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NARUS 2018: Pushing the Envelope in the Surgical Treatment of Bladder Cancer

Las Vegas, NV (UroToday.com) Dr. Cynthia Leung and colleagues from Yale School of Medicine presented their experience with advanced robotic surgery for bladder cancer at NARUS 2018 annual meeting. Certainly, benefits of robotic surgery for radical cystectomy have been touted as having less blood less and shorter hospitalization. However, in a randomized control trial from Memorial Sloan Kettering Cancer Center, there were comparable outcomes between patients undergoing an open vs robotic approach. The objective of this study was to assess performing robotic cystectomy in older and sicker patients and to assess short-term outcomes. 

The authors undertook a retrospective review of a prospectively maintained database at a single, large volume institution to identify 309 patients undergoing radical cystectomy between 2007-2017. They found 114 robotic cystectomies and 195 open cystectomies. The selection for the robotic vs open approach was based on surgeon preference, and the Charlson Comorbidity Index (CCI) was used as a proxy for patient overall health. The primary end points were intraoperative blood loss (EBL), margin positivity, pathologic stage, complication rate, and length of stay (LOS).

Patients that underwent open surgery were younger (mean 65.5 years vs 72.4 years, p<0.0001), healthier (mean CCI 4.9 vs 6.2, p<0.0001), had greater EBL (mean 818 cc vs 619 cc, p=0.04), and shorter LOS (mean 9.2 vs 11.7 days, p=0.02) compared to patients undergoing robotic cystectomy. Between the two cohorts, there was no significant difference for margin positivity, lymph node positivity, type of urinary diversion, and complication rate. A limitation of the study is the purely descriptive nature of the analysis. 

The authors concluded that robotic cystectomy is a viable alternative to open cystectomy, consistent with previous non-inferiority studies available in the literature. Peri-operative outcomes and oncological control were comparable between the two patient cohorts. Robotic cystectomy may be an option for older patients with greater comorbidities compared to open cystectomy. However, as the authors note, additional long-term follow-up is needed to determine if these two surgical approaches are equivalent in long-term oncologic control, particularly in this high-risk, elderly population. 

Presented By: Cynthia Leung, Yale School of Medicine, New Haven, CT
Co-Author: James Rosoff, Thomas Martin, David Hess

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md ,at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV 

References:
1. Bochner BH, Dalbagni G, Sjoberg DD, et al. Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial. Eur Urol 2015;67(6):1042-1050.