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

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
Robotics Beyond The Prostate Carcinoma

  • Radical Cystectomy

  • Can we achieve equal oncological outcome?


Radical cystectomy
Radical Cystectomy Carcinoma

  • 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
Was the Effect all Chemotherapy? CarcinomaAre surgical variables important?

  • Post cystectomy survival predicted by: a.) age b.) stage c.) node status d.) negative surgical margins e.) >10 nodes removed

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

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


Radical cystectomy for t1 tcc
Radical Cystectomy for T1 TCC Carcinoma

  • 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
Early Vs. Late Cystectomy Carcinoma

  • 90 pts who had TUR + BCG ultimately underwent cystectomy

  • 41/90 had T1 disease

  • Median Follow up of 96 mos Early cystectomy (<2 years): 92% survival Late cystectomy (>2 years): 56% survival

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


Extent of lymphadenectomy
Extent of Lymphadenectomy Carcinoma

  • 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 lymphadenectomy1
Extent of Lymphadenectomy Carcinoma

  • 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 lymphadenectomy2
Extent of Lymphadenectomy Carcinoma

  • 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 LND b.) 12.7% of LND had <4 nodes removed

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

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


Douglas s scherr m d weill medical college of cornell university

Extent of Pelvic Lymph Node Dissection Carcinoma

IMA

Genitofemoral

nerve

Genitofemoral

nerve

Aortic

Nodes

Common Iliac Nodes

Hypogastric and

Obturator Nodes


Douglas s scherr m d weill medical college of cornell university

Survival By Number Of Lymph Nodes Removed Carcinoma

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


Douglas s scherr m d weill medical college of cornell university

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
Post Cystectomy Survival removed

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


Gold standard
Gold Standard removed

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


Minimally invasive bladder cancer surgery
Minimally Invasive Bladder Cancer Surgery removed

  • 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 of Robotic Cystectomy? removed

  • 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
Outcome Measures of Minimally Invasive Bladder Surgery removed

  • 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
Comparison of Surgical Techniques removed

  • Lymph node yield

  • Margin status

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


Study comparison
Study Comparison removed

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


Methods
Methods removed

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

  • 22 open

  • 21 robotic


Technique
Technique removed

  • 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 Collection and Analysis removed

  • 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
Results: Patient Characteristics removed

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

  • Age

  • BMI

  • ASA class

  • Prior abdominal surgery

  • Prior abdominal radiation

  • Neoadjuvant chemotherapy




Operative time
Operative Time removed

* P < 0.05


Robotic learning curve
Robotic Learning Curve removed

* P < 0.05




Pathologic stage
Pathologic Stage removed

* P < 0.05


Node margin status
Node & Margin Status removed

* P < 0.05


Conclusions robotic cystectomy
Conclusions: removedRobotic 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 cystectomy1
Conclusions: removedRobotic Cystectomy

  • Decreased

    • Blood loss

    • Transfusion requirement

    • Time to regular diet

    • Length of hospital stay


Conclusions robotic cystectomy2
Conclusions: removedRobotic 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 Cystectomy removed

  • Minimally Invasive = Cancer Sparing


Prostate sparing cystectomy
Prostate Sparing Cystectomy removed

  • Role for improved continence and potency

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

  • Functional Results are good: a.) 97% complete continence b.) No episodes of retention c.) 82% maintained potency

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


Prostate sparing cystectomy1
Prostate Sparing Cystectomy removed

  • 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.