What is Robotic Radical Cystectomy? In Which Cases is it Applied? What are its Advantages?

In the treatment of advanced bladder cancer, cystectomy is an important surgical method, and today, robotic technology has made this surgery much more effective. Robotic radical cystectomy is a major surgery that involves the removal of the bladder, prostate, and some surrounding lymph nodes.

The robotic cystectomy surgery offers many advantages over traditional open surgery. For example, it provides smaller incisions, less postoperative pain, and less blood loss. Additionally, in this modern surgical method, the surgeon controls special surgical arms placed inside the body through several small incisions from a console. As a result, robotic radical cystectomy offers a faster recovery process, and patients can often get back on their feet within a few days.

What is Robotic Radical Cystectomy?

Robotic radical cystectomy is a procedure used in the treatment of bladder cancer that involves the robotic removal of the entire bladder. In this modern surgical method, the surgeon performs the operation by controlling the robotic arms through a console.

What is Radical Cystectomy and When is it Applied?

Radical cystectomy is the surgical removal of the entire bladder and surrounding lymph nodes. In men, the prostate and seminal vesicles may also be removed, while in women, the uterus, ovaries, and part of the vagina may be taken out. This surgery is particularly applied when bladder cancer has progressed to the muscle layer but has not spread to other parts of the body.

Bladder cancer that has spread to the muscle layer is a rapidly progressing and life-threatening disease if left untreated. The most effective treatment method at this stage is cystectomy. Although rare, this surgery may also be preferred in cases of chronic bladder disorders that do not respond to treatment or severe bladder trauma.

Differences Between Robotic Surgery and Traditional Surgery

While traditional open cystectomy is performed by making a large incision in the abdominal area, robotic radical cystectomy is performed through robotic instruments placed via small incisions. There are significant differences between these two methods:

• Image quality: The robotic system provides the surgeon with 3D, high-resolution, and magnified images.
• Precision: Robotic arms can perform more precise movements than human hands and filter out vibrations.
• Blood loss: Less blood loss occurs due to more precise dissection in robotic surgery.
• Recovery time: Patients recover faster after robotic cystectomy and their hospital stays are shorter.
• Pain level: Postoperative pain is less due to smaller incisions.

However, the robotic surgical technique is a complex procedure that requires the surgeon’s experience, and the duration may be longer compared to open surgery.

Difference Between Partial and Radical Cystectomy

Radical cystectomy (total cystectomy) is the complete removal of the bladder. This method is the most commonly used technique in the treatment of bladder cancer and aims to completely eliminate the cancer.

Partial cystectomy (segmental cystectomy) involves the removal of only the cancerous part of the bladder. This procedure may be preferred when the tumor is small and limited to a specific area of the bladder. Unfortunately, this approach is only possible in a small number of patients because tumors are usually large or numerous, making it difficult to reconstruct the bladder.

After total cystectomy, a urinary diversion procedure must be performed to allow urine to exit the body. In this procedure, a new bladder (neobladder) is typically created from the intestine, or a pouch (ileal conduit) is prepared using the intestine to allow urine to flow outside the body.

How is Robotic Cystectomy Performed?

Robotic cystectomy is a complex procedure performed with the precise surgical capabilities offered by modern technology. In this surgery, robotic systems such as Da Vinci are used to meticulously remove the bladder and surrounding tissues.

General Anesthesia and Incision Process

Robotic cystectomy is performed under general anesthesia. This way, you will not feel pain during the surgery. While a large incision is made from above the navel to the root of the penis in traditional open surgery, only 4-6 small incisions are made in robotic cystectomy. Each of these small incisions is about 1 cm long.

One of the incisions is used for the camera, while the others are used for placing surgical instruments. Then, carbon dioxide gas is introduced into the abdomen to expand the surgical area, and the robotic arms are placed.

Removal of the Bladder and Surrounding Tissues

At this stage of the surgery, the surgeon uses the robotic system to clean the area between the bladder and the colon. The robotic arms can perform precise actions inside the body by following the surgeon’s movements at the console.

In male patients, the prostate and seminal vesicles may also be removed, while in female patients, the uterus, ovaries, and part of the vagina may be taken out. If a nerve-sparing surgery is to be performed, the nerves responsible for sexual function are carefully preserved at this stage.

After the blood vessels of the bladder are tied off, the bladder and other tissues to be removed are placed in a bag. Additionally, lymph nodes are cleaned to assess the risk of cancer spread.

Urinary Diversion Methods

After the bladder is removed, a decision must be made on how to expel urine from the body. This is called “urinary diversion,” and there are three main methods:

• ileal conduit (Ileal Loop): A piece taken from the small intestine is used to allow urine to flow out through an opening in the abdominal wall (stoma).
• Neobladder (New Bladder): A 45-60 cm piece taken from the small intestine is shaped to create a new bladder and connected to the urinary canal.
• Continent Diversion: A reservoir is made from the intestine, allowing the patient to control urination and empty it using a catheter at certain intervals.

