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Year : 2019  |  Volume : 30  |  Issue : 4  |  Page : 157-163

Robot-assisted radical cystectomy with intracorporeal urinary diversion: A feasible option for elderly patients? Results from a single high-volume center

1 Department of Urology, Abano Terme Hospital, Abano Terme, PD, Italy
2 Department of Urology, Urology Universitary Clinic, Bologna, BO, Italy

Date of Submission30-Jan-2019
Date of Decision17-Mar-2019
Date of Acceptance25-Mar-2019
Date of Web Publication29-Jul-2019

Correspondence Address:
Daniele Romagnoli
Policlinico Abano Terme, Piazza Cristoforo Colombo 2, Abano Terme, PD 35031
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_5_19

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Aim: We report the oncological and functional outcomes of a population of elderly patients who underwent robotic-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (IUD) at a single high-volume center with extensive experience in robotic surgery.Patients and Methods: Each procedure was performed by a single main surgeon, who previously attained a 30-day modified modular training program at a referring center. None technical variation was performed, and the surgical technique was performed exactly as taught. Demographics, intraoperative data, and postoperative complications were recorded for each patient of the aforementioned population. Results: From July 2015 to December 2018, we submitted to RARC with totally IUD at our institution 29 elderly patients (aged ≥75 years). Median age was 78 years (interquartile range [IQR]: 76–82). Eleven (37.9%), 12 (41.4%), and 6 (20.7%) patients received RARC with ureterocutaneostomy, ileal conduit, and orthotopic neobladder, respectively. Overall, median operative time was 360 min (IQR: 270–410). The median number of lymph node retrieved was 24 (17–34), the median intraoperative estimated blood loss (EBL) was 200 mL (150–300), with median hospitalization time of 7 days (IQR: 6–9). Each procedure was successfully completed without open conversion. A statistically significant reduction was found in the operative time, when compared to a population of younger patients (aged <75 years), probably reflecting the significant reduction in the choice of the nerve-sparing approach. Early (<30 days) and late (≥30 and <90 days) complication rates and cancer-specific mortality and overall mortality rates were not found statistically significant difference. Conclusions: In experienced hands, RARC with IUD can be safely applied to elderly patients, without a significant difference in terms of complication rates, cancer-specific survival, and overall survival.

Keywords: Complications, elderly, robotic radical cystectomy

How to cite this article:
Romagnoli D, Bianchi FM, Giampaoli M, Corsi P, D'agostino D, Schiavina R, Brunocilla E, Artibani W, Porreca A. Robot-assisted radical cystectomy with intracorporeal urinary diversion: A feasible option for elderly patients? Results from a single high-volume center. Urol Sci 2019;30:157-63

How to cite this URL:
Romagnoli D, Bianchi FM, Giampaoli M, Corsi P, D'agostino D, Schiavina R, Brunocilla E, Artibani W, Porreca A. Robot-assisted radical cystectomy with intracorporeal urinary diversion: A feasible option for elderly patients? Results from a single high-volume center. Urol Sci [serial online] 2019 [cited 2020 Aug 6];30:157-63. Available from: http://www.e-urol-sci.com/text.asp?2019/30/4/157/263651

  Introduction Top

Bladder cancer (BC) ranks the 9th worldwide as the most commonly diagnosed cancer and the 13th in terms of cause of death.[1] BC incidence increases with age, and given the increase of life expectancy, the number of newly diagnosed BC in elderly patients is going to further elevate in the upcoming future.[2]

Open radical cystectomy (ORC) with pelvic lymph node dissection (PLND) was proved to be the gold standard for nonmetastatic muscle-invasive BC (MIBC) and for non-MIBC (NMIBC) with multiple high-risk features.[3],[4]

Since its first description in 2003, robot-assisted radical cystectomy (RARC)[5] has gained much popularity among tertiary centers, despite higher costs as compared to ORC and similar complication rates. Parekh et al. recently released data from RAZOR study, the first randomized controlled trial comparing ORC and RARC, which demonstrated the noninferiority of the robotic approach compared to the laparotomic one in terms of surgical success and early oncologic control.

