Category: Laparoscopic/ Robotic: Other
Introduction & Objective :
Robotic radical cystectomy has been touted as a less morbid operation alternative to open cystectomy. Decreased blood loss and shorter hospitalization has resulted in adoption of robotic cystectomy in several institutions. We hypothesize that performing robotic cystectomy allows us to operate on older and sicker patients without compromising short or long-term outcomes. To evaluate this, we reviewed our experience at a large volume, academic, multi-site healthcare delivery network.
Retrospective review of a prospectively maintained database included 309 patients (114 robotic, 195 open) who underwent radical cystectomy for treatment of bladder cancer between 2007 and 2017. Patients were selected for open or robotic surgery based on experienced surgeon preference. The Charlson Comorbidity Index (CCI) was used as a proxy for overall patient health. Review of medical records was performed to determine the primary end points of intraoperative blood loss (EBL), margin positivity, pathologic stage, complication rate, and length of hospital stay (LOS). Kaplan-Meier survival curves were constructed with prospective data recorded following robotic or open cystectomy. Overall survival (OS) and recurrence free survival (RFS) were also evaluated.
Overall, patients in the robotic cohort were older (72.4 vs. 65.5 years; p < 0.0001) and had a higher CCI (6.2 vs. 4.9; p < 0.0001). Patients who underwent robotic cystectomy had lower EBL (619 vs. 818 cc; p = 0.038), but greater LOS (11.2 vs. 9.2 days; p = 0.022). There was no significant difference between the robotic and open cohorts with regards to margin positivity (p = 0.11), lymph node positivity (p = 0.19), complication rate (p = 0.16) or type of urinary diversion (p = 0.44). Patients in the robotic cohort had a higher proportion of advanced pathologic T stage disease (pT3 and pT4), (59.8% vs. 39.6%; p = 0.007). There was no statistically significant difference in OS (p = 0.103) or RFS (p = 0.67) between the two groups. There was also no statistically significant difference in OS (p = 0.95) or RFS (p = 0.74) when evaluating according to gender.
The results of our study demonstrate that robotic cystectomy is a viable alternative to open cystectomy. Longer LOS and higher pathologic T stage may be attributable to advanced age and higher CCI in that specific population. In particular, robotic cystectomy may be an option for older, sicker patients without impacting peri-operative outcomes or compromising short-term oncologic control. Our study suggests that robotic and open cystectomy may have similar long-term oncologic outcomes, though further study is certainly needed.
Cynthia Leung– Resident Physician , Yale Urology , New Haven, Connecticut
James Rosoff– New Haven, Connecticut
Thomas Martin– New Haven, Connecticut
David Hesse– New Haven, Connecticut
Jeannie Su– Resident Physician, Yale New Haven Hospital, New Haven, Connecticut