Is robotic-assisted radical cystectomy (RARC) with intracorporeal diversion becoming the new gold standard of care?

Pre-Op Hydronephrosis Predicts Outcomes in Patients Receiving Robot-Assisted Radical Cystectomy

INTRODUCTION

Robot-assisted radical cystectomy (RARC) has gained momentum in the management of muscle invasive bladder cancer (MIBC). Predictors of RARC outcomes are not thoroughly studied. We aim to investigate the implications of preoperative hydronephrosis on oncological outcomes.

PATIENTS AND METHODS

This study analysed data from the Asian RARC consortium, a multicentre registry involving nine Asian centres. Cases were divided into two groups according to the presence or absence of pre-operative hydronephrosis. Background characteristics, operative details, perioperative outcomes, and oncological results were reviewed. Outcomes were (1) survival outcomes, including 10-year disease-free survival (DFS) and overall survival (OS), and (2) perioperative and pathological results. Multivariate regression analyses were performed on survival outcomes.

RESULTS

From 2007 to 2020, 536 non-metastatic MIBC patients receiving RARC were analysed. 429 had no hydronephrosis (80.0%), and 107 (20.0%) had hydronephrosis. Hydronephrosis was found to be predictive of inferior DFS (HR = 1.701, p = 0.003, 95% CI = 1.196-2.418) and OS (HR = 1.834, p = 0.008, 95% CI = 1.173-2.866). Subgroup analysis demonstrated differences in the T2-or-above subgroup (HR = 1.65; p = 0.004 in DFS and HR = 1.888; p = 0.008 in OS) and the T3-or-above subgroup (HR = 1.757; p = 0.017 in DFS and HR = 1.807; p = 0.034 in OS).

CONCLUSIONS

The presence of preoperative hydronephrosis among MIBC patients carries additional prognostic implications on top of tumour staging. Its importance in case selection needs to be highlighted.

Robot-assisted radical cystectomy with intracorporeal Mainz Ⅱ rectosigmoid pouch for muscle-invasive bladder cancer

BACKGROUND

To report the surgical techniques and results of robot-assisted radical cystectomy (RARC) with intracorporeal Mainz Ⅱ rectosigmoid pouch at our centre.

METHODS

Two female patients were treated with this procedure. Construction of the pouch was divided into four main steps: incision of the rectum and sigmoid colon, closure of the posterior wall of the pouch, reimplantation of the ureters at the bottom of pouch in an anti-reflux manner, and closure of the anterior wall. Surgical results and perioperative complications were assessed.

RESULTS

The operations were performed completely intracorporeally. No perioperative complications were observed. Postoperatively, high-grade invasive urothelial carcinoma was detected. On postoperative day 60, no bilateral ureteral dilation was detected. Two patients demonstrated total continence. Clinical recurrence was not observed during the follow-up period.

CONCLUSIONS

With careful patient selection, robot-assisted intracorporeal Mainz Ⅱ rectosigmoid pouch might be a simple minimally invasive surgical technique to be evaluated in repeated applications.

Incidence and risk factors of parastomal hernia after radical cystectomy and ileal conduit diversion: a systematic review and meta-analysis

Background

Our aim is to report the incidence and risk factors of parastomal hernia (PH) after radical cystectomy (RC) and ileal conduit (IC) diversion with a cumulative analysis.

Methods

Various databases, including PubMed, the Cochrane Library, Embase and Web of Science, were retrieved electronically and manually to identify eligible studies from inception to August 20, 2020. Two reviewers independently searched the above databases and selected the studies using prespecified standardized criteria. The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias in the included studies, and the data was completed by STATA version 14.2.

