This transcript has been edited for clarity.
Cheryl Lee, MD: Welcome to Medscape InDiscussion. I'm Cheryl Lee, and today we'll be discussing a topic that has continued to be controversial. I'm referring to the technical approach to radical cystectomy for patients with high-risk bladder cancer — open vs robotic cystectomy. The big question: Is robotic surgery superior to open cystectomy? We've been having this conversation in the field for some time, and when it started, we wanted to know if robotic surgery was inferior to open surgery. I feel like we've come a long way. We've also introduced enhanced recovery after surgery (ERAS) protocols into our care for patients with bladder cancer. Is this neutralizing some of the benefits we expected to see from robotic surgery early on? We hope to pull back the layers on some of these questions with an expert and friend, Dr Khurshid Guru, who is joining us today. In addition to serving as director of robotic surgery at Roswell Park Comprehensive Cancer Center in Buffalo, New York, he's also chair of the Department of Urology at Roswell Park, and he has contributed to numerous publications and clinical trials related to bladder cancer and robotic surgery. Welcome, Khurshid.
Khurshid Guru, MD: Thank you, Cheryl. It's a pleasure to be here.
Lee: Fantastic. Well, before we delve into our conversation about cystectomy and technical approaches to radical surgery, I'm sure our audience would really enjoy understanding a bit about what attracted you to the subspecialty of bladder cancer and how you became interested in robotic surgery.
Guru: Yes, it's in fact a very interesting milieu. What happened was that when I was in my training, robot-assisted surgery, or robotic surgery, was kind of evolving at Henry Ford Health System with my mentors, Drs Mani Menon and James Peabody. They were developing the technology and techniques needed to incorporate the robot into performing prostatectomy.
At that point, I had a lot of interest in working in bladder cancer. I approached Professor Menon about it, and he recommended I get further background training in bladder cancer. Being a mentor and a man with a lot of vision, he decided to send me to Egypt in the middle of my training — a very unconventional thought, as you know well; you've been doing this for a long time. I met with professors Mohamed Ghoneim and Hassan Abol-Enein in Egypt. I was shipped out there for 6 months, performed a certain number of procedures with them, and learned the techniques and the nuances of master surgeons. As you know well — and I think the audience may know a little bit — because of the Nile River flowing through there, the parasite schistosomiasis had previously been the main cause of bladder cancer in Egypt. Now, obviously, smoking is taking over as the main cause. This led me to build the foundation of the approach to bladder cancer — looking at both the biology and the technique. I returned and completed my training at Henry Ford Health System where I completed my robotic surgery training. So, I had training in open cystectomy at a world-class center and training in robot-assisted surgery at another center — and in addition to that I learned more about the biology of bladder cancer.
Lee: That's a phenomenal story I didn't even know about. Traveling to the extremely high-volume center in Egypt to train with Dr Ghoneim was really an amazing opportunity.
Guru: Yes, absolutely.
Lee: You mentioned Dr Menon who was one of the early adopters of robotic surgery, particularly as it relates to prostatectomy. It reminds me that the uptake of robotic surgery in urology happened much more quickly in radical nephrectomy and radical prostatectomy. Why do you think it's been slower to be taken up by surgeons in our field as it relates to radical cystectomy?
Guru: That's a great question. One of the major things we all know in the field — and that people who take care of patients with bladder cancer clearly realize — is that bladder cancer is a different disease. It comes with a package where the tumor is very sensitive, and surgical techniques are very critical because they form the fundamental foundations of taking care of patients with bladder cancer. Surgical technique defines outcome. I think that's the mantra we all know, and it has been defined very well by the open surgeons who have taken their time to refine the techniques.
Now, how does this reflect on robotic surgery? So, bladder cancer is a different disease. [The surgical evolution also was time-consuming because] these are longer surgeries with multiple steps. Patients would stay longer in house to be treated. They were older and sicker. There was a lot of need for postoperative care, and the learning curve for prostatectomy was already harder; the learning curve became even more complicated with bladder cancer. I think that led, in a fair way and a good way, for us to go slower on the bladder path because it would have led to a lot of harmful outcomes for our patients while we were evolving or trying to learn new techniques. This slow growth and slow kind of progress was perfect for us because there was a lot to learn from people who had been doing open cystectomy. There was a lot for the newer-generation surgeons, who wanted to believe in minimally invasive techniques, to learn about the biology of the disease. There was a lot to learn about the care of patients with bladder cancer because they come in with a lot of issues that need to be addressed. So, I'm not only glad but also thankful that we took our time to incorporate robot-assisted surgery.
