Editor’s Choice The evolution of robotic cystectomy A decade has passed since the publication of the first series of robot-assisted radical cystectomies in the BJUI by Menon et al. [1]. New technologies are fascinating, and many surgeons who aspire to leave a mark in history take the lead in pioneering new procedures. Others follow without waiting for any evidence to justify the adoption of new procedures. In this race, the opinion of the most important stakeholder, the patient, gets ignored. Although their study has many methodological flaws, Guru et al. [2] have made the effort to collect data on patients’ health-related quality of life (HRQL) after robot-assisted radical cystectomy for bladder cancer. Radical cystectomy is a morbid procedure with a serious impact on patients’ HRQL, no matter how it is performed. Loosing an organ which is responsible for the storage and evacuation of urine several times a day and replacing it with alternatives of continent or incontinent diversion has a serious impact on quality of life, as is evident from this study. Robotic cystectomy is still evolving. With more experience, a few experts have ventured to perform intracorporeal reconstruction of the urinary diversion. While we await the long-term functional outcomes of this switch over in surgical approach, Guru et al. report the short-term HQRL outcomes in a series of 43 patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion at their institution. Most patients (n = 38) had ileal conduit urinary diversion. The authors went on to compare the postoperative outcomes of this cohort with another group of 70 patients who only completed the questionnaire after having undergone robot-assisted radical cystectomy and extracorporeal urinary diversion.
It is interesting to note that there was no significant difference in HRQL between those undergoing extracorporeal and those undergoing intracorporeal reconstruction. These outcomes reinforce the need to gather robust scientific evidence from properly conducted multi-centre, multinational randomized trials before the introduction of new procedures, instead of evaluation with retrospective studies. The urological community has embraced new technologies and patients have benefited a great deal from these innovative approaches; however, it is incumbent upon us to develop a culture of independent, unbiased data collection on outcomes. In this regard we must make the HQRL one of the most important quality indicators in assessment of the new procedures. Such an approach will enable us to justify the extra cost which society has to bear for our innovative trends in the management of old problems [3].
Conflict of Interest None declared. Muhammad Shamim Khan Guy’s and St Thomas’s Hospital and King’s College London, London, UK
References 1 2
3
Menon M, Hemal AK, Tewari A et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int 2003; 92: 232–6 Poch MA, Stegemann AP, Rehman S et al. Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC). BJU Int 2014; 113: 260–5 Wang TT, Ahmed KA, Khan MS et al. Quality-of-care framework in urological cancers: where do we stand? BJU Int 2011; 109: 1436–43
A bit of LESS appears to be more In this issue of the BJUI, Springer et al. [1] present a multi-institutional analysis of oncological outcomes and renal function after laparoendoscopic single-site surgery partial nephrectomy (LESS-PN). Nephron-sparing surgery is the reference standard for small renal tumours, with a goal of optimising overall renal function after ablative surgery. Laparoscopic PN (LPN) is an ever increasingly used treatment option in the management of small
BJU Int 2014; 113: 178–183 wileyonlinelibrary.com
renal masses, demonstrated to render equal oncological efficacy [2] with improved convalescence compared with open PN [3]. All laparoscopic urological procedures have been performed using LESS, and it was no great surprise to receive this article for review. Data over a period of 5 years has been analysed; the study design is admittedly somewhat flawed, as patient selection criteria and surgical technique was not standardised. The authors conclude that, although challenging LESS-PN is oncologically safe, with outcomes equivalent to LPN.
© 2014 The Author BJU International © 2014 BJU International | doi:10.1111/bju.12607,12419,12393,12477,12394 Published by John Wiley & Sons Ltd. www.bjui.org
Editor’s Choice
When we started with urological LESS in 2007 [4], it was a technique that drew strident criticism from peers who thought that the absence of triangulation defied the established teaching fundamentals in laparoscopy, and the procedure would never advance. LESS surgery has since developed as an evolutionary advance in laparoscopy with the goal of improving cosmetic outcomes and minimising convalescence. Cosmesis is an undeniable advantage of LESS, and several studies have already suggested improvements in pain scores and earlier recovery [5]. Despite the goals of the LESS approach, any extirpative renal surgery with oncological indications should maintain the ultimate goal of curative oncological outcomes. Let us therefore concentrate on specifics: what are the current indications for LESS-PN? Arguably, these are broadly similar to those for LPN, but the bottom line is that it boils down to surgeon experience, with bodily habitus, ease of resection (i.e. size, position and proximity to hilar vessels) and perhaps patient preference playing a small but significant role. LESS-PN remains a challenging procedure, and I feel that this should only be attempted by that select cohort of surgeons who have had adequate experience with extirpative and other reconstructive LESS procedures, such as LESS pyeloplasty. I also think that it important that a technique such as LESS-PN, whilst immensely satisfying for the surgeon, adopts the adage primum non nocere. I was sceptical about the use of the LESS approach for any oncological procedure, and indeed in my own practice I have decided against it. Paradoxically, in this instance I am somewhat pleased to be proven wrong. The
authors show that in the right hands, LESS-PN may be a viable proposition for management of small renal masses. I look forward to the day when purpose built, LESS-specific robotic instrumentation becomes available. At the present time, however, it will be useful to see whether a comparative trial between robot-assisted PN, robotic LESS-PN and conventional LESS-PN will show any significant differences. Takers, anybody?
