Expert Compares Open vs Robotic Radical Cystectomy Approaches in Muscle Invasive Bladder Cancer

Bryon Lee, MD, PhD

Recent advances in surgical technique, approach, and perioperative care have made radical cystectomy significantly less morbid for patients with muscle invasive bladder cancer, according to Bryon Lee, MD, PhD, who added that outcomes are comparable between robotic and open techniques.

“We have seen a lot of improvements made with radical cystectomies over the past 15 to 20 years in terms of quality. We are more experienced in doing this surgery and we've been able to decrease the rates of complications,” said Lee. “As a result, we can now use this technique on more patients, including those who would not have been able to undergo this procedure in the past. Whether this will translate to the community is tough to say; however, we have seen much progress in the academic setting.”

In an interview with OncLive^® during the 2020 Institutional Perspectives in Cancer webinar on Bladder Cancer, Lee, a urologic oncologist at Cleveland Clinic, compared open vs robotic radical cystectomy approaches in bladder cancer.

OncLive^®: Could you highlight some of the advancements that have been made with radical cystectomies in recent years?

Lee: Over the years, several advancements have been made to the radical cystectomy technique. This is the mainstay of treatment for patients with muscle invasive bladder cancer who can tolerate surgery. Of course, there are a number of patients who can't tolerate surgery, but those who can undergo surgery are the ones who will benefit the most from this operation.

That being said, it is a very morbid operation, as we know from previous experience at other institutions. The operation itself is very long and arduous because it could involve removing the patient’s bladder, prostate, surrounding lymph nodes, and then reconstructing the urinary tract in 1 of 3 ways. In a woman, it could involve removing the uterus, bladder, fallopian tubes, ovaries, a thin strip of the anterior vaginal wall, the local lymph nodes, and reconstructing the urinary tract. As such, it's a long and tough surgery that could include several potential complications; this is especially true in a population that has several other medical comorbidities. Many patients are lifelong smokers who have some kind of coronary artery disease or peripheral vascular disease, a history of hypertension, or even diabetes. For these patients, the surgery is a challenge. 

After understanding the complication rates, the types of complications, and how they affect the patients, we have been trying to determine how to improve surgical outcomes. About 60% to 70% of patients experience some complications from the surgery within 90 days, but most of these complications are not serious. One such complication is postoperative ileus, which is when the bowels haven't completely woken up after surgery. The patients may suffer from some nausea or vomiting and may require a nasogastric tube inserted temporarily until the bowels wake up and they can then tolerate liquids and solid foods after that. However, about 10% to 20% of patients do experience serious complications, which could potentially be life threatening. The 90 day-mortality rate is around 1% to 3%. As such, although it’s small, there’s still a chance of death for these patients.

At Cleveland Clinic, we have moved to a more minimally invasive approach. We initially began with the laparoscopic approach and then we quickly moved on to the robotic approach. In 2020, we published a study in the Journal of Urology, where we described our approach, but also the reduction in complications that followed in result of this change—especially with the incorporation of the intracorporeal urinary diversions. This involves the manipulation of the bowel robotically, instead of making an incision.

Do you believe the radical cystectomy approach has been underutilized?

I do believe the radical cystectomy procedure is generally underutilized. The major tertiary care centers that do many of these procedures have a process. It's a complicated surgery that involves many members from a multidisciplinary team to carry out successfully. Patient follow-up is also critical. Ultimately, tertiary care centers do many of these surgeries and they do them well; however, this tends to be underutilized in the community [setting].

What are the advantages with the robotic approach over the laparoscopic approach?

Both approaches are minimally invasive. Essentially, this means that the surgery is done through small keyhole incisions that are about half an inch in diameter. Oftentimes, we use about 4 or 5 of these incisions to do the surgery. Unlike an open surgery, the surgeon’s hands remain outside the body and only working instruments that fit through these small keyhole incisions are used to carry out the entire surgery.

There are also a few differences between laparoscopy and robotics. The first one is that the instruments used to carry out the latter approach are hooked up to a robot, and the surgeon sits at a console to perform the surgery several feet away from the patient. By hooking up the instruments to the robot, we have more freedom to manipulate the tissue or needle so that we can be more precise in our movements.

The other advantage of using the robots is the 3D vision that it provides. Laparoscopy also has 3D monitors, but it requires wearing special glasses and a special monitor setup. With robotic surgery, it's all built into the console. Essentially, robotics is a more advanced version of laparoscopic surgery; it flattens the learning curve for many surgeons because we're able to perform very precise movements in a more natural way.

Are there any data indicating that the robotic approach is superior?

Data suggest that the surgeon is the most important part of the equation. Whether the surgeon is more comfortable performing a radical cystectomy in an open or robotic fashion, that's the way that the surgery should be performed. For example, a surgeon who has performed an open surgery thousands of times and is comfortable with this approach should not be asked to do a robotic surgery if their experience in that is more limited. Some studies, such as the RAZOR trial, along with research from Memorial Sloan Kettering Cancer Center, suggests that outcomes are similar between both approaches.

What has been your experience in clinical practice?

Although the randomized trials did not show a significant difference between the open and robotic approaches, our experience at Cleveland Clinic has been a little bit different. We've definitely found significant differences between the intracorporeal urinary diversion technique compared with both open and robotic cystectomies using an extracorporeal technique. With the latter technique, the bladder, prostate, and lymph nodes are removed robotically, but then the surgeon makes an incision in the middle of the abdomen to perform the urinary diversion in a more traditional way. We found that there are fewer complications with the intracorporeal diversion technique compared with the open technique, as well as the extracorporeal technique.

If a surgeon is comfortable with both approaches, what factors are considered when choosing between them?

Traditionally, surgeons have been very hesitant about performing a robotic surgery in patients who have had previous abdominal surgery, or if they felt as though the anatomy was tough to get at in a robotic fashion. However, as we become more well versed in performing robotic surgeries, those are not contraindications anymore. In fact, most of our patients who undergo a robotic surgery have had previous abdominal surgery. Sometimes they've even had mesh in place, which creates a lot of scar tissue between the intra-abdominal contents and the abdominal wall. We're now able to get through that without any issues most of the time. As such, with this said, it’s really up to each individual surgeon, in terms of their judgement and what they are comfortable with.