Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Current status of robot-assisted radical cystectomy for bladder cancer

Nature Reviews Urology volume 9, pages 573–582 (2012)Cite this article

Subjects

Abstract

Radical cystectomy is associated with significant morbidity. However, the introduction of minimally invasive surgical approaches has attempted to improve perioperative outcomes and decrease surgical complications. Emerging data suggest that robot-assisted radical cystectomy (RARC) might have some advantages compared with open radical cystectomy (ORC). However, the oncologic performance of RARC in patients with locally advanced disease is currently unclear, making it crucial to select patients for the procedure very carefully. No long-term prospective studies comparing the robot-assisted and open techniques have been reported. Until long-term oncologic outcomes of RARC and the results of currently ongoing randomized trials comparing the two techniques become available, ORC remains the gold standard.

Key Points

  • Most data on robot-assisted radical cystectomy (RARC) stems from retrospective comparisons and single-centre or multi-institutional case series that have short follow-up durations and are, by definition, subject to selection bias

  • The only prospective randomized trial of robot-assisted versus open radical cystectomy (ORC) was a small single-centre study that was only powered to compare lymph node yield between the two techniques

  • Available literature suggests that RARC is an acceptable alternative to the open technique

  • Until more data are available, RARC should be limited to patients with few comorbidities and high likelihood of organ-confined disease, especially during the surgeon's early learning curve

  • Two prospective randomized clinical trials comparing robot-assisted and open radical cystectomy are currently ongoing

  • Until the results of these prospective trials and long-term oncologic outcomes of RARC become available, the open technique remains the gold standard

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Port placement for robot-assisted radical cystectomy.
Figure 2: Isolation of an ileal segment using the marionette technique.16
Figure 3: Ureteral spatulation and set-up for a Bricker ureteroileal anastomosis.

Similar content being viewed by others

References

  1. Siegel, R., Ward, E., Brawley, O. & Jemal, A. Cancer statistics, the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J. Clin. 61, 212–236 (2011).

    PubMed  Google Scholar 

  2. Frazier, H. A., Robertson, J. E. & Paulson, D. F. Complications of radical cystectomy and urinary diversion: a retrospective review of 675 cases in 2 decades. J. Urol. 148, 1401–1405 (1992).

    Article  CAS  Google Scholar 

  3. Davis, J. W., Castle, E. P., Pruthi, R. S., Ornstein, D. K. & Guru, K. A. Robot-assisted radical cystectomy: an expert panel review of the current status and future direction. Urol. Oncol. 28, 480–486 (2010).

    Article  Google Scholar 

  4. Parra, R. O., Andrus, C. H., Jones, J. P. & Boullier, J. A. Laparoscopic cystectomy: initial report on a new treatment for the retained bladder. J. Urol. 148, 1140–1144 (1992).

    Article  CAS  Google Scholar 

  5. Sánchez de Badajoz, E., Gallego Perales, J. L., Reche Rosado, A., Gutiérrez de la Cruz, J. M. & Jiménez Garrido, A. Radical cystectomy and laparoscopic ileal conduit. Arch. Esp. Urol. 46, 621–624 (1993).

    PubMed  Google Scholar 

  6. Gill, I. S. et al. Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases. Urology 56, 26–29 (2000).

    Article  CAS  Google Scholar 

  7. Gill, I. S. et al. Laparoscopic radical cystectomy and continent orthotopic ileal neobladder performed completely intracorporeally: the initial experience. J. Urol. 168, 13–18 (2002).

    Article  Google Scholar 

  8. Türk, I., Deger, S., Winkelmann, B., Schönberger, B. & Loening, S. A. Laparoscopic radical cystectomy with continent urinary diversion (rectal sigmoid pouch) performed completely intracorporeally: the initial 5 cases. J. Urol. 165 (6 Pt 1), 1863–1866 (2001).

    Article  Google Scholar 

  9. Menon, M. et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int. 92, 232–236 (2003).

    Article  CAS  Google Scholar 

  10. Yohannes, P., Puri, V., Yi, B., Khan, A. K. & Sudan, R. Laparoscopy-assisted robotic radical cystoprostatectomy with ileal conduit urinary diversion for muscle invasive bladder cancer: intial two cases. J. Endourol. 17, 729–732 (2003).

