Laparoscopic and robotic assisted radical cystectomy for bladder cancer: a critical analysis

CONTEXT AND OBJECTIVES: Interest in laparoscopic assisted radical cystectomy (LRC) and robotic assisted radical cystectomy (RRC) is increasing at select centers worldwide. In this update we present the recent worldwide experience and critically evaluate the role of minimally invasive radical surgery for patients with bladder cancer. EVIDENCE ACQUISITION: English-language literature between 1992 and 2007 was reviewed using the National Library of Medicine database and the following key words: laparoscopic, laparoscopic-assisted, robotic, robotic-assisted, and radical cystectomy. Over 102 papers were identified, 48 of which were selected for this review on the basis of their contribution to advancing the field with regard to three criteria: (1) evolution of concepts, (2) development and refinement of techniques, and (3) intermediate- and long-term clinical outcomes. These were evaluated with respect to current techniques and perioperative, functional, and oncological outcomes. Our initial experience is also reported. EVIDENCE SYNTHESIS: Minimally invasive techniques can adequately achieve the extirpative aspects of LRC and extended template lymphadenectomy. At most institutions the reconstructive urinary diversion is now typically being performed extracorporeally through a minilaparotomy. Perioperative data indicate that minimally invasive techniques are associated with reduced blood loss, slightly increased operating time, and shorter hospital stay without any significant difference in postoperative complications compared with open surgery. Intermediate-term oncological outcomes appear to be comparable with the open approach. Worldwide experience continues to increase; >700 surgeries have already been performed. CONCLUSION: LRC or RRC with extracorporeally constructed urinary diversion is a safe and effective operation for appropriate patients with bladder cancer. Perioperative and functional outcomes are comparable with open surgery. More focus on extended lymphadenectomy is necessary to routinely achieve higher node yields. Surrogate and intermediate oncological outcomes are encouraging, and long-term assessment is ongoing.