Comparison of Oncologic Outcomes Following Open and Robotic-assisted Radical Cystectomy with both Extracorporeal and Intracorporeal Urinary Diversion - Beyond the Abstract

Robot-assisted radical cystectomy (RARC) with intracorporeal or extracorporeal urinary diversion has become the preferred approach for radical cystectomy at many institutions. The use of RARC has been justified through improved perioperative outcomes such as blood loss, length of stay, and major complications.


Concerns have been raised about the oncologic efficacy of RARC due to reports of atypical recurrence patterns.1 Randomized controlled studies, such as the RAZOR trial, have not demonstrated any differences in oncologic outcomes.2 However, these assessments may have been underpowered to aberrant recurrences due to low event rate and patient enrollment volume. Additionally, intracorporeal urinary diversion was not performed in these trials. Though large multi-institutional retrospective studies, such as those from the International Robotic Cystectomy Consortium (IRCC), included patients undergoing intracorporeal urinary diversion, may be limited due to their non-comparative nature and heterogeneity in individual surgeon volume and practice pattern.3 Therefore, a large single-institution study from a high-volume center may help elucidate any differences in oncologic outcomes for patients undergoing radical cystectomy (RC).

We conducted a retrospective review of our institutional database for patients receiving open RC or RARC with intracorporeal or extracorporeal urinary diversion during 2010-2018. Patients undergoing cystectomy for non-oncologic indications, palliative cystectomy, or non-primary urothelial histology were excluded. Seven surgeons, each with at least 50 cases, compromised more than 90% of the database. Our primary outcomes were recurrence-free survival (RFS) and overall survival (OS) and were compared with the Kaplan-Meier method with log-rank. Predictors of OS and RFS were found using multivariable Cox Regression. Sites of recurrence were also captured and compared utilizing the Pearson Chi-Squared test.

Our cohort included 916 patients with median follow-up ranging from 52 months (ORC) to 37 months (iRARC). On Kaplan Meier analysis, there were no statistically significant differences in either OS or RFS. Additionally, predictors of oncologic outcomes were established predictors such as pathologic T2 disease or worse or N2/N3 disease. Surgical approach was not a significant predictor on adjusted regression analysis. When comparing recurrence patterns, there were no statistically significant differences between the groups, which reduces concerns about abnormal recurrence patterns that have been reported in prior series. Contrary to prior retrospective series, we did not observe any increased rates of port-site recurrences or peritoneal carcinomatosis.4

The strengths of our study are its large sample size with RC performed by a diverse yet experienced group of surgeons. While our study is subject to the limitations of a retrospective review, it confirms findings in previous randomized control trials and validates previously reported predictors of oncologic outcomes following radical cystectomy. Given the rapid increase in iRARC, our cohort provides a real-world contemporary analysis of these patients undergoing RC and suggests that as long as surgical technique is properly applied, RARC is an oncologically sound surgery that may offer benefits with regards to convalescence.

Written by: Prithvi B. Murthy, MD, Zaeem Lone & Byron H. Lee, MD, PhDDepartment of Urology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA


References:

  1. Bochner BH, Dalbagni G, Marzouk KH, Sjoberg DD, Lee J, Donat SM, et al. Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: Oncologic Outcomes. Eur Urol 2018;74:465–71. https://doi.org/10.1016/j.eururo.2018.04.030.
  2. Parekh DJ, Reis IM, Castle EP, Gonzalgo ML, Woods ME, Svatek RS, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. The Lancet 2018;391:2525–36. https://doi.org/10.1016/S0140-6736(18)30996-6.
  3. Hussein AA, May PR, Jing Z, Ahmed YE, Wijburg CJ, Canda AE, et al. Outcomes of Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium. J Urol 2018;199:1302–11. https://doi.org/10.1016/j.juro.2017.12.045.
  4. 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. doi:10.1016/j.eururo.2015.02.003

 
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