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European Urology
Volume 58, issue 2, pages e19-e28, August 2010Bladder Cancer
Reply from Authors re: Urs E. Studer, Laurence Collette. Robot-Assisted Cystectomy: Does It Meet Expectations? Eur Urol 2010;58:203–4
Matthew H. Hayn a, Abid Hussain a, Ahmed M. Mansour a, Paul E. Andrews b, Paul Carpentier h, Erik Castle b, Prokar Dasgupta d, Peter Rimington d, Raju Thomas c, Shamim Khan d, Adam Kibel e, Hyung Kim o, Murugesan Manoharan f, Mani Menon g, Alex Mottrie h, David Ornstein i, James Peabody g, Raj Pruthi j, Joan Palou Redorta k, Lee Richstone l, Francis Schanne m, Hans Stricker g, Peter Wiklund n, Rameela Chandrasekhar a, Greg E. Wilding a, Khurshid A. Guru a 
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Published online 15 June 2010, pages 204 - 206
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Refers to article:
The Learning Curve of Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium
Accepted 14 April 2010
August 2010 (Vol. 58, Issue 2, pages 197 - 202)
Refers to article:
Robot-Assisted Cystectomy: Does It Meet Expectations?
August 2010 (Vol. 58, Issue 2, pages 203 - 204)
Article Outline
We appreciate the opportunity to publish our study, which provides timely information on the learning curve associated with robot-assisted radical cystectomy (RARC) [1]. We also welcome the editorial comments from Drs. Studer and Collette [2]. Incorporating a novel surgical approach into a urology practice can be challenging. Accurate assessment of the challenge is difficult due to various factors including influence of baseline surgical experience, variability of surgeon ability, and differences in patient selection. The introduction of RARC represents an incremental progression from robot-assisted radical prostatectomy (RARP).
Several issues raised in Studer and Collette's editorial [2] need to be addressed. The current operative principles of open radical cystectomy (ORC) have evolved over the past century. Do we really know what the learning curve looks like for ORC? In fact, initial mortality rates with ORC approached 35% [3]. The first reported RARC was performed only 8 yr ago [4]. Learning curves exist in any operation, and there have clearly been improvements in ORC and urinary diversion over the previous half century. It is possible that even the large number of cases required to master RARC is really no different than the number required to master ORC.
As stated in the editorial [2], all surgeons in the International Robotic Cystectomy Consortium (IRCC) series had some prior RARP experience, ranging from <50 to >1000 cases [1]. Although intuitively one would think that increased RARP experience would lead to improved outcomes at RARC, this was not borne out in separate analyses [5]. Surgical outcomes, such as estimated blood loss, operative time, and lymph node yields, improved for surgeons who had performed <50 prior RARPs and 50–100 RARPs, but additional prior RARP experience did not further improve RARC outcomes [5]. The IRCC agrees that “novice” robotic surgeons should probably not be performing RARC; however, it is not necessary to have thousands of prior robotic cases to become initially proficient at RARC.
Given the multi-institutional and international scope of the IRCC, it was impossible to quantify the influence of patient selection separately from the individual institutions and surgeons. Studer and Collette raise the issue that only 36% of the patients had pT3/T4 disease, which they infer is secondary to patient selection [2]. Extravesical disease in the IRCC cohort, however, is no different than large ORC series in which the rates of pT3/T4 disease ranged from 33% to 45% [6], and [7]. The median age and prior comorbidities reported in our series were also similar to ORC series.
Urinary diversion and functional outcomes were not addressed in this initial report from the IRCC. Even in the setting of extracorporeal diversion, dissection and preservation of well-vascularized ureters of adequate length are facilitated by the enhanced vision and magnification allowed by the robot. The ability to cut the ureter short to allow for anastomosis to an afferent isoperistaltic ileal segment, as described by Studer et al. [8], has been controversial so far. However, the incidence of stricture using the Studer technique is similar to ORC series that utilize the entire length of ureter for urinary diversion [9], [10], and [11]. In addition, types and methods for robot-assisted intracorporeal urinary diversion are evolving and use minimum manipulation of the ureters [12], and [13]. These techniques should largely eliminate the need for extensive ureteral mobilization for urinary diversion. Long-term follow-up for functional outcomes and the need for secondary procedures in patients who undergo RARC are still needed to address this issue.
The concerns regarding soft tissue surgical margins are valid and perhaps are the single most important aspect in invasive bladder cancer surgery. A positive margin is, in essence, a death sentence for the patient. Without dwelling on older data, a recent multicenter ORC series evaluated 4400 patients treated at 12 academic institutions from 1980 to 2008 (40% treated from 1990 to 2000 and 47% treated after 2000) [7]. The group demonstrated an overall soft tissue surgical margin rate of 6.3%, with a 12.3% positive margin rate in pT3/T4 disease. Despite their impressive numbers (approximately 368 cases per institution), the margin rates did not differ significantly from those seen by our group (7% overall and 16% in patients with pT3/T4 disease), which averaged 35 cases per institution [1]. Other IRCC operative parameters, including lymph node yield, blood loss, and operative times, are also similar to ORC series.
