Robotic cystectomy safer than open cystectomy

Robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) comes with lower perioperative blood loss and a shorter recovery period than open cystectomy (ORC), according to a recent Singapore study.

“Evidence supporting RARC with iRARC remains limited, with mostly case series. Herein, we compare the perioperative and oncological outcomes between total iRARC versus ORC for primary bladder carcinoma in a contemporary cohort,” researchers said.

Nineteen patients underwent iRARC (mean age, 63 years; 84.2 percent male), while 21 received ORC (mean age, 67 years; 66.7 percent male), for the treatment of bladder carcinoma. Neoadjuvant chemotherapy was more common in the iRARC group, as was the use of salvage surgery for radiorecurrent disease. Otherwise, the two cohorts were largely equivalent and required little propensity score adjustment. [Int J Urol 2020;doi:10.1111/iju.14300]

Patients in the iRARC group had significantly longer procedures (581 vs 446 minutes; p=0.03), during which they lost a significantly smaller volume of blood (397 vs 787 mL; p=0.05; hazard ratio [HR], 2.11, 95 percent confidence interval [CI], 1.26–3.52).

Length of stay (7.0 vs 8.3 days; p=0.55) and postoperative opioid administration (1.0 vs 3.0 days; p=0.11) were likewise nominally shorter in the iRARC vs ORC groups. Rates of minor and major complications, as well as of unexpected 30-day readmissions, were comparable between groups.

The relative advantage in iRARC safety was not accompanied by compromises in efficacy. The average lymph node yield was 29, which was not significantly worse than the 34 yield in ORC patients (p=0.23). Pathological outcomes were likewise similar, with 52.6 percent and 47.7 percent of the iRARC and ORC patients at ≥T3 disease, respectively (p=0.85).

The iRARC procedure conferred a better recurrence-free survival duration than ORC (37.5 vs 21.4 months), with a difference that was of borderline significance (p=0.09). Overall survival was likewise nominally better with iRARC (43.0 vs 35.3 months; p=0.14). All patients achieved negative margins.

“The present study expanded on the current literature by evaluating the added benefit of iRARC compared with ORC in the setting of a standardized [enhanced recovery after surgery] protocol,” the researchers said. “The propensity-matched analyses ensured comparable patient demographics and tumour characteristics, which could invariably impact outcomes.”

Important limitations of the present study are its nonrandomized design and the lack of a longer-term follow-up. The oncological efficacy of iRARC relative to ORC was assessed for only up to approximately 33 months, and thus could have missed important outcomes that might arise thereafter.

However, the researchers pointed out that their intermediate-term efficacy findings would likely be representative of future trends. “Despite lacking a longer follow-up period, it remains unlikely that long-term oncological effectiveness will diverge, given the comparable pathological outcomes in both groups.”

“The favourable perioperative and oncological outcomes support the implementation of iRARC as a reasonable alternative approach for treating bladder cancer in centres with a modest workload,” they added.