Female robotic radical cystectomy

Efficacy of the Mercedes-Benz closure technique for vaginal reconstruction in female robot-assisted radical cystectomy

INTRODUCTION

Vaginal reconstruction using the posterior vaginal wall is required following radical cystectomy in women with resection of the uterus, adnexa, and anterior vaginal wall. Roll closure and clamshell closure are two widely known techniques. Of these, clamshell closure is recommended because roll closure has a high likelihood of breakdown or a resultant canal that is too narrow for sexual intercourse. In clamshell closure, however, folding the posterior vaginal wall anteriorly can be difficult. Therefore, we devised Mercedes-Benz closure, in which the vaginal wall is sutured from three directions to form a Mercedes-Benz shape, for anastomosis without tension on the vaginal wall. The present study was performed to investigate the efficacy of this alternative surgical technique for vaginal reconstruction.

METHODS

Twenty-six patients who underwent vaginal reconstruction following robot-assisted radical cystectomy were divided into two groups: 15 underwent clamshell closure and 11 underwent Mercedes-Benz closure. The patients' characteristics and surgical outcomes were compared between the two groups.

RESULTS

There were no significant differences in clinical characteristics, including age, body mass index, and prior abdominal surgery between the two groups. The median vaginal reconstruction time tended to be longer in the Mercedes-Benz closure group than in the clamshell closure group (35.0 vs. 27.0 min, p = 0.102). No complications associated with vaginal reconstruction were identified.

CONCLUSION

The surgical outcomes were comparable between Mercedes-Benz closure and clamshell closure. If vaginal reconstruction with clamshell closure is difficult, Mercedes-Benz closure is a valuable alternative technique.

Oncological and functional outcomes of female reproductive organ-sparing radical cystectomy and ileal neobladder construction

OBJECTIVES

To examine the oncological and urinary functional outcomes of reproductive organ-sparing radical cystectomy (ROS-RC) and U-shaped ileal neobladder construction in females compared with male patients.

METHODS

We retrospectively examined 357 patients (281 male and 76 female) with muscle-invasive bladder cancer who were treated with RC plus U-shaped ileal neobladder construction between May 1996 and July 2021. All female patients were treated with ROS-RC. We compared disease-free survival (DFS), cancer-specific survival (CSS), overall survival (OS), and urinary functional outcomes between male and female patients. We evaluated the effect of gender on DFS, CSS, and OS. Furthermore, urinary functional outcomes were evaluated in 140 males and 48 females using a pressure-flow study at 3, 6, 9, and 12 months postoperatively.

RESULTS

Female patients were considerably older than male patients at the time of radical cystectomy. No significant difference was noted in the tumor stage preoperatively. The multivariable Cox regression analysis with an inverse probability treatment weighted model revealed that the female gender was not significantly related to DFS, CSS, and OS. Moreover, urinary functions at 12 months were not markedly different between males and females, except for the capacity of the neobladder, detrusor pressure, and maximum urethral closure pressure.

CONCLUSIONS

This study demonstrates that female patients with ROS-RC and U-shaped ileal neobladder construction did not significantly correlate with worse oncological outcomes. The combination of ROS-RC and U-shaped ileal neobladder construction might attain adequate urinary function without sacrificing oncologic outcomes.

The Effect of Surgical Experience on Perioperative and Oncological Outcomes After Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Evidence from a Referral Centre with Extensive Experience in Robotic Surgery

BACKGROUND

Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited.

OBJECTIVE

To assess the effect of surgical experience (SE) on perioperative and intermediate-term oncological outcomes in a large contemporary cohort of RARC patients after accounting for the impact of intersurgeon variability.

DESIGN, SETTING, AND PARTICIPANTS

The study cohort included 164 patients treated with RARC and ICUD by two surgeons between 2004 and 2017 at a single European referral centre.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

For each patient, SE was defined as the total number of RARCs performed by each surgeon before the patient's operation. The relationship between SE and operative time (OT), lymph node yield (LNY), positive surgical margins (PSMs), Clavien-Dindo grade ≥2 30-d postoperative complication (CD≥2), and oncological outcomes (18-mo recurrence rate) was evaluated in multivariable linear and logistic regression models, clustering at a single-surgeon level.

RESULTS AND LIMITATIONS

After adjusting for case mix, SE was associated with shorter OT (p= 0.003), lower probability of postoperative CD≥2 rates (p= 0.01), and lower 18-mo recurrence rates (p= 0.002). Conversely, SE did not predict lower PSM rates (p= 0.3) and higher LNY (p= 0.4). The relationship between SE and OT was nonlinear, with a plateau observed after 50 cases. Conversely, the relationship between SE and CD≥2 and 18-mo recurrence was linear without reaching a plateau after 88 procedures.

CONCLUSIONS

SE affects perioperative and oncological outcomes after RARC with ICUD in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, after 50 cases, no further improvement was observed for OT.

PATIENT SUMMARY

Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve.

Anatomical description of the umbilical arteries and impact of their ligation on pelvic and perineal vascular supply after cystectomy in women

OBJECTIVE

In radical cystectomy, the surgeon generally ligates the umbilical artery at its origin. This artery may give rise to several arteries that supply the sexual organs. Our aim was to evaluate pelvic and perineal devascularisation in women after total cystectomy.

PATIENTS AND METHODS

We carried out a prospective anatomical and radiological study. We performed bilateral pelvic dissections of fresh adult female cadavers to identify the dividing branches of the umbilical artery. In parallel, we examined and compared the pre- and postoperative imaging investigations [magnetic resonance imaging (MRI) angiography] in patients undergoing cystectomy for benign disease to quantify the loss of pelvic vascularisation on the postoperative images by identifying the occluded arteries.

