open radical cystectomy ( orc ) is currently regarded as the gold standard for the management of muscle - invasive bladder cancer , extensive uncontrollable non - muscle - invasive cancer , and refractory carcinoma in situ ( cis ) .
although recent development and refinement of surgical technique has improved postoperative patients ' quality of life and has reduced complications , orc is still associated with significant morbidity .
laparoscopic radical cystectomy ( lrc ) is one of the minimally invasive options , and some reports have shown that oncological outcomes were equivalent to orc [ 3 - 5 ] .
however , lrc does not yet have widespread use because of the technical difficulty of the procedure and long operation time .
with the recent development of the da vinci robot system , robot - associated laparoscopic surgery has been applied to radical cystectomy .
surgeons have begun to report small series of robot - assisted laparoscopic radical cystectomy ( rlrc ) [ 6 - 8 ] .
these reports have demonstrated the surgical effectiveness of rlrc with advantages in blood loss , return of bowel function , and even hospital discharge . however , a large case of prospective randomized trials has not been reported . in this study
, we present the short - term clinical and oncologic outcomes of our 17 consecutive cases of rlrc with pelvic lymph node dissection and extracorporeal urinary diversion .
between october 2008 and november 2009 , a total of 17 consecutive patients underwent rlrc using the da vinci robot system ( intuitive surgical , sunnyvale , usa ) with four robot arms by a single surgeon .
the patients included 5 women and 12 men with a mean age of 63.7 years ( range , 48 - 74 years ) . according to american society of anesthesiologists ( asa ) risk classification , 10 were asa score i and 7 were asa score ii .
mean body mass index ( bmi ) was 22.6 kg / m ( range , 18.3 - 26.5 kg / m ) ( table 1 ) .
all patients requiring cystectomy were offered the robot - assisted operation if they met the inclusion criteria .
these consisted of patients with radiologically localized disease , no history of previous major lower abdominal pelvic surgery , no previous pelvic radiation , and ability to tolerate a steep trendelenburg position at the anesthetic assessment .
all patients received mechanical bowel preparation ( using an osmotic laxative ) 2 days prior to surgery and a phosphate enema 8 hours prior to surgery .
the 12 mm camera port was inserted in the midline 5 cm above the upper umbilical margin and two 8 mm robotic ports were placed 8 cm away from the umbilicus , along the line from the umbilicus to the anterior spine of the iliac crest ( asic ) bilaterally .
an additional 8 mm robotic port for the fourth arm was placed 8 cm directly lateral from the right - sided robotic port .
a 12 mm assistant port for retraction and stapling was placed 8 cm lateral from the left - side robotic port . a further 5 mm assistant port for suction and irrigation
was placed on the left side between the camera port and the left robotic arm port ( fig .
standard pelvic lymphadenectomies ( both obturator , external iliac ) were performed in all patients .
all patients underwent extracorporeal urinary diversions ( 13 ileal conduits and 4 orthotopic neobladders by studer method ) and 5 - 7 cm lower midline incisions were made for specimen removal and urinary diversion . in case of an ileal conduit , uretero - ileal anastomosis was performed over 6 fr double j stents by using 4 - 0 pds suture , and the distal end of the conduit was fashioned as a stoma at the right robot arm port site .
all orthotopic neobladder was performed by using the studer method and ureteral stents were used and brought out anteriorly through separate stab wounds .
urethro - enteric anastomosis was then performed intracorporeally after redocking the robotic system ( fig .
a jackson - pratt drain was placed in the pelvic cavity and around the uretero - enteric anastomosis site , respectively .
the nasogastric tube was removed 4 days after surgery and oral liquids were started as tolerated .
patients were reviewed at 4 weeks and checked by a renal ultrasound at 2 weeks after stent removal , by computed tomography scans at 3 and 6 months postoperatively , and then at 6-month intervals . at these visits
, they had a clinical examination , assessment of hemoglobin , electrolytes , creatinine , chloride , bicarbonate , and urethral washing cytology .
the mean total operative time was 379.1 minutes ( range , 330 - 460 minutes ) , including 32.6 minutes for pelvic lymph node dissection , 185.2 minutes for rlrc , and 159.4 minutes for urinary diversion .
all patients underwent extracorporeal urinary diversions ( 13 ileal conduits and 4 orthotopic neobladders by the studer method ) , and there were no patients who underwent urethrectomy . the mean operative time for the ileal conduit ( ic ) group was significantly shorter than that for the orthotopic neobladder ( on ) group ( 371.0 minutes vs. 442.5 minutes , p=0.010 ) .
the mean estimated blood loss was 215.3 ml ( range , 120 - 400 ml ) for the ic group and 195.0 ml ( range , 180 - 200 ml ) for the on group ( p=0.871 ) .
the time to oral intake and time to ambulation were 5.0 days ( range , 4 - 8 days ) and 1.3 days ( range , 1 - 3 days ) , respectively .
mean hospital stay was 20.7 days ( range , 11 - 41 days ) , including 18.2 days ( range , 11 - 41 days ) for the ic group and 27.5 days ( range , 17 - 40 days ) for the on group ( p=0.245 ) .
the time to oral intake ( 5.1 vs. 4.5 days ) and time to ambulation ( 1.4 vs. 1.0 day ) were similar between the groups ( p>0.05 ) .
perioperative complications occurred in 4 patients ( 23.5% ) , including 1 ileus , 1 acute renal failure , 1 acute pyelonephritis , and 1 urinary leakage .
there were no significant differences in perioperative outcomes between the male and female groups ( table 3 ) .
the pathologic reports showed urothelial cell carcinomas in all cases , and the pathologic stages were 1 tisn0m0 , 5 t1n0m0 , 1 t1n1m0 , 3 t2n0m0 , 5 t3n0m0 , and 2 t4n0m0 .
