Opposing Views
Robotic Radical CystectomydIs the Diversion the Achilles’ Heel? YES OPEN radical cystectomy (RC) is the standard treatment for invasive bladder cancer. Although a morbid procedure, it does save lives and quality of surgery is critical to its success. Most of the morbidity is related to the obligatory urinary diversion (UD). Robotic radical cystectomy (RRC) has recently been advocated, with claims of fewer complications, faster recovery and functional outcomes similar to those of RC.1 Such claims are based on retrospective analysis of collected cases fraught with selection bias, missing data, short followup and unquantified variables. It remains to be seen whether RRC provides results comparable to RC in unselected patients. After RRC, urinary diversion may be done as an open procedure (though small incisions) or entirely within the abdomen using the robot. In a randomized trial Bochner et al reported no advantage of RRC and extracorporeal UD over conventional RC in 90-day complications, recovery times or surgical outcomes,2 suggesting that any real benefit of RRC requires intracorporeal robotic urinary diversion, whether as an ileal stoma or orthotopic neobladder. Despite the potential advantages of RRC, such as decreased blood loss, quicker bowel recovery and decreased analgesic requirements, it is associated with longer operative time, similar length of stay, steeper learning curve, especially for intracorporeal UD, and higher costs. The main drawback of RRC is that the long-term functional performance of robot-constructed diversion remains unknown. Compromised technique of extracorporeal and intracorporeal robotic orthotopic neobladder Experience with open orthotopic neobladder (ONB) has shown that several principles are critical to ensure successful functional outcomes. Detubularization, cross (double) folding and, to a lesser extent, a spherical shape result in a larger radius, greater volume and ultimately lower pressure.3 Almost all robotic reservoirs are constructed from short (40 cm) ileal segments, have significant undetubularized portions and are only U-shaped.4e7 As a result, they have a small radius of 2.4 cm, geometric capacity of 0022-5347/14/1926-1601/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
just 180 to 271 cc and pressure twice as high compared to a standard open ONB with a radius of 4.8 cm and geometric capacity as high as 1,085 cc.8 If the UD is performed extracorporeally, the devascularized ureters must be left long and an increased stenosis rate is to be expected. Patients expect results obtained with a novel technique to be at least as good as those obtained with an established technique. Decreased use of continent UD It is also a concern that in most RRC series less than 20% of patients undergo orthotopic reconstruction. Given such a highly selected group of patients, one would expect this technique to be performed in at least 50% to 60% of patients. Inferior functional outcomes of robotic ONB The ultimate success with ONB depends on achievement of continence. Daytime continence is determined only by the condition of the external sphincter, irrespective of the type of reservoir and whether it was constructed from a tubularized or detubularized intestinal segment. Nighttime continence depends on the functionality of the reservoir.9 Daytime and nighttime urinary incontinence has been reported in 7% to 13% and 14% to 43% of patients with an open ONB, respectively.9 Regrettably, robotic series define continence differently (allowing diapers in continent patients)6 and report quality of life metrics instead of urinary incontinence data. Using standard definitions, Canda et al reported as expected daytime continence in 73% of patients following robotic ONB but just 20% of the patients were dry at night and 53% were totally incontinent.5 Inappropriate outcome reporting Robotic surgeons claim to replicate open surgical principles and outcomes with 90-day complication rates of 70% and Clavien 3 to 5 complication rates of 15% to 50% in highly selected groups of patients.5,6,10 However, they disregard the fact that these corresponding rates after 113 cases of open ONB were as low as 46% and 4%.8 http://dx.doi.org/10.1016/j.juro.2014.09.042 Vol. 192, 1601-1603, December 2014 Printed in U.S.A.
