Robot bladder surgery fails to deliver fewer complications

NEW YORK Wed Jul 23, 2014 5:16pm EDT

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NEW YORK (Reuters Health) - Using robotic techniques to remove a cancerous bladder doesn't reduce the risk of complications compared with conventional "open" surgery, according to a new comparison of 118 patients conducted by surgeons at the Memorial Sloan Kettering Cancer Center in New York.

The study, detailed in the New England Journal of Medicine, marks the first ongoing comparison of the risks and benefits of the two techniques. Past studies concluded that the robotic technique meant less time in the hospital and fewer complications but they were done by looking back at the records of already-treated patients.

"There's been a lot of hype surrounding robots and it's been hard to gain perspective," said Dr. Vincent Laudone, one of the coauthors.

Dr. Jennifer Yates, director of minimally invasive urology at the University of Massachusetts Medical School, who was not involved in the test, told Reuters Health that the findings will give surgeons pause because they're going to be surprised by the results.

Robots have shown to be so valuable for prostate removal, many surgeons were convinced that a similar benefit would appear when they were used for bladder removal, she said. "They're going to say, 'Hey, I'm kinda surprised by this.' They're also going to be encouraged that the complication rate was comparable."

"Bottom line: It looks like it was pretty much a wash," Laudone told Reuters Health. For patients, it means "if you're going to a surgeon who is experienced in traditional surgery and recommends traditional surgery, that's a reasonable recommendation."

He estimated that perhaps 25 percent of bladder cancer removals, known as radical cystectomies, are currently done with robots.

The study also found that patients who underwent conventional surgery spent about 28 percent less time in the operating room. They experienced more blood loss - about 5 ounces more - but "with that amount, we wouldn't expect to see any significant side effect," Laudone said.

"These results highlight the need for randomized trials to inform the benefits and risks of new surgical technologies before widespread implementation," he and his colleagues concluded.

About 67,000 bladder tumors are discovered in the U.S. each year and one quarter of them require bladder removal.

The new study involved patients who needed both the bladder and nearby lymph nodes extracted. The men also lost their prostate and the women lost their ovaries, fallopian tubes, uterus and related organs. Even when a $2 million robot was used, conventional surgery was employed to redirect urine to the intestine.

With robot-assisted surgery, 22 percent of the 60 patients had at least one serious complication within the first 90 days. A complication was regarded as serious if it required further surgery, intubation or major rehabilitation. The rate was essentially the same - 21 percent - with traditional surgery.

When the researchers included lesser complications, such as those requiring intravenous medicine or blood transfusion, the risk was 62 percent with robot-assisted surgery versus 66 percent with open surgery.

The average length of hospital stay was eight days for both groups.

But the patients in the robot group spent two hours longer in the operating room. The average time was 5 hours 29 minutes with conventional surgery and 7 hours 36 minutes with robotic assistance.

Both Laudone and Yates said that time difference is expected to shrink as doctors become more adept at working with robots.

"It's an evolving technology and we're evolving in our learning to use the robot," Laudone said. "We're getting better as robotic surgeons, so operating time is diminishing. With prostate surgery, the same thing was true. Now, in some cases, doing it with the robot is faster. So the time difference is something I think will disappear with more experience."

Yates cautioned that "this was a small study and I think it needs to be fleshed out with larger numbers. And you have to remember that Sloan Kettering is one of the more prominent high-volume institutions in the country. Whether this is generalizable to other institutions remains to be seen."

SOURCE: bit.ly/1wN4FCQ New England Journal of Medicine, online July 23, 2014.

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