Results

Fifteen studies were included in the final analysis. A pooled analysis of eight studies representing 1,878 patients reported the incidence of overall radiographic PH was 23% (95% CI: 17–29%). The 1-year PH incidence rate and 2-year incidence rate of RC and IC were 14% (95% CI: 6–22%) and 26% (95% CI: 14–38%), respectively. A pooled analysis of nine studies reported the incidence of clinically evident PH was 15% (95% CI: 10–19%). PH-related symptoms were reported in six studies, and the pooled result was 29% (95% CI: 24–33%), and a pooled analysis of ten studies showed that 20% (95% CI: 11–28%) of patients required surgical repair. However, it’s noteworthy that among symptomatic PH patients undergoing surgical repair, the pooled analysis of five studies showed that up to 26% (95% CI: 16–36%) of patients suffered PH recurrence. The most frequent risk factor was body mass index (BMI). Patients with BMI ≥22.9 kg/m² experienced 2.92-fold higher risk of PH than their counterparts [hazard ratio (HR): 2.92; 95% CI: 1.65–5.19].

Conclusions

Our findings indicated that the PH incidence rate after RC and IC was significantly higher in radiographic evaluation than that of clinical examination, and the recurrence of repairment is considerable for patients requiring reconstruction.

Comparison of open and intracorporeal modified ureterosigmoidostomy (Mainz II) after laparoscopic radical cystectomy with bladder cancer

Objective

To compare perioperative and oncologic outcomes of open modified ureterosigmoidostomy urinary diversion (OMUUD) and intracorporeal modified ureterosigmoidostomy urinary diversion (IMUUD) following laparoscopic radical cystectomy (LRC).

Patients and methods

We retrospectively reviewed our single institutional collected database patients undergoing LRC from October 2011 to October 2019. The perioperative characteristics were compared between OMUUD and IMUUD, and overall survival (OS) and progression-free survival (PFS) were evaluated by the Kaplan-Meier method.

Results

Overall, 84 patients were included. OMUUD and IMUUD were performed in 63 (75%) and 21 (25%) patients, respectively. IMUUD patients demonstrated shorter postoperative length of stay (16.24 ± 3.91 days vs. 18.98 ± 7.41 days, P = 0.033), similar operation time (498.57 ± 121.44 vs. 462.24 ± 99.71, P = 0.175), similar estimated blood loss [400 (200–475) ml vs. 400 (200–700) ml, P = 0.095], and similar overall complication rate within 30 days (19.05% vs. 25.40%, P = 0.848) and 90 days (23.81% vs. 17.46%, P = 0.748). Complete urinary control rate was 87.3% (55/63) in the OMUUD group. In IMUUD, the complete urinary control rate was 90.5% (19/21). There was no significant difference in OS (χ² = 0.015, P = 0.901) and PFS (χ² = 0.107, P = 0.743) between the two groups.

Conclusion

IMUUD postoperative recovery is faster; other perioperative outcomes and oncology results are not significantly different with OMUUD. It is indicated that IMUUD can be utilized safely and effectively in the urinary diversion after LRC.

Intracorporeal versus extracorporeal urinary diversion after robotic-assisted radical cystectomy: evidence from a systematic review and pooled analysis of observational studies

INTRODUCTION

We aimed to compare the perioperative, pathological and oncological outcomes of patients undergoing extracorporeal urinary diversion (EUD) and intracorporeal urinary diversion (IUD) following robot-assisted radical cystectomy (RARC).

EVIDENCE ACQUISITION

Multiple scientific databases were searched up to January 2020 for comparative studies comparing IUD and EUD. The data was analyzed by Review Manager 5.3.

EVIDENCE SYNTHESIS

A total of 9 observational studies comprising 3582 patients were included in the final analysis. We observed that IUD approach were significantly associated with lower estimated blood loss (EBL) (MD: -90.50, 95% CI: -131.26 to -49.74, P<0.0001), fewer gastrointestinal complications (RR: 0.65; 95% CI: 0.45 to 0.93; P=0.02), and lower risk of uretero-ileal anastomotic stricture (RR: 0.36; 95% CI: 0.14 to 0.91; P=0.03). We did not detect significant difference in terms of length of stay (P=0.14), operative time (P=0.55), blood transfusion (P=0.10), 30-day complication (P=0.50), 90-day complication (P=0.40), 30-day readmission (P=0.12), 90-day readmission (P=0.95), positive surgical margins (P=0.42), lymph node yield (P=0.13), 30-day reoperation (P=0.11) and 90-day mortality (0.27) between IUD and EUD.

