A comparison of pathologic and intermediate term oncologic outcomes following open and robotic radical cystectomy.

Positive Surgical Margins in Soft Tissue Following Radical Cystectomy for Bladder Cancer and Cancer Specific Survival

Analysis of open and intracorporeal robotic assisted radical cystectomy shows no significant difference in recurrence patterns and oncological outcomes

To compare surgical parameters and short-term outcomes between open radical cystectomy (ORC) and robotic radical cystectomy with total intracorporeal urinary diversion (icRARC). Among the study period, 133 patients who underwent ORC and pelvic node dissection for bladder cancer (group 1) were matched and compared to 61 patients who underwent icRARC during the same period (group 2). The groups were matched 1:1 according to their propensity scores adjusted on their baseline demographics and disease characteristics. The main surgical parameters compared were: operative time, estimated blood loss (EBL), and postoperative outcomes including time to oral intake, ninety-day complications, readmission rate, and secondary procedures. Overall, 122 patients (61 in each group) were matched and finally analyzed. Although operative times (307 ± 97min vs. 444 ± 113min; p < 0.001) were longer, EBL (948 ± 657ml vs. 357 ± 219ml; p < 0.001) and transfusion rates were lower in the icRARC group. Overall complications were comparable but late complications tended to be lower in the icRARC group (p = 0.06). Readmission rate (54.8% vs. 26.8%, p = 0.01) was higher in the ORC group while secondary procedures (28.6% vs. 12.5%, p = 0.07) also tended to be lower in the robotic approach. Finally, in multivariable logistic regression the icRARC group was not associated with any complications of any grade including grade 3 or higher compared to the open approach. This study comparing open radical cystectomy to robotic radical cystectomy with total intracorporeal urinary diversion demonstrated encouraging outcomes for the minimally invasive management of urothelial carcinoma.

Radical cystectomy represents the standard of care for muscle-invasive bladder cancer (MIBC). Due to its novelty the use of robotic radical cystectomy (RARC) is still under debate. We examined intraoperative and postoperative morbidity and mortality in addition to impact on length of stay (LOS) and total hospital charges (THCGs) of RARC compared with open radical cystectomy (ORC). Within National Inpatient Sample (2008-2013), we identified patients with nonmetastatic bladder cancer treated with either ORC or RARC. We relied on inverse probability of treatment weighting to reduce the effect of inherent differences between ORC vs RARC. Multivariable logistic regression (MLR) and multivariable Poisson regression (MPR) models were used. Of all 10,027 patients, 12.6% underwent RARC. Between 2008 and 2013, RARC rates increased from 0.8% to 20.4% [estimated annual percentage change (EAPC): +26.5%, 95% confidence interval (CI): +11.1 to +48.3; p = 0.035] and RARC THCGs decreased from 45,981 to 31,749 United States dollars (EAPC: -6.8%, 95% CI: -9.6 to -3.9; p = 0.01). In MLR models RARC resulted in lower rates of overall complications [odds ratio (OR): 0.6; p < 0.001] and transfusions (OR: 0.44; p < 0.001). In MPR models, RARC was associated with shorter LOS (relative risk 0.91; p < 0.001). Finally, higher THCGs (OR: 1.09; p < 0.001) were recorded for RARC. Data are retrospective and no tumor characteristics were available. RARC is related to lower rates of overall complications and transfusions rates. In consequence, RARC is a safe and feasible technique in select MIBC patients. Moreover, RARC is associated with shorter LOS, although higher THCGs.

To compare the outcomes of robotic-assisted (RARC) vs. open radical cystectomy (ORC) at a single academic institution. We retrospectively identified patients undergoing radical cystectomy for urothelial carcinoma of the bladder at our institution from 2007 to 2017. Data collected included age, sex, Body Mass Index (BMI), Charlson Age-Adjusted Comorbidity Index (CCI), final pathologic stage, surgical margins, lymph-node yield, estimated blood loss (EBL), 90-day complication rate, and length of stay (LOS). We evaluated overall survival (OS) and recurrence-free survival (RFS). Multivariable Cox proportional hazard models were used to adjust for covariates. We identified 232 patients (73 RARC, 159 ORC) who underwent radical cystectomy. Patients who underwent RARC were older (71.8 vs. 67.5, p < 0.05) and had higher CCI scores (6.2 vs. 5.3, p < 0.05). In comparing perioperative outcomes, RARC patients had lower EBL (500 vs. 850, p < 0.01), lower blood transfusion rate (p < 0.01), and lower lymph-node yield (12 vs. 20, p < 0.01), and higher ICU admission rate (29% vs. 16% p < 0.01). There was no difference in BMI (p = 0.93), sex (p = 0.28), final pathological stage (p = 0.35), positive surgical margins (p = 0.47), complications (p = 0.58), or LOS (p = 0.34). Kaplan-Meier analysis showed no difference in OS (p = 0.26) or RFS (p = 0.86). There was no difference in restricted mean survival time for OS (53 vs. 56months, p = 0.81) or for RFS (65 vs. 64months, p = 0.90). Cox multivariate regression models showed that surgical approach does not have a significant impact on OS (p = 0.46) or RFS (p = 0.35). Our study indicates that in our 10-year experience, patients undergoing there was no difference between RARC and ORC patients with respect to OS and RFS despite being older and having more comorbidities. Our work supports the importance of patient selection to optimize outcomes.

