Comparison of Open Radical Cystectomy vs Robot-Assisted Radical Cystectomy Perioperative Outcomes and Complications at a Single Center: An Analysis of Matched Pairs

Year 2023, Volume: 15 Issue: 2, 61 - 68, 31.05.2023

Harun Özdemir , Emin Taha Keskin , Merve Şam Özdemir , Metin Savun , Halil Lütfi Canat , Abdülmüttalip Şimşek

https://doi.org/10.54233/endouroloji.20231502-1290426

Abstract

Objective: The standard curative treatment for non-metastatic high-risk non-muscle-invasive and muscle-invasive bladder cancer is regional pelvic lymphadenectomy (PLND) combined with radical cystectomy. The most prefered surgical procedure is an open radical cystectomy (ORC). However, there are significant risks related to this surgical procedure. Robot-assisted radical cystectomy (RARC), one of the minimally invasive surgical procedures, has been demonstrated to reduce surgical morbidity and boost recovery. In this study, we examined the postoperative complications and outcomes of patients who underwent RARC and ORC for bladder cancer in our clinic using matched pair analysis.

Material and Methods: Between January 2021 and February 2023, datas of radical cystectomy patients were collected retrospectivelly at our clinic. Twenty patients who underwent RARC and forty patients who underwent ORC were matched at a ratio of 1:2 for age (± 2 years), gender, clinical TNM stage, and urinary diversion (ileal conduit or orthotopic neobladder) during the same period. The outcomes and complications of perioperative and postoperative procedures have been compared.

Results: There was no difference in preoperative data between the two groups. The RARC group had found significantly longer operative times (307.5 versus 391.7 minutes; P=0.001). Patients with RARC group had significantly lower bood-loss (P=0.001) and required less intraoperative blood transfusions (P=0.023). ICU stays were significantly longer in ORC (p =.047). The rates of mild Clavien complications were found to be similar between groups in the postoperative first 90 days. Open surgery was found to be associated with a significantly higher incidence of major (clavien 3-5) complications (p =.042). The 90-day mortality rates for RARC and ORC were found to be 0% and 7.5%, respectively. There was no difference in pathological outcomes between the two groups.

Conclusion: Our initial experience with RARC has demonstrated its safety and practicability, with comparable pathology outcomes, reduction of perioperative blood loss, and advances in 90-day mortality, when compared to ORCs with more years of experience.

Keywords

Bladder cancer, Complication, Robot-assisted radical cystectomy

Tek Merkezde Açık Radikal Sistektomi ile Robot Yardımlı Radikal Sistektominin Perioperatif Sonuçları ve Komplikasyonlarının Karşılaştırılması: Eşleştirilmiş Çift Analizi

Abstract

Amaç: Metastatik olmayan yüksek riskli kasa invazif olmayan ya da kasa invazif mesane kanserinde standart küratif tedavi yöntemi bölgesel pelvik lenfadenektomi (PLND) ile birlikte radikal sistektomidir. Açık radikal sistektomi (ARS), birincil tedavi şeklidir, fakat bu cerrahi yöntem önemli riskler taşımaktadır. Minimal invazif cerrahi tekniklerinden robotik cerrahinin uygulanmasıyla cerrahi morbiditeyi en aza indirmek ve daha hızlı iyileşme gösterilmiştir. Bu çalışmada amacımız kendi kliniğimizde mesane kanseri nedeniyle robot yardımlı radikal sistektomi (RYRS) ve ARS uygulanan hastaların eşleştirilmiş çift analizi kullanarak komplikasyonlar ve perioperatif sonuçlarını karşılaştırmaktır.

Gereç ve Yöntemler: Kliniğimizde Ocak 2021 - Şubat 2023 tarihleri arasında radikal sistektomi hastaların verileri retrospektif olarak elde edildi. RYRS uygulanan 20 hasta, aynı dönemde yaş (± 2 yaş), cinsiyet, klinik TNM evresi ve üriner diversiyon (ileal konduit veya ortotopik yeni mesane) açısından 1:2 oranında ARS uygulanan 40 hasta ile eşleştirildi. Perioperatif, postoperatif sonuçlar ve komplikasyonlar karşılaştırıldı.

