‘In the long history of humankind (and animal kind, too) those who learned to collaborate and improvise most effectively have prevailed’.
Open radical cystectomy (ORC) has been the gold standard for nonmuscle invasive high risk and muscle invasive bladder cancer. ORC has been associated with significant morbidity and mortality even at centers of excellence. With the introduction of robot-assisted radical cystectomy (RARC), first reported by Menon in 2003 , its evolution and acceptable safe outcomes have led to its acceptance as an alternative for ORC [2,3,4▪]. As with any novel surgical procedure, technical challenges have been identified and addressed leading to an improved surgical procedure [5–7]. Several fundamental tenets that have been used to advance the surgical technique for RARC and Intracorporeal Ileal Conduit (ICIC) are described.
ROBOT ASSISTED RADICAL CYSTECTOMY
ORC has been the gold standard and is associated with significant morbidity and mortality even at centers of excellence. Introduction of RARC has brought in a new technical paradigm in pelvic urologic oncology.
Clear liquid diet the day prior to surgery and mechanical bowel preparation is based on the anticipated urinary diversion selected and surgeon's choice. ICIC does not require mechanical bowel preparation and this approach has been shown to be safe and effective. Preoperative antibiotics are administered according to the American Urologic Association guidelines .
Patient positioning for RARC and ICIC is similar to Robot-assisted radical prostatectomy and the operating table is tilted at maximum trendellenburg (>200). Three 8 mm robotic trocars, 1–15 mm assistant port, 1–12 mm additional (bowel anastomosis) port and 1–5 mm suction port are used. The abdomen is insufflated using the Veress needle or Hassan technique. All ports are placed under direct vision.
Incorporation of ‘technique of spaces’ is critical for dividing a procedure with multiple steps, which helps with ease of teaching and keeping the procedure focused. Previous reports have described the technique of spaces as elements of the cystectomy dissection.  The four spaces of dissection are the periureteral space, lateral pelvic space, anterior rectal space, and retropubic space.
The dissection begins with an incision in the posterior peritoneum above the iliac vessels and identification of the ureter. Ureteral identification is typically more difficult on the left compared with the right because of the possibility of inflammatory adhesions from previous diverticular disease. The fourth arm can be used to retract the sigmoid colon medially for easier retraction. (Fig. 1)
The ureter is dissected distally toward the ureterovesical junction (UVJ) maintaining adequate periureteral tissue to prevent ischemia to the distal ureter. The distal margin is cut using the cold scissors and is immediately sent for frozen section.
LATERAL PELVIC SPACE
The posterior peritoneum is incised lateral to the medial umbilical ligament and carried toward the ipsilateral ureter. Areolar tissue is swept from lateral to medial to maintain adequate soft tissue margin and avoid injury to the iliac vessels. The endopelvic fascia is identified and incised (Fig. 2).
ANTERIOR RECTAL SPACE
Once both spaces are developed on either side, the posterior peritoneum remaining between the two ureters is incised across the midline. In men, this incision is made just below the vas deferens, as they travel toward the midline. Blunt dissection in a sweeping motion is used to separate Denonvillier's fascia from the rectum (Fig. 3).
LIGATION OF VASCULAR PEDICLES
After the above spaces have been developed, the fourth robotic arm is used to apply anterior retraction to the bladder. The right and left arms are used to manipulate the perivesical tissue medially and laterally in order to identify the vascular pedicle. The endo GIA stapler is used to ligate the vascular pedicle including the superior vesicle artery.
The anterior attachments of the bladder are divided by incising the urachus and medial umbilical ligaments as cranial as possible in order to ensure an adequate soft tissue margin. The space of Retzius is entered and the bladder is dropped. The dorsal venous complex (DVC) is exposed. The insufflation pressure is increased to 20 cm and the DVC can either be incised using the hook cautery (if non-nerve-sparing is performed) or cold using the scissors (if nerve-sparing is performed). The DVC is oversewn using a barbed suture and insuflation pressure is returned to 15 cm. The urethra is exposed and the indwelling foley catheter is drawn out. A large clip is placed across the urethra to prevent antegrade tumor spillage. If a urethrectomy is performed a second clip may be placed distally for identification. The urethra is divided and the specimen is placed in an Endo Catch (Covidien, Mansfield, MA, USA) bag.
CYSTECTOMY IN WOMEN
With the development of surgical expertise, a growing interest in sexual and reproductive sparing radical techniques have been described. The procedure employs the same principle of exploring the spaces as described above for male cystectomy with slight variation. While developing the periureteral space the uterine artery is encountered crossing the ureter. These structures are left intact until all other landmarks are identified. The lateral pelvic space is developed similar to male radical cystectomy. It contains the round ligament traversing across from the deep inguinal ring to the uterus. The ligation of the pedicles is achieved by separating the peritoneum connecting the infundibulopelvic ligament with the internal iliac vessels. This ligament contains the ovarian vessels that travel anterior and lateral to the ipsilateral ureter. The ureter, uterine and vesical blood vessels are ligated.
