Oncological safety of Retrograde Extraperitoneal Open Radical Cystectomy (REORC) has been questioned, as keeping the peritoneal intact without exploration of the peritoneal contents and not removing a wide area of the peritoneal reflection over the bladder dome may jeopardize the oncological safety of the procedure either by missing some peritoneal deposits; if present, or by having a positive surgical margin. Nowadays, peritoneal deposits are hard to be missed with current diagnostic modalities. In the present study, we found no differences between REORC and intracorporeal Robot-Assisted Radical Cystectomy (iRARC) regarding the postoperative pathologic outcomes, including the surgical margins and lymph node yield.
Distant tumor seeding by use of the pneumoperitoneum or from port site recurrence raises questions regarding the oncological safety of RARC. However, the RAZOR trial reported comparable local and distant recurrence patterns between both RARC and ORC.
The high cost of acquiring the system and the maintenance costs have always been an important issue in robotic surgery. Bansal et al reported that the cost of RARC is 18.9% greater than that of ORC, with the LOS and operative time the most important cost drivers1. In contrast, because the same platform can be used by different oncologic sub-specialties and surgical specialties, it has been difficult to predict the exact costs of surgical robot usage for a single procedure. We were unable to conduct a cost analysis in the present study owing to the different cost reporting methods used by the healthcare systems in the two countries.
Thus, in institutions in which surgical robots are not readily available, mostly owing to the high costs, REORC could constitute a much more cost-effective approach that is less morbid than ORC, with advantages and outcomes comparable to those with iRARC. A larger prospective randomized study comparing both techniques to the reference standard ORC, including a cost analysis, would be beneficial.
Written by: Khaled Refaai, MD, Uro-Oncology Unit, Department of Genitourinary Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
References:
1. Bansal, Sukhchain S., Tara Dogra, Peter W. Smith, Maisarah Amran, Ishna Auluck, Maninder Bhambra, Manraj S. Sura, Edward Rowe, and Anthony Koupparis. "Cost analysis of open radical cystectomy versus robot‐assisted radical cystectomy." BJU international 121, no. 3 (2018): 437-444.
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