Effect of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer-Reply

Sexual-Sparing Radical Cystectomy in the Robot-Assisted Era: A Review on Functional and Oncological Outcomes

Background/Objectives: Radical cystectomy (RC) is the standard treatment for muscle-invasive and high-risk non-muscle-invasive bladder cancer, but it often results in significant functional impairments, including sexual and urinary dysfunction, adversely affecting quality of life (QoL). Sexual-sparing robotic-assisted radical cystectomy (RARC) has been introduced to mitigate these effects. This review evaluates the oncological and functional outcomes of sexual-sparing RARC in male and female patients. Methods: A systematic literature search identified 15 studies including 793 patients who underwent sexual-sparing RARC using techniques such as nerve-sparing, capsule-sparing, and pelvic organ-preserving approaches. Data on oncological and functional outcomes were analyzed. Results: Sexual-sparing RARC achieves oncological outcomes comparable to open RC, with negative surgical margin (NSM) rates exceeding 95% in most studies. RFS and CSS rates were robust, often surpassing 85% at intermediate follow-ups. Functional outcomes were also favorable, with continence rates exceeding 90% and erectile function recovery surpassing 70% in well-selected male patients. Female patients undergoing pelvic organ-preserving techniques demonstrated improved continence, preserved sexual function, and enhanced QoL. Patient selection emerged as critical, favoring those with organ-confined disease and good baseline function. Conclusions: Sexual-sparing RARC offers a promising balance between oncological control and functional preservation, making it an effective option for selected patients. Further research is needed to refine techniques and establish standardized protocols for broader adoption.

Robot-assisted radical cystectomy with neobladder diversion in females: Safety profile and functional outcomes

Objective

Radical cystectomy (RC) is a standard treatment for localized muscle invasive bladder cancer and high-risk or very high-risk non-muscle invasive bladder cancer not responding to adequate endovesical therapy. In women, traditionally RC is performed with hystero-adnexectomy and resection of the anterior vaginal wall, often resulting in sexual disorders. Vaginal-sparing techniques have been developed to improve functional outcomes. The present study explores the safety and the functional outcome of vaginal-sparing techniques.

Methods

We retrospectively analyzed all consecutive female patients undergoing robot-assisted RC (RARC) with neobladder diversion between October 2017 and February 2022. The indications for vaginal-sparing RC were absence of tumor on bladder neck or urethra and no sign of infiltration of posterior bladder wall at the preoperative MRI. Functional results were evaluated with the aid of five questions out of the Bladder Cancer Index questionnaire. Complications were reported according to the Clavien-Dindo classification and cancer control was evaluated by recurrence-free and cancer-specific survival.

Results

A total of 22 female patients underwent RARC with neobladder diversion. Neoadjuvant chemotherapy was given in 17 (77%) cases. Clavien-Dindo grades III-IV complications occurred in four (18%) cases. After a mean follow-up of 29 (interquartile range 16-44) months, six (27.3%) patients developed distant metastases, and one (4.5%) woman loco-regional relapse. Sexual-sparing surgery was performed in 19 (86%) patients, and in the others the anterior vaginal wall was resected, but neobladder was still performed. During daytime, no patients reported total incontinence and 73% (11/15) reported total continence or only occasional leaks. Sexual results showed that seven of 15 (47%) women regained sexual activity after surgery, with a quality reported as "good" or "very good" in 40% of all 19 cases.

Conclusion

RARC in female with anterior vaginal wall preservation is feasible. The approach showed a good safety profile, with satisfying results on continence and sexual activity. Sexual-sparing approaches should be carried out after correct patient selection.

Robot-assisted pelvic and renal surgery compared with laparoscopic or open surgery: Literature review of cost-effectiveness and clinical outcomes

BACKGROUND AND AIM

The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations.

METHODS

A narrative review was carried out.

RESULTS

When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs.

CONCLUSIONS

Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.

