Minimally Invasive Approaches in the Treatment of Urothelial Carcinoma Robotic Radical Cystectomy

1
Minimally Invasive Approaches in the Treatment of
Urothelial CarcinomaRobotic Radical
Cystectomy

• Douglas S. Scherr, M.D.
• Weill Medical College of Cornell University

2
Robotics Beyond The Prostate

• Radical Cystectomy
• Can we achieve equal oncological outcome?

3
Radical Cystectomy

• Gold Standard for Invasive Disease
• Role in T1 Disease
• Quality of surgery impacts outcome and survival

4
Was the Effect all Chemotherapy?Are surgical
variables important?

• Post cystectomy survival predicted by a.)
  age b.) stage c.) node status d.) negative
  surgical margins e.) gt10 nodes removed
• Hazard ratio for death a.) 2.7 for surgical
  margin b.) 2.0 for lt10 nodes removed

Herr et al. JCO, 22(14) 2781, 2004
5
Radical Cystectomy for T1 TCC

• USC Experience 208 pts with T1 disease
• USC Experience with T2 disease

Recurrence Free Survival Overall
Survival 5 Year 10 Year
5 Year 10 Year 80 75
74 51
Recurrence Free Survival Overall
Survival 5 Year 10 Year
5 Year 10 Year 81 80
72 56
Stein et al., J Clin Oncol, 19(3) 666-75, 2001
6
Early Vs. Late Cystectomy

• 90 pts who had TUR BCG ultimately underwent
  cystectomy
• 41/90 had T1 disease
• Median Follow up of 96 mos Early cystectomy (lt2
  years) 92 survival Late cystectomy (gt2 years)
  56 survival

Herr and Sogani, J Urol, 166 1296-9, 2001
7
Extent of Lymphadenectomy

• Is there more to the node dissection than
  staging?
• 1936 Colston and Leadbetter performed studies on
  98 cadavers limited metastatic disease was
  restricted to the pelvic nodes
• 1946 Dr. Jewett cardinal site of metastasis

Colston and Leadbetter, J Urol, 36 669,
1936 Jewett et al. J Urol, 55 366, 1946
8
Extent of Lymphadenectomy

• Node positive patients can enjoy long term
  survival
• 24 of grossly node positive disease survived 10
  years without adjuvant therapy
• More nodes removed correlates with improved
  survival

Sanderson et al. Urol Oncol., 22 205, 2004
9
Extent of Lymphadenectomy

• Likely no staging advantage to extending the node
  dissection above the aortic bifurcation
• 33 of unsuspected nodes found at common iliacs
• Practice patterns vary widely
• a.) 40 of cystectomies have no LND b.) 12.7
  of LND had lt4 nodes removed
• Lymph node density ( pos nodes/total nodes)

Konety et al. J Urol, 170 1765, 2003
10
Extent of Pelvic Lymph Node Dissection
IMA
Genitofemoral nerve
Genitofemoral nerve
Aortic Nodes
Common Iliac Nodes
Hypogastric and Obturator Nodes
11
Survival By Number Of Lymph Nodes Removed
Herr et al. JCO, 22(14) 2781, 2004
12
Postcystectomy survival by node status and number
of nodes removed
Herr, H. W. et al. J Clin Oncol 222781-2789 2004
13
Post Cystectomy Survival

• Herr, H. W. et al. J Clin Oncol 222781-2789
  2004

14
Gold Standard

• Open radical cystectomy (RC) is the gold standard
  for treatment of muscle-invasive bladder cancer.

15
Minimally Invasive Bladder Cancer Surgery

• Efforts to reduce the operative morbidity of RC
  have fostered interest in minimally invasive
  approaches.

• Laparoscopic RC
• Robot-assisted laparoscopic RC

16
Concerns of Robotic Cystectomy?

• Concerns regarding minimally invasive RC
• Absence of long term oncologic outcomes
• Absence of long term functional outcomes
• Limited pelvic lymphadenectomy
• Longer operative time
• Increased cost

Miller NL et al World J Urol (2006) 24180
17
Outcome Measures of Minimally Invasive Bladder
Surgery

• Previous reports comparing open versus minimally
  invasive RC have focused on perioperative
  outcomes.
• Blood loss
• Operative time
• Analgesic requirement
• Time to regular diet
• Length of hospital stay

Hemal AK et al Urol Clin N Am (2004)
31719 Basillote JB et al J Urol (2004)
172489 Taylor GD et al J Urol (2004)
1721291 Galich A et al JSLS (2006) 10145 Rhee
JJ et al BJU Int (2006) 981059
18
Comparison of Surgical Techniques

• However, direct comparison between open and
  minimally invasive RC of early oncologic
  parameters is lacking.

