RARC Pasadena Consensus Panel – Editorial

Referring to the articles published on pp. 363–431 of this issue

Robotic Radical Cystectomy: So Far, So Good—What Next?

In this study, we compared perioperative and oncologic outcomes of patients treated with either open or robot-assisted radical cystectomy and intracorporeal neobladder at a tertiary care center.

The institutional prospective bladder cancer database was queried for “cystectomy with curative intent” and “neobladder”. All patients underwent robot-assisted radical cystectomy and intracorporeal neobladder or open radical cystectomy and orthotopic neobladder for high-grade non-muscle invasive bladder cancer or muscle invasive bladder cancer with a follow-up length ≥2 years were included. A 1:1 propensity score matching analysis was used. Kaplan-Meier method was performed to compare oncologic outcomes of selected cohorts. Survival rates were computed at 1,2,3 and 4 years after surgery and the log rank test was applied to assess statistical significance between the matched groups.

Overall, 363 patients (299 open and 64 robotic) were included. Open radical cystectomy patients were more frequently male (p = 0.08), with higher pT stages (p = 0.003), lower incidence of urothelial histologies (p = 0.05) and lesser adoption of neoadjuvant chemotherapy (<0.001). After applying the propensity score matching, 64 robot-assisted radical cystectomy patients were matched with 46 open radical cystectomy cases (all p ≥ 0.22). Open cohort showed a higher rate of perioperative overall complications (91.3% vs 42.2%, p 0.001). At Kaplan-Meier analysis robotic and open cohorts displayed comparable disease-free survival (log-rank p = 0.746), cancer-specific survival (p = 0.753) and overall-survival rates (p = 0.909).

Robot-assisted radical cystectomy and intracorporeal neobladder provides comparable oncologic outcomes of open radical cystectomy and orthotopic neobladder at intermediate term survival analysis.

Intracorporeal orthotopic neobladder (iONB) creation following robotic radical cystectomy is an emerging procedure and robust functional data are required.

To evaluate urodynamic features of iONB and bladder cancer–specific and general health-related quality-of-life (HRQOL) outcomes.

We retrospectively assessed 28 men who underwent iONB creation (January 2012 to October 2013) and compared results to a previously characterized cohort of 79 of open ONB procedures.

iONB pressure-volume properties were characterized using multichannel urodynamics (UDS). The Bladder Cancer Index (BCI) questionnaire, modified with mucus- and pad-related questions, and the Short Form Health Survey (SF-36) were used to evaluate urinary function and HRQOL. ONB cohorts were compared for functional outcomes and BCI score. Multivariable linear regression was used to assess predictors of BCI score.

The median follow-up was 9.4 mo for the iONB and 62.1 mo for the open ONB group (p < 0.0001); ≥2-yr follow-up had been completed for one (4%) patient in the iONB group compared to 75 (95%) patients in the open ONB group (p < 0.0001). In UDS tests, the iONB group had minimal postvoid residual volume, normal compliance, and a mean capacity of 514 cm³ (range 339–1001). BCI mean scores for urinary function (p = 0.58) and urinary bother (p = 0.31) were comparable between the groups. The surgical approach was not associated with the BCI score on multivariable analysis. Rates of 24-h pad use were comparable between iONB and open ONB groups (pad-free 17% vs 19%; ≤2 pads 84% vs 79%), as reflected by total pad usage (p = 0.1); pad size and daytime wetness were worse in the iONB group. The clean intermittent catheterization rate was 10.7% in the iONB and 6.3% in the open ONB group. Limitations include the retrospective comparison, small number of patients and short follow-up for the iONB group.

iONB had adequate UDS characteristics and comparable bladder cancer–specific HRQOL scores to open ONB. However, pad size and daytime wetness were worse for iONB, albeit over significantly shorter follow-up.

We demonstrate that the volumetric and pressure characteristics are acceptable for a neobladder created using an entirely robot-assisted laparoscopic technique after bladder removal for cancer. Urinary function and quality-of-life outcomes related to the robotic technique were compared to those for neobladders created via an open surgical technique. We found that urinary function and bother indices were comparable; however, the robotic group required larger incontinence pads that were wetter during the daytime. This may be explained by the significantly shorter duration of recovery after surgery in the robotic group.