PerspectiveIn the Journals

Laparoscopic radical cystectomy conferred favorable long-term survival outcomes

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May 4, 2015

Patients with muscle-invasive or high-risk bladder cancer experienced favorable RFS, OS and cancer-specific survival outcomes after undergoing laparoscopic radical cystectomy, according to retrospective study results.

The survival outcomes associated with the laparoscopic procedure were comparable to those previously reported with open radical cystectomy, results showed.

“These results are vital to globally evaluate the efficacy of this procedure,” Simone Albisinni, MD, of the department of urology at the Université Libre de Bruxelles in Belgium, said in a press release. “They suggest that a laparoscopic approach to bladder cancer, when performed correctly, can be as safe as open surgery with regards to cancer control, though maintaining the benefits of a minimally invasive approach.”

Albisinni and colleagues evaluated data from 503 patients who underwent laparoscopic radical cystectomy for muscle-invasive or high-risk non–muscle-invasive urothelial cell carcinoma (n=495) or squamous cell carcinoma (n=5) and adenocarcinoma (n=3) of the bladder. The median age of patients was 68 years (interquartile range [IQR], 62-74) and 82% were male.

Thirty-nine percent of patients experienced minor surgical complications, the most common of which was postoperative infections. Major complications, such as those requiring a second surgical procedure, occurred in 17% of patients. Ten patients (2%) died postoperatively.

The median lymph node retrieval was 14 (IQR, 9-17), and 5.8% of patients had positive surgical margins.

Median follow-up was 50 months (IQR, 19-90). During this time, 134 patients (27%) experienced disease recurrence, which included 118 patients (23%) who had metastatic disease. Deaths due to bladder cancer occurred in 108 patients, and 52 patients died of non-cancer specific causes.

Actuarial 5-year RFS was 66%, 5-year cancer-specific survival was 75%, and 5-year OS was 62%. At 10 years, RFS was 62%, cancer-specific survival was 55% and OS was 38%. These data were comparable to a previous open radical cystectomy report in which 5-year RFS was 68% and 10-year RFS was 66%.

Results of a multivariate analysis indicated RFS, cancer-specific survival and OS were significantly associated with tumor state and lymph node involvement (P˂.001 for both). Positive margins also were significantly associated with RFS (P=.016) and cancer-specific survival (P=.043).

“This data represents crucial information for urologists who are performing laparoscopic surgery, or who wish to implement laparoscopic cystectomy in their departments,” Albisinni said. “In spite of the technical difficulty and the need for a learning curve, these findings support the use of a laparoscopic approach for the management of bladder cancer.”

Disclosure: The researchers report no relevant financial disclosures.

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Radical cystectomy remains a critical and, perhaps, under-utilized aspect of treatment of carcinoma of the bladder. Surgical approach to cystectomy lacks standardization with center-to-center variability on approach (open, laparoscopic, robotic-assisted laparoscopic), extent of lymph node dissection and urinary diversion. With the significant morbidity and extended hospital stay associated with radical cystectomy, a multitude of studies have been published recently with respect to surgical technique and post-operative pathways to improve care. There is limited randomized data, however, to help delineate the optimal approach and the urology community will rely on prospective cohort studies like the one presented by Albisinni and colleagues to gauge efficacy.

Albisinni and colleagues present data from a large cohort of 511 patients undergoing laparoscopic radical cystectomy. Their cohort appears to be fairly representative of the average cystectomy patient seen by American urologists, and their complication rate is in line with most large published series. From an oncologic standpoint, their surgical margin positivity rates and long-term cancer-specific survival by stage are also consistent with other series. The lymph node yield is lower than other series, although, this is difficult to interpret as differences in pathologic processing as well as surgical technique can account for this. Many prior series (particularly by Stein and colleagues) have shown that thorough lymph node dissection is associated with a survival benefit.

Laparoscopic radical cystectomy appears to be a viable alternative to open- and robotic-assisted approaches provided it is performed at high-volume centers with a strong focus on adequate lymph node dissection. While further studies are needed to improve comparison, it is possible that the laparoscopic approach may yield cost benefits when compared with robotic approaches and improved convalescence with lower blood loss when compared with open approaches.

Ali Zhumkhawala, MD
City of Hope National Cancer Center

Disclosure: Zhumkhawala reports no relevant financial disclosures.