EAU 2018: Bladder Cancer: Immediate and Late Complications of Robotic Cystectomy
Dr. Palou, starts his discussion reviewing the common definitions of operative complications used in the literature and the variability in reporting. He notes that over the last 10 years, the rates of complications reported have ranged from 16% up to 86%, the main difference being the actual definition of a complication. Sadly, there is no consensus procedure-specific complications, forcing us to rely on universal reporting systems, such as the Clavien-Dindo Classification, which often leads to significant variation in reporting.
Dr. Palou identifies two phases in which tend to affect the surgical outcomes of patients undergoing a radical cystectomy: pre-operative, and intra-operative setting. Given the elderly and frail state of bladder cancer patients, pre-operative optimization of patients prior to radical cystectomy is likely the most significant modifiable factor for the prevention of operative complications. Moreover, identification of possible intra-operative difficulties with a careful review of the patient’s medical history (prior pelvic surgery, radiation or IBD) and cross-sectional imaging (tumor extension into adjacent structures) have the potential to avoid many intra-operative complications.
In regard to intra-operative complications, several reports have compared open radical cystectomy to robotic most showing improvements in blood loss and length of hospital stay. Patients undergoing an open cystectomy tend to have shorter operations, but their pain scores appear to be worse. The introduction of ERAS pathways during progression of these trials may have blunted the benefit of robotic radical cystectomy, given the faster return of bowel function and overall shorter hospitalization rates seen in ERAS protocols. Transfusion rates were also significantly lower in the robotic cohorts, which is important given the rising evidence that post-operative transfusions may lead to worse oncological outcomes. Lastly, early reports of robotic cystectomy reported a higher than usually local recurrence rates which were thought to occur due to urine extravasation during the operation. A report by the group at Roswell Park Cancer Institute (Raza et al. Eur Urol 2014), showed that careful clipping or tying of urethral stump could prevent tumor seeding and local recurrences comparable to those seen with open cystectomy. Lastly, recent reports have noted a possible reduction in ureteroenetric anastomotic stricture rates with robotic cystectomy, due to the ability to perform the anastomosis deep in the pelvis where the ureters require less manipulation. These studies remain small, and retrospective in nature and validation with prospective trials will be needed, but they do offer some insight into the prevention of a complication which continues to plague the field, where there is limited data on its prevention.
In summary, robotic cystectomy appears to be comparable to open radical cystectomy in regard to early and late post-operative complications, with robotic radical cystectomy having the benefit of decreased blood loss and shorter hospital stays. Increasing experience with intra-corporeal diversions appears to show a benefit with a lower incidence of ureteroeneteric anastomotic strictures, which if validated in prospective trials may move the field into a faster adoption of minimally invasive robotic radical cystectomies with intra-corporeal urinary diversions.
Presented by: Joan Palou Redorta MD, Chief of Urology Department, Fundacio Pulgvert, Associated Professor of Urology, Universidad Autonoma de Barcelona
Written by: Andres F. Correa, Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark