Retrospective review of open versus laparoscopic radical cystectomy for the treatment of bladder cancer: complications and oncological outcome

Includes bibliographical referencesObjective: Radical cystectomy with extended lymphadenectomy and urinary diversion remains the standard of care for muscle-invasive urothelial carcinoma. Our centre (Groote Schuur Hospital) has been performing laparoscopic radical cystectomies since 2009. We aimed to audit our data regarding complications and oncological outcome and compare it to data obtained from patients undergoing open radical cystectomy by the same surgeon since 2007. The two procedures will be compared in terms of operative duration, intra-operative blood loss, peri-operative blood transfusion requirements, post-operative complications (using the Clavien Classification) and differences in pre- vs. post-operative staging. Patients and Methods: All adult patients (>18 years) that underwent open and laparoscopic radical cystectomy from 2007 to 2013 have been included in the study. Data on demographics, operative time, intra-operative blood loss, post-operative complications (as per Clavien-Dindo Classification), margin positivity, and lymph nodes (number obtained and number of positive nodes) was obtained retrospectively by means of folder review. Extracted data was collected on a Microsoft Excel spreadsheet. Only folders with complete data sets were included f or statistical analysis. Patients undergoing laparoscopic radical cystectomy converted to open were analysed on an intention-to-treat basis. Data was analysed using bivariate statistics and survival analysis was performed to compare mortality rate. Results: Physician's choice of surgical modality was associated with clinical disease staging with 59% of participants who underwent ORC presented with a palpable mass on examination under anaesthesia (EUA) compared to 36% of participants in the LRC arm. This association was confirmed on pathological staging. Participants undergoing ORC experienced shorter operative duration (301 minutes versus 382 minutes; p-value < 0.0001), increased blood loss (1376ml versus 778 ml; p-value = 0.00 2 3) and transfusion requirement (2 units versus 0; p-value = 0.071) in contrast to LRC. Post-operative complications were more prevalent in the ORC arm compared to the LRC arm (61% versus 43%) and this trend was reflected in the Clavien classification. The only complication that differed in its occurrence between the two arms was wound complications (18% for LRC versus 44% for ORC) with the main type being sepsis. Patients with a past medical history were at higher risk of experiencing post-operative complications (p-value = 0.04; Risk Ratio: 1.6). Margin positivity was comparable between the two arms. A trend was observed when comparing the number of lymph nodes sampled using the two techniques and this trend was maintained irrespective of the area sampled, whereby a higher number of nodes was sampled by the laparoscopic technique in this study (overall p-value = 0.07 ). Conclusion: Laparoscopic radical cystectomy is associated with longer operative times, decreased blood loss, and equivalent oncological outcomes when compared to open radical cystectomy. Laparoscopic RC is a feasible option in our setting. LRC affords patients a lower risk of requiring transfusion, with minimal risk of post-operative ileus and a lower risk of wound complications. Given the increasing number of laparoscopic procedures being performed at GSH, a prospective trial would be possible in order to confirm these findings