Urinary bladder cancers arise from the inner epithelial (urothelium) covering of the bladder. They can range from superficial to metastatic (distant spread) disease at presentation. In treating these cancers an attempt is always made to preserve the urinary bladder. Low risk superficial bladder cancers can be treated with BCG instillation into bladder. However, radical cystectomy (removal of entire urinary bladder along with draining lymph nodes in the pelvis) is the treatment of choice for high-risk superficial disease as well as localized but muscle-invasive bladder cancer. Chemoradiation (chemotherapy along with radiation) can be used in muscle invasive cancers in order to avoid radical cystectomy. This is called bladder conservation protocol. By this patients can have normal voiding till there is a recurrence (usually for 2 years). Salvage cystectomy is performed once there is recurrence following chemoradiation.
Laparoscopic Radical Cystectomy
Traditionally radical cystectomy has been performed using an open approach via a liberal lower abdominal incision that allows wide excision of the bladder, lymph node dissection and urinary diversion procedure. Laparoscopy was first used for removal of the urinary bladder in 1992 for a non-cancerous disease. Subsequent advances have allowed a laparoscopic radical cystectomy to be performed safely. There are many small single institution studies which have compared robotic assisted laparoscopic with open surgery. Overall the results have consistently shown lower morbidity and shorter time to start oral feeds.
Studies available today on minimally invassive radical cystectomy are small and single institutional. Unfortunately there are no randimised controlled trials comparing the open with minimally invasive modality. The largest published series on laproscopic radical cystectomy is by Huang J et al who reported the oncological outcomes of 171 patients with a median follow-up of 3 years. All patients had an orthotopic ileal neobladder constructed extracorporeally. They did note have to convert any patients to open. They had median operating time of 5.4 hours which is comparable to open surgery. The pathological evaluation showed no positive surgical margins. Guillotreau et al have prospectively compared the outcomes in 38 laparoscopic with 30 open cases for blood loss, transfusion rate, minor complications, mortality, opioid requirement, resumption of oral intake and hospital discharge which were all significantly shorter in the laparoscopy group. Of interest in that study is that patients spent 4 days after laparoscopic surgery in an intensive-care unit, compared to 9 days after open. Porpigila et al. has reported no significant difference in operative time, blood loss or complications, with significantly less analgesic requirement and a shorter time to resumption of oral intake in laparoscopic surgery than the open group. Most of the other studies that are available today have shown similar results indicating feasibility and comparability of laparoscopic radical cystectomy with open modality.
Urologists were the first ones to embrace robotics when it made an entry into medicine. Due to anatomical difficulties in pelvic surgeries which make laparoscopy difficult, robot has been used for pelvic urological surgeries. Conceptually the laparoscopic and robotic differ only in instrumentation and comfort for the surgeon.
The presently available evidence is strong enough to call MACS for urinary bladder cancer oncologically safe procedure and is comparable to open procedure in oncological outcomes along with all the advantages of MACS. Careful case selection is recommended.
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