with decisions to proceed based on the surgeon’s experience. For example, patients with prior abdominal surgery can present with extensive intra‐abdominal adhesions [21] requiring careful lysis of adhesions. Yet, while patients with previous abdominal surgery have a higher risk of postoperative complications, the likelihood of a safe completion of robot‐assisted cystectomy is not affected [21]. Similarly, although previous pelvic radiation is a relative contraindication to a robotic approach, in experienced hands complications rates after RARC do not show significant differences between patients with or without a history of pelvic irradiation [22]. Other relative contraindications include evidence of locally advanced disease and obesity [20].

Operative technique

Patient preparation

Prior to surgery, bowel preparation includes 48 hours clear liquid diet, 300 ml of magnesium citrate, and one tablespoon of mineral oil the day before surgery. If the patient is undergoing continent cutaneous diversion with the right colon, 4 liters of polyethylene glycol is used for bowel prep the day before surgery, and antibiotics (1 g of oral neomycin and 1 g of erythromycin), with one tablespoon of mineral oil are given the day before surgery. Rectal enema is also done the evening before and morning of surgery.

Operative setup

Specifics of the operative setup for RARC will be dictated by the characteristics of the individual surgeon’s operating room. At our institution, we employ a single assistant on the patient’s right side, and feel that at least three monitors are needed to allow for each team member to have optimum viewing. Figure 96.1 provides a schematic overhead view of our preferred operative setup.

Image described by caption and surrounding text. — **Figure 96.1** Schematic overhead of operative set up for robotic‐assisted radical cystectomy. (A) Surgeon; (B) robotic console; (C) da Vinci®; (D) scrub nurse; (E, J) high‐definition monitors; (G) bedside assistant; (H) anesthesiologist.

*Source:* Golombos DM. *Robot‐Assisted and Partial Cystectomy*. Berlin: Springer‐Verlag, 2017. Reproduced with permission of Springer.

Patient positioning and preparation

As illustrated in Figure 96.2, the patient is placed in a dorsal lithotomy position using standard operative stirrups. The arms are tucked and protected using egg‐crate foam padding, legs placed in sequential compression stocking devices, and a cross‐shoulder harness is used to secure the patient to the operating table. The table is tilted to a steep 30–40° Trendelenburg position. A urethral catheter is placed sterilely on the operative field. Along with perioperative antibiotics, we routinely administer 5000 units of subcutaneous heparin prior to the start of the operation.

Trocar configuration

Initial insufflation of the abdomen is done via the Veress needle technique to 15 mmHg. Figure 96.3 outlines our standard trocar configuration for RARC. A camera trocar is placed in the periumbilical location using a 10–12 mm, blunt, disposable trocar. At 10 cm lateral and 4 cm inferior to the camera trocar, a left 8 mm robotic trocar is placed. Three centimeters superior to the anterior superior iliac spine (ASIS), a second 8 mm robotic trocar is placed along the midaxillary line. At 4 cm inferior and 10 cm lateral to the camera trocar, a right 8 mm is placed. The main right assistant trocar is placed at 3 cm superior to the ASIS in the midaxillary line using a Versaport™ Plus 5–15 mm trocar (Covidien/Medtronic, Minneapolis, MN, USA). Midway between the right robotic trocar and the camera trocar, a 5 mm AirSeal® Access Port (Conmed, Utica, NY, USA) is placed, which is used primarily for suction–irrigation.

Steps of the procedure

The techniques described below apply directly to robotic cystectomy; laparoscopic cystectomy, however, follows a similar procedural flow with noted differences in the instruments used. We begin the procedure with identifying and dissecting the right ureter by incising the posterior peritoneum along the white line of Toldt and sweeping the bowel medially to expose the psoas muscle. The ureter can usually be readily identified medially along the psoas at its crossing of the external iliac artery. Proximal dissection is performed first to approximately the level of the gonadal vessels, with care taken to preserve blood supply and to avoid direct grasping. Distal dissection is then performed to the level of the ureteral hiatus, with the final distal dissection performed after the division of the anterior pedicle.

Development of the avascular plane between the left bladder and pelvic sidewall reveals the anterior bladder pedicle, which contains the superior vesicle artery. The pedicle can be isolated and transected by various techniques, including the robotic vessel sealer. Once the pedicle is divided, the dissection of the remainder of distal ureter is performed. Prior to transection of the ureter, a large clip is applied distally and a second large clip with a long suture attached is applied proximally, which will facilitate identification duration the later steps of the procedure. Once the clips are secured, the ureter is transected sharply. A similar dissection is carried out on the right side, exposing the right anterior bladder pedicle, ureter, and pelvic sidewall.

After both the anterior pedicle and ureter are divided, a posterior plane is developed by separating the bladder from the rectum. The surgeon lifts the bladder anterior while the bedside assistant retracts the posterior peritoneal edge. Using a combination of blunt and sharp dissection, the posterior plane between the bladder and rectum beneath the posterior leaflet of Denonvilliers’ fascia is carried as distally as possible to the level of the prostatic apex, allowing for identification of the posterior pedicles of the bladder. The posterior bladder pedicles are divided using the vessel sealer device for non‐nerve‐sparing operation, and large Hem‐o‐lok® (Teleflex Medical, Research Triangle Park, NC, USA) clips in a nerve‐sparing procedure. The division is complete once the endopelvic fascia is encountered.

The endopelvic fascia is then divided sharply as caudally as possible, because once the bladder is released from the anterior abdominal wall, the posterior prostatic apex becomes difficult to visualize. The prostatic pedicles are then divided using either the vessel sealer device or Hem‐o‐lok and titanium clips depending on desired nerve‐sparing. During this dissection, to avoid injury to the rectum, the bladder and prostate are retracted superomedially while the rectum is retracted posteriorly using the robotic third arm and prograsp, respectively.

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