Standardization, Simplification Needed for Wider Adoption of Robotic Cystectomy

Amit Gupta, MD

Until the bladder cancer community has an effective alternative for patients who have progressed on Bacillus Calmette-Guérin (BCG) immunotherapy, robotic cystectomy is an optimal treatment option for patients with nonmuscle-invasive disease, according to Amit Gupta, MD.

Robotic cystectomy results in less intraoperative blood loss, a lower rate of ileus, a faster recovery time, and less of a need for pain management medication.¹ However, Gupta says that once experts have “standardized and simplified” the procedure, it will become more openly adopted.

Findings from other studies have demonstrated the efficacy of robotic cystectomy. The phase II SWOG S0353 trial examined intravesical gemcitabine for BCG failures in patients with nonmuscle-invasive bladder cancer (NMIBC). Data reflected a recurrence-free survival of 21% at 12 months.² Another trial is investigating the use of atezolizumab (Tecentriq), the PD-L1 inhibitor, in these patients (NCT02844816).³ The estimated study completion date is February 28, 2019.

OncLive^®: What advances in bladder cancer over the past year did you cover in your talk?

What is the biggest challenge in the widespread adoption of robotic resection?

Is the conversion from robotic cystectomy to open urinary diversion also a challenge?

How are immunotherapy and chemotherapy agents altering the role of surgery in bladder cancer?

What is the biggest unmet need in bladder cancer?

Where else should clinical trials focus their efforts?

In an interview during the 2018 OncLive^® State of the Science Summit™ on Genitourinary Cancers, Gupta, urologic oncologist, Department of Surgery, Cedars-Sinai Medical Center, discussed the superiority of robotic cystectomy compared with open cystectomies and its relevance in the current treatment landscape.Gupta: I spoke about the surgical aspects of bladder cancer and some of the developments in the NMIBC space. I reviewed the randomized data for robotic versus open cystectomy and also some of the upcoming data we are expecting for a trial we are conducting of extended versus limited lymph node dissection. The biggest challenge is surgical training and expertise. There is a significant learning curve, and that learning curve can only be overcome through dedicated training and mentorship. There is a steady uptake of robotic cystectomy and intracorporeal diversions, but it’s still only being done at select centers. As the surgery gets more standardized and simplified, it will be adopted more and more. Yes. Right now, most surgeons convert to open urinary diversions after doing a robotic cystectomy. That is a good way to get a program started. As the program matures, they should convert to intracorporeal diversions rather than extracorporeal diversions. Right now, immunotherapy agents are not affecting surgery. That being said, if they are proven to be viable alternatives to patients with BCG-unresponsive or BCG-refractory NMIBC, surgery would be used later in those patients rather than earlier. Right now, the treatment paradigm for the patient who has failed BCG is typically cystectomy, but cystectomy may be moved to a later line of therapy if a viable immunotherapy option arises.The biggest unmet need is finding an alternative to BCG or at least a good option for patients who have failed BCG. A lot of patients who come to need cystectomy, after failing intravesical therapy, start with NMIBC. While they are getting intravesical therapy, the disease progresses to muscle-invasive bladder cancer; that is when they require cystectomy. If we can get more effective options to either enhance BCG, replace it, or be an option after BCG, we can help our patients avoid a morbid surgery.Clinical trials should focus on all aspects of bladder cancer care, whether that is in nonmuscle-invasive disease or in patients who have muscle-invasive disease and need neoadjuvant therapies. Additionally, in all patients who may need adjuvant therapies after surgery or concurrent with chemoradiation. There are numerous trials ongoing in patients with locally advanced metastatic disease.

References

1. Smith AB, Raynor M, Amling CL, et al. Multi-institutional analysis of robotic radical cystectomy for bladder cancer: perioperative outcomes and complications in 227 patients. J Laparoendosc Adv Surg Tech A. 2012;22(1):17-21. doi: 10.1089/lap.2011.0326.
2. Skinner EC, Goldman B, Sakr WA, et al. SWOG S0353: Phase II trial of intravesical gemcitabine in patients with non-muscle invasive bladder cancer and recurrence after 2 prior courses of intravesical Bacillus Calmette-Guérin. J Urol. 2013;190(4):1200-1204. sciencedirect.com/science/article/pii/ S0022534713040779. Published October 2013. Accessed March 6, 2018.
3. Atezolizumab in Treating Patients With Recurrent BCG-Unresponsive Non-muscle Invasive Bladder Cancer. clinicaltrials.gov/ct2/show/NCT02844816. Updated March 13, 2018. Accessed March 14, 2018.