Minimally invasive approaches in the treatment of urothelial carcinoma robotic radical cystectomy
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Minimally Invasive Approaches in the Treatment of Urothelial Carcinoma “ Robotic Radical Cystectomy ”. Douglas S. Scherr, M.D. Weill Medical College of Cornell University. Robotics Beyond The Prostate. Radical Cystectomy Can we achieve equal oncological outcome?. Radical Cystectomy.

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Minimally Invasive Approaches in the Treatment of Urothelial Carcinoma“Robotic Radical Cystectomy”

Douglas S. Scherr, M.D.

Weill Medical College of Cornell University


Robotics Beyond The Prostate

  • Radical Cystectomy

  • Can we achieve equal oncological outcome?


Radical Cystectomy

  • Gold Standard for Invasive Disease

  • Role in T1 Disease

  • Quality of surgery impacts outcome and survival


Was the Effect all Chemotherapy?Are surgical variables important?

  • Post cystectomy survival predicted by:a.) ageb.) stagec.) node statusd.) negative surgical marginse.) >10 nodes removed

  • Hazard ratio for death:a.) 2.7 for + surgical marginb.) 2.0 for <10 nodes removed

Herr et al. JCO, 22(14): 2781, 2004


Radical Cystectomy for T1 TCC

  • USC Experience: 208 pts with T1 disease

  • USC Experience with T2 disease

Recurrence Free Survival Overall Survival

5 Year 10 Year 5 Year 10 Year

80% 75% 74% 51%

Recurrence Free Survival Overall Survival

5 Year 10 Year 5 Year 10 Year

81% 80% 72% 56%

Stein et al., J Clin Oncol, 19(3): 666-75, 2001


Early Vs. Late Cystectomy

  • 90 pts who had TUR + BCG ultimately underwent cystectomy

  • 41/90 had T1 disease

  • Median Follow up of 96 mosEarly cystectomy (<2 years): 92% survivalLate cystectomy (>2 years): 56% survival

Herr and Sogani, J Urol, 166: 1296-9, 2001


Extent of Lymphadenectomy

  • Is there more to the node dissection than staging?

  • 1936 Colston and Leadbetter performed studies on 98 cadavers “limited metastatic disease was restricted to the pelvic nodes”

  • 1946 – Dr. Jewett “cardinal site of metastasis”

Colston and Leadbetter, J Urol, 36: 669, 1936

Jewett et al. J Urol, 55: 366, 1946


Extent of Lymphadenectomy

  • Node positive patients can enjoy long term survival

  • 24% of grossly node positive disease survived 10 years without adjuvant therapy

  • More nodes removed correlates with improved survival

Sanderson et al. Urol Oncol., 22: 205, 2004


Extent of Lymphadenectomy

  • Likely no staging advantage to extending the node dissection above the aortic bifurcation

  • 33% of unsuspected nodes found at common iliacs

  • Practice patterns vary widely:

    a.) 40% of cystectomies have no LNDb.) 12.7% of LND had <4 nodes removed

    Lymph node density (# pos nodes/total # nodes)

Konety et al. J Urol, 170: 1765, 2003


Extent of Pelvic Lymph Node Dissection

IMA

Genitofemoral

nerve

Genitofemoral

nerve

Aortic

Nodes

Common Iliac Nodes

Hypogastric and

Obturator Nodes


Survival By Number Of Lymph Nodes Removed

Herr et al. JCO, 22(14): 2781, 2004


Postcystectomy survival by node status and number of nodes removed

Herr, H. W. et al. J Clin Oncol; 22:2781-2789 2004


Post Cystectomy Survival

Herr, H. W. et al. J Clin Oncol; 22:2781-2789 2004


Gold Standard

  • Open radical cystectomy (RC) is the gold standard for treatment of muscle-invasive bladder cancer.


Minimally Invasive Bladder Cancer Surgery

  • Efforts to reduce the operative morbidity of RC have fostered interest in minimally invasive approaches.

  • Laparoscopic RC

  • Robot-assisted laparoscopic RC


Concerns of Robotic Cystectomy?