The high incidence of complications even with a less-invasive approach raises the question about potential beneficial effects of RARC among elderly patients.

Existing guidelines do not prevent from offering older cancer patients a curative treatment though an accurate geriatric assessment might be paramount to limit under- or overtreating elderly individuals and thus alter the quality of life.[6]

The aim of this study is to compare the surgical and early oncological results of RARC with different totally intracorporeal urinary derivations between elderly patients and younger individuals (namely ≥75 years vs. <75 years).

  Patients and Methods Top

We evaluated data from 100 consecutive patients who underwent RARC with intracorporeal urinary diversions (IUDs) at our institution between January 2015 and May 2018. All the surgical procedures were performed by a single experienced robotic surgeon (A.P.), after attending an intensive modular training program in a referral European center under supervision of a highly skilled mentor (P.W.).[7] Patients were scheduled for RARC with PLND if diagnosed with MIBC or high-risk NMIBC, except one patient who underwent this surgical procedure due to symptomatic postradiation microbladder. Neoadjuvant platinum-based chemotherapy, consisting of three cycles for 3 weeks, was given according to treating physicians' preference.

Patients were scheduled to different types of IUD according to clinical stage, renal function, body mass index (BMI), comorbidities, and patients' preferences. Orthotopic neobladder (ONB) reconstruction was excluded in individuals with preexisting incontinence, tumor extending to the prostatic urethra in male patients or behind the bladder neck in female patients, and chronic renal failure. Age itself was not considered as an absolute contraindication for ONB reconstruction.

RARC was performed as previously described with extended PLND.[8] A frozen urethral section was performed in those submitted to ONB reconstruction. Clinical, intraoperative, and pathologic data were prospectively collected. Early (≤30 days) and late (≥30 and <90 days) postoperative complications were graded according to the Clavien–Dindo classification.[9] Daytime and nighttime continence defined as the need for no or 1 pad per day and potency defined as erection adequate for penetration were also evaluated after 3 months from surgery for individuals submitted to ON. We divided our population in two groups according to age at surgery, namely <75-year-old versus ≥75-year-old patients. Demographic, perioperative, pathological data as well as Clavien–Dindo grade complications were compared among the two groups. Cancer-specific mortality (CSM) and overall mortality (OM) were assessed with subsequent follow-up visits or phone calls.

Our primary end points were the comparison of complication rates, CSM, and OM between <75-year-old and ≥75-year-old patients.

Statistical analysis

Each statistical elaboration was performed using SPSS version 21.0 for Macintosh (IBM Corp, Armonk, NY, USA).

Medians (with interquartile ranges [IQRs]) and frequencies (with percentages) were used to describe continuous and categorical variables, respectively. The Mann–Whitney and Pearson's Chi-square test were used to compare medians and frequencies between <75-year-old and ≥75-year-old patients, respectively. Uni- and multivariate logistic regression models with enter method were used to identify which covariates could be used to predict 90-day complications, reporting odds ratio with 95% confidence interval.

Kaplan–Meier plots were used to estimate cancer-specific survival (CSS) and overall survival (OS) during follow-up, stratifying population in four groups according to age at surgery and ASA score.

Any statistical difference in terms of CSS and OS was assessed using log-rank test. Statistical analyses were conducted using SPSS version 21.0 for Macintosh (IBM Corp, Armonk, NY, USA).