We agree with the plea for a randomized multi-institutional trials examining open versus robot-assisted radical cystectomy. Until such a trial is completed, however, patients should be offered all options. Is it ethical to withhold such information? Our retrospective analysis creates the framework for offering patients all available options.
In conclusion, history is repeating itself! It was not long ago that laparoscopic nephrectomy, shock wave lithotripsy, and percutaneous stone extraction were considered experimental. Surgeons who perform both open and robot-assisted cystectomies will agree that robot-assisted surgery can reproduce the maneuvers performed in an open fashion. The question is how difficult it is to teach a surgeon to perform these maneuvers. Our paper attempts to address this question [1].
Conflicts of interest
Kibel is affiliated with Sonofi Adventis, Spectrum, and Envisioneering. Kim is affiliated with Pfizer. Ornstein is affiliated with Correlogies. Peabody is affiliated with Intuitive Surgical. Pruthi is affiliated with GTX. Thomas is affiliated with Gulf South Lithotripsy, Olympus, and Intuitive Surgical. Guru is affiliated with Intuitive Surgical and Simulated Surgical Systems.
References
- [1] M.H. Hayn, A. Hussain, A.M. Mansour, et al.. The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol 58 (2010) (197 - 202) Abstract, Full-text, PDF, Crossref.
- [2] U.E. Studer, L. Collette. Robot-assisted cystectomy: does it meet expectations?. Eur Urol 58 (2010) (203 - 204) Abstract, Full-text, PDF, Crossref.
- [3] F. Hinman. The technique and late results of ureterointestinal implantation and cystectomy for cancer of the bladder. Int Soc Urol Rep 7 (1939) (464 - 524)
- [4] M. Menon, A.K. Hemal, A. Tewari, et al.. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int 92 (2003) (232 - 236) Crossref.
- [5] Hayn MH, Hellenthal NJ, Hussain A, et al. Does prior robot-assisted radical prostatectomy experience affect outcomes at robot-assisted radical cystectomy? Results from the International Robotic Cystectomy Consortium. Urology. In press.
- [6] discussion 491–2 R.E. Hautmann, J.E. Gschwend, R.C. de Petriconi, M. Kron, B.G. Volkmer. Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era. J Urol 176 (2006) (486 - 492) Crossref.
- [7] G. Novara, R.S. Svatek, P.I. Karakiewicz, et al.. Soft tissue surgical margin status is a powerful predictor of outcomes after radical cystectomy: a multicenter study of more than 4,400 patients. J Urol 183 (2010) (2165 - 2170) Crossref.
- [8] U.E. Studer, D. Ackermann, G.A. Casanova, E.J. Zingg. Three years’ experience with an ileal low pressure bladder substitute. Br J Urol 63 (1989) (43 - 52) Crossref.
- [9] discussion 2034 H.C. Thoeny, M.J. Sonnenschein, S. Madersbacher, P. Vock, U.E. Studer. Is ileal orthotopic bladder substitution with an afferent tubular segment detrimental to the upper urinary tract in the long term?. J Urol 168 (2002) (2030 - 2034)
- [10] discussion 427–8 R.E. Hautmann, R. de Petriconi, H.W. Gottfried, K. Kleinschmidt, R. Mattes, T. Paiss. The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol 161 (1999) (422 - 427) Crossref.
- [11] H. Abol-Enein, M.A. Ghoneim. Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation: experience with 450 patients. J Urol 165 (2001) (1427 - 1432)
- [12] Guru K, Seixas-Mikelus SA, Hussain A, et al. Robot-assisted intracorporeal ileal conduit: marionette technique and initial experience at Roswell Park Cancer Institute. Urology. In press.
- [13] R.S. Pruthi, J. Nix, D. McRackan, et al.. Robotic-assisted laparoscopic intracorporeal urinary diversion. Eur Urol 57 (2010) (1013 - 1021) Abstract, Full-text, PDF, Crossref.
Footnotes
a Department of Urologic Oncology, Roswell Park Cancer Institute, Buffalo, New York, USA
b Mayo Clinic, Phoenix, Arizona, USA
c Department of Urologic Oncology, Tulane University, New Orleans, Louisiana, USA
d Department of Urologic Oncology, Guy's Hospital, King's College, London, England
e Department of Urologic Oncology, Washington University, St. Louis, Missouri, USA
f Department of Urologic Oncology, University of Miami, Miami, Florida, USA
g Henry Ford Health System, Detroit, Michigan, USA
h Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
i Department of Urologic Oncology, Vanguard Urologic Institute, Houston, Texas, USA
j Department of Urologic Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
k Fundacio Puigvert, Barcelona, Spain
l Arthur Smith Institute for Urology, Long Island, New York, USA
m Urologic Surgical Associates of Delaware, Wilmington, Delaware, USA
n Karoliniska University, Stockholm, Sweden
o Cedars-Sinai Medical Center, Los Angeles, California, USA
Corresponding author. Department of Urologic Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA. Tel. +1 716 845 3389; Fax: +1 716 845 3300.
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