Robotic-assisted radical cystectomy for bladder cancer: Intracorporeal urinary diversion of benefit

Intracorporeal urinary diversion (ICUD) is associated with similar postoperative complication rates, reduced blood loss and shorter hospitalization vs extracorporeal urinary diversion (ECUD) in patients undergoing robotic-assisted radical cystectomy (RARC) for localized bladder cancer, data from the Asian RARC Consortium registry have shown.

In a recent study, researchers from the nine centres participating in the Asian RARC Consortium evaluated perioperative outcomes of 556 consecutive patients with bladder cancer who underwent RARC between 2007 and 2020. The primary outcomes were minor (ie, grade 1/2), major (ie, grade ≥3) and overall postoperative complication rates. [Ann Surg Oncol 2021;28:9209-9215]

The study, led by urologists from the Chinese University of Hong Kong (CUHK), showed similar overall complication rates between the 307 patients who underwent ICUD and the 249 patients who underwent ECUD (51.3 percent vs 47.8 percent; p=0.409).

“Major complications occurred in 15.0 percent vs 17.4 percent of patients in the ICUD vs ECUD group, while minor complications occurred in 36.3 percent vs 30.4 percent of the patients,” reported first author, Dr Jeremy Teoh of the Division of Urology, Department of Surgery, CUHK.

Furthermore, ICUD was associated with additional benefits of reduced estimated blood loss (423.1 mL vs 541.3 mL for ECUD; p=0.002) despite a longer operative time (362.8 minutes vs 329.4 minutes; p=0.002), as well as shorter hospital stay (15.7 days vs 17.8 days; p=0.042).

The study included patients from Korea (n=177), Japan (n=110), Hong Kong (n=82), Australia (n=60), Taiwan (n=46), mainland China (n=38), Thailand (n=23), and Singapore (n=20). At baseline, patient characteristics and disease characteristics were similar between the ICUD and ECUD groups. Approximately three quarters of patients had high-grade tumours, more than half had T2 or above disease, while about one-fifth had positive nodal status.

Neobladder was more commonly performed for urinary reconstruction in the ICUD vs ECUD group (48.4 percent vs 29.5 percent; p<0.001), while urethrectomy was more commonly performed in the ECUD vs ICUD group (14.7 percent vs 8.5 percent; p=0.026).

“Our study shows that RARC with ICUD is equally safe and feasible compared with ECUD, with additional benefits of reduced blood loss and shorter hospitalization. RARC plus ICUD could potentially be the best possible minimally invasive approach in treating muscle-invasive bladder cancer [MIBC],” Teoh suggested.

“At the Prince of Wales Hospital, more than 100 patients with MIBC have been treated with RARC plus ICUD so far,” he added.

However, the expertise of centres and surgeons involved may partially attribute to the favourable results for ICUD in the current study, the researchers pointed out. “Centres participating in the Asian RARC Consortium were dedicated to urological cancers, and the surgeons involved were all experts in managing bladder cancer,” they noted.

“There is certainly a steep learning curve for performing RARC with ICUD, which is regarded as one of the most challenging robotic-assisted surgeries in urology. A 30-case experience was generally needed to attain an acceptable level of proficiency,” they continued. “The impacts of learning curve on the perioperative outcome of RARC with ICUD should not be overlooked.”

Currently, the multicentre, randomized iROC trial is comparing RARC with ICUD vs open radical cystectomy, with an aim to recruit 320 patients. Initial results from the first 30 patients showed that RARC with ICUD was safe and well tolerated. [BMJ Open 2018;8:e020500; European Urol 2018;74:531-534]