Review Article: Special Contribution

Yonago Acta medica 2015;58:95–99

Current Status of Robot-Assisted Radical Cystectomy: What is the Real Benefit?
Atsushi Takenaka

Division of Urology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8503, Japan

ABSTRACTIn recent years, robot-assisted radical cystectomy hasreceived attention worldwide as a useful procedurethat helps to overcome the limitations of open radical
cystectomy. We compared the surgical technique, perioperative and oncological outcomes, and learning curveof robot-assisted radical cystectomy with those of open
radical cystectomy. The indications for robot-assisted
radical cystectomy are identical to those of open radical
cystectomy. Relative contraindications are due to patient
positioning in the Trendelenburg position for long periods. Urinary diversion is performed either extracorporeally with a small skin incision or intracorporeally witha totally robotic-assisted maneuver. Accordingly, robotassisted radical cystectomy can be performed safely
with an acceptable operative time, little blood loss, andlow transfusion rates. The lymph node yield and positive
surgical margin rate were not significantly different between robot-assisted radical cystectomy and open radical cystectomy. The survival rates after robot-assisted
radical cystectomy are estimated to be similar to thatafter open radical cystectomy. However, the recurrence
pattern is different between robot-assisted radical cystectomy and open radical cystectomy, i.e., extrapelvic
lymph node recurrence and peritoneal carcinomatosis
were more frequently found in patients who underwent
robot-assisted radical cystectomy than in those who underwent open radical cystectomy. Further validation isnecessary to prove the feasibility of oncological control.
A steep learning curve is one of the benefits of the newtechnique. The experience of only 50 robot-assisted
radical prostatectomies is a minimum requirement for
performing feasible robot-assisted radical cystectomy,
and surgeons who have performed only 30 surgeries canreach an acceptable level of quality for robot-assisted
radical cystectomy.

Key words

bladder cancer; complication; oncologicaloutcome; robot-assisted radical cystectomy; urinary diversion
The gold standard treatment for patients with muscleinvasive and high-risk superficial bladder cancer is open
radical cystectomy (ORC) with pelvic lymph node dissection (PLND).1 However, ORC is a challenging procedure requiring not only high-quality cancer control but
also functional preservation, for which urinary diversion
using the intestinal tract is performed. Moreover, perioperative morbidity of ORC is not always low, even when
performed by an experienced surgeon, while considering the high probability of blood transfusion owing toextensive intraoperative bleeding, postoperative wound
pain resulting from a longer skin incision, postoperative ileus caused by prolonged open abdominal surgery
and excessive handling of the intestinal tract, and longer
hospitalization resulting from a delay in the recovery ofgeneral health.2 Therefore, some patients cannot undergo
ORC owing to advanced age, performance status, andthe presence of multiple comorbidities, and so on.
Since the first report of robot-assisted radical cystectomy (RARC) by Menon et al.3 in 2003, many studies have documented that RARC is less-invasive andequivalent in oncologic efficacy compared to ORC. In
recent years, RARC has received attention worldwide asa useful procedure that helps to overcome the limitationsof ORC.4 In the United States, the proportion of RARC
being performed has increased steadily over the years,
from 0.6% in 2004 to 12.8% in 2010.5 Owing to increasing use of RARC, we compared the surgical technique,perioperative and oncological outcomes, and learning
curve of RARC with those of ORC.
SURGICAL TECHNIQUE
Patient selection

Corresponding author: Atsushi Takenaka, MD, PhD
atake@med.tottori-u.ac.jp
Received 2015 August 6
Accepted 2015 August 10
Abbreviations: CSS, cancer specific survival; DFS, disease-freesurvival; ECUD, extracorporeal urinary diversion; ICUD, intracorporeal urinary diversion; ORC, open radical cystectomy; OS, overall survival; PLND, pelvic lymph node dissection; PSM, positive
surgical margin; RARC, robot-assisted radical cystectomy; RARP,
robot-assisted radical prostatectomy

The indications for RARC are identical to those of ORC.
There are no absolute contraindications for RARC.
However, we should take care not to injure the rectumin patients with a history of extensive pelvic surgery andradiation. Relative contraindications come from patient
positioning in the Trendelenburg position over long
period. We should carefully select patients with angle
95

A. Takenaka

closure glaucoma, intracranial aneurysm, severe mitralvalve insufficiency, and severe pulmonary dysfunction.

posterior surface of the prostate by making an incisionof the Denonvilliers’ fascia; vi) dissection of the anterior
surface of the bladder and prostate, by cutting the dorsal
vein complex and vii) extraction of the urethra inside thepelvis.

