Port-Site Metastases After Robotic Radical Cystectomy: A Systematic Review and Management Options

Oncologic Outcomes for Robotic Vs. Open Radical Cystectomy Among Locally Advanced and Node-Positive Patients: Analysis of The National Cancer Database

INTRODUCTION

Despite concerns of atypical recurrence following robotic-assisted radical cystectomy (RARC), utilization of the modality is increasing. The presumed mechanisms of peritoneal immunomodulation and pneumoperitoneum-induced tumor cell intravasation are especially relevant for higher stage, locally advanced disease, where intrinsic metastatic potential of tumor cells may be greater. This study aims to compare the oncologic outcomes and survival after RARC compared to open radical cystectomy (ORC) among patients with stage pT3-4 or node-positive muscle-invasive bladder cancer.

PATIENTS AND METHODS

Retrospective cohort analysis of pT3-4N0-3 and pT(any)N1-3 patients who underwent RARC or ORC was performed using the National Cancer Database (2010-2016) to investigate perioperative and oncologic outcomes.

RESULTS

9,062 ORC cases and 2,544 RARC cases met inclusion criteria. The robotic approach was significantly associated with superior unadjusted survival compared to open as well as lower proportions of unadjusted 30- and 90-day mortality, lower positive margin status, and shorter surgical inpatient stay (all respective P<.05). However, after adjusting for confounding covariates, multivariable analysis revealed no difference in mortality hazard or odds of any of the above secondary outcomes with the exception of shorter inpatient stay and higher lymph node yield. Patients treated with RARC were more likely to have neoadjuvant chemotherapy.

CONCLUSIONS

RARC is no less safe than ORC for patients with locally advanced bladder cancer on the basis of overall, 30- and 90-day survival. Unadjusted mortality and surgical outcomes demonstrate advantages to RARC, which are attenuated after multivariate analysis. Perioperative benefits may favor the robotic approach, consistent with previous randomized control studies.

Intra-corporeal robot-assisted versus open radical cystectomy: a propensity score-matched analysis comparing perioperative and long-term survival outcomes and recurrence patterns

BACKGROUND

To compare perioperative and long-term oncological outcomes and recurrence patterns between robot-assisted radical cystectomy with intra-corporeal urinary diversion (iRARC) and open radical cystectomy (ORC).

METHODS

We retrospectively analyzed 177 bladder cancer patients who received iRARC or ORC at Fujita Health University between 2008 and 2020. Our primary endpoint was long-term oncological outcomes. As a secondary endpoint, we examined perioperative outcomes, complications, and recurrence patterns. These outcome measures were compared between the propensity score (PS)-matched cohorts.

RESULTS

PS-matched analysis resulted in 60 matched pairs from iRARC and ORC groups. The iRARC cohort was associated with significantly longer operative time (p = 0.02), lower estimated blood loss (p < 0.001), lower blood transfusion rate (p < 0.001), shorter length of hospital stay (p < 0.001), fewer overall complications (p = 0.03), and lower rate of postoperative ileus (p = 0.02). There was no statistically significant difference between iRARC and ORC in 5-year RFS (p = 0.46), CSS (p = 0.63), and OS (p = 0.71). RFS and CSS were also comparable, even in locally advanced (≥ cT3) disease. Multivariate analysis identified lymphovascular invasion as a robust predictor of RFS, CSS, and OS. The number of recurrence was similar between the groups, while extra-pelvic lymph nodes were more frequent in iRARC than that in ORC (22.7% vs. 7.7%).

CONCLUSIONS

iRARC has favorable perioperative outcomes, fewer complications, and comparable long-term survival outcomes, including locally advanced (≥ cT3) disease, compared to that in ORC. Our results need to be validated in prospective randomized clinical trials.

Cutaneous seeding of transitional cell carcinoma of the urinary bladder after placement of a subcutaneous ureteral bypass device in a dog with bilateral ureteral obstruction

CASE DESCRIPTION

A 12-year-old spayed female Jack Russell Terrier was presented with pollakiuria and stranguria.

CLINICAL FINDINGS

Transitional cell carcinoma (TCC) of the urinary bladder trigone and urethra was diagnosed via CT, cystoscopic, and histologic examinations. Azotemia developed 2 weeks following diagnosis, secondary to bilateral ureteral obstruction.

TREATMENT AND OUTCOME

Percutaneous antegrade ureteral stenting was unsuccessful; therefore, a subcutaneous ureteral bypass (SUB) device with 2 nephrostomy and 1 cystostomy catheters was surgically placed. Two months following placement of the SUB device, the dog developed a firm, multilobulated cutaneous mass at the site of the subcutaneous access port of the SUB device. Results of cytologic examination of cells aspirated from the mass were consistent with TCC. Within 1 month of confirmation of TCC of the cutaneous mass, the mass was ulcerated and infected, and the dog was euthanized because of signs of pain and perceived poor quality of life.

