Robot-assisted radical cystectomy

The introduction of robot-assisted surgery for pelvic laparoscopy, especially in performing radical prostatectomy, is starting to broaden the possibilities in performing complicated operations in the pelvis. Three-dimensional vision with tenfold magnification, and the dexterity provided by the EndoWrist (Intuitive Surgical, Sunnyvale, Calif.; six degrees of freedom) allows the surgeon to operate the tips of the laparoscopic instruments like an open surgeon. The surgeon will benefit from a faster learning curve as compared with conventional laparoscopy. These advantages have allowed surgeons to translate standard open surgical procedure to a minimally invasive field, especially with its potential in operating in a narrow pelvis as well as reconstructing a urinary neobladder which requires extensive suturing. Multiple centers in North America and Europe have already started to use the robot for surgery in advanced bladder cancer. Various technical procedures have been described concerning both the radical cystectomy and the type of urinary diversion. The potential advantages of robotic surgery is similar to those of conventional laparoscopic surgery, i.e., decreased pain, decreased hospital stay, shorter recovery time, decreased blood loss, and smaller incisions. These differences are easily noted by the patients and may lead to increased demand for robot-assisted treatment. The robot-assisted cystectomy has limitations such as longer operating time, more difficult lymph node dissection, and higher cost for the procedure. To date, only limited data on the oncological outcome in minimally invasive cystectomy series have been presented. The only 5-year data available suggest comparable oncological outcome for laparoscopic and open surgery. It is unclear if robot-assisted cystectomy will have a place in the treatment of invasive bladder cancer; however, the next generation of robots will probably be less expensive than current systems. New instruments that will simplify as well as allow more exact dissection will be developed, and the possibility to combine radiology and other imaging techniques with live online vision systems is also likely to be developed in the near future. Patient selection, preoperative preparation, and surgical technique for cystectomy and lymph node dissection are discussed as well as the technique used for intracorporeal construction of the urinary diversion.