Bulgular: Her iki grupta preoperatif veriler açısından fark yoktu. Ameliyat süresi RYRS grubunda anlamlı olarak daha uzundu (307,5’e karşılık 391,7 dakika; P=0.0001). RYRS’de önemli ölçüde daha düşük kanama miktarı (P=0.001) ve daha az intraoperatif kan transfüzyonu (P=0.023) izlendi. Yoğun bakımda kalış süreci ARS’de anlamlı olarak daha yüksek izlendi ( P=0.047). Gruplar arasında 90 günlük minör (clavien 1-2) komplikasyon oranları benzer izlendi. Majör (clavien 3-5) komplikasyonlar açık cerrahide anlamlı şekilde daha fazla görüldü (P=0.042). 90 günlük mortalite oranı, RYRS ve ARS için sırasıyla %0’a karşılık %7.5 idi. Her iki grup arasında önemli patolojik sonuçlar açısından fark görülmedi.

Sonuç: RYRS ile ilk deneyimlerimiz, daha yüksek ARS deneyimiyle karşılaştırıldığında bile benzer patolojik sonuçlar, perioperatif kan kaybını önleme ve 90 günlük mortalite iyileştirmeleri ile güvenli ve uygulanabilir olduğunu göstermiştir.

Keywords

Komplikasyon, Mesane kanseri, Robot yardımlı radikal sistektomi

References

• 1. Saurabh Chavan , Freddie Bray, Joannie Lortet-Tieulent, Michael Goodman, Ahmedin Jemal. International variations in bladder cancer incidence and mortality. Eur Urol. 2014 Jul;66(1):59-73. https://doi.org/10.1016/j.eururo.2013.10.001
• 2. IARC. Estimated number of new cases in 2020, worldwide, both sexes, all ages. 2020. Access date December 2022.
• 3. Cumberbatch MGK, Jubber I, Black PC, et al.. Epidemiology of bladder cancer: a systematic review and contemporary update of risk factors in 2018. Eur Urol. 2018;74(6):784-795. https://doi.org/10.1016/j.eururo.2018.09.001
• 4. Patel R, Szymaniak J, Radadia K, Faiena I, Lasser M. Controversies in robotics: open versus robotic radical cystectomy. Clin Genitourin Cancer. 2015;13:421–427. https://doi.org/10.1016/j.clgc.2015.06.006
• 5. Lau CS, Blackwell RH, Quek ML. Radical cystectomy: open vs robotic approach. J Urol. 2015;193:400–402. https://doi.org/10.1016/j.juro.2014.11.079
• 6. Vetterlein MW, Klemm J, Gild P, et al.. Improving estimates of perioperative morbidity after radical cystectomy using the European Association of Urology quality criteria for standardized reporting and introducing the Comprehensive Complication Index. Eur Urol. 2020;77(1):55-65. doi: 10.1016/j.eururo.2019.08.011. https://doi.org/10.1016/j.eururo.2019.08.011
• 7. Williams SB, Cumberbatch MGK, Kamat AM, et al.. Reporting radical cystectomy outcomes following implementation of enhanced recovery after surgery protocols: a systematic review and individual patient data meta-analysis. Eur Urol. 2020;78(5):719-730. https://doi.org/10.1016/j.eururo.2020.06.039
• 8. Leow JJ, Cole AP, Seisen T, et al.. Variations in the costs of radical cystectomy for bladder cancer in the USA. Eur Urol. 2018;73(3):374-382. doi: 10.1016/j.eururo.2017.07.016. https://doi.org/10.1016/j.eururo.2017.07.016
• 9. Johar RS, Hayn MH, Stegemann AP, et al. Complications after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol. 2013;64:52–7. https://doi.org/10.1016/j.eururo.2013.01.010
• 10. Khan MS, Elhage O, Challacombe B, Rimington P, Murphy D, Dasgupta P. Analysis of early complications of robotic-assisted radical cystectomy using a standardized reporting system. Urology. 2011;77:357–62. https://doi.org/10.1016/j.urology.2010.04.063
• 11. Pruthi RS, Wallen EM. Robotic assisted laparoscopic radical cystoprostatectomy: operative and pathological outcomes. J Urol. 2007;178:814–8. https://doi.org/10.1016/j.juro.2007.05.040
