Open radical cystectomy (ORC) has long been widely performed as a standard treatment option of muscle-invasive or high-risk non–muscle-invasive bladder cancer.1 However, ORC has many disadvantages, such as a long incision, long abdominal wall retraction, poor visibility, high rates of blood transfusion, prolonged exposure of the peritoneal surface, and postoperative wound pain. Thus, minimally invasive surgery besides ORC is required.
Several studies have reported the laparoscopic radical cystectomy (LRC) as a minimally invasive technique and have demonstrated its safety and feasibility.2–4 In Japan, LRC was approved to be covered by the national health insurance system in 2012. Although LRC is expected to overcome some disadvantages of ORC, its technical difficulty may lengthen operating time or cause fatigue of surgeons.5,6
The da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA USA) was pharmaceutically approved in November 2009. It enables us to perform more precise procedures than conventional surgical approaches do using robotic forceps with joint function and high-resolution three-dimensional vision. Therefore, it is expected to contribute to overcoming the procedural difficulty of conventional laparoscopic surgery. In addition to LRC, robot-assisted radical prostatectomy (RARP) using the da Vinci surgical system has been approved for coverage by the national health insurance system in April 2012, a first for robot-assisted surgery in Japan. It has since spread rapidly. Because robot-assisted surgeries are still just beginning, few studies have evaluated their benefit for Japanese patients. We installed robot-assisted laparoscopic radical cystectomy (RARC) using the da Vinci surgical system with two arms at the same time as LRC. We herein report the initial experience of using RARC compared with that of LRC.
MATERIALS AND METHODS
Starting on October 2011, six patients with muscle-invasive or high-risk non–muscle-invasive bladder cancer underwent RARC (RARC group) conducted by a single surgeon who had experiences with 10 cases of RARP for prostate cancer and had never experienced routine LRC. The ethical committee in our institute had approved RARC before we started because it has not yet been approved for coverage by the national health insurance system in Japan. During the same period, another five patients with muscle-invasive or high-risk non–muscle-invasive bladder cancer underwent LRC (LRC group). Which procedure was selected depended on the desire of each patient.
Characteristics of the patients are listed in Table 1. The ages, indices, Charson comorbidity indices, and clinical T stages of the patients in the RARC group were compared with those in the LRC group.
The outline of RARC is as follows:
1. The transperitoneal approach with six ports shown in Figure 1 was used. Under general and epidural anesthesia, a 12-mm trocar for the camera was placed above the umbilicus by an open laparotomy technique, and then pneumoperitoneum was started. Two 8-mm robotic ports were placed at 8 cm lateral to the umbilicus. A 12-mm assistant port was placed 8 cm lateral to the left-sided robotic port. A 5-mm suction port was placed between the camera and the right-sided assistant port. A 15-mm assistant port was placed between the camera and the left-sided assistant port.
2. The patients were placed in a lithotomy position with 30-degree Trendelenburg tilt. After docking of a patient cart, surgery was started.
3. The colon was mobilized medially, and bilateral ureters were identified. They were isolated proximally and then distally to the level of the bladder wall and were then divided using Hem-o-lok clips (Weck Closure System, Research Triangle Park, NC USA). Frozen sections of ureteral margins were analyzed to confirm whether they were free of cancer tissues.
4. Bilateral cutting margins of the retroperitoneum were jointed at the Douglas fossa, and after the blunt dissection beneath the posterior bladder wall, lateral vascular pedicle of the bladder was divided using a shield device. Bilateral seminal vesicles were identified and isolated.
5. Denonvilliers’ fascia was divided, and the posterior layer of the prostate was bluntly dissected from the anterior side of the rectum. Bilateral lateral vascular pedicles of the prostate were divided using a shield device after incision of endopelvic fascia.
6. Medial umbilical ligaments and the urachus were divided, and the prevesical cavity was exposed. The dorsal vein complex was divided.