Differences Between Ileal Conduit, Neobladder, and Continent Diversion

Ileal conduit is a simpler and faster method. Therefore, it is preferred in older patients and those with comorbidities. However, the patient must have a permanent stoma on the abdominal wall and use a bag to collect urine.

Neobladder is a method that preserves body image and allows for natural urination. In men, the daytime and nighttime continence rates are between 87-100% and 70-95%, respectively. In women, these rates may be lower.

Continent diversion allows for controlled urination without the need for an external stoma, but the patient must perform regular catheterization.

Surgery Duration and Technical Details

Robotic cystectomy surgery typically lasts 5-7 hours. If a neobladder is to be created, this time may extend to 8 hours. The duration of the surgery may vary depending on the stage of cancer, the patient’s overall health, and the surgeon’s experience.

At the end of the surgery, the robotic arms are removed, and the incisions are closed with stitches. After the surgery, there are drains in the abdomen and a catheter in the urinary tract. The drains are usually removed within a few days, but if a new bladder has been created, the catheter may remain for 2-3 weeks.

What are the Advantages of Robotic Cystectomy?

Robotic surgical technology offers significant advantages over traditional methods in the treatment of bladder cancer. With technological advancements, radical cystectomy surgery has become more precise and patient-friendly. Here are the main benefits of robotic radical cystectomy.

Minimal Invasiveness and Less Pain

Robotic radical cystectomy is performed through only a few small incisions in the abdomen, unlike traditional open surgery. These small incisions significantly reduce postoperative pain and speed up the recovery process. Since the small incisions in the robotic system cause less damage to muscle and nerve tissues, the discomfort experienced by patients after surgery is minimal. Additionally, the small incisions in robotic surgery yield better cosmetic results.

Less Blood Loss and Infection Risk

During robotic surgery, the three-dimensional magnified images allow for clearer visualization of vascular structures, thus reducing the risk of bleeding. Studies show that blood loss in robotic cystectomy averages 125 ml or less, and most patients do not require transfusions. In fact, patients who opt for open surgery may experience five times more blood loss compared to robotic surgery. Additionally, the small incision areas minimize the risk of infection.

Shorter Hospital Stay

Patients undergoing robotic radical cystectomy are generally discharged more quickly than those who have open surgery. Patients are typically discharged within 1-2 days after robotic cystectomy, while this period is longer for open surgery. Patients recover faster and return to their normal lives more quickly. This situation provides advantages in terms of patient comfort and reduces hospital costs.

Nerve Preservation and Sexual Function Advantage

Robotic surgery allows for safer application of nerve-sparing techniques. The precision of robotic arms and 3D imaging enable better preservation of the nerves that control sexual function. In particular, the high-resolution images provided by the robotic system and the surgical arms’ wrist-like movement capabilities allow for much more precise nerve-sparing dissection. As a result, the rate of preservation of erectile function in the postoperative period is significantly higher compared to open surgery.

More Effective Removal of Lymph Nodes

The precision offered by robotic surgery allows for more complete removal of lymph nodes. This reduces the risk of cancer spread. Clinical studies have shown that an average of 40% more lymph nodes are removed with robotic radical cystectomy. Obtaining sufficient lymph nodes (22 to 37 nodes) is crucial for the effectiveness of cancer treatment. Lymph node dissection performed with robotic assistance can be done in more detail thanks to the 15-fold magnified high-resolution images.

Risks and Disadvantages of Robotic Cystectomy

Like any surgical procedure, robotic radical cystectomy carries certain risks and disadvantages. Knowing the limitations of this method, in addition to its advantages, helps patients make more informed decisions.

Cost and Equipment Requirements

The most significant disadvantage of robotic cystectomy is its high cost. The purchase, maintenance, and provision of robotic systems are quite expensive. This directly reflects on the surgical fees, and insurance coverage may be limited.

Moreover, not every hospital has this technology. The costs required for centers dealing with minimally invasive surgery to acquire and maintain robots are high. Therefore, finding a suitable center for robotic cystectomy can sometimes be challenging.

Preparing the robotic system before surgery and attaching it to the ports also takes extra time. This may extend the duration of the operation.

Importance of Surgeon Experience

Robotic surgical procedures require specialized training and extensive surgical experience. For inexperienced surgeons, the duration of the surgery may be prolonged, and the risk of complications may increase.

Robotic cystectomy requires advanced technical knowledge and a long learning curve. Experienced robotic surgeons can ensure both the safe preservation of oncological margins and the maximum preservation of nerve bundles.

