Keywords: Robotic Cystectomy; Orthotropic Neobladder; Learning Curve.
There have been a number of articles recently on intracorporeal neobladder formation post robotic radical cystectomy. This clearly highlights a number of issues in the robotic urology world.
A complete minimally invasive approach shows consistent advantages compared with open radical cystectomy, such as blood loss and length of stay . The lower complications rates, and shorter length of stay all contribute to better functional outcomes and oncological outcomes. This procedure can be long in length, with impact on haemodynamic status due to Trendelenburg position. As a result, appropriate patient selection remains paramount.
Prior open experience in these cases is often invaluable. However, with today’s training programmes, it is harder and harder to get open surgical experience for the urology trainee. The development of a robotic surgical curriculum must take this into account. Previously, it has been shown to be a safe procedure, even for trainees on the learning curve . What is also known, is the fact that greater volumes are required to expedite the learning curve. It is also important to highlight, this procedure although robotic, is complicated. As part of standard training, not all urologists will be trained to do these procedures, with many undertaking fellowships. Central to making training standardised across the world, is the robotic surgery curriculum, developed by Guys and St Thomas Hospitals .
An experienced team, both surgeon, trainee and assistant are required to work in harmony together . This is what makes the difference giving shorter lengths of stay, lower complication rates and better outcomes. Additionally, it is better to be an experienced robotic prostatectomist, prior to conducting robotic cystectomies and neobladder.
The RAZOR trial, is a landmark study looking at open vs. robotic cystectomy as part of a multi-institutional none-inferiority study, oncological outcomes, surgical complications and health related quality of life measures will be reviewed as part of this . However other studies [5,6] concluded oncologic and functional data from robotic cystectomies are comparable to laparoscopic procedures.
The only limiting factor for this procedure becoming widespread is cost, as so much of healthcare is cost driven. Open or laparoscopic cystectomies are cheaper, yet, many hospitals may not have access to a Davinci platform. In these cases a laparoscopic approach with extracorporeal diversion or a standard open cystectomy remains a valid approach. At the end of the day, care should be patient centred, not cost centred.