Expanding the use of robotic-assisted radical cystectomy

According to data from the National Cancer Institute, by the time 2013 comes to a close, more than 72,000 people in the United States will be diagnosed with bladder cancer. The average age for a patient diagnosed with bladder cancer is 68. Demographics show a higher incidence of bladder cancer among men than women — about 4-to-1. Mortality rates have been stable in men since 1998 and slowly declining in women. In general, however, incidence and mortality rates have changed very little over the past 20 years. But, with increased longevity and a growing baby boomer population, the incidence of bladder cancer is expected to rise over the next decade.

The classical standard of care for patients with invasive bladder cancer is open radical cystectomy. But another surgical technique, robotic-assisted radical cystectomy (RARC), is emerging as a less invasive approach for the treatment of invasive bladder cancer. According to Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS), there were 10,529 radical cystectomies performed in 2010.

Mayo Clinic continues to be on the cutting edge of treating patients with invasive bladder cancer, having been one of the early adopters of robotic-assisted radical cystectomy. In 2007, a Mayo Clinic team, led by Erik P. Castle, M.D., a Mayo Clinic urologist who helped pioneer the robotic technique as a fellowship-trained specialist, conducted the first RARC at Mayo Clinic. Since 2007, this less invasive approach has been performed by Mayo Clinic surgeons on more than 175 patients, and today is available at all three Mayo campuses.

Because of the complexity of a radical cystectomy with urinary reconstruction, adoption of robotic-assisted technology has a steep learning curve. "Early on, people were skeptical because it is a complex operation doing open, let alone doing robotically," explains Dr. Castle. But seen as a natural evolution of technology developed from robotic radical prostatectomy, RARC is one of the last frontiers of robotic urologic surgery.

Urinary diversion

When robotic technology was first adopted, the urinary diversion portion of the procedure — the ileal conduit or neobladder — was conducted extracorporeally. Now Mayo Clinic surgeons at the Arizona campus also perform the urinary diversion portion of the procedure intracorporeally. From start to finish, the entire operation can be completed with laparoscopic incisions. In female patients, the bladder is removed through the vagina. In male patients, a 7- to 10-centimeter incision below the bellybutton allows for the removal of the bladder and creation of the ileal conduit.

Mayo Clinic surgeons have performed numerous intracorporeal urinary diversion procedures since the advent of the technology in 2007. This is just one way Mayo Clinic continues to be on the cutting edge of bladder cancer treatment. "The experience and protocols in place at Mayo Clinic are enhancing recovery following surgery as well as improving outcomes and making the surgery safer every day," notes Mayo Clinic urologist Matthew K. Tollefson, M.D.

Oncologic equivalent?

Because RARC is still a relatively new procedure, long-term studies on patient oncologic outcomes comparing the RARC with radical open cystectomy are lacking. To date, Mayo Clinic data on patient outcomes over a seven-year period show an oncologic equivalency for the two procedures, with RARC demonstrating decreased transfusion rates, shorter hospital stays and fewer complications.

Absent long-term published data comparing outcomes of patients of equal health status, debate continues within the urologic community as to whether or not patients undergoing RARC have an equivalent oncologic outcome to those undergoing the radical open cystectomy, says Dr. Castle. To provide this long-term data, Mayo Clinic is currently involved in the first multi-institutional randomized trial sponsored by the National Institutes of Health.

Measured by two-year progression-free survival, the trial will evaluate oncologic, perioperative and functional outcomes of patients undergoing the two procedures to determine if RARC delivers the same oncologic result as open radical cystectomy.

Dr. Tollefson explains the significance of the study, "Once we get the results of these studies, I believe we will see more and more patients with bladder cancer treated with RARC." Dr. Castle agrees, "Hopefully this will settle the debate. So far the data supports and suggests they are equivalent."

Reduced complications

Paul R. Young, M.D., also a urologist at Mayo Clinic, has spent a significant portion of his career performing open radical cystectomies as a treatment for patients who have invasive bladder cancer. In the past three-plus years, he has incorporated robotic-assisted radical cystectomy, the less invasive technique, into his practice. It is clear to him that patients lose less blood during that surgery, resulting in a reduced need for postoperative transfusions. And while the data are not yet conclusive, Dr. Young is hopeful that the long-term studies will confirm oncologic outcomes to be comparable and the number of postoperative complications to be reduced.

"Postoperative complications following cystectomies are very high. Since these patients tend to be older and the risk of complications is 20 to 30 percent no matter how you do it, where or who does it, my big hope is that we can decrease the complication rate and it will not be as big a project of managing these patients," says Dr. Young. Incorporating robotic technology into his arsenal of bladder cancer treatment allows Dr. Young to offer his patients an additional course of treatment — "one I hope will meet my goal of decreased post-surgical complications, resulting in decreased length of stay and faster postoperative recovery."

Like his fellow Mayo Clinic urologists, Dr. Young sees the future in bladder cancer surgery moving toward RARC. "The beauty of the RARC is it is essentially the same space, the same operation, just done with different instruments. So if it's in the best interest of the patient to convert to open, it is an easy transition," explains Dr. Young. "This approach helped significantly during my learning curve and helped with the transition from open to robotic cystectomy." He anticipates that in the near future, when consulting patients on treatment options, he will tell patients they have the two surgical options. But based on his experience, RARC will be the preferred one. "It will be an equivalent way to do this, and it might become the new standard of care," he emphasizes.

For more information

Open vs. Robotic-Assisted Radical Cystectomy: A Randomized Trial. ClinicalTrials.gov.