Improving Outcomes and Expanding Options for Patients With Bladder Cancer

For patients with muscle invasive bladder cancer, neoadjuvant chemotherapy followed by radical cystectomy remains the mainstay for treatment. Radical cystectomy involves removal of the bladder, adjacent pelvic organs and pelvic lymph nodes; it is followed by urinary tract diversion.

Robotic radical cystectomy has steadily gained popularity as a minimally-invasive alternative to open radical cystectomy. Currently, most urinary diversions after robotic cystectomy are performed using an open (extracorporeal) approach, with an incision made to exteriorize the bowel.

Multicenter studies comparing open radical cystectomy with robotic radical cystectomy and extracorporeal urinary diversion found a benefit for robotic radical cystectomy with respect to blood loss. However, the data were mixed with respect to length of hospital stay—and no differences were observed in complication rates.

Cleveland Clinic surgeons have increasingly standardized the use of intracorporeal urinary diversion. After robotic radical cystectomy, the urinary diversion is performed entirely using the surgical robot, without any additional incision to exteriorize the bowel. While more technically challenging, the team adopted this approach as a way to make robotic radical cystectomy even less invasive for this frail patient population.

Assessing outcomes among surgical approaches

In 2020, a team led by Byron Lee, MD, PhD, published a study that examined perioperative outcomes for open radical cystectomy, robotic radical cystectomy with extracorporeal urinary diversion, and robotic radical cystectomy with intracorporeal urinary diversion at Cleveland Clinic. The study found that robotic radical cystectomy with intracorporeal urinary diversion outperformed the other approaches when it came to blood loss, length of stay and complication rates.

“These findings underscore the perioperative benefits of this technique, which we have understood anecdotally for years,” says Dr. Lee, “but there were still questions regarding oncologic outcomes since robotic cystectomy is a relatively newer surgical approach, and muscle invasive bladder cancer can exhibit very different biological behavior compared with other urologic cancers that we routinely manage robotically.”

Dr. Lee and his team once again examined the experience at Cleveland Clinic to evaluate found of radical cystectomy as they relate to surgical approach. They found no differences in rates or patterns of cancer recurrence.

“These studies demonstrate that robotic cystectomy with intracorporeal urinary diversion is just as effective at cancer control as the other approaches but has significant perioperative benefit for the patient. Moving forward, we will continue to improve surgical quality and perioperative and postoperative management so that our bladder cancer patients requiring radical cystectomy will receive the best care possible,” says Dr. Lee.

Bladder preservation options for patients with muscle-invasive bladder cancer

Recognizing that bladder preservation may play an increasing role in the management of muscle-invasive bladder cancer, Nima Almassi, MD, is leading research to improve patient selection for this approach. One such option is partial cystectomy, a surgical treatment in which only the portion of the bladder that contains cancer is removed, often in conjunction with chemotherapy.

“Right now, only a very select group of patients qualify for this procedure, but we are actively investigating clinical characteristics and outcomes that may allow us to broaden the selection pool and offer a less-invasive approach to more patients.”

Cleveland Clinic is participating in a multicenter clinical trial examining the safety of bladder-sparing in select patients with muscle-invasive bladder cancer who have a complete response to chemotherapy.

Studies have shown that patients with specific genetic changes in their bladder cancer respond very well to chemotherapy, with many patients having no residual cancer identified after completing chemotherapy. In this trial, patients who have one of these specific genetic changes and a full response to chemotherapy are managed with surveillance, rather than undergoing cystectomy.

“Our goal is to provide as many novel options as possible in service of our patients,” concludes Dr. Almassi.