Building a Program in Robot-Assisted Radical Cystectomy with Intracorporeal Ileal Conduit
Adrian J. Waisman Malaret, MD, Sara Hyde, BS, Lauren Dewey, PhD, Kimberly Taylor, BS, Kyle McAnally, BS, Catrina Crociani, MPH, Andrew A. Wagner, MD, Peter Chang, MD, MPH
Beth Israel Deaconess Medical Center, Boston, MA
BACKGROUND: Robot-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (ICIC) is primarily performed at very high-volume centers, and the prospect of integrating this surgery into routine practice can be daunting. Our objective is to describe a reproducible process by which to start a program in RARC with ICIC, and to report on our initial experience, including learning curve outcomes and integration of trainee teaching.
METHODS: First, two fellowship-trained attending surgeons with prior RARC experience observed ICIC creation at a high-volume center. We identified and documented each case step, and referred to this document as needed before and during surgery. We prioritized attending co-surgery for initial cases. Trainee console participation was integrated per surgeon′s discretion based on case times and patient safety. We prospectively recorded peri-operative outcomes, 90-day complications (Clavien-Dindo classification), individual case step times in minutes, and trainee participation. Outcomes were separated into quartiles to describe learning curve trends.
RESULTS: We report on 80 cases of RARC with ICIC from 2013-2018 (Table), excluding cases with intracorporeal neobladder, nephroureterectomy, and non-cancer indications. Two-attending cases were the norm initially (78% Q1/Q2) and were less common over time (38% Q3/Q4). With increasing experience, the percent of subjects that experienced major (Clavien grade 3+) complications (30% Q1 vs 10% Q4), any complications (70% Q1 vs 45% Q4), and hospital readmission (45% Q1 vs 20% Q4) decreased significantly. Total operative time, initially shorter with two attendings (mean 471 min in Q1), was relatively consistent throughout the series (mean 504 min). Mean ileal conduit time (defined as ICIC to close) decreased from 236 min in Q2 to 214 min in Q4, allowing concomitant increases in resident/fellow robotic console time (33 min Q1 to 62 min Q3/50 min Q4).
CONCLUSIONS: Key elements for starting a program in RARC with ICIC include expert case observation, detailed step documentation/review, and initial two-attending co-surgery. This approach facilitates overcoming the learning curve while also incorporating trainee involvement.
| Variable | Q1 (n=20) | Q2 (n=20) | Q3 (n=20) | Q4 (n=20) | Total (n=80) |
| Attending co-surgery (%) | 17 (85) | 14 (70) | 6 (30) | 9 (45) | 46 (57.5) |
| Estimated blood loss (cc) | 328 | 373 | 368 | 316 | 346 |
| Kengh of stay (days) | 7.8 | 9.5 | 9 | 6.9 | 8.3 |
| Minor complications (Clavien 1-2) (%) | 8 (40) | 12 (60) | 11 (55) | 7 (35) | 38 (47.5) |
| Major complications (Clavien 3-5) (%) | 6 (30) | 2 (10) | 4 (20) | 2 (10) | 14 (17.5) |
| Hospital readmission rate (%) | 9 (45) | 7 (35) | 6 (30) | 4 (20) | 46 (57.5) |
| total operative time (min) | 471 | 503 | 52 | 515 | 504 |
| Ileal conduit time (min) | 219 | 236 | 221 | 214 | 222 |
| Trainee console time (min) | 33 | 57 | 62 | 50 | 51 |
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