Robotic-assisted radical cystectomy (RARC) is the operation to remove the bladder, together with nearby lymph nodes and other organs as the cancer requires, followed by creating a new way for urine to leave the body. It is a major operation and one of the most important in the treatment of Bladder Cancer.
This article explains when it is advised, how the robotic operation is done, the urinary diversion options and what to expect. For the question of whether the bladder can sometimes be preserved, see Radical cystectomy or bladder preservation?
When is radical cystectomy advised?
Radical cystectomy is a standard curative treatment for:
- Muscle-invasive Bladder Cancer (T2 or higher) that has not spread to distant organs, in patients fit for major surgery
- High-risk non-muscle-invasive Bladder Cancer that has not responded to BCG, or that is judged too risky to keep treating with bladder-preserving methods
- Some very high-risk tumours, such as certain variant histologies, where early surgery is discussed
Many patients with muscle-invasive disease are first offered chemotherapy before surgery when they are suitable. Your treatment plan is best made after staging scans and a multidisciplinary discussion.
Related: Reading your TURBT pathology report · Bladder Cancer
What does the operation involve?
RARC is done under general anaesthesia through several small cuts. The essential cancer operation is the same as in open surgery, and the approach is chosen to allow good cancer clearance:
- Access. Ports are placed and the robot docked.
- Lymph node dissection. The lymph nodes around the pelvic vessels are removed because Bladder Cancer can spread through the lymphatics.
- Remove the bladder. In men the bladder is removed with the prostate and seminal vesicles; in women with the uterus and part of the vagina when needed, and sometimes the ovaries, depending on the cancer. In selected patients nearby organs can be spared.
- Make the urinary diversion. A new route for urine is created from a segment of bowel (see below).
- Join the ureters. The tubes from the kidneys are connected to the new urine channel.
- Check and close. Drains are placed and the specimen is removed.
The reconstruction can be done inside the body (intracorporeal) using the robot, or through a small cut (extracorporeal). Both are used, and the choice depends on the surgeon's experience and your anatomy. RARC takes longer than most urological operations, often five to eight hours.
Urinary diversion options
Ileal conduit
A short segment of small bowel forms a channel that brings urine to an opening on the abdominal wall (a urostomy) where it drains into a bag. It is the most commonly used option. It is dependable and suits most patients, including older patients and those with other illnesses.
Orthotopic neobladder
A longer bowel segment is shaped into a reservoir and connected to the urethra, allowing selected patients to pass urine in the natural way. It needs a suitable cancer location, a healthy urethra, good kidney function and the ability to learn bladder training and, sometimes, self-catheterisation.
Which diversion is right for you depends on your cancer, your kidney and bowel health, your general fitness and your preference. This is discussed in detail before surgery, and a stoma nurse can help you plan a urostomy.
What does the evidence show?
Randomised trials comparing robotic and open radical cystectomy have found similar cancer outcomes and broadly similar complication rates, with less blood loss in the robotic groups. Hospital stay was similar in some trials. The operation remains major either way. The robot does not change what the cancer operation has to achieve. The quality of the dissection, the lymph node clearance and the care around the operation are what matter, and these depend on surgeon and team experience.
Risks
Radical cystectomy has higher complication rates than most urological operations. They may include:
- Bowel-related problems, such as slow return of bowel function (ileus), obstruction or leak from the bowel join
- Infection, including urinary infections and wound infection
- Bleeding and blood clots
- Problems with the urinary channel: leak, narrowing at the ureter join, or stoma problems such as skin irritation or hernia
- Changes in sexual function, which in men commonly include erectile dysfunction; in women, changes related to vaginal surgery
- Vitamin B12 deficiency over the long term with some bowel segments
- Need for readmission after discharge, which is not uncommon
Preparation, a nutritious diet, stopping smoking and fitness before surgery reduce these risks.
Recovery
Most hospitals now use an enhanced recovery pathway: early walking, early feeding, careful pain control and avoiding unnecessary tubes. Typical stay is about seven to ten days, longer if there are complications. Expect fatigue for several weeks. You and your family will be taught to care for the stoma or the neobladder before discharge. Return to normal activity usually takes six to twelve weeks.
Follow-up
The pathology report gives the final stage and the lymph node status and may suggest further treatment. Follow-up includes scans, blood tests including kidney function and vitamin B12, and examination of the urinary channel.
Guidelines
This article is consistent with the EAU guidelines on muscle-invasive and metastatic Bladder Cancer and the AUA/ASCO/ASTRO/SUO guideline on muscle-invasive Bladder Cancer.
Consultation
Dr. Anshuman Singh, Uro-Oncologist & Robotic Surgeon, performs robotic uro-oncological surgery in Lucknow and sees patients at the Uro-Oncology OPD, Chandan Hospital (10 AM – 4 PM) and at Uro-Onco Connect, Gomti Nagar (6 – 9 PM), Monday to Friday, and by teleconsultation. Pathology reports and staging scans can be shared in advance. Book a consultation.
Frequently asked questions
What does RARC stand for?
Robot-assisted radical cystectomy: removal of the bladder, with nearby organs and pelvic lymph nodes as needed, and creation of a urinary diversion, using a robotic system.
Is robotic cystectomy better than open cystectomy?
Cancer outcomes are similar in randomised trials. Robotic surgery can reduce blood loss, but it is still a major operation with similar complication rates. Experience and quality of surgery matter most.
How long is the surgery and hospital stay?
Usually five to eight hours, and a hospital stay of about seven to ten days.
Can I have a neobladder?
Only selected patients are suitable, depending on cancer location, urethral health, kidney function and fitness. An ileal conduit suits most patients.
Can bladder removal be avoided?
In carefully selected patients with muscle-invasive disease, bladder-preserving trimodality therapy is an option, but not for everyone. See the article on radical cystectomy vs bladder preservation.
What follow-up is needed after cystectomy?
Regular scans and blood tests, including kidney function and vitamin B12, and checks of the urinary channel. Your surgeon sets the schedule.
Treatment in Lucknow
Dr. Anshuman Singh is a Uro-Oncologist and Robotic Surgeon in Lucknow. Read about Bladder Cancer treatment in Lucknow and Robotic Surgery for Urological Cancers, or book a consultation in person or by teleconsultation.
This article is for general education and does not replace a personal medical consultation.