Survival rates appear comparable for robotic, open cystectomy

“Journal Article of the Month” is a new Urology Times section in which Badar M. Mian, MD (left), offers perspective on noteworthy research in the peer-reviewed literature. Dr. Mian is professor of surgery in the division of urology at Albany Medical College, Albany, NY.

Radical cystectomy is probably one of the most complex urologic procedures which, despite its significant morbidity, is offered as a life-saving measure. Robot-assisted radical cystectomy (RARC) has been promoted as a means to reduce morbidity of this procedure. Some concerns have been raised that while attempting to reduce the morbidity, a minimally invasive (laparoscopic, robotic) approach could potentially compromise cancer control.

Analyzing the data collected by the International Robotic Cystectomy Consortium (IRCC), Hussein et al report that the long-term oncologic outcomes of RARC appear to be comparable to those reported by others for open cystectomy (J Urol June 12, 2019 [Epub ahead of print]).

The IRCC database contains patient records that were contributed by 26 different institutions from 13 countries. The authors queried the database to identify 731 consecutive patients who underwent RARC at least 10 years ago and noted that 285 (39%) of these patients had either incomplete data or were lost to follow-up.

Of the 446 patients (median age, 67 years) who met the study criteria, only 10% received neoadjuvant chemotherapy. Urinary diversion was performed extracorporeally (open) in 60% of cases and an ileal conduit diversion was constructed in 80% of the cases. Some type of complications (minor or major) were noted in 51%, and high-grade complications were noted in nearly one fourth of the patients (23%) after RARC. The median hospital length of stay was 9 days, and the 90-day mortality after RARC was 4%.

Pathologic stage T3 or higher was noted in 43% (clinical T3 was only 10%), lymph node metastases in 24%, and positive surgical margins 7%. Despite a significant number of patients of high-risk pathology who would probably qualify for adjuvant chemotherapy, it was used in only 20% of cases.

At median follow-up of 5 years, 35% of patients suffered a relapse (local and/or distant). Local recurrence was noted in 15% and distant recurrence in 29% of patients. Peritoneal carcinomatosis developed in six patients (1%) and there were no port site recurrences. The pelvis (5%) and the lungs (7%) were the most common sites of recurrence.

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For the entire cohort, 10-year recurrence-free, disease-specific and overall survival rates were 59%, 65%, and 35%, respectively. As expected, pathologic stage T3, N+, positive margins were associated with worse survival outcomes. Interestingly, longer operative time was associated with worse disease-specific survival. With some exception, RARC often has longer operative time than open cystectomy.

In comparing the results of this analysis of RARC outcomes with previously published open cystectomy series, the authors state that the survival rates and recurrence patterns appear to be comparable. The IRCC should be congratulated for such an effort to collect data from multiple institutions. Despite including their early experience, the long-term data do appear to be comparable to other series.

While not a randomized study, it would be a worthwhile exercise to compare the recurrence and survival rates of RARC with contemporaneous open cystectomy outcomes from the same centers that contributed RARC data to the IRCC. A previously published randomized trial reviewed in an earlier column (“Robot-assisted cystectomy: Do the pros outweigh the cons?” July 2018, p. 9) comparing open cystectomy with RARC demonstrated similar short-term oncologic control and mostly similar perioperative outcomes.

The authors correctly state that the oncologic outcomes appear to be mainly driven by disease aggressiveness rather than by the surgical approach. It’s critically important to not overemphasize the benefits or overlook the concerns related to new technology or surgical approaches as is too often the case in the marketing campaigns by various centers (both academic and community). The incremental improvements in estimated blood loss, operative time, or length of hospital stay are important. But these are typically not the major concerns for these patients undergoing life-changing surgery.

In treating a lethal disease such as muscle-invasive bladder cancer, our efforts must remain squarely focused on improving long-term disease control and survival.