EUROPEAN UROLOGY 65 (2014) 348–349

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Platinum Priority – Editorial Referring to the article published on pp. 340–347 of this issue

Intracorporeal Urinary Diversion After Robot-assisted Cystectomy: Time to Climb the Next Learning Curve? Matthew Brown, Benjamin Challacombe * The Urology Centre, Department of Urology, Guy’s & St Thomas’ Hospitals NHS Foundation Trust, London, UK

The initial series of robot-assisted radical cystectomies (RARCs) was reported by Menon et al., 10 yr ago, in 2003 [1], but widespread adoption of this approach has been significantly slower than for robot-assisted radical prostatectomy. The reason may be the technically demanding nature of the procedure, limitations on prolonged operative times in patients with multiple comorbidities, the substantial cost of RARC relative to open surgery [2], uncertainty about the morbidity of RARC compared with open cystectomy [3], and a paucity of mature oncologic data [4]. Given the technical demands of RARC and early reports indicating long operative times and high complication rates with intracorporeal diversion [5], extracorporeal urinary diversion (ECUD) was initially the preferred approach for most centres [6]. One criticism of ECUD is that it requires a similar incision and comparable bowel manipulation and exposure as open cystectomy/diversion, which removes some of the benefits of a minimally invasive approach. Perhaps with those issues in mind and with increasing data showing acceptable operating times and morbidity with intracorporeal diversion, several centres have begun to adopt intracorporeal urinary diversion (ICUD), at least for ileal conduit [7]. In this month’s European Urology, the impressive International Robotic Cystectomy Consortium (IRCC) strengthens the impetus for a broader adoption of ICUD, reporting fewer complications compared with ECUD and comparable operative times [8]. The IRCC study is a retrospective analysis of 935 patients who underwent radical cystectomy and pelvic node dissection across 18 international centres. Within that cohort, 768 patients who underwent ECUD were compared with 167 patients who had ICUD with respect to operative time, hospital stay, reoperation rate, readmission rate, oncologic

outcomes, and complication rates. The proportion of patients who underwent neobladder as opposed to ileal conduit diversion was 26% for the ECUD group and 36% for the ICUD group. The median follow-up period was relatively short at 9 mo. The key finding of this study is a 32% lower complication rate for ICUD (odds ratio: 0.68; p = 0.02) relative to ECUD. The reduction in complications was because of reduced gastrointestinal morbidity, presumably ileus (23% vs 10%, p < 0.001) and infection (18% vs 12%, p = 0.035). Of note, there was no statistically significant difference in highergrade (Clavien 3–5) complications between ECUD and ICUD. The IRCC study does have a number of limitations that must qualify the interpretation of the results. As the authors acknowledge, it is a retrospective nonrandomised study, and selection bias is likely to be significant. Additionally, the database, while admirable for its scale and inclusiveness, lacked complication data for >100 of the included patients. The duration of follow-up is brief (mean: 9 mo), and the complications are painted in broad strokes with general categories. Numerous useful details (eg, the comparison of urinary leak and stricture rate between the ECUD and ICUD groups) are omitted. The potential lower complication rates could point to the performance of ICUD by experienced surgeons causing less traction and less tissue skeletalisation of the ureters, in addition to reduced bowel exposure, illustrating potential advantages to the intracorporeal approach. The most significant limitation is the unaccounted-for variable of learning curve and surgical quality between the ICUD and ECUD groups. Although refined techniques for ICUD have been published [9], RARC with ICUD (especially an intracorporeal neobladder) requires the highest level of

DOI of original article: * Corresponding author. The Urology Centre, 1st Floor Southward Wing, Guy’s Hospital, Great Maze Pond, London SE1 9RT, UK. Fax: +44 20 7188 6787. E-mail addresses: [email protected], [email protected] (B. Challacombe). 0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.

EUROPEAN UROLOGY 65 (2014) 348–349

robotic proficiency and is a daunting task, even for seasoned robot-assisted cystectomists. In the consortium study, in fact, only 18% of patients had an ICUD, and only 10 of the 18 contributing centres performed ICUD at all (most having conduits). As such, patients undergoing ICUD are likely receiving the highest-quality procedures performed by the most experienced surgeons at the upper end of the robotic learning curve. Indeed, this idea substantiated by higher lymph node yields in the ICUD group relative to the ECUD group, as well as by the lower soft tissue margin rate in the ICUD group. Surgical selection might underlie those differences; however, node yield and positive margin rate are recognised markers of surgical quality, so a disparity between the two groups is suggested. The consortium authors do not reference or control for this confounding variable. The similar operating time for RARC with ICUD and RARC with ECUD was another striking finding of the study, considering the significant robotic procedural steps and dexterity required for an entirely intracorporeal diversion relative to open exposure. Again, this finding might reflect surgical quality or a learning curve effect, but it could also be interpreted as strengthening the case for ICUD, indicating that ICUD is logistically feasible (in terms of operative time). In summary, RARC has not been widely adopted, and until data mature, questions are likely to remain regarding its economic imposition, morbidity benefits, and oncologic merits relative to the open operation. If superiority is present, it is likely to be most noticeable when the entire procedure (extirpation plus reconstruction) can be performed intracorporeally. The IRCC study in this issue of European Urology strengthens the case for progression towards standard ICUD in robot-assisted cystectomy by demonstrating the feasibility and potential reduced


complications associated with this approach. Perhaps it is time to be brave and climb the learning curve for ICUD to offer our patients another advance in minimally invasive urologic oncology. Conflicts of interest: Benjamin Challacombe has acted as a consultant to Intuitive Surgical.

References [1] Menon M, Hemal AK, Tewari A, et al. Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int 2003;92: 232–6. [2] Mmeje CO, Martin AD, Nunez-Nateras R, Parker AS, Thiel DD, Castle EP. Cost analysis of open radical cystectomy versus robot-assisted radical cystectomy. Curr Urol Rep 2013;14:26–31. [3] Yuh BE, Nazmy M, Ruel NH, et al. Standardized analysis of frequency and severity of complications after robot-assisted radical cystectomy. Eur Urol 2012;62:806–13. [4] Khan MS, Elhage O, Challacombe B, et al. Long-term outcomes of robot-assisted radical cystectomy for bladder cancer. Eur Urol 2013; 64:219–24. [5] Haber GP, Campbell SC, Colombo Jr RJ. Perioperative outcomes with laparoscopic radical cystectomy. Urology 2007;70:910–5. [6] Jonsson MN, Adding LC, Hosseini A, et al. Robot-assisted radical cystectomy with intracorporeal urinary diversion in patients with transitional cell carcinoma of the bladder. Eur Urol 2011;60:1066–73. [7] Pruthi RS, Nix J, McRackan D, et al. Robotic-assisted laparoscopic intracorporeal urinary diversion. Eur Urol 2010;57:1013–21. [8] Ahmed K, Khan SA, Hayn MH, et al. Analysis of intracorporeal compared with extracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol 2014;65:340–7. [9] Collins JW, Tyritzis S, Nyberg T, et al. Robot-assisted radical cystectomy: description of an evolved approach to radical cystectomy. Eur Urol 2013;64:654–63.

Intracorporeal urinary diversion after robot-assisted cystectomy: time to climb the next learning curve?

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