1
|
Sathianathen NJ, Risk MC, Konety BR. Lymphadenectomy for Muscle-Invasive Bladder Cancer and Upper Tract Urothelial Cell Carcinoma. Urol Clin North Am 2018; 45:215-228. [PMID: 29650137 DOI: 10.1016/j.ucl.2017.12.006] [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] [Indexed: 01/26/2023]
Abstract
There are currently no reported randomized trials that characterize the staging or therapeutic benefit of performing a lymph node dissection in either bladder cancer or upper tract urothelial carcinoma. Several unanswered questions remain in this domain focused on the indications and patient selection for pelvic lymph node dissection, extent of dissection, its impact on outcome, and potential risks. However, the results of observational studies suggest that the burden of metastasis is high in both diseases when muscle invasive and performing a lymphadenectomy can provide prognostic information and yield therapeutic benefit.
Collapse
Affiliation(s)
- Niranjan J Sathianathen
- Department of Urology, University of Minnesota, Delaware Street Southeast, Minneapolis, MN 55455, USA
| | - Michael C Risk
- Department of Urology, University of Minnesota, Delaware Street Southeast, Minneapolis, MN 55455, USA
| | - Badrinath R Konety
- Department of Urology, University of Minnesota, Delaware Street Southeast, Minneapolis, MN 55455, USA.
| |
Collapse
|
2
|
Mita K, Kobatake K, Ohara S, Kato M. [LAPAROSCOPIC RADICAL CYSTECTOMY AT HIROSHIMA CITY ASA HOSPITAL]. Nihon Hinyokika Gakkai Zasshi 2018; 109:1-6. [PMID: 30662045 DOI: 10.5980/jpnjurol.109.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
(Objective) To evaluate the utility of laparoscopic radical cystectomy (LRC), we retrospectively compared the background factors and perioperative parameters of LRC with those of open radical cystectomy (ORC). (Patients and methods) The study cohort consisted of 116 consecutive patients who underwent radical cystectomy by LRC (n=59) or ORC (n=57). The background factors and perioperative parameters were compared between LRC and ORC. (Results) The patients consisted of 103 men and 13 women with a median age of 69 years and median BMI of 23.0. Their clinical stage was as follows, ≤T1: 19 cases, T2: 69 cases, T3: 25 cases and T4: 3 cases, respectively.While the patients' age at the time of LRC was significantly higher than that of ORC (71.3 yrs vs. 66.2 yrs, P<0.001) and the ASA physical status of LRC was significantly higher than that of ORC (P=0.028), the other background factors were not different between the two groups.Although there was no difference in the total operating time between LRC and ORC, the estimated blood loss for LRC was significantly less than that for ORC (372.3 ml vs. 2,134.5 ml, P<0.001) and the duration of the postoperative hospital stay for LRC was significantly shorter than that for ORC (23.5 days vs. 36.9 days, P<0.001).There were no significant differences in the pathological findings, of the postoperative recurrence-free rate or cancer-specific survival rate between the LRC and ORC groups. In multivariate analysis, only pN+was an independent predictive factor of postoperative recurrence. (Conclusion) This study showed that LRC is less invasive and can lead to similar oncological outcomes compared with ORC.
Collapse
Affiliation(s)
- Koji Mita
- Department of Urology, Hiroshima City Asa Hospital
| | | | - Shinya Ohara
- Department of Urology, Hiroshima City Asa Hospital
| | - Masao Kato
- Department of Urology, Hiroshima City Asa Hospital
| |
Collapse
|
3
|
Son SK, Lee NR, Kang SH, Lee SH. Safety and Effectiveness of Robot-Assisted Versus Open Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2017; 27:1109-1120. [PMID: 28350238 DOI: 10.1089/lap.2016.0437] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES To evaluate the safety and effectiveness of robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC) in bladder cancer. METHODS A literature search for the systematic review was conducted using international databases as well as domestic databases up to April 2015. Outcomes of interest included baseline characteristics, complication rates, perioperative, and oncologic outcomes. RESULTS Twenty-four articles were finally selected for inclusion in the meta-analysis. Complication rates of RARC were similar to those of ORC, except for 90-day overall complication rate, wound dehiscence, abscess, pneumonia, respiratory failure, and sepsis, which was lower after RARC. RARC was also associated with a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield, whereas ORC was associated with a shorter operation time and lower rate of stricture. Considering oncologic outcomes, there were no differences between RARC and ORC. CONCLUSIONS RARC seems to be associated with equivalent complication rates, a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield. Randomized controlled trials with a large sample size and comparative studies with long-term follow-up data are warranted to assess our findings and the oncologic effectiveness of RARC.