  Results Top

Overall and age-stratified preoperative features are reported in [Table 1]. The two groups were homogeneous in terms of sex distribution (P = 1), BMI (P = 0.9), ASA score (P = 0.08), clinical stage (P = 0.3), clinical stage (P = 0.2), and previous Bacillus Calmette–Guerin bladder instillations status (P = 1). Less than 75-year-old group had significantly higher rates of associated carcinoma in situ (CIS), and a larger proportion of patients received neoadjuvant chemotherapy (P = 0.04 and P = 0.02, respectively).
Table 1: Patients' demographic and preoperative data stratified according to type of urinary derivation

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Median operative times were significantly longer among <75-year-old patients as compared to ≥75-year-old group (420 vs. 360, P < 0.001) [Table 2]. Indeed, the proportion of urinary diversion type was significantly different among two groups (P < 0.001), with 45 (63.4%), 20 (28.2%), and 6 (8.5%) younger patients undergoing ONB, ileal conduit, and ureterocutaneostomy versus 6 (20.7%), 12 (41.3%), and 6 (20.7%) in the older group, respectively, as depicted in [Table 2]. Estimated blood loss (EBL) and intraoperative transfusion rate were comparable between two groups (P = 0.2 and P = 1, respectively). Any procedure was not converted to open surgery. Concomitant urethrectomy, pathologic stage (pT), concomitant CIS, pathologic histotype, and positive surgical margins were not statistically different among <75-year-old and ≥75-year-old groups. As expected, neurovascular bundles were spared either uni- or bilaterally in a higher proportion of patients in the younger group (P = 0.002). No statistical differences were found in terms of PLND (100% vs. 96.6%, P = 0.3), median number of lymph nodes (LNs) yielded (28 vs. 24, P = 0.2), pathologic nodal involvement (33.8% vs. 24.1%, P = 0.3), and median number of pathologic LNs involved (4 vs. 4, P = 0.4).
Table 2: Patients' perioperative and pathologic data stratified according to three groups of surgery

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Concomitant prostate cancer (PCa) was identified in the surgical specimen in 37.5% of <75-year-old versus 30.8% of ≥75-year-old individuals (P = 0.6), with similar Gleason group grade distribution and PCa-positive margins status among two groups (both P = 1).

As shown in [Table 3], median hospital stay and catheterization time (for those who received an ONB reconstruction) were 7 days (IQR: 6–7) and 21 days (IQR: 19–22) without statistical differences between younger and older patients (both P = 0.8) [Table 3]. No statistical differences were identified also in terms of adjuvant chemotherapy rates (P = 0.7).
Table 3: Postoperative and 90-day follow-up data stratified according to age at surgery (namely <75 years vs. .75 years)

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Early postoperative complications were statistically homogeneous between <75-year-old and ≥75-year-old patients (P = 0.5), with 6 (8.5%) Grade 3 complications in the former group versus 2 (6.9%) in the latter group. During the first 30 postoperative days, we recorded only 1 Grade 5 Clavien complication (multidrug-resistant sepsis).

Considering late postoperative complications (30–90 days), no statistically significant differences were found among the two population, also in terms of late readmission rate and 90-day mortality rate. At univariate and multivariate analysis, as shown in [Table 4], ASA score was found the only independent predictive factor of late postoperative complications.
Table 4: Uni- and multivariate logistic regression model predicting complications during the first 90 postoperative days after robot-assisted radical cystectomy

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From the functional point of view, a significant improvement in daytime urinary continence ratio, in case of patients submitted to ONB, was found in the younger group (P < 0.009) though no statistically significant difference was found in terms of nighttime continence, sexual potency, and duration of follow-up (15 months for patients <75 years and 13 months for patients ≥75 years, P = 0.3).

[Figure 1] and [Figure 2] show Kaplan–Meier plots with CSS and OS curves stratified accordingly to age at surgery and ASA score (log-rank test, P = 0.12, and log-rank test, P = 0.7), respectively. At a median follow-up time of 14 months (IQR: 10–20), no statistically significant difference in terms of CSM [Table 5] and OM [Figure 2] was found among the two population, nor stratifying them according to ASA score.{Figure 1}
Figure 2: Kaplan-Meier showing overall survival stratified according to age at surgery and ASA score (P = 0.12)

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Table 5: Cancer specific mortality adjusted for age and ASA score

