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Platinum Priority – Editorial
Referring to the article published on pp. 1042–1050 of this issue

The Surgeon Makes the Difference, Not the Instrument Used

By: Urs E. Studer lowast

European Urology, Volume 67 Issue 6, June 2015, Pages 1051-1052

Published online: 01 June 2015

Abstract Full Text Full Text PDF (179 KB)

Refers to article:

Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial eulogo1

Bernard H. Bochner, Guido Dalbagni, Daniel D. Sjoberg, Jonathan Silberstein, Gal E. Keren Paz, S. Machele Donat, Jonathan A. Coleman, Sheila Mathew, Andrew Vickers, Geoffrey C. Schnorr, Michael A. Feuerstein, Bruce Rapkin, Raul O. Parra, Harry W. Herr and Vincent P. Laudone

Accepted 21 November 2014

June 2015 (Vol. 67, Issue 6, pages 1042 - 1050)

Several single-center and multicenter reports have suggested that complication rates, length of hospital stay, and quality of life (QOL) after surgery are better after robotic assisted radical cystectomy (RARC) than after open radical cystectomy (ORC) and that the oncologic safety of the two procedures is equal. In this month's issue ofEuropean Urology, Bochner et al present results of their prospective randomized trial [1] , which had been published in part recently [2] , of 118 patients who underwent ORC or RARC combined with pelvic lymph node dissection (PLND). Urinary diversion was performed by open surgery. The authors concluded that 90-d complication rates, hospital stays, pathologic outcomes, and 3- and 6-mo QOL assessments for the two techniques were similar. The mean estimated blood loss for RARC was 159 ml less than for ORC, at the cost of 2 h longer operating room time.

The authors are to be commended for conducting this prospective randomized trial, which is long overdue. Wishful thinking is finally replaced by hard facts, of which patients must be duly informed before undergoing radical cystectomy. Still, some points regarding the trial by Bochner et al [1] must be noted.

  • The trial is not sufficiently powered to conclude that all results are equivalent, only that the difference between results is not >20%.
  • The patient population is not representative of all cystectomy patients. Of all evaluated patients, 23% failed the inclusion criteria and of the evaluable patients only 25% consented to be randomized. Surprisingly, only 8.5% of RARC patients and 8.8% of ORC patients were staged with T3/T4 disease, and 58% of RARC patients and 55% of ORC patients had non–muscle-invasive disease (pT0/1 disease).
  • Only 17% of patients had positive lymph nodes, also suggesting a trend toward selection of patients with good risk (usually about 25% of N0 patients have positive nodes [3] ). Moreover, with only 17 RARC patients and 19 ORC patients having pT3/4 disease, it is not surprising that no difference was found with regard to positive margins.
  • The RARC surgeons had performed thousands of robotic pelvic procedures. Given RARC's long learning curve, less experienced urologists probably would have had poorer results.
  • The authors wisely included a QOL assessment; however, <50% of their patients returned the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 form, substantially diminishing the data's validity. Moreover, the EORTC QOL form was not designed to assess QOL after cystectomy. Questions such as “Did you feel tense?” or “Did you feel irritable?” and “Have you had difficulty remembering things?” can hardly discriminate between QOL after two different surgical approaches.
  • More important than questionnaire results would be functional outcomes, such as incontinence or the need for intermittent catheterization after orthotopic urinary diversion, because electrocautery or Endo GIA (Covidien, Dublin, Ireland) may damage the autonomic nerves. The incidence of pyelonephritis or ureterointestinal strictures requiring secondary surgery would be of interest because urinary outlet obstruction is a major cause of renal function deterioration [4] ; extracorporeal urinary diversion necessitates leaving the ureters long, with consequent increased risk of ischemia and strictures. We await these data, which are most relevant for patients, with interest.
  • The extent of PLND differed substantially depending on the surgeon's preference. The primary lymphatic landing sites may be anywhere in the pelvis and, rarely, even up to the level of the inferior mesenteric artery [5] . Metastatic spread is not step-by-step dissemination from a caudal level to a more proximal one. If a patient requires PLND (which is every patient with imperative indications for cystectomy), then PLND at least up to the proximal or middle third of the common iliac artery (where the ureter crosses it) is mandatory.