the average number of retrieved lymph nodes was 5.9 ( range , 0 - 18 ) .
one patient had lymph node metastasis and 1 of 3 nodes was involved by the tumor .
the mean follow - up period for rlrc was 8.3 months ( range , 3 - 19 months ) , and there was no local recurrence or distant metastasis during the follow - up period .
rlrc is in evolution and is a procedure that can combine the minimally invasive advantages of lrc with the technical advantages of robotics . apart from superior visualization and articulated instrumentation , the improved ergonomic position offered at the robotic console benefits the surgeon during prolonged procedures . in 2003 , menon et al first reported the feasibility of rlrc using the da vinci surgical system .
the operative time ranged from 260 to 308 minutes depending on whether an ileal conduit or orthotopic neobladder was performed .
blood loss was less than 150 ml and surgical margins were clear in all cases .
guru et al reported their experience with rlrc and extracorporeal urinary diversion in 20 patients .
the mean total operative time was 442 minutes , including 133 minutes for urinary diversion .
the mean hospital stay was 10 days and the time to return to strenuous activity was 10 weeks .
rhee et al compared 23 orc with 7 rlrc cases and found that although blood loss was lower for rlrc , 4 of 7 patients needed transfusion .
the operative time was 638 minutes for rlrc compared with 507 minutes for orc and hospital stay was 11 and 13 days , respectively .
pruthi and wallen also compared 20 men undergoing rlrc and extracorporeal urinary diversion with 24 matched men who underwent orc .
the mean operative time for rlrc was 6.1 hours as opposed to 3.8 hours for orc .
mean time to flatus and bowel movement was significantly shorter than in men undergoing orc .
there were six postoperative complications ( 30% ) in five patients , including one rectal injury ( repaired intraoperatively ) , one postoperative hemorrhage requiring laparotomy , and one parastomal hernia requiring repair . in our initial experiences ,
the mean total operative time was 379.1 minutes ( range , 330 - 460 minutes ) , including 32.6 minutes for pelvic lymph node dissection , 185.2 minutes for rlrc , and 159.4 minutes for urinary diversion .
these results were relative longer than that of orc , which was reported in another study .
however , mean estimated blood loss was acceptable ( 210.5 ml ) and diet was usually resumed on postoperative day 4 or 5 .
these results might be due to lower intraoperative bleeding and minimal bowel exposure and manipulation .
although rlrc with complete intracorporeal urinary diversion has been reported , long operating times have prevented widespread adoption of this approach , and most units prefer an extracorporeal approach for urinary diversion .
we also performed extracorporeal urinary diversion in all cases to reduce operative time , but in case of orthotopic neobladder , urethro - ileal anastomosis was performed intracorporeally using a robotic system for the surgeon 's convenience .
the obvious goal of rlrc must be to maintain the oncologic standards of orc while reducing the associated morbidity .
it is not clear whether pneumoperitoneum has an effect on the spread or recurrence of urothelial cell carcinoma in the medium to long term .
it is interesting to note a report of port - site metastasis following rlrc for a pt3bg3 urothelial cell carcinoma of the bladder .
it is hoped that this outcome will be a very rare phenomenon , which it appears to be with other types of laparoscopic surgery .
although several studies have reported encouraging short - term oncologic outcomes of rlrc and our perioperative outcomes of rlrc were comparable to orc , the ultimate oncologic safety of rlrc is not yet clear . to adequately evaluate and validate this procedure ,
a randomized prospective trial is needed to compare orc , lrc , and rlrc in terms of operative , oncological , and functional outcomes .
moreover , the feasibility of performing rlrc can not be separated from the costs of developing new surgical methods in the current economic environment . therefore , the cost / benefit ratio will require continuous review .
although rlrc still has concerns about long operative time and high cost , and long - term follow - up is needed to establish oncologic equivalence with orc , robot - assisted surgery may provide benefits to patients including minimal blood loss , rapid recovery , and smaller surgical wounds .
our initial clinical experience indicates that rlrc is a safe and feasible procedure that may be an alternative to the open technique .
 purposerobot - assisted laparoscopic radical cystectomy ( rlrc ) is a new option for the treatment of muscle - invasive bladder cancer , and case series for rlrc have been increasing recently . 
 we report our operative technique and initial experiences with rlrc with extracorporeal urinary diversion.materials and methodsbetween october 2008 and 
 november 2009 , 17 consecutive patients with muscle - invasive bladder cancer underwent rlrc , pelvic lymph node dissection , and extracorporeal urinary diversion . 
 urinary diversion included 13 ileal conduits and 4 orthotopic neobladders ( studer method ) . 
 data were collected prospectively on patient demographics , intraoperative parameters , pathologic staging , and postoperative outcomes.resultsthe mean patient age was 63.7 years . 
 the mean body mass index was 22.6 kg / m2 . 
 no patients had a history of previous abdominal surgery . 
 the mean operative time was 379.1 minutes , including 32.6 minutes for pelvic lymph node dissection , 185.2 minutes for rlrc , and 159.4 minutes for urinary diversion . 
 the mean estimated blood loss was 210.5 ml . 
 the mean hospital stay was 20.7 days and the mean time to oral intake and ambulation was 5.0 and 1.3 days , respectively . 
 there were no major perioperative complications . 
 the pathologic reports showed urothelial cell carcinomas in all cases.conclusionsour initial clinical experiences indicate that rlrc with pelvic lymph node dissection and extracorporeal urinary diversion is a safe and feasible procedure with minimal blood loss and rapid recovery . 
 long - term follow up in a larger patient population is needed to determine the true oncological and functional benefit of this procedure . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS