Robotic cystectomy shows favorable oncologic outcomes

San Francisco-Based on new mid-term study results, robot-assisted laparoscopic cystectomy appears to be slowly moving toward mainstream surgical practice.

That was the key message from a review presented at the American College of Surgeons Clinical Congress here. A retrospective evaluation of 50 robot-assisted laparoscopic radical cystectomies performed at the University of North Carolina at Chapel Hill found that the robotic procedure offers perioperative outcomes similar to those of more traditional cystectomies and similar oncologic outcomes in the medium term.

"Robot-assisted laparoscopy has emerged as a viable alternative to other techniques," said first author Matthew Pearson, MD, a urology resident at the University of North Carolina working under the direction of Raj S. Pruthi, MD. "This series of procedures shows robotic cystectomy to be technically feasible, with acceptable medium-term oncologic outcomes, but we need longer follow-up before making a positive recommendation."

Potential problems with the robotic procedure include prolonged operating times, increased cost, and compromised oncologic outcomes, including a higher rate of positive margins, more bladder entries, and increased tumor seeding.

Several earlier reports established the technical feasibility of robotic cystectomy, Dr. Pearson noted. But the majority of those early reports focused on surgical and perioperative results, rather than on the oncologic efficacy of the procedure.

Good pathologic outcomes

A total of 86 patients underwent robot-assisted cystectomy at Chapel Hill between January 2006 and June 2008. Researchers selected 50 patients from that population who had had at least 12 months of clinical follow-up for retrospective evaluation. Factors used to evaluate the results included perioperative and pathologic outcomes as well as disease recurrence rate and disease-specific survival.

The mean age of patients in the analysis was 64.5 years. Within the group, 72% were male, 24% had T1 disease, 74% had T2 disease, and 2% had T4 disease. Mean estimated blood loss during surgery was 271 mL and the mean operative time was 5.1 hours. Time to flatus was 2.0 days, time to initial bowel movement was 2.6 days, and time to discharge was 4.5 days. Dr. Pearson noted that 85% of patients had been discharged by day 4 or 5.

Pathologic outcomes were generally good. Sixty-eight percent of the tumors were T2N0 or less, 14% were T3N0 to T4N0, and 18% were TxN+. No patients had positive margins, there was just one bladder entry in the group, and a mean of 19 lymph nodes were removed.

Mean follow-up time was 19.3 months. Thirteen patients (26%) underwent adjuvant chemotherapy. Mean time to adjuvant therapy was 7.3 weeks compared to 10.2 weeks during open cystectomy. There were seven recurrences (14%) and two (4%) disease-specific deaths. Two additional patients died from other causes more than 30 days following cystectomy.

"I do this procedure all the time, and I love it," commented Badrinath R. Konety, MD, associate professor and vice chair of urology and epidemiology and biostatistics, University of California, San Francisco. "The robotic approach to cystectomy gives you much smaller incisions and clear visualization. There are some definite technical advantages; however, longer-term data are needed to clearly establish its benefits vis a vis the open cystectomy."

Dr. Pearson said that surgeons at Chapel Hill are accepting more cystectomy patients for the robotic procedure. In 2006, they were extremely selective, excluding patients with T3 and higher tumors in order to minimize the risk of positive margins. Experience has shown that more advanced tumors also can be removed without leaving positive margins using the robotic procedure.

A randomized, controlled trial to compare oncologic outcomes of robotic and manual laparoscopic radical cystectomy has accrued 30 patients, he added.