Salvage robotic-assisted radical cystectomy is safe in patients with history of pelvic irradiation

Abstract

Objectives: To describe the surgical approach and perioperative outcomes of a multicenter series evaluating a robotic-assisted approach to radical cystectomy with total intracorporeal urinary diversion in the setting of prior pelvic radiotherapy.

Materials and methods: We analyzed our prospective cystectomy database for patients who underwent robotic-assisted radical cystectomy for bladder cancer after radiotherapy between 2018 and 2022. Demographic information and data regarding preoperative factors including stage of disease, preoperative hydronephrosis, and history of pelvic radiotherapy were collected via review of electronic medical records. All operations were performed by 1 of 2 experienced urologists using the da Vinci X, Xi, or Si surgical platforms.

Results: Ten patients were identified for this study. The median age of participants was 73.5 years (range, 41-84 years). The median American Society of Anesthesiologists classification score was 3 (range, 3-4). The median Charlson Comorbidity Index was 6 (range, 2-12). Among the patients, 4 out of 10 patients (40%) had muscle invasive bladder cancer before salvage surgery. Intracorporeal ileal conduit urinary diversion was performed in 8 patients, whereas 2 patients underwent intracorporeal neobladder formation. Median intraoperative blood loss was 250 mL (range, 150-600 mL), and median operative duration was 390 minutes (range, 195-450 minutes). The overall 30-day complication rate was 60% with a Clavien-Dindo grade ≥3 complication rate of 15%. Perioperative mortality was 0%. Median duration of follow-up was 210 days (range, 60-1580 days).

Conclusions: This series describing the outcomes of salvage robotic-assisted radical cystectomy using total intracorporeal urinary diversion demonstrates the safety of this technique. Further studies with long-term follow-up, including oncological outcomes, are required to support the widespread adoption of this procedure.

Keywords

Robotic-assisted radical cystectomy / Intracorporeal urinary diversion / Radiotherapy / Salvage / Ileal conduit / Neobladder / Bladder cancer

Acknowledgments

The authors would like to acknowledge Marco Lamonaca for the assistance in data collection.

Statement of ethics

This study has been conducted in accordance with the Declaration of Helsinki ethical principles for medical research, and approved for completion after ethical board review by the Royal North Shore Hospital department of medical services 2022.

Conflict of interest statement

No member of the authorship has any significant disclosures to make regarding this manuscript, nor were any financial incentives gained through the writing of this manuscript or possible future publication.

Funding source

No funding was received in the writing nor publication of this manuscript.

Author contributions

J. Kovacic: Research design, writing of the paper, performance of the research and analysis of data;

AD, J. Kam, AS: Research design and writing of the paper;

AG, MW: Research design and senior overview of manuscript writing.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

References

[1] Morris KA, Haboubi NY. Pelvic radiation therapy: Between delight and disaster. World J Gastrointest Surg 2015; 7(11):279-288.

[2] Boorjian SA, Karnes RJ, Viterbo R, et al. Long-term survival after radical prostatectomy versus external-beam radiotherapy for patients with high-risk prostate cancer. Cancer 2011; 117(13):2883-2891.

[3] Hautmann RE, de Petriconi R, Volkmer BG. Neobladder formation after pelvic irradiation. World J Urol 2009; 27(1):57-62.

[4] Al Hussein Al Awamlh B, Nguyen DP, Otto B, et al. The safety of robot-assisted cystectomy in patients with previous history of pelvic irradiation. BJU Int 2016; 118(3):437-443.

[5] Piazza P, Rosiello G, Chacon VT, et al. Robot-assisted cystectomy with intracorporeal urinary diversion after pelvic irradiation for prostate cancer: Technique and results from a single high-volume center. Eur Urol 2021; 80(4):489-496.

[6] Kubota Y, Hatakeyama S, Hashimoto T, et al. Robot-assisted radical cystectomy in a patient with muscle-invasive bladder cancer following radiotherapy for prostate cancer. IJU Case Rep 2019; 2(4):236-239.

[7] Huned D, Tiwari R, Jack Tay K, et al. The benefit of robotic surgery in postradiorecurrent invasive bladder cancer. Videoscopy. 2021; 31(3). doi: 10.1089/vor.2021.0002.

