BLADDER cancer (BC) ranks as the 10th most common malignancy globally, with approximately 600,000 new cases in 2020. For patients with localised muscle-invasive bladder cancer (MIBC) or recurrent high-risk non-muscle-invasive bladder cancer (NMIBC), radical cystectomy with pelvic lymph node dissection (PLND) remains the gold standard treatment. This approach offers five- and ten-year survival rates of 66% and 43%, respectively.
Traditionally, radical cystectomy has been performed through an open surgical approach (ORC), which is associated with significant postoperative complications. Over 30% of patients experience severe complications within 30 days of surgery. To address this, minimally invasive techniques such as robot-assisted radical cystectomy (RARC) have emerged as transformative alternatives. RARC has gained global adoption due to its ergonomic advantages over pure laparoscopy, particularly for complex procedures like urinary diversion (UD).
Evidence from multiple studies and randomised controlled trials (RCTs) suggests that RARC delivers improved perioperative outcomes, including reduced blood loss and shorter hospital stays, while maintaining comparable oncological results to ORC. Notably, RARC with intracorporeal urinary diversion (ICUD) offers further enhancements in recovery metrics compared to extracorporeal UD (ECUD). For instance, patients undergoing RARC with ICUD benefit from more days alive and out of hospital within 90 days of surgery, as confirmed by the largest RCT on the topic.
A single-centre study further supports these findings, demonstrating that RARC with ICUD reduces the risk of major complications, decreases transfusion requirements, and maintains similar operative times compared to ORC. Oncologically, RARC achieves similar rates of surgical margin positivity while yielding a higher lymph node count – an indicator of effective cancer clearance.
Although concerns about uretero-ileal strictures remain, multivariable analysis suggests these outcomes are influenced more by surgeon experience and patient factors than by the surgical approach itself.
In conclusion, the combination of better perioperative outcomes, equivalent oncological safety, and promising real-world results positions RARC with ICUD as a likely future standard for treating MIBC and high-risk NMIBC. Further research and adoption of enhanced recovery protocols could solidify its role in modern bladder cancer care.
Reference
Gabriel PE et al. Comparative effectiveness of robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy for bladder cancer. BJU Int. 2024;DOI:10.1111/bju.16565.