7. Bilateral common, external iliac, internal iliac, and obturator lymph nodes were dissected.
8. The urethra was sufficiently exposed and divided after suture-ligature for the distal side, the bladder and the prostate were isolated, and then the resected specimen was kept by Endocatch II (Covidien Ltd, CT USA) inserted from a 15-mm port. When necessary, urethrectomy was performed using a perineal approach by other surgeons.
9. The left ureter was moved to the right side through the retroperitoneal cavity.
10. The patient cart was undocked, and the Trendelenburg position was restored to the flat position with the legs open.
11. The wound for the camera port was extended to 5 cm (Fig. 2), and the bladder and the prostate were removed out through it. Bilateral ureters were moved through the wound, and then the ileal conduit was made extracorporeally.
Laparoscopic radical cystectomy was performed using the same approach as RARC.
A two-sided comparison for several variables between the RARC and LRC groups was performed by Mann-Whitney U test using Stat View (version 5.0; SAS, Cary, NC USA). P values less than 0.05 were statistically significant.
Characteristics of the patients are listed in Table 1. There were no significant differences in age, body mass index, or history of abdominal surgery.
All 11 patients underwent RARC or LRC without conversion to open surgery. In the first case of RARC, it took a long time to isolate the ureters and move the left ureter to the right side, and blood transfusion was required. Perioperative data are listed in Table 2. There was no significant difference in estimated blood loss, operative time, or insufflations time between RARC and LRC. Although two cases of troubles at the ureteroconduit anastomosis sites (urine leakage and difficulty in removal of ureteral stent after surgery) were experienced after LRC, postoperative complication related to urinary diversion was not experienced after RARC.
Pathological examination of specimens resected by RARC revealed that the component of urothelial carcinoma in situ was shown at the resected margins of bilateral ureters in one of the cases but no positive surgical margin in the other cases. The number of resected lymph nodes was 4 to 31 (median, 11) in RARC, which was not significantly different compared with that in LRC (6–42; median, 12; P = 0.8548). Lymph node metastasis was detected microscopically in one case after LRC. All six patients after RARC and five patients after LRC returned to normal daily life after leaving our hospital and have continued to be followed up without clinical recurrence.
A previous study has demonstrated that LRC by well-experienced surgeons is expected to obtain surgical outcomes equal to those of ORC.6 Despite its benefit as a minimally invasive surgery, LRC has a long learning curve, and it has been difficult to spread widely because of its procedural complexity.
Binder and Kramer7 demonstrated the procedures of RARP as the first report of robot-assisted surgery for urologic diseases. Robot-assisted radical prostatectomy has spread widely as a standard technique since being approved by the Food and Drug Administration. A previous study has demonstrated that more delicate procedures in a small pelvic cavity using three-dimensional vision in RARP lead to less bleeding, shorter hospitalization, and quicker recovery of urinary and sexual functions.8 Because there are many similarities between RARC and RARP, the advantages of RARP are expected also in RARC. The number of times surgeons perform RARP and the surgical outcome of RARC have been reported to correlate positively.9 In our institute, we first had set up a special team for RARP consisting of not only urologists but also anesthesiologists, nurses, and medical engineers and had them master handling the da Vinci surgical system through 10 cases of RARP before RARC was started.
Reports about RARC have increased since it was initially reported by Menon et al10 in 2003. Several studies demonstrated its surgical outcomes, including significantly less bleeding than ORC even in the beginning periods.11–14 In contrast, in Japan, although laparoscopic surgery has long been widely spread for urologic diseases and most Japanese urologic surgeons are well experienced in laparoscopic surgery, robot-assisted surgery is still just beginning. On the basis of these situations, which procedure, RARC or LRC, was more suitable for Japanese urologic surgeons in the initial periods was unclear. Thus, we compared the perioperative outcomes in initial periods of RARC with those of LRC in this study. As a result, there was neither perioperative nor pathological outcomes that significantly differed between RARC and LRC. The da Vinci surgical system enabled safe and precise procedures using the forceps with joint function in all steps during surgery including mobilization of the ureters and the intestines. Patients who had undergone RARC had no severe complication. These results indicate that RARC was a tolerable procedure even in the initial period.
