Robot-assisted radical cystectomy
When is this procedure indicated?
Robotic radical cystectomy is the standard treatment of infiltrating bladder cancer or recurrent superficial cancer at high risk for progression.
How is it performed?
Robotic radical cystectomy (RARC) surgery is performed in the operating room under general anesthesia.
Minimally invasive robotic approach has revolutionized bladder cancer surgery. 6 holes are drilled at abdominal level, through which the surgical instruments are inserted, connected to the four arms of the robot operated remotely by the surgeon. In men, bladder, prostate, seminal vesicles, vas deferens and obturator and iliac lymph nodes are removed. In women, bladder, uterus, adnexa, anterior wall of the vagina and regional lymph nodes are removed.
The removal of the bladder makes it necessary to draw out urine, since their physiological elimination is no longer possible. The choice of type of urinary shunt depends on numerous clinical variables, disease, physical conformation of the patient, and intraoperative findings. The main shunts used at our center are:
- Orthotopic neobladder: the bladder is replaced by a reservoir made from an approximately 40-60 cm segment of ileal intestine or colon-sigma, properly configured to look like a spherical container, which is placed in the pelvic cavity and anastomosed to the urethra. With this shunt, the patient does not have to use any external prostheses.
- Uretero-ileo-cutaneostomy (Bricker): A 15-20 cm segment of intestine is used, which is connected on one side to the ureters and on the other side to the abdominal skin. Urine is collected in a bag applied at the skin ostomy.
- Uretero-cutaneostomy (UCS): the ureters will be connected directly to the outside through the skin. In this case, you will also need the outer bag.
The proven advantages of the robotic technique over the classic open approach are: reduced post-operative pain, three-dimensional vision of the operated area, reduced need for transfusions, greater surgical precision, less surgical time, less blood loss, faster post-operative recovery, better aesthetic performance.
In case of ureteroileocutaneostomy or ureterocutaneostomy, the presence of the pouch on the skin makes it necessary to modify one's life habits: the patient and the relatives will have to be instructed in the emptying and periodical substitution of the pouches, so initially the assistance of a specialized stomatal nurse will be fundamental.
In case of neovesis, the urinary urge is no longer felt and the patient usually reports feeling full or vague suprapubic pain. The patient will urinate through the urethra after releasing perineal plane muscles and increasing abdominal pressure (sitting position with trunk flexed forward and hand compression of lower abdomen). Occasionally, incomplete reservoir emptying (such that periodic catheterizations are required to empty the neobladder) and/or partial daytime or nighttime urinary incontinence may occur. In addition, the patient will be referred for pelvic floor rehabilitation treatment in order to accelerate the recovery of urinary continence post-operatively.
In addition, during follow-up, it will be necessary to monitor the acid-base balance and supplement the patient's diet with bicarbonate tablets to counteract the acidosis that is associated with reabsorption of the section of bowel used for the neobladder.
In this type of surgery, complications are very frequent, up to 70% of patients can incur them. The most common complication is postoperative fever, in 50% of cases, which is treated with intravenous antibiotic therapy, followed by delayed intestinal canalization that may require enemas and prokinetics to restart. Slight urinary bleeding, irritation of the skin around the ostomy may also occur.
After several weeks, hernias may form at the surgical incision site of the abdominal wall (laparocele) or at the level of the ostomy (stomal hernia). A stenosis of the anastomosis between the ureter and bowel can also be created, which can result in renal failure. In this case, it may be necessary to place a percutaneous nephrostomy in order to place a ureteral catheter to safeguard renal function. In the long term, it should be remembered that several metabolic imbalances of different nature may occur. The literature notes vitamin deficits, metabolic acidosis and, in some cases, worsening of renal function and, in some cases, occurrence of renal failure.