• Lymph node yield
• Margin status

19
Study Comparison

• Comparison of perioperative and early pathologic
  outcomes in a consecutive series of open and
  robotic RCs at our institution.

20
Methods

• 100 consecutive patients underwent RC by a single
  surgeon at our institution 2006-2007

• 22 open
• 78 robotic

21
Technique

• Posterior dissection
• Isolation of ureters
• Lateral dissection
• Control of bladder pedicles
• Anterior dissection
• Control of DVC and division of urethra
• Control of prostate pedicles and nerve-sparing
• Pelvic lymph node dissection
• External iliac, hypogastric, and obturator
  lymphadenectomy up to the level of the mid-common
  iliac vessels
• Extracorporeal urinary diversion through a 5-7cm
  midline incision
• Orthotopic neobladder robot re-docked for
  urethral neovesical anastomosis

22
(No Transcript)
23
Data Collection and Analysis

• Data was collected prospectively
• Patient characteristics
• Perioperative outcomes
• Early pathologic outcomes
• Data analysis
• Chi-square test
• Fishers exact test
• Students t-test

24
Results Patient Characteristics

• There was no difference in the following
  parameters among the 2 cohorts.

• Age
• BMI
• ASA class
• Prior abdominal surgery
• Prior abdominal radiation
• Neoadjuvant chemotherapy

25
Results Clinical Stage
26
Urinary Diversion
27
Operative Time
P lt 0.05
28
Robotic Learning Curve
P lt 0.05
29
Blood Loss Postoperative Parameters
P lt 0.05
30
Postoperative Complications
31
Pathologic Stage
P lt 0.05
32
Node Margin Status
P lt 0.05
33
Cost Results
34
Cost Conclusions

• Robotic cystectomy appears more cost-effective
  than open cystectomy for treatment of bladder
  cancer
• Majority of improvement driven by lower LOS
• High initial materials cost of robotic surgery
  defrayed by subsequent cost savings during
  hospitalization
• Annual robotic volume does not need to be high
  (lt25 cases per year) to justify use of robotic
  cystectomy
• Cost savings of robotic cystectomy however is
  diminished with decreased open cystectomy LOS (2
  to 9 days)

35
ConclusionsRobotic Cystectomy

• Increased operative time
• significantly longer operative time in the
  robotic neobladder cohort (p0.01)
• Decreased operative time with increased
  experience
• 450 to 338 min (p0.007)

36
ConclusionsRobotic Cystectomy

• Decreased
• Blood loss
• Transfusion requirement
• Time to regular diet
• Length of hospital stay

37
ConclusionsRobotic Cystectomy

• Equivalent lymph node yield
• 17.4 (robotic) vs. 18.9 (open), p0.6
• Equivalent margin rate
• 2 (robotic) vs. 8 (open), p0.2
• Long term oncologic and functional outcomes are
  required

Stein JP et al J Urol (2003) 170 35 Herr H et
al J Urol (2004) 171 1823
38
Minimally Invasive Cystectomy

• Minimally Invasive Cancer Sparing

39
Future Directions

• Prostate Sparing?
• Improved Diagnostics

40
Prostate Sparing Cystectomy

• Role for improved continence and potency
• Need to rule out prostate cancer or TCC of
  prostatic urethra
• Functional Results are good a.) 97 complete
  continence b.) No episodes of retention c.) 82
  maintained potency

Vallancien et al. J Urol, 168 2413, 2002
41
Prostate Sparing Cystectomy

• Incidence of Pca is 30-50 with approx. 48 are
  clinically significant
• 60 of CaP involve the apex (79 significant and
  42 insignificant)
• 48 of prostates had urothelial ca involvement of
  which 33 had apical involvement

42
Multiphoton Images
43
Multiphoton Images