NARUS 2018: Robotic Cystectomy: Lessons Learned After 15 Years
Dr. Wiklund states that the same guidelines and indications as open radical cystectomy apply to RARC, namely: complete bilateral pelvic lymph node dissection, attempt to minimize positive margin risk, and perform continent and non-continent urinary diversion. During his RARC, as compared to robotic prostatectomy, Dr. Wiklund is quite aggressive with his nerve-sparing on the prostate. Furthermore, when performing a intracorporeal neobladder he prefers the Studer neobladder, performing the urethral anastomosis prior to creating the pouch. During robotic prostatectomy, he rarely uses a Rocco stitch, however when performing an intracorporeal neobladder he does, stating that with the amount of bowel mobilizing required to bring the neobladder down to the pelvis, it is crucial to take tension off the anastomosis. To assist with bowel mobilization, he utilizes the robotic bowel grasper in his right hand.
Dr. Wiklund is part of the 18 international International Robotic Cystectomy Consortium (IRCC), and this group published their comparison of intracorporeal to extracorporeal urinary diversion after RARC in 2014 [1]. Between 2003 and 2001, 935 patients underwent RARC, of which 167 patients (17.9%) underwent intracorporeal urinary diversion (106 ileal conduit; 61 neobladder), and 768 patients (82.1%) underwent extracorporeal urinary diversion. 90-day post-operative complications were available for 817 patients, of which there was no difference in age, gender, BMI, ASA, rate of prior abdominal surgery, or operative time between the groups. Importantly, the 90-day complication rate was not significant between the groups, however there was a trend favoring intracorporeal diversion (41% vs 49%, p=0.05). However, intracorporeal diversion has not been completely adopted, particularly in North America where in 2014 the rate was 80%, compared to nearly 100% in Europe.
Whether RARC leads to more perioperative complications compared to open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) was addressed in a recent systematic review and cumulative analysis study of which Dr. Wiklund was a co-author [2]. Mean in-hospital stay was roughly 9 days for all approaches, with consistently high readmission rates. In series reporting on RARC with either extracorporeal or intracorporeal conduit diversion, overall 90-day complication rates were 59% (high-grade complication: 15%), and in those reporting intracorporeal continent diversion, the overall 30-day complication rate was 45.7% (high-grade complication: 28%). Comparing RARC and ORC, cumulative analyses demonstrated shorter operative time for ORC, whereas blood loss and in-hospital stay were better with RARC (p values <0.003). Furthermore, comparing ORC and RARC, 90-day complication rates of any-grade and 90-day grade 3 complication rates were lower for RARC (p values <0.04).
A separate systematic review and cumulative analysis assessed the oncologic and functional outcomes after RARC compared to ORC [3]. Among 105 retrieved studies, 87 reported on pathologic, oncologic, or functional outcomes. The lymph node yield for pelvic lymph node dissection was 19 (range: 3-55), with half of the series following an extended template (yield range: 11-55); there was no significant difference in lymph node yield between RARC and ORC. Overall, positive surgical margin (PSM) rates were 5.6% (1-1.5% in pT2 disease and 0-25% in pT3 and higher disease), of which there was no significant difference in rates of surgical margins between RARC and ORC or RARC and LRC. Only six series reported a mean follow-up of >36 mo. The reported 3-year disease-free survival (DFS) was 67-76%, cancer-specific survival (CSS) was 68-83%, and overall survival (OS) was 61-80%. The 5-yr DFS, CSS, and OS rates were 53-74%, 66-80%, and 39-66%, respectively. Limited data were available with respect to functional outcomes: 12-month continence rates with continent diversion were 83-100% in men for daytime continence and 66-76% for nighttime continence. In one series, potency was recovered in 63% of patients at 12 months. The IRCC has also published their long-term oncologic outcomes for 702 patients undergoing RARC with ≥5 year [4]. Pathologic organ-confined disease was found in 62% of patients, soft tissue PSM rate was 8%, and median lymph node yield was 16. Five-year RFS was 67%, CSS was 75%, and OS was 50%. Adjuvant chemotherapy (HR 3.20) and PSMs (HR 2.16) were predictors of RFS.
Dr. Wiklund notes that there is a subset of surgeons with concerns regarding recurrence patterns among patients undergoing RARC. In a single-institution assessment of 383 consecutive patients who underwent ORC (n=120) or RARC (n=263). Over a median follow-up of 30 months, within 2 years of surgery, there was no difference in the number of local recurrences between ORC and RARC patients (23% vs 18%) [5]. The distribution of local recurrences was similar between the two groups, however, there were distinct patterns of distant recurrence: extrapelvic lymph node locations were more frequent for RARC than ORC (23% vs 15%). Furthermore, peritoneal carcinomatosis was found in 21% RARC patients compared to 8% of ORC patients. As Dr. Wiklund points out, these differences reported for extrapelvic nodal recurrence and peritoneal carcinomatosis were not statistically significant.
Dr. Wiklund concluded that RARC has superior results compared to ORC with regards to length of stay, EBL, and shorter time to bowel movements. Furthermore, he notes that there is evidence for equivalent oncologic results between RARC and ORC, and that the evidence to support an association between RARC and unusual recurrence patterns is not strong. According to Dr. Wiklund, future studies should focus on functional outcomes of RARC, as current data are limited.
Presented By: Peter Wiklund, Karolinska University Hospital, Sweden
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. Ahmed K, Khan SA, Hayn MH, et al. Analysis of intracorporeal compared with extracorporeal urinary diversion after robot-assisted radical cystectomy: Results from the International Robotic Cystectomy Consortium. Eur Urol 2014;65(2):340-347.
2. Novara G, Catto JW, Wilson T, et al. Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 2015;67(3):376-401.
3. Yuh B, Wilson T, Bochner B, et al. Systematic review and cumulative analysis of oncologic and functional outcomes after robot-assisted radical cystectomy. Eur Urol 2015;67(3):402-422.
4. Raza SJ, Wilson T, Peabody JO, et al. Long-term oncologic outcomes following robot-assisted radical cystectomy: Results from the International Robotic Cystectomy Consortium. Eur Urol 2015;68(4):721-728.
5. Nguyen DP, Al Hussein Al Awamlh B, Wu X, et al. Recurrence patterns after open and robot-assisted radical cystectomy for bladder cancer. Eur Urol 2015;68(3):399-405.