RESULTS

The anatomical study together with the radiological study visualised 35 umbilical arteries (n = 70) with their branching patterns and collateral arteries. The uterine artery originated from the umbilical artery in more than 75% of cases (n = 54) of the internal pudendal artery in 34% (n = 24) and the vaginal artery in 43% (n = 30). The postoperative MRI angiograms showed pelvic devascularisation in four patients. Devascularisation was dependent on the level of surgical ligation. In the four patients with loss of pelvic vascular supply, the umbilical artery had been ligated at its origin.

CONCLUSION

The umbilical artery gives rise to various branches that supply the pelvis and perineum. If the surgeon ligates the umbilical artery at its origin during total cystectomy, there is a significant risk of pelvic and perineal devascularisation.

Robot-Assisted Radical Cystectomy for Bladder Cancer in Octogenarians

OBJECTIVE

To evaluate perioperative morbidity and mortality rate, a 3-year recurrence-free survival, and cancer-specific mortality rate in patients older than 80 years undergoing robot-assisted radical cystectomy (RARC).

MATERIALS AND METHODS

We retrospectively collected data of 155 consecutive patients who received RARC for muscle-invasive or high-risk nonmuscle-invasive urothelial carcinoma of the bladder between 2003 and 2014 at a high-volume robotic center. Diversion was performed intra- or extracorporeally according to the surgeon's preferences. Complications were graded according to the Clavien-Dindo system. Logistic regression analyses were used to assess the impact of age on postoperative outcomes.

RESULTS

Of 155 consecutive patients, 22 (14.2%) patients were 80 years or older. Octogenarians did not significantly differ from younger patients in ASA score (p = 0.4) and Charlson comorbidity index (p = 0.4). Prevalence of any grade and high-grade complications was similar in both groups (all p ≥ 0.6). Older patients had a significantly higher pathologic tumor grade (p = 0.04) and a lower use of pelvic lymphadenectomy (p < 0.001). No perioperative mortality rate was recorded within 90 days from surgery. Elderly patients had a similar risk of 3-year oncologic recurrence after surgery compared with their younger counterparts (odds ratio [OR] 1.63; p = 0.2). Conversely, the risk of cancer-specific mortality rate was significantly higher (OR 2.78; p = 0.02).

CONCLUSIONS

Patients 80 years or older undergoing RARC for bladder cancer did not have a higher risk of peri- and postoperative morbidity and mortality rate and had a similar 3-year recurrence-free survival, suggesting that RARC can be safely performed in selected elderly patients by experienced surgeons.

Oncologic Outcomes of Robot-Assisted Radical Cystectomy: Results of a High-Volume Robotic Center

BACKGROUND AND PURPOSE

The aim of our study was to assess the oncologic outcomes of robot-assisted radical cystectomy (RARC) in patients with bladder cancer (BCa) treated in a high-volume robotic center.

MATERIALS AND METHODS

We retrospectively collected data of 155 consecutive patients who received RARC for urothelial BCa from January 2004 to May 2014. Kaplan-Meier analyses were used to assess time to recurrence, cancer-specific mortality (CSM) rate, and overall mortality rate. Uni- and multivariable Cox regression models addressed the predictors of recurrence and CSM.

RESULTS

Median follow-up for survivors was 42 months. Overall, 43%, 34%, 55%, and 18% of the patients had pT ≤1, pT2, pT3/4, and pN1-3 disease, respectively. Overall, 76% of the patients had high-grade disease at final pathology. The positive surgical margin rate was 9%. The 5-year recurrence-free, CSM-free, and overall survival estimates were 53.7%, 73.5%, and 65.2%, respectively. Among patients who experienced recurrence, 12.0%, 4.0%, and 84.0% had local, peritoneal, and distant recurrence, respectively. In multivariable Cox regression analyses, pathologic stage and nodal status represented independent predictors of recurrence and CSM (all p ≤ 0.04).

CONCLUSIONS

In a high-volume robotic center, RARC provides acceptable oncologic outcomes in patients with urothelial BCa. Tumor stage and nodal status represent independent predictors of recurrence and CSM in this setting.

Ileal neobladder in women with bladder cancer: cancer control and functional aspects

PURPOSE OF REVIEW

Radical cystectomy and urinary diversion is the accepted standard of care for invasive bladder cancer. Although orthotopic neobladder is the preferred method of urinary diversion in men, less experience is available for women. Recent studies and reports on this subject are summarized and reviewed.

RECENT FINDINGS

Urethra-sparing cystectomy in women and orthotopic urinary diversion can be performed safely in appropriately selected women with invasive bladder cancer. Excellent oncological outcomes can be expected with a minimal risk of urethral recurrence in case of negative frozen section of the proximal urethra. Orthotopic neobladder diversion offers excellent clinical and functional results, and should be the diversion of choice in most women following cystectomy. Female sexual dysfunction can be avoided in patients who received neurovascular preservation, although quality of life declined in women who had undergone non-nerve-sparing radical cystectomy.

SUMMARY

Urethra-sparing cystectomy does not compromise the oncologic outcome in women with bladder cancer. The excellent functional outcome and voiding pattern with orthotopic urinary diversion argues in favor of this technique as the preferred method for lower urinary tract reconstruction after radical cystectomy. Nerve-sparing radical cystectomy preserves female sexual function and improves quality of life.