Radical cystectomy with pelvic lymphadenectomy and urinary diversion is the standard of care for patients with muscle-invasive bladder cancer and for those with high-grade, nonmuscle-invasive bladder cancer refractory to intravesical therapy. There has been increasing utilization of robotic-assisted radical cystectomy (RARC), which has been shown to be a safe and efficacious alternative to open cystectomy.
Two randomized trials have compared open radical cystectomy to RARC and found no significant differences in recurrence rates, progression-free survival, or overall survival between the two operations. , The robotic approach is associated with lower blood loss but longer operative time, with similar overall complication rates. , No study to date has prospectively evaluated RARC with intracorporeal urinary diversion, and the effect of intracorporeal urinary diversion on complication rates remains unknown.
Given the comparable oncologic outcomes, similar complication rates, and reduced intraoperative blood loss, RARC is a viable option for patients requiring radical cystectomy and is an operation that is being increasingly utilized by urologists as robotic training becomes more ubiquitous. The choice of robotic versus open cystectomy should ultimately be based upon surgeon experience and comfort level in addition to careful patient selection. This chapter outlines a step-by-step approach to RARC and provides recommendations on preoperative and postoperative management of these patients.
Indications and contraindications
The indications for RARC are the same as those for open radical cystectomy; it is most commonly performed for muscle-invasive bladder cancer, though it is also utilized for carcinoma in situ (CIS) and high-grade nonmuscle-invasive bladder cancer that is refractory to intravesical therapy. Contraindications to the robotic approach to radical cystectomy include severe pulmonary disease that prohibits adequate ventilation once the patient is placed into the steep Trendelenburg position and pneumoperitoneum is established. Relative contraindications include extensive prior abdominal surgeries with resulting intraabdominal adhesions, morbid obesity (which can result in difficulty with positioning and ventilation), and bulky or locally advanced tumors. In these cases the decision regarding the surgical approach depends on surgeon preference and experience.
There is a substantial learning curve for RARC, and patient selection is important in the early stages of the learning curve. As robotic training becomes more prevalent in urology, proficiency with robotic-assisted prostatectomy serves as a useful skillset for RARC. The ideal patient of choice for a surgeon early in their learning curve is a nonobese man with no or minimal prior abdominal surgery and a nonbulky primary tumor.
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, complete blood count, urine culture) should be performed; assessment of glomerular filtration rate is particularly important because it may inform the choice of urinary diversion. Complete staging should be performed including computed tomography (CT) or magnetic resonance imaging of the abdomen and pelvis as well as chest x-ray or chest CT. A bone scan should be performed in the setting of abnormal laboratory findings or symptoms. Patients should be evaluated by an enterostomal nurse preoperatively to choose an appropriate stomal site, even if they are hoping for a continent urinary diversion. Involvement of a dietitian may be useful to identify potential nutritional deficiencies. Neoadjuvant chemotherapy should be offered to all cisplatin-eligible patients with muscle-invasive urothelial cancer, and involvement of a medical oncologist is essential.
Radical cystectomy, whether performed robotically or via an open approach, is associated with a high rate of perioperative morbidity. Setting appropriate postoperative expectations for recovery and return to baseline function is critical. Informed consent should involve a thorough discussion with the patient and family members regarding the risk of morbidity and mortality as well as the significant impact on quality of life. When counseling specifically about RARC, the discussion should include the risk of open conversion and positional injuries. While RARC is associated with decreased blood loss and lower rates of blood transfusion, the operating time is longer than with open cystectomy, and overall complication rates are similar.
Our institutional protocol includes immunonutrition drinks three times daily for 1 week prior to surgery, and clear carbohydrate drinks the day prior to and morning of surgery. Patients are instructed to self-cleanse with chlorhexidine gluconate wipes for several days prior to surgery. Preoperative bowel preparation can be utilized at the surgeon’s discretion. Alvimopan (a peripherally acting µ-opioid antagonist) is recommended as it has been shown to expedite recovery of bowel function in the cystectomy population. Unless contraindicated, the first dose is given in the preoperative holding area before surgery. A single dose of antibiotics is given within 60 minutes of incision. The perioperative antibiotic should have coverage against Gram-positive, Gram-negative, and anaerobic bacteria; cefoxitin is commonly used in the absence of documented allergy. Choice of antibiotic and timing of readministration, if needed, are based on the Surgical Care Improvement Project and American Urological Association guidelines. Venous thromboembolism (VTE) prophylaxis is also initiated in the holding area and may be continued postoperatively for up to 4 weeks. Regional nerve blocks such as transversus abdominis plane (TAP) blocks can be a useful adjunct as part of an extended recovery after surgery (ERAS) pathway to limit the use of perioperative opioids and can be performed after induction of anesthesia.
