Robotic Prostate Sparing Radical Cystectomy

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A radical cystectomy in a woman, or a radical cystoprostatectomy in a man, is a major operation which encompasses really several major surgeries performed simultaneously. Such operations routinely may take upwards of eight hours or more, and may carry up to a 20% major complication rate. This operation is considered the mainstay of treatment for muscle invasive bladder cancer (T2) and beyond, but is also offered in the setting of recurrent CIS or T1G3 bladder cancer as well. Contemporary thinking is that giving a chemotherapy regimen consisting of gemcytobine and cis-platin prior to surgery, called neoadjuvant chemotherapy, offers a survival advantage and is usually offered. Some circumstances call for surgery before chemotherapy, in Dr. Engel’s opinion, such as kidney failure due to obstruction, if a muscle invasive tumor is caught very early, or if there will likely be delay in starting chemotherapy before surgery.

A robotic cystectomy or robotic cystoprostatectomy offers similar advantages to what is seen with prostate cancer surgery. The robotic approach allows for a superior nerve-sparing operation which aids in the hopeful recovery of erections in men, and it provides for a much better ability to dissect the urethra and leave a very long stump to sew a neobladder to. Blood loss is far less with the robotic approach. Only the resection portion of the case is performed robotically by Dr. Engel; the urinary diversion, either an ileal conduit, a Studer ileal neobladder in men, or an Indiana pouch in women, is performed through a small incision. Once created, the neobladder is sewn robotically to the urethra, or the prostatic capsule if the prostate is spared as described below.

Sparing The Prostate

Recently it has been shown that, in highly selected patients, it can be considered oncologically appropriate to leave the prostate in place in men. Sparing the prostate allows for near immediate continence even though a neobladder is placed and allows for immediate and complete preservation of erectile function. Unfortunately, only a small subset of men are deemed appropriate for this modality. Such patients would be younger, sexually active men with small or recurrent tumors located away from the bladder neck and prostate. When such patients are encountered, they are encouraged to consider this as a fine option. Sparing the prostate requires the added step of performing a simple prostatectomy, or enucleating the prostatic adenoma, so as to disallow prostatic obstruction to the neobladder.

This video represents an actual Prostate Sparing Robotic Cystectomy
Warning – content is graphic

A robotic cystectomy or cystoprostatectomy will utilize the same laparoscopic port placement as for a robotic prostatectomy, but the ports are shifted slightly higher in the abdomen. The case is comprised of five major operations: removal of the bladder, an extensive lymph node dissection, a bowel resection so as to harvest a long piece of ileum, and then extensive reconstruction of the bowel, bladder and ureters.

Risks of a Prostate Sparing Cystectomy

Possible complications include urine leak, bowel leak, stricturing or scarring at any one of the suture lines, particularly where the ureters are connected to the urinary diversion, lymph collection, bowel dilation called ileus, blood clots, peritonitis and even sepsis. For these reasons, an intensive care unit stay usually lasts 2-3 days, and total hospitalization is between 6-10 days.

Obviously a cystectomy is a serious and major undertaking. A patient undergoing this operation must understand that their surgeon is agreeing to take responsibility for them, and care for them whenever possible. It is a lifetime commitment on the part of patient and surgeon. Patients must always report to the hospital they had their surgery at so that their surgeon can care for them effectively.