Tools
Robotic Radical Cystectomy of the Bladder
Introduction
As the utilization of the robotic platform gains momentum in managing various urologic pathologies, its application to bladder surgery continues to evolve. Traditionally, open radical cystectomy with bilateral pelvic node dissection and urinary diversion has been the standard of care for managing muscle-invasive and select high-risk nonmuscle-invasive bladder cancer.[1][2] However, robotic radical cystectomy has emerged as a minimally invasive surgical technique for managing these conditions and reducing surgical morbidity for advanced localized bladder cancer without compromising oncologic outcomes.
Since the first documented case series on robotic cystectomy in 2003, the utilization of this approach has been gradually gaining popularity.[3][4] Despite its technical challenges, long learning curve, and longer operating times, robotic radical cystectomy has been associated with several benefits compared to open radical cystectomy. These include less intraoperative blood loss, reduced need for transfusions, fewer major postoperative complications, a lower rate of positive surgical margins, 40% more lymph nodes recovered on average, and earlier hospital discharge.[5][6][7][8][9][10][11][12] In addition, robotic surgery also offers a reduced risk of wound-related complications and thromboembolic events.[8][13]
Quality of life scores are generally similar between the robotic and open surgical approaches, but when the robotic intracorporeal urinary diversion was added, quality of life scores improved.[7][8] Comparative studies have demonstrated that oncological outcomes are comparable between open and robotic surgical approaches to radical cystectomy over 10 years with regard to recurrence-free, progression-free, and overall survival.[14][15][16][17][18] Given its potential value, long learning curve, high technical complexity, and limitations, the role of minimally invasive major robotic bladder surgery continues to evolve and is the subject of ongoing investigation and study.
Anatomy and Physiology
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Anatomy and Physiology
The primary histological type of bladder cancer is urothelial carcinoma, accounting for approximately 90% of all bladder tumors. Less common types include schistosoma-related squamous cell carcinoma, which makes up about 5% of bladder tumors and is more prevalent in the Middle East and Africa, and adenocarcinoma, which accounts for about 2% of bladder tumors and may develop from the urachus.[19]
Robotic radical cystectomy in males involves the removal of the bladder, distal ureters, prostate, and vas deferens. In females, the procedure classically involves anterior pelvic exenteration, removing the bladder, urethra, uterus, cervix, and anterior vaginal wall, although pelvic organ-sparing cystectomy may be performed in selected patients. When performing bilateral pelvic lymphadenectomy, surgeons should remove, at a minimum, the external and internal iliac nodes as well as the obturator lymph nodes (standard lymphadenectomy).
Indications
Indications for robotic radical cystectomy are similar to those for open cystectomy. These include the absence of metastatic urothelial lesions and the patient's willingness and ability to undergo a major surgical intervention.
Indications for cystectomy surgery include muscle-invasive bladder cancer or non-muscle–invasive cancer with at least 1 of the following criteria:[20][21][22][23][24][25]
- High-risk patients with persistent high-grade T1 disease on repeat transurethral resection or recurrent disease.
- High-risk patients with persistent or recurrent carcinoma in situ within 1 year after 2 cycles of Bacillus Calmette-Guerin (BCG) induction therapy or while on maintenance BCG treatment.
- High-risk patients with persistent or recurrent T1 tumors associated with lymphovascular invasion or variant bladder cancer histology, as well as low glomerular filtration rate (GFR) and larger tumor size (>3 cm) who are not responding to BCG.
- T1 disease associated with carcinoma in situ.
Special considerations arise with the robotic approach, particularly regarding patient positioning, tolerance of pneumoperitoneum, and abdominal access. The combination of the steep Trendelenburg position and pneumoperitoneum used during this procedure can lead to cardiopulmonary consequences, such as decreased lung compliance, reduced functional residual capacity, increased ventilation/perfusion mismatch, and heightened risk of hypercarbia/metabolic acidosis. Previous intrabdominal or pelvic surgery, as well as radiation therapy, may complicate robotic access to the abdomen.[26] Therefore, it is crucial to thoroughly evaluate and discuss these critical preoperative considerations on an individual basis with the entire care team before proceeding with robotic radical cystectomy.
