Platinum Priority – Bladder Cancer – Editor's ChoiceEditorial by Bertram Yuh, Kevin Chan and Timothy Wilson on pp. 472–473 of this issueRandomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: Oncologic Outcomes
Introduction
Radical cystectomy (RC) with regional pelvic lymphadenectomy (PLND) is the established standard of care for treating high-risk bladder cancer (BCa) [1], [2]. BCa is common in older individuals and strongly linked to smoking exposure. Performing extensive pelvic surgery and reconstruction of the urinary system in an elderly, comorbid population carries significant surgical risks. The development of minimally invasive surgical techniques has been widely used in a variety of surgical procedures. One major goal associated with the adaptation of minimally invasive techniques is to minimize surgical morbidity and improve recovery.
Robot-assisted RC (RARC) was introduced in hopes of decreasing the substantial morbidity following standard of RC and urinary diversion. Several retrospective series had reported perioperative outcomes including complications following RARC with either open or intracorporeal techniques [3], [4], [5], [6]. We reported our results of a randomized controlled study designed to compare complications between open RC (ORC) and RARC [7], [8]. In that trial, we reported no large differences in 90-d overall complications, high-grade complications, or hospital length of stay. Pathologic outcomes including positive soft tissue margin (PSTM) rates and lymph node yield were similar between open and robotic techniques. Margin rates and lymph node yields were similar to previously reported benchmarks.
Long-term oncologic outcomes following RARC have not been well documented in the reported literature. Here, we describe the oncologic outcomes from our ORC versus RARC randomized controlled trial, including the secondary endpoints of recurrence-free survival, overall survival, and patterns of first recurrence.
Section snippets
Patients
Patients with BCa scheduled to undergo RC and PLND were recruited from the urology clinics at Memorial Sloan Kettering Cancer Center (MSKCC) between March 2010 and March 2013. The study protocol was approved by the Institutional Review Board, and all patients were required to provide written consent prior to enrollment and surgery. Patients were randomized 1:1 to undergo RARC or ORC using MSKCC's Clinical Research Database, a secure system that ensures allocation concealment.
Eligible patients
Patient population
Patient demographics and disease characteristics of the two groups were similar (Table 1). Pathologic staging of the two groups was not significantly different (Table 1). Pathologic stage T4 was found in five patients (8.3%) undergoing RARC and four (6.9%) undergoing ORC. There was no difference in the lymph node yield based on the extent of dissection and PSTM rate between RARC (3.6%) and ORC (4.8%).
Among the 118 enrolled patients, the median follow-up was 4.9 (IQR: 3.9–5.9) yr after surgery
Discussion
RC and PLND have become the established gold standard for managing nonmetastatic high-risk BCa. The critical surgical tenets of this procedure have been developed over decades and focus on wide resection of the bladder, surrounding tissues, and adjacent organs as well as avoidance of entry into the bladder and thoroughness of PLND to optimize local and regional disease control. Benchmarks for recurrence-free survival following RC using standard open surgical techniques are strongly affected by
Conclusions
In this secondary analysis of cancer outcomes from our randomized controlled trial, we did not find a difference in overall recurrence rates and cancer-specific survival between ORC and RARC for BCa. The observed pattern of first recurrence after ORC and RARC in this study suggests an increased risk for local/abdominal recurrences following RARC. Future studies should be designed to definitively assess if alterations in the patterns of recurrence truly exist. Although both groups demonstrated
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Current affiliation: Division of Urology, Department of Surgery, Lions Gate Hospital, North Vancouver, BC, Canada.