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  Discussion Top

The data presented support the premise that, in experienced hands, a robotic approach to radical cystectomy is a safe and effective option for older patients. With the aging population and increasing incidence of BC, our treatments must be applied to a growing older population, even when the treatment involves radical surgery. Age has been shown to contribute to the treatment decisions for patients with muscle-invasive disease. In a recent retrospective study of 820 patients with newly diagnosed BC identified in the Surveillance, Epidemiology, and End Results database, of those patients with muscle-invasive disease, the patients aged ≥75 years were much less likely to undergo radical cystectomy (14%) compared with patients aged 55–64 years (48%) and those aged 65–74 years (43%).[10] The adoption of minimally invasive techniques for radical cystectomy has extended the spectrum of the surgical management of clinically localized MIBC for an aging population. The safety and efficacy of the actual gold standard, the open technique of radical cystectomy, in the elderly has been previously demonstrated.[11],[12],[13],[14],[15] We suggest that elderly patients might actually achieve great benefits from a procedure with potentially reduced morbidity, as RARC with IUD is. The purpose of the present study was to report our maturing experience with robotic-assisted laparoscopic radical cystectomy, after the adoption of a dedicated modified modular training,[16] as applied to an older patient population with regard to perioperative, oncological, and functional outcomes. Specifically, we wanted to search for any significant difference in terms of CSM, OM, and complication rates, to prove the efficacy and safety of the procedure as applied to the elderly. In the present series, the older cohort had a higher ASA score (but the difference was not statistically significant) and shorter operative time. The explanation for this second aspect might be due to the significant reduction in the number of nerve-sparing procedures applied in the older population. In fact, older patients have usually a worst preoperative sexual function, and the spare of the neurovascular bundles, as shown by preoperative magnetic resonance imaging,[17] which is useful also to detect any suspect concomitant PCa,[18] can be avoided in patients with low preoperative sexual function. However, the perioperative parameters of EBL and interval to discharge were not different between the two groups. Considering postoperative complications, which are quite common in relation to any technical variant of radical cystectomy,[19] older patients did not have a significantly different complication rate compared with the younger patient cohort, neither in early nor in late domains. Undoubtedly, the most important aspect in the evaluation of a novel technique in surgical oncology is to rigorously maintain the oncologic principles of the reference standard. In our experience, the oncologic principles and pathologic outcomes appeared to be maintained using the robotic approach to radical cystectomy in the short term.[20] The surgical pathologic results were not significantly different statistically between the two age cohorts, with numerically similar LN yields and positive surgical margins ratio among the two populations. Our mean LN count of 27 nodes in the older cohort compares favorably with that of other published reports of pelvic lymphadenectomy during ORC,[21],[22] underlining the efficacy of the robotic approach in the extended PLND. Considering functional parameters, such as daytime and nighttime continence, we found a significant improvement in the daytime continence in the elderly when compared with the younger. This result can be explained by the small sample size of the elderly submitted to ONB. Anyway, an important factor to achieve this result is also our personal urethro-ileal anastomotic technique, which is characterized by a barbed bidirectional suture, as previously described relative to the anastomosis realized in case of radical prostatectomy.[23],[24] The present analysis had some noteworthy limitations. Incidental PCa ratio was not different among the two groups, reflecting the ratio of a large national population study.[25] Anyway, no PCa group ≥3 was detected. The present study has, however, some limitations. First, the present series is a single-institution experience. A more widespread applicability to other groups of surgeons and institutions would be best analyzed in a multi-institutional study, thus providing better significance to any result. Second, the present study does not evaluate the long-term cancer-related outcomes (5-year results), which is considered a benchmark for oncologic efficacy.

  Conclusions Top

In our experience, robot-assisted radical cystectomy with IUD is a procedure which, in experienced hands, can be safely applied to elderly patients, without affecting the complications ratio and the oncological and functional outcomes. Further studies, with longer follow-up, larger population samples and multiple centers involved are necessary to give more strength to these promising results.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 7], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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