MSK Surgeon Alvin C. Goh, MD
Performing minimally invasive robotic cystectomy and bladder reconstruction in one operation provides a viable alternative, while maintaining the oncologic standards of the open approach. Some of the benefits appear to be less blood loss, decreased pain, and potentially less wound complications.
Our aim with the minimally invasive approach to bladder cancer surgery is to improve perioperative outcomes. Full recovery after a radical cystectomy can take several months. With a minimally invasive approach, our goal is to help patients make a quicker recovery. Offering a completely minimally invasive cystectomy and reconstruction complements our comprehensive, multi-disciplinary approach to the management of bladder cancer.
Radical Cystectomy and Bladder Reconstruction
The standard surgical approach for muscle-invasive bladder cancer has been open radical cystectomy, extended lymphadenectomy, and urinary diversion performed through an incision that starts below the navel. This type of operation can be done safely and has a proven cancer control experience. However, as with all major surgical procedure, open radical cystectomy carries a risk for complications and is associated with a several month total recovery time.
Memorial Sloan Kettering Cancer Center (MSK) is one of a few centers in the world that provides robotic cystectomy and completely intracorporeal bladder reconstruction in the same operation. I have helped to pioneer this minimally invasive approach for cystectomy and bladder reconstruction, I have taught surgeons how to perform this operation domestically and abroad, and I have published experience in intracorporeal diversion. (1) (2)
My, as yet unpublished data (manuscript in review) - collected at another center prior to me joining MSK – shows that of 100 patients that underwent robotic cystectomy and intracorporeal urinary diversion without open conversion, half were able to receive a continent urinary reconstruction. Median overall total operating time was seven hours (range four-13). The overall median blood loss was 200 milliliters, median time to return of bowel function was three days, and median length of hospital stay was five days. Almost 40 percent of all patients were able to leave the hospital within four days after their surgery.
Investigators at MSK have also conducted one of the largest randomized controlled trials comparing open cystectomy to robotic cystectomy. (3) In this study, 118 patients were randomized to either robotic cystectomy or open radical cystectomy. All patients received their urinary diversion by an open surgical approach (extracorporeal). We did not detect any difference in overall or high-grade complications rates. There was no difference in surrogates for oncologic outcomes, including positive surgical margin rates, lymph node yields, and lymph node positivity rates. However, it is notable that the robotic cystectomy group had less blood loss, fewer wound complications, and longer operative times. Hospital length of stay for each group was the same.
At centers that offer a minimally invasive approach, like robotic cystectomy and lymphadenectomy, most will perform the reconstruction with an open incision due to less experience, perceived difficulties with intracorporeal bowel reconstruction, and concerns about prolonged operative time compared with open surgery. A completely minimally invasive technique for bladder removal and urinary reconstruction may offer additional benefits, including less bowel manipulation and less wound morbidity.
Minimally Invasive Cystectomy and Bladder Reconstruction
Our transperitoneal approach replicates the important steps established and standardized by open surgery through keyhole incisions. We perform robot-assisted cystectomy and extended lymph node dissection followed by the full range of urinary diversions, both continent and incontinent forms, through these small incisions. (1) (2)
We construct a neobladder from part of the patient’s small intestine and connect it to the urethra, enabling the patient to urinate normally. This method eliminates the need for an external pouch to collect urine. In cases where the urethra must be removed, we can create a reservoir to store urine with a small stoma brought to the abdomen, which can be catheterized. (2)
Robotic technology allows surgeons to perform precise maneuvers, but overall, the urologic surgeon’s experience is the most critical factor for achieving the best patient outcomes. With robotic cystectomy and intracorporeal diversion, we are actively pursuing ways to improve the outcomes for bladder cancer patients that require removal and reconstruction of the bladder.
As the first center to develop a comprehensive robotic surgery simulation training platform, MSK is a leader in robot-assisted surgery. We welcome colleagues to our training center to observe cases and share knowledge.