The retrouterine space is developed to complete the posterior dissection of the uterus in the female cystectomy. This is achieved by incising the posterior peritoneum in the rectouterine pouch and blunt dissection to the posterior vaginal fornix. Manipulation of an intravaginal dilator helps identify the junction of posterior fornix with the cervical os. The pelvic plexus supplies the vagina and urethra and descends on the lateral vaginal wall, and therefore care must be taken to save this plexus for adequate sexual function. Development of the anterior vaginal space is recommended in order to preserve adequate length of anterior vaginal wall. Traction is applied on the uterus using the fourth arm and with careful dissection between the anterior vaginal and posterior bladder walls. The vagina is closed in a transverse fashion to prevent the creation of a narrow dysfunctional vagina. Preservation of anterior vaginal wall is based on oncological planning before surgery is planned.
Immediate and intermediate oncologic outcomes have been reported for RARC. University of North Carolina completed the first RCT's in robot-assisted urologic surgery. Nix et al. in a small prospective, randomized trial demonstrated equivalent lymph node yield and decrease in estimated blood loss, analgesic requirement and return of bowel function. Meanwhile several other groups have initiated RCTs comparing open versus robot-assisted radical cystectomy. Controlled Trial of Open, Robotic, and Laparoscopic Radical Cystectomy  cystectomy and Bladder cancer: Open vs Laparoscopic or robotic cystectomy  trials in UK and the University of Texas at San Antonio and Memorial Sloan Kettering trials in the USA  have been initiated and should help corroborate equal early clinical outcomes as seen by several single institution series and the International Robotic Cystectomy Consortium (IRCC), a conglomerate of over 35 institutions from seven countries collecting standardized outcomes data.
SOFT TISSUE SURGICAL MARGIN
Avoidance of soft tissue surgical margins forms the basic tenet of an oncologic procedure. IRCC reported an overall positive margin rate of 6.8% in 513 patients . Age, higher pathologic stage and positive lymph nodes were found to be predictive of a soft tissue surgical margin (STSM). Styn et al.[4▪] compared case matched RARC to ORC and found no difference in positive STSM (2%) and final pathological outcomes. Pruthi et al. reported no positive STSM in 100 RARC cases. Although higher STSM have been reported in pathologic T3 and greater stages from RARC series, alluding to absence of tactile feedback and early learning curve, there is an absence of early learning curve ORC data for appropriate comparison.
Nepple et al. described early oncologic outcomes in patients undergoing RARC and open cystectomy by a single surgeon (n = 65). There was no difference found in pathologic stage, margin status and nodes count. At a median of 12 months follow-up, recurrence-free, disease-specific, and overall survival were similar between the two groups.
After the bladder is dissected completion of a thorough extended lymph node dissection is an essential component of this procedure. An advantage of performing the lymphadenectomy after complete bladder dissection is that it allows more freedom of movement within the pelvis. The fourth arm is routinely used to retract the sigmoid medially away from the floor of the dissection. This allows access to the proximal nodes. Equal number of surgeons prefers to perform lymphadenectomy prior to radical cystectomy with the goal of setting up the vascular pedicle control while lymphadenectomy is being performed.
It has been well established that a higher lymph node yield is diagnostic as well as therapeutic [17,18]. Data from the IRCC demonstrated mean lymph node yield of 19. Nix et al. in their randomized trial showed a mean lymph node yield of 19 in the RARC group compared with 18 in the ORC. Davis et al. reported outcomes of primary RARC lymphadenectomy followed by a second look open pelvic lymphadenectomy in 11 patients. The mean lymph node yield for the primary RARC was 43 (range 19–63) with only retrieving a mean lymph node yield of 4 (range 0–8) on open second look.
Increase in life span and late diagnosis (higher morbidity) and absence of standardized reporting of up to 3 months after open surgery have been at the center of attention regarding RARC and its outcomes. Shabsigh et al. reported an overall, 90-day postoperative complication rate of 64% during open cystectomy comparable to the Roswell Park Series of 52% 90 days after surgery . Meanwhile Yuh et al.[22▪▪] reported a higher complication rate of 80% by including any blood transfusion and significant high-grade Clavien complications (categorization of procedural intervention). Yu et al.[23▪▪] utilizing US nationwide Inpatient Sample data compared ORC versus RARC in population-based settings and found lower parental nutritional use, fewer inpatient complications and zero deaths in the RARC group as compared with 2.5% open mortality.
