Robot-Assisted Intracorporeal Neobladder: The Karolinska Standardized Technique

Abstract

Radical cystectomy with extended pelvic lymphadenectomy (ePLND) and urinary diversion still represents the gold standard treatment for muscle invasive bladder cancer and high-risk bladder cancer unresponsive to intravesical treatments. Irrespective of surgical approach RC remains a complex multistep surgery, being associated with a high rate of complications [Stenzl et al. (Eur Urol 59:1009-1, 2011), Collins et al. (Scand J Urol. 50(1):39–46, 2016)]. With the purpose of further reducing morbidity, minimally invasive approaches have been described, and the 2020 EAU guidelines [Witjes et al. (Eur Urol 79:82, 2021)] consider robot-assisted radical cystectomy (RARC) as a viable alternative to open radical cystectomy (ORC). Concluding current evidence indicates RARC has longer operative time (1–1.5 h) and major costs but shorter length of hospital stay (1–1.5 days) and less blood loss compared to ORC [Tang et al. (Eur J Surg Oncol, 2014)]. Surgeons’ experience and institutional volume are considered the key factor for outcome of both RARC and ORC [Dell’Oglio et al. (Eur Urol Focus 7(2):352–358, 2021)]. Laparoscopic radical cystectomy never gained wide acceptance in the urological community due to long operative time and the technical difficulties related to both ePLND and urinary diversion reconfiguration. With the introduction of robot-assisted laparoscopic surgery, RARC has emerged as a more viable alternative to both open and laparoscopic approaches to radical cystectomy [Collins et al. (Eur Urol 64:654–63, 2013), Hosseini et al. (BJU Int 126(4):464–471, 2020)].

To date, the RARC experience is increasing worldwide, minimizing surgical insult, and aiming to result in reductions in postoperative morbidity while offering improved ergonomics for the surgeon [Yu et al. (Surg Endosc 31(2):877–886, 2017)]. Several meta-analyses have demonstrated that RARC decreases blood loss and reduces overall complication rates, resulting in reduced transfusion rates, shorter time to normal diet, and length of stay [Tang et al. (Eur J Surg Oncol, 2014), Li et al. (Cancer Treat Rev 39(6):551–60, 2013)], without compromising oncologic safety as compared to open surgery [Snow-Lisy et al. (Eur Urol 65(1):193–200, 2014)]. Several urinary diversions have been described, but only limited randomized clinical trials performed by few super-specialized tertiary referral centers have demonstrated the advantages offered by intracorporeal urinary diversion (ICUD). The potential advantages of a complete intracorporeal procedure are less intraoperative blood loss, decreased bowel manipulation and exposure, reduced insensible losses, decreased morbidity from smaller incisions, reduced postoperative analgesic requirements, shorter hospital stay, and earlier return to normal activities [Hosseini et al. (BJU Int 126(4):464–471, 2020)].

In this paper we describe our standardized approach with modifications to technique for intracorporeal neobladder formation performed since December 2003 [Collins et al. (Eur Urol 64:654–63, 2013)].