What Is Robotic Cystectomy? 

Introduction

Robotic cystectomy is a cutting-edge surgical technique that has revolutionised the way bladder cancer is treated. This minimally invasive approach has replaced the traditional open cystectomy, which required a large abdominal incision. The history of robotic surgery can be traced back to the early 20th century, as technology advanced and medical professionals began to explore the potential of robotics in medicine. The development of robotic cystectomy represents a significant milestone in this journey. This innovative procedure offers numerous benefits to patients, including faster recovery times and reduced post-operative pain.¹

Bladder cancer is a malignant condition that develops in the tissues of the bladder, the organ responsible for storing urine. Over time, cancerous cells can multiply and form a tumour, which can potentially spread to deeper layers of the bladder wall. It is worth noting that bladder cancer is the second most common type of cancer that affects the urinary tract.² The severity of bladder cancer can vary, with non-invasive cancer confined to the inner lining of the bladder and muscle-invasive cancer that infiltrates the muscular layers. Common symptoms include blood in the urine, frequent urination, and pain during urination. Treatment options depend on the stage and type of bladder cancer and may involve surgery, chemotherapy, immunotherapy, or a combination of these modalities.³

In cases where non-invasive treatments prove insufficient, cystectomy, the surgical removal of the bladder, may be deemed essential. This procedure is typically performed in cases of muscle-invasive bladder cancer. Additionally, cystectomy may be recommended in instances of refractory non-muscle invasive bladder cancer, where the cancer persists or recurs despite prior treatments. The decision to undergo cystectomy is complex and takes into account factors such as the stage and aggressiveness of the cancer, the overall health of the patient, and their individual preferences. Ultimately, the surgical removal of the bladder serves as a crucial strategy to enhance the chances of remission, improve the quality of life, and address the specific challenges posed by advanced bladder cancer.⁴

Surgical procedure- how it works

Robotic cystectomy involves the removal of the bladder as well as nearby lymph nodes, part of the urethra, and depending on patient factors, the prostate (in men), uterus, fallopian tubes, ovaries, and part of the vagina (in women). It is a complex procedure that requires surgical expertise and the use of specialized instruments.⁵

To begin, the patient is placed under general anaesthesia and prepped for surgery. The surgeon makes a small incision just above the pubic bone and inserts a needle to inflate the abdomen with carbon dioxide gas. This allows space for the robotic instruments to manoeuvre. Several additional small incisions are made to create ports through which the robot’s operating arms and camera enter. The surgeon, stationed at a console a few feet away from both the robot and the patient, manipulates the robotic instruments to excise the bladder and surrounding organs. As part of the procedure, the pelvic lymph nodes are also removed. Following bladder removal, the subsequent task involves diverting urine in a manner that permits its expulsion from the patient's body. The surgical team then ensures the proper functioning of the urinary diversion, facilitating the elimination of urine through an external urostomy bag or the patient's natural urethra, depending on the chosen diversion technique. The entire procedure may take about 4-5 hours. The patient will remain in the hospital for around a week for post-operative care⁶.

Advantages of the robotic approach

Proponents of robotic cystectomy highlight numerous potential benefits compared to open surgery:

1. Enhanced precision - The 3D, high-definition camera provides surgeons with a greatly magnified view of the operative field with excellent depth perception. This facilitates delicate dissection and identification of important anatomical structures. Moreover, the instruments allow a full range of motion well beyond the limits of the human wrist. This improves fine motor control and enables meticulous dissection.⁷
2. Decreased blood loss - The robotic system's precision, coupled with the ability to cauterize blood vessels effectively, contributes to a lower risk of excessive bleeding during the procedure.⁸
3. Faster recovery times- Patients usually recover bowel function faster due to decreased tissue trauma. The average length of stay is 7-10 days with robotics versus 9-14 days after open surgery. The smaller incisions lead to less postoperative pain and a quicker return to daily activities.⁸
4. Lower complication rates - Studies show robotic cystectomy has lower rates of postoperative complications like infection, blood clots, and cardiac events compared to open surgery.⁸
5. Improved cosmesis- The smaller incisions result in improved cosmetic outcomes. Patients often appreciate the smaller, less noticeable scars associated with robotic surgery compared to the more prominent scars characteristic of open procedures.⁷

Patient selection and outcomes

Careful patient selection is important for robotic cystectomy. Ideal candidates are typically younger, healthier patients with localised muscle-invasive bladder cancer. Patients who may not be ideal candidates for robotic cystectomy include those who are elderly, extremely overweight, have a history of pelvic radiation, extensive bladder cancer, or other conditions that could make the use of the gas used to inflate the abdomen during surgery risky.⁹

Results from observational studies demonstrate that in appropriately selected patients, robotic and open cystectomy have similar intermediate-term oncologic outcomes related to cancer cure and recurrence. Long-term survival data is still pending. However, multiple studies show lower complication rates and shorter hospital stays with the robotic approach. Patient-reported outcomes also favour robotics, with patients experiencing less pain and faster recovery of urinary and sexual function compared to open surgery. Overall health-related quality of life is improved after robotic cystectomy.¹⁰

