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.

OBJECTIVE

• To report the outcomes of 27 patients whom we performed robot-assisted radical cystoprostatectomy and cystectomy (RARC) with intracorporeal urinary diversion (Studer pouch and ileal conduit) for bladder cancer.

PATIENTS AND METHODS

• Between December 2009 and December 2010, we performed RARC in 25 men (intrafascial bilateral [22], unilateral [one], non-neurovascular bundle [NVB] sparing [two]), NVB-sparing RARC with anterior pelvic exenteration in two women, bilateral extended robot-assisted pelvic lymph node dissection (RAPLND) (25), intracorporeal Studer pouch (23), ileal conduit (two), and extracorporeal Studer pouch (two) construction. • Patient demographics, operative and postoperative variables, pathological variables, complications (according to modified Clavien system) and functional outcomes were evaluated.

RESULTS

• The mean (sd, range) operative duration, intraoperative estimated blood loss and mean lymph node (LN) yield were 9.9 (1.4, 7.1-12.4) h, 429 (257, 100-1200) mL and 24.8 (9.2, 8-46), respectively. • The mean (sd, range) hospital stay was 10.5 (6.8, 7-36) days, there was one perioperative death (3.7%), lodge drains were removed at a mean of 11.3 (5.6, 9-35) days and surgical margins were negative in all but one patient who had pT4b disease. • The postoperative pathological stages were: pT0 (five), pTis (one), pT1 (one), pT2a (five), pT2b (three), pT3a (six), pT3b (two), pT4a (three) and pT4b (one). • Positive LNs and incidental prostate cancer were detected in six and nine patients, respectively and at a mean follow-up of 6.3 (2.9, 1.8-11.3) months, three patients died from metastatic disease and one from cardiac disease. • According to the modified Clavien system, there were nine minor (Grade 1 and 2) and four major (Grade 3-5) complications in the perioperative (0-30 days) period; four minor and three major complications in the postoperative (31-90 days) period. Of the available 18 patients, 11 were fully continent, four had mild and two had severe day-time incontinence.

CONCLUSIONS

• Bilateral NVB-sparing RARC with RAPLND and intracorporeal Studer pouch or ileal conduit reconstruction are complex procedures with acceptable morbidity, excellent short-term surgical and pathological outcomes and satisfactory functional results. • Studies with more patients and longer follow-ups are required to evaluate the feasibility of these RA totally intracorporeal complex procedures.