    Article  Google Scholar 

  11. Beecken, W. D. et al. Robotic-assisted laparoscopic radical cystectomy and intra-abdominal formation of an orthotopic ileal neobladder. Eur. Urol. 44, 337–339 (2003).

    Article  Google Scholar 

  12. Rogers, C. G. et al. Maximizing console surgeon independence during robot-assisted renal surgery by using the Fourth Arm and TilePro. J. Endourol. 23, 115–121 (2009).

    Article  Google Scholar 

  13. Singh, I. Robotics in urological surgery: review of current status and maneuverability, and comparison of robot-assisted and traditional laparoscopy. Comput. Aided Surg. 16, 38–45 (2011).

    Article  Google Scholar 

  14. Hosseini, A., Adding, C., Nilsson, A., Jonsson, M. N. & Wiklund, N. P. Robotic cystectomy: surgical technique. BJU Int. 108 (6 Pt 2), 962–968 (2011).

    Article  Google Scholar 

  15. Hasson, H. M. Open laparoscopy. Biomed. Bull. 5, 1–6 (1984).

    CAS  PubMed  Google Scholar 

  16. Guru, K. et al. Robot-assisted Intracorporeal Ileal Conduit: Marionette Technique and Initial Experience at Roswell Park Cancer Institute. Urology 76, 866–872 (2010).

    Article  Google Scholar 

  17. Stein, J., Quek, M. & Skinner, D. Lymphadenectomy for invasive bladder cancer. Technical aspects and prognostic factors. BJU Int. 97, 232–237 (2006).

    Article  Google Scholar 

  18. Bochner, B., Herr, H. & Reuter, V. Impact of separate versus en bloc pelvic lymph node dissection on the number of lymph nodes retrieved in cystectomy specimens. J. Urol. 166, 2295–2296 (2001).

    Article  CAS  Google Scholar 

  19. Pruthi, R. S. et al. Robotic-assisted laparoscopic intracorporeal urinary diversion. Eur. Urol. 57, 1013–1021 (2010).

    Article  Google Scholar 

  20. Jonsson, M. N. et al. Robot-assisted radical cystectomy with intracorporeal urinary diversion in patients with transitional cell carcinoma of the bladder. Eur. Urol. 60, 1066–1073 (2011).

    Article  Google Scholar 

  21. Canda, A. E., Atmaca, A. F., Altinova, S., Akbulut, Z. & Balbay, M. D. Robot-assisted nerve-sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases. BJU Int. http://dx.doi.org/10.1111/j.1464-1410X.2011.10794.x.

  22. Nix, J. et al. Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur. Urol. 57, 196–201 (2010).

    Article  Google Scholar 

  23. Murphy, D. G. et al. Robotic-assisted laparoscopic radical cystectomy with extracorporeal urinary diversion: initial experience. Eur. Urol. 54, 570–580 (2008).

    Article  Google Scholar 

  24. Herrell, S. D. & Smith J. A. Jr. Robotic-assisted laparoscopic prostatectomy: what is the learning curve? Urology 66, 105–107 (2005).

    Article  Google Scholar 

  25. Guru, K. A. et al. The learning curve for robot-assisted radical cystectomy. JSLS 13, 509–514 (2009).

    Article  Google Scholar 

  26. Pruthi, R. S., Smith, A. & Wallen, E. M. Evaluating the learning curve for robot-assisted laparoscopic radical cystectomy. J. Endourol. 22, 2469–2474 (2008).

    Article  Google Scholar 

  27. Hayn, M. H. et al. The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur. Urol. 58, 197–202 (2010).

    Article  Google Scholar 

  28. Hayn, M. H. et al. Does previous robot assisted radical prostatectomy experience affect outcomes at robot assisted radical cystectomy? Results from the International Robotic Cystectomy Consortium. Urology 76, 1111–1116 (2010).

    Article  Google Scholar 

  29. Richards, K. A., Kader, K., Pettus, J. A., Smith, J. J. & Hemal, A. K. Does initial learning curve compromise outcomes for robot-assisted radical cystectomy? A critical evaluation of the first 60 cases while establishing a robotics program. J. Endourol. 25, 1553–1558 (2011).

    Article  Google Scholar 

  30. Hayn, M. H. et al. Is patient outcome compromised during the initial experience with robot-assisted radical cystectomy? Results of 164 consecutive cases. BJU Int. 108, 882–887 (2011).

