A recent clinical trial revealed faster recovery times for patients when bladder cancer removal and reconstruction was done with robot-assisted surgery

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When robot-assisted surgery is used for bladder cancer removal and reconstruction, patients recover far more quickly and spend significantly less time in hospital.

In a first-of-its kind clinical trial, published in JAMA, scientists have suggested that their new findings provide the ‘strongest evidence so far’ of the patient benefit of robot-assisted surgery.

Co-chief investigator, Professor John Kelly, Consultant Surgeon at University College London (UCL) Hospitals and Professor of Uro-oncology at UCL’s division of Surgery and Interventional Science, explained that, despite robot-assisted surgery becoming more widely available, there had been ‘no significant clinical evaluation of its overall benefit to patients’ recovery’.

For the new study, led by scientists at UCL and the University of Sheffield, researchers set out to compare recovery and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction versus open radical cystectomy. In the trial, which involved 29 surgeons at nine UK hospital trusts, 338 patients with non-metastatic bladder cancer—recruited from March 2017 to March 2020—were randomised to receive robot-assisted surgery (169) or open surgery (169). Follow-up was conducted at 90 days, 6 months, and 12 months, with final follow-up on 23 September 2021.

The primary outcome was the number of days alive and out of the hospital within 90 days of surgery. In addition, there were 20 secondary outcomes, including complications, quality of life, disability, stamina, activity levels, and survival.

Unexpected and striking finding

On average, the robot-assisted group stayed 8 days in hospital, compared with 10 days for the open surgery group—a 20% reduction. Re-admission to hospital within 90 days of surgery was also significantly reduced, 21% for the robot-assisted group versus 32% for open surgery.

All secondary outcomes were improved by robot-assisted surgery or, if not improved, almost equal to open surgery, the authors said.

The researchers also found that patients undergoing robot-assisted surgery were less likely to experience thromboembolic complications compared with patients who had open surgery (1.9% versus 8.3%), and also less likely to experience wound-related complications (5.6% versus 16.0%).

Professor Kelly highlighted that the ‘unexpected’ and ‘striking’ finding of a reduction in thromboembolic complications indicated a ‘safe surgery with patients benefiting from far fewer complications, early mobilisation, and a quicker return to normal life’.

Patients’ physical activity (