Conflict of Interest None declared. Abhay Rane East Surrey Hospital, Redhill, UK e-mail: [email protected]
References 1
2 3
4
5
Springer C, Greco F, Autorino R et al. Analysis of oncological outcomes and renal function after laparoendoscopic single site partial nephrectomy: a multi-institutional outcome analysis. BJU Int 2014; 113: 266–74 Volpe A, Cadeddu JA, Cestari A et al. Contemporary management of small renal masses. Eur Urol 2011; 60: 501–15 Porpiglia F, Volpe A, Billia M, Scarpa RM. Laparoscopic versus open partial nephrectomy: analysis of the current literature. Eur Urol 2008; 53: 732–42 Rane A, Rao P, Rao P. Single-port-access nephrectomy and other laparoscopic urologic procedures using a novel laparoscopic port (R-port). Urology 2008; 72: 260–4 Ganpule AP, Sharma R, Kurien A et al. Laparoendoscopic single site surgery in urology: a single centre experience. J Minim Access Surg 2012; 8: 79–84
Prostate cancer surgery vs radiation: has the fat lady sung? The current article by Sun et al. [1] representing a number of institutions involved in prostate cancer treatment provision is thought-provoking and hypothesis-generating. The authors contention when mining Surveillance, Epidemiology and End Results data for 67 000 men who had localized prostate cancer between 1988 and 2005 is that those with a life expectancy >10 years had less likelihood of prostate cancer death when treated with surgery rather than by radiotherapy or being left to observation. The Scandinavians have already shown, in the randomized study by Hugosson et al. [2], that if you have your prostate cancer removed you have less likelihood of symptomatic local recurrence, lower likelihood of metastasis and progression, and a 29% reduced likelihood of prostate cancer death. The current study asks the question ‘Is radiation
therapy less likely to provide a long-term cure for prostate cancer than surgery?’ and gives an answer in the affirmative. The current paper, in its way, neatly encapsulates the contemporary angst generated in the community when prostate cancer screening, diagnosis and therapy are discussed. The Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial [3] allegedly shows no benefit from treatment over observation and contends perhaps that we surgeons and radiation oncologists are harm-workers, not life-savers. The PLCO has a 52% PSA contamination in its control arm [3]. That flawed trial compared screening with de facto screening and produced, in my view, a null hypothesis. How do we explain the paradox of a 44% © 2014 The Author BJU International © 2014 BJU International
179
It is interesting to note that there was no significant difference in HRQL between those undergoing extracorporeal and those undergoing intracorporeal reconstruction. These outcomes reinforce the need to gather robust scientific evidence from properly conducted multi-centre, multinational randomized trials before the introduction of new procedures, instead of evaluation with retrospective studies. The urological community has embraced new technologies and patients have benefited a great deal from these innovative approaches; however, it is incumbent upon us to develop a culture of independent, unbiased data collection on outcomes. In this regard we must make the HQRL one of the most important quality indicators in assessment of the new procedures. Such an approach will enable us to justify the extra cost which society has to bear for our innovative trends in the management of old problems [3].
Conflict of Interest None declared. Muhammad Shamim Khan Guy’s and St Thomas’s Hospital and King’s College London, London, UK
References 1 2
3
Menon M, Hemal AK, Tewari A et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int 2003; 92: 232–6 Poch MA, Stegemann AP, Rehman S et al. Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC). BJU Int 2014; 113: 260–5 Wang TT, Ahmed KA, Khan MS et al. Quality-of-care framework in urological cancers: where do we stand? BJU Int 2011; 109: 1436–43
A bit of LESS appears to be more In this issue of the BJUI, Springer et al. [1] present a multi-institutional analysis of oncological outcomes and renal function after laparoendoscopic single-site surgery partial nephrectomy (LESS-PN). Nephron-sparing surgery is the reference standard for small renal tumours, with a goal of optimising overall renal function after ablative surgery. Laparoscopic PN (LPN) is an ever increasingly used treatment option in the management of small
BJU Int 2014; 113: 178–183 wileyonlinelibrary.com
renal masses, demonstrated to render equal oncological efficacy [2] with improved convalescence compared with open PN [3]. All laparoscopic urological procedures have been performed using LESS, and it was no great surprise to receive this article for review. Data over a period of 5 years has been analysed; the study design is admittedly somewhat flawed, as patient selection criteria and surgical technique was not standardised. The authors conclude that, although challenging LESS-PN is oncologically safe, with outcomes equivalent to LPN.