Because larger targets such as the urinary bladder and the prostate are handled during surgery in RARC, the role of the assistant is very important. In RARC, we used only two arms without the third arm. Although the third arm is a useful tool for a surgeon, it often collides with other instruments of the robot arm or of the assistant in the initial period. Instead of trocar for the third arm, the port for the assistants was placed so that they could perform more effectively using both arms. On the other hand, for surgeons who have gained mature techniques after enough experiences, there might be the advantage of the third arm in some cases.
Urinary diversion in LRC has been reported in both intracorporeal4 and extracorporeal6 methods. Also in RARC, although some studies have reported whole processes of surgery intracorporeally,15,16 others have demonstrated the procedures of RARC with extracorporeal urinary diversion after undocking the patient cart.17,18 We considered the necessity of the lithotomy position with 30-degree Trendelenburg tilt in RARC and the elongation of the pneumoperitoneum with CO2. Therefore, urinary diversion was performed after undocking, stopping the pneumoperitonem, and changing the Trendelenberg tilt to a flat position in our observations. The ileal conduit was able to be completed using median wound for the camera port elongated to 5 cm. In the first case, it took a long time to mobilize the left ureter during ileal conduit, resulting in the elongation of total operative time and increase in bleeding volume. It is difficult to isolate and mobilize the ureters in the small midline wound extracorporeally. After that, the ureters were sufficiently isolated, and the left ureter was sufficiently mobilized through the retroperitoneal cavity using da Vinci, and operative time has been shortened since the second case.
Another theme in our experiences of RARC is lymph node dissection. A previous study reported that 30 cases of experiences were required to establish a technique dissecting more than 20 lymph nodes in RARC.19 Although the median number of dissected lymph nodes in our experiences is 11, a total of 32 lymph nodes were dissected in the sixth case. The quality of lymph node dissection might be expected to improve after further experiences are accumulated but in a shorter learning curve.
Because many patients with bladder cancer are elderly, they often have cardiovascular or respiratory illnesses. Therefore, we must carefully consider the risk for perioperative complication originating in the overload for the circulatory system and elevated ocular tension caused by elongated Trendelenburg position or the pneumoperitoneum. Although there was no severe perioperative complication in our six cases, three have cardiovascular illness and one has a respiratory illness. Although the risk for postoperative complication in RARC has been reported to be equal to that in ORC, biases in the selection of patients were pointed out in such retrospective studies.20–22 Further accumulation of the experiences and long-term follow-up of RARC and high-volume, prospective studies might be required to confirm the safety and efficacy of RARC.
In Japan, robot-assisted surgery is just beginning, whereas laparoscopic surgery has already spread widely. Even in such situations, we successfully experienced the initial cases of RARC as same as those of LRC. Our impression is that RARC is a safe and acceptable option for surgical treatments of muscle-invasive or high-risk non–muscle-invasive bladder cancer. Robot-assisted laparoscopic radical cystectomy might be expected to become a standard procedure in the near future after the recent rapid spread of robot-assisted surgery in Japan.
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This case series examined 6 patients who underwent robotically assisted laparoscopic radical cystectomy and compared those to another 6 patients undergoing laparoscopic radical cystectomy for muscle invasive or high-risk non-muscle invasive bladder cancer. There were no differences in perioperative outcomes between the two small groups. The authors felt that robotically assisted laparoscopic radical cystectomy is a feasible option in this group of patients and further studies are needed to confirm both effectiveness and safety.
The principal weaknesses of this study are the small number of patients and its non-randomized nature. Future and larger studies are keenly anticipated to allow surgeons to define the role of robotic assistance in this patient population.