Collapse
Affiliation(s)
- Soo Kyung Son
- 1 Division for Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,2 Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University , Seoul, Korea
| | - Na Rae Lee
- 1 Division for Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,2 Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University , Seoul, Korea
| | - Seok Ho Kang
- 3 Department of Urology, College of Medicine, Korea University , Seoul, Korea
| | - Seon Heui Lee
- 4 Department of Nursing Science, College of Nursing, Gachon University , Incheon, Korea
| |
Collapse
|
4
|
Bochner BH, Dalbagni G, Sjoberg DD, Silberstein J, Keren Paz GE, Donat SM, Coleman JA, Mathew S, Vickers A, Schnorr GC, Feuerstein MA, Rapkin B, Parra RO, Herr HW, Laudone VP. Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial. Eur Urol 2015; 67:1042-1050. [PMID: 25496767 PMCID: PMC4424172 DOI: 10.1016/j.eururo.2014.11.043] [Citation(s) in RCA: 400] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 11/21/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Open radical cystectomy (ORC) and urinary diversion in patients with bladder cancer (BCa) are associated with significant perioperative complication risk. OBJECTIVE To compare perioperative complications between robot-assisted radical cystectomy (RARC) and ORC techniques. DESIGN, SETTING, AND PARTICIPANTS A prospective randomized controlled trial was conducted during 2010 and 2013 in BCa patients scheduled for definitive treatment by radical cystectomy (RC), pelvic lymph node dissection (PLND), and urinary diversion. Patients were randomized to ORC/PLND or RARC/PLND, both with open urinary diversion. Patients were followed for 90 d postoperatively. INTERVENTION Standard ORC or RARC with PLND; all urinary diversions were performed via an open approach. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcomes were overall 90-d grade 2-5 complications defined by a modified Clavien system. Secondary outcomes included comparison of high-grade complications, estimated blood loss, operative time, pathologic outcomes, 3- and 6-mo patient-reported quality-of-life (QOL) outcomes, and total operative room and inpatient costs. Differences in binary outcomes were assessed with the chi-square test, with differences in continuous outcomes assessed by analysis of covariance with randomization group as covariate and, for QOL end points, baseline score. RESULTS AND LIMITATIONS The trial enrolled 124 patients, of whom 118 were randomized and underwent RC/PLND. Sixty were randomized to RARC and 58 to ORC. At 90 d, grade 2-5 complications were observed in 62% and 66% of RARC and ORC patients, respectively (95% confidence interval for difference, -21% to -13%; p=0.7). The similar rates of grade 2-5 complications at our mandated interim analysis met futility criteria; thus, early closure of the trial occurred. The RARC group had lower mean intraoperative blood loss (p=0.027) but significantly longer operative time than the ORC group (p<0.001). Pathologic variables including positive surgical margins and lymph node yields were similar. Mean hospital stay was 8 d in both arms (standard deviation, 3 and 5 d, respectively; p=0.5). Three- and 6-mo QOL outcomes were similar between arms. Cost analysis demonstrated an advantage to ORC compared with RARC. A limitation is the setting at a single high-volume, referral center; our findings may not be generalizable to all settings. CONCLUSIONS This trial failed to identify a large advantage for robot-assisted techniques over standard open surgery for patients undergoing RC/PLND and urinary diversion. Similar 90-d complication rates, hospital stay, pathologic outcomes, and 3- and 6-mo QOL outcomes were observed regardless of surgical technique. PATIENT SUMMARY Of 118 patients with bladder cancer who underwent radical cystectomy, pelvic lymph node dissection, and urinary diversion, half were randomized to open surgery and half to robot-assisted laparoscopic surgery. We compared the rate of complications within 90 d after surgery for the open group versus the robotic group and found no significant difference between the two groups. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01076387, www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Guido Dalbagni
- 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
| | - Jonathan Silberstein
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Gal E Keren Paz
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - S Machele Donat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sheila Mathew
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Geoffrey C Schnorr
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael A Feuerstein
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bruce Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Raul O Parra
- Urology Service, Department of Surgery, 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
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
5
|
[Lymphadenectomy for bladder cancer: current status and controversies]. Urologe A 2012; 51:310-8. [PMID: 22399109 DOI: 10.1007/s00120-012-2833-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Pelvic lymph node dissection is an integral part of the radical cystectomy procedure for patients with muscle-invasive bladder cancer. The optimal extent of the lymphadenectomy (LND) and mainly the proximal template boundary remain controversial issues. In view of the existing mapping studies and retrospective analyses, extended LND up to the mid-upper third of the common iliac vessels appears to provide further prognostic and therapeutic benefit and therefore should be defined as standard LND. This applies for all procedures irrespective of the choice of surgical approach (open surgery, minimally invasive approach). In this context total lymph node count is not a quality criterion because nodal yield is overly influenced by the individual patient's anatomy, surgical technique, template applied and pathological work-up. Consecutively, considerable inter-institutional differences result, which render any comparison impossible. Lymph node density is thought to be a superior prognostic factor, but it is similarly influenced by the above-mentioned factors. Concerning molecular techniques to improve the sensitivity of postoperative nodal staging further research is necessary. The two ongoing prospective randomized trials will potentially help to further define the optimal LND template.
