Robot-Assisted Surgery Shows Good Survival and Less Blood Loss in Bladder Cancer

Khurshid Guru, MD

Khurshid Guru, MD

Patients with bladder cancer who undergo robot-assisted radical cystectomy (RARC) appear to have acceptable 5-year survival, according to the largest multi-institutional series to date to collect data on RARC outcomes in this population.¹The outcomes in this series appear to be comparable with those of historical controls who underwent open radical cystectomy (ORC), according to the authors of this study.

"We found that robot-assisted radical cystectomy, an advanced surgical procedure used to treat bladder cancer that has spread to the bladder wall or recurred despite local treatment in the bladder, provides similar early oncologic outcomes [to open radical cystectomy], while reducing operative blood loss," said senior author of the paper, Khurshid Guru, MD, director of robotic surgery at Roswell Park Cancer Institute, Buffalo, NY.

"The importance of this study is that it provides good evidence that you can treat patients with RARC without compromising oncologic outcomes. Before we jump on the bandwagon [of robotic surgery], we want to make sure we can provide oncologic efficacy," Guru stated in an interview withTargeted Oncology.

The retrospective study was based on a review of prospectively treated patients entered on the International Robotic Cystectomy Consortium (IRCC) multi-institutional database. The study was not designed as a direct comparison of RARC and ORC; the authors cited data from four earlier studies of ORC to compare outcomes with more recent studies of RARC.

The study included 743 patients with clinically localized bladder cancer treated with RARC at least 5 years ago or longer. Patients who underwent palliative RARC were excluded, and some patients had missing data. The final analysis was based on 702 patients from 11 different institutions in 6 countries.

Median age was 69 years, 569 (82%) were male, and median time in the operating room was 7.3 hours. Almost two-thirds of patients (62%) had pathologic organ-confined (OC) disease. Eight percent had positive surgical margins. Seventy-five percent of patients were node negative. Positive lymph nodes were found in 137 (21%). One hundred thirty-four patients (24%) received adjuvant chemotherapy, and 507 patients (72%) had extended lymph node dissection, which is thought to contribute to improved staging, and outcomes.

At a median follow-up of 67 months, 5-year rates of relapse-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were 67%, 75%, and 50%, respectively. Overall recurrence rate was 29%, which included an 11% local recurrence rate.  Median time to cancer-specific death and noncancer-specific death was 14 months and 10 months, respectively.

A multivariate analysis showed that nonorgan-confined disease and positive surgical margins were predictors of poorer RFS, CSS, and OS. Age was a significant predictor of CSS and OS. Adjuvant chemotherapy and positive surgical margins were significant predictors of RFS. As would be expected for patients with bladder cancer, poorer survival was associated with positive surgical margins, positive lymph nodes, and nonorgan-confined disease.

In the discussion section of the published study, Guru et al compared 5-year outcomes in the IRCC patients with historical outcomes in previous studies of ORC. Although the ORC studies had different patient characteristics, it would appear that in general, RFS, CSS, and OS are comparable with those of LARC.

RARC is only available at about 1000 or more centers in the United States, Guru said. Advocates of robotic-assisted surgery cite potential advantages such as fewer complications and less blood loss compared with conventional open surgery. However, the robotic technology is expensive. Currently, the cost of the Da Vinci knife is about $2 million or more, and the robotic equipment needs to be maintained and updated. RARC is estimated to cost about $1500 more than ORC.²

"The world is evolving and the times are changing. As more companies come out with robotic technology, the cost is likely to decrease," Guru said.

Small studies to date have shown mixed results on whether or not robotics produce superior outcomes versus open surgery. The present study suggests that outcomes may be similar between the two techniques, but not superior, with robotics.

Guru and colleagues acknowledge the limitations of this retrospective analysis and the inherent differences in experience of surgeons, operative volume, patient selection, and reporting bias of their study. They hope that the information gleaned from this series will prompt randomized trials to compare RARC and ORC directly and provide more definitive data.

References:

1) 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. doi: 10.1016/j.eururo.2015.04.021.

2. Robotic Oncology.http://www.roboticoncology.com/pr/IsTheCostOfRoboticSurgeryJustified/. Accessed July 30, 2015.