Single incision robotic cystectomy and urinary diversion

PURPOSE

In this review, we aim to provide readers with a balanced understanding of all aspects of single incision robotic cystectomy (SIRC) and urinary diversion using the single-port (SP) robot. The review will trace the historical progression from open surgery to the introduction of minimally invasive approaches and present an in-depth description of the SIRC technique, offering a step-by-step guide for reference. Emphasis will be placed on indications and patient selection criteria to equip surgeons with well-rounded insights for decision-making.

METHODS

The review analyzes preliminary surgical outcomes by drawing from existing literature and clinical experiences, endeavoring to present a balanced view of the potential benefits and limitations. Addressing the learning curve and training prerequisites is paramount, and this review explores strategies and challenges in preparing surgeons for proficiency. Finally, the focus shifts to current challenges and future directions, identifying key issues and potential advancements in the field.

CONCLUSIONS

By presenting historical context, technical insights, clinical evidence, and strategic foresight, the review aims to provide a comprehensive resource that engages surgeons, researchers, and trainees from diverse perspectives.

Preoperative optimization of the radical cystectomy patient: Current state and future directions

Radical cystectomy (RC) is associated with high rates of morbidity and mortality despite adoption of robotics and implementation of enhanced recovery after surgery protocols. There have been increased efforts to investigate preoperative optimization through comprehensive nutritional evaluation, preoperative supplementation, and prehabilitation outside of previously described enhanced recovery after surgery protocols to reduce mortality and morbidity from RC. In this review, we summarize and evaluate the current literature on preoperative assessment and optimization in RC.

First case of robot-assisted radical cystectomy and intracorporeal neobladder reconstruction with the Hugo RAS system: step-by-step surgical setup and technique

Robotic assisted radical cystectomy (RARC) is a standard option for the treatment of bladder cancer. Currently, novel platforms are entering the market and the Hugo RAS (Medtronic, Minneapolis, MN, USA) is a new system consisting of an open console with 3D-HD screen and a multi-modular fashion. Even if several series are already available for radical prostatectomy, to now a full description of RARC performed with Hugo RAS is still lacking. We report the first case of RARC with intracorporeal neobladder performed with the Hugo RAS-and another case of RARC with ureterostomy. Both patients were affected by MIBC. Case 1 was a 61-year-old patient without comorbidities (CCI 4), in which a Bordeaux ileal neobladder was scheduled after previous NAC. The second was the case of a 70-year-old one with CCI 7 and BMI 35; in this case, a ureterostomy was planned. Details of the robotic system: one 11 mm endoscope port was placed on the midline 2 cm above the umbilicus. Another two 8 mm robotic ports were symmetrically placed under vision on a transversal line-located 1 cm below the umbilicus. A third robotic port was positioned on the left side in a W configuration. All ports were located at least 9 cm between each other. Finally, two assistant ports were positioned in the right abdominal site. All arm-carts were parked 45-60 cm from the operative bed, before the docking process begins. Three arm-carts were parked on the left side, the assistant and the scrub nurse worked on the right side, while the energy tower stayed at the foot of the bed, according to the previous description of Hugo RAS robotic radical prostatectomy. The endoscope arm-cart is docked first, then the adjacent left carts are docked; finally, the surgeon's right-hand cart is docked from the right side of the bed. The docking angles and tilt we applied were: endoscope: 175°; minus 45°; surgeon left hand 140°; minus 30°; surgeon right hand 225°; minus 30°; fourth arm 125°; plus 15°. The instruments we used were those fitting our conventional four-instrument setup for RARC: monopolar shears, Maryland forceps, needle driver and Cadiere as the fourth arm. The procedures were completed without technical errors or technological failures-requiring a change in surgical strategy. Docking time was approximately 35 min; console time up to urethral dissection was 150 and 140 min in Case 1 and 2. The time for pelvic nodal dissection was approximately 37 min for both. The multi-modularity fashion of the Hugo RAS allowed an easy management of the bowel in Case 1; the absence of robotic staplers required the use of the laparoscopic ones, managed by an adjunctive assistant with room within the cart. In conclusion, RARC with the Hugo RAS is a feasible procedure able to reproduce all surgical steps without critical errors or complications requiring a change in surgical planning. Urinary diversion with intracorporeal reconstruction is feasible as well, with adequate preliminary outcomes.

