Robotic Cystectomy Utilization on the Rise

The increasing use of robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is part of a major shift underway in the field of urologic oncology.

Though slower to gain acceptance in clinical practice than robotic prostatectomy, the most commonly performed robotic oncologic procedure in the United States, robotic cystectomy has made notable inroads for the treatment of bladder cancer since it was first introduced in 2003. An analysis of the National Cancer Database published in 2022 found a jump in RARC utilization, from 22% in 2010 to 40% in 2015.

Board-certified urologist Alberto Pieretti, MD, mastered the approach during his fellowship training and has incorporated it as standard practice since joining Cleveland Clinic Weston Hospital in 2022. Dr. Pieretti and his colleague Fernando Cabrera, MD, also have embraced a unique two-surgeon approach in hopes of maximizing the benefits of minimally invasive bladder cancer surgery.

Treatment guidelines

More than 83,000 new bladder cancer diagnoses and nearly 17,000 bladder cancer deaths are expected in the U.S. in 2024, reports the American Cancer Society. Most patients will be in their 70s and 80s, with a 3:1 male to female ratio.

Of the two main types of bladder cancer, non-muscle invasive (NMIBC) and muscle invasive (MIBC), the latter is less common but has a greater risk of death. The 5-year survival rate for MIBC is about 50% following standard treatment. And while only one in four newly diagnosed patients will have MIBC, many with high-risk NMIBC may ultimately progress to invasive disease.

According to American Urological Association (AUA) guidelines, which were updated earlier this year, the current standard of treatment for non-metastatic MIBC is neoadjuvant chemotherapy (NAC) followed by radical cystectomy with bilateral pelvic lymphadenectomy for surgically eligible patients.

These guidelines recognize robotic cystectomy as a surgical option but cite the need for long-term data to demonstrate the oncologic efficacy and potential for improved clinical outcomes and QOL when compared to open radical cystectomy (ORC).

Robotic versus open surgery

Radical cystectomy is a complex surgery with a high rate of perioperative complications and hospital readmission. There is a significant risk of morbidity and prolonged recovery time associated with the surgery. “Patients with bladder cancer are typically older with multiple comorbidities, so they usually take longer to recover from this major surgery,” adds Dr. Pieretti.

In addition to removing the bladder and surrounding lymph nodes, most radical cystectomies also entail removing parts of the reproductive system. For men, this means the prostate and seminal vesicles. In women, this may include the uterus, ovaries, fallopian tubes, cervix and anterior vaginal wall, though organ-sparing options may be possible. The urinary tract is then reconstructed so that urine can move out of the body.

Open surgery requires a large incision running from the umbilicus to just above the pubic bone. For robotic cystectomy, the surgeon creates five to six 8 mm ports, depending on instrument placement. One port is usually elongated to about 2 cm to allow for organ removal, though some female patients can have the bladder removed through the vagina, describes Dr. Pieretti.

A literature review published in 2023 in Investigative and Clinical Urology found RARC to be associated with comparable oncological outcomes, reduced blood loss and transfusion rates, shorter hospital stays, less risk for complications, and fewer hospital readmissions when compared to ORC.

“Patients also benefit from less pain and a quicker recovery, typical of a robot-assisted approach,” says Dr. Pieretti. “With robotic cystectomy, most of our patients at Weston Hospital are discharged to home instead of short term rehab, and many patients are back to baseline in about four to six weeks.”

Minimally invasive urinary diversion

Part of the surgical complexity associated with radical cystectomy is the restoration of urinary function. Three methods of urinary diversion are currently used.

• An ileal conduit diversion uses a segment of the intestine to direct urine through a stoma into an external collecting bag.
• Continent cutaneous diversion uses a reservoir made from a portion of the intestines to store urine until it is drained via a catheter inserted through a stoma.
• A neobladder is a bladder-like pouch reconstructed from a portion of the intestine. It allows urine to be stored and voided through the urethra.

“A majority of our patients receive an ileal conduit, though some of our younger patients opt for a neobladder to return to a more normal way of life,” says Dr. Pieretti.

When robotic cystectomy was initially adopted, most surgeons reverted to an open approach for the urinary diversion part of the procedure, known as extracorporeal urinary diversion (ECUD). But by 2015, intracorporeal urinary diversion had become the preferred method, according to a report by the International Robotic Cystectomy Consortium.

A study by Cleveland Clinic researchers in Ohio found ICUD, when compared to ECUD, resulted in lower estimated blood loss, shorter hospitalization and a lower rate of postoperative ileus, a common gastrointestinal complication associated with radical cystectomy.

Dr. Pieretti and Dr. Cabrera have adopted a two-surgeon approach, in which Dr. Cabrera will often perform the ICUD portion of the procedure after Dr. Pieretti performs the RARC and pelvic node dissection.

“These surgeries are highly complex and usually take five to six hours to complete,” explains Dr. Pieretti. “Using a team approach allows us to minimize surgeon fatigue while maximizing the benefit of a fully minimally invasive approach, including faster patient recovery and return to baseline.”