Operating room configuration and patient positioning
The operating room setup is similar to that used for a robotic-assisted radical prostatectomy. As is the case for prostatectomy, the operating room can be arranged to accommodate either a left- or a right-sided assistant based upon surgeon preference. The following description discusses the operating room configuration for a right-sided assistant.
At least two monitors are used for the procedure. One monitor should be located lateral to the patient’s left shoulder, across from the bedside assistant. 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 arrangement 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. 34.1 ). 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, CA), side docking is possible.
After induction of general anesthesia, an orogastric tube is placed, and an arterial line may be placed as well. If the Xi robot is used, the patient may be placed in supine position to reduce the risk of nerve injuries. If the Si robot is used, the patient is positioned in low lithotomy with use of Yellofins stirrups (Allen Medical, Acton, MA). The arms are tucked bilaterally with a draw sheet, and foam is used to protect all pressure points. If needed, the patient may be secured to the table with a strap or tape to prevent slippage while in the Trendelenburg position ( Fig. 34.2 ). The use of shoulder blocks should be avoided because of the risk of brachial plexus injury. A tilt test should be performed to ensure the patient is secure on the operating table in steep Trendelenburg. The patient is then prepared and draped under sterile conditions. A Foley catheter is placed in the sterile field.
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 the Trendelenburg position. A total of six trocars are used: four for the robotic system and two for the assistant. The first trocar is for the camera, placed 2 to 3 cm cephalad to the umbilicus with a 12-mm camera port for the Si robot and an 8-mm robotic port for the Xi robot. Before placement of any additional ports, the patient should be placed into the Trendelenburg position, which will allow additional lateral exposure of the abdominal wall. An 8-mm robotic trocar is placed on each side lateral to the camera port, 8 cm from the camera port for the Xi robot (one small handbreadth) and 11 cm from the camera port for the Si robot (one large handbreadth), in line with the upper edge of the umbilicus. The final robotic port, used for the fourth robotic arm, is placed directly lateral to the existing left-sided robotic port with equal spacing between ports. 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. A 15-mm port is preferable 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 cephalad (approximately one handbreadth superior) and approximately halfway between the right robotic port and the camera port. A 12-mm port in this location allows the placement of a laparoscopic stapler directly onto the vascular pedicles of the bladder ( Fig. 34.3 ). 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). One assistant port can also be utilized depending on surgeon and assistant preference.
Procedure ( 
)
As with open radical cystectomy, the pelvic lymphadenectomy can be performed before or after the cystectomy is completed, based upon surgeon preference. In the section below, we describe RARC with the PLND performed after the cystectomy is completed, according to the following steps:
- 1.
Left ureteral dissection
- 2.
Left vascular pedicle development
- 3.
Right ureteral dissection
- 4.
Right vascular pedicle development
- 5.
Posterior bladder dissection and development of the prerectal space
- 6.
Division of the vascular pedicles of the bladder
- 7.
Anterior bladder dissection
- 8.
Dissection and division of the urethra
- 9.
Bilateral PLND
- 10.
Mobilization of the sigmoid colon and passing of the left ureter behind the sigmoid
- 11.
Extraction and extracorporeal urinary diversion or intracorporeal urinary diversion
Left 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. Robotic instruments include monopolar scissors in the right hand, a fenestrated bipolar instrument in the left hand, and ProGrasp or Cobra forceps (Intuitive Surgical, Sunnyvale, CA) in the fourth arm. The left colon is mobilized by incising the peritoneum lateral to the bowel, allowing the sigmoid colon to be rotated medially, exposing the left common iliac vessels and left ureter. If the ureter is not seen, it may be adherent to the backside of the sigmoid mesentery, which occurs frequently in obese patients. If the ureter still 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 carefully dissected distally to its insertion into the bladder, with care taken to preserve the periureteral tissue. Cautery should be used judiciously around the ureter, and care must be taken to avoid excessive upward traction. The obliterated umbilical artery may be clipped and divided if encountered during the distal dissection. In female patients, the infundibulopelvic ligament will need to be divided for completion of the distal ureteral dissection. The ovarian pedicle and round ligament will also need to be clipped and divided.
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, which will allow atraumatic manipulation during urinary diversion ( Fig. 34.4 ). 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 the risk of ureteroenteric anastomotic strictures. If desired, a frozen section of the ureter can be sent at this time. The clipped ureter should then be placed cephalad out of the operative field above the common iliac vessels for the remainder of the cystectomy portion of the case.
