Overview of Robotic Radical Cystectomy of the Bladder
As robot-assisted surgeries become more commonly used in managing different urologic conditions, their use in bladder surgery is also changing. Traditionally, a surgery known as an open radical cystectomy with bilateral pelvic node dissection and urinary diversion was the standard treatment for serious and certain high-risk bladder cancers. In simpler terms, this is a surgery that involves a large incision to remove the bladder and surrounding lymph nodes, and then creating a new way for the body to store and remove urine. More recently, a less invasive version of this surgery using robotic help has emerged for these conditions. This robotic version of cystectomy, which is removing the bladder, can reduce side effects from the surgery while still helping combat bladder cancer effectively.
Since the first use of robotic cystectomy in 2003, more and more surgeons have started using this approach. Even though it can often take longer to perform than the traditional surgery and has a steep learning curve for surgeons, it has several advantages. These benefits include less blood loss during surgery, fewer transfusions, fewer serious complications after surgery, a lower chance of leaving behind cancerous tissue, the removal of more lymph nodes, and earlier release from the hospital.
Additional benefits of robotic surgery include a lower risk of complications related to the surgical wound and blood clots.
Studies have found that the quality of life after surgery is generally similar for patients who undergo open surgery and those who undergo robot-assisted surgery. However, when the bladder diversion is done entirely inside the body with the robot, quality of life scores improved. Studies have also shown that both traditional and robotic surgery have similar success in terms of cancer coming back, the cancer getting worse, and overall survival over a 10-year period.
With these potential advantages, but also a learning curve and its complexity, the role of minimally invasive major robotic bladder surgery is continually evolving and being studied for further improvements.
Anatomy and Physiology of Robotic Radical Cystectomy of the Bladder
The most common type of bladder cancer is urothelial carcinoma, which makes up about 90% of all bladder tumors. Other, less common types include schistosoma-related squamous cell carcinoma, accounting for around 5% of cases and is more common in the Middle East and Africa, and adenocarcinoma, which makes up roughly 2% of cases and can develop from a small tube in the body called the urachus.
In men, a surgical treatment for bladder cancer often involves a robotic radical cystectomy. This procedure includes the removal of the bladder, the tubes that carry urine from the kidneys to the bladder (distal ureters), the prostate gland that produces seminal fluid, and ducts that carry sperm (vas deferens). In women, the surgery typically involves an anterior pelvic exenteration, which is the removal of the bladder, urethra (the tube that allows urine to pass out of the body), uterus, cervix, and the front wall of the vagina. However, in some cases, a procedure that spares these pelvic organs can be performed.
When the surgeon performs a bilateral pelvic lymphadenectomy, a procedure that removes lymph nodes from the pelvis, they remove specific lymph nodes known as the external and internal iliac nodes. These nodes are part of the body’s lymphatic system that helps fight infections and diseases. The obturator lymph nodes, located in the pelvic area, are also removed. This is considered a standard lymphadenectomy.
Why do People Need Robotic Radical Cystectomy of the Bladder
Robotic radical cystectomy, a type of surgery to remove the bladder, has the same conditions for its use as open cystectomy (traditional surgery). These conditions include not having metastatic urothelial lesions (spreading bladder cancer cells) and the person being willing and capable of undergoing a significant surgical procedure.
The reasons someone might require a cystectomy surgery include if they have bladder cancer that has spread to the muscle, or if the cancer has not spread to the muscle, but at least one of the following criteria is met:
- The person is at high risk and remains to have high-grade T1 bladder disease (bladder cancer that is confined to the inner layers of the bladder) despite repeat surgery, or reoccurring disease.
- The person is at high risk and continues to have or reoccuring carcinoma in situ (a type of cancer that is still in the place where it started) within a year after two cycles of Bacillus Calmette-Guerin (BCG) induction therapy (a type of tuberculosis vaccine that is used to treat bladder cancer) or during maintenance BCG treatment.