    PubMed  Google Scholar 

  31. Ng, C. K. et al. A comparison of postoperative complications in open versus robotic cystectomy. Eur. Urol. 57, 274–281 (2010).

    Article  Google Scholar 

  32. Wang, G. J., Barocas, D. A., Raman, J. D. & Scherr, D. S. Robotic vs. open radical cystectomy: prospective comparison of perioperative outcomes and pathologic measures of early oncologic efficacy. BJU Int. 101, 89–93 (2007).

    PubMed  Google Scholar 

  33. Richards, K. A., Hemal, A. K., Kader, A. K. & Pettus, J. A. Robot assisted laparoscopic pelvic lymphadenectomy at the time of radical cystectomy rivals that of open surgery: single institution report. Urology 76, 1400–1404 (2010).

    Article  Google Scholar 

  34. Guru, K. A. et al. Robot-assisted radical cystectomy versus open radical cystectomy: assessment of postoperative pain. Can. J. Urol. 14, 3753–3756 (2007).

    PubMed  Google Scholar 

  35. Herr, H., Lee, C., Chang, S. & Lerner, S. Bladder Cancer Collaborative Group. Standardization of radical cystectomy and pelvic lymph node dissection for bladder cancer. A collaborative group report. J. Urol. 171, 1823–1828 (2004).

    Article  Google Scholar 

  36. Dotan, Z. A. et al. Positive surgical margins in soft tissue following radical cystectomy for bladder cancer and cancer specific survival. J. Urol. 178, 2308–2312 (2007).

    Article  Google Scholar 

  37. Novara, G. et al. Soft tissue surgical margin status is a powerful predictor of outcomes after radical cystectomy: a multicenter study of over 4,400 patients. J. Urol. 184, 2165–2170 (2010).

    Article  Google Scholar 

  38. Hellenthal, N. J. et al. Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. J. Urol. 184, 87–91 (2010).

    Article  Google Scholar 

  39. Hellenthal, N. J. et al. Lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. BJU Int. 107, 642–646 (2011).

    Article  Google Scholar 

  40. Guru, K. A. et al. The lymph node yield during robot-assisted radical cystectomy. BJU Int. 102, 231–234 (2008).

    Article  Google Scholar 

  41. Shabsigh, A. et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur. Urol. 55, 164–174 (2009).

    Article  Google Scholar 

  42. Hayn, M. H., Hellenthal, N. J., Hussain, A., Stegemann, A. P. & Guru, K. A. Defining morbidity of robot-assisted radical cystectomy using a standardized reporting methodology. Eur. Urol. 59, 213–218 (2011).

    Article  Google Scholar 

  43. US National Library of Medicine. ClinicalTrials.gov [online], (2012).

  44. US National Library of Medicine. ClinicalTrials.gov [online], (2012).

  45. Haber, G. P. et al. Perioperative outcomes with laparoscopic radical cystectomy: “pure laparoscopic” and “open-assisted laparoscopic” approaches. Urology 70, 910–915 (2007).

    Article  Google Scholar 

  46. Rehman, J. et al. Total intracorporeal robot-assisted laparoscopic ileal conduit (Bricker) urinary diversion: technique and outcomes. Can. J. Urol. 18, 5548–5556 (2011).

    PubMed  Google Scholar 

  47. Pruthi, R. S. et al. Robotic radical cystectomy for bladder cancer: surgical and pathologic outcomes in 100 consecutive cases. J. Urol. 183, 510–515 (2010).

    Article  Google Scholar 

  48. Dasgupta, P. et al. Robotic assisted radical cystectomy: short to medium-term oncologic and functional outcomes. Int. J. Clin. Pract. 62, 1709–1714 (2008).

    Article  CAS  Google Scholar 

  49. Martin, A. D. et al. Robot-assisted radical cystectomy: Intermediate survival results at a mean followup of 25 months. BJU Int. 105, 1706–1709 (2010).

    Article  Google Scholar 

  50. Stein, J. P. et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J. Clin. Oncol. 19, 666–675 (2001).

    Article  CAS  Google Scholar 

  51. Ghoneim, M. A. et al. Radical cystectomy for carcinoma of the bladder: 2,720 consecutive cases 5 years later. J. Urol. 180, 121–127 (2008).

