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Bignante G, Manfredi C, Lasorsa F, Orsini A, Licari LC, Bologna E, Roadman DF, Amparore D, Lucarelli G, Schips L, Fiori C, Porpiglia F, Autorino R. Incidence, Timing, and Pattern of Atypical Recurrence after Minimally Invasive Surgery for Urothelial Carcinoma. J Clin Med 2024; 13:3537. [PMID: 38930066 PMCID: PMC11204747 DOI: 10.3390/jcm13123537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/09/2024] [Accepted: 06/16/2024] [Indexed: 06/28/2024] Open
Abstract
The management of urothelial carcinoma has evolved with the introduction of minimally invasive techniques such as laparoscopic or robotic procedures, challenging the traditional approach of open surgery, and giving rise to atypical recurrences (ARs). ARs include port-site metastasis and peritoneal carcinomatosis, yet discrepancies persist among authors regarding their precise classification. Incidence rates of ARs vary widely across studies, ranging from less than 1% to over 10% in both muscle-invasive bladder cancer (MIBC) and upper tract urothelial tumor (UTUC). Peritoneal metastases predominate as the most common ARs in patients with MIBC, while retroperitoneal metastases are prevalent in those with UTUC due to differing surgical approaches. The timing of AR presentation and survival outcomes closely mirror those of conventional recurrences, with which they are frequently associated. Pneumoperitoneum has progressively been regarded less as the cause of ARs, while surgical-related risk factors have gained prominence. Current major surgical-related causes include tumor spillage and urinary tract violation during surgery, avoidance of endo bag use for specimen extraction, and low surgical experience. Factors such as tumor stage, histological variants, and lympho-vascular invasion correlate with the risk of ARs, suggesting a close association with tumor biology. Further studies are required to better understand the incidence, risk factors, characteristics, and outcomes of ARs.
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Affiliation(s)
- Gabriele Bignante
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA; (G.B.); (F.L.); (A.O.); (L.C.L.); (E.B.); (D.F.R.); (R.A.)
- Division of Urology, Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, 10043 Turin, Italy; (D.A.); (C.F.); (F.P.)
| | - Celeste Manfredi
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA; (G.B.); (F.L.); (A.O.); (L.C.L.); (E.B.); (D.F.R.); (R.A.)
- Unit of Urology, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Francesco Lasorsa
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA; (G.B.); (F.L.); (A.O.); (L.C.L.); (E.B.); (D.F.R.); (R.A.)
- Andrology and Kidney Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area-Urology, University of Bari “Aldo Moro”, 70124 Bari, Italy;
| | - Angelo Orsini
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA; (G.B.); (F.L.); (A.O.); (L.C.L.); (E.B.); (D.F.R.); (R.A.)
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, “G. d’Annunzio” University, 66100 Chieti, Italy;
| | - Leslie Claire Licari
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA; (G.B.); (F.L.); (A.O.); (L.C.L.); (E.B.); (D.F.R.); (R.A.)
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Eugenio Bologna
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA; (G.B.); (F.L.); (A.O.); (L.C.L.); (E.B.); (D.F.R.); (R.A.)
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Daniel F. Roadman
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA; (G.B.); (F.L.); (A.O.); (L.C.L.); (E.B.); (D.F.R.); (R.A.)
| | - Daniele Amparore
- Division of Urology, Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, 10043 Turin, Italy; (D.A.); (C.F.); (F.P.)
| | - Giuseppe Lucarelli
- Andrology and Kidney Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area-Urology, University of Bari “Aldo Moro”, 70124 Bari, Italy;
| | - Luigi Schips
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, “G. d’Annunzio” University, 66100 Chieti, Italy;
| | - Cristian Fiori
- Division of Urology, Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, 10043 Turin, Italy; (D.A.); (C.F.); (F.P.)
| | - Francesco Porpiglia
- Division of Urology, Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, 10043 Turin, Italy; (D.A.); (C.F.); (F.P.)
| | - Riccardo Autorino
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA; (G.B.); (F.L.); (A.O.); (L.C.L.); (E.B.); (D.F.R.); (R.A.)
