Robotic Radical Cystectomy Safe, Feasible in the Elderly

The procedure takes longer than open radical cystectomy, but is associated with less blood loss, fewer transfusions, and shorter hospital stays.
The procedure takes longer than open radical cystectomy, but is associated with less blood loss, fewer transfusions, and shorter hospital stays.

Robot-assisted radical cystectomy (RARC) is a safe and feasible alternative to open radical cystectomy (ORC) in elderly patients, according to a new study.

RARC appears to be associated with longer operative time, but less blood loss and shorter hospital stays, according to a team at the University of Washington in Seattle led by Brian R. Winters, MD.

The retrospective study included 87 patients with a mean age of 79.6 years—of whom 29 and 58 underwent RARC and ORC, respectively. The median follow-up after RARC and ORC was 0.7 years and 1.7 years, respectively.

The mean operative time for the RARC group was 413 minutes compared with 370 minutes for the ORC group, Dr. Winters and his colleagues reported online in the Journal of Endourology. The mean estimated blood loss (EBL) was 257 mL (SD 144 mL) in the RARC group versus 641 mL (SD 291 mL) in the ORC group. The ORC patients more frequently required blood transfusions than the RARC patients (36% vs. 10%). The mean length of hospital stay was 7 days (SD 2) for the RARC group compared with 9 days (SD 2) for the ORC group. All of these between-group differences were significant. Statistically significant outliers were excluded for OR time, EBL, and LOS, creating a more conservative comparison between groups. The RARC and ORC groups did not differ significantly with respect to surgical complication rates (38% and 38%, respectively) or 90-day readmission rates (23% and 19%).

“Our study contributes to emerging evidence that RARC patients may experience less blood loss, fewer transfusions, and shorter hospital stays than ORC patients with no difference in complication rates,” the authors wrote. “As elderly patients present with substantial comorbidity, decreased functional status, and risk for prolonged convalescence, these data show that RARC is safe and associated with potential benefit.”

Limitations of the study include its retrospective design, small sample size, and the evolution in perioperative care over time, which may influence outcome comparisons, the investigators stated. Another limitation is the relatively short follow-up, which prevented robust analysis of bladder cancer recurrence and disease-specific and overall survival. Additionally, the investigators pointed out that their analysis is limited to a single robotic surgeon compared with several surgeons perform ORC.

These new findings echo those of some prior studies. For example, in a study of bladder cancer patients aged 75 years or older, Kyle A. Richards, MD, and colleagues at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., found that the RARC patients had a significantly longer median operative time compared with ORC patients (461 [IQR 331, 554] vs. 370 minutes [IQR 294, 460]), but experienced a significant decrease in median EBL (275 [IQR 150, 450] vs. 600 mL [IQR 500, 1925]), and median hospital stay (7 [IQR 5, 8] vs. 14.5 days [IQR 8, 22]), according to a report in the Journal of Endourology (2012;26:1301-1306). “For an experienced robotic team, RARC should be considered in elderly patients because it may offer significant advantage with respect to perioperative morbidity over ORC,” the authors concluded.

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