Radical cystectomy nowadays is the treatment of choice for muscle-invasive bladder cancer. Despite many efforts, the overall, cancer-specific survival and complication rate of patients after this procedure has not changed in the last few decades. In the recent years many fast recovery protocols or “fast track” programs have been designed to become the basis of perioperative management after colorectal surgery, vascular, thoracic, and even more recently radical cystectomy [1, 2]. These programs attempt to modify the physiological and psychological responses to major surgery, contributing to the reduction of post- surgical complications and hospital stay, and to the improvement of the cardiopulmonary and bowel function after surgery; this is translated into a faster recovery for patients [3, 4]. Nowadays, there are only a few studies based on the use of fast recovery protocols in urological surgery, this is why the authors of the paper “Alvimopan: A cost-effective tool to decrease cystectomy length of stay” [5] should be congratulated on presenting their experience concerning this topic. Arumainayagam et al. in 2007 implemented a fast recovery protocol which led to a significant reduction in hospital stay and an equivalent reduction in morbidity for patients undergoing radical cystectomy compared with traditional clinical guidelines [1]. The usage of a minimally invasive approach is included in the 22 items of the ERAS society recommendations [4]. Minimally invasive pelvic surgery has been shown to decrease the inflammatory response when compared to the open approach. Recently, laparoscopic and robotic radical cystectomy has been increasingly performed in the treatment of bladder cancer and merits special consideration. While open radical cystectomy and pelvic lymph node dissection remain the gold standard in treating non-metastatic muscle invasive bladder cancer, this major surgery is still associated with high morbidity close to 70% in some cases. Numerous centers have reported in the last years their experience with laparoscopic or robotic approach [6]. Unfortunately, most of these studies reported retrospective data or prospective comparative data. Despite these limitations, laparoscopic and robot-assisted radical cystectomy seem to be associated with overall lower perioperative complications, and shorter hospital stay with equivalent short term oncological safety. Future high quality, high volume controlled studies should help in reaching definitive conclusions. Intestinal complications are one of the most common problems after radical cystectomy. The etiology of ileus is multifactorial with a combination of central and peripheral nervous system, hormonal influences, neurotransmitter and local inflammatory pathways. Surgical stress, bowel manipulation, opioids and intraoperative fluids can break the standard homeostasis in the gastrointestinal tract and produce postoperative ileus and impaired function of gastrointestinal absorption; so the prevention and management of this complication should be with a multidisciplinary team (Nutrition, Anesthesiology and Urologist). Factors that help to reduce this are epidural anesthesia, minimally invasive surgery, fine tissue manipulation, avoidance of fluid overload, and early oral feeding. In addition, the routine use of nasogastric tube decompression should be avoided after surgery because of the higher incidence of fever, atelectasis and pneumonia in patients who carry it, and if any nasogastric tube is used during surgery it should be removed before extubation. Since 2012 our department has been exercising the application of an “early recovery protocol after surgery” program for patients undergoing laparoscopic radical cystectomy and urinary diversion with the collaboration of the Anesthesiology and Reanimation Department, and the Nutrition Unit of our hospital. We hope to have positive results in the years to come. The usage of fast recovery programs as the presented in this article using the Alvimopan shows that this is a feasible multidisciplinary challenge and is useful in the recovery of patients undergoing radical cystectomy, demonstrated by a shorter hospital stay without the increasing risk of postoperative complications. Future multicenter collaborations evaluating prospective cohorts of urological patients following identical standardized care pathways should be performed.

Robotic Radical Cystectomy with Intracorporeal Neobladder: Ready for Prime Time?

1226 PERIOPERATIVE COST COMPARISON OF ROBOTIC AND OPEN RADICAL CYSTECTOMY FOR BLADDER CANCER

Robotic vs. open radical cystectomy in bladder cancer: A systematic review and meta-analysis

Implications of Definitive Prostate Cancer Therapy on Soft Tissue Margins and Survival in Patients Undergoing Radical Cystectomy for Bladder Urothelial Cancer

Evaluation of the learning curve associated with robotic radical cystectomy: Initial 100 cases

Chewing Gum Has a Stimulatory Effect on Bowel Motility in Patients After Open or Robotic Radical Cystectomy for Bladder Cancer: A Prospective Randomized Comparative Study

