Recurrence Patterns After Open and Robot-assisted Radical Cystectomy for Bladder Cancer

Abstract

Background Concerns remain whether robot-assisted radical cystectomy (RARC) compromises survival because of inadequate oncologic resection or alteration of recurrence patterns. Objective To describe recurrence patterns following open radical cystectomy (ORC) and RARC. Design, setting, and participants Retrospective review of 383 consecutive patients who underwent ORC (n = 120) or RARC (n = 263) at an academic institution from July 2001 to February 2014. Intervention ORC and RARC. Outcome measurements and statistical analysis Recurrence-free survival estimates were illustrated using the Kaplan-Meier method. Recurrence patterns (local vs distant and anatomic locations) within 2 yr of surgery were tabulated. Cox regression models were built to evaluate the effect of surgical technique on the risk of recurrence. Results and limitations The median follow-up time for patients without recurrence was 30 mo (interquartile range [IQR] 5–72) for ORC and 23 mo (IQR 9–48) for RARC (p = 0.6). Within 2 yr of surgery, there was no large difference in the number of local recurrences between ORC and RARC patients (15/65 [23%] vs 24/136 [18%]), and the distribution of local recurrences was similar between the two groups. Similarly, the number of distant recurrences did not differ between the groups (26/73 [36%] vs 43/147 [29%]). However, there were distinct patterns of distant recurrence. Extrapelvic lymph node locations were more frequent for RARC than ORC (10/43 [23%] vs 4/26 [15%]). Furthermore, peritoneal carcinomatosis was found in 9/43 (21%) RARC patients compared to 2/26 (8%) ORC patients. In multivariable analyses, RARC was not a predictor of recurrence. Limitations of the study include selection bias and a limited sample size. Conclusions Within limitations, we found that RARC is not an independent predictor of recurrence after surgery. Interestingly, extrapelvic lymph node locations and peritoneal carcinomatosis were more frequent in RARC than in ORC patients. Further validation is warranted to better understand the oncologic implications of RARC. Patient summary In this study, the locations of bladder cancer recurrences following conventional and robotic techniques for removal of the bladder are described. Although the numbers are small, the results show that the distribution of distant recurrences differs between the two techniques.

Comparison of 2-Year Oncological Outcome and Early Recurrence Patterns in Patients with Urothelial Bladder Carcinoma Treated with Open or Robot-Assisted Radical Cystectomy with an Extracorporeal Urinary Diversion

“…This thoughtprovoking retrospective evidence raised many criticisms and concerns on RARC. Though similar rates of unusual metastatic dissemination were observed, the trend showed that uBCa in RARC patients more often did recur in extrapelvic nodal sites and with peritoneal carcinomatosis [13]. However, in a detailed analysis from the same institution, atypical dissemination was found to be dictated by tumor biology rather than surgical aspects [14].…”

“…Atypic metastatic location was defined according to the previous study by Nguyen et al [13] and consisted of clinical or pathologic evidence of peritoneal carcinomatosis and extrapelvic lymph node metastasis. First, means, medians, and interquartile ranges (IQR) or frequencies and proportions were reported for continuous or categorical variables on the study populations respectively.…”

“…Patients submitted to RARC were reported to have a higher rate of unusual relapse pattern compared to ORC patients [10][11][12][13]. This thoughtprovoking retrospective evidence raised many criticisms and concerns on RARC.…”

Robotic Assisted Radical Cystectomy, Current Status and Future Directions

“…Khan et al [9] showed an overall survival of 64%, disease-specific survival of 75%, and disease-free survival of 50% after RARC at minimum of 5 years follow up. Furthermore, RARC is not known to act as an independent predictor of recurrence [10].There has been much debate on the suitable approach for urinary diversion (intracorporeal or extracorporeal) following RARC. Intracorporeal urinary diversion (ICUD) has the potential advantages of a small incision, decreased bowel exposure and less post-operative pain.…”

“…Khan et al [9] showed an overall survival of 64%, disease-specific survival of 75%, and disease-free survival of 50% after RARC at minimum of 5 years follow up. Furthermore, RARC is not known to act as an independent predictor of recurrence [10].…”