  • Concerns regarding minimally invasive RC

    • Absence of long term oncologic outcomes

    • Absence of long term functional outcomes

    • Limited pelvic lymphadenectomy

    • Longer operative time

    • Increased cost

Miller NL et al: World J Urol (2006) 24:180


Outcome Measures of Minimally Invasive Bladder Surgery

  • Previous reports comparing open versus minimally invasive RC have focused on perioperative outcomes.

    • Blood loss

    • Operative time

    • Analgesic requirement

    • Time to regular diet

    • Length of hospital stay

Hemal AK et al: Urol Clin N Am (2004) 31:719

Basillote JB et al: J Urol (2004) 172:489

Taylor GD et al: J Urol (2004) 172:1291

Galich A et al: JSLS (2006) 10:145

Rhee JJ et al: BJU Int (2006) 98:1059


Comparison of Surgical Techniques

  • Lymph node yield

  • Margin status

  • However, direct comparison between open and minimally invasive RC of early oncologic parameters is lacking.


Study Comparison

  • Comparison of perioperative and early pathologic outcomes in a consecutive series of open and robotic RCs at our institution.


Methods

  • From February to December 2006, 43 consecutive patients underwent RC by a single surgeon at our institution.

  • 22 open

  • 21 robotic


Technique

  • Posterior dissection

  • Isolation of ureters

  • Lateral dissection

  • Control of bladder pedicles

  • Anterior dissection

  • Control of DVC and division of urethra

  • Control of prostate pedicles and nerve-sparing

  • Pelvic lymph node dissection

    • External iliac, hypogastric, and obturator lymphadenectomy up to the level of the mid-common iliac vessels

  • Extracorporeal urinary diversion through a 5-7cm midline incision

    • Orthotopic neobladder: robot re-docked for urethral neovesical anastomosis


Data Collection and Analysis

  • Data was collected prospectively

    • Patient characteristics

    • Perioperative outcomes

    • Early pathologic outcomes

  • Data analysis

    • Chi-square test

    • Fisher’s exact test

    • Student’s t-test


Results: Patient Characteristics

  • There was no difference in the following parameters among the 2 cohorts.

  • Age

  • BMI

  • ASA class

  • Prior abdominal surgery

  • Prior abdominal radiation

  • Neoadjuvant chemotherapy


Results: Clinical Stage


Urinary Diversion


Operative Time

* P < 0.05


Robotic Learning Curve

* P < 0.05


Blood Loss & Postoperative Parameters

* P < 0.05


Postoperative Complications


Pathologic Stage

* P < 0.05


Node & Margin Status

* P < 0.05


Conclusions:Robotic Cystectomy

  • Increased operative time

    • significantly longer operative time in the robotic neobladder cohort (p=0.01)

  • Decreased operative time with increased experience

    • 450 to 338 min (p=0.007)


Conclusions:Robotic Cystectomy

  • Decreased

    • Blood loss

    • Transfusion requirement

    • Time to regular diet

    • Length of hospital stay


Conclusions:Robotic Cystectomy

  • Equivalent lymph node yield

    • 17.4 (robotic) vs. 18.9 (open), p=0.6

  • Equivalent margin rate

    • 9% (robotic) vs. 19% (open), p=0.2

  • Long term oncologic and functional outcomes are required

Stein JP et al: J Urol (2003) 170: 35

Herr H et al: J Urol (2004) 171: 1823


Minimally Invasive Cystectomy

  • Minimally Invasive = Cancer Sparing


Prostate Sparing Cystectomy

  • Role for improved continence and potency

  • Need to rule out prostate cancer or TCC of prostatic urethra

  • Functional Results are good:a.) 97% complete continenceb.) No episodes of retentionc.) 82% maintained potency

Vallancien et al. J Urol, 168: 2413, 2002


Prostate Sparing Cystectomy

  • Incidence of Pca is 30-50% with approx. 48% are clinically significant

  • 60% of CaP involve the apex (79% significant and 42% insignificant)

  • 48% of prostates had urothelial ca involvement of which 33% had apical involvement

  • 61% had no prostatic apical involvement of CaP or Urothelial ca.


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