CONCLUSIONS

The approach of urinary diversion does not have a considerable impact on pathological, perioperative and oncological outcomes in patients undergoing RARC. The benefits conferred by IUD are lower EBL, lower risk of gastrointestinal complications, and uretero-ileal anastomotic stricture. Subgroup analysis of patients with ileal conduit showed similar results on perioperative and complication outcomes. Well-designed trials conducted by large volumes and experienced surgeons, and reporting complications based on standardized methodology are still warranted.

Current evidence for robotic surgery in radical cystectomy

Robotic-assisted radical cystectomy (RARC) has been gaining momentum as an alternative to its conventional open radical cystectomy (ORC) for the management of invasive bladder cancer. Although RARC, in general, demonstrated less blood loss and shorter hospital stay than ORC, whether there is any significant difference in the overall complication rate still requires further investigation. Thus, both RARC and ORC share a similar oncology outcome, with comparable positive surgical margin rates, disease-free survival, and overall survival. Techniques of intracorporeal urinary diversion (ICUD) have not yet been standardized. ICUD may result in a lower risk of ureteroileal anastomotic stricture than extracorporeal urinary diversion (ECUD). However, ECUD is still a valid and commonly practiced option according to the available data. In general, RARC has been demonstrated to provide promising results. Long-term data and functional outcome after RARC and ICUD are needed to further validate the role of RARC in the management of bladder cancer.

Do patients benefit from total intracorporeal robotic radical cystectomy?: A comparative analysis with extracorporeal robotic radical cystectomy from a Korean multicenter study

Purpose

This study aimed to compare complications, perioperative parameters, and oncologic outcomes between robot-assisted radical cystectomy (RARC) with extracorporeal urinary diversion (ECUD) and RARC with intracorporeal urinary diversion (ICUD).

Materials and Methods

Between 2007 and 2017, 362 patients who underwent RARC with ECUD or ICUD at multiple tertiary referral institutions were assessed. The primary endpoints were complication rates. The secondary outcomes were perioperative recovery parameters and oncological outcomes including estimated recurrence-free survival (RFS) and recurrence pattern between the 2 groups. Additionally, the complication rates of 2 expert surgeons with experience of >100 RARCs were analyzed.

Results

The ICUD group showed lower overall, gastrointestinal, and genitourinary complications (p=0.001, p=0.036, and p=0.036, respectively) than the ECUD group. Concerning perioperative outcomes, the ICUD group had a significantly longer operation time (p=0.002), although recovery parameters such as time to flatus passage, oral intake, and length of hospital stay were significantly shorter in this group (p=0.001, p<0.001, and p<0.001, respectively). There was no difference in oncologic outcomes such as positive margin rate (p=0.944) and 2-year RFS (p=0.496), and in the recurrence pattern between groups. In the comparison of the expert surgeons' complication rates, the major and total complication rates did not show differences (p=0.814 and p=0.102, respectively) while the minor complication rates were lower in the ICUD group (p=0.058).

Conclusions

This multi-institutional cohort study demonstrated the benefits of the ICUD approach, as indicated by lower complication rates and better recovery parameters, although the oncological results were similar to those of ECUD.

Utility of robot-assisted radical cystectomy with intracorporeal urinary diversion for muscle-invasive bladder cancer

Radical cystectomy remains the gold standard for treatment of muscle‐invasive bladder cancer. Robot‐assisted radical cystectomy has technical advantages over laparoscopic radical cystectomy and has emerged as an alternative to open radical cystectomy. Despite the advancements in robotic surgery, experience with total intracorporeal reconstruction of urinary diversion remains limited. Most surgeons have carried out the hybrid approach of robot‐assisted radical cystectomy and extracorporeal reconstruction of urinary diversion, as intracorporeal reconstruction of urinary diversion remains technically challenging. However, intracorporeal reconstruction of urinary diversion might potentially proffer additional benefits, such as decreased fluid loss, reduction in estimated blood loss and a quicker return of bowel function. The adoption of intracorporeal ileal neobladder reconstruction has hitherto been limited to high‐volume academic institutions. In the present review, we compare the totally intracorporeal robot‐assisted radical cystectomy approach with open radical cystectomy and robot‐assisted radical cystectomy + extracorporeal reconstruction of urinary diversion in muscle‐invasive bladder cancer patients.

