Robot-assisted radical cystectomy reduces recovery time vs. open surgery in bladder cancer
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Use of robot-assisted vs. open radical cystectomy led to a significantly increased number of days alive and out of the hospital among patients with nonmetastatic bladder cancer.
The results, published in JAMA, also showed robot-assisted radical cystectomy with intracorporeal urinary diversion resulted in a 52% decrease in the chance for hospital readmission and 77% reduction in prevalence of deep vein thrombosis and pulmonary embolism.
Rationale and methods
Although robot-assisted radical cystectomy has been performed with increasing frequency, it is unknown whether total intracorporeal surgery improves recovery time compared with open radical cystectomy for patients with bladder cancer.
For this reason, James W. F. Catto, PhD, researcher in the department of oncology and metabolism at The Medical School of University of Sheffield in England, and colleagues sought to compare recovery time and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction vs. open radical cystectomy.
Investigators assigned 317 patients (median age, 69 years; 79% men) with nonmetastatic bladder cancer receiving treatment across nine U.K. hospitals to either robot-assisted radical cystectomy with intracorporeal urinary diversion (n = 169) or open radical cystectomy (n = 169).
Hospital length of stay after surgery served as the primary outcome. Secondary outcomes included complications, quality of life, disability, stamina, activity levels and survival.
Median follow-up was 18.4 months. The researchers analyzed the primary outcome in 305 patients.
Key findings
Results showed the median number of days alive and out of the hospital within 90 days of surgery was 82 (interquartile range, 76-84) with robotic surgery compared with 80 (IQR, 72-83) with open surgery, for an adjusted difference of 2.2 days (95% CI, 0.5-3.85). Patients who underwent robotic surgery experienced fewer thromboembolic (1.9% vs. 8.3%; percentage-point difference, 6.5%; 95% CI, 11.4 to 1.4) and wound complications (5.6% vs. 16%; percentage-point difference, 11.7%; 95% CI, 18.6 to 4.6) than those who underwent open surgery.
In addition, patients who underwent open surgery reported worse quality of life at 5 weeks (difference in mean European Quality of Life 5-Dimension, 5-Level instrument scores, 0.07; 95% CI, 0.11 to 0.03) and greater disability at 5 weeks (difference in WHO Disability Assessment schedule [WHODAS] 2.0 scores, 0.48; 95% CI, 0.15-0.73) and at 12 weeks (difference in WHODAS 2.0 scores, 0.38; 95% CI, 0.09-0.68). However, the researchers found these differences insignificant at 12 weeks.
Of note, the researchers observed no significant differences in cancer recurrence (18% vs. 16%) or overall morality (14.3% vs. 14.7%) with robotic vs. open surgery.
Study limitations included adherence to in-person measurement of endpoints being compromised because of the COVID-19 pandemic and the trial having been conducted in high-volume hospitals, so the findings may not be generalizable to low-volume centers.
Implications
The study by Catto and colleagues represents an important milestone for robotic surgery, according to an accompanying editorial by Avinash Maganty, MD; Lindsey A. Herrel, MD, MS; and Brent K. Hollenbeck, MD, MS, all researchers at University of Michigan.
“Whether the benefit in days spent outside of the hospital is clinically meaningful and sufficient to promote further diffusion is likely to be a source of debate, with rational arguments on both sides of quality and cost issues,” they wrote. “Nonetheless, robotic surgery is here to stay. Further similar trials in other disease contexts are warranted to refine robotic surgery’s niche in the surgical armamentarium to maximize its value to patients.”
References:
- Catto JWF, et al. JAMA. 2022;doi:10.1001/jama.2022.7393.
- Maganty A, et al. JAMA. 2022;doi:10.1001/jama.2022.6417.
Perspective
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David Y.T. Chen, MD, FACS
Catto and colleagues reported results of a third major randomized prospective trial examining outcomes of radical cystectomy for bladder cancer, comparing robotic approach with traditional open surgery. The initial study, reported in 2015, was a single-institution trial with a primary objective of comparing the 90-day complication rate. It found no statistically significant difference between the approaches. The second trial, a multicenter study published in 2018, was a noninferiority comparison of the 2-year PFS outcome. Again, it showed a similar result between the approaches. Both prior trials had common secondary-outcome conclusions — that robotic surgery demonstrated longer operative time and less blood loss, and an equal or possibly slightly shorter length of stay for the robotic cystectomy approach — but neither identified a measurable benefit of robotic surgery vs. open surgery.
This current phase 3 study conducted at nine U.K. sites applies as primary objective a novel patient-centered quality-of-life and health measure, comparing the cumulative number of days patients were alive and out of the hospital at 90 days after surgery. The authors describe this as a composite index of a patient's recovery, incorporating the length of stay, readmissions and deaths within that postoperative period.
This report provides quantitative evidence on the robotic surgery approach resulting in a statistically significant shortened recovery over open surgery, where the benefit largely disappears beyond 26 weeks, and the authors comment on having uncertainty about whether this degree of difference is clinically important and meaningful.
References:
Bochner BH, et al. Eur Urol. 2015;doi:10.1016/j.eururo.2014.11.043.
Parekh DJ, et al. Lancet. 2018;doi:10.1016/S0140-6736(18)30996-6.
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