#EAU15 - Is robotic cystectomy (RARC) the future standard? Con position - Session Highlights

MADRID, SPAIN (UroToday.com) - Dr. Bernard Bochner proposed criteria by which to judge a new “standard” for radical cystectomy. First, oncologic—does robotic cystectomy achieve similar cancer-specific outcomes and improve patterns of recurrence? Second, complications/recovery—does robotic surgery lower complication rates, shorten length of stay, and ease overall recovery time? Third, functional—at minimum achieve similar outcomes? Fourth, cost—does it reduce overall costs or achieve significant improvements in the above criteria to justify any increase in cost?

eauDr. Bochner next discussed the meta-analysis of perioperative outcomes and complications after robotic-assisted radical cystectomy (Novara, et al. Eur Urol, 2015). Nearly all studies used in the meta-analysis are level IV data (comprising of case reports or case series) and only 3 studies were level II (randomized, masked).

Complication rates have not changed significantly or decreased between open and robotic cystectomy groups. As there have not been many comparative studies, one can compare robotic series to established reported rates in open cystectomy groups. Dr. Bochner highlighted that 90-day complication rates have remained high (upwards of 75%) in RARC with extracorporeal diversion. Even when intracorporeal diversions had been performed, there had not been any difference in the 90-day complication rates, which ranged to upwards of 75%. Similarly, from the large open radical cystectomy report from MSKCC, 90-day complication rates had been upwards of 64%. Therefore, robotic cystectomies have not changed the complication rates, and reported rates are at best equivalent to open series.

Dr. Bochner then showed the only prospective data from the MSKCC Phase III randomized trial comparing 90-day complications between robotic versus open radical cystectomy. The study was mandated to close early at interim analysis because it met the futility of clinical trial criteria. The study showed no differences in complication rates or differences in length of hospitalization.

He then discussed oncologic and functional outcomes after robotic cystectomy. He highlighted that in the Pasadena Consensus Panel review (Yuh et al, Eur Urol, 2015) there were only 18 publications reported and all survival data was level 4 evidence. Additionally, case-mix of the robotic cystectomy was biased towards less than or equal to T2 disease. For example, in one study, 75% were less than or equal to T2 disease while 25% were > T2 disease. These studies also had shorter follow-up. Both of these limitations make it difficult to compare the robotic cystectomy oncologic outcomes to open cystectomy outcomes. He did highlight one study comparing recurrence patterns of open and robot-assisted cystectomy (Nguyen, et al, Eur Urol 2015). In this study, the robotic cohort had higher incidence of extrapelvic lymph node recurrences compared to open (23% vs 15%) and also had higher rate of peritoneal carcinomatosis on follow-up (6.1% vs 2.7%). Oncologic and functional data from RARC remain immature, and long-term prospective studies are needed.

With respect to cost, Dr. Bochner showed data from a randomized study from MSKCC indicating there is up to $4000 increased cost in robotic cystectomy with neobladder and $1700 increased cost in robotic cystectomy with ileal conduit.

Finally, he summarized each element of the criteria that he had initially outlined. With respect to oncologic outcome, RARC is selected towards early stage disease, has shorter follow-up and there is lack of information on patterns of recurrence. With respect to complications, there is no difference in complications or improvement in length of stay. With respect to function, data is limited, and thus, no conclusions can be drawn. With respect to cost, RARC is significantly more costly.

Presented by Bernard H. Bochner, MD at the 30th Annual European Association of Urology (EAU) Congress - March 20 - 24, 2015 - IFEMA - Feria de Madrid - Madrid, Spain

Memorial Sloan Kettering Cancer Center, New York, NY USA

Reported by Mohammed Haseebuddin, MD, medical writer for UroToday.com