One limitation is that the surgeon cannot directly feel the tissues. However, experienced surgeons can manage this situation using visual cues.

Risk of Urinary Incontinence and Sexual Function Loss

Since the prostate is also removed along with the bladder during radical cystectomy, men may experience erectile problems. Nerve-sparing procedures can be applied in suitable patients to preserve sexual function.

Women may also experience sexual side effects. While sexual intercourse may still be possible, the removal of part of the vagina may cause discomfort. The nerves responsible for arousal and orgasm may sometimes be affected during radical cystectomy.

Urinary incontinence can also be a significant complication. The rates of these risks vary depending on the surgeon’s experience.

Wound Infection and Healing Issues

Cystectomy is a major surgery, and there are risks associated with every major surgical procedure. These include bleeding, embolism, infection, damage to surrounding organs, and reactions related to anesthesia.

Although robotic surgery is minimally invasive, complications related to infection and wound healing can still arise. These complications may be similar to those seen in open surgery.

The rate of conversion to open or laparoscopic procedures is 0.17%.

Postoperative Recovery and Quality of Life

The recovery process after robotic radical cystectomy is an important period that requires patients to adapt to a new lifestyle. This process is personalized according to the type of surgery, the urinary diversion method applied, and the patient’s overall health.

Use of Catheters and Drains

After the surgery, there will be some drains and catheters in your body. After robotic radical cystectomy, the catheter and drains are usually removed at the surgeon’s discretion. In patients who have had a neobladder created, a Foley catheter is placed for the healing of the urinary tract, and this catheter is typically removed a few weeks after surgery. In patients who have had an ileal conduit, the catheters placed in the kidneys are removed within 7-10 days. Proper care of catheters and drains after cystectomy is crucial to reduce the risk of infection.

Urinary Control and Adjustment Process

Urinary incontinence after neobladder surgery is one of the most common issues in the postoperative period and is usually a temporary process. Pelvic floor exercises are very important for regaining urinary control. While lying down or sitting, you can perform exercises by tightening only the muscles around the anus and buttocks without tightening your abdominal muscles, holding for 4-5 seconds, and then relaxing, three times a day. Most patients regain urinary control over time, but this period can vary from a few weeks to a few months.

Return to Physical Activity

For the first 4-6 weeks after robotic cystectomy, heavy physical activity and exercise should be avoided. However, prolonged bed rest is not recommended, as early mobilization supports recovery, helps restore bowel function, and prevents complications such as blood clots. In the early postoperative period, you can start with short walks in bed and gradually increase your activity level in the following weeks.

Sexual Life and Psychological Effects

The preservation of sexual functions with robotic cystectomy depends on the application of nerve-sparing techniques during the surgery. In robotic surgery, the surgical field can be magnified 15 times, and high-resolution images allow for the preservation of blood vessels and nerves leading to the sexual organs. After robotic cystectomy performed by an experienced surgeon, the success rate of preserving sexual functions in men is approximately 90-95%. However, many patients may experience psychological distress and body image issues after cystectomy.

Risk of Cancer Recurrence

As with other types of cancer, there is a risk of recurrence after robotic cystectomy. Therefore, regular follow-ups after surgery are very important. Typically, checks are performed every three months for the first two years based on pathology results. Blood tests every three months and radiological checks every six months are recommended for the first year. After the fifth year, annual follow-ups continue for life. These regular follow-ups are vital for the early detection of possible recurrences.

In Summary: Robotic Radical Cystectomy

Robotic radical cystectomy stands out as a revolutionary step in the treatment of bladder cancer. It provides much smaller incisions, less blood loss, and shorter recovery times compared to traditional open surgery. Thus, your hospital stay is shorter, and you can return to your normal life more quickly.

Robotic technology allows surgeons to perform precise movements and remove cancerous tissues more effectively. Additionally, the likelihood of preserving sexual functions increases due to nerve-sparing techniques. More complete removal of lymph nodes also reduces the risk of cancer spread.

However, robotic cystectomy may not be suitable for every patient. High costs, equipment requirements, and the importance of surgeon experience are among the disadvantages of this method. Therefore, it is crucial to evaluate all options with your doctor.

During the postoperative process, you must be patient to regain urinary control. You can speed up this process by performing regular pelvic floor exercises. Although you need to avoid heavy physical activities for the first 4-6 weeks, short walks will support your recovery.

In conclusion, robotic radical cystectomy is an effective and safe option for the treatment of bladder cancer in suitable patients. Technological advancements aim to reduce surgical risks while preserving your quality of life. However, as with any major surgery, carefully following your doctor’s recommendations and maintaining regular check-ups are fundamental elements for achieving successful outcomes.

Frequently Asked Questions