Dr Naresh Kaul, Urologiat T Max Institute of Cancer Care,Vaishali talks about the current updates and evidence for Robotic Assisted Radical Cystectomy
Since the initial case series of robotic-assisted radical cystectomy (RARC) in 2003 by Menon et al (1), there has been a gradual shift towards RARC, with a more than 30-fold increase in the utilization of RARC since then.(2)
One of the first landmark trials comparing open radical cystectomy (ORC) with RARC is the RAZOR (Robot-assisted radical cystectomy versus open radical cystectomy) trial, which reported lower blood loss, longer operative time and similar hospital stay with a similar 2-year PFS for both approaches. Further analysis reported similar oncological outcomes at 3 year follow-up.(3,4) A recent meta-analysis encompassing 1024 patients across eight RCTs to compare RARC and ORC demonstrated lower blood loss and reduced intraoperative transfusion rates, shorter hospital stays, and fewer severe complications albeit with longer operative times. The benefits may be attributed to enhanced visualization, precise robotic instrumentation, and the haemostatic effects of pneumoperitoneum used in robotic surgery. In terms of equivalent oncological efficacy to ORC, there was no significant difference in recurrence patterns, OS, or RFS.(5)
Another point of contemplation with robotic approach is comparison of extracorporeal vs intracorporeal urinary diversion. The iROC (Intracorporeal Robotic urinary diversion versus Open Radical Cystectomy) multicentric trial compared robotic intracorporeal versus open urinary diversion and reported shorter hospital stay within 90 days post-surgery, lower transfusion rates, fewer thromboembolic and wound-related complications along with better quality of life, reduced disability, and improved stamina with intracorporeal urinary diversion.(6)
Quality of life (QoL) assessments post-RARC reveal encouraging results, particularly with intracorporeal urinary diversion, showing superior outcomes in physical and role functioning domains compared to extracorporeal urinary diversion or ORC. (7,8) But it usually requires 3 to 6 months to recover baseline levels post RC irrespective of the surgical approach.(9)
In a nutshell, radical cystectomy is one of the most challenging and morbid surgical procedures involving both ablative and reconstructive surgery. In experienced hands and high-volume centres, RARC has similar oncological outcomes with improved perioperative and functional outcomes, however, cost and learning curve still remains a challenge.
Table 1: Select studies comparing RARC & ORC
Parameter | RAZOR (3,4) ORC/RARC | iROC (6) ORC/RARC | CORAL(10) ORC/RARC | Meta-analysis (5) ORC/RARC |
Study Design | RCT | RCT | RCT | 8 RCT |
N (Number) | 152/150 | 156/151 | 20/20 | 509/515 |
Diversion | EC/IC | IC | EC | IC/EC |
Perioperative outcomes | ||||
Operative time (min) | 361/428 (p=0·0005) | 258/300 | 293/389 (p< 0.001) | RARC>ORC [WMD = 75.71, p<0.00001] |
Blood loss (ml) | 700/300 (p<0.001 ) | 759/281 | 808/585(p= 0.070 ) | ORC>RARC [ WMD =321.6, p = <0.00001] |
Major complications (%) | 22.3/22 (p= 0.94) | 22/16.5 | 20/20 (p= 0.2) | ORC=RARC [WMD =1.08, p=0.62] |
Hospital stay (days) | 7.5/6.8 (p=0·0407) | 9/7.5 | 14.4/11.9 (p= 0.031) | ORC>RARC [WMD= 0.23, p =0.02] |
Oncological outcomes (%) | ||||
OS | 3y OS: 68.5% /73.9% (p = 0.334) | 5 yr OS: 55% / 65% (p >0.05) | 3 yr OS: ORC=RARC (p=0.9) | |
PFS/RFS | 3y PFS: 65.4% / 68.4% (p = 0.6) | Recurrence at 18 months 11/156(ORC) vs 15/151 (RARC) | 5y PFS: 60% / 58% (p>0.05) | 3 yr PFS: ORC=RARC (p>0.9) |
QOL | ||||
Scores | FACT-VCI 125.2/126.5 | QLQ-C30 81.96/86.06 | FACT-BII 124.9/122.3 | RARC superior to ORC |