Patients with indications for a radical cystectomy but are unwilling or medically unfit to undergo surgery are best addressed with trimodal therapy. This approach typically involves maximal transurethral bladder tumor resection followed by chemotherapy and external beam radiation treatment.[27][28][29]
Contraindications
Robotic radical cystectomy is a major operative procedure that can carry significant perioperative morbidity and mortality risks.[30] Therefore, patients with localized disease being considered for this surgery must undergo a comprehensive preoperative medical evaluation of their functional status. This evaluation aims to identify any significant or unexpected medical comorbidities, such as bleeding diathesis, poor pulmonary function, or cardiac issues, which could potentially prevent them from undergoing surgery or lead to preventable major complications.
Specific contraindications for robotic radical cystectomy surgery include disease that extends into the pelvis or surrounding structures with bladder fixation, as well as an uncorrected bleeding diathesis.[31]
Morbid obesity, prior abdominal intestinal or vascular surgery, previous radiation therapy to the abdomen, locally advanced disease, and advanced age of older patients may pose technical challenges for robotic cystectomy surgery. However, they are not absolute contraindications, as good outcomes can still be achieved with careful surgical planning and management.[32][33][34][35]
Various contraindications may exist for specific types of urinary diversion, including:
- Patients with short bowel syndrome, inflammatory small bowel disease, and a history of extensive radiation to the ileum should not undergo an ileal conduit diversion.
- Continent cutaneous diversions may have relative contraindications, such as poor renal function and severe hepatic dysfunction, due to the higher risk of metabolic complications associated with these techniques.
- Mental impairment, disability, or extreme frailty are other potential contraindications for continent cutaneous diversions, as they require the ability to self-catheterize postoperatively.[36]
Equipment
The techniques and equipment used can vary. The described technique for robotic radical cystectomy involves the use of 6 ports, as outlined in the "Technique or Treatment" section below.
Standard robotic instruments utilized in this procedure include the permanent cautery hook on the right arm, Maryland bipolar forceps, SynchroSeal, or Vessel Sealer on the left arm, the Tip-Up Fenestrated grasper, and the 60-mm robotic stapler on the fourth arm. Large needle drivers are utilized for suturing during the urinary diversion.
The assistant's primary instruments include a laparoscopic grasper, a long suction-irrigator, and laparoscopic scissors.
Personnel
Performing and caring for a patient undergoing robotic cystectomy of the bladder requires a multidisciplinary team of specialized personnel. This includes a complete surgical team comprising the urologic surgeon, anesthesiologist, circulating nurse, scrub technician, bedside assistant, and other operating room personnel essential for performing this operation.
Postoperatively, the post-anesthesia recovery nurses, intensive care unit nurses, floor nurses, stoma nurses, and case managers play vital roles in aftercare. A dedicated team comprising physical therapists, dietitians, and oncologists also contributes to the patient's rehabilitation and long-term care, ensuring a comprehensive approach to recovery and overall health management.
Preparation
Preparation for this procedure includes administering a high carbohydrate diet to the patient 2 to 3 days before surgery, along with participation in a preoperative education class. Clear liquids are started the day before surgery, followed by nothing-by-mouth starting at midnight. Routine use of laxatives or mechanical bowel preparation before surgery is avoided, as they have not been shown to reduce rates of anastomotic leaks or wound infections.[37]
In the preoperative holding area, the patient receives a single dose of broad-spectrum antimicrobial prophylaxis, deep venous thrombosis prophylaxis, and a μ-opioid receptor antagonist (alvimopan 12 mg) to promote early return of bowel function postoperatively.[38] Alvimopan can be continued postoperatively at 12 mg BID.[39][40]
A stoma therapist will mark the site if the patient is expected to receive an ileal conduit. This practice is often beneficial, even if another type of urinary diversion is planned, due to potential unforeseen developments during surgery.
