Update on Robotic Cystectomy

Ralph Grauer; N. Peter Wiklund


Curr Opin Urol. 2021;31(6):537-541. 

In This Article

Abstract and Introduction


Purpose of Review: This article aims to discuss recently published (2019–2021) studies on robot-assisted radical cystectomy (RARC) with attention to evidence comparing intracorporeal (ICUD) and extracorporeal urinary diversion (ECUD) in terms of intraoperative and perioperative metrics.

Recent Findings: RARC produces equivalent oncological outcomes compared to open radical cystectomy (ORC). The benefits of RARC are most pronounced perioperatively. ICUD has been increasingly used at centers of excellence as it reduces intestinal exposure, which may incrementally minimize morbidity compared to ECUD or ORC. As the learning curve for ICUD diversion has flattened, retrospective analyses have emerged that suggest this technique may hold benefit over both ORC and RARC with ECUD, though current data is conflicting, and a randomized controlled study is forthcoming.

Summary: ORC is the current 'gold standard' management for muscle-invasive bladder cancer. Based on the premise of the minimization of perioperative morbidity, the development of RARC, most recently with ICUD, seeks to improve patient outcomes. Despite a protracted learning curve, many expert bladder cancer centers have adopted an intracorporeal approach. As more centers adopt, refine, and climb the learning curve for ICUD, a clearer insight of its effect on morbidity will be revealed—informing further adoption of the technique.


The reduction of surgical morbidity is the chief principle of minimally invasive robotic surgery. The shift from open radical cystectomy (ORC) to robot-assisted radical cystectomy (RARC) has resulted in improved perioperative outcomes, though differences in oncological outcomes and rates of major complications have not been demonstrated. In 2018, the largest prospective, randomized controlled trial (RAZOR) found RARC with extracorporeal urinary diversion (ECUD) (eRARC) to be noninferior to ORC with respect to the primary endpoint of two-year progression-free survival.[1] Secondary endpoints analysis showed a lower proportion of patients requiring blood transfusion, shorter length of hospital stay, and lower estimated blood loss (EBL) in the eRARC group but there were no differences in major or minor Clavien-Dindo (CD) complications. RARC with intracorporeal urinary diversion (ICUD) (iRARC) was developed from the premise that the reconstructive phase of radical cystectomy is the primary factor in morbidity; thus, minimizing bowel exposure to ambient temperature and air would decrease perioperative morbidity. The aim of this manuscript is to examine and comment on recent evidence comparing both ICUD and ECUD with respect to intraoperative metrics and perioperative morbidity.