An Improving Outlook for Robotic Radical Cystectomy

By Homayoun Zargar Shostari, MD; Vishnuvardhan Ganesan,BS; and Georges-Pascal Haber, MD, PhD

Despite the decline in morbidity and mortality of open radical cystectomy (ORC) during the past two decades, the high rate of perioperative complications remains a challenge for clinicians. After a rocky start with a technically challenging laparoscopic approach, the robot-assisted procedure offered a new horizon.

Expanding on the experience gained with robotic radical prostatectomy, robotic radical cystectomy (RRC) has gained momentum as an alternative to the open approach. Long-term oncologic outcomes with RRC are equivalent to those with ORC.

However, recent prospective data showed that RRC was not superior to ORC in terms of complications and was associated with increased cost. Even though the cystectomy was done robotically, the diversion was performed extracorporeally through an open approach, diluting the advantages of minimally invasive surgery.

Improving RRC Outcomes Through Standardization

Our experience with RRC and intracorporeal diversion has been encouraging.

Standardizing our technique and defining the steps for intracorporeal ileal conduit and intracorporeal neobladder have allowed us to improve both the intraoperative and postoperative outcomes.

Since the refinement of our technique, we have performed more than 70 RRCs with intracorporeal diversion. The median blood loss for our series is 300 cc. The overall 90-day complication rate is approximately 50 percent, with a 20 percent rate of high-grade complications (Clavien III/IV) and a 90-day mortality rate of 2 percent. The median time to full diet is 5.5 days, and median hospital stay is seven days.

In comparing the overall cost of our RRCs to ORCs, the overall cost is approximately $2,000 less for the robotic group, despite the higher direct operating room (OR) cost. The lower cost is mainly due to reductions in length of stay and in the rates of major complications and secondary procedures. Although OR time and minor perioperative complications were comparable between RRC and ORC, blood loss, transfusion rate, the rate of major perioperative complications, length of stay and the rate of readmissions were superior with RRC.

Reducing Paralytic Ileus Incidence

More recently, we have modified our perioperative care pathways for patients undergoing RRC. In an effort to further reduce the incidence of paralytic ileus, we have adopted a multimodal opioid-sparing approach to postoperative analgesia. In our early experience, the combination of intraoperative injectable liposomal bupivacaine, regular acetaminophen and ketorolac tromethamine has enabled us to minimize and in some cases eliminate the need for narcotic analgesia.

The minimally invasive approach is only one component of enhanced recovery after surgery (ERAS) for RRC. Robotic radical cystectomy in combination with other components of ERAS such as early feeding, early mobilization and opioidsparing multimodal analgesia is likely to become the gold standard for performing RRC in the future.

RRC with intracorporeal urinary diversion has enabled us to decrease the morbidity associated with this major procedure without compromising oncologic outcomes. Its widespread use would not be a surprise but a natural evolution.

Dr. Zargar Shostari is a clinical fellow in Cleveland Clinic’s Glickman Urological & Kidney Institute.
Mr. Ganesan is a medical student at Cleveland Clinic Lerner College of Medicine.
Dr. Haber is a staff member of Cleveland Clinic Glickman Urological & Kidney Institute’s Department of Urology.