Lee: In truth, the use of robotic surgery has a lot to offer bladder cancer patients and the same is true for radical surgery because bladder cancer is a disease where there's a very high rate of comorbidity. It is a disease where recovery is prolonged. It is a disease where quality of life is greatly impacted by surgical treatment. It is a disease in which it's so important to optimize surgical technique and reduce local recurrence. For all these reasons, open surgeons in the field wanted to improve and optimize the surgical approaches. I would argue that the surgical advances are probably more critical in bladder cancer than in some of the other diseases.
There have been randomized, surgically based trials in this space trying to see how open and robotic techniques relate to one another and what the outcomes are like. Dipen Parekh's trial was published in 2018. The goal there was to determine whether robotic surgery was inferior to open surgery. After coming out of that trial and some other single-institution, randomized trials, like the Bochner trial from Memorial [Sloan Kettering Cancer Center], as a field, we felt there's some advantage to robotic surgery — perhaps reduced blood loss, reduced transfusion, maybe a reduction in length of stay — although we knew open surgeons weren't being pushed in utilizing ERAS the way robotic surgeons were. We were really trying to make each other better. I think robotic surgeons have made open surgeons better.
But along comes the iROC trial, which was published in the past week and a half or so and just presented at the recent American Urological Association meeting. This is a trial from the UK that randomized bladder cancer patients with nonmetastatic disease to either robotic-assisted radical cystectomy — with complete and total intracorporeal reconstruction — or open radical cystectomy. This is key, too, because in Dipen's trial, many of those patients had small incisions made and had extracorporeal urinary diversion performed. Many robotic surgeons said that if it could be completely intracorporeal, we'd see greater differences. This trial is important. There were about 169 patients in each arm, and they were looking at a primary outcome, which is also somewhat unique: the number of days alive and out of the hospital within 90 days. This is an important issue for patients. How long are they going to be in the hospital? Are they readmitted? It's an important issue for hospitals. I find this primary endpoint quite intriguing. I'd be interested in your thoughts on this endpoint. It's a little different than in many studies.
Guru: I want to reaffirm that their endpoint is not just about how many days a patient is going to stay. They're mixing the reality on ground, which is length of stay with complications, with readmissions, delays in discharges, the complexity of the readmission, and all these things together. It gives you a new or unique measure overall. How long is a patient out of the hospital for any reason? How long was a patient in the hospital initially? Was a patient readmitted?
We know well in the field that some people have tried to modify results by keeping patients only for a few days and then readmitting them later because of problems. That doesn't give you the true measure of the field. I think it's more about the whole picture together, and I think that's what the iROC trial tries to address.
Lee: I think we're going to be seeing this endpoint in the future. I want to talk a little bit about the results. In looking at this primary outcome — the median number of days alive and out of the hospital within 90 days of surgery — it was 82 days for patients undergoing robotic surgery vs 80 days for open surgery. This was about a 2.2-day advantage for robotic surgery. Now, you could argue how significant that is, but I think that was also coupled with the fact that their primary length of stay wasn't very different.
When you look at complications, the thromboembolic complications and wound complications were a bit less common in the robotic surgery group than in the open surgery group. You're getting at the issue of complications, which we know for radical cystectomy has been quite high — 40%-60%. We really haven't made substantial improvements in these rates over time, although with home use of anticoagulants and other things, I think we've gotten better. But we're certainly not where we want to be.
I'm curious about your thoughts on these findings. Do you find them significant? What does that mean, then, when you go to counsel a patient who needs surgery? How do you think these data should impact the patient consultations?
Guru: I agree with you 100%. If you're just looking at 82 days vs 80 days, there is not a big difference. But when you add a mix of less blood loss, a lower transfusion rate, and fewer thromboembolic events and wound complications, they add up. Now, do they add up substantially? I don't think so. I think it makes both robotic and open surgeons improve their processes, such as perhaps the wounds need to be addressed better. Maybe they're going to look closely at how they are closing the wounds.
At the end of the day, it does move patient care forward. It also challenges us — both open and robotic surgeons — to improve and fine-tune these small things, which in the end, are measurable for the patient. We also know that operating in deeper, narrower pelvises is difficult to control. So when you have a magnification of seven times and you're closer to the vessel, you have an easier chance of clipping it before it bleeds. If you have a narrower, deeper pelvis in a patient with a high BMI, it's much harder to do this with open surgery vs robotic.
I don't think the people who are doing this as a passion — that is, taking care of patients with bladder cancer vs just looking at technique — knew that there was not a huge difference. I think in the end, the experience of the surgeon is what matters.
One of the things they did in this trial is they had a cutoff in the number of cases you had to do. Early on, it made little difference if a patient had smaller wounds and they were able to ambulate. It's these small added differences that might help us push the field forward, not only for open surgery but for robotic surgery as well.
