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The Impact of Previous Prostate Surgery on Surgical Outcomes for Patients Treated with Robot-assisted Radical Cystectomy for Bladder Cancer

  • Giuseppe Rosiello,
  • Pietro Piazza,
  • Victor Tames,
  • Rui Farinha,
  • Artur Paludo,
  • Stefano Puliatti,
  • Marco Amato,
  • Elio Mazzone,
  • Ruben De Groote,
  • Camille Berquin,
  • Riccardo Schiavina,
  • Geert De Naeyer,
  • Peter Schatteman,
  • Paul Carpentier,
  • Francesco Montorsi,
  • Frederiek D’Hondt,
  • Alexandre Mottrie,
  • Dries Develtere,
  • Ralf Veys,
  • Celine Sinatti

Background 

The feasibility and safety of robot-assisted radical cystectomy (RARC) may be undermined by unfavorable preoperative surgical characteristics such as previous prostate surgery (PPS).

Objective 

To compare perioperative outcomes for patients undergoing RARC with versus without a history of PPS.

Design, setting, and participants

The study included 220 consecutive patients treated with RARC and pelvic lymph node dissection for bladder cancer at a single European tertiary centre. Of these, 43 had previously undergone PPS, defined as transurethral resection of the prostate/holmium laser enucleation of the prostate (n=21) or robot-assisted radical prostatectomy (n=22).

Surgical procedure

RARC in patients with a history of PPS.

Measurements 

Data on postoperative complications were collected according to the quality criteria for accurate and comprehensive reporting of surgical outcomes recommended by the European Association of Urology guidelines. Multivariable logistic, linear, and Poisson regression analyses were performed to test the effect of PPS on surgical outcomes.

Results and limitations 

Overall, 43 patients (20%) were treated with RARC after PPS. Operative time (OT) was longer in the PPS group (360 vs 330min; p<0.001). Patients with PPS experienced higher rates of intraoperative complications (19% vs 6.8%) and higher rates of 30-d (67% vs 39%), and Clavien-Dindo >3 (33% vs 16%) postoperative complications (all p<0.05). Moreover, the positive surgical margin (PSM) rate after RARC was higher in the PPS group (14% vs 4%; p=0.03). On multivariable analyses, PPS at RARC independently predicted higher risk of intraoperative (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.04-6.21; p=0.01) and 30-d complications (OR 2.26, 95% CI 1.05-5.22; p=0.02), as well as longer OT (relative risk [RR] 1.03, 95% CI 1.00-1.05; p=0.02) and length of stay (RR 1.13, 95% CI 1.02-1.26; p=0.02). Lack of randomization represents the main limitation.

Conclusions

RARC in patients with a history of PPS is feasible, but it is associated with a higher risk of complications and longer OT and length of stay. Moreover, higher PSM rates have been reported for these patients. Thus, measures aimed at improving surgical outcomes appear to be warranted.

Commentary by Dr. Marco Moschini

In this retrospective single-centre study, the authors evaluated 220 bladder cancer patients treated with robotic-assisted radical cystectomy (RARC) and bilateral pelvic lymph node dissection. Of these 220 patients, 43 had had a previous prostate surgery defined as a transurethral resection of the prostate/holmium laser enucleation of the prostate (n=21) or a robot-assisted radical prostatectomy (n=22). All the data regarding preoperative and postoperative complications were collected according to the quality criteria for accurate and comprehensive reporting of surgical outcomes recommended by the European Association of Urology (EAU) Guidelines.

Patients treated with previous prostate surgery were found to need longer operative time (360 vs 330 minutes, p<0.001) compared to those who did not receive any prior prostatic surgery. Similar outcomes were found considering intraoperative (19% vs. 6.8%) and Clavien Dindo >3 postoperative (33% vs 16%) complications and 30-day readmissions (67% vs. 39%). Patients treated with previous prostate surgery even faced a greater risk of having positive surgical margins (14% vs. 4%, p=0.03).

The authors conclude that robotic-assisted radical cystectomy is feasible but associated with an increased risk of perioperative complications and having positive surgical margins.

Expert summary

RARC in patients treated with previous prostate surgery is associated with higher rates of perioperative complications and positive surgical margins compared to patients not previously surgically treated in the prostate. However, no data exist about whether these differences between the two groups translate into survival disparities. These data do confirm that RARC is challenging and require a skilled surgeon.