Technique or Treatment
Radical cystectomy surgery for urothelial cancer should be preceded by neoadjuvant cisplatin-based chemotherapy.[23][41][42] Robotic radical cystectomy, especially when combined with intracorporeal urinary diversion, presents significant challenges and complexities. Yet, it has become the predominant surgical approach for invasive bladder cancer in tertiary care centers.[8] Notably, it is estimated that over 130 procedures are required for surgeons to achieve a stable level of maximum proficiency with minimal 90-day postoperative complication rates.[43] Patients requiring this advanced type of robotic surgery are recommended to be referred to high-volume centers of excellence (performing more than 50 such cases per year) to optimize outcomes and minimize complications.[44][45]
Treatment Procedures for Robotic Radical Cystectomy
Patient positioning and equipment: The patient is initially placed in a supine position on an anti-skid foam pad to prevent sliding and pressure injuries. Female patients requiring vaginal access are positioned in a low lithotomy position. The patient's arms are wrapped in foam padding and tucked at their sides, ensuring padding for the hands and elbows. A chest and leg straps may also be utilized to secure the patient further. A warming blanket and intermittent compression hose are applied for comfort and circulation support.
Once appropriately positioned, it is crucial to test the patient in steep Trendelenburg to confirm stability and minimize movement. A Foley catheter is then inserted and allowed to drain under gravity. Best practice typically involves temporarily reducing the steep Trendelenburg position after about 4 hours to mitigate the risk of positional injuries.
The robot is positioned on the patient's left side, with the primary assistant and surgical technician seated on the right side. While different positioning setups are acceptable, it is preferable for the assistant to sit on the side where bowel work is conducted, opposite the robotic stapler. Alternatively, the robot may be placed and secured between the patient's legs.[46][47][48][49]
Port placement and robotic equipment: A Veress needle is inserted through a periumbilical puncture to insufflate the peritoneum for port placement. Notably, 6 ports are utilized, positioned similarly to a robotic radical prostatectomy but more cephalad.[50] This strategic port placement is crucial for executing the urinary diversion and extended lymph node dissection (see Image. Port Placement for Robotic Radical Cystectomy).
- The robotic arm and camera ports are positioned approximately 5 to 7 cm cephalad from the umbilicus to facilitate bowel work on the ileum. This also permits a cephalad dissection of lymph nodes if necessary.
- An 8-mm supraumbilical camera port is initially placed, and a 30° camera is utilized. Subsequently, the patient is then placed in a steep Trendelenburg position.
- Under direct vision, a 12-mm assistant port is placed 3 fingerbreadths cranial to the right iliac crest in a location anterior to the cecum.
- An 8-mm right robotic instrument port is positioned 1 handbreadth (10-12 cm) lateral to the camera port.
- A 5-mm assistant port is then placed between the camera port and the right robotic instrument port.
- Another 8-mm robotic instrument port is positioned on the left side of the abdomen to replicate the placement of the right robotic instrument port.
- A 12-mm robotic port is placed in the left lower quadrant, approximately 2 fingerbreadths (4 cm) off of the left anterior superior iliac spine.
This positioning is designed to enhance the maneuverability of the fourth robotic arm, facilitating easier placement of the stapler during the creation of the urinary diversion.
Alternative approaches include adding a 15-mm port to facilitate easier manipulation of the GIA stapler by the assistant.[46] This additional port also facilitates the placement of an intracorporeal specimen bag.[46] Another option involves adding a 12-mm suprapubic port after placing the bladder in the specimen bag.[51] This modification enhances access for side-to-side bowel anastomoses and helps prevent torsion.[51]
The pneumoperitoneum is generally set at 10 mm Hg throughout the procedure unless there is limited visualization necessitating adjustment.
Bowel mobilization and ureteral dissection: The procedure begins by releasing the white line of Toldt adjacent to the ascending and descending colon to maximize exposure of the deep pelvis. The sigmoid peritoneal attachments are then released, facilitating the retraction of the large bowel from the pelvis. This mobilization is crucial for exposing the pelvis and accessing and mobilizing the small bowel to create the urinary diversion. Once the retroperitoneum is exposed, the right ureteral dissection is performed (see Image. Right Ureteral Identification, Dissection, and Transection). The right ureter is identified at approximately the level of the right iliac artery bifurcation. The ureter is then circumferentially dissected distally toward the ureterovesical junction.