Positioning and port placement

The patient is placed in the Trendelenburg position withthe head placed at angle of approximately 20–25°. The
angle in RARC is less steep than that in robot-assisted
radical prostatectomy (RARP). Except for the angle, thepatient positioning is almost the same as in RARP. Port
placement is also similar to that of RARP. Fig. 1 shows
the configuration used in Tottori University. The camera
port is placed at the midline, i.e., 18 cm from the pubic
symphysis, which is 2–3 cm higher than that in RARP.
Besides the configuration in RARP, a second assistant
12 mm port is added 7 cm above from the midpoint between the camera and the left robotic port.

Technique for PLND

The area for performing PLND includes the external,
internal, common iliac, and obturator lymph nodes.6
Although there are some debates whether to perform
PLND before or after cystectomy, the surgical principle
is more critical than the order. The obliterated umbilicalartery provides a very useful landmark and the proximal
limit is cautiously decided with good vision.7
Urinary diversion

Urinary diversion is performed either extracorporeallywith a small skin incision or intracorporeally with a totally robotic-assisted maneuver.
In extracorporeal urinary diversion (ECUD),8 subumbilical (separate from the camera port) or periumbilical (camera port) midline incision is used for extractionof the specimen and subsequent manipulations. Most
surgeons prefer a 5–7 cm long subumbilical midline
incision with a wound retractor that provides the best
access to the ureters and the distal ileum. Care is taken
to isolate the ileum for urinary diversion and to perform
ureteral anastomosis especially in obese patients and inwhom the ureters need to be resected more proximally.
We usually perform urethro-neovesical anastomosis robotically after pouch formation completion and ureteralanastomosis.
In intracorporeal urinary diversion (ICUD), bowel
division and anastomosis is completely performed robotically. Some procedures of intracorporeal neobladderinclude those by Guru,9 Jonsson,10 Gill11 and so on. To
improve efficiency of pouch formation, several robotic
modifications have been used. One modification is using a shorter bowel and another is when to perform
urethroileal anastomosis, i.e., before or after pouchformation completion. The masterpiece of intracorporeal orthotopic ileal neobladder is described by Gill etal.11 as follows: i) 60 cm distal ileum isolation (44 cm
for the pouch, 16 cm for the chimney); ii) detubularization of the ileum and completion of the posterior plate;iii) 90° counterclockwise rotation and the urethroileal
anastomosis; iv) anterior pouch closure and v) bilateral
ureteroileal anastomosis to the chimney by using the
Bricker technique with a ureteral stent.

Technique for cystectomy

If necessary, the urethra was detached via the perineal
approach to the genitourinary diaphragm before a console maneuver. Our RARC procedure is summarized
as follows; i) detachment of the ureters; ii) dissection of
the posterior surface of the bladder; iii) dissection of thelateral surface of the bladder; iv) cutting of the vascular
pedicle of the bladder and ureters; v) dissection of theFig. 1. Port position.
: Camera port (12mm): Robot right arm (8mm): Robot left arm (8mm): Robot 4th arm (8mm): 1st assistant right arm (12mm): 1st assistant left arm (12mm): 2nd assistant (12mm)

96Current status of robot-assisted radical cystectomy

Perioperative outcomes

Positive surgical margin rate

Novara et al.12 performed a systematic review and cumulative analysis of perioperative outcomes and complications of RARC in compared to ORC. They showedstatistically significant differences in the operative time
(P < 0.00001 in favor of ORC), blood loss (P < 0.00001
in favor of RARC), transfusion (P < 0.00001 in favorof RARC), and in-hospital stay (P = 0.003 in favor ofRARC), whereas the intraoperative complication rate
was similar. Among postoperative complication, therates for any grade of complications at 90 days (P <0.0001) and for grade 3 complications at 90 days (P =0.04) were in favor of RARC. However, the rates of any
grade complications at 30 days (P = 0.09) and grade 3
complications at 30 days (P = 0.14) as well as the 30-day(P = 0.18) and 90-day (P = 0.23) mortality rates weresimilar for RARC and ORC. Thus, RARC can be performed safely with an acceptable operative time, little
blood loss, and low transfusion rates. Although the riskof intraoperative complication is low, postoperative complication and readmission after discharge are common.

