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Bladder Cancer
Table 1: Current Laparoscopic Radical Cystectomy Series (selection) versus
Contemporary Open Radical Cystectomy Series (selection)
Patients Follow-up ≤pT2 >pT2 G3 LN+ LN Removed Margin+ Loco-regional Metastases
(n) (months) (%) (%) (%) (%) (n) (%) (%) (%)
Haber
6
2008 572 NA NA NA NA 16 13 2 5 8
Rassweiler
12
2006 (308) 18 58 42 – 17 – – 10 7
Haber, Gill
13
2007 37 31 62 38 78 18 14 5 0 5
Gerullis
14
2007 34 12 66.7 33 NA 7.4 14 7.4 NA 6
Porpiglia
3
2009 43 28 61 39 NA 27.5 19.1 0 1 6
Deger
15
2004 20 33 75 25 NA 15 10 0 0 15
Hemal
2
2007 30 38 50 50 76 6.7 12 3.3 0 10
Open RCX
9,10,11
>6062389122– 18 27
Hrouda
16
2004 102 NA NA NA – 6 NA 0 – –
(feasibility)
LN = lymph node; RCX = radical cystectomy.
LRC with extracorporeally constructed urinary diversion is a safe We and others have developed an international BC nomogram
and effective operation for appropriate patients with BC. Peri- predicting recurrence risk after RCX for BC. The nomogram
operative and functional outcomes are comparable to those outperformed prognostic models that use standard pathological
achieved with open surgery. subgroupings and should improve our ability to provide accurate
risk assessments to patients after the surgical management of BC.
More focus on extended lymphadenectomy is necessary to routinely
achieve higher node yields. Surrogate and intermediate oncological Three major contributors
9–11
with a total of ≥2,000 cystectomies
outcomes are encouraging, and long-term assessment is ongoing.
7
were selected to serve as the control cohort for the comparison of
LRC versus open RCX. The most appropriate is the Ulm series due
Short- and intermediate-term oncological outcomes are claimed to be to its size and because it is a surgery-only series, which makes it
comparable to those achieved with open RCX by laparoscopic particularly appropriate for comparison with LRC.
surgeons. Worldwide experience continues to increase: approximately
1,000 LRC surgeries have already been performed.
6
The data from these three RCX series showed a stage distribution of
organ- versus non-organ-confined tumours of 62 versus 38%. The
Open Radical Cystectomy – average rate of high-grade tumours was 91%. Overall, lymph-node
The Benchmark of Cystectomy Outcome positivity was seen in 22%. The margin-positive rate of these three series
RCX and pelvic lymphadenectomy remains the standard treatment was 1%, the local recurrence rate 8% and the overall distant failure rate
for localised and regionally advanced invasive BC. We and others (metastases) 27%. These figures are used in Table 1 for comparison with
have constructed an international BC database from centres of the respective LRC data from representative LRC series.
2,3,6,12–16
excellence in the management of BC consisting of patients treated
with RCX and pelvic lymph-node dissection (PLND). The goal of this Of further interest is a comparison of the LRC outcome data with
study was the development of a prognostic outcomes nomogram to outcomes of open RCX for organ-confined tumours, since the results
predict the five-year disease recurrence risk after RCX.
8
should ideally correspond with the indications for LRC, which include
predominantly organ-confined, non-bulky BC and absence of bulky
Institutional RCX databases containing detailed information on BC lymphadenopathy and locally advanced disease. The outcome for
patients were obtained from 12 centres of excellence worldwide. open RCX in ≤pT2 BC is a lymph-node-positivity rate of 11%, a margin-
Data were collected on more than 9,000 post-operative patients positivity rate of 0%, a local recurrence rate of 4% and a distant failure
and combined into a relational database formatted with patient rate of 15%.
The Use of Surrogate Markers for the
Comparison of Open versus Laparoscopic
In the future, novel bladder substitutes
Radical Cystectomy
such as tissue engineering and
Almost all authors of LRC series use survival to demonstrate the
equivalence of LRC and open RCX. The LRC series manuscripts offer
ureteral augmentation may reduce the
the opportunity to cross-check the conclusions of these authors. The
technical difficulty associated with
survival of the two cohorts, LRC versus open RCX, can only be
compared if the patient characteristics are comparable. Almost all
laparascopic reconstruction.
manuscripts include data obtained independently of the laparascopic
surgeon: tumour grade and stage, margin status and lymph-node
characteristics, pathological details of the pre- and post- status and local and distant recurrence are all provided by third
cystectomy specimens and recurrence and survival status. Patients parties, i.e. pathologists, oncologists, radiologists, etc. These surrogate
with available information for all study criteria were included in the oncological markers, such as margin status and lymph-node yields,
formation of the final prognostic nomogram designed to predict will provide interesting information, but they must be complemented
five-year progression-free probability.
8
by extended (five-year) clinical and oncological follow-up. The
36 EUROPEAN UROLOGICAL REVIEW