Editor's Note: Robot-assisted radical cystectomy is playing an increasingly significant role in the treatment of bladder cancer. At the 2024 Annual Meeting of the Urological Surgeons Branch of the Chinese Medical Association (CUDA) held in Xi'an from August 8 to 11, Dr. Jian Huang from Sun Yat-sen Memorial Hospital, Sun Yat-sen University, shared his insights on "Robot-Assisted Function-Preserving Radical Cystectomy." After the conference, Urology Frontier invited Professor Huang to delve deeper into this topic.
1. Urology Frontier: As an expert in bladder cancer, could you share your insights on the unmet clinical needs of patients based on your experience?
Dr. Jian Huang: Bladder cancer is one of the most common malignant tumors in the urinary system, mainly divided into muscle-invasive bladder cancer (MIBC) and non-muscle-invasive bladder cancer (NMIBC). Historically, NMIBC has been treated with transurethral resection of bladder tumors (TURBT), followed by intravesical chemotherapy or immunotherapy to prevent recurrence. However, TURBT may miss small tumors or carcinoma in situ. Despite post-operative chemotherapy, BCG instillation, or ADC drug instillation, and even systemic treatment to prevent recurrence, complete prevention remains a challenge, which is a pressing need in clinical practice.
Additionally, the repeated instillations and cystoscopic examinations required post-operatively can be painful for patients. Chemotherapy instillations are typically administered weekly for 6-8 sessions, followed by monthly sessions for up to a year. Immunotherapy instillations require 15 sessions over a year, and frequent cystoscopies during this period can significantly impact the patient’s quality of life.
For MIBC, radical cystectomy is required, which not only affects urinary function but can also damage erectile nerves, potentially leading to erectile dysfunction. For patients of reproductive age, it may also affect fertility. Therefore, more research is being conducted to explore function-preserving surgical options to improve the quality of life for patients. However, function-preserving bladder surgery may increase the risk of tumor recurrence and perioperative complications (such as intestinal adhesions, fistulas, and obstructions). These issues require further investigation. With ongoing advancements in chemotherapy, immunotherapy, and antibody-drug conjugates (ADCs), there is growing hope for bladder preservation in MIBC patients. If drug treatment fails, radical cystectomy can still be performed, further enhancing the patient’s quality of life.
2. Urology Frontier: For patients who achieve complete remission after neoadjuvant therapy, do you recommend radical surgery or bladder-preserving treatment?
Dr. Jian Huang: About 50% of patients achieve complete remission after neoadjuvant therapy, but whether this equates to a cure remains uncertain. In the past, patients treated with single-agent chemotherapy had an average recurrence after about nine months, necessitating radical cystectomy. However, with the addition of immunotherapy, patients may now achieve longer remission periods. Many centers are currently exploring this, and if the remission time for bladder-preserving treatment can be maintained for 3-5 years, or even 10 years, radical surgery may not be necessary. We hope that patients in these clinical trials who receive bladder-preserving treatment will achieve good outcomes with close follow-up, thereby improving current clinical practices.
3. Urology Frontier: How can robot-assisted radical cystectomy be optimized to provide the most benefit to patients?
Dr. Jian Huang: The precision of robot-assisted radical cystectomy allows for the preservation of nerves while reconstructing the bladder, which is difficult to achieve with traditional laparoscopic or open surgery. Although robot-assisted surgery is continually being refined, every technological advancement must be validated clinically. If the bladder tumor has not invaded the prostate, it is possible to preserve the prostate capsule with nerves using robotic surgery, which can improve postoperative urinary control. Patients can achieve complete urinary control after catheter removal or reduce the duration of incontinence, while also preserving erectile function, thereby significantly improving the patient’s quality of life.
4. Urology Frontier: What future directions do you see for the exploration of radical cystectomy?
Dr. Jian Huang: The current trend in radical cystectomy is towards minimally invasive techniques, evolving from traditional open surgery to multi-port laparoscopy, single-port laparoscopy, and now robot-assisted surgery. Bladder reconstruction has progressed from urinary diversion through abdominal stoma to orthotopic bladder reconstruction, minimizing trauma. The precise suturing advantages of robotic surgery further enable the development of fully intracorporeal minimally invasive procedures. Future directions may involve research in tissue engineering to create artificial bladders, eliminating the need to harvest the patient’s intestines. The artificial bladder could be directly connected to the ureters and urethra, restoring storage and voiding functions and improving the patient’s quality of life.
Dr. Jian Huang
- Director, Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University
- Chief Physician, Professor, and PhD Supervisor
- Chairperson, Urology Branch of the Chinese Medical Association
- Vice President, Medical Robotics Branch, Chinese Medical Doctor Association
- Leader, Oncology Group, Urology Branch, Chinese Medical Association
- Editor-in-Chief of Chinese Guidelines for the Diagnosis and Treatment of Urological and Andrological Diseases
- Editor-in-Chief of Chinese Journal of Urology
- Editorial board member of International Journal of Urology, Asian Journal of Urology, and Journal of Endourology