www.jurology.com
j
1601
1602
OPPOSING VIEWS
Conclusions When one must resort to a simple U-shaped reservoir rather than the standard (and more complicated) intracorporeal ONB, urinary function is bound to suffer. However, optimum function is more important than a smaller scar or time to first flatus. Patients with bladder cancer must be assured that they will get the best possible functional results, which may seriously impact future quality of life. Open ONB remains the gold standard for continent diversion following RC. Robotic intracorporeal ONB remains investigational and must not compromise surgical principles optimizing survival. It has not been shown whether RRC and robotic UD provide survival, local control or urinary function comparable to that of RC. Furthermore, functional as well as oncologic and quality of life outcomes of RRC and robotic UD must be confirmed in randomized and prospective controlled cohort studies. Richard E. Hautmann University of Ulm Ulm, Germany and
Harry W. Herr Department of Urology Memorial Sloan Kettering Cancer Center New York, New York
NO Since the initial description of the technique of robotic radical cystectomy by Menon et al in 2003,11 a number of authors have published their outcomes, mostly in retrospective case series. To date, only 3 randomized studies comparing RRC with open radical cystectomy (ORC), the reference standard, have been published.2,12,13 Current data indicate that RRC is not inferior to ORC in terms of oncological parameters as well as morbidity. Decreased blood loss is a clear benefit of RRC.2,12,13 There also appears to be lower narcotic requirement and a trend towards shorter length of stay (LOS) with RRC.12,13 Due to the cost of the robot, disposables and annual maintenance contract, direct costs are higher for RRC. However, a recent population based study indicated that overall cost differences between RRC and ORC are not significant for high volume surgeons (7 or more surgeries a year) and hospitals (19 or more surgeries ar year).1 It is estimated that if the LOS were reduced to 7 days, which is possible with enhanced recovery pathways, then RRC would be at a cost advantage with operating room time 380 minutes or less, which is achievable at high volume centers.1 Accordingly, RRC use has increased 21-fold from 0.6% in 2004 to 12.8% in 2010.1 However, most of
these cases have been done using a hybrid technique, wherein a robotic approach is used for the extirpative part of the operation followed by an extracorporeal urinary diversion. Even with this hybrid approach, the aforementioned benefits on outcomes have been repeatedly demonstrated, suggesting improved outcomes at a similar cost. Thus, there seems to be a benefit with a robotic approach to the extirpative portion of the surgery, even with open diversion. Could these benefits be further extended with the use of an intracorporeal diversion? As the adoption of RRC has grown exponentially, there has been increasing interest in using an intracorporeal, purely robotic, approach to the diversion.4,14e16 Given the advantages of the robotic platform for reconstruction, in terms of wristed instrumentation and 3-D visualization, intracorporeal diversion would seem to be a natural extension of robotics in cystectomy. In a recent report on the International Robotic Cystectomy Consortium database (a multiinstitutional database of almost 1,000 patients who have undergone RRC at 1 of 18 institutions) Ahmed et al evaluated the outcomes of patients undergoing RRC with an extracorporeal diversion vs an intracorporeal diversion.17 The intracorporeal group had a lower rate of overall complications (p ¼ 0.05), gastrointestinal complications (p
Robotic Radical CystectomydIs the Diversion the Achilles’ Heel? YES OPEN radical cystectomy (RC) is the standard treatment for invasive bladder cancer. Although a morbid procedure, it does save lives and quality of surgery is critical to its success. Most of the morbidity is related to the obligatory urinary diversion (UD). Robotic radical cystectomy (RRC) has recently been advocated, with claims of fewer complications, faster recovery and functional outcomes similar to those of RC.1 Such claims are based on retrospective analysis of collected cases fraught with selection bias, missing data, short followup and unquantified variables. It remains to be seen whether RRC provides results comparable to RC in unselected patients. After RRC, urinary diversion may be done as an open procedure (though small incisions) or entirely within the abdomen using the robot. In a randomized trial Bochner et al reported no advantage of RRC and extracorporeal UD over conventional RC in 90-day complications, recovery times or surgical outcomes,2 suggesting that any real benefit of RRC requires intracorporeal robotic urinary diversion, whether as an ileal stoma or orthotopic neobladder. Despite the potential advantages of RRC, such as decreased blood loss, quicker bowel recovery and decreased analgesic requirements, it is associated with longer operative time, similar length of stay, steeper learning curve, especially for intracorporeal UD, and higher costs. The main drawback of RRC is that the long-term functional performance of robot-constructed diversion remains unknown. Compromised technique of extracorporeal and intracorporeal robotic orthotopic neobladder Experience with open orthotopic neobladder (ONB) has shown that several principles are critical to ensure successful functional outcomes. Detubularization, cross (double) folding and, to a lesser extent, a spherical shape result in a larger radius, greater volume and ultimately lower pressure.3 Almost all robotic reservoirs are constructed from short (40 cm) ileal segments, have significant undetubularized portions and are only U-shaped.4e7 As a result, they have a small radius of 2.4 cm, geometric capacity of 0022-5347/14/1926-1601/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