Complications and health-related quality of life after robot-assisted versus open radical cystectomy: a systematic review and meta-analysis of four RCTs

BACKGROUND

Radical cystectomy is associated with high rates of perioperative morbidity. Robotic-assisted radical cystectomy (RARC) is widely used today despite limited evidence for clinical superiority. The aim of this review was to evaluate the effect of RARC compared to open radical cystectomy (ORC) on complications and secondary on length of stay, time back to work and health-related quality of life (HRQoL).

METHODS

The databases PubMed, The Cochrane Library, Embase and CINAHL were searched. A systematic review according to the PRISMA guidelines and cumulative analysis was conducted. Randomized controlled trials (RCTs) that examined RARC compared to ORC were included in this review. We assessed the quality of evidence using the Cochrane Collaboration's 'Risk of bias' tool and Grading of Recommendations Assessment, Development and Evaluation approach. Data were extracted and analysed.

RESULTS

The search retrieved 273 articles. Four RCTs were included involving overall 239 patients. The quality of the evidence was of low to moderate quality. There was no significant difference between RARC and ORC in the number of patients developing complications within 30 or 90 days postoperatively or in overall grade 3-5 complications within 30 or 90 days postoperatively. Types of complications differed between the RARC and the ORC group. Likewise, length of stay and HRQoL at 3 and 6 months did not differ.

CONCLUSION

Our review presents evidence for RARC not being superior to ORC regarding complications, LOS and HRQoL. High-quality studies with consistent registration of complications and patient-related outcomes are warranted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016038232.

Robotic-assisted radical cystectomy versus open radical cystectomy for management of bladder cancer: review of literature and randomized trials

Among the many milestones in the last several decades in the management of muscle-invasive bladder cancer and high-risk nonmuscle-invasive bladder cancer including the extension of the standard lymph node dissection and the use of neoadjuvant chemotherapy, minimally invasive techniques have gained traction as an attractive option for radical cystectomy. Open radical cystectomy is plagued with high rates of perioperative and postoperative morbidity and mortality, and as robotic assistance has demonstrated benefits in other arenas of surgery and urology, the evolution of the approach to radical cystectomy has likewise incorporated robotic assistance. We thus sought to critically review the literature comparing open radical cystectomy with robotic-assisted radical cystectomy. Perioperative and oncologic outcomes as well as cost analyses and health-related quality of life were compared between the two approaches, and identified manuscripts were categorized according to level of evidence.

Advances in surgical management of muscle invasive bladder cancer

INTRODUCTION

Bladder cancer remains a disease of the elderly with relatively few advances that have improved survival over the last 20 years. Radical cystectomy (RC) has long remained the principal treatment for muscle-invasive bladder cancer (MIBC).

METHODS

A literature search of PubMed was performed. The content was reviewed for continuity with the topic of surgical advances in MIBC. Articles and society guidelines were included in this review.

RESULTS

Despite the associated morbidity, even in the elderly, RC is still a reasonable option. Modifications during RC may have a positive or negative impact on survival and quality of life. The extent of pelvic lymph node dissection is one such factor which may positively impact survival outcomes. In addition, preservation of pelvic organs, robotic surgery and the adoption of enhanced recovery after surgery principles continues to improve the postoperative recovery and quality of life in RC patients.

CONCLUSION

There are some ongoing studies in many of these areas, but overall the new advances in MIBC may improve patient quality and quantity of life. The advances in surgical treatment of MIBC are important and the focus of the review here.