- The person is at high risk and continues to have or reoccurring T1 tumors that are associated with lymphovascular invasion (cancer spread to the lymph fluid and blood vessels) or variant bladder cancer histology (unusual cell structure in the bladder).
Also, there are other factors that might impact on how a person responds to the treatment, like having a low glomerular filtration rate (your kidneys are not working effectively to filter your blood) and large tumor size over 3 cm that are not responding to BCG.
There are some important points to consider with the robotic approach. This includes how the person’s body is positioned during surgery, how well they can tolerate having air or gas put into their stomach to make it easier for the surgeon to see and work, and access to their abdomen. The position a person is put in during this surgery and the technique of inflating their abdomen can have effects on their heart and lungs, such as decreasing lung functionality, reducing the amount of air left in the lungs during expiration, increased mismatching of air supply to blood supply in the lungs, and a higher risk of high carbon dioxide levels or metabolic acidosis (high acid levels in the body). Past surgeries or radiation therapy in the abdomen or pelvis might complicate robotic access to the abdomen. So, it’s important for doctors to evaluate these conditions thoroughly before the surgery.
For people who meet the criteria for radical cystectomy but cannot or do not want to undergo surgery, a combination therapy might be the best solution. This usually includes the removal of as much of the bladder tumor as possible through the urethra (the tube carrying urine out of the body), followed by chemotherapy and external beam radiation treatment (using targeted radiation to kill cancer cells).
When a Person Should Avoid Robotic Radical Cystectomy of the Bladder
A robotic radical cystectomy is a significant surgery method used to remove the urinary bladder, which can come with some potential risks during or after the operation. Therefore, if you have localized disease – meaning it’s not widespread – and are considered for this type of surgery, doctors will thoroughly check your overall health and functioning. They aim to spot any serious or unexpected health conditions such as blood clotting disorders, weak lung function, or heart problems. These could potentially stop you from getting the surgery or might lead to preventable significant complications.
Specific conditions discourage this robotic surgery. For instance, when the disease has spread into the pelvic area or surrounding structures and the bladder remains fixed or if a problem with blood clotting (bleeding diathesis) hasn’t been corrected.
Being severely overweight, having previous abdominal surgery involving the guts or blood vessels, receiving radiation therapy to the abdomen before, having a locally advanced disease, and old age might make the robotic bladder removal surgery more challenging. However, these are not absolute no-nos. Good results can still be achieved with careful planning and management of the operation.
Other conditions might discourage certain types of urinary diversions, including:
- Patients with short bowel syndrome (a condition where part of the small intestine is missing), chronic small bowel disease, or a history of extensive radiation to the ileum (the final part of the small intestine) should avoid an ileal conduit diversion (a process where urine is rerouted through a constructed pathway).
- For people who have inferior kidney function or serious liver dysfunction, doing a continent cutaneous diversion (a procedure that reconfigures urine flow to an opening in the abdomen) may not be best, due to increased risk of problems related to the body’s metabolism.
- Having cognitive impairment, disability, or extreme frailty are other potential avoids for continent cutaneous diversions, as they require the ability to self-drain urine after the surgery.
Equipment used for Robotic Radical Cystectomy of the Bladder
The methods and tools used in a certain type of bladder removal surgery, called a robotic radical cystectomy, can differ. This specific approach uses six openings or ‘ports’ in the body, which is detailed in the section about the treatment method.
The standard tools used for this surgery include a continuous heat-providing tool called a cautery hook on the right robot arm. Instruments that create a type of heat that can control bleeding, called Maryland bipolar forceps, SynchroSeal, or Vessel Sealer, are on the left robot arm. The Tip-up Fenestrated grasper, a device used to hold and control tissues, and an automatic surgical tool used for quick stitching of tissues called 60-mm robotic stapler are used by the fourth robot arm. Large tools used for holding a needle in stitching, called needle drivers, are used in the step where the urinary system gets reconstructed.
