Bio: Thomas Fonseka is an academic researcher from King's College London. The author has an hindex of 1, co-authored 1 publications receiving 45 citations.
TL;DR: RARC is comparable to LRC with better surgical results than ORC and LRC has better surgical outcomes than OrC.
Abstract: Objective: To conduct a systematic review and meta-analysis comparing outcomes between Open Radical Cystectomy (ORC), Laparoscopic Radical Cystectomy (LRC) and Robot-assisted Radical Cystectomy (RARC). RARC is to be compared to LRC and ORC and LRC compared to ORC. Material and methods: A systematic review of the literature was conducted, collating studies comparing RARC, LRC and ORC. Surgical and oncological outcome data were extracted and a meta-analysis was performed. Results: Twenty-four studies were selected with total of 2,104 cases analyzed. RARC had a longer operative time (OPT) compared to LRC with no statistical difference between length of stay (LOS) and estimated blood loss (EBL). RARC had a significantly shorter LOS, reduced EBL, lower complication rate and longer OPT compared to ORC. There were no significant differences regarding lymph node yield (LNY) and positive surgical margins (PSM.) LRC had a reduced EBL, shorter LOS and increased OPT compared to ORC. There was no significant difference regarding LNY. Conclusion: RARC is comparable to LRC with better surgical results than ORC. LRC has better surgical outcomes than ORC. With the unique technological features of the robotic surgical system and increasing trend of intra-corporeal reconstruction it is likely that RARC will become the surgical option of choice.
TL;DR: There was no difference in 5-yr RFS, CSS, and OS rates of patients who underwent ORC, RARC, and LRC for management of bladder cancer, and minimally invasive techniques achieved equivalent oncological outcomes to the gold standard of ORC.
TL;DR: This study does not provide evidence to support a benefit for RARC compared to ORC in patients with bladder cancer and well-designed trials with appropriate endpoints conducted by equally experienced ORC and RARC surgeons will be needed to address this.
Abstract: Background: The number of robotic assisted radical cystectomy (RARC) procedures is increasing despite the lack of Level I evidence showing any advantages over open radical cystectomy (ORC). However, several systematic reviews with meta-analyses including non-randomised studies, suggest an overall benefit for RARC compared to ORC. We performed a systematic review with meta-analysis of randomised controlled trials (RCTs) to evaluate the perioperative morbidity and efficacy of RARC compared to ORC in patients with bladder cancer. Methods: Literature searches of Medline/Pubmed, Embase, Web of Science and clinicaltrials.gov databases up to 10th March 2016 were performed. The inclusion criteria for eligible studies were RCTs which compared perioperative outcomes of ORC and RARC for bladder cancer. Primary objective was perioperative and histopathological outcomes of RARC versus ORC while the secondary objective was quality of life assessment (QoL), oncological outcomes and cost analysis. Results: Four RCTs (from 5 articles) met the inclusion criteria, with a total of 239 patients all with extracorporeal urinary diversion. Patient demographics and clinical characteristics of RARC and ORC patients were evenly matched. There was no significant difference between groups in perioperative morbidity, length of stay, positive surgical margin, lymph node yield and positive lymph node status. RARC group had significantly lower estimated blood loss (p<0.001) and wound complications (p = 0.03) but required significantly longer operating time (p<0.001). QoL was not measured uniformly across trials and cost analysis was reported in one RCTs. A test for heterogeneity did highlight differences across operating time of trials suggesting that surgeon experience may influence outcomes. Conclusions: This study does not provide evidence to support a benefit for RARC compared to ORC. These results may not have inference for RARC with intracorporeal urinary diversion. Well-designed trials with appropriate endpoints conducted by equally experienced ORC and RARC surgeons will be needed to address this.
Tan Tock Seng Hospital1, University of Tübingen2, University of California, Los Angeles3, Karolinska Institutet4, University of Southern California5, University of Washington6, University of Rochester Medical Center7, University of North Carolina at Chapel Hill8, Albert Einstein College of Medicine9, Harvard University10, University of Lille Nord de France11
TL;DR: A multi-disciplinary approach is paramount to achieving optimal outcomes for MIBC patients, irrespective of their age, performance and nutritional status, fitness/frailty, renal and other organ function, or disease severity.
