Robotic Cystectomy Versus Open Cystectomy: Are We There Yet?

Introduction: Open radical cystectomy (ORC) with extended pelvic lymph node dissection (PLND) represents the treatment of choice for muscle-invasive and/or high-risk non-muscle-invasive bladder cancer (BCa), especially when it does not respond to bacillus Calmette-Guérin. However, robotic cystectomy is steadily increasing as a minimally invasive option for the management of BCa. Some studies have shown the advantages of the robotic surgery over the laparoscopic approach, including a shortened learning curve, better precision, and comfort for the surgeon. Furthermore, short-term oncologic results as well as functional results appeared to be similar to those of ORC and laparoscopic radical cystectomy. Surgical technique: The patient is placed in a Trendelenburg position and the trocars placed similarly as for prostate cancer surgery. Then, an anatomic dissection of the ureter and paravesical space allows easy section with the use of LigaSure (Covidien, Boulder, CO, USA) on all the pedicles. When the seminal vesical is reached, the section of the pedicles and the plane (interfascial or extrafascial) are developed according to a nerve-sparing or non-nerve-sparing technique. After the cystectomy, we proceed to PLND. The urinary diversion (UD) is performed extracorporeally. Results: Recent reports have demonstrated surgical and perioperative results similar to or even better than the open experience. From the oncologic point of view, there is still short follow-up in robot-assisted cystectomy, but the results about margins and the number of nodes are similar to open series. The UD is done extracorporeally to improve operative time. Preservation of the neurovascular bundle during radical cystectomy (RC) has been explored by some authors in order to maximise recovery for sexual function, and the results are promising. Postoperative complications in recent published series are globally decreased in comparison to open surgery. Further studies are warranted to validate these initial results. Conclusions: Robot-assisted laparoscopic radical cystectomy with extracorporeal UD reconstruction is slowly entering the realm of the urologist because it appears to incorporate the advantages of minimally invasive surgery with the safety of the open approach. Nevertheless, future data about long-term oncologic and functional results will have to prove the real position of robot-assisted cystectomy in the management of BCa. © 2010 European Association of Urology.