Landmark Trial Puts Robotic Surgery to the Test in Bladder Cancer

Vivek Venkatramani, MD, and Dipen J. Parekh, MD
Published: Tuesday, Dec 11, 2018
University of Miami Miller School
of MedicineVivek Venkatramani, MD
Vivek Venkatramani, MD
Visiting Assistant Professor,
Department of Urology
University of Miami Miller
School of Medicine
Miami, Florida
Dipen J. Parekh, MD
Dipen J. Parekh, MD
Professor and Chair,
Department of Urology
Director, Robotic Surgery
The Victor A. Politano Endowed
Chair in Urology
University of Miami Miller
School of Medicine
Sylvester Comprehensive Cancer Center
Chief Clinical Officer
University of Miami
Health System
Miami, Florida
Strategic Partnership
Robotic surgery using the Intuitive da Vinci Surgical System was introduced nearly 2 decades ago. The platform allows the surgeon an ergonomically comfortable position to perform the operation, a magnified 3-dimensional view, and “wristed” instruments that mimic the movements of the surgeon’s hand, often in tight spaces in the human body. It was expected that this technology would lead to more precise surgery, translating into better patient outcomes, and the robotic platform was adopted rapidly, crossing 5 million total surgeries performed and 4409 robotic systems installed worldwide by the end of 2017.1

One would expect that robotic surgery would have been put through the scientific process of rigorous clinical trials before such widespread adoption. However, this was not the case and no adequately powered, prospective multicenter randomized trials were performed comparing it with the open approach in any surgical specialty. Only a small number of single-center randomized trials were conducted, with endpoints focused on perioperative recovery and not on oncologic outcomes.

Challenges in Bladder Cancer

Surgical techniques are particularly important in bladder cancer, which is among the most common cancers in both men (4th) and women (11th) in the United States, with an estimated 81,190 new patients diagnosed with bladder cancer and 17,240 deaths attributable to it in 2018.2 Invasive disease is treated surgically with radical cystectomy and urinary diversion. Traditionally, this has been a formidable procedure, with significant morbidity and even mortality, but it does provide patients with the best oncological survival. A laparoscopic approach to radical cystectomy was attempted in order to improve perioperative outcomes, but it was a very time-consuming procedure with a large learning curve and was never widely adopted.

With the advent of the surgical robot, it was believed that the disadvantages of traditional laparoscopy could be overcome and that a truly minimally invasive alternative to open cystectomy was available. Retrospective studies and case series suggested that the robotic approach was indeed technically feasible and reproducible, and that it had potential perioperative benefits in terms of reduced blood loss, complication rates, and length of hospital stay. Two single-center pilot studies and 1 small singlecenter randomized trial comparing open with robotic cystectomy found no difference between the procedures in oncological surrogates such as positive margins and lymph node yield, with similar complication rates. The study findings also noted better perioperative outcomes, including reduced blood loss and length of hospital stay, in the robotic group.

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Community Practice Connections™: 2nd Annual International Congress on Oncology Pathology™Aug 31, 20191.5
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