Background: Minimally invasive cystectomy is being increasingly performed, however, data comparing laparoscopic radical cystectomy (LRC) and robotic radical cystectomy (RRC) are scarce. We compared 30- and 90-day Clavien-Dindo Classification (CDC) complications between patients undergoing LRC and RRC at our center. Materials and Methods: We retrospectively evaluated 300 patients who underwent minimally invasive radical cystectomy from January 2007 to July 2019 and grouped them into LRC (112 patients) and RRC (188 patients). We compared the two groups for demographic variables, perioperative characteristics, and 30- and 90-day CDC overall, minor, and major complications. Multivariable logistic regression analysis was performed to identify variables that predict perioperative complications. Results: The two groups were comparable for the duration of surgery (270 minutes in LRC vs 265 minutes in RRC) and rate of conversion to open surgery. The RRC cohort had a higher estimated blood loss (EBL) (675 mL vs 500 mL, p = 0.006), but the two groups had a comparable need for intraoperative transfusion. Patients undergoing RRC also had a shorter duration of hospital stay (13 days vs 14 days, p < 0.001). There was no difference between the two groups for 30- and 90-day CDC overall, minor, and major complications. The incidence of rehospitalization within 30 days (p = 0.1) and surgical reintervention (p = 0.5) was also comparable between the two groups. On multivariable logistic regression analysis, approach to cystectomy (RRC vs LRC) was not a significant predictor of 30-day CDC overall and major complications. Conclusion: LRC was associated with lesser EBL, whereas the hospital stay was shorter in patients undergoing RRC. The two approaches were comparable with each other for 30- and 90-day CDC overall, minor, and major complications. The choice between the two approaches should depend on availability and surgeon experience and preference, rather than any specific perioperative parameter.

Radical cystectomy with pelvic lymph node dissection is the recommended treatment in non-metastatic muscle-invasive bladder cancer (MIBC). In randomised trials, robot-assisted radical cystectomy (RARC) showed non-inferior short-term oncological outcomes compared with open radical cystectomy (ORC). Data on intermediate and long-term oncological outcomes of RARC are limited. To assess the intermediate-term overall survival (OS) and recurrence-free survival (RFS) of patients with MIBC and high-risk non-MIBC (NMIBC) who underwent ORC versus RARC in clinical practice. A nationwide retrospective study in 19 Dutch hospitals including patients with MIBC and high-risk NMIBC treated by ORC (n = 1086) or RARC (n = 386) between January 1, 2012 and December 31, 2015. Primary and secondary outcome measures were median OS and RFS, respectively. Survival outcomes were estimated using Kaplan-Meier curves. A multivariable Cox regression model was developed to adjust for possible confounders and to assess prognostic factors for survival including clinical variables, clinical and pathological disease stage, neoadjuvant therapy and surgical margin status. The median follow-up was 5.1 years (95% confidence interval ([95%CI] 5.0-5.2). The median OS after ORC was 5.0 years (95%CI 4.3-5.6) versus 5.8 years after RARC (95%CI 5.1-6.5). The median RFS was 3.8 years (95%CI 3.1-4.5) after ORC versus 5.0 years after RARC (95%CI 3.9-6.0). After multivariable adjustment, the hazard ratio for OS was 1.00 (95%CI 0.84-1.20) and for RFS 1.08 (95%CI 0.91-1.27) of ORC versus RARC. Patients who underwent ORC were older, had higher preoperative serum creatinine levels and more advanced clinical and pathological disease stage. ORC and RARC resulted in similar intermediate-term OS and RFS in a cohort of almost 1500 MIBC and high-risk NMIBC.

Neoadjuvant chemotherapy (NAC) in the management of muscle-invasive bladder carcinoma has not been adopted universally. We studied the oncological outcomes and complications in patients who underwent radical cystectomy (RC) with or without NAC. A retrospective review of patients who underwent RC with or without NAC from June 2009 to June 2020 was conducted. Oncological outcomes, overall survival (OS) and recurrence-free survival (RFS), complications, and prognostic factors were analyzed. Of the 314 patients who underwent RC, 83 patients received NAC (Group A), and 231 underwent RC alone (Group B). The median age was 58 years. The median follow-up duration was 22 (3-64) and 24 (3-62) months, respectively. The median OS in Group A was significantly higher than Group B (38 months [confidence interval (CI): 34-42] and 32 [CI: 29-35], respectively, [P = 0.033]). The RFS in Groups A and B was 34 (CI: 30-39) and 31 (CI: 28-34) months, respectively (P = 0.47). Higher pathological T stage (T3/4), node positivity and lymphovascular invasion (LVI) were predictors of poor OS and RFS (P < 0.0001). Clavien grades 3/4 complications were comparable (8% vs. 15%; P = 0.19). Glomerular filtration rate (GFR) <60 mL/min/1.73 m2 was associated with higher postoperative complications in both groups (P = 0.012). The OS with NAC was superior to upfront RC. RFS was, however, comparable. NAC was safe and well-tolerated. Pathologically, higher T stage, node positivity, and LVI were associated with poorer OS and RFS. Low GFR negatively influenced postoperative complications.