George Washington University School of Medicine.
Department of Surgery, George Washington University Medical Faculty Associates.
Clin Genitourin Cancer. 2021 Dec;19(6):547-553. doi: 10.1016/j.clgc.2021.07.006. Epub 2021 Jul 10.
Despite concerns of atypical recurrence following robotic-assisted radical cystectomy (RARC), utilization of the modality is increasing. The presumed mechanisms of peritoneal immunomodulation and pneumoperitoneum-induced tumor cell intravasation are especially relevant for higher stage, locally advanced disease, where intrinsic metastatic potential of tumor cells may be greater. This study aims to compare the oncologic outcomes and survival after RARC compared to open radical cystectomy (ORC) among patients with stage pT3-4 or node-positive muscle-invasive bladder cancer.
Retrospective cohort analysis of pT3-4N0-3 and pT(any)N1-3 patients who underwent RARC or ORC was performed using the National Cancer Database (2010-2016) to investigate perioperative and oncologic outcomes.
9,062 ORC cases and 2,544 RARC cases met inclusion criteria. The robotic approach was significantly associated with superior unadjusted survival compared to open as well as lower proportions of unadjusted 30- and 90-day mortality, lower positive margin status, and shorter surgical inpatient stay (all respective P<.05). However, after adjusting for confounding covariates, multivariable analysis revealed no difference in mortality hazard or odds of any of the above secondary outcomes with the exception of shorter inpatient stay and higher lymph node yield. Patients treated with RARC were more likely to have neoadjuvant chemotherapy.
RARC is no less safe than ORC for patients with locally advanced bladder cancer on the basis of overall, 30- and 90-day survival. Unadjusted mortality and surgical outcomes demonstrate advantages to RARC, which are attenuated after multivariate analysis. Perioperative benefits may favor the robotic approach, consistent with previous randomized control studies.
尽管机器人辅助根治性膀胱切除术（RARC）后存在非典型复发的担忧，但该术式的应用正在增加。腹膜免疫调节和人工气腹引起肿瘤细胞浸润的假定机制对于更高分期、局部进展期疾病尤其相关，因为肿瘤细胞的内在转移潜能可能更大。本研究旨在比较 RARC 与开放性根治性膀胱切除术（ORC）治疗 pT3-4 或淋巴结阳性肌层浸润性膀胱癌患者的肿瘤学结果和生存情况。
使用国家癌症数据库（2010-2016 年）对接受 RARC 或 ORC 的 pT3-4N0-3 和 pT（任何）N1-3 患者进行回顾性队列分析，以调查围手术期和肿瘤学结果。
纳入 9062 例 ORC 病例和 2544 例 RARC 病例。与开放手术相比，机器人手术在未调整的生存方面明显具有优势，未调整的 30 天和 90 天死亡率、阳性切缘状态以及手术住院时间更短（所有 P 值均<.05）。然而，在调整混杂协变量后，多变量分析显示，死亡率风险或上述任何次要结局的可能性没有差异，除了住院时间更短和淋巴结检出量更高。接受 RARC 治疗的患者更有可能接受新辅助化疗。
在基于总体、30 天和 90 天生存率的基础上，RARC 对局部进展性膀胱癌患者的安全性不亚于 ORC。未调整的死亡率和手术结果显示 RARC 具有优势，在多变量分析后这些优势减弱。围手术期获益可能有利于机器人手术，与之前的随机对照研究一致。
