SUO 2018: Impact of Robotics - The Changing Face of Urologic Oncologic Surgery from 2000-2018

Phoenix, Arizona ( Dr. Gill presented work from his department titled “The Changing Face of Urologic Oncologic Surgery from 2000-2018 (63,141 patients) - Impact of Robotics”. This work evaluated the current status of urologic oncologic surgery by comparing outcomes of open and robotic surgery over the past 17 years.  The five key questions that were studied through this systemic review were a comparison of open and robotic surgery regarding penetrance in the field, peri-operative outcomes, oncologic outcomes and survival, functional outcomes and financial cost.  Premier database was utilized to study penetrance of robotics in the field of urology. Radical prostatectomy (RP) is dominated by robotics (85%) with cross-over of curves occurring around 2008. For Partial Nephrectomy (PN), again most surgeries are performed robotically (66%) with cross-over of curves occurring around 2012. For Radical Cystectomy (RC), open surgery continues to be dominant with 33% of cases being done robotically. Similarly, for Radical Nephrectomy (RN), open surgery continues to be dominant with only 24% of cases being done robotically. Compared to 2005, these 2017 data indicate robotic surgery increased 4-fold for RP, 11-fold for RC, 110-fold for PN and 9-fold for RN. In 2005, of the 105,300 prostate, bladder and kidney cancer surgeries, robotics comprised 30%; in 2017, this increased to 69% of the aggregate 88,198 surgeries. Robotic surgery had higher costs, primarily operative.

Dr. Gill summarized the methodology and results of this meta-analysis using summary forest plots, which included data from 181 papers comprising 63,141 unique surgical cases. Overall, 2043 Forest plots were generated in this meta-analysis and showed that robotic-assisted surgery was associated with less blood loss, fewer surgical complications, and shorter hospital length of stay compared with open surgery, but it costs more than open surgery and takes longer to perform. Robotic-assisted RP was associated with improved continence and potency rates compared with open RP. Positive surgical margin status favored robotic RP, and the recurrence rate was lower in robotic RP and robotic PN. Surprisingly, overall and cancer-specific mortality for radical cystectomy favored robotic surgery. Lymph node yield was also higher for robotic RC. Sensitivity analyses were performed to adjust for baseline characteristics. Dr. Gill explained this surprising result and stressed that the quality of the systemic review is based on the included studies and therefore the oncological outcomes results could be flawed. Only 27% of the included studies were Level 1 or 2 evidence.

Dr. Gill concluded his talk by summarizing the strengths and limitations of their meta-analysis. He highlighted the weakness such as sub-optimal level of evidence of included studies and unable to adjust for unknown covariates. This is the first study to examine the entire spectrum of urologic oncologic surgery over 17 years.

Presented by: Inderbir S. Gill, MD, Chairman of Urology, University of Southern California, Los Angeles, California

Written by: Abhishek Srivastava, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, Pennsylvania, @shekabhishek, at the 19th Annual Meeting of the Society of Urologic Oncology (SUO), November 28-30, 2018 – Phoenix, Arizona