• 12. Yuh BE, Nazmy M, Ruel NH, et al. Standardized analysis of frequency and severity of complications after robot-assisted radical cystectomy. Eur Urol. 2012;62:806–13. https://doi.org/10.1016/j.eururo.2012.06.007
• 13. Stein J.P., Skinner D.G.: Surgical atlas. Radical cystectomy. BJU Int 2004; 94: pp. 197-221. https://doi.org/10.1111/j.1464-410X.2004.04981.x
• 14. Stein J.P., Quek M.L., Skinner D.G.: Lymphadenectomy for invasive bladder cancer. II. Technical aspects and prognostic factors. BJU Int 2006; 97: pp. 232-237. https://doi.org/10.1111/j.1464-410X.2006.05901.x
• 15. Menon M, Hemal AK, Tewari A et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int 2003; 92: 232–6. https://doi.org/10.1046/j.1464-410x.2003.04329.x
• 16. Wang G.J., Barocas D.A., Raman J.D., and Scherr D.S.: Robotic vs open radical cystectomy: prospective comparison of perioperative outcomes and pathological measures of early oncological efficacy. BJU Int 2007; 101: pp. 89-93. https://doi.org/10.1111/j.1464-410X.2007.07212.x
• 17. Yoon PD, Chalasani V, Woo H. Use of Clavien-Dindo Classification in Reporting and Grading Complications after Urological Surgical Procedures: Analysis of 2010 to 2012. The Journal of Urology 2013;190(4):1271-4. https://doi.org/10.1016/j.juro.2013.04.025
• 18. Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009;55:164–74. https://doi.org/10.1016/j.eururo.2008.07.031
• 19. Novara G, Catto JW, Wilson T, Annerstedt M, Chan K, Murphy DG, et al. Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol. 2015;67:376–401. https://doi.org/10.1016/j.eururo.2014.12.007
• 20. Bochner BH, Dalbagni G, Sjoberg DD, Silberstein J, Keren Paz GE, Donat SM, et al. Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol. 2015;67:1042–1050. https://doi.org/10.1016/j.eururo.2014.11.043
• 21. Riccardo Mastroianni, Mariaconsiglia Ferriero, Gabriele Tuderti, et al. Open Radical Cystectomy versus Robot-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Early Outcomes of a Single-Center Randomized Controlled Trial. J Urol. 2022 May;207(5):982-992. https://doi.org/10.1097/JU.0000000000002422
• 22. Muhammad Shamim Khan, Christine Gan, Kamran Ahmed, et al.A Single-centre Early Phase Randomised Controlled Three-arm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL). Eur Urol. 2016 Apr;69(4):613-621. https://doi.org/10.1016/j.eururo.2015.07.038
• 23. Jeff Nix, Angela Smith, Raj Kurpad, Matthew E Nielsen, Eric M Wallen, Raj S Pruthi. Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur Urol. 2010 Feb;57(2):196-201. https://doi.org/10.1016/j.eururo.2009.10.024
• 24. Casey K. Ng a , Eric C. Kauffman a , Ming-Ming Lee a , et al. A Comparison of Postoperative Complications in Open versus Robotic Cystectomy. Eur Urol. 2010 Feb;57(2):274-81. https://doi.org/10.1016/j.eururo.2009.06.001
• 25. Hayn MH, Hellenthal NJ, Hussain A, et al. Defining morbidity ofrobot-assisted radical cystectomy using a standardized reportingmethodology. Eur Urol. 2011;59:213-218. https://doi.org/10.1016/j.eururo.2010.10.044
• 26. Ng CK, Kauffman EC, Lee MM, et al. A comparison of postoperative complications in open versus robotic cystectomy. Eur Urol.2010;57:274-282. https://doi.org/10.1016/j.eururo.2009.06.001
• 27. Catto JWF, Khetrapal P, Ricciardi F, et al; iROC Study Team. Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer: A Randomized Clinical Trial. JAMA. 2022 Jun 7;327(21):2092-2103. https://doi.org/10.1001/jama.2022.7393