Robotic-assisted laparoscopic radical cystectomy: where do we stand?

摘要

In the last decades, laparoscopic surgery has gained large diffusion in the urological community, changing substantially the everyday clinical practice in most institutions. Since the first reports of laparoscopic radical prostatectomy in 1992 by Schuessler et al. (1) and the pioneering works of two French groups (2,3), the laparoscopic approach to radical prostatectomy has gained significant popularity and is, to date, the technique of choice in several European centres, despite the fact that only a single underpowered, randomised, controlled study with a short term follow-up has been published (4). Similarly, laparoscopic radical nephrectomy is an established surgical procedure for those patients with clinically localised renal cell carcinoma unsuitable for partial nephrectomy (5) and laparoscopic dismembered pyeloplasty is considered an excellent treatment for ureteropelvic junction obstruction (6). The diffusion of laparoscopic surgery in the treatment of muscle-invasive or high-grade recurrent non-muscle-invasive transitional cell carcinoma (TCC) of the bladder has been greeted with less enthusiasm. Only a few surgical series have been published, all of them with small number of evaluated patients and only short-term follow-up and laparoscopic radical cystectomy have not reached large diffusion in urological practice. There are several possible explanations for this, such as the usually high comorbidity rates of those patients undergoing radical cystectomy, fear of aggressive tumour behaviour of TCC and the high surgical complexity of a procedure including radical cystectomy, extended pelvic lymph node dissection and urinary diversion. However, the available data suggest that in well-selected patients, laparoscopic radical cystectomy with extracorporeal reconstruction of urinary diversion combines the advantages of minimally-invasive surgery with the safety of open surgery, reducing blood loss and allowing efficient convalescence without any significant increase in complications. Moreover, from the oncological point of view, the available data are encouraging, being comparable with those of the series of open radical cystectomy at the available follow-up durations (7). The reduction in the range of motion (only 4 df), two-dimensional vision (two-dimensional camera and display), impaired eye–hand coordination (misorientation between real and visible movements) and the reduced haptic sense (only minimal tactile feedback) are the main restrictions of pure laparoscopic surgery, which can be considered responsible for the steep learning curve in laparoscopic procedure (8). Robotic systems have been introduced in an attempt to reduce the difficulty in performing complex laparoscopic urological procedures, particularly for non-laparoscopic surgeons. Specifically, the da Vinci robot includes a true three-dimensional imaging system that provides magnification up to ×12. This system also incorporates the patented Endowrist technology, which duplicates the dexterity of the surgeon’s forearm and wrist at the operative site, thus providing 7 df (9). Robotic-assistance is currently used very commonly during radical prostatectomy, and it has been estimated that in the USA, 60% of the radical prostatectomies will be performed robotically in 2008 (10). Moreover, other urological procedures such as dismembered pyeloplasty (11–13), partial nephrectomy (14–18) and sacrocolpopexy (19–21) are performed robotically in many centres. The feasibility of radical cystectomy with a robotic approach was shown by Menon et al. in 2003, when the authors reported on 17 patients who underwent radical cystectomy and extracorporeal reconstruction of urinary diversion. Specifically, the mean operative duration for RARC was 140 min, and mean blood loss was lower than 150 ml. A single case was converted to open cystectomy because of technical problem with the robot’s lens. One patient needed re-exploration for bleeding, but only a port-site haematoma was identi