The learning curve for robot-assisted radical cystectomy with total intracorporeal urinary diversion based on radical cystectomy pentafecta

Improving safety in the performance of robotic urinary diversions: a narrative review

Urinary diversions are performed for a wide variety of indications, including bladder removal for cancer treatment, post-cancer treatment complications, trauma, or bladder pain. The robotic approach has been increasingly used in performing urinary diversions since the introduction of the surgical robot. A PubMed keyword search was performed on September 14, 2023 with the terms: robotic and urinary diversion. A narrative review of the literature was then conducted, with a focus on outcomes and complications following urinary diversion. Studies demonstrated that the robotic approach to cystectomy with urinary diversion was safe and productive, whether the diversion was performed intracorporeally or extracorporeally, and that outcomes are comparable to the open approach. Despite reports of successes and technique improvements, the complication rate following robotic cystectomy with urinary diversion is over 50%. Common complications associated with urinary diversion include bowel complications, ureteroenteric anastomotic strictures, urine leak, urinary tract infections, internal hernias, and parastomal hernias. Many strategies have been developed to improve the complication rate following robotic urinary diversion, including specialized training programs and enhanced recovery after surgery protocols. In conclusion, with the increasing adoption of the robotic approach for urinary diversions, it is important to continue to develop strategies to mitigate surgical risk. Future research should focus on further refinement of training and surgical approaches to prevent and treat complications following robotic urinary diversions.

The current role of pentafecta in the reporting of radical cystectomy outcomes: a scoping review

Background

Pentafecta has recently been validated for reporting radical cystectomy (RC) outcomes in open, laparoscopic and robotic series. We aim in this review to explore the current role of pentafecta in the reporting of RC outcomes.

Methods

A comprehensive literature search was performed in the PubMed database to identify relevant articles. The pentafecta achievement (PA) was defined originally as negative soft tissue surgical margin (NSTSM), lymph node (LN) dissection (LND) with removal of ≥16 LNs, absence of 90-days grade ≥3 Clavien-Dindo (CD) complications, a time interval of less than 3 months between the last transurethral resection of bladder tumor (TURBT) with evidence of muscle invasive bladder cancer (MIBC) and RC, and absence of local pelvic recurrence within 1 year. The definition was later modified and the last two criteria were replaced by absence of urinary diversion (UD) related complications and any clinical recurrence at one year.

Results

Twelve studies with 4,946 patients were enrolled in the present review. All the studies were retrospective except one recently published randomized study comparing open and robotic-assisted RC. Pentafecta was totally achieved in 34% and main causes of missing pentafecta were the number of resected LNs and 90-days major complications. Type of UD, increasing age, advanced tumor stage, and decreasing surgical experience were the factors most commonly associated with a lower likelihood of PA. A positive correlation was seen between PA and long-term oncological outcome and quality of life. The main limitations in the present studies are their retrospective nature, relatively small sample size, and short median follow-up, most of which was less than 3 years.

Conclusions

The new pentafecta definition provides a comprehensive tool for reporting RC outcomes by including measures of postoperative morbidity, functional outcomes and local cancer control. Pentafecta include standards that could be useful for improving surgical quality, surgical education and comparing different techniques. However, pentafecta is not yet suitable for perioperative risk stratification and patient counseling.

Postoperative complications and determinant of selecting non intracorporeal urinary diversion in patients undergoing robot-assisted radical cystectomy: an initial experience

Background

Robot-assisted radical cystectomy (RARC) with urinary diversion has become a standard surgical procedure because of its three-dimensional high-definition surgical field of view, flexibility, and stability. However, because of the highly complex steps of surgery, postoperative complications cannot be ignored.

Methods

This retrospective, single-center, observational cohort study investigated the postoperative complications following RARC at a non-high-volume center in Japan. From August 2019 to March 2023, 50 consecutive patients who underwent RARC for histologically proven muscle-invasive bladder cancer (MIBC) or high-risk non-MIBC with an indication for radical cystectomy according to the Japanese Urological Association Guideline 2019 were included. Factors correlated with the selection of extracorporeal urinary diversion (ECUD) or cutaneous ureterostomy rather than intracorporeal urinary diversion (ICUD) for urinary diversion were also investigated.

Results

In total, 33 (66%) and 31 (62%) patients experienced complications during the first 90 and 30 days after RARC, respectively. Among them, 19 (38%) and 18 (36%) patients developed Clavien-Dindo classification G2 complications, and 12 (24%) and 11 (22%) developed G3 or higher (major) complications during the first 90 and 30 days after RARC, respectively. The most common complications were gastrointestinal complications (26%) and urinary tract infections (22%). Nine patients (18%) underwent surgical intervention within 90 days of undergoing RARC. Higher infusion volume during the operations was significantly correlated with the occurrence of major complications within 90 days (P=0.025) and 30 days (P=0.0158) after RARC. Nineteen patients (38%) underwent non-ICUD. Twelve patients received ECUD as an ileal conduit or neobladder, and among them, three patients received ECUD due to intraabdominal adhesion for previous abdominal surgery or radiation, while four patients received ECUD ileal conduit due to comorbidities and advanced cases (palliative surgery) to shorten the surgery time.

Conclusions

Surgical complications related to the initial experience with RARC at a non-high-volume center in Japan cannot be ignored. Although this complicated surgical procedure requires a learning curve to achieve a stable rate of much fewer major complications after RARC, careful assessment of patients' status before surgery and critical postoperative management may reduce complication rates more quickly, even at non-high-volume centers.

Oncological and functional outcome of robotic-assisted radical cystectomy with total intracorporeal stentless J-pouch neobladder reconstruction

BACKGROUND

Robotic-assisted radical cystectomy (RARC) with neobladder reconstruction has gained popularity in recent years.

METHODS

We conducted a retrospective study of 17 consecutive patients who underwent RARC with totally intracorporeal J-pouch neobladder reconstruction without ureteral stent by a single experienced surgeon to evaluate perioperative, oncological and functional outcomes.

RESULTS

The median follow-up duration was 32.8 months (range: 17.4-59.0 months), and the 2-year disease-free survival rate was 88.2%. Five out of 12 patients were totally continent, and none required more than one pad per day. The overall complication rate was 41.2%, and hydronephrosis was the most common adverse event. The renal function remained stable, and no long-term renal function impairment was detected.

CONCLUSION

Our study suggests that RARC with totally intracorporeal J-pouch neobladder reconstruction without ureteral stent is a safe and feasible option for the treatment of muscle-invasive bladder cancer, with good oncological and functional outcomes.