Dr. Moncada began the debate presenting the RAZOR study comparing RARC with extracorporeal diversion and open radical cystectomy (ORC) for patients with bladder cancer1. The study demonstrated that RARC was non-inferior to ORC for 2-year progression-free survival. According to Dr. Modana, the morbidity of radical cystectomy stems not from its extirpative component, but rather from the UD component.
A study that compared intracorporeal to extracorporeal UD in RARC demonstrated that patients who underwent intracorporeal UD had a relatively lower risk of complications2. In this multicenter study encompassing 18 centers, 935 patients were analyzed. A total of 82% had extracorporeal UD (with 26% having neobladders), and 17% had intracorporeal UD (with 36.5% having neobladders). In another similar study, comparing intracorporeal to extracorporeal UD, 2432 patients from a total of 29 institutions were analyzed. The study demonstrated that intracorporeal UD was associated with higher grade complications than extracorporeal UD, although they were shown to decrease with time3.
Unfortunately, we still do not have randomized clinical trials assessing whether intracorporeal UD is better than extracorporeal UD in RARC. There is currently a growing trend towards using intracorporeal UD. However, surgeon experience is a key factor, and a minimum of 250 robotic radical prostatectomy cases are required before attempting to perform RARC with intracorporeal UD. Dr. Modana concluded his talk by stating that the surgeon needs to be able to perform RARC with intracorporeal UD in under 4 hours, to make this procedure worthwhile to the patient.
In the next section, Dr. Kelly argued most entertainingly, why intracorporeal UD is the only way to go. In the recently published study in the Journal of Urology, mentioned earlier3, 1094 cases of RARC were analyzed with 51% being intracorporeal UD. Importantly, the rate of intracorporeal UD increased from a meager 9% of cases in 2005 to a staggering 97% of cases in 2015. The study demonstrated that intracorporeal UD was associated with shorter operating time, lower blood loss and need for transfusion and decreasing rate of complications with gained experience.
According to Dr. Kelly, the RAZOR study1 which compared ORC to RARC with extracorporeal UD showed that the potential gains are lost by conversion of the robotic case to an open case.
Currently, there is an ongoing randomized clinical trial comparing intracorporeal RARC with ORC, which is called IROC. The trial’s endpoints include days alive and out of the hospital, length of hospital stay, readmission rates, complications, quality of life, activity tracking, and costs.
Currently, in the UK, intracorporeal UD is being trained in most large centers, while extracorporeal UD is not part of the curriculum, as there is no need to convert to extracorporeal diversion in any scenario, according to Dr. Kelly. In RARC with intracorporeal UD, the bladder is removed through a small 5 cm Pfannenstiel incision, with no bowel exposure or manipulation, no need for retraction and closing of the incision is completed within minutes.
Dr. Kelly concluded his entertaining talk, stating that extracorporeal UD was historically necessary, but negates the gains of robotic surgery. On the other hand, intracorporeal UD is faster, easier, and with fewer complications, leading it to be the most attractive therapeutic choice.
Presented by: Moncada, Madrid, Spain, and Dr. J. Kelly, London, UK
Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter:@GoldbergHanan at the EAU Robotic Urology Section (ERUS) Meeting - September 5 - 7, 2018 - Marseille, France
References:
- Parekh DJ, Reis IM, Castle EP, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet (London, England) 2018; 391(10139): 2525-36.
- Ahmed K, Khan SA, Hayn MH, et al. Analysis of intracorporeal compared with extracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. European Urology 2014; 65(2): 340-7.
- Hussein AA, May PR, Jing Z, et al. Outcomes of Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium. The Journal of urology 2018; 199(5): 1302-11.