CLINICAL RELEVANCE

Seeding of neoplastic cells is a known complication of needle aspiration or biopsy or surgery in people and dogs with carcinomas. The occurrence of TCC at the SUB port site suggested caution with the placement of a SUB device in dogs with obstructive TCC.

Port-site metastasis and atypical recurrences after robotic-assisted radical cystectomy (RARC): an updated comprehensive and systematic review of current evidences

The objective of this systematic review is to evaluate the current evidence regarding atypical metastases in patients undergoing robotic-assisted radical cystectomy (RARC). A review of the current literature was conducted through the Medline and NCBI PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases in October 2019. From the literature search using the cited keys and after a careful evaluation of the full texts, we included 31 articles in the study. Fourteen studies (45.2%) reported at least an atypical recurrence during the follow-up period with a rate between 4 and 40% of all the recurrences. Overall, 105 (1.63%) of the 6720 patients who have been evaluated in the included studies developed an atypical recurrence. Sixty-three (60%) of these atypical metastases were peritoneal carcinomatosis, 16 (15.2%) extrapelvic lymph nodes metastases, 11 (10.5%) port-site metastases, 10 (9.5%) retroperitoneal nodal metastases, while 5 (3.8%) patients developed more than one type of atypical recurrence. In literature, there is a low but not negligible incidence of atypical recurrences after RARC. However, publication bias and retrospective design of most studies could influence the evidences. Further prospective randomized studies are needed to clarify the real risk of patients undergoing RARC to develop atypical metastases.

Oncological outcomes and recurrence patterns after laparoscopic radical cystectomy for bladder cancer: A Japanese multicenter cohort

OBJECTIVE

To investigate oncological outcomes and recurrence patterns after laparoscopic radical cystectomy for bladder cancer in a Japanese multicenter cohort, and to explore the risk factors associated with recurrences due to tumor dissemination.

METHOD

Laparoscopic radical cystectomies carried out at 10 institutions were included in this retrospective study. Multivariate analyses were carried out to identify the clinical parameters associated with overall recurrences together with specific recurrence types. Kaplan-Meier curves were created to elucidate time to recurrence and survival.

RESULTS

A total of 411 patients were included after the final analysis. Postoperative pathology was T2 or higher in 196 patients (48%), and lymph node metastasis was present in 46 patients (11%). The median follow-up period was 23 months, and the 2-year recurrence-free and cancer-specific survival rates were 71.0% and 84.7%, respectively. The recurrence sites involved distant metastasis in 75 patients (18%), local recurrence in 52 patients (13%) and urinary tract recurrence in eight patients (2%). When local recurrence at the cystectomy bed (28 patients; 7%) and abdominal recurrence including peritoneal carcinomatosis or port site recurrence (17 patients; 4%), which might be caused by tumor dissemination, were combined into a single group, prolonged surgical time was a significant risk factor, in addition to high pathological stage (T3-4 and/or positive lymph nodes), positive surgical margins, and variant histology by both univariate and multivariate analyses.

CONCLUSIONS

Our study findings suggest that recurrences after laparoscopic radical cystectomy might be caused by tumor dissemination, and attention should be paid to avoid prolonged surgical time in laparoscopic radical cystectomy.

Atypical Early Recurrence after Robot-Assisted Radical Cystectomy: Port-Site Metastasis

Port-site metastasis (PSM) have gained importance due to increasing number of robot-assisted radical cystectomy (RARC). To the best of our knowledge, there are 13 cases in the literature, with only one reporting, treatment modality and oncological outcome. There is no consensus about the treatment for PSM developing after RARC. Here, we report a PSM occurring in the early period after RARCand recommend a treatment modality.

Incidence and risk factors for peritoneal carcinomatosis following open radical cystectomy

OBJECTIVE

To characterize the frequency and risk factors of peritoneal carcinomatosis (PC) in patients undergoing open radical cystectomy (RC).

METHODS

We identified 3,285 patients with urothelial carcinoma treated with RC for curative intent between 1980 and 2016. At last follow-up, 72.1% (2,370/3,285) of patients had died, with a median follow-up of 8.6 years (Interquartile Range, (IQR) 3.7, 14.1). PC was defined as any recurrence involving the omentum, small bowel, and mesentery. Overall-specific survival (OSS) and cancer-specific survival (CSS) was evaluated using Kaplan-Meier methodology and log-rank test. Risk factors for mortality and recurrence were performed using Cox proportional hazards regression models.

