Radical cystectomy for bladder cancer: Tools vs. technique
Basic principles of cystectomy remain the same regardless of surgical approach used
Invasive bladder cancer is one of the most lethal malignancies we treat in urology. Although some debate the significance of a delay in treatment or positive surgical margins in the treatment of prostate cancer or small renal masses, few would debate these factors’ significance in bladder cancer. Studies have demonstrated that the timing of treatment, positive surgical margins, and number of lymph nodes removed all impact recurrence and/or survival in individuals with bladder cancer.
It’s also clear is that basic principles hold true for the technique of cystectomy regardless of the approach used. Although retrospective data have suggested that the robotic approach may offer improved convalescence, a recent randomized study found no difference in morbidity or pathologic outcomes, ie, positive surgical margins and lymph node yield (Eur Urol 2015; 67:1042-50). Therefore, the purpose of this article is to discuss important principles of radical cystectomy, whether performed using the open, laparoscopic, or robotic approach.
Staging and surgical planning
Since no two cystectomies are the same, it is important to adequately plan for surgery. One must review the patients’ prior operative reports in order to know tumor location, size, and bimanual exam findings. Review of the CT scan allows for the identification of borderline enlarged lymph nodes, presence of hydronephrosis, or suspected involvement of adjacent tissues/organs. If there is a question of extravesical disease, an MRI can provide information on the integrity of surrounding soft tissue. This information will allow the surgeon to determine how wide a dissection should be performed and whether the participation of other specialty surgeons may be required.
After access to the abdomen is obtained, either in an open or robotic fashion, setting up adequate exposure is critical to optimize surgical efficiency and minimize the risk of injury to adjacent structures. Sigmoid colon and small bowel adhesions to the bladder and pelvic sidewalls need to be dissected sharply and the bowel needs to packed into the upper abdomen and away from the operative field. This is achieved with either a self-retaining retractor in the case of open surgery or gravity (steep Trendelenburg position) in the case of robotic surgery.