The rate of postoperative complications was the primary end point of the trial by Bochner et al [1] because complications occur in approximately two-thirds of patients undergoing radical cystectomy and orthotopic diversion. In the trial, 21% of all patients experienced high-grade complications. If robotic assisted surgery cannot substantially reduce this rate, how can it be reduced independently from the surgical (robotic or open) approach? Analysis of the most frequent complications in Bochner and colleagues’ study may provide some hints:

  • Infectious complications (grade 2–5) occurred in 38% of RARC and 29% of ORC patients. These high rates should make us rethink the issue of short- or long-term perioperative antibiotic prophylactic treatment.
  • It is noteworthy that an additional 14% of ORC patients suffered wound infections. Such infections can be substantially reduced by not using a Bovie knife to open up the patient because burned fatty tissue is susceptible to infection. Moreover, subcutaneous suction drainage can prevent the formation of hematomas and seromas that facilitate abscess formation.
  • Cardiac and gastrointestinal grade 2–5 complications were observed in 38% of RARC and 43% of ORC patients. These complications are often promoted by overhydrating patients to maintain sufficient arterial pressure to compensate for the vasodilational effect of the analgesics and anesthetics administered by the anesthesiologists. The use of α-mimetic agents can substantially reduce the amount of intravenous crystalloids, with the added advantages of a drier surgical field and significantly fewer cardiac and gastrointestinal complications [6] . Furthermore, maintaining the patient's physiologic vasoconstriction and low central venous pressure can reduce perioperative and postoperative blood loss by much more than the 159 ml less blood lost in the RARC arm [7] .
  • Although it is understandable that every woman underwent a hysterectomy and salpingectomy combined with radical cystectomy to avoid possible disparity between the RARC and ORC groups, the trend should be toward more individualized cystectomy, which ensures maximal oncologic safety with minimal avoidable comorbidities. Specifically, in the case of orthotopic diversion, individualized nerve-sparing cystectomy (facilitated by avoiding hysterectomy) may have lifelong consequences regarding residual-free voiding and urinary continence with orthotopic bladder substitution.

In summary, the trial by Bochner et al [1] shows that in a carefully selected, rather low-risk group of patients, RARC does not substantially improve outcomes versus ORC. What the trial does not show are the long-term functional outcomes, such as preservation of sexual and renal function or the incidence of perfectly functioning orthotopic bladder substitutes, which is most important for patients. Obtaining these requires the surgeon's profound understanding of urologic–oncologic principles of how to preserve the autonomic nerves and how to construct an orthotopic bladder substitute that does not necessitate clean intermittent catheterization, by avoiding a funnel-shaped outlet. Consequently, it is the surgeon that makes the difference, not the instrument used.

Conflicts of interest

The author has nothing to disclose.

References

  • [1] B.H. Bochner, G. Dalbagni, D.D. Sjoberg, et al. Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol. 2015;67:1042-1050
  • [2] B.H. Bochner, D.D. Sjoberg, V.P. Laudone. A randomized trial of robot-assisted laparoscopic radical cystectomy. N Engl J Med. 2014;371:389-390
  • [3] P. Zehnder, U.R. Studer, E.C. Skinner, et al. Super extended versus extended pelvic lymph node dissection in patients undergoing radical cystectomy for bladder cancer: a comparative study. J Urol. 2011;186:1261-1268 Crossref
  • [4] Xiao-Dong Jin, S. Roethlisberger, F.C. Burkhard, et al. Long-term renal function after urinary diversion by ileal conduit or orthotopic ileal bladder substitution. Eur Urol. 2012;61:491-497
  • [5] B. Roth, M.P. Wissmeyer, P. Zehnder, et al. A new multimodality technique accurately maps the primary lymphatic landing sites of the bladder. Eur Urol. 2010;57:205-211 Crossref
  • [6] P.Y. Wuethrich, F.C. Burkhard, G.N. Thalmann, et al. Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time. Anesthesiology. 2014;120:365-377
  • [7] P.Y. Wuethrich, U.E. Studer, G.N. Thalmann, et al. Intraoperative continuous norepinephrine infusion combined with restrictive deferred hydration significantly reduces the need for blood transfusion in patients undergoing open radical cystectomy: results of a prospective randomized trial. Eur Urol. 2014;66:352-360

Footnotes

Department of Urology, University Hospital of Bern, Bern, Switzerland

lowast University Hospital Bern, Department of Urology, 3010 Bern, Switzerland. Tel. +41 31 6323621; Fax: +41 31 6322180.

Comments

  • Michael Cookson - 7 February 2015

    This article highlights the Achilles heal of radical cystectomy, namely that aside from blood loss the majority of the morbidity of the surgery is directly related to the urinary diversion. Since both arms undergo similar bowel and diversion-related surgery, they are "at risk" for similar rates of postoperative morbidity. So, I agree that it is the surgeon, not the tool, I also believe it is the bowel and not the bladder.

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