If an intracorporeal urinary diversion is planned, the ureter should not be dissected deeply close to the bladder, as much of the distal ureter will be discarded. Thus, it is important to utilize an atraumatic technique during ureteral dissection and to preserve a healthy margin of surrounding fat and periureteral vasculature.
Once the distal portion of the right ureter is dissected, the ureter is transected sharply. A section from the distal right ureter is sent for frozen section analysis to rule out malignancy. The distal end of the proximal ureter should be clipped to prevent urine from dripping into the peritoneum and to induce proximal hydronephrosis and mild ureteral distension. This distension will be helpful when creating the ureteral-intestinal anastomoses for urinary diversion (see Image. Clipping and Transection of Urethra).
The left ureteral dissection is performed similarly but must be continued distally to account for its passage under the sigmoid colon. A sample from the distal edge of the left ureter is sent for frozen section analysis to ensure a negative surgical margin.
Posterior dissection: The posterior dissection is performed before entry into the space of Retzius, providing anterior traction for exposure of the posterior plane and dissection of the vascular pedicles.
The bladder is retracted proximally and anteriorly using the fourth robotic arm. A transverse incision is made through the peritoneum at the rectovesical cul-de-sac. The seminal vesicles and vas deferens are identified bilaterally and dissected.
The dissection plane is carried posteriorly between the seminal vesicles and the rectum until Denonvilliers fascia is reached and incised. This allows the posterior dissection to be carried bluntly distally toward the prostatic apex, taking care to avoid injury to the rectum, which lies immediately inferior. To aid exposure, the fourth arm and/or an assistant are used to help retract the seminal vesicles cephalad.
Control of the vascular pedicles: An incision is made in the parietal peritoneum just lateral to the medial umbilical ligament bilaterally to separate the bladder from the pelvic side wall and pelvic vasculature. The vas deferens are clipped and divided.
Blunt dissection is continued caudally toward the endopelvic fascia, exposing the superior vesical pedicle. The superior vesical artery is ligated bilaterally at the origin of the hypogastric artery using clips, a SynchroSeal, or a Vessel Sealer. The exposed endopelvic fascia is then opened to define the lateral plane of the prostatic pedicles (see Image. Release of Endopelvic Fascia).
Dissection between the pelvic side wall and the bladder can be facilitated by medial retraction of the bladder using the fourth robotic arm. This maneuver ensures clearance from the obturator nerve and external iliac vessels and enhances the exposure of the bladder's lateral pedicles.
- Non-nerve–sparing procedures: In non-nerve-sparing procedures, anterior-cranial traction is applied by the assistant or robotic arm. The lateral pedicles of the bladder can then be managed, ligated, and divided using 60-mm laparoscopic vascular staplers, clips, or similar devices (see Image. Control of Bladder Pedicle).
- Nerve-sparing procedures: The neurovascular bundles may be spared similarly to nerve-sparing techniques used during radical prostatectomy in appropriately selected patients. In a nerve-sparing approach, the neurovascular bundles located on the posterior-lateral aspects of the prostate can be released along the surface of the prostate or vagina.
The dissection begins at the seminal vesicles and proceeds toward the prostate. The neurovascular bundles are meticulously separated from the bladder and the posterolateral prostate by gently peeling them off in a superolateral direction. In such cases, it is typically preferable to clip the inferior vesical and prostate pedicles rather than dividing them sharply.
Anterior dissection: Anterior dissection involves retracting the urachus cranially with the fourth robotic arm to facilitate transection of the urachus and medial umbilical ligaments. This maneuver exposes the space of Retzius, allowing the bladder to descend from the anterior abdominal wall. The avascular plane between the anterior abdominal wall and bladder is then carefully extended toward the pubic bone, with blunt dissection in the soft areolar tissue anterior to the prostate and bladder.
The levator ani muscles can be dissected after the endopelvic fascia has been incised. The lateral pelvic fascia is then incised above the level of the neurovascular bundles, allowing them to fall posterolaterally, which is crucial for nerve-sparing procedures.