Challenges and considerations

Robotic cystectomy is a highly complex and demanding surgical procedure that requires the utmost precision and expertise to achieve optimal outcomes. The operation's success depends on various factors, including the surgeon's skill and experience, the medical institution's quality, and the ability to minimise potential complications. The following can be considered challenges or limitations of this procedure:

1. Cost: Robotic surgery, including robotic cystectomy, can be expensive. The initial setup costs, maintenance, and training for surgeons contribute to the overall expense. This can limit accessibility for some patients and healthcare facilities.¹¹
2. Training requirements: Surgeons need specialized training to operate the robotic system effectively. The learning curve can be steep, potentially impacting the widespread adoption of the procedure. Ensuring a sufficient number of trained surgeons is crucial for expanding access to robotic cystectomy.¹³
3. Technology limitations: While robotic technology continues to advance, there are limitations to its capabilities. Surgeons may face challenges in intricate procedures or when dealing with complex anatomical variations. Ongoing technological developments are necessary to overcome these limitations.
4. Resource dependency: Robotic cystectomy is dependent on the availability of specialized robotic systems. In regions or healthcare settings where these resources are scarce, access to the benefits of robotic surgery will be limited.¹¹
5. Lack of tactile feedback: Unlike traditional open surgery, where surgeons can feel the tissues directly, robotic surgery lacks tactile feedback. This absence of touch sensation can make it challenging for surgeons to assess the texture and consistency of tissues, leading them to heavily rely on visual cues.¹⁰
6. Patient Selection: Not all patients are suitable candidates for robotic cystectomy. Obesity, previous abdominal surgeries, or complex medical conditions may limit eligibility. Proper patient selection is critical to ensure favourable outcomes.
7. Surgery time: Robotic cystectomy procedures can take longer compared to open surgery. The setup, docking of the robot, and the intricate nature of robotic manoeuvres contribute to extended operating times. Prolonged surgery durations may increase the risk of complications.¹³

Summary

Robotic cystectomy stands as a groundbreaking advancement in urological surgery, providing patients with a minimally invasive alternative to open cystectomy for treating bladder cancer. Its proven benefits, encompassing smaller incisions, reduced pain, and accelerated recovery, have fundamentally transformed the landscape of bladder cancer treatment. Despite persistent challenges like cost and training requirements, ongoing technological evolution promises an exciting future. What remains certain is that robotic cystectomy continues to lead, consistently refining its role in optimizing patient outcomes.

FAQs

How is robotic cystectomy different from open cystectomy?

Robotic cystectomy and open cystectomy differ mainly in the way the surgery is performed. In robotic cystectomy, the surgeon uses a robot with small instruments to remove the bladder through small incisions. This approach is minimally invasive, resulting in less pain and a quicker recovery. On the other hand, open cystectomy involves a larger incision in the abdomen for bladder removal. While both methods aim to treat bladder issues, robotic cystectomy generally offers smaller scars, reduced pain, and faster healing compared to open cystectomy.⁹

How is urine managed after the removal of the bladder?

After the bladder is removed, urine is managed through different methods. One way is called an "ileal conduit" or "urostomy," where a part of the small bowel creates a tube connecting the ureters to a small opening (stoma) on the abdomen. Urine then flows through this tube into an external bag. Another method is the "orthotopic neobladder," where a new bladder is made using a portion of the small bowel. This neobladder connects to both the ureters and urethra, allowing urine to be passed out through the natural pathway, avoiding the need for an external bag.¹⁴ The choice between these methods depends on factors like the patient's health and personal preferences, and the healthcare team helps in deciding the best approach for each individual.

What are the risks of robotic cystectomy?

While robotic cystectomy is generally safe, potential risks exist. These include the possibility of infection, bleeding, and anesthesia-related complications. There is a slight risk of damage to nearby organs during the procedure. Blood clots and complications related to urinary tract management, such as leakage or blockage, may occur. Breathing problems and reactions to medications are also potential but rare risks.¹⁵ The surgical team takes precautions, closely monitors patients, and addresses any issues promptly. It's essential for individuals considering robotic cystectomy to discuss these potential risks with their healthcare team to make informed decisions about the procedure.

What can I expect during the recovery period after robotic cystectomy?

After undergoing a robotic cystectomy, your recovery will involve a hospital stay of a few days, where your healthcare team will monitor your progress and manage any postoperative issues. The pain experienced is generally less compared to open surgery, and pain management strategies, including medications, will be provided for your comfort. Resuming normal activities varies for each patient, but light activities can typically begin within a few weeks. Dietary changes, if needed, will be discussed, and you'll receive guidance on urinary function management based on the chosen diversion method. Wound care instructions for the incisions will be provided to ensure proper healing. Follow-up appointments are crucial for monitoring recovery, and your healthcare team will schedule these, along with any necessary tests. Be vigilant for signs of complications and contact your healthcare team promptly if you experience persistent symptoms. Sexual activity resumption, lifting restrictions, and specific dietary advice will be addressed during follow-up appointments.¹⁶ 

Should I choose robotic cystectomy over open cystectomy?

The decision between robotic cystectomy (RC) and open cystectomy depends on the specific characteristics of your medical condition, your overall health, and personal preferences. RC offers benefits such as smaller incisions, reduced pain, and quicker recovery.¹⁰ However, the choice is individual, and factors like the surgeon's expertise, availability of technology, and the complexity of the case also play a role.