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Long-term oncologic outcomes of robot-assisted radical cystectomy: update series from a high-volume robotic center beyond 10 years of follow-up. J Robot Surg 2022; 17:1143-1150. [DOI: 10.1007/s11701-022-01473-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 10/13/2022] [Indexed: 11/16/2022]
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Kukreja JB, Li R, Narayan VM, Lim A, Seif M, Wang X, Kamat A, Dinney C, Navai N. Oncologic Equipoise Between Robotic and Open Radical Cystectomy. J Endourol 2021; 35:1168-1176. [PMID: 33619985 DOI: 10.1089/end.2020.0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Our objective was to establish the incidence of positive surgical margins, recurrence patterns, and recurrence-free (RFS) and overall survival (OS) in a large cohort of patients undergoing robotic (robot-assisted radical cystectomy [RARC]) and open radical cystectomy (ORC). Materials and Methods: We performed a large retrospective cohort study at a high-volume academic tertiary referral center. Patients were those who underwent RC for bladder cancer from 2005 to 2017. Patients were allocated to ORC or RARC by patient and surgeon choice. Propensity matching and a multivariable analysis were performed to determine factors predictive of RFS and OS after RC. All analyses were done with SAS 9.4. Results: The study included 1885 patients, 13.5% of whom underwent RARC. There was no difference in positive soft tissue surgical margins (2.4% in ORC and 1.2% in RARC). There were no differences in recurrence patterns, nor in the severity of pathology distribution between the two cohorts. Peritoneal carcinomatosis was seen in 1.1% of ORC and 0.8% in RARC. Shorter RFS was associated with younger age (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.03-1.05, p < 0.001), neoadjuvant chemotherapy (HR 1.41, 95% CI 1.14-1.75, p = 0.002), higher pathologic stage (stage ≥T2 HR 2.45, 95% CI 1.91-3.16, p < 0.001), lymph node positivity at cystectomy (HR 1.92, 95% CI 1.50-2.47, p < 0.001), and positive surgical margins (HR 1.49, 95% CI 1.09-2.05, p = 0.01). RFS and OS did not differ by surgical approach (HR 1.04, 95% CI 0.83-1.30), p = 0.75 and (HR 0.89, 95% CI 0.67-1.19), p = 0.43, respectively. Conclusion: The data from this study support continued use of RARC as a safe oncologic procedure, with similar outcomes to ORC.
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Affiliation(s)
- Janet Baack Kukreja
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Division of Urology, University of Colorado, Denver, Colorado, USA
| | - Roger Li
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Division of Urology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Vikram M Narayan
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amy Lim
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mohamed Seif
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xuemei Wang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ashish Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Colin Dinney
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Neema Navai
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Ip KL, Javier-DesLoges JF, Leung C, Nie J, Khajir G, Nawaf CB, Syed J, Rosoff JS, Martin TV, Hesse DG. Comparison of long-term outcomes in a 10-year experience of robotic cystectomy vs. open cystectomy. J Robot Surg 2020; 15:773-780. [PMID: 33226567 DOI: 10.1007/s11701-020-01175-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/11/2020] [Indexed: 10/22/2022]
Abstract
To compare the outcomes of robotic-assisted (RARC) vs. open radical cystectomy (ORC) at a single academic institution. We retrospectively identified patients undergoing radical cystectomy for urothelial carcinoma of the bladder at our institution from 2007 to 2017. Data collected included age, sex, Body Mass Index (BMI), Charlson Age-Adjusted Comorbidity Index (CCI), final pathologic stage, surgical margins, lymph-node yield, estimated blood loss (EBL), 90-day complication rate, and length of stay (LOS). We evaluated overall survival (OS) and recurrence-free survival (RFS). Multivariable Cox proportional hazard models were used to adjust for covariates. We identified 232 patients (73 RARC, 159 ORC) who underwent radical cystectomy. Patients who underwent RARC were older (71.8 vs. 67.5, p < 0.05) and had higher CCI scores (6.2 vs. 5.3, p < 0.05). In comparing perioperative outcomes, RARC patients had lower EBL (500 vs. 850, p < 0.01), lower blood transfusion rate (p < 0.01), and lower lymph-node yield (12 vs. 20, p < 0.01), and higher ICU admission rate (29% vs. 16% p < 0.01). There was no difference in BMI (p = 0.93), sex (p = 0.28), final pathological stage (p = 0.35), positive surgical margins (p = 0.47), complications (p = 0.58), or LOS (p = 0.34). Kaplan-Meier analysis showed no difference in OS (p = 0.26) or RFS (p = 0.86). There was no difference in restricted mean survival time for OS (53 vs. 56 months, p = 0.81) or for RFS (65 vs. 64 months, p = 0.90). Cox multivariate regression models showed that surgical approach does not have a significant impact on OS (p = 0.46) or RFS (p = 0.35). Our study indicates that in our 10-year experience, patients undergoing there was no difference between RARC and ORC patients with respect to OS and RFS despite being older and having more comorbidities. Our work supports the importance of patient selection to optimize outcomes.