© 2014 The Author BJU International © 2014 BJU International | doi:10.1111/bju.12607,12419,12393,12477,12394 Published by John Wiley & Sons Ltd. www.bjui.org
Editor’s Choice
When we started with urological LESS in 2007 [4], it was a technique that drew strident criticism from peers who thought that the absence of triangulation defied the established teaching fundamentals in laparoscopy, and the procedure would never advance. LESS surgery has since developed as an evolutionary advance in laparoscopy with the goal of improving cosmetic outcomes and minimising convalescence. Cosmesis is an undeniable advantage of LESS, and several studies have already suggested improvements in pain scores and earlier recovery [5]. Despite the goals of the LESS approach, any extirpative renal surgery with oncological indications should maintain the ultimate goal of curative oncological outcomes. Let us therefore concentrate on specifics: what are the current indications for LESS-PN? Arguably, these are broadly similar to those for LPN, but the bottom line is that it boils down to surgeon experience, with bodily habitus, ease of resection (i.e. size, position and proximity to hilar vessels) and perhaps patient preference playing a small but significant role. LESS-PN remains a challenging procedure, and I feel that this should only be attempted by that select cohort of surgeons who have had adequate experience with extirpative and other reconstructive LESS procedures, such as LESS pyeloplasty. I also think that it important that a technique such as LESS-PN, whilst immensely satisfying for the surgeon, adopts the adage primum non nocere. I was sceptical about the use of the LESS approach for any oncological procedure, and indeed in my own practice I have decided against it. Paradoxically, in this instance I am somewhat pleased to be proven wrong. The
authors show that in the right hands, LESS-PN may be a viable proposition for management of small renal masses. I look forward to the day when purpose built, LESS-specific robotic instrumentation becomes available. At the present time, however, it will be useful to see whether a comparative trial between robot-assisted PN, robotic LESS-PN and conventional LESS-PN will show any significant differences. Takers, anybody?
Conflict of Interest None declared. Abhay Rane East Surrey Hospital, Redhill, UK e-mail: [email protected]
References 1
2 3
4
5
Springer C, Greco F, Autorino R et al. Analysis of oncological outcomes and renal function after laparoendoscopic single site partial nephrectomy: a multi-institutional outcome analysis. BJU Int 2014; 113: 266–74 Volpe A, Cadeddu JA, Cestari A et al. Contemporary management of small renal masses. Eur Urol 2011; 60: 501–15 Porpiglia F, Volpe A, Billia M, Scarpa RM. Laparoscopic versus open partial nephrectomy: analysis of the current literature. Eur Urol 2008; 53: 732–42 Rane A, Rao P, Rao P. Single-port-access nephrectomy and other laparoscopic urologic procedures using a novel laparoscopic port (R-port). Urology 2008; 72: 260–4 Ganpule AP, Sharma R, Kurien A et al. Laparoendoscopic single site surgery in urology: a single centre experience. J Minim Access Surg 2012; 8: 79–84
Prostate cancer surgery vs radiation: has the fat lady sung? The current article by Sun et al. [1] representing a number of institutions involved in prostate cancer treatment provision is thought-provoking and hypothesis-generating. The authors contention when mining Surveillance, Epidemiology and End Results data for 67 000 men who had localized prostate cancer between 1988 and 2005 is that those with a life expectancy >10 years had less likelihood of prostate cancer death when treated with surgery rather than by radiotherapy or being left to observation. The Scandinavians have already shown, in the randomized study by Hugosson et al. [2], that if you have your prostate cancer removed you have less likelihood of symptomatic local recurrence, lower likelihood of metastasis and progression, and a 29% reduced likelihood of prostate cancer death. The current study asks the question ‘Is radiation
therapy less likely to provide a long-term cure for prostate cancer than surgery?’ and gives an answer in the affirmative. The current paper, in its way, neatly encapsulates the contemporary angst generated in the community when prostate cancer screening, diagnosis and therapy are discussed. The Prostate, Lung, Colorectal, and Ovarian Cancer Screening (PLCO) trial [3] allegedly shows no benefit from treatment over observation and contends perhaps that we surgeons and radiation oncologists are harm-workers, not life-savers. The PLCO has a 52% PSA contamination in its control arm [3]. That flawed trial compared screening with de facto screening and produced, in my view, a null hypothesis. How do we explain the paradox of a 44% © 2014 The Author BJU International © 2014 BJU International
179