The fourth robotic arm and assistant provide cephalad traction on the bladder to expose the dorsal venous complex (DVC). The puboprostatic ligaments and DVC are identified and then transected using monopolar cautery or cold scissors. Optionally, the transected DVC complex may be oversewn with a running suture ligature to minimize bleeding.
The prostatic apex and urethra are circumferentially dissected. Once the urethral stump is isolated, the Foley catheter is removed, and a clip is placed proximally on the urethra to prevent spillage. Alternatively, the apical prostate can be oversewn. The urethra is transected proximal to the verumontanum, and the freed specimen is then fully released and placed into an intracorporeal specimen bag. A specimen of the urethral margin from the apical prostatic urethra is sent to pathology for a frozen section.
A urethrectomy should be performed if high-grade malignant tissue is identified by a frozen or permanent section of the surgical margin of the apical prostatic urethra after its surgical removal.[23][52] In women, a urethrectomy should be considered if they are not planning to undergo orthotopic neobladder reconstruction, aiming to reduce the risk of recurrence or inadvertent positive surgical margins.[23]
Bilateral pelvic lymph node dissections (standard and extended): Bilateral pelvic lymph node dissection involves a standard bilateral lymphadenectomy, which includes the removal of the external iliac, obturator, and internal iliac (hypogastric) nodes.[53][54][55] More than 12 nodes should be resected for adequate staging.[23] A larger number of identifiable lymph nodes is also considered a positive indicator of the quality of the surgery.[22][56]
The anatomic boundaries of the standard dissection template typically include the genitofemoral nerves laterally, the internal iliac artery medially, the node of Cloquet inferiorly, and the common iliac artery superiorly. Careful attention is crucial during lymphadenectomy to prevent injury to critical nerves and vasculature.
Optionally, the lymphadenectomy can be expanded to encompass the common iliac and presacral lymph nodes (extended lymph node dissection) using a "split and roll" technique. However, an extended lymph node dissection adds considerable time to an already lengthy procedure, heightens the risk of complications and inadvertent injury to surrounding structures, and increases the likelihood of lymphocele formation. Importantly, large-scale clinical trials have not shown significant survival benefits compared to standard lymph node dissection.[57]
A few important tips for pelvic lymph node dissections include:
- All major lymphatic channels should be clipped to avoid chylous ascites and the development of lymphoceles.
- Nodes should not be cut to avoid the possibility of tumor spillage.
- All lymph nodes collected should be placed in separate packets based on the anatomical region of their dissection.
Pelvic lymph node dissections usually commence at the node of Cloquet on the right side and proceed superiorly up to the aortic bifurcation. Proximal freeing of the right ureter may be necessary to avoid inadvertent injury during this process.
The external iliac vessels can be gently reflected to facilitate the removal of the entire Triangle of Marcille lymph node packet at the origin of the obturator nerve, approached laterally. Lateral retraction of the sigmoid colon provides access to the presacral lymph nodes, enabling their dissection and retrieval.
On the left side, a small opening can be made posterior to the sigmoid colon, which will later facilitate the movement of the left ureter to the right side during the creation of the urinary diversion. The sigmoid is then retracted medially, allowing for a left-sided lymph node dissection performed in a manner similar to the right side.
- Earlier studies suggested that more extensive lymph node dissections, including up to the aortic bifurcation, might lead to lower overall and urothelial cancer-specific mortality rates. However, these findings have been questioned due to methodological issues, variations in surgical techniques, and inconsistent results across studies.[58][59][60][61][62] More recent studies indicate minimal or no significant benefit from extended lymph node dissections in terms of overall survival.[63][64][65][66]
- A recent systematic review and meta-analysis indicated that a moderately extended lymph node dissection may offer optimal benefits by improving recurrence-free survival without the additional time or morbidity associated with superextended dissections (above the aortic bifurcation).[67] However, the review found that overall survival rates were comparable to those achieved with the more limited standard dissection template.[67]
- Many surgeons opt for the extended lymph node dissection template based on studies suggesting improvements in recurrence-free and cancer-specific survival; however, this approach remains optional.[67][68][69] Evidence does not support the use of the superextended dissection, as it does not provide any oncological or survival advantage; hence, it is not recommended.[67][70][71]
- The current guidelines from the American Urological Association (AUA) and European Urological Association (EUA) recommend only a standard bilateral lymph node dissection as the minimal requirement. This recommendation is based on insufficient evidence to justify the routine use of the extended template at this time.[57][72][73]
Female radical cystectomy and anterior exenteration: In female patients, radical cystectomy typically involves a total anterior pelvic exenteration, which includes removal of the bladder, urethra, anterior vagina, uterus, and cervix. After completing ureteral dissection and controlling the vessels, the next step is to proceed with the dissection of the uterus and vagina.