Collapse
|
6
|
Abaza R, Dangle PP, Gong MC, Bahnson RR, Pohar KS. Quality of lymphadenectomy is equivalent with robotic and open cystectomy using an extended template. J Urol 2012; 187:1200-4. [PMID: 22341295 DOI: 10.1016/j.juro.2011.11.092] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE Extended lymph node dissection for bladder cancer provides better staging, cancerous node removal and potentially survival. Minimally invasive techniques have been criticized about the ability to adequately perform extended lymph node dissection. We compared the extended lymph node dissection quality of robotic and open cystectomy by assessing node yield and positivity. MATERIALS AND METHODS We compared extended lymph node dissection in 120 open and 35 robotic cystectomy cases. Extended lymph node dissection included skeletonization of structures in each nodal group below the aortic bifurcation (common iliac, external iliac, obturator, hypogastric and presacral nodes). Nodes were processed identically but submitted as 1 or 2 packets for robotic cases and as 10 or more packets for open surgery cases. RESULTS The mean±SD node count in the open group was 36.9±14.8 (range 11 to 87) and in the robotic group the mean yield was 37.5±13.2 (range 18 to 64). Only 12 of 120 open (10%) and 2 of 35 robotic (6%) cases had fewer than 20 nodes. A total of 36 open (30%) and 12 robotic (34%) cases were node positive. Open extended lymph node dissection identified 80% and 90% confidence of accurate staging as pN0 when obtaining 23 and 27 nodes, respectively. A node count of 23 or 27 was achieved in 87% and 77% of open cases, and in 91% and 83% of robotic cases, respectively. Of patients with open surgery 36% received neoadjuvant chemotherapy compared to 31% of those with robotic surgery. CONCLUSIONS No difference was identified in the lymph node yield or the positive node rate when comparing open and robotic extended lymph node dissection. Local recurrence and survival data are needed to confirm whether the 2 techniques are oncologically equivalent.
Collapse
Affiliation(s)
- Ronney Abaza
- Department of Urology, Ohio State University Medical Center and James Cancer Hospital, Columbus, Ohio 43210, USA.
| | | | | | | | | |
Collapse
|
7
|
Pelvic lymphadenectomy in the treatment of invasive bladder cancer: literature review. Adv Urol 2011; 2011:701481. [PMID: 21904544 PMCID: PMC3166563 DOI: 10.1155/2011/701481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Accepted: 05/15/2011] [Indexed: 11/23/2022] Open
Abstract
The standard surgical treatment of invasive bladder cancer is the radical cystectomy and pelvic lymph node dissection (PLND). Up to one-third of patients with invasive bladder cancer have lymph node metastasis. Thus, PLND has important therapeutic and prognostic benefits. The number of lymph nodes that should be removed and the extent of the PLND are still a controversial issue. Recently, the trend of PLND increased toward more
extended PLND. Several prognostic factors related to PLND were reported in the literature. In this paper, we will discuss the different PLND templates, number of lymph nodes that should be resected, lymph node density, lymphovascular invasion, tumor burden, extracapsular extension, and the aggregate lymph node metastasis diameter.
