Robotic Surgery in Urology


with the conventional laparoscopic approach was also twice that of the robotic group (113 versus 61ml). The robotic hysterectomies had longer operative times by an average of 27 minutes. However, the subanalysis of the last 25 robotic cases included in the study showed that the operative time for the robotic approach was even shorter (78.7 versus 92.2 minutes). Reported complications were similar in both groups.


Another urogynaecological operation that can be performed with robotic assistance is a vesicovaginal repair. Current literature shows the feasibility of the robotic approach.25,26


The current literature for urogynaecological surgery is relatively limited, but it suggests that robotic surgery can be adopted as a valid therapy regime. Good short-term results with decreased patient hospitalisation and acceptable morbidity and operative times suggest that there will be some interesting developments within the field in the future.


Robotic Cystectomy


Muscle-invasive bladder cancer is a potentially lethal disease with survival rates of less than 15% at two-year follow-up if left untreated. The gold standard for its treatment is open radical cystectomy with bilateral pelvic lymphadenectomy and urinary diversion. In 2003, Menon et al.27


and Beecken et al.28 published the


Although these initial results of robot-assisted radical cystectomies seemed to be promising, it has to be pointed out that a radical cystectomy – open, laparoscopic or robot-assisted – still represents a very challenging operation with high rates of patient mortality and morbidity. The current literature shows that operative times for the robotic approach have decreased in experienced centres (down to four to six hours).29,30 The most important question when talking about robot-assisted radical cystectomy is the type of urinary diversion, which can be performed intra- or extracorporally. Most authors report extracorporeal construction of urinary diversion with either an open or robotic urethroneovesical anastomosis for orthotopic neobladders. The intracorporeal reconstruction of urinary diversion is very long-winded and can take up to nine to 13 hours, which has limited its widespread acceptance.31


first series of robot-assisted radical cystectomies and urinary diversions. Beecken et al. described their surgical approach for this challenging procedure and could demonstrate that even radical cystectomies were able to be performed with the help of the da Vinci system. The average operating time of their initial series was eight and a half hours and reported blood loss was approximately 200ml. The formation of the urinary diversion was performed intra-abdominally. The reported oncological as well as the functional results of the intra-abdominally formed neobladder were excellent.28


The Karolinska group published


their data on intracorporeal urinary diversion. They reported a mean operation time of 501 minutes (range 382–750 minutes). Three of 18 patients had to be converted to conventional open surgery.32


Pruthi et al.33


reported on their initial experience with intracorporeal urinary diversion during robotic radical cystectomy. They included 12 patients in single-centre case series. The mean operating-room time of all patients was 5.3 hours, and mean surgical blood loss was 221ml. The reported mean time to flatus, bowel movement and hospital discharge was 2.2, 3.2 and 4.5 days, respectively. Eleven of the 12 patients could be discharged on or before post-operative day


EUROPEAN UROLOGICAL REVIEW


One of the most important factors for post-operative success is to achieve negative surgical margins during radical cystectomy. Patients with positive surgical margins (PSMs) have an increased rate of recurrence and a clear reduction of survival. Leaders in the field of bladder cancer have suggested that a rate of PSM less than 10% overall and less than 15% for T3/4 carcinomas is acceptable.36


Schumacher et al.32 included 11 studies with 230


patients in their literature review analysing the positive margin rate after robot-assisted radical cystectomy. The results showed an overall rate of 2.6% positive margins; therefore, the authors concluded that robot-assisted radical cystectomy provides similar soft-tissue margins to open surgery.


Since robotic surgery in the field of muscle-invasive bladder cancer is still in its infancy, long-term follow-up after radical cystectomy does not yet exist. Recently, Martin et al.37


published intermediate


follow-up data. Of a total of 80 robot-assisted radical cystectomies, 59 patients had a follow-up of more than six months from surgery and were included in the analysis. Survival curves were compared with those from historical series of open cystectomy. The mean follow-up was 25 months (range six to 49 months). Overall survival rates at 12 and 36 months were 82 and 69%, respectively, and disease-specific survival rates were 82 and 72% at 12 and 36 months, respectively.37


The International Cystectomy Consortium38 recently provided an


update on the learning curve of robotic radical cystectomy. A total of 496 patients were included in this retrospective multicentre analysis. The median operative times were 441, 368 and 307 minutes for those surgeons who had performed 50 operations, respectively (p50 cases (p


Their statistical analysis


showed that 21 robot-assisted radical cystectomies were required for a surgeon to reach a mean operative time of 390 minutes.


71


five. The post-operative complication rate was 42% (six complications in five patients), with one complication being Clavien grade 3 or higher. The presented data showed similar results with current literature and led to the conclusion that robot-assisted laparoscopic intracorporeal diversion appears to be a feasible and favourable operative method with acceptable operative and short-term clinical outcomes.33


published a non-randomised, prospective study including 187 patients undergoing radical cystectomy: 104 were performed using the conventional open approach and 83 underwent robotic radical cystectomy. Both groups were similar in their parameters. Operative times did not differ significantly between the two groups, but estimated blood loss and blood transfusions were significantly lower in the robotic group. Furthermore, the length of hospitalisation was reduced in the da Vinci cystectomy group (5.5 versus 8 days; p


Ng et al.29 however, results showed


that there was a significantly higher positive margin rate for non-organ-confined disease in the overweight (BMI 25–29) and obese groups (BMI >30).


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