Learning From Our Patients: Complications and the Future of Radical Cystectomy for Bladder Cancer

Learning From Our Patients: Complications and the Future of Radical Cystectomy for Bladder Cancer

Video of the Month Learning From Our Patients: Complications and the Future of Radical Cystectomy for Bladder Cancer The scope of minimally invasive l...

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Video of the Month Learning From Our Patients: Complications and the Future of Radical Cystectomy for Bladder Cancer The scope of minimally invasive laparoscopic and robotic techniques for urological surgery has expanded vastly during the last decade. These techniques hold the promise of applying modern surgical technology to decrease patient morbidity and improve surgical outcomes. Application of minimally invasive techniques in urology may yield the most significant clinical impact for treatment of bladder cancer by potentially decreasing the morbidity traditionally associated with radical cystectomy. Long considered the gold standard for muscle invasive bladder cancer, radical cystectomy has significant morbidity and mortality compared to other urological operations, even when performed by experienced surgeons at tertiary medical centers. In this month’s video entitled “Early oncologic outcomes & postoperative complications following robotic radical cystectomy” (http://www.auanet.org/dev/pat/ video/video.cfm?play⫽2010/V1699.mp4&main⫽2) Wang et al describe their technique of robotic assisted laparoscopic radical cystectomy. Acceptable pathological and perioperative outcomes were demonstrated in a cohort of 85 patients. Positive margin rate was 6% (all occurring with pT3 or greater disease), overall complication rate at 30 days 40% and major complication rate at 30 days (modified Clavien grade 3 or greater) 10%. Several similar case series have shown that minimally invasive techniques can be effectively used to treat bladder cancer with good operative and pathological outcomes. However, long-term oncologic outcomes and potential perioperative advantages in minimizing morbidity have yet to be fully realized.1–3 The scope of health care costs associated with the morbidity of radical cystectomy is not well defined. The overall cost per patient is already the highest of all malignancies in the developed world.4 In this issue of The Journal Kim et al (page 2011) use the Nationwide

Inpatient Sample to characterize the incidence of hospital acquired adverse events in 10,856 patients undergoing radical cystectomy from 2001 to 2008. Adverse events including accidental puncture, decubitus ulcer, deep venous thrombosis/pulmonary embolism, MRSA infection, Clostridium difficile, surgical site infections and sepsis were associated with a higher risk of in-hospital death, prolonged length of stay and higher hospital costs. The rate of these hospital acquired “never events” was 11.3%, incurring total incremental hospital costs of $43.8 million. While such a classification scheme for complications could potentially unjustly penalize surgeons and hospitals based on overall patient and procedure related comorbidity, such data have an inherent appeal to payers and regulatory bodies. Although complications and costs are a target for increasing reimbursement scrutiny, they provide an opportunity for us to achieve improved patient care in an evidence-based manner. Beyond documenting the incidence of such adverse events associated with radical cystectomy, we should consider risk stratifying expectations of such events to help identify complications that are more preventable than others. We must also prospectively compare patient morbidity and long-term oncologic outcomes for robotic cystectomy rather than just demonstrating feasibility of this surgical approach. Ongoing randomized clinical trials of robotic versus open cystectomy will provide us with the opportunity to address these questions, advance patient care and assess the potential impact of this type of technology on future health care costs. Alan E. Thong and Mark L. Gonzalgo Department of Urology Stanford University School of Medicine Stanford, California

REFERENCES 1. Ng CK, Kauffman EC, Lee MM et al: A comparison of postoperative complications in open versus robotic cystectomy. Eur Urol 2010; 57: 274.

open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur Urol 2010; 57: 196.

2. Nix J, Smith A, Kurpad R et al: Prospective randomized controlled trial of robotic versus

3. Hayn MH, Hellenthal NJ, Hussain A et al: Defining morbidity of robot-assisted radical cystectomy

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using a standardized reporting methodology. Eur Urol 2011; 59: 213. 4. Botteman MF, Pashos CL, Redaelli A et al: The health economics of bladder cancer: a comprehensive review of the published literature. Pharmacoeconomics 2003; 21: 1315.

Vol. 187, 2018, June 2012 Printed in U.S.A. DOI:10.1016/j.juro.2012.03.032