title: Robot-assisted radical cystectomy: description of an evolved approach to radical cystectomy.
abstract: BACKGROUND
  Although open radical cystectomy (ORC) remains the gold standard of care for muscle-invasive bladder cancer, robot-assisted radical cystectomy (RARC) continues to gain wider acceptance. In this article, we focus on the steps of RARC, describing our approach, which has been developed over the past 10 yr. Totally intracorporeal RARC aims to offer the benefits of a complete minimally invasive approach while replicating the oncologic outcomes of open surgery.
  
  
  OBJECTIVE
  We report our outcomes of a totally intracorporeal RARC procedure, describing step by step our technique and highlighting the variations on this standard template of nerve-sparing and female organ-preserving approaches in men and women.
  
  
  METHODS
  Between December 2003 and October 2012, a total of 113 patients (94 male and 19 female) underwent totally intracorporeal RARC.
  
  
  METHODS
  We performed RARC, extended pelvic lymph node dissection, and a totally intracorporeal urinary diversion (UD) in all patients. In the accompanying video, we focus on the standard template for RARC, also describing nerve-sparing and female organ-preserving approaches.
  
  
  METHODS
  Complications and oncologic outcomes are reported, including overall survival (OS) and cancer-specific survival (CSS) using Kaplan-Meier analysis.
  
  
  CONCLUSIONS
  RARC with intracorporeal UD was performed in 113 patients. Mean age was 64 yr (range: 37-84). Forty-three patients underwent intracorporeal ileal conduit, and 70 had intracorporeal neobladder. On surgical pathology, 48% of patients had ≤ pT1 disease, 27% had pT2 disease, 13% had pT3 disease, and 12% had pT4 disease. The mean number of lymph nodes removed was 21 (range: 0-57). Twenty percent of patients had lymph node-positive disease. Positive surgical margins occurred in six cases (5.3%). Median follow-up was 25 mo (range: 3-107). We recorded a total of 70 early complications (0-30 d) in 54 patients (47.8%), with 37 patients (32.7%) having Clavien grade ≥ 3. Thirty-six late complications (>30 d) were recorded in 30 patients (26.5%), with 20 patients (17.7%) having Clavien grade ≥ 3. One patient (0.9%) died within 90 days of operation from pulmonary embolism. Using Kaplan-Meier analysis, CSS was 81% at 3 yr and 67% at 5 yr.
  
  
  CONCLUSIONS
  Our structured approach to RARC has enabled us to develop this complex service while maintaining patient outcomes and complication rates comparable with ORC series. Our results demonstrate acceptable oncologic outcomes and encouraging long-term CSS rates.
authors.affiliation: Karolinska University Hospital, Stockholm, Sweden. jwcol@yahoo.co.uk
authors.forename: Justin W
authors.initials: JW
authors.lastname: Collins
authors.forename: Stavros
authors.initials: S
authors.lastname: Tyritzis
authors.forename: Tommy
authors.initials: T
authors.lastname: Nyberg
authors.forename: Martin
authors.initials: M
authors.lastname: Schumacher
authors.forename: Oscar
authors.initials: O
authors.lastname: Laurin
authors.forename: Dinyar
authors.initials: D
authors.lastname: Khazaeli
authors.forename: Christofer
authors.initials: C
authors.lastname: Adding
authors.forename: Martin N
authors.initials: MN
authors.lastname: Jonsson
authors.forename: Abolfazl
authors.initials: A
authors.lastname: Hosseini
authors.forename: N Peter
authors.initials: NP
authors.lastname: Wiklund
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015653:Cystectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D018450:Disease Progression; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011183:Postoperative Complications / Q000209:etiology; D012307:Risk Factors; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D014547:Urinary Diversion
keywords: RARC; Radical cystectomy; Robotics; Surgical technique; Urinary bladder neoplasms