Elsevier

European Urology

Volume 67, Issue 3, March 2015, Pages 423-431
European Urology

RARC Pasadena Consensus Panel – Surgery in Motion
Editorial by Monish Aron and Inderbir S. Gill on pp. 361–362 of this issue
Robot-assisted Radical Cystectomy and Urinary Diversion: Technical Recommendations from the Pasadena Consensus Panel

https://doi.org/10.1016/j.eururo.2014.12.027Get rights and content

Abstract

Background

The technique of robot-assisted radical cystectomy (RARC) has evolved significantly since its inception >10 yr ago. Several high-volume centers have reported standardized techniques with refinements and subsequent outcomes.

Objective

To review all existing literature on RARC and urinary diversion techniques and summarize key points that may affect oncologic, surgical, and functional outcomes.

Design, setting, and participants

The Pasadena Consensus Panel on RARC and urinary reconstruction convened May 3–4, 2014, to review the existing peer-reviewed literature and create recommendations for best practice. The panel consisted of experts in open radical cystectomy and RARC. No commercial support was received.

Surgical procedure

The consensus panel extensively reviewed the surgical technique of RARC in men and women, extended pelvic lymph node dissection, extracorporeal urinary diversion, and intracorporeal urinary diversion. Critical aspects of the technique are described.

Outcome measurements and statistical analysis

Preoperative, operative, and postoperative parameters from the largest and most contemporary RARC series, stratified by urinary diversion technique, are presented.

Results and limitations

Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery.

Conclusions

Refinement of techniques for RARC and urinary diversion over the past 10 yr has made it safe, reproducible, and oncologically sound.

Patient summary

We summarize the critical aspects of surgical techniques reviewed at the Pasadena international consensus meeting on RARC and urinary reconstruction. Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery.

Introduction

Robot-assisted radical cystectomy (RARC) was first described by Menon et al in 2003 [1]. Over the past 10 yr, RARC has pushed accepted standards of open radical cystectomy (ORC) and become the standard treatment for muscle-invasive bladder cancer. RARC has demonstrated operative, functional, and oncologic outcomes comparable to ORC.

The 2014 Pasadena Consensus Panel on RARC convened to review a decade of experience. In this paper, we summarize the surgical technical recommendations from the consensus group. We highlight aspects of the procedure that facilitate the transition from ORC to RARC and urinary diversion. We also discuss technical points to aid the advanced robotic surgeon. Finally, we emphasize key technical points that may affect oncologic, surgical, and functional outcomes.

Section snippets

Methods

The international Pasadena Consensus Panel consisted of a 2-d conference of experts in radical cystectomy and urinary reconstruction who reviewed the existing peer-reviewed literature on RARC, pelvic lymphadenectomy, and urinary reconstruction. This conference was organized in Pasadena, California, and convened at the City of Hope Cancer Center in Duarte, California. No commercial support was obtained for this conference. This report was compiled based on a comprehensive review of the most

Patient selection

The degree of difficulty of RARC varies based on patient-related and disease-specific features. Favorable characteristics include the following:

  • Absence of previous abdominal surgery

  • Favorable body mass index (BMI)

  • No previous history of pelvic radiation

  • No bulky disease

  • No cardiovascular or pulmonary disease

  • Good performance status

The selection process should include appropriate preoperative investigations to ensure fitness for surgery, especially the ability to tolerate prolonged pneumoperitoneum

Discussion

Over the past decade, surgical robotic technology has become increasingly accessible, and our overall robotic surgical experience has become more robust with refinements in technique and operative times. RARC has transitioned from the novel efforts of innovators and early adopters to what is now becoming the product of the early majority. Still early in our experience, the extracorporeal urinary diversion has made the transition from ORC to RARC palatable to many surgeons. RARC has become

Conclusions

Remarkable progress has been made in RARC, ePLND, and urinary diversion. The technique has been significantly refined since its inception and has been shown to be safe, reproducible, and oncologically sound. Increasing expertise and significant improvements in technology will help improve both operative and functional outcomes.

References (23)

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