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Affiliation(s)
- Kevan L Ip
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Juan F Javier-DesLoges
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Cynthia Leung
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - James Nie
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Ghazal Khajir
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Cayce B Nawaf
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Jamil Syed
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - James S Rosoff
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Thomas V Martin
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - David G Hesse
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA.
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Posada Calderon L, Al Hussein Al Awamlh B, Shoag J, Patel N, Nicolas JD, Scherr DS. The role of surgical experience in patient selection, surgical quality, and outcomes in robot-assisted radical cystectomy. Urol Oncol 2020; 39:6-12. [PMID: 33127299 DOI: 10.1016/j.urolonc.2020.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Robot-assisted radical cystectomy (RARC) remains one of the most complex urological procedures. Due to regionalization of bladder cancer care, there is likely an imbalance in experience among urologists performing RARC. We sought to describe changes in patient selection, surgical quality surrogates and rates of complications in relation to surgical experience. METHODS We retrospectively reviewed 409 consecutive patients with bladder cancer who underwent RARC between 2006 and 2017 by a single surgeon. The cohort was divided into 4 quartiles (Q1-Q4) according to surgical experience, based on the chronologic order at which RARC was performed. Baseline, perioperative and pathologic characteristics of patients were compared among the 4 groups. 30-day and 90-day complications were assessed using the Clavien-Dindo system. The association between surgical experience (quartile) and complications was assessed using multivariable logistic regression analyses. RESULTS Median age (interquartile range [IQR] from 70-73 years), body mass index (IQR from 25 to 27 kg/m2) and preoperative glomerular filtration rate (IQR from 59 to 65 ml/min) were similar among all quartiles (all P > 0.05). Patients in Q4 had higher rates of previous abdominopelvic surgery (46.1% vs. 30.4%, P = 0.031) and American Society of Anesthesiologists score of 3 to 4 (72.3% vs. 47.1%, P = 0.003) compared to patients in Q1. Patients who underwent RARC in Q4 compared to Q1, had less estimated blood loss (250 ml vs. 350 ml, P < 0.001), shorter operative time (346 vs. 360 minutes, P < 0.001), and higher lymph node yield (22 vs. 17 nodes, P < 0.001). The 30-day and 90-day complication rates were 53% and 62%, respectively. Thirty-day complication rates were similar among all 4 quartiles (P > 0.05), but higher among patients in Q4 compared to Q1 within 90 days (74% vs. 54%, P = 0.01). On multivariable analysis, patients in Q4 were more likely to experience any 90-day complication (OR 2.03, 95%Cl 1.11-3.70) compared to Q1. CONCLUSION Our results show that with surgical experience, more complex cases can be performed while continuing to improve surgical quality. Nonetheless, there appears to be a trade-off between the increase in complexity of cases performed with experience and accepting higher rates of complications.
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Affiliation(s)
- Lina Posada Calderon
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY
| | | | - Jonathan Shoag
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA; Department of Urology, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Neal Patel
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY
| | - Joseph D Nicolas
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY
| | - Douglas S Scherr
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY.
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Port-site metastasis and atypical recurrences after robotic-assisted radical cystectomy (RARC): an updated comprehensive and systematic review of current evidences. J Robot Surg 2020; 14:805-812. [PMID: 32152900 DOI: 10.1007/s11701-020-01062-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/03/2020] [Indexed: 10/24/2022]
Abstract
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.
