Treating bladder cancer: is robotic-assisted surgery the answer?

Bladder cancer is a significant cause of morbidity and mortality worldwide, but with the exception of countries where schistosomiasis is prevalent, such as Egypt, the disease most commonly affects older men in developed countries. In EU residents it is the fourth most frequent cancer among men, accounting for around 7% of total cancers and 6% of cancer deaths; in women it is the tenth most frequent cancer accounting for 2% of cancer deaths.

Surgery is involved in the management of most bladder cancers, with transurethral resection being the usual approach to facilitate diagnosis and staging, and to remove small superficial tumours, but for areas of the bladder that are not easily accessible, manipulation of the endoscope and other instruments may injure healthy tissues. For the approximately 30% of tumours that are muscle-invasive, open radical cystectomy (ORC) is the normal standard of care. This procedure is medically challenging for the patient, and because of the duration of the surgery together with the inevitable loss of blood and other fluids, it is contraindicated for many elderly patients.

The answer to these problems is robotic-assisted surgery. An innovative telerobotic system, which is under development at Vanderbilt and Colombia universities, USA, incorporates a segmented working arm of only 5.5 mm diameter for viewing as well as supporting micro-instruments. The inherent flexibility of the device should eventually allow micrometer-resolution images of the entire bladder wall and removal of all superficial tumour cells.
A recently published pilot trial in the US involving 47 randomized patients with invasive bladder cancer compared ORC with robotic-assisted laparoscopic radical cystectomy (RARC). While there was no reported difference in treatment outcomes, the latter group lost less blood and needed fewer transfusions, experienced a quicker return of bowel function and had shorter hospital stays. A larger scale trial involving several healthcare centres is now ongoing, which will also follow long-term outcomes.

Robotic-assisted surgery is expensive, though. Already in terms of average healthcare costs per patient, bladder cancer is the most expensive adult cancer in the West, mainly due to the high rate of recurrence. But telerobots could actually go a long way towards preventing recurrence and thus reducing costs, and while the actual procedure of RARC is currently more expensive than ORC, shorter hospital stays with fewer interventions should help balance the books.