STOCKHOLM, SWEDEN (UroToday.com) - Dr. R. Gaston presented the pro-side of the debate in favor of robotic-assisted radical cystectomy (RARC).
The EAU guidelines state that RARC does not improve oncologic outcomes, rather surgical expertise does (Grade A recommendation). In retrospective series, complication rates are comparable between open and robotic cystectomy (ranging from 11-50%). In a number of small series, no significant difference in positive surgical margin rate and lymph node yield has been demonstrated between RARC and open cystectomy (OC). At least one small prospective randomized-controlled trial has confirmed the non-inferiority of RARC to ORC.
With respect to urinary diversion, the extracorporeal approach is most widely used. Intracorporeal diversion has been shown to generate increased rates of major complications and longer operative times in single-center series. The type of diversion performed is patient dependent, and no benefit has been associated with diversion type. The Saint Augustin series of RARC was then presented (2010-2012). Of the 114 patients treated with RARC, 51.5% received neobladders, and 63.2% were performed extracorporeally. A higher rate of complications was noted for patients undergoing intracorporeal versus extracorporeal urinary diversion (42.3% vs. 29.6%, respectively). A 15-month recurrence-free survival rate of 64% was observed. Finally, Dr Hemal’s series of 200 patients treated with RARC was presented, in which RARC was associated with less blood loss, shorter length of stay, and lower overall complication rates when compared with ORC.
Dr. M. Brausi then delivered the counter-arguments in support of ORC. The question proposed was whether ORC can be simplified into a minimally invasive procedure and compared to a RARC. Dr. Brausi then presented the Modena technique of minimally invasive extraperitoneal ORC. The entire bladder is removed via an extraperitoneal approach, and then a small peritonotomy is made to deliver and prepare the intestine for neobladder or ileal conduit construction. Utilization of the Modena approach has been associated with a reduction in complication rates from 54% to 45%. Blood loss was reduced from a mean of 780cc to 423cc, and recurrence rates were reduced from 4.3% to 2%. Data demonstrating higher positive surgical margin rates following RARC was presented (6.8% RARC (T1), 1.6% (T2) vs ORC (0% for T2)). Finally, a cost analysis from the Nationwide Inpatient Sample revealed median costs of $24,000 and $28,000 for ORC and RARC, respectively. Finally, among patients treated with RARC, only 48% underwent an extended PLND, and some have cited concerns of possible tumor cell seeding to other organs and the peritoneum. Long-term follow-up data is required prior to making conclusions regarding comparative oncological efficacy.
Presented by R. Gastona and M. Brausib at the 29th Annual European Association of Urology (EAU) Congress - April 11 - 15, 2014 - Stockholmsmässan - Stockholm, Sweden
Bordeaux (FR);a Modena (IT)b
Written by Jeffrey J. Tomaszewski, MD, medical writer for UroToday.com