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Predictors of Recurrence, and Progression-Free and Overall Survival following Open versus Robotic Radical Cystectomy: Analysis from the RAZOR Trial with a 3-Year Followup. J Urol 2019; 203:522-529. [PMID: 31549935 DOI: 10.1097/ju.0000000000000565] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE The RAZOR (Randomized Open versus Robotic Cystectomy) trial revealed noninferior 2-year progression-free survival for robotic radical cystectomy. This update was performed with extended followup for 3 years to determine potential differences between the approaches. We also report 3-year overall survival and sought to identify factors predicting recurrence, and progression-free and overall survival. MATERIALS AND METHODS We analyzed the per protocol population of 302 patients from the RAZOR study. Cumulative recurrence was estimated using nonbladder cancer death as the competing risk event and the Gray test was applied to assess significance in differences. Progression-free survival and overall survival were estimated by the Kaplan-Meier method and compared with the log rank test. Predictors of outcomes were determined by Cox proportional hazard analysis. RESULTS Estimated progression-free survival at 36 months was 68.4% (95% CI 60.1-75.3) and 65.4% (95% CI 56.8-72.7) in the robotic and open groups, respectively (p=0.600). At 36 months overall survival was 73.9% (95% CI 65.5-80.5) and 68.5% (95% CI 59.8-75.7) in the robotic and open groups, respectively (p=0.334). There was no significant difference in the cumulative incidence rates of recurrence (p=0.802). Patient age greater than 70 years, poor performance status and major complications were significant predictors of 36-month progression-free survival. Stage and positive margins were significant predictors of recurrence, and progression-free and overall survival. Surgical approach was not a significant predictor of any outcome. CONCLUSIONS This analysis showed no difference in recurrence, 3-year progression-free survival or 3-year overall survival for robotic vs open radical cystectomy. It provides important prospective data on the oncologic efficacy of robotic radical cystectomy and high level data for patient counseling.
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Honore M, Roberts MJ, Morton A, Teloken PE, Navaratnam A, Coughlin GD. Outcomes and learning curve for robotic‐assisted radical cystectomy: an Australian experience. ANZ J Surg 2019; 89:1593-1598. [DOI: 10.1111/ans.15413] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 07/10/2019] [Accepted: 07/23/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Matthew Honore
- Department of UrologyRoyal Brisbane and Women's Hospital Brisbane Queensland Australia
- Faculty of MedicineThe University of Queensland Brisbane Queensland Australia
| | - Matthew J. Roberts
- Department of UrologyRoyal Brisbane and Women's Hospital Brisbane Queensland Australia
- Faculty of MedicineThe University of Queensland Brisbane Queensland Australia
| | - Andrew Morton
- Department of UrologyRoyal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - Patrick E. Teloken
- Department of UrologyRoyal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - Anojan Navaratnam
- Department of UrologyRoyal Brisbane and Women's Hospital Brisbane Queensland Australia
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Yang DY, Frank I, Avant RA, Miller AR, Thapa P, Boorjian SA, Tollefson MK. Incidence and risk factors for peritoneal carcinomatosis following open radical cystectomy. Urol Oncol 2019; 37:886-892. [PMID: 31427158 DOI: 10.1016/j.urolonc.2019.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/30/2019] [Accepted: 06/21/2019] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- David Y Yang
- Mayo Clinic, Department of Urology, Rochester, MN
| | - Igor Frank
- Mayo Clinic, Department of Urology, Rochester, MN
| | - Ross A Avant
- Mayo Clinic, Department of Urology, Rochester, MN
| | | | - Prabin Thapa
- Mayo Clinic, Division of Biomedical Statistics and Informatics, Rochester, MN
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Tyritzis SI, Gaya JM, Wallestedt-Lantz A, Pini G, Everaerts W, de Naeyer G, Palou J, Kelly J, Wiklund NP. Current role of robotic bladder cancer surgery. MINERVA UROL NEFROL 2019; 71:301-308. [PMID: 31086134 DOI: 10.23736/s0393-2249.19.03435-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in urology, that is not devoid of postoperative complications. Minimally invasive surgery, and especially robot-assisted RC (RARC) has emerged as an alternative to open RC (ORC) in an attempt to minimize surgical morbidity and facilitate the surgical approach. The aim of this paper was to present the current knowledge on the oncological efficacy and complication outcomes of RARC. EVIDENCE ACQUISITION A non-systematic review on all relevant studies with the keywords "Radical cystectomy," "Open," "Robot-assisted," "Complications," "Recurrence," "Survival," "Neobladder," "Potency," "Continence" and "Intracorporeal" was performed using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) Guidelines. EVIDENCE SYNTHESIS RARC shows similar lymph node yields and positive surgical margin rates as well as perioperative complication outcomes compared with ORC. RARC exhibits significantly less blood loss and less intra- and postoperative blood transfusion. Moreover, survival and recurrence rates are not related to the surgical approach. Finally, RARC seems to be more expensive and has a longer operating time compared to the open technique. CONCLUSIONS As current evidence shows, RARC seems as a technically feasible and safe procedure, providing equivalent perioperative and oncological results compared to ORC. More prospective, randomized-controlled trials are necessary to draw definitive conclusions on all comparative aspects.
