Robotic-Assisted Radical Cystectomy

Radical cystectomy is the standard of care for muscle-invasive and refractory non–muscle-invasive bladder cancer. An open radical cystectomy is the most thoroughly studied approach and remains more frequently used by urologists—although, since the first report of robotic-assisted radical cystectomy (RARC) by Menon and colleagues, we have seen a steady rise in the performance of this minimally invasive approach to radical cystectomy. There has been some controversy surrounding the use of RARC, mainly questioning the true impact on patient morbidity in the setting of unproven oncologic outcomes. However, there continue to emerge numerous reports in the literature suggesting some distinct benefits of the robotic approach, but robust randomized data are lacking. Fortunately, Level I data will be available in the future because the RAZOR (Randomized Open versus Robotic Cystectomy) trial—a large multicenter phase 3 randomized trial comparing open and robotic cystectomy—has recently completed accrual. Despite the current limitations of the available data, RARC is a viable option for radical cystectomy that is being increasingly embraced by both patients and urologists. This chapter outlines a step-by-step approach to RARC and provides some recommendations on preoperative and postoperative management of these patients.

Indications and Contraindications

The indications for RARC are the same as for an open radical cystectomy; in general, RARC will be performed for the treatment of muscle-invasive bladder cancer. An absolute contraindication to RARC is severe pulmonary disease that prohibits adequate ventilation while a patient has a pneumoperitoneum and is placed into steep Trendelenburg position (which is required to perform RARC). Some relative contraindications include extensive prior abdominal surgeries, morbid obesity (positioning and ventilation issues), and bulky or locally advanced tumors. Ultimately, the decision to perform RARC in these situations will come down to surgeon preference and experience.

When a surgeon first starts performing RARC, the procedure can be challenging and lengthy; thus patient selection is extremely important early in one’s learning curve. The ideal patient to choose when starting RARC is a nonobese man with no or minimal prior abdominal surgery and a nonbulky primary tumor. It also is advisable to be proficient in robotic-assisted prostatectomy before undertaking RARC.

Patient Preoperative Evaluation and Preparation

The preoperative evaluation of a patient undergoing RARC is the same as would be performed for open cystectomy. Routine laboratory tests (comprehensive metabolic panel [CMP], complete blood count [CBC], urine culture) should be performed with particular attention paid to renal function because of its impact on choice of urinary diversion. Patients require standard staging studies with computed tomography (CT) of the abdomen and pelvis and chest radiography or chest CT. Additional imaging with a bone scan should be undertaken in the setting of abnormal laboratory findings or symptoms. Although not routinely used, magnetic resonance imaging (MRI) may provide superior soft tissue definition of the primary tumor and aid in patient selection early in one’s experience. Patients should be evaluated by an enterostomal nurse preoperatively to choose an appropriate stomal site, and involvement of a dietitian to identify potential nutritional deficiencies should be considered.

When obtaining informed consent for a radical cystectomy, a thorough discussion is required with the patient and any involved family members concerning perioperative morbidity and mortality as well as the impact on quality of life. Radical cystectomy is plagued with high complication and readmission rates; appropriate counseling preoperatively will set realistic expectations for the patient and family. When counseling about RARC, the discussion should include the risk of open conversion and positional injuries, as well as the available data concerning oncologic outcomes and convalescence after RARC versus open radical cystectomy. Regardless of approach used, the oncologic principles of bladder cancer must be followed, and neoadjuvant chemotherapy should be offered to eligible patients.

No bowel preparation is required (if colon is to be used, then we perform a mechanical preparation only). One can consider an enema preoperatively in an attempt to decrease rectal distention, which may improve visualization during the posterior bladder dissection. We routinely use alvimopan (a peripherally acting μ-opioid antagonist) because there is evidence of improved bowel function with its use in the cystectomy population. The first dose is given in the preoperative holding area before surgery. A single dose of antibiotics is given before incision. The choice of antibiotic and timing of readministration, if needed, are based on the Surgical Care Improvement Project (SCIP) guidelines. Venous thromboembolism (VTE) prophylaxis is also initiated in the holding area and typically is continued postoperatively for up to 4 weeks.

Operating Room Configuration and Patient Positioning

The operating room setup will be very similar to that used for a robotic-assisted prostatectomy. As is the case for prostatectomies, the operating room can be arranged to accommodate either a left- or a right-sided assistant; this is purely a matter of surgeon preference. The following description discusses the operating room configuration for a right-sided assistant.

We use at least two monitors for the procedure. One should be placed directly across from the bedside assistant, just lateral to the patient’s left shoulder; this will be ergonomic for the assistant by preventing rotation of the neck. Of note, this monitor is associated with the robotic tower (i.e., light source, energy sources). The second monitor is located adjacent to the instrument table for use by the surgical technician. The instrument table is located to the right of the patient at the level of the right leg. This allows adequate room for the assistant and surgical technician. The instrument table could also be placed on the left side of the patient based on the configuration of a particular operating room ( Fig. 35-1 ). This arrangement allows the robotic system to be located between the patient’s legs, but with the advancements of the da Vinci Xi system (Intuitive Surgical, Sunnyvale Calif.), side docking is possible.