Lee: I agree. It's something to build upon and certainly to congratulate this group on for their work. Now, when I think about this study — and of course, it's a European study — my recollection is that the average lengths of stay were around a week or so . . . 7, 8, 9 days or in that range. But in truth, with ERAS protocols, where it used to be fairly common to have patients in the hospital for a week, now patients' lengths of stay are only 3 or 4 days. You need to balance that with the issues of readmission. Using patient navigation, we can keep readmission rates lower. There has traditionally been around a 20%-25% readmission rate with cystectomy. Even if you get this down to 15%-20%, with nurse navigators, we still have done a phenomenal job in broadening the use of these protocols across the country and are beginning to see a decline in length of stay. How do you think this factors in?
Guru: It was an incredibly big step. As much as a lot of people will think that robot- assisted surgery for bladder cancer was a big leap, I think a bigger leap were the ERAS protocols, which came at the same time. If you look at the study and compare it to the other randomized controlled trials, they incorporated the ERAS in there, and it was a requirement for them. Is it needed? Absolutely. Bladder cancer will not be impacted and surgical options for bladder cancer will not be impacted by one factor; it is multifactorial. The navigator is another critical aspect. Elderly patients living at home . . . living alone . . . no support. All these things will matter, so ERAS is critical.
Lee: Our time is beginning to wind down, but I also want to ask you quickly about your thoughts on that Swedish registry study that [was published] in the last couple of weeks. It's not a randomized prospective study, but it was a large population of patients — 2000 or closer to 3000 patients — who had undergone either robotic or open radical cystectomy in Sweden where they have a comprehensive database. Propensity-based matching was used to try to learn more from this retrospective dataset. They had some interesting observations around the mortality from . . . I won't say from surgery alone because obviously this is a very challenged population with a lot of morbidity even prior to surgery and independent from their bladder cancer. What are your thoughts about that registry study?
Guru: The Swedish health system has done a wonderful job with maintaining their registries. We've seen that specifically in our field with prostate and bladder. This study is, I think, critical in the sense that although it might not be a randomized controlled trial, but all-cause mortality is definitely higher on both sides. One of the aspects is that the Swedish measuring tool is precise. They have a better way of measuring outcomes. What's specific to robotics is that it drills down and hammers the whole concept of less blood loss and fewer transfusions, but it also brings back something we talked about earlier. In this registry study from Sweden, they had a shorter hospital stay, but the readmission and rehospitalization rates were higher. So, it proves the point we were just talking about.
The other thing that it showed was that the higher Clavien-Dindo classification — grade III or higher — was higher with open surgery. But the infection rates were also higher with robotic surgery. With open surgery, you saw some complications, which were cardiovascular and respiratory. What I would love to see is even though the robotic group had only eight centers, 16 centers were doing open surgery. A registry gives you more of a feel for what the population is doing or the state is doing vs a randomized controlled trial, which usually happens in highly accomplished institutions. This gives you more of a generic landscape view. Whichever way or approach you use to address your patients, you have to make sure you have the expertise to deliver the operation, be it open or robotic assisted. You need to make sure the techniques are so good that you don't leave any margins behind. Because at the end of the day, this is a cancer operation. It's more about the biology of the disease, how you take care of it, and how meticulous you are in defining these surgical principles. The open surgeons have pushed the robotic surgeons, and both together have moved the field forward in a very nice way.
Lee: I completely agree with you. I've got one last question for you: What do you think is going to be the role of open surgery for our trainees?
Guru: What I tell people is that if you look at stone disease — when I was a resident and when you were a resident — you had these big staghorn kidney stones, and surgeons would filet the kidney, take out the stones, and then close it up with massive blood losses . . . big operations. Nobody ever would have imagined there would be a time when the rate of big anatrophic nephrolithotomy would be less than 1%, despite a big stone. Now, I think the field is moving forward this way, but I personally feel that the rate of surgery might be a much smaller percentage in the future because of the way people are addressing the biology of the disease. You and I might be doing this for a very short time. In the future, the majority of patients might be handled in a very different way — hopefully, without these big cuts and high morbidity.
Lee: I think that's a very interesting way to end this conversation. I really want to thank you for joining today, Khurshid. This has been a great conversation for our audience. I heard, as a takeaway, that robotic surgery is bringing new advances, and we've got to continue to build on top of these advances. So, to really take notice, and volume does matter as it relates to quality. We should continue to strive to push each other — be you open or robotic in your interest. For a patient coming in to talk with someone about treatment with radical surgery, the most important thing is to do what you are most comfortable doing and have good outcomes doing it. We'll continue to push each other. Thanks for listening. I'm Cheryl Lee for Medscape InDiscussion.
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Cite this: Bladder Cancer Choices: Robotic or Open Cystectomy? - Medscape - Jul 06, 2022.