












































International Journal of Cancer Therapy and Oncology
www.ijcto.org

Copyright © Vasdev et al. ISSN 2330-4049

Nikhil Vasdev, Ben Lamb, Tim Lane, Gregory Boustead, James M Adshead

Hertfordshire and South Bedfordshire Urological Robotic Centre, Department of Urology, Lister Hospital, Stevenage, UK

Received September 03, 2013; Accepted September 18, 2013; Published Online September 20, 2013

Scientific Note

A radical cystectomy (RC) with pelvic lymph node dissec-
tion (PLND) is the gold standard for the management of the
appropriately selected patient with muscle invasive bladder
cancer (MIBC) and non-muscle invasive bladder cancer
(NMIBC)/carcinoma in situ (CIS) who fail appropriate
intravesical therapy. In the last decade, Robotic Radical Cys-
tectomy (RRC) is being performed in a large number of in-
ternational Centre’s with the published advantages of de-
creased blood loss, improved post-operative convalescence
and earlier initiation of adjuvant therapy1 when compared to
open cystectomy (OC). Current literature indicates that a RC
is equivalent to OC from the oncological perspective. An OC
is associated with high rates of morbidity (19-64%) or mor-
tality (6-11%), although there is a wide variation in current
literature.1-11 A RRC is perhaps just one modality in a raft of
measures to try reducing mortality and morbidity of a cys-
tectomy.

To the Robotic Urological Surgeon, a RRC comes with nu-
merous specific challenges. Questions that arise at the time
of commencing a RRC include the learning curve of the
procedure, learning steps to enhances ones speed to perform
the procedure efficiently and safely, level of lymphnode
dissection, whether one should embark of performing an
intracorpealileal conduit or neobladder formation and the
cost of commencing a RRC service. The patient’s postopera-
tive management is the most important step to ensure that
the post-operative complications are kept to a minimum
using a multi-disciplinary team (MDT) approach.

In current literature high volume centers with experienced
surgeons have reported patient outcomes that are acceptable
from the perspective of extended pelvic lymph node dissec-
tion, positive surgical margin rates and highlight that pa-
tients are not being compromised from the surgical perspec-
tive in undergoing a RC.2

The learning curve of a RRC is not as clearly defined in
comparison to Robotic Radical Prostatectomy (RRP). Before
commencing aRRC it is important to be proficient and fa-
miliar with robotic pelvic surgery. Most robotic surgeons are
proficient in RRP before embarking on performing inde-
pendent RRC. Hayn et al.3 have indicated that an acceptable
level of proficiency to perform a RRC is established after the
30th case by measuring post-operative parameters such as
operative time, lymph node yield (LNY), estimated blood
loss (EBL), and margin positivity. At our center we com-
menced performing RC after performing 150 Robotic RRP.
We would strongly recommend that a robotic urological
surgeon who is keen to commence Robotic RC should be
proficient in robotic RRP and in performing an extended
pelvic lymph node dissection (EPLND). A well-trained Ro-
botic Team consisting of the lead experience console sur-
geon, experienced assistant, nursing staff and an experience
anesthetist is essential for the commencement of a RRC pro-
gram. The techniques that a team needs to develop to aid in
improving intra-operative times including a fast docking/
undocking time, piggyback techniques for ports and , the use
of different specimen retrieval bags, use of laparoscopic sta-
plers and new intraoperative hemostatic agents.

Whilst performing an adequate RRC involves the removal of
the bladder, the importance of performing an EPLND cannot
be understated. There is no defined lymph node dissection
template for a RRC and some centers now perform an
EPLND before performing the robotic cystectomy during a
RRP.4 The anatomical landmark that we recommend to be
followed is up to the level of the aortic bifurcation or the
Inferior mesenteric artery (IMA), lymph node of cloquet
distally, genitofemoral nerve laterally and perivesical tissue
laterally. Using this template the surgeon will be able to
excise the external iliac, obturator, hyogastic and common

Corresponding author: Nikhil Vasdev, FRCS (Urol); Hertfordshire
and South Bedfordshire Urological Robotic Centre, Department of
Urology, Lister Hospital, Stevenage, UK.
Email: nikhilvasdev@doctors.org.uk

Cite this article as:
Vasdev N, Lamb B, Lane T, Boustead G, Adshead J. Robotic Cys-
tectomy : Important considerations before commencing the pro-
cedure independently. Int J Cancer Ther Oncol 2013;1(1):01017.
DOI: 10.14319/ijcto.0101.7

Robotic Cystectomy : Important considerations before
commencing the procedure independently

http://dx.doi.org/10.14319/ijcto.0101.7


2 Vasdev et al.: Robotic Cystectomy International Journal of Cancer Therapy and Oncology
www.ijcto.org

Copyright © Vasdev et al. ISSN 2330-4049

iliac. Some authors5 recommend the excision of the
presacrallymphnode as the excision of this lymph node
group facilitates the transposition of the left ureter behind
the sigmoid mesentery to aid in intracorporeal anastomosis.

With an evolution in robotic systems there has been an in-
crease in the number of patients undergoing intracorporeal
ileal conduit and neobladder formation. The excellent tech-
nical description of the procedure has led to the adoption of
these techniques worldwide.5 We have recently published
the results of our initial patients.6 Robotic surgeons must be
proficient in the performing the cystectomy part of the RRC
before embarking on either an intracorporeal ileal conduit or
neobladders formation due the complications of keeping
patients in the steep Trendelenburg position for prolonged
periods, which include compartment syndrome, neurological
complications, intraocular complications, and
rhabdomyolysis.7,8 Recent evidence from high volume cen-
tres performing RRC and intracorporeal neobladders diver-
sion confirm that initial results are comparable to contem-
porary open series with regards to complication rates, func-
tional and oncological outcomes.9 We recommend that a
surgeon should embark on performing an intracorporeal ileal
conduit and neobladder formation only if the ablative part of
RRC is less than 2.5 hours of total operative time. If the abla-
tive times are longer we recommend performing a
mini-laparotomy for excision of the cystectomy specimen
and completing an extracorporeal ileal conduit or
neobladders.6

The cost effectiveness of a RRC when compared to an open
radical cystectomy (ORC) has a disadvantage of being more
expensive due to the initial high purchase and mainte-
nance contract cost, although when the indirect costs of
complications and extended hospital stay with ORC are con-
sidered, RRC may be less expensive than the traditional open
procedure. In order to accurately evaluate the cost effec-
tiveness of RARC versus ORC, prospective randomized trials
between the two surgical techniques with long-term onco-
logic efficacy are needed.10

In conclusion, a RRC with intracorporeal ileal conduit or
neobladders formation is a complex robotic procedure that
should only be undertaken by an experienced robotic pelvic
oncological surgeon who is completely competent at per-
forming a RRP + EPLND. A carefully mentored approach
and a well-trained robotic team are the two key components
to make the procedure a success.

Competing interests

The authors declare that they have no conflicts of interest.
The authors alone are responsible for the content and writ-
ing of the paper.

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