The gold standard procedure for patients with invasive bladder cancer is open radical cystectomy with pelvic lymph node dissection (PLND) and urinary diversion; however, this procedure remains associated with considerable complication rates, even in high-volume, specialist centers.

Robot-assisted laparoscopic radical cystectomy (RALRC)—including PLND and intracorporeal urinary diversion—is an alternative approach that is being developed at several institutions. In an article published in European Urology, Jonsson and colleagues at the Karolinska Institute in Stockholm, Sweden, describe their technique and report the oncologic and functional outcomes in 45 patients who underwent the procedure at their center.

The patients (38 men, 7 women) all had high-grade and/or muscle-invasive bladder cancer and underwent RALRC (a six-port transperitoneal approach in accordance with the Hasson technique) with PLND and intracorporeal urinary diversion (orthotopic neobladder [n = 36] or ileal conduit [n = 9]) between 2004 and 2009.

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Three different PLND templates were employed, depending on the robot system used and the stage and grade of the patient's disease: the median overall number of lymph nodes removed was 19 (range 10–52). Early complications (occurring within 30 days of surgery) were reported in 40% of patients, and were predominantly of Clavien grades 1–3. Late complications were observed in one-third of patients. Surgical conversion to an open procedure was required in two patients owing to “technical problems”, long operative times and anastomotic insufficiency of the neobladder construct.

...RALRC [was] associated with acceptable morbidity and promising oncologic outcomes...

In terms of oncologic outcomes, overall recurrence-free survival after a median follow-up duration of 25 months (range 3–90 months) was 84%, and 3-year cancer-specific survival was 86% (95% CI 65–95%). Four patients died during follow-up after developing metastatic disease. Daytime and nocturnal continence rates at 12 months were 97% and 83%, respectively, in patients who underwent neobladder creation. Of the 20 men who underwent bilateral nerve-sparing surgery, only 1 reported impotence.

Despite the high complexity of the procedure, the authors conclude that their RALRC technique is feasible and associated with acceptable morbidity and promising oncologic outcomes. A comparison of the first 18 and last 18 cases showed marked improvements in operative time, hospital stay and early and late complications over time, indicating a favorable learning curve. Randomized studies will be needed in order to provide a true comparison between the robot-assisted and open surgical procedures.