109 © Springer Nature Switzerland AG 2020 S. L. Best, S. Y. Nakada (eds.), Minimally Invasive Urology, https://doi.org/10.1007/978-3-030-23993-0_7 Robotic-Assisted Radical Cystectomy Granville L. Lloyd and Janet E. Baack Kukreja Introduction The role of robot-assisted radical cystectomy (RARC) in the treatment of bladder cancer is expanding. Advocates suggest that this mini- mally invasive operation offers reduced blood loss, less pain, and the promise of shorter hospi- talizations with fewer complications and equiva- lent oncologic outcomes. Most of these putative advantages have yet to be demonstrated and are balanced against the increased up-front cost of the robotic platform and longer operative times. Nevertheless, the evidence available to date sug- gests a robust future for this relatively new technology. Modern radical cystectomy with lymph node dissection, as described by Marshall and Whitmore in 1949, has been associated with high complication rates. In that pioneering report of six patients, two expired of surgical complication before leaving the hospital and at least another two had signifcant morbidity [1]. Since that time, the application of improved operative and in-hospital strategies and care pathways has resulted in decreased mortality and morbidity, but modern series of open radical cystectomy (ORC) continue to be plagued by signifcant complication rates. When the standardized Clavien-Dindo [2] complication reporting scale is strictly applied, open cystectomy complication rates at centers of excellence reach into the 60–70% range [3]. Other high-volume centers have reported lower rates, albeit in the absence of a standardized reporting system [4]. History of Minimally Invasive Cystectomy Since the frst reported pure laparoscopic cystec- tomy in 1995 [5, 6] and then the robotic approach in 2002 [7], an increasing number of series have been published. Early retrospective series sug- gested a possible beneft to robotic approach, and very few data reporting RARC outcomes to be inferior to open cystectomy in clinical or oncologic effcacy. Usage of the robotic platform for cystectomy increased, and large non-ran- domized database assessments continued to show non-inferiority of this approach [8]. More recently, a number of randomized controlled tri- als (RCTs) have been completed, confrming those early suggestions of oncologic equiva- lence, but not showing a clear beneft to perform- ing the extirpative portion of the operation with robotic assistance [9]. G. L. Lloyd (*) Department of Urology, Rocky Mountain Regional Veterans Hospital, University of Colorado Anschutz Medical Campus, Aurora, CO, USA e-mail: granville.lloyd@ucdenver.edu J. E. B. Kukreja Division of Urology, Department of Surgery, University of Colorado, Aurora, CO, USA 7