Robotic radical cystectomy has mostly failed to live up to the hype. Robotic approaches were originally developed as an alternative to open cystectomy in an effort to mitigate the risk of complications and expedite convalescence, but it hasn’t done either. In fact, the only 2 veritable benefits to emerge from a panoply of retrospective studies and 5 randomized trials are blood loss and wound complications. In the RAZOR study 25% of robotic patients required transfusion compared to 45% of open patients, and in the Memorial trial the estimated blood loss was about 24% lower.^1,2 Wound complications were about half as common in both studies.^1,2

However, with respect to most other outcomes related to length of stay and convalescence, the robot is not associated with meaningful improvement. In average terms, robotic cystectomy may facilitate an earlier discharge from the hospital by 12 to 24 hours, but in an era where most cystectomy patients are being entered into enhanced recovery protocols this advantage is diminishing.³ With respect to quality of life, non-wound related complications, cancer outcomes and readmissions, there does not appear to be much difference between the 2 approaches when one considers the totality of the evidence.⁴ This seems to hold true even with intracorporeal diversion.⁵

On the other hand, there are several advantages of open cystectomy that are readily apparent. The open approach is faster and less costly in terms of operating room time and expenditures.² Some data suggest open cystectomy may be associated with fewer anastomotic strictures.⁶ When one considers all these factors on balance, it’s easy to see why many skilled open surgeons have not adopted robotic techniques for bladder cancer like many have for prostate or kidney cancer.

Figure. Incision 1 month after a single incision SP robotic radical cystectomy with ileal conduit.

Yet, there is an important point worth making regarding the comparative effectiveness of robotic and open cystectomy. Even though robotic surgery has mostly failed to significantly improve perioperative outcomes to date, these innovations are potential steppingstones in the developmental pathway toward better systems. Had the evolution of the electric vehicle stopped with the hybrid models because of short battery life and cost, we would have never had the Tesla. To the extent that robotic surgical systems have facilitated next generation surgical tools, the robot has undoubtedly achieved some level of success, even while failing to empirically improve outcomes in the short term for bladder cancer patients.

One potential advancement is the Da Vinci^® single-port (SP) platform. Introduced in late 2018, the SP robot has been adopted for prostate and kidney surgery, but radical cystectomy may be a more suitable application. The main problem with multiport robotic cystectomy is the catch-22 one faces when deciding whether to open for the diversion to save time, particularly for neobladders. However, when one considers the aggregate length of all the robotic ports, laparoscopic assistant ports and the incision to perform the extracorporeal diversion, this ends up being just as invasive as open cystectomy. The SP robot overcomes this challenge by joining together the benefits of both the robotic and open approaches through a single 4 cm periumbilical incision (see figure).⁷ The robotic cystectomy and lymphadenectomy is completed in the usual fashion robotically, and the neobladder (or conduit) is constructed through that single incision in an open fashion and then returned to the abdomen for intracorporeal urethral and ureteral anastomoses, similar to what has been described for the Xi.⁸

This hybrid robotic-open SP approach has several theoretical advantages over existing robotic approaches. First, the incisional footprint is smaller than the Xi robot and limited to what would otherwise be required for extraction anyway. Theoretically this may reduce pain and expedite convalescence but further study is obviously required. Second, and more importantly, it more closely replicates open neobladder reconstructive techniques without requiring a laparotomy incision. There are longstanding principles of neobladder reconstruction that are sometimes abandoned with intracorporeal techniques. While the importance of these principles can be reasonably debated, forgoing them for the sake of staying intracorporeal runs counter to the ostensible goal of minimally invasive surgery to replicate open techniques.

Its important to note that hybrid SP cystectomy has numerous disadvantages and potential contraindications. The disadvantages mostly pertain to the SP instrumentation such as lack of variation in grip strength, lack of advanced energy devices such as vessel sealers and lack of different sizes for the robotic clips. The learning curve is also very steep, and our first few cases were exceptionally long. At this stage of development, the SP robotic approach is not ideal for locally advanced carcinomas or patients with extreme obesity.

Taken together, a sober reading of the literature suggests that the existing robotic techniques for cystectomy have not substantially improved most patient outcomes. It’s possible, and maybe even likely, that the SP robot will also fail to improve outcomes for bladder cancer patients. But this doesn’t mean that we should abandon ship. Given that there is so much room for improvement in the cystectomy population, any progress, even if only incremental, is preferable to the status quo. Forging a new frontier might be the only meaningful contribution that robotics has made to bladder cancer patients to date, but it is an important one.