Abstract: To provide a comprehensive overview and update of the Joint Societe Internationale d’Urologie–International Consultation on Urological Diseases (SIU–ICUD) Consultation on Bladder Cancer for muscle-invasive presumably node-negative bladder cancer (MIBC). Contemporary literature was analyzed for the latest evidence in treatment options, outcomes, including radical surgery, neoadjuvant and adjuvant treatment modalities, and bladder-sparing approaches. An international multi-disciplinary expert panel evaluated and graded the data according to guidelines from the Oxford Centre for Evidence-Based Medicine. Radical cystectomy (RC) is the standard of care for MIBC patients considered to be surgical candidates. While associated with substantial morbidity and mortality, this has been mitigated with improved technique, minimally invasive technology, and better perioperative care pathways (e.g., enhanced recovery after surgery). Neoadjuvant (NA) cisplatin-based combination chemotherapy improves overall survival and should be offered to eligible ≥ cT2N0 patients. Adjuvant (Adj) cisplatin-based combination chemotherapy may be considered, particularly for pT3–4 and/or pN+ disease without prior NA chemotherapy. Trimodal bladder-preserving treatment via maximum transurethral resection of bladder tumor followed by concurrent chemoradiation is safe and, when combined with early salvage RC for recurrence, offers long-term survival rates in selected patients comparable to RC. Immunotherapy is still experimental and is given either alone or in combination with chemotherapy and/or radiation. A multi-disciplinary approach is paramount to achieving optimal outcomes for MIBC patients, irrespective of their age, performance and nutritional status, fitness/frailty, renal and other organ function, or disease severity.
TL;DR: The findings indicate that the type of surgical approach is not associated with RFS, CSS, and OS in patients with bladder cancer.
Abstract: Purpose: To investigate oncological outcomes in patients with muscle-invasive bladder cancer who underwent open radical cystectomy (ORC), laparoscopic radical cystectomy (LRC), or robot-assisted radical cystectomy (RARC). Patients and Methods: A retrospective analysis was performed on 230 patients who underwent ORC (n = 150), LRC (n = 22), or RARC (n = 58) between September 2009 and June 2012. Perioperative outcomes were compared between the three surgical approaches. The influence of the type of surgical approach on recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) was analyzed using the Kaplan–Meier method, and differences were assessed with the log-rank test. Predictors of RFS, CSS, and OS were also analyzed with a Cox regression model. Results: The median patient age for ORC, LRC, and RARC groups was 68.0 (interquartile range [IQR]: 60.0–73.0), 65.0 (IQR: 62.8–74.0), and 61.5 (IQR: 54.8–72.0) years, respectively (p = 0.017), and the median follow-up dur...
TL;DR: Evidence is presented for RARC not being superior to ORC regarding complications, LOS and HRQoL and high-quality studies with consistent registration of complications and patient-related outcomes are warranted.
Abstract: Radical cystectomy is associated with high rates of perioperative morbidity. Robotic-assisted radical cystectomy (RARC) is widely used today despite limited evidence for clinical superiority. The aim of this review was to evaluate the effect of RARC compared to open radical cystectomy (ORC) on complications and secondary on length of stay, time back to work and health-related quality of life (HRQoL). The databases PubMed, The Cochrane Library, Embase and CINAHL were searched. A systematic review according to the PRISMA guidelines and cumulative analysis was conducted. Randomized controlled trials (RCTs) that examined RARC compared to ORC were included in this review. We assessed the quality of evidence using the Cochrane Collaboration’s ‘Risk of bias’ tool and Grading of Recommendations Assessment, Development and Evaluation approach. Data were extracted and analysed. The search retrieved 273 articles. Four RCTs were included involving overall 239 patients. The quality of the evidence was of low to moderate quality. There was no significant difference between RARC and ORC in the number of patients developing complications within 30 or 90 days postoperatively or in overall grade 3–5 complications within 30 or 90 days postoperatively. Types of complications differed between the RARC and the ORC group. Likewise, length of stay and HRQoL at 3 and 6 months did not differ. Our review presents evidence for RARC not being superior to ORC regarding complications, LOS and HRQoL. High-quality studies with consistent registration of complications and patient-related outcomes are warranted. PROSPERO CRD42016038232