[8] Cooke PW, Dunn JA, Latief T, et al. Long-term risk of salvage cystectomy after radiotherapy for muscle-invasive bladder cancer. Eur Urol 2000; 38(3):279-286.

[9] Pieretti A, Krasnow R, Drumm M, et al. Complications and outcomes of salvage cystectomy after trimodality therapy. J Urol 2021; 206(1):29-36.

[10] Kim HL, Steinberg GD. Complications of cystectomy in patients with a history of pelvic radiation. Urology 2001; 58(4):557-560.

[11] Gontero P, Pisano F, Palou J, et al. Complication rate after cystectomy following pelvic radiotherapy: An international, multicenter, retrospective series of 682 cases. World J Urol 2020; 38(8):1959-1968.

[12] Crawford ED, Skinner DG. Salvage cystectomy after irradiation failure. J Urol 1980; 123(1):32-34.

[13] Smith JA Jr., Whitmore WF Jr. Salvage cystectomy for bladder cancer after failure of definitive irradiation. J Urol 1981; 125(5):643-645.

[14] Abratt RP, Wilson JA, Pontin AR, Barnes RD. Salvage cystectomy after radical irradiation for bladder cancer—Prognostic factors and complications. Br J Urol 1993; 72(5 Pt2):756-760.

[15] Schuettfort VM, Pradere B, Quhal F, et al. Incidence and outcome of salvage cystectomy after bladder sparing therapy for muscle invasive bladder cancer: A systematic review and meta-analysis. World J Urol 2021; 39(6):1757-1768.

[16] Chang SS, Bochner BH, Chou R, et al. Treatment of non-metastatic muscle-invasive bladder cancer: AUA/ASCO/ASTRO/SUO guideline. J Urol 2017; 198(3):552-559.

[17] Alfred Witjes J, Lebret T, Comperat EM, et al. Updated 2016 EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Urol 2017; 71(3):462-475.

[18] Wilson TG, Guru K, Rosen RC, et al. Best practices in robot-assisted radical cystectomy and urinary reconstruction: Recommendations of the Pasadena Consensus Panel. Eur Urol 2015; 67(3):363-375.

[19] Tanneru K, Jazayeri SB, Kumar J, et al. Intracorporeal versus extracorporeal urinary diversion following robot-assisted radical cystectomy: A meta-analysis, cumulative analysis, and systematic review. J Robot Surg 2021; 15(3):321-333.

[20] Mitropoulos D, Artibani W, Graefen M, et al; European Association of Urology Guidelines Panel. Reporting and grading of complications after urologic surgical procedures: An ad hoc EAU guidelines panel assessment and recommendations. Eur Urol 2012; 61(2):341-349.

[21] Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009; 55(1):164-174.

[22] Kazaryan AM, Røsok BI, Edwin B. Morbidity assessment in surgery: Refinement proposal based on a concept of perioperative adverse events. ISRN Surg 2013;2013:625093.

[23] Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: Five-year experience. Ann Surg 2009; 250(2):187-196.

[24] Eisenberg MS, Dorin RP, Bartsch G, Cai J, Miranda G, Skinner EC. Early complications of cystectomy after high dose pelvic radiation. J Urol 2010; 184(6):2264-2269.

[25] Shepherd AR, Bunjo Z, Sutherland P, Fuller A. Robotic-assisted radical cystectomy with intracorporeal urinary diversion: Initial South Australian experience. J Clin Urol 2024; 17(4):341-345.

[26] Chow K, Zargar H, Corcoran NM, et al. Robotic-assisted radical cystectomy with intracorporeal urinary diversion versus open: Early Australian experience. ANZ J Surg 2018; 88(10):1028-1032.

[27] Honore M, Roberts MJ, Morton A, et al. Outcomes and learning curve for robotic-assisted radical cystectomy: An Australian experience. ANZ J Surg 2019; 89(12):1593-1598.

[28] Yuh B, Wilson T, Bochner B, et al. Systematic review and cumulative analysis of oncologic and functional outcomes after robot-assisted radical cystectomy. Eur Urol 2015; 67(3):402-422.