COMMENTARY

Robotic vs Open Cystectomy: Which Fares Better for Bladder Cancer?

Albert B. Lowenfels, MD

Disclosures

August 31, 2018

How does robot-assisted radical cystectomy compare with traditional open radical cystectomy for management of patients with bladder cancer? To answer this question, the authors of a study published in the Lancet [1] performed a randomized trial comparing these two types of surgery in 350 patients randomly allocated to each method.

Seventeen (10%) of 176 patients in the robotic cystectomy group did not undergo surgery and nine (5%) patients underwent a different type of surgery. In the open cystectomy group, twenty-one (12%) of 174 patients did not have surgery and one (1%) patient had robotic instead of open cystectomy.

The major endpoint was 2-year progression-free survival. The study results showed a nonsignificant difference between the two methods: 72.3% (150) of patients treated with robotic surgery survived and were considered disease-free compared with 71.6% (152) of conventionally treated patients.

However, other important measures of outcome, such as blood loss (P < .0001), intraoperative transfusions (P < .0001), and hospital length of stay (P = .022), were significantly better in the robot-assisted group.

Viewpoint

There are limited data available to compare robotic with conventional surgery for bladder cancer. This is especially true for oncologic outcomes. This trial reports no difference (noninferiority) for robotic versus conventional surgery for tumor-free survival after 2 years of observation. This is an important endpoint because it is a good indicator of survival from bladder cancer over longer periods.

There were no differences in surgical complication rates (P = .75), and robotic surgery offered significant benefit with respect to blood loss and reduced hospitalization. These significant advantages need to be balanced against the extra costs and the extra training required to learn this advanced technique.

This was a noninferiority trial, so we can only conclude that at 2 years tumor-free survival in the two groups was similar. Longer follow-up and additional clinical trials will be required to perform a cost-benefit analysis.

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