CUOS 2019: Robotic Radical Cystectomy, Controversial Topics in Urothelial Carcinoma

Toronto, Ontario ( Radical cystectomy is the gold standard surgical therapy for muscle-invasive bladder cancer and refractory non-muscle invasive bladder cancer. Open radical cystectomy is a highly morbid procedure, with a very extended recovery period. Robotic radical cystectomy is a procedure with a potentially faster recovery period, with potential greater benefit to the patients and the surgeon.

When adopting new technologies, they should prove to be superior or at least equivalent. This should be manifested in:

1.Cancer outcomes
2. Quality of life
3. Functional outcomes, blood loss, operative time, complications and length of hospital stay.
4. Costs

According to Dr. Girish Kulkarni, there have been five randomized trials published so far (Figure 1). However, the risk of bias in the five randomized controlled trials is not negligible, as can be seen in figure 2.

Figure 1- The five randomized controlled trials comparing open to radical cystectomy:
UroToday CUOS19 Robotic Radical cystectomy
Figure 2 – The risk of bias in the five randomized controlled trials:
UroToday CUOS19 risk of bias
Long term data from the Memorial Sloan Kettering Cancer Center (MSKCC) randomized controlled trial comparing robotic to open radical cystectomy demonstrated no difference in oncologic outcomes, including recurrence-free survival and disease-specific survival. Furthermore, there was no difference in short term oncologic outcomes. These included lymph-node yield, T stage, and positive margin rate. However, the rate of distant recurrences was significantly higher among the open radical cystectomy group, but no differences in the overall recurrence rates were apparent. When assessing the disease progression rates in some of the other randomized trials, no significant differences could be discerned in disease progression parameters (Figure 3)

Figure 3 – Disease progression:
UroToday CUOS19 Disease progression
Additional parameters that have been assessed in the relevant randomized controlled trials included the health-related quality of life at 90 days post-surgery, which was almost identical between the two modalities. The rate of major complications was similar in all randomized controlled trials as well. When assessing the various additional outcomes among these studies, the forest plots (figure 4) demonstrate that there is a clear benefit to robotic radical cystectomy with lower blood transfusion rates and shorter operating times, but the length of hospital stay was very similar. Lastly, bowel function was compared as well, and the scores were quite similar. An important point the difference in cost-effectiveness, which demonstrated that robotic radical cystectomy was not cost effective in any of the studies. On average, an additional 3000-4000$ was spent per each case, irrespective of follow-up. This is a significant limitation of robotic radical cystectomy that should be recognized.

Figure 4 - Comparison of various outcomes among the various trials:
UroToday CUOS19 Robotic Radical cystectomy 2
Summarizing all the data, Dr. Kulkarni stated that level one evidence currently exists demonstrating that robotic radical cystectomy is not inferior to open radical cystectomy.  He concluded his talk stating that the same advantages and disadvantages that were shown many years ago, when robotic radical prostatectomy was compared to open radical prostatectomy are seen in the comparison of open and robotic radical cystectomy (Figure 5). This should lead us to adopt robotic radical cystectomy in the same manner as robotic radical prostatectomy had been adopted, taking into account the required learning curve needed to master this modality.

Figure 5 – Summarizing the comparison between robotic and open radical cystectomy:
UroToday CUOS19 comparison between robotic and open radical cystectomy

Presented by: Girish S. Kulkarni, MD, Ph.D., FRCSC, Medical Advisory and Research Board, University of Toronto, Toronto, Ontario

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter: @GoldbergHanan at the CUOS – Canadian Uro-Oncology Summit 2019, #CUOS19 January 10-12, 2019 Westin Harbour Castle, Toronto, Ontario, Canada

Further Related Content:
Open Radical Cystectomy, Controversial Topics in Urothelial Carcinoma