ILEAL CONDUIT DIVERSION
Urinary diversion is the only section of the procedure that has been performed with an open approach. Recently, urinary diversion has also been performed with robot-assistance.
MARIONETTE STITCH AND THE ISOLATION OF BOWEL SEGMENT
A 12 cm segment of bowel is identified (15 cm proximal to the ileocecal valve) and a Keith needle silk suture is passed through the hypogastrium of the anterior abdominal wall. The stitch is passed through the distal end of the bowel segment and then brought back through the same location on the anterior abdominal wall. The stitch is not tied but kept in position with a surgical instrument. This allows raising and lowering of the bowel segment during the creation of the conduit.
The proximal segment of bowel is controlled using the fourth-arm. The hook cautery is used to incise the peritoneum of the bowel mesentery. Small mesenteric vessels are controlled using the bipolar cautery. Two mesenteric windows are created. It is important to keep appropriate orientation of the bowel to prevent narrowing of the base of the conduit (blood supply). The Endo GIA (Covidien, Mansfield, MA, USA) stapler is used to divide the bowel. Bowel continuity is not established at this point but the incised ends of bowel are reapproximated using a silk suture in order to maintain appropriate orientation of the bowel for the anastomosis.
Using the hook cautery two enterotomies are made in the proximal end of the conduit. The ureter is incised and spatulated. The running anastomosis is performed using the Van-Velthoven technique using two monofilament sutures tied together. After half of the anastomosis is complete an enterotomy is made at the distal end of the ileal conduit. A laparoscopic suction tip is gently passed through the distal enterotomy to the ureteroileal anastomosis. A 90 cm single J stent is passed through the suction tip and into the ureter.
Once the stent is deployed, the metal suction tip is removed while keeping the stent in position with one of the robotic arms. The inner-wire of the stent should remain in place. To prevent accidental stent dislodgement, a suture is used to secure the stent 1 cm from the anastomosis to prevent accidental dislodgement. The guide wire is removed and the anastomosis is completed.
An additional 12 mm port is placed in the left lower quadrant. The port incision may be extended for specimen removal in men. The proximal and distal bowel ends are identified. An enterotomy is made in each bowel segment and raised toward the 12 mm port. The 60 mm Endo GIA (Covidien, Mansfield, MA, USA) stapler is used to perform a side-to-side anastomosis ensuring appropriate alignment on the antimesenteric border. The Endo GIA (Covidien, Mansfield, MA, USA) stapler is placed through the right assistant port for final closure of the bowel. The mesenteric window is closed using interrupted sutures.
INTRACORPOREAL URINARY DIVERSION
Evolution of minimally invasive approach for bladder cancer patients should ideally include completion of intracorporeal urinary diversion. Guru et al. demonstrated similar perioperative outcomes (conduit operative time, bowel complications) between patients undergoing extracorporeal and intracorporeal conduit (n = 26). Several other series of intracorporeal urinary diversion have shown acceptable early clinical outcomes with smaller series including diversion times (159 versus 120 min), inpatient narcotic requirement in morphine sulphate equivalents (57.6 versus 97.6) and immediate complication results. Single hospital series of 45 robot-assisted neobladders displayed significant improvement in overall operative times (517–417 min), complications (50–17%) during early experience [24,25]. Poch et al. demonstrated that ICIC may be safely performed on patients of all BMI indices.
QUALITY OF LIFE
Prospective analysis after using the validated Functional Assessment of Cancer Therapy - Bladder Cancer (FACT-BL) questionnaire, before and after surgery revealed at 6 months, FACT-BL scores exceeded presurgical baseline . Short-term health status based on Convalescence and Recovery Evaluation questionnaire found that patients who underwent RARC approached preoperative baseline levels within 90 days in all domains (pain, cognition, and activity domains) except gastrointestinal domains .
Robot-assisted radical cystectomy with extended pelvic lymphadenectomy and intracorporeal urinary diversion is an effective, lower morbidity alternative to open surgery.
Conflicts of interest
K.A.G. is a board member of Simulated Surgical Systems, LLC.
M.A.P., J.R. and J.N. have no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 101).
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This study evaluated the complication rate of the 224 patients undergoing RARC using standardized Clavien methodology. Eighty percent of patients had any complication 90 or less days after surgery. Thirty five percent of patients had a major complication 90 or less days after surgery. This study is important because it demonstrates the importance of appropriate and standardized classification systems (also seen in  and ) and the providing data for appropriate patient counseling and assessment of surgical success. Outcomes in this study are comparable to that of series.
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