    Article  Google Scholar 

  52. Hautmann, R. E., Gschwend, J. E., de Petriconi, R. C., Kron, M. & Volkmer, B. G. Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era. J. Urol. 176, 486–492 (2006).

    Article  Google Scholar 

  53. Nepple, K. G., Strope, S. A., Grubb R. L. 3rd & Kibel, A. S. Early oncologic outcomes of robotic vs. open radical cystectomy for urothelial cancer. Urol. Oncol. http://dx.doi.org/10.1016/j.urolonc.2011.06.009.

  54. Shih, C. & Porter, M. Health-related quality of life after cystectomy and urinary diversion for bladder cancer. Adv. Urol. http://dx.doi.org/10.1155/2011/715892.

  55. Porter, M. & Penson, D. Health related quality of life after radical cystectomy and urinary diversion for bladder cancer: a systematic review and critical analysis of the literature. J. Urol. 173, 1318–1322 (2005).

    Article  Google Scholar 

  56. Gerharz, E. W., Månsson, A., Hunt, S., Skinner, E. & Månsson, W. Quality of life after cystectomy and urinary diversion: an evidence based analysis. J. Urol. 174, 1729–1736 (2005).

    Article  Google Scholar 

  57. Yuh, B. et al. Short-term quality-of-life assessed after robot-assisted radical cystectomy: a prospective analysis. BJU Int. 103, 800–804 (2009).

    Article  Google Scholar 

  58. Kulaksizoglu, H., Toktas, G., Kulaksizoglu, I. B., Aglamis, E. & Unlüer, E. When should quality of life be measured after radical cystectomy? Eur. Urol. 42, 350–355 (2002).

    Article  Google Scholar 

  59. Smith, A. et al. Cost analysis of robotic versus open radical cystectomy for bladder cancer. J. Urol. 183, 505–509 (2010).

    Article  Google Scholar 

  60. Martin, A. D., Nunez, R. N. & Castle, E. P. Robot-assisted radical cystectomy versus open radical cystectomy: a complete cost analysis. Urology 77, 621–625 (2011).

    Article  Google Scholar 

  61. Lee, R. et al. The economics of robotic cystectomy: cost comparison of open versus robotic cystectomy. BJU Int. 108, 1886–1892 (2011).

    Article  Google Scholar 

  62. Lee, R., Chughtai, B., Herman, M., Shariat, S. F. & Scherr, D. S. Cost-analysis comparison of robot-assisted laparoscopic radical cystectomy vs. open radical cystectomy. BJU Int. 108, 976–983 (2011).

    Article  Google Scholar 

  63. Haber, G. P., Crouzet, S. & Gill, I. S. Laparoscopic and robotic assisted radical cystectomy for bladder cancer: a critical analysis. Eur. Urol. 54, 54–62 (2008).

    Article  Google Scholar 

  64. Huang, J. et al. Laparoscopic radical cystectomy with orthotopic ileal neobladder for bladder cancer: oncologic results of 171 cases with a median 3-year follow-up. Eur. Urol. 58, 442–449 (2010).

    Article  Google Scholar 

  65. Cathelineau, X., Arroyo, C., Rozet, F., Barret, E. & Vallancien, G. Laparoscopic assisted radical cystectomy: the Montsouris experience after 84 cases. Eur. Urol. 47, 780–784 (2005).

    Article  Google Scholar 

  66. Smith, A. B. et al. Multi-institutional analysis of robotic radical cystectomy for bladder cancer: perioperative outcomes and complications in 227 patients. J. Laparoendosc. Adv. Surg. Tech. 22, 17–21 (2012).

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Urology, Roswell Park Cancer Institute, Elm and Carlton streets, Buffalo, 14263, NY, USA

    Faris Azzouni

Authors
  1. Faris Azzouni
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Azzouni, F. Current status of robot-assisted radical cystectomy for bladder cancer. Nat Rev Urol 9, 573–582 (2012). https://doi.org/10.1038/nrurol.2012.144

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrurol.2012.144

This article is cited by

Search

Advanced search

Quick links

Nature Briefing: Cancer

Sign up for the Nature Briefing: Cancer newsletter — what matters in cancer research, free to your inbox weekly.

Get what matters in cancer research, free to your inbox weekly. Sign up for Nature Briefing: Cancer