Operative time linked to disease-specific survival
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.