Washington, DC (UroToday.com) In this morning’s bladder cancer session, Dr. Dipen Parekh opened the debate between open (ORC) and robotic radical cystectomy (RALRC) with evidence in favor of RALRC. A comparison of variables between the two approaches showed that EBL, transfusion requirement, narcotic use, and time to oral diet all favor RALRC, while OR time favors ORC, depending on the diversion used. Further support came from the 2014 randomized trial between RALRC and ORC (Bochner
et al, NEJM) that demonstrated no difference in complications between the two approaches, a longer OR time for the robotic approach, and similar length of stay. Dr. Parekh’s group performed a pilot study that randomized patients between RALRC and ORC, and found similar EBL, longer OR time, and shorter length of stay in the robotic arm. A separate study by their group also demonstrated no difference between the groups in quality of life.
An important comparison between the two arms is whether the same procedure can be performed oncologically. Dr. Parekh reviewed data showing no difference in positive margin rate and nodal yield (RALRC demonstrated increased nodal yield in one meta-analysis). Data from the IRCC demonstrates 5-year RFS of 67%, CSS of 75%, and OS of 50%.
Costs are mostly impacted by OR time and length of stay. For institutions showing a decreased length of stay in RALRC, while direct OR costs are more expensive, total patient costs are 38% less with RALRC.
Dr. Parekh suggested that the surgeon is the most important variable, regardless of the approach, and that open surgery isn’t necessarily the gold standard. Evidence comes from multiple studies showing failure to perform lymph node dissection in up to 40% of cases, and lymph node yield < 10 nodes in up to 78% of cases. He concluded that while RALRC is here to stay, it is critical to train current and future surgeons in sound oncologic principles using both approaches.
Dr. Dipen Parekh, MD
University of Miami
Dr. Nikhil Waingankar, MD from the Society of Urologic Oncology Meeting - December 2 - 4, 2015 – Washington, DC.
Fox Chase Cancer Center, Philadelphia, PA.