Comparison of Robotic vs Open Cystectomy: A Systematic Review

BACKGROUND

The benefits of a robot-assisted radical cystectomy (RARC) compared to an open approach is still under debate. Initial data on RARC were from trials where urinary diversion was performed by an extracorporeal approach, which does not represent a completely minimally invasive procedure. There are now updated data for RARC with intracorporeal urinary diversion that add to the evidence profile of RARC.

OBJECTIVE

To perform a systematic review and meta-analysis of the effectiveness of RARC compared with open radical cystectomy (ORC).

MATERIALS AND METHODS

Multiple databases were searched up to May 2022. We included randomised trials in which patients underwent RARC and ORC. Oncological and safety outcomes were assessed.

RESULTS

Seven trials of 907 participants were included. There were no differences seen in primary outcomes: disease progression [RR 0.98, 95% CI 0.78 to 1.23], major complications [RR 0.95, 95% CI 0.72 to 1.24] and quality of life [SMD 0.05, 95% CI -0.13 to 0.38]. RARC resulted in a decreased risk of perioperative blood transfusion [RR 0.57, 95% CI 0.43 to 0.76], wound complications [RR 0.34, 95% CI 0.21 to 0.55] and reduced length of hospital stay [MD -0.62 days, 95% CI -1.11 to -0.13]. However, there was an increased risk of developing a ureteric stricture [RR 4.21, 95% CI 1.07 to 16.53] in the RARC group and a prolonged operative time [MD 70.4 minutes, 95% CI 34.1 to 106.7]. The approach for urinary diversion did not impact outcomes.

CONCLUSION

RARC is an oncologically safe procedure compared to ORC and provides the benefits of a minimally invasive approach. There was an increased risk of developing a ureteric stricture in patients undergoing RARC that warrants further investigation. There was no difference in oncological outcomes between approaches.

Health-related quality of life prior to and 1 year after radical cystectomy evaluated with FACT-G and FACT-VCI questionnaires

OBJECTIVE

The aim of this study was to investigate health-related quality of life (HRQoL) before and 1 year after radical cystectomy in relation to age and gender.

METHODS

This prospective study involves 112 men and 40 women with bladder cancer treated with radical cystectomy between 2015 and 2018. HRQoL was assessed preoperatively and 1 year post-surgery through Functional Assessment of Cancer Therapy Scale - General (FACT-G) and Functional Assessment of Cancer Therapy Scale - Vanderbilt Cystectomy Index (FACT-VCI) questionnaires. The median age of the 152 patients was 71.5 years.

RESULTS

Preoperatively, emotional and functional well-being were negatively affected. Physical, emotional and functional well-being presented higher values 1 year after surgery compared to before radical cystectomy, that is, better HRQoL. Social well-being showed a reduction, especially regarding closeness to partner and support from family. Men and women were equally satisfied with their sex life before radical cystectomy, but less so 1 year after, where men were less satisfied compared to women. Additionally, one out of five patients reported that they had to limit their physical activities, were afraid of being far from a toilet and were dissatisfied with their body appearance after surgery.

CONCLUSIONS

Recovery regarding HRQoL was ongoing 1 year after radical cystectomy. Patients recovered in three out of four dimensions of HRQoL, but social well-being was still negatively affected 1 year after treatment. Sexual function after radical cystectomy was exceedingly limited for both men and women. An individual sexual rehabilitation plan involving the couple with special intention to encourage intimacy, might not only improve sexual life but also have a positive effect on social well-being as a consequence.