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Affiliation(s)
- Stavros I Tyritzis
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden - .,Department of Urology, HYGEIA Hospital, Athens, Greece -
| | - Josep M Gaya
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - Anna Wallestedt-Lantz
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden
| | - Giovannalberto Pini
- Department of Urology, San Raffaele Turro Hospital, San Raffaele University, Milan, Italy
| | - Wouter Everaerts
- Department of Urology, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Joan Palou
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - John Kelly
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospital, London, UK
| | - Nils P Wiklund
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden.,ICAHN School of Medicine, Mount Sinai Hospital, New York, NY, USA
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Mottrie A, Larcher A, Patel V. The Past, the Present, and the Future of Robotic Urology: Robot-assisted Surgery and Human-assisted Robots. Eur Urol Focus 2018; 4:629-631. [PMID: 30337191 DOI: 10.1016/j.euf.2018.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 10/02/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Alexandre Mottrie
- ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium
| | - Alessandro Larcher
- ORSI Academy, Melle, Belgium; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium; Department of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Vipul Patel
- Department of Urology, Global Robotic Institute-Florida Hospital, Celebration, FL, USA
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Bochner BH, Dalbagni G, Marzouk KH, Sjoberg DD, Lee J, Donat SM, Coleman JA, Vickers A, Herr HW, Laudone VP. Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: Oncologic Outcomes. Eur Urol 2018; 74:465-471. [PMID: 29784190 DOI: 10.1016/j.eururo.2018.04.030] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Open radical cystectomy (ORC) has proven to be an important component in the treatment of high-risk bladder cancer (BCa). ORC surgical morbidity remains high; therefore, minimally invasive surgical techniques have been introduced in an attempt to improve patient outcomes. OBJECTIVE To compare cancer outcomes in BCa patients managed with ORC or robotic-assisted radical cystectomy (RARC). DESIGN, SETTING, AND PARTICIPANTS A prospective, randomized trial was completed between 2010 and 2013. Patients were randomized to ORC/pelvic lymphadenectomy (PLND) or RARC/PLND, with all undergoing open/extracorporeal urinary diversion. Median follow-up was 4.9 (IQR: 3.9-5.9) yr after surgery among surviving patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Secondary outcomes to the trial included recurrence-free, cancer-specific, and overall survival. RESULTS AND LIMITATIONS The trial randomized 118 patients who underwent RC/PLND and urinary diversion. Sixty were randomized to RARC and 58 to ORC. Four RARC-assigned patients refused randomization and received ORC; however, an intention to treat analysis was performed. No differences were observed in recurrence (hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 0.69-2.36; p=0.4) or cancer-specific survival (p=0.4). No difference in overall survival was observed (p=0.8). However, the pattern of first recurrence demonstrated a nonstatistically significant increase in metastatic sites for those undergoing ORC (sub-HR [sHR]: 2.21; 95% CI: 0.96-5.12; p=0.064) and a greater number of local/abdominal sites in the RARC-treated patients (sHR: 0.34; 95% CI: 0.12-0.93; p=0.035). The major limitation to this study is that the trial was not powered to determine differences in cancer recurrences, survival outcomes, or patterns of recurrence. CONCLUSIONS The secondary outcomes from our randomized trial did not definitively demonstrate differences in cancer outcomes in patients treated with ORC or RARC. However, differences in observed patterns of first recurrence highlight the need for future studies. PATIENT SUMMARY Of 118 patients randomly assigned to undergo radical cystectomy/pelvic lymphadenectomy and urinary diversion, half were assigned to open surgery and half to robot-assisted techniques. We found no difference in risk of recurring or dying of bladder cancer between the two groups.
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Affiliation(s)
- Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA.
