Laparoscopic radical cystectomy: current status, outcomes, and patient selection

Radical cystectomy remains the gold standard for the treatment of muscle invasive and high-risk urothelial cancers of the bladder. In attempts to decrease the morbidity of the procedure, minimally invasive techniques have been employed for both the extirpative as well as the reconstructive portions of the procedure. Current laparoscopic and robotic-assisted techniques allow for the performance of these procedures in selected patients with improvements in estimated blood loss while adhering to the oncologic principles required for cancer control including obtaining negative margins and performing an adequate extended lymph node dissection. While completely intracorporeal approaches are technically feasible, they have been, thus far, associated with significant increases in operative times and perioperative complications. Open-assisted approaches in which the extirpative portions of the case (i.e. radical cystectomy, extended lymph node dissection) are completed laparoscopically and the urinary reconstruction is performed in a limited open fashion appear to provide the best outcomes with current techniques. Intermediate cancer outcomes are promising when compared to their open surgical counterparts. While this approach remains investigational, long-term outcomes are currently being accrued and may allow for the shift of the standard of care to minimally invasive approaches for select patients as has been the case in renal and prostatic cancers.