A vaginal vault manipulator, such as a sponge stick, is inserted into the vagina to facilitate anterior traction and expose the posterior vaginal fornix, which is then incised. Subsequently, the infundibulopelvic ligaments and uterine vessels are transected and ligated using GIA staplers. The pouch of Douglas is also incised during this step.
Dissection of the bladder and transection of the pedicles, urachus, and DVC are performed as previously described, allowing the bladder to fall posteriorly. The dissection plane of the posterior vaginal canal is then extended anteriorly toward the urethra. The presence of the Foley catheter facilitates anatomical identification. The urethra is transected as described previously. This facilitates the removal of the specimen, which includes a small strip of the anterior vaginal wall along with the bladder, adnexa, and uterus.
Using a sponge stick, the uterus is directed posteriorly, while the fourth robotic arm provides anterior traction to the bladder. Posterior dissection of the bladder proceeds toward the vaginal canal. Laterally to the cervix, the ureter is identified, running posteriorly to the cardinal ligament, which houses the uterine artery. The ureter is dissected free, preserving the uterine pedicle. A urethrectomy can now be performed if an orthotopic urinary diversion is not planned.
An ongoing discussion regarding the potential role of organ-sparing and sexual function-sparing cystectomy exists in select patients, which emphasizes the preservation of reproductive organs, including the vagina, uterus, fallopian tubes, and ovaries. To optimize postoperative sexual and urinary function while maintaining oncologic control, organ-sparing radical cystectomy may be considered in female patients who are young, sexually active with early, unifocal, organ-confined disease, and in whom an orthotopic neobladder may be planned.[74][75] Women with a family history of breast or ovarian cancer should undergo bilateral salpingo-oophorectomy.
Patients with evidence of malignancy at the bladder neck and posterior bladder are generally considered poor candidates for vaginal sparing cystectomy due to concern for positive margins. In most cases, the entire specimen can be extracted through the vaginal canal, thereby forgoing a large extraction site incision on the abdomen. A sponge is used to pack the vaginal canal to preserve the pneumoperitoneum until the vaginal canal is closed using a 2-0 suture.
Urinary diversion: Urinary diversion options, based on preoperative patient characteristics, may now include intracorporeal techniques. These techniques commonly involve intracorporeal ileal conduit, orthotopic neobladder, or continent cutaneous diversion.[8][76][77]
Robotic radical cystectomy with bilateral lymph node dissection and intracorporeal urinary diversion has become the preferred approach for bladder cancer patients in high-volume tertiary care centers.[8][43][77] The technique of robotic radical cystectomy and orthotopic intracorporeal ileal neobladder is well described by Abreu, Simone, Truong, and others.[74][78][79][80][81][82][83][84]
The AUA maintains a series of instructional videos on robotic radical cystectomy and intracorporeal urinary diversions, accessible to members via their website. Additional educational resources on robotic radical cystectomy and intracorporeal urinary diversion can be found on YouTube, featuring videos by experts such as Steven Chang from Brigham and Women's Hospital, Raj Pruthi MD from the University of California, San Francisco (UCSF), Mark Tyson from the Mayo Clinic, Joan Palau, Richard Gaston from the European Congress on Robotics, among others.
