Ask The Doctor

Winter 2010

Dr. Mark Gonzalgo, Associate Professor of Urology and Director of Robotic-Assisted Urologic Cancer Surgery at Stanford University, shares his expertise regarding robotic cystectomy.

“I understand that a robotic cystectomy procedure is now available.  What are the advantages/ disadvantages of this procedure vs. open cystectomy?  Is robotic cystectomy the preferred option for all patients undergoing bladder removal?”

Standard surgical treatment for aggressive bladder cancer is radical cystectomy with an extensive lymph node dissection (removal of nearby lymph nodes).  Traditionally, the surgery is performed through an incision in the abdomen just below the umbilicus (belly button). Hospitalization is generally between 5 and 10 days, and up to 6 weeks are needed for complete recovery. Over the past few years, both laparoscopic and robotic-assisted radical cystectomy have been developed for treatment of bladder cancer. These types of procedures are now being routinely performed at highly specialized centers. The principles of surgery remain the same, but the procedure is performed through smaller incisions using laparoscopic instruments. The use of minimally-invasive laparoscopic techniques in surgery is associated with faster recovery times, less pain, and less blood loss. Robotic-assisted laparoscopic surgery allows surgeons to perform certain techniques with less difficulty associated with traditional laparoscopic surgery.  Robotic surgery has already revolutionized the treatment of prostate cancer and has surpassed the open procedure in terms of the number of radical prostatectomies performed annually in the United States. Robotic cystectomy represents one of the newest areas of clinical application for minimally-invasive surgical techniques in the field of urology.

Over the past few years, there have been an increasing number of centers that have adopted minimally-invasive approaches for radical cystectomy. However, the long-term effectiveness of this procedure is unknown.  Currently, there are a few small, single-institution studies indicating that robotic cystectomy provides effective cancer control with decreased blood loss, transfusion rates, and length of hospital stay. Overall complication rates with robotic cystectomy have been reported to be similar to the traditional open procedure. There has been at least one randomized trial directly comparing robotic cystectomy to open radical cystectomy. One potential disadvantage of minimally-invasive techniques for treatment of bladder cancer is related to the extent of the lymph node dissection.   Although there is still some controversy among urologists as to exactly how extensive of a pelvic lymph node dissection should be performed, there is no debate that one should be performed during radical cystectomy. In a recent study, however, robotic cystectomy was found not to be inferior to open cystectomy when comparing the number of lymph nodes removed during surgery. More studies and long term follow up are needed in order to better understand the role of laparoscopic and robotic-assisted techniques in bladder cancer surgery

Robotic surgery is not necessarily the preferred option for all patients undergoing bladder removal, but this procedure gives patients another surgical option that was previously not available.  Regardless of whether a surgeon is using the robot or performing an open surgery, the goal remains the same: to achieve cancer cure with the lowest impact on a patient’s quality of life. In general, most patients who are considering traditional open cystectomy for bladder cancer will also be suitable candidates for robotic cystectomy. The decision to choose robotic cystectomy for treatment of bladder cancer is a personal choice and should be made with the help of a urologic oncologist with expertise in both open and minimally-invasive surgical techniques.

Response kindly provided by Dr. Mark Gonzalgo.