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Robot-assisted radical cystectomy or open radical cystectomy?

Presented by
Prof. Jens Bedke, Prof. Seth Lerner, Prof. James Catto
EAU 2019
Bladder cancer poses a special challenge to urologists due to unclear data concerning the best approach to radical cystectomy with pelvic lymph node dissection. In a debate with Prof. Jens Bedke (University Tübingen, Germany), Prof. Seth Lerner (Baylor College of Medicine, Houston, USA) argued the case for radical cystectomy over robot-assisted radical cystectomy using data from the recent RAZOR trial. In this trial, 350 patients with bladder cancer were randomly assigned to either open or robot-assisted cystectomy, and the primary endpoint was 2-year progression-free survival [1].

Open radical cystectomy (RC) is historically the treatment of choice for patients who present with invasive disease, progressive disease, or disease refractory to intravesical therapy. Although retrospective data has suggested that robot-assisted radical cystectomy (RARC) is safer than RC, prospective data have been lacking. RAZOR indicated that RARC is associated with lower blood loss, lower transfusion rates, and a shorter length of hospital stay which was balanced by operating time (open radical cystectomy was faster); however, the trial did not show a difference in complication rates, which was the original attraction to RARC in the first place (see Table). So: is RARC justified? Some of the discussion was centred around whether the urinary diversions were performed extracorporeally, and whether intracorporeal diversion (less invasive) would demonstrate the benefit of robotic cystectomy. In addition, RARC was performed by surgeons whose operating times (averaging >7 h) were slower than average times for experienced surgeons, suggesting that the data may have been disproportionately affected by a learning curve.

Table: Selected findings from the RAZOR trial [1]

Should RARC be recommended in daily clinical practice on the basis of these results? On the one hand, the RAZOR trial provides level 1 evidence robustly arguing the oncological efficacy of RARC and supporting clinical advantages such as reduced blood loss and reduced hospital stay. On the other hand, RAZOR data indicates that RARC does not lower the rate of perioperative complications. The majority of cystectomies are performed in low-volume centres where robot-expertise is not available. One critical question that was also discussed is whether a cost–benefit analysis will favour one approach over the other. Lastly, high-level prospective data about intracorporeal urinary diversions will help settle this discussion.

Prof. James Catto (University of Sheffield, United Kingdom), referring to the UK-based iROC trial responds that he is awaiting iROC to complete accrual, with 219/340 patients registered/randomised at this time, since this prospective randomised controlled trial will either independently validate RAZOR’s conclusions, or -if contradictory- raise the discussion to an even more pitched level.

  1. Parekh et al. Lancet 2018; 391: 2525-2536.

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