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW To present recent advances in the field of lymph node dissection (LND) in the context of bladder cancer, upper urinary tract urothelial carcinoma and renal cell carcinoma with focus on dissection extent. RECENT FINDINGS A recent Technetium-based lymph node mapping study has provided several observations to help guide the scientific practice of LND during radical cystectomy. Only 8-10% of primary lymphatic landing sites were located above the uretero-iliac crossing. In contrast, considerable lymph nodes were found in the fossa of Marcille and the internal iliac region. Intraoperative frozen sections are unlikely to abbreviate the LND procedure. Total nodal yield is influenced by numerous factors and may not represent the ideal surrogate for adequacy of LND. The lymphatic drainage of the upper urinary tract is less predictive. For upper urinary tract urothelial cancer, conflicting data question even the staging benefit. In contrast, the results from the sole prospective randomized trial evaluating the value of LND in renal cell carcinoma cannot be generalized because of the limited inclusion of patients with higher stage disease. SUMMARY In invasive bladder cancer, meticulous extended LND offers both a prognostic and therapeutic benefit. However, the proximal boundaries of the LND template remain undefined. For upper urinary tract urothelial cancer there is a need to define a standardized approach (indication, template) in view of directing patients properly to adjuvant therapies and consecutively evaluate both prognostic and therapeutic value of LND. Similarly, the need for standardization accounts for renal cell carcinoma.
Collapse
|
9
|
Challacombe BJ, Bochner BH, Dasgupta P, Gill I, Guru K, Herr H, Mottrie A, Pruthi R, Redorta JP, Wiklund P. The role of laparoscopic and robotic cystectomy in the management of muscle-invasive bladder cancer with special emphasis on cancer control and complications. Eur Urol 2011; 60:767-75. [PMID: 21620562 DOI: 10.1016/j.eururo.2011.05.012] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 05/03/2011] [Indexed: 10/18/2022]
Abstract
CONTEXT Minimally invasive radical cystectomy (MIRC) techniques for the treatment of muscle-invasive bladder cancer (BCa) are being increasingly applied. MIRC offers the potential benefits of a minimally invasive approach in terms of reduced blood loss and analgesic requirements whilst striving to provide similar oncologic efficacy to open radical cystectomy (ORC). Whether quicker recovery, shorter hospital stay, and a reduction in complications are routinely achieved with MIRC remains to be proved in prospective comparisons. OBJECTIVE To explore both laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RRC), focusing specifically on the oncologic parameters and comorbidity of the procedures. Reported complications from major centres are identified and categorised via the Clavien system. Positive margins rates, local recurrence, and both cancer-specific survival (CSS) and overall survival rates are assessed. EVIDENCE ACQUISITION A comprehensive electronic literature search was conducted in November 2010 using the Medline database to identify publications relating to laparoscopic, robotic, or minimally invasive radical cystectomy. EVIDENCE SYNTHESIS There are encouraging short- to medium-term results for both LRC and RRC in terms of postoperative morbidity and oncologic outcomes. It seems possible in experienced hands to perform a satisfactory minimally invasive lymphadenectomy regarding lymph node counts and levels of dissection. Positive soft-tissue margins are similar to large open series for T2/T3 disease but inferior for bulky T4 disease. Local recurrence rates and CSS rates seem equivalent to ORC at up to 3 yr of follow-up; however, mature outcome data still need to be presented before definitive comparisons can be made. CONCLUSIONS Robotic and laparoscopic cystectomy has a growing role in the management of muscle-invasive BCa. Long-term oncologic results are awaited, and there are concerns over the ability of MIRC to treat bulky and locally advanced disease, making careful patient selection vital. Forthcoming randomised trials in this area will more fully address these issues.
Collapse
Affiliation(s)
- Ben J Challacombe
- The Urology Centre, Guy's and Thomas' NHS Foundation Trust and KCL, London, UK.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Schumacher MC, Jonsson MN, Hosseini A, Nyberg T, Poulakis V, Pardalidis NP, John H, Wiklund PN. Surgery-related Complications of Robot-assisted Radical Cystectomy With Intracorporeal Urinary Diversion. Urology 2011; 77:871-6. [DOI: 10.1016/j.urology.2010.11.035] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 10/24/2010] [Accepted: 11/04/2010] [Indexed: 10/18/2022]
|
11
|
Current world literature. Curr Opin Urol 2010; 21:84-91. [PMID: 21127406 DOI: 10.1097/mou.0b013e328341a1a3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
12
|
Lavery HJ, Martinez-Suarez HJ, Abaza R. Robotic extended pelvic lymphadenectomy for bladder cancer with increased nodal yield. BJU Int 2010; 107:1802-5. [DOI: 10.1111/j.1464-410x.2010.09789.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
13
|
Current world literature. Curr Opin Urol 2010; 20:443-51. [PMID: 20679773 DOI: 10.1097/mou.0b013e32833dde0d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
14
|
|