MONTEREY, CA, USA (UroToday.com) – A State-of-the-Art lecture by Erik Castle addressed the question of whether robotic cystectomy was ready for “prime time.” Prime time was defined as an operation that is equivalent to open surgery, reasonable, reproducible, and teachable.

Is it equivalent to open cystectomy? He discussed the oncologic outcome of lymph node count, which improved with experience in his series from 11 in the first 10 cases to 21 in the last 10 cases. The operative time decreased from 477 minutes to 274 minutes. He has had no cases of peritoneal cancer seeding. Patient disease specific survival was comparable to open cystectomy in short term follow-up.

Is it reasonable? He addressed cost, and whether there is an advantage for patients. Robotic prostatectomy is more expensive than open, he pointed out. The instrument cost is $200-300 per instrument use and is limited to 10 uses per instrument. However, for cystectomy the length of hospital stay is only 5 days vs. 10 days for open cystectomy. Also, while blood loss was less, the operative time was longer. The shorter hospital stay results in overall lower costs for robotic cystectomy, he said.

Is it reasonable? Less blood loss and less bowel manipulation results in less fluid shifts and leads to quicker ambulation and dietary progression. This makes it reasonable for patient benefit due to quicker recovery.

Is it reproducible? In 2008 there are over 30 robotic cystectomy publications from institutions. This suggests that it is reproducible, he stated.

Is it teachable? He addressed training of residents, fellows and urologists in the community. Volumes are correlated with outcomes, pointing out that teaching something that some surgeons may be performing infrequently will be an obstacle. On average, community urologists perform 3 cystectomies or less per year. The urinary diversion is still done in an open fashion, so residents still get to participate in this component of the operation. Also, operative visualization is excellent for everyone in the room. The principles of robotic surgery incorporate those of open surgery and thus remain similar. It is uncertain whether community urologists will take this on, except for those who learn it in training.

He concluded that robot assisted radical cystectomy is ready for prime time.

Presented by Erik Castle, MD, at the 84th Annual Meeting of the AUA – Western Section – October 26 – 30, 2008 – Monterey, California

Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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