After general anesthesia has been administered, an orogastric tube is placed, then a bladder catheter is placed after the patient has been prepared and draped. The patient is positioned in low lithotomy with use of Yellofins stirrups (Allen Medical, Acton, Mass.), and the arms are tucked bilaterally with a draw sheet. Foam is used to protect pressure points, in particular at the calf and elbows. It is our practice to place a strip of 3-inch silk tape over foam at the level of the chest to prevent slippage of the patient while in Trendelenburg position ( Fig. 35-2 ). The use of shoulder blocks should be avoided because of the risk of brachial plexus injury. The use of laparoscopically assisted vaginal hysterectomy (LAVH) drape simplifies the draping of patients undergoing RARC.

Trocar Placement

Access to the abdomen and creation of the pneumoperitoneum can be achieved according to the surgeon’s preference. Our approach is to use a Veress needle through the site where the camera trocar will be placed; this is done before placing the patient in Trendelenburg position. A total of six trocars are used for a RARC: four for the robotic system and two for the assistant. The first trocar, where the camera will be located, is placed 2 to 3 cm cephalad to the umbilicus and is a 12-mm port. The two 8-mm robotic trocars are placed 11 cm lateral to the camera port at the upper edge of the umbilicus. Before placement of any additional ports, the patient should be placed into Trendelenburg position, which will allow additional lateral exposure of the abdominal wall. The last robotic port is placed 11 cm directly lateral to the existing left-side robotic port and will be the site of the fourth robotic arm. Two assistant ports are placed on the right side, 12 mm and 15 mm in size. The 15-mm port is placed approximately halfway between the right robotic port and the right anterior superior iliac spine (ASIS). We prefer a 15-mm port in this location to aid in the extraction of lymph node packets during the pelvic lymph node dissection (PLND) as well as to allow the placement of a 15-mm specimen extraction pouch for the removal of the cystectomy specimen. The remaining 12-mm assistant port is placed directly above (or slightly medial to) the right robotic port just below the costal margin. A 12-mm port in this location allows the placement of a laparoscopic stapler directly onto the vascular pedicles of the bladder. This is discussed in greater detail later in this chapter ( Fig. 35-3 ). A mirror image of this configuration can used to accommodate a left-sided assistant (which is preferred if an intracorporeal urinary diversion is being performed).

Procedure (See )

As is the case with an open radical cystectomy, the PLND can be performed either before or after the cystectomy portion of the surgery. This is largely based on surgeon preference. The following section describes the steps for RARC with the PLND being performed first:

1.

Right ureteral dissection
2.

Right PLND
3.

Mobilization of the sigmoid colon, left ureteral dissection, left PLND
4.

Transferring left ureter
5.

Development of the prerectal space and posterior bladder dissection
6.

Division of vascular pedicles to the bladder
7.

Anterior bladder dissection
8.

Dissection and division of the urethra
9.

Specimen extraction and extracorporeal urinary diversion

Right Ureteral Dissection

A 30-degree downward lens should be used at the start of the procedure. This provides a better perspective when working in the pelvis for the ureteral and lymph node dissection. At the outset of the procedure, monopolar scissors are used in the right hand, a fenestrated bipolar instrument is used in the left hand, and ProGrasp forceps (Intuitive Surgical, Sunnyvale, Calif.) are placed in the fourth arm. After releasing any attachment from the cecum and terminal ilium, the pulsations of the right common iliac artery should be identified. In many cases the ureter can be identified at this time. When it cannot be seen, the peritoneum and lymphatic tissue on the proximal common iliac artery should be opened and dissection should be carried distally along the vessel until the ureter is located. The ureter should be dissected away from the posterior structures and freed circumferentially, with care taken to maintain adequate periureteral tissue. The dissection should be carried distally to the insertion of the ureter into the bladder. One needs to be careful not to place too much upward traction on the ureter with the robotic arms, which could result in significant trauma. In female patients, the infundibulopelvic ligament will need to be divided for completion of the distal ureteral dissection.

When the distal dissection is complete, the ureter should be controlled and divided between two locking clips. The proximal clip should have a 10-inch preplaced tie on it. This tie will allow atraumatic manipulation during urinary diversion ( Fig. 35-4 ). If any additional cephalad mobilization of the ureter is required, it should be completed before distal division because this dissection can be challenging once the ureter is free. Proximal dissection should be limited to minimize disruption of the vascular supply and decrease risk of ureteroenteric anastomotic strictures. If desired, a frozen section of the ureter can be sent at this time, although the benefits of its routine use remain uncertain.