Society of Robotic Surgery 2017: State-of-the-Art Lecture: Improving Outcomes of Radical Cystectomy and Urinary Diversion With Robotics

Miami, Florida USA (UroToday.com) Raj Pruthi, MD, University of North Carolina, presented his state-of-the-art lecture on robotic cystectomy: 10 years later. At first, robotic cystectomy was frowned on and questioned regarding its application in the management of bladder cancer. Large meta-analyses have shown no difference in positive margins between open and robotic cystectomy. In Dr. Pruthi’s randomized trial assessing open vs. robotic cystectomy, there was no difference in lymph node yield, and such findings were confirmed in other series. Furthermore, survival outcomes have not been sacrificed with use of the robot, with no variation in recurrence-free or cancer-specific outcomes between open and robotic approaches. We have increased confidence that we are not compromising oncologic efficacy by performing cystectomy via the robotic approach.

Morbidity associated with robotic cystectomy has been further explored, with a number of studies—single-center and randomized—showing less blood loss and fewer transfusions with the robotic approach. Such a procedure takes approximately one hour longer than the open approach, which can be interpreted as a potential disadvantage with the goal of getting patients off the table as quickly as possible, regardless of method. There is decreased pain and about 1 to 2 fewer days in the hospital with the robotic approach than with the open one. With further refinements in early recovery after surgery pathways and the use of intracorporeal diversion, there may be even less of a stay. There are data to suggest decreased complications with the robotic vs. the open approach.

Quality-of-life (QOL) data are improved for the robotic approach. This was confirmed by FACT BL and FACT VCI QOL with either no difference if not improved QOL outcomes, with a faster return to daily activities/work. Costs of care are important determinants when considering value-based medicine. According to Nix and associates, there was no difference in cost according to approach. These cost data were confirmed in other series and large population-based data from SEER-Medicare where there were no changes in costs based on the approach utilized. Taking the above potential improved outcomes (decreased length of stay, pain, and equivalent oncologic outcomes) with no variations in costs, robotic cystectomy may be the improved value-based modus operandi for treating bladder cancer.

Future directions after a decade of data include expanded worldwide experience. The RAZOR trial is forthcoming and will further elucidate the purported benefits of robotic surgery. The RAZOR trial in the RO1-funded, non-inferior designed trial assesses a 15% difference for robotic vs. open radical cystectomy. The same surgeon is performing both the open and the robotic surgeries in this trial.

Presented By: Raj Pruthi, MD, University of North Carolina

Contributed by Stephen B. Williams, MD, Assistant Professor, The University of Texas Medical Branch at Galveston, Galveston, TX

at the 2017 Society of Robotic Surgery - February 24 - 26, 2017 – Miami, Florida USA

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