RESULTS

One hundred and twenty nine (3.9%) patients were diagnosed with PC, while a total of 1,148 (34.9%) patients experienced recurrence at other sites. Median time to PC vs. other-site recurrence was 1.3 (IQR 1.3, 2.3) and 0.9 (IQR 0.5, 2.1) years, respectively (P= 0.04). Only increasing pathologic stage on multivariable analysis was associated with developing PC (pT1 HR 2.51, 95CI 1.14-5.55, P= 0.02; pT2 OR 2.82, 95CI 1.47-5.43, P= 0.002; pT3+ 2.40, 95CI 1.31-4.42, P= 0.005) over other recurrence patterns. Nodal status and tumor margin status were not associated. Patients with PC experienced worse OSS and CSS than other types of recurrence (P< 0.001).

CONCLUSION

PC was identified in almost 4% of patients undergoing open RC. PC is a rare occurrence after RC and primarily impacts patients with locally advanced disease.

Current status and future perspective of robot-assisted radical cystectomy for invasive bladder cancer

The current status of robot-assisted radical cystectomy was reviewed 16 years after the initial robot-assisted radical cystectomy for the treatment of invasive bladder cancer. Articles associated with robot-assisted radical cystectomy and written in English were selected from the PubMed database from January 2003 to February 2019. The present review article focused on the distribution of robot-assisted radical cystectomy, patient selection, preoperative management, surgical technique, lymph node dissection, urinary diversion, recurrence pattern, oncological outcomes, cost, learning curve, complications and educational programs. A total of 400 articles were divided according to the country of the first author's affiliation. The USA was the most dominant at 198 (50%), whereas the number of articles from the countries belonging to the Urological Association of Asia was 15 (3.8%) for China, 17 (4.3%) for South Korea, 10 (2.5%) for Japan, eight (2%) for Taiwan, eight (2%) for Turkey and one (0.2%) for Iran. The percentage of robot-assisted radical cystectomy carried out is increasing, and intracorporeal urinary diversion and ileal neobladder are also frequently carried out. With a refined technique being performed in high-volume centers, robot-assisted radical cystectomy has contributed to the reduction in transfusion rate, length of stay and severe complications; however, it has not yet shown any cancer-specific survival benefits. Robot-assisted radical cystectomy is not fully spread throughout the Urological Association of Asia. Further investigation with respect to worldwide results is needed to prove the real benefit of robot-assisted radical cystectomy regarding low morbidity, reduced total medical cost, and survival benefit. In the era of precision medicine, appropriate drug and surgery will be given based on each genetic profile.

Requiem for Open Radical Cystectomy in Bladder Cancer Patients

In the hands of experienced surgeons at referral centers, robotic surgery with an intracorporeal urinary diversion has the potential to provide better perioperative outcomes without affecting cancer control when compared to open surgery for radical cystectomy.

Evidence of Atypical Recurrences After Robot-Assisted Radical Cystectomy: A Comprehensive Review of the Literature

Robot-assisted radical cystectomy (RARC) has seen remarkable growth in the last decade. Despite a low level of evidence, numerous publications reporting on outcomes after RARC are now available. While definitive data on the long-term oncologic safety and efficacy of this technique are still lacking, similar oncological and functional outcomes compared to open radical cystectomy (ORC) have been reported. Several studies have also reported on atypical recurrences after RARC, including peritoneal carcinomatosis, extra-pelvic lymph node metastasis and port-site metastasis. While distant metastases overall do not appear to be affected by technique, it is possible that RARC may be associated with an increased risk of some atypical recurrences and this should be prospectively studied in RARC. However, atypical recurrences are rare events and are infrequent in their description. To date, there is no convincing evidence that, in the hands of equally experienced surgeons who treat bladder cancer routinely, a skillfully performed RARC is less oncologically efficacious than a skillfully performed ORC.

The Role of Robotics in the Invasive Management of Bladder Cancer

Robot-assisted radical cystectomy (RARC) has been adopted widely in many centres, owed largely to the success of robot-assisted laparoscopic prostatectomy (RALP). It aims to replicate the oncological outcomes of open radical cystectomy (ORC), while providing a shorter recovery period. Despite this, previous RCTs have failed to show a benefit for RARC over ORC. These trials have compared extracorporeal RARC (eRARC) with ORC, which requires a further incision to mobilise the bowel for urinary reconstruction with an open technique. For intracorporeal RARC (iRARC), this urinary reconstruction is performed robotically without further incisions. There are theoretical benefits to this approach such as reduced recovery time for the bowel and reduced ileus rates, but no level 1 evidence currently exists to support this. While there has been an improvement in patient outcomes since the adoption of RARC, various other factors, such as enhanced recovery programmes and surgical learning curve, have made it difficult to attribute this solely to the robotic approach as many centres performing ORC have also shown similar improvements. In this review, we will discuss implementation of RARC as well as perioperative measures that have helped improve outcomes, offer a comparison of outcomes between ORC and RARC and highlight upcoming RCTs that may offer new evidence for or against a paradigm shift in the future of bladder cancer surgery.