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Karim H Marzouk
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin Lee
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sheri M Donat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Harry W Herr
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
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13
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Mari A, Kimura S, Foerster B, Abufaraj M, D'Andrea D, Gust KM, Shariat SF. A systematic review and meta-analysis of lymphovascular invasion in patients treated with radical cystectomy for bladder cancer. Urol Oncol 2018; 36:293-305. [PMID: 29685374 DOI: 10.1016/j.urolonc.2018.03.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/06/2018] [Accepted: 03/26/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Lymphovascular invasion (LVI) is an important step in bladder cancer cell dissemination. We aimed to perform a systematic review and meta-analysis of the literature to assess the prognostic value of LVI in radical cystectomy (RC) specimens. PATIENTS AND METHODS A systematic review and meta-analysis of the last 10 years was performed using the MEDLINE, EMBASE, and the Cochrane libraries in July 2017. The analyses were performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. RESULTS We retrieved 65 studies (including 78,107 patients) evaluating the effect of LVI on oncologic outcomes in patients treated with RC. LVI was reported in 35.4% of patients. LVI was associated with disease recurrence (pooled hazard ratio [HR] = 1.57; 95% CI: 1.45-1.70) and cancer-specific mortality (CSM) (pooled HR = 1.59; 95% CI: 1.48-1.73) in all studies regardless of tumor stage and node status (pT1-4 pN0-2). LVI was associated with recurrence and CSM in patients with node-negative bladder cancer (BC). In patients with node-negative BC, LVI rate increased and was associated with worse oncologic outcome. LVI had a lower but still significant association with disease recurrence and CSM in node-positive BC. CONCLUSIONS LVI is a strong prognostic factor of worse prognosis in patients treated with RC for bladder cancer. This association is strongest in node-negative BC, but it is also in node-positive BC. LVI should be part of all pathological reporting and could provide additional information for treatment-decision making regarding adjuvant therapy after RC.
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Affiliation(s)
- Andrea Mari
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University of Florence, Careggi Hospital, Florence, Italy
| | - Shoji Kimura
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Jikei University School of Medicine, Tokyo, Japan
| | - Beat Foerster
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Mohammad Abufaraj
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Special Surgery, Jordan University hospital, The University of Jordan, Amman, Jordan
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kilian M Gust
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Urology, Weill Cornell Medical College, New York, NY.
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14
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Abstract
Robot-assistance is being increasingly used for radical cystectomy (RC). Fifteen years of surgical evolution might be considered a short period for a radical procedure to be established as the treatment of choice, but robot assisted radical cystectomy (RARC) is showing promising results when compared with the current gold standard, open RC (ORC). In this review, we describe the current status of RARC and continue the discussion on the on-going RARC versus ORC debate.
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Affiliation(s)
- Stavros Ioannis Tyritzis
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Nils Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
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15
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Audenet F, Sfakianos JP. Evidence of Atypical Recurrences After Robot-Assisted Radical Cystectomy: A Comprehensive Review of the Literature. Bladder Cancer 2017; 3:231-236. [PMID: 29152547 PMCID: PMC5676761 DOI: 10.3233/blc-170127] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- François Audenet
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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16
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Kukreja JB, Shah JB. Advances in surgical management of muscle invasive bladder cancer. Indian J Urol 2017; 33:106-110. [PMID: 28469297 PMCID: PMC5396397 DOI: 10.4103/0970-1591.203416] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/22/2016] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Bladder cancer remains a disease of the elderly with relatively few advances that have improved survival over the last 20 years. Radical cystectomy (RC) has long remained the principal treatment for muscle-invasive bladder cancer (MIBC). METHODS A literature search of PubMed was performed. The content was reviewed for continuity with the topic of surgical advances in MIBC. Articles and society guidelines were included in this review. RESULTS Despite the associated morbidity, even in the elderly, RC is still a reasonable option. Modifications during RC may have a positive or negative impact on survival and quality of life. The extent of pelvic lymph node dissection is one such factor which may positively impact survival outcomes. In addition, preservation of pelvic organs, robotic surgery and the adoption of enhanced recovery after surgery principles continues to improve the postoperative recovery and quality of life in RC patients. CONCLUSION There are some ongoing studies in many of these areas, but overall the new advances in MIBC may improve patient quality and quantity of life. The advances in surgical treatment of MIBC are important and the focus of the review here.
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Affiliation(s)
- Janet Baack Kukreja
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay B. Shah
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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17
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Factors Impacting the Occurrence of Local, Distant and Atypical Recurrences after Robot-Assisted Radical Cystectomy: A Detailed Analysis of 310 Patients. J Urol 2016; 196:1390-1396. [DOI: 10.1016/j.juro.2016.05.101] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2016] [Indexed: 11/23/2022]
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18
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Gandaglia G, Karl A, Novara G, de Groote R, Buchner A, D'Hondt F, Montorsi F, Stief C, Mottrie A, Gratzke C. Perioperative and oncologic outcomes of robot-assisted vs. open radical cystectomy in bladder cancer patients: A comparison of two high-volume referral centers. Eur J Surg Oncol 2016; 42:1736-1743. [DOI: 10.1016/j.ejso.2016.02.254] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/13/2016] [Accepted: 02/24/2016] [Indexed: 01/19/2023] Open
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