Why a robot took my bladder

Abstract

Honore et al. are to be congratulated for presenting such a large series of robotic cystectomy and urinary diversion procedures with excellent outcomes. In 2016, Yaxley et al. previously published the only trial randomizing robotic prostatectomy against open prostatectomy in Lancet. Interestingly, in that study, it was difficult to define what the true measurable outcome differences were. In this paper, we have a single surgeon series of 100 cases where one of the most challenging open surgeries in urology radical cysto-prostatectomy and urinary diversion was performed using the robotic approach. In the majority of cases, the urinary diversion was undertaken intracorporeally. Again, the authors have demonstrated non-inferiority of the robotic approach to open surgery, in a series which included a robotic learning curve for the procedure when they commenced doing this procedure in 2012. Historically, open radical cystectomy has a 25–30% major complication rate reported in many series. Bladder cancer is predominantly a male disease, and patients who develop this cancer often are elderly and have severe comorbidities, in particular cardiovascular disease and lung disease associated with smoking. It is also associated with a 1–3% mortality, which has remained stubbornly fixed over time. In our experience of robotic radical cystectomy and intracorporeal diversion at The Royal Melbourne Hospital in a smaller series, our outcomes were similar to the Brisbane report. Long operative times in the learning curve and anastomotic ureteroileo-stricture remain problematic in the early phase. We decided not to perform any extracorporeal component of the surgery as it seems pointless to turn a minimally invasive procedure into an open surgery, losing the potential benefit of the keyhole approach. An obvious insight gained from this paper is that this operation needs to be performed by very experienced surgeons working with the team in a centre where there is a high volume of cystectomy and urinary diversion in order to optimize satisfactory outcomes. In the UK, the National Health Service some time ago mandated that cystectomy and diversion for bladder cancer could only be performed in high-volume centres. There is ample evidence in the literature that complication rates are lowered when this complex surgery is performed in centres where there are dedicated teams of surgeons undertaking this procedure. In Queensland, from 2002 to 2016, there were 1230 radical cystectomy operations performed, average 80/year. It seems timely, stimulated by this excellent and provocative paper, to have a discussion around centralization of cystectomy surgery, be it open or robotic. Intuitively, it seems inevitable that all major urological surgeries will be performed robotically. This will include nephrectomy, partial nephrectomy, cysto-prostatectomy and urinary diversion, radical prostatectomy and retroperitoneal lymph node dissection. It is also clear, as promoted in this article, that the Enhanced Recovery After Surgery programme does indeed improve post-operative recovery and shortens length of stay. It is also noteworthy that 36% of this cancer cohort were able to be safely given neoadjuvant chemotherapy without compromising outcomes by increasing post-operative complications. It is now feasible to use neoadjuvant chemotherapy prior to cystectomy for bladder cancer to improve cancer-specific survival in a disease which has remained stubbornly resistant to improved cancer-specific survival over the past 40 years. Radical cystectomy only became surgically widespread as a safe operation in the 1980s. The finding of equivalent outcomes to open radical cystectomy using a robotic approach is heartening.My view is that all cystectomies will be performed robotically in major centres by dedicated teams of highly skilled robotic surgeons, working in tandem, one team performing the cystectomy and the other performing the diversion. In 2020, there will be a much wider distribution of the new robotic surgical technology into the teaching hospitals where our surgical trainees learn their craft. The Cambridge Medical Robotic Systems and Medtronic Robotic Surgical Systems will enter the market in 2020 in Australia. The presence of these new and less expensive technologies will mean our Australian public health system will be able to afford to install these machines. It will then be possible to train Australian Surgical Education and Training surgical students in foundational robotics and craft-based procedures such as radical cystectomy. The next few years will herald a dramatic change in provision of surgical training in a teaching hospital using these modern technologies.