The surgical assistant mainly uses an instrument to firmly grasp things in surgery, a tool for sucking up fluid and cleaning the surgical area, and a scissors designed for laparoscopic surgery, which is a procedure using a small incision through the abdominal wall.
Who is needed to perform Robotic Radical Cystectomy of the Bladder?
Having a bladder cystectomy, which is a procedure that removes the bladder, requires a team of specialized healthcare professionals. This includes a complete surgical team made up of the urologic surgeon (a doctor specialized in urinary tract issues), anesthesiologist (the doctor who ensures you don’t feel pain during surgery), a circulating nurse, a scrub technician, a bedside assistant, and other important staff working in the operating room.
After the operation, nurses who specialize in recovery from anesthesia, intensive care, and other areas are crucial for your aftercare. You’ll also interact with stoma nurses (nurses who specialize in caring for surgical openings), and case managers who oversee your overall care. Other team members such as physical therapists, dietitians, and oncologists (doctors who treat cancer) contribute to your long-term care and recovery. They all work together to ensure that you receive comprehensive care for your overall health.
Preparing for Robotic Radical Cystectomy of the Bladder
Before proceeding with a specific surgical procedure, there are certain steps patients need to follow. For a few days prior to the operation (about 2 to 3), they should follow a high carbohydrate diet. Their nutrition will then transition to clear liquids the day before the surgery, and they will need to fast—meaning no eating or drinking—beginning from midnight before the operation. Unlike a common belief, the use of laxatives or bowel preparation before the surgery is not necessary, as research has shown that they do not decrease the risk of complications like leaks from the surgical junctions or infections.
To provide the best care and preparation, when patients arrive before their surgery, they are given a wide-ranging antibiotic to fend off any potential infections, along with medicine to prevent clots in the deep veins—deep venous thrombosis prophylaxis. Panis also given a pill known as a μ-opioid receptor antagonist (specifically, alvimopan 12 mg) which helps return their bowel to its normal function more quickly after the surgery. This drug would typically continue to be given in the same dose twice daily following the surgery.
Lastly, if the patient is expected to get an ileal conduit—a method used to re-route urine from the kidneys to the outside of the body—a stoma therapist would mark the site on the body prior to the surgery. This step is often useful, even if the patient is planned for a different type of urinary diversion, because unexpected circumstances may crop up during the operation.
How is Robotic Radical Cystectomy of the Bladder performed
For bladder cancer, specifically urothelial cancer, it’s generally advised to precede surgical treatment with certain types of chemotherapy, especially ones involving cisplatin. Robotic radical cystectomy, a complex procedure for removing the bladder, has become a common approach for invasive bladder cancer in specialized hospitals. However, it’s important to note that surgeons need to carry out a significant number of these surgeries (over 130) before they achieve maximum proficiency and reduce the chance of complications happening within 90 days post-surgery. So if you need this kind of surgery, it’s best to go to a hospital that does a lot of them (more than 50 a year), as this could give you better results and lower the risk of complications.
For robotic radical cystectomy, there are specific procedures for patient preparation and surgery. The patient needs to be lying flat(back-down) on a non-slip foam pad to prevent any slips or pressure injuries. Certain equipment is used to make sure the patient is comfortable and secure, including foam padding, straps, a warming blanket and compression hose. If you’re a female patient and vaginal access is needed, a lithotomy position is used, which is when you’re on your back and your legs are raised and apart. After you’re positioned properly, you’ll be tested in a steep Trendelenburg position, which means your feet are elevated higher than your head, to check for stability. A Foley catheter, a thin, flexible tube, is also inserted to drain your bladder.