just 180 to 271 cc and pressure twice as high compared to a standard open ONB with a radius of 4.8 cm and geometric capacity as high as 1,085 cc.8 If the UD is performed extracorporeally, the devascularized ureters must be left long and an increased stenosis rate is to be expected. Patients expect results obtained with a novel technique to be at least as good as those obtained with an established technique. Decreased use of continent UD It is also a concern that in most RRC series less than 20% of patients undergo orthotopic reconstruction. Given such a highly selected group of patients, one would expect this technique to be performed in at least 50% to 60% of patients. Inferior functional outcomes of robotic ONB The ultimate success with ONB depends on achievement of continence. Daytime continence is determined only by the condition of the external sphincter, irrespective of the type of reservoir and whether it was constructed from a tubularized or detubularized intestinal segment. Nighttime continence depends on the functionality of the reservoir.9 Daytime and nighttime urinary incontinence has been reported in 7% to 13% and 14% to 43% of patients with an open ONB, respectively.9 Regrettably, robotic series define continence differently (allowing diapers in continent patients)6 and report quality of life metrics instead of urinary incontinence data. Using standard definitions, Canda et al reported as expected daytime continence in 73% of patients following robotic ONB but just 20% of the patients were dry at night and 53% were totally incontinent.5 Inappropriate outcome reporting Robotic surgeons claim to replicate open surgical principles and outcomes with 90-day complication rates of 70% and Clavien 3 to 5 complication rates of 15% to 50% in highly selected groups of patients.5,6,10 However, they disregard the fact that these corresponding rates after 113 cases of open ONB were as low as 46% and 4%.8 http://dx.doi.org/10.1016/j.juro.2014.09.042 Vol. 192, 1601-1603, December 2014 Printed in U.S.A.
www.jurology.com
j
1601
1602
OPPOSING VIEWS
Conclusions When one must resort to a simple U-shaped reservoir rather than the standard (and more complicated) intracorporeal ONB, urinary function is bound to suffer. However, optimum function is more important than a smaller scar or time to first flatus. Patients with bladder cancer must be assured that they will get the best possible functional results, which may seriously impact future quality of life. Open ONB remains the gold standard for continent diversion following RC. Robotic intracorporeal ONB remains investigational and must not compromise surgical principles optimizing survival. It has not been shown whether RRC and robotic UD provide survival, local control or urinary function comparable to that of RC. Furthermore, functional as well as oncologic and quality of life outcomes of RRC and robotic UD must be confirmed in randomized and prospective controlled cohort studies. Richard E. Hautmann University of Ulm Ulm, Germany and
Harry W. Herr Department of Urology Memorial Sloan Kettering Cancer Center New York, New York
NO Since the initial description of the technique of robotic radical cystectomy by Menon et al in 2003,11 a number of authors have published their outcomes, mostly in retrospective case series. To date, only 3 randomized studies comparing RRC with open radical cystectomy (ORC), the reference standard, have been published.2,12,13 Current data indicate that RRC is not inferior to ORC in terms of oncological parameters as well as morbidity. Decreased blood loss is a clear benefit of RRC.2,12,13 There also appears to be lower narcotic requirement and a trend towards shorter length of stay (LOS) with RRC.12,13 Due to the cost of the robot, disposables and annual maintenance contract, direct costs are higher for RRC. However, a recent population based study indicated that overall cost differences between RRC and ORC are not significant for high volume surgeons (7 or more surgeries a year) and hospitals (19 or more surgeries ar year).1 It is estimated that if the LOS were reduced to 7 days, which is possible with enhanced recovery pathways, then RRC would be at a cost advantage with operating room time 380 minutes or less, which is achievable at high volume centers.1 Accordingly, RRC use has increased 21-fold from 0.6% in 2004 to 12.8% in 2010.1 However, most of
these cases have been done using a hybrid technique, wherein a robotic approach is used for the extirpative part of the operation followed by an extracorporeal urinary diversion. Even with this hybrid approach, the aforementioned benefits on outcomes have been repeatedly demonstrated, suggesting improved outcomes at a similar cost. Thus, there seems to be a benefit with a robotic approach to the extirpative portion of the surgery, even with open diversion. Could these benefits be further extended with the use of an intracorporeal diversion? As the adoption of RRC has grown exponentially, there has been increasing interest in using an intracorporeal, purely robotic, approach to the diversion.4,14e16 Given the advantages of the robotic platform for reconstruction, in terms of wristed instrumentation and 3-D visualization, intracorporeal diversion would seem to be a natural extension of robotics in cystectomy. In a recent report on the International Robotic Cystectomy Consortium database (a multiinstitutional database of almost 1,000 patients who have undergone RRC at 1 of 18 institutions) Ahmed et al evaluated the outcomes of patients undergoing RRC with an extracorporeal diversion vs an intracorporeal diversion.17 The intracorporeal group had a lower rate of overall complications (p ¼ 0.05), gastrointestinal complications (p
