EAU 2017: Debate on bladder cancer surgery: open cystectomy is still the way - Con

London, England (UroToday.com) In this session, Dr. Wiklund took the side of the debate favoring a robotic approach to radical cystectomy. He concedes that open cystectomy (ORC) is the current standard of care; therefore, robotic cystectomy (RARC) must be compared to it. General principles of RARC are that they have the same guidelines and indications as open cystectomy. Complete bilateral pelvic lymphadenectomy must be performed and negative surgical margins are paramount.

Dr. Wiklund compared his experience with RARC at Karolinska hospital to the Swedish registry including ORC. Blood loss and transfusion rates were less favoring RARC. Operating time was lower in the ORC cohort, but he advanced the caveat that the RARC surgeons may not have been in their optimal learning curve. In fact, the diversion time at Karolinska has decreased from 240 in the first 1-50 cases to 75 minutes over the last 450-499 cases.

There is no difference in intraoperative complications between the two groups. Length of stay favors RARC. He noted that differences may not be seen in randomized trials since postoperative pathways are typically standardized. Therefore, one may fail to realize the benefit of a minimally invasive approach.

From an oncologic standpoint, the positive margin rates are similar. Lymph node count favors RARC, though this may have to do more with the surgeon than the surgical approach. Data regarding survival outcomes are few; however, there does not appear to be an early difference. He touched briefly on unusual spread of metastases (e.g. port sites). While reports exist, he has not seen this at Karolinska and wonders if the nearly universal neoadjuvant chemotherapy that his patients receive may play a role.

Quality of life outcomes have not been different. Specifically, no differences have been note in continence or potency.
In conclusion, Dr. Wiklund stated firmly his belief that RARC is the future of surgical oncology in bladder cancer.

Presented by: N.Peter Wiklund, Stockholm, SE

Written by: Benjamin T. Ristau, MD, SUO Fellow, Fox Chase Cancer Center, Philadelphia, PA

at the #EAU17 -March 24-28, 2017- London, England