The robot is positioned on your left side, and the surgical assistance and technician are on the right. After these positions are set, a needle, known as a Veress needle, is inserted to inflate your stomach, which will help with placing ports. Ports are small plastic tubes that are placed into your body to help the robotic arms. For this surgery, there are 6 ports that are placed similarly to a different type of surgery used to remove the prostate, but they’re located farther up on the body. This helps with carrying out other parts of the surgery and lymph node dissection, which involves removing certain lymph nodes, the small glands that filter lymph fluid as part of your immune system.
Once your abdomen is inflated with gas, the procedure begins by releasing some tissue next to the ascending and descending colon for full exposure of the deep pelvis where the procedure is conducted. The procedure then moves on to dissecting the right ureter, which is the tube that carries urine from your kidney to your bladder. The right ureter is located and then dissected, or cut open, all the way towards the point where the ureter meets the bladder. It’s critical during this dissection to use a method that doesn’t cause tissue trauma and to keep a healthy margin of fat and vasculature around the ureter.
Once the lower part of the right ureter is dissected, it’s cut open, and a piece is sent away for testing to make sure it’s not cancerous. The end of the upper ureter, the part closer to the kidney, is then closed up to stop urine from entering the abdominal space and to let the upper ureter swell and open slightly. This slight swelling and opening will help when creating anastomoses for urinary diversion, which involves rerouting the flow of urine. The same procedure is repeated on the left ureter, but this one extends under the sigmoid colon, a part of your large intestine, and goes a bit farther down. This way, when a piece is sent for testing, we can make sure that we’ve managed to keep a safe distance from the cancer during the surgery.
The surgery then proceeds with a posterior dissection before the bladder and prostate are approached, helping to expose this area by holding the bladder up and slightly forward using the fourth robotic arm. A cut is made into the peritoneum, the thin membrane that lines the abdominal and pelvic cavities, at a place known as the rectovesical cul-de-sac. The seminal vesicles and vas deferens, a tube that carries sperm from the testicles, are found on both sides and then dissected. The dissection process is then carried around the back between these organs and the rectum.
Possible Complications of Robotic Radical Cystectomy of the Bladder
Robotic surgery for bladder removal, or robotic radical cystectomy, is a complex procedure that can lead to several complications. These complications often involve the urinary and digestive systems, and can happen quite frequently. The most common complications include digestive issues (up to 20% of the time), infections (up to 17% of the time), and issues with the urinary system (up to 10% of the time). These issues can range from urinary or wound infections to anemia or ileus, a condition where the intestines don’t move food through as they should. Despite the fact that up to 48% of patients may experience complications within 30 days of the surgery, most of these are not severe.
The percentage of patients who experience complications from this type of robotic surgery is similar to the percentage of patients who experience complications from an open surgery for the same condition. Efforts are underway to improve pre-operative and post-operative care to help reduce the risk of complications after the surgery.
One strategy that has been shown to help improve patient recovery following robotic bladder removal is the use of Enhanced Recovery After Surgery (ERAS) protocols. ERAS is a team-based approach involving various health professionals to improve patient outcomes. It focuses on getting patients moving soon after surgery, managing fluids carefully, controlling pain through various methods, and starting food intake as early as possible. These protocols have been successful in helping patients recover more quickly, spend less time in the hospital, and have a lower overall rate of complications.
What Else Should I Know About Robotic Radical Cystectomy of the Bladder?
Surgeries for invasive bladder cancer, where the cancer has grown into the muscles of the bladder, are increasingly using a method called robotic cystectomy. This method involves a robotic system to perform the surgery, and while it can be a bit more time-consuming and costly compared to traditional surgery, it offers similar results in terms of managing the cancer and preserving quality of life.
In addition to these, robotic cystectomy also comes with several benefits. These include less blood loss during the surgery, a lower chance of needing blood transfusions, a decreased risk of leaving cancer cells (positive margins), fewer major complications, an enlarged removal of lymph nodes for testing, and a shortened hospital stay.
As more and more doctors get training in using robotic systems, it’s expected that this type of surgery will become more common in the treatment of bladder cancer.