The overall positive surgical margin (PSM) rate was
0–26% (mean, 5.6%).15, 16 According to the pathologicalstage, the PSM rate was 1–1.5% in pT2 and 0–25% in
pT3 or higher disease. Cumulative analysis showed nosignificant difference between RARC and ORC (5% vs.
7%, P = 0.13).
Survival and recurrence

Recently, a few reports17–19 showed the 5-year survival
rates as an outcome was similar between RARC and
ORC. At 1, 3 and 5 years, disease-free survival (DFS)
was 79–96%, 67–76%, and 53–74%, respectively; cancer specific survival (CSS) was 88–94%, 68–83%, and
66–80%, respectively; and overall survival (OS) was
82–90%, 61–80%, and 39–66%, respectively.14 Table
1 shows the oncologic outcomes followed more than
3 years after surgery. Accordingly, the survival ratesof RARC are similar to that of ORC. Nguyen et al.20
reported notable differences between RARC and ORC
considering the recurrence pattern. Within 2 years after
surgery, there was no major difference in the local recurrence (18% vs. 23%) and distant metastasis (29% vs.
36%) between RARC and ORC. On multivariate analysis, RARC was not a predictor of recurrence. However,there were distinct different patterns of distant metastasis. Extrapelvic lymph node recurrence (23% vs. 15%)
and peritoneal carcinomatosis (21% vs. 8%) were more
frequently found in patients who underwent RARC thanin those who underwent ORC. As the numbers of patients was small, further validation is necessary to prove
the feasibility of oncological control.

ONCOLOGICAL OUTCOME
Lymphnode yields

Abaza et al.7 showed that similar template technique toopen could be performed, i.e., external iliac, internal
iliac, common iliac, obturator, and presacral to aortic
bifurcation. The mean lymph node yield was 37.5. Davis et al.13 reported that he removed only an additional
4 lymph nodes with the open approach after 43 lymph
nodes were removed robotically. The robotic procedure
is technically safe and feasible because vascular injuries
were rare and the lymphocele rates were 0–9%. Yuh etal.14 showed that there was no significant difference inthe lymph node yield between RARC and ORC whileconsidering standard, extended, and total cases, (P =0.20, 0.26 and 0.07, respectively).

LEARNING CURVE
A steep learning curve is one of the benefits of a newtechnique. Hayn et al.21 examined whether the numberof previous RARP performed by surgeons affected theoutcomes of RARC. In surgeons who had performed
less than 50 RARP, the operative time was longer, blood

Table 1. Oncologic outcomes followed more than 3 years after surgery
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61

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97

45

42
54

A. Takenaka

loss was more, and lymph node yield was lesser compared to those who had performed more than 50 RARP.
Therefore, the experience of only 50 RARP is a minimum requirement for performing RARC of a certain
quality. Hayn et al.22 also demonstrated the actual learning curve for RARC in another study. It was estimatedthat 21 patients were required for the operative time toreach 6.5 h, 30 patients for a lymph node yield of 20, 30
patients for the PSM rate to be less than 5%, and 24 patients for the PSM rate to be less than 15% in pathologic
T3–4 patients. However, the mean estimated blood loss
was only 408 ml, and the learning curve was nearly flat.
The study demonstrated an acceptable level of proficiency by only the 30th case for proxy measures of RARC
quality.

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of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol. 2015;67:376-401. PMID:
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13 Davis JW, Gaston K, Anderson R, Dinney CP, Grossman HB,
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Systematic review and cumulative analysis of oncologic andfunctional outcomes after robot-assisted radical cystectomy.
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20 Nguyen DP, Al Hussein Al Awamlh B, Wu X, O’Malley P,
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21 Hayn MH, Hellenthal NJ, Hussain A, Andrews PE,

CONCLUSIONS
Remarkable progress has been made in RARC with
PLND and urinary diversion. RARC can be safely
performed by a surgeon who has performed more than
50 RARP. However, recent data showed different oncological outcomes considering the different recurrence
patterns from ORC. Further studies about the outcomesconsidering the recurrence patterns and long-term survival data are required.
The author declares no conflict of interest.

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