Complications
Robotic radical cystectomy is a complex procedure involving both the genitourinary and gastrointestinal tracts, which may lead to frequent morbidity and high complication rates. The most common complications include gastrointestinal (up to 20%), infectious (up to 17%), and genitourinary complications (up to 10%), such as urinary tract infections, wound infections, ileus formation, and anemia requiring transfusion.[85] Despite an overall high 30-day complication rate (up to 48%), most complications are low-grade. Furthermore, the complication rate is similar to the corresponding open surgical technique.[85][86][87] Efforts have been focused on perioperative care to reduce the risk of complications following surgery.
Multimodal, interdisciplinary Enhanced Recovery After Surgery (ERAS) protocols have been established to shorten hospital stays, accelerate recovery of bowel function, and decrease overall morbidity following robotic cystectomy.[88][89][90][90][91][92][93] These protocols typically emphasize early ambulation, goal-directed fluid management, multimodal postoperative analgesia, and early enteral feeding.[94][95][88]
Clinical Significance
The surgical management of muscle-invasive bladder cancer has seen increasing adoption of robotic cystectomy. This approach offers comparable oncologic outcomes and quality of life scores to the open approach, albeit with longer operating times and higher costs. However, robotic cystectomy also demonstrates advantages such as reduced operative blood loss, lower transfusion rates, decreased incidence of positive margins, fewer major complications, increased lymph node yields, and shorter length of hospital stays.[46] As robotic training advances and expands, robotic radical cystectomy is expected to become more commonplace in the urological and surgical armamentarium.
Enhancing Healthcare Team Outcomes
Providing patient-centered care for individuals undergoing robotic cystectomy requires a collaborative approach among healthcare professionals. Bladder cancer can be a life-altering diagnosis for patients, which requires high-quality, integrated, multidisciplinary care throughout the perioperative period.
Before undergoing robotic cystectomy, patients will need comprehensive multidisciplinary education and counseling. This includes information about the benefits and risks of surgery and anesthesia, preoperative nutrition, future self-care for a stoma (if applicable), and expectations for recovery.
During the intraoperative phase, each member of the surgical team must fulfill their designated roles to ensure an efficient and safe procedure. Postoperatively, efforts are directed at reducing the risk of complications and optimizing the restoration of normal physiological functions. This involves a coordinated effort involving the entire interprofessional healthcare team, including, but not limited to, bedside nurses, physical therapists, occupational therapists, stoma nurses, dieticians, pharmacists, and physicians. Ultimately, each member of the healthcare team plays a crucial role in ensuring a safe and enhanced recovery for patients undergoing robotic cystectomy.
Nursing, Allied Health, and Interprofessional Team Interventions
Postoperative interprofessional care is essential for a successful outcome after robotic radical cystectomy. Regarding nursing care, key focuses in the immediate postoperative period include postoperative analgesia, early ambulation, and an emphasis on the return of bowel function.[96][97]
Healthcare professionals should regularly assess patients' pain levels and treat them using a multimodal approach. Early ambulation should be encouraged to reduce the risk of cardiovascular and pulmonary complications. Frequent assessments of gastrointestinal function should be made to determine the appropriate timing for enteral feeding. Interdisciplinary ERAS protocols should be implemented. Postoperatively, patients often have many externalized tubes (such as drains, ureteral stents, urostomy, and catheters), which require strict monitoring to assess fluid balance and ensure optimal recovery.
Stoma nurses play a pivotal role in the comprehensive aftercare of patients following conduit diversion. They may offer personalized guidance on stoma care techniques, including proper cleaning, appliance fitting, and troubleshooting potential problems.[96] Before discharge from the hospital, the interprofessional healthcare team should educate patients and their family members on dietary adjustments, physical activities, and lifestyle modifications essential for optimal recovery.
Media
(Click Image to Enlarge)
Port Placement for Robotic Radical Cystectomy
Contributed by M Lee, MD
(Click Image to Enlarge)
Right Ureteral Identification, Dissection, and Transection
Contributed by M Lee, MD
(Click Image to Enlarge)
Control of Bladder Pedicle
Contributed by M Lee, MD
(Click Image to Enlarge)
Release of Endopelvic Fascia
Contributed by M Lee, MD
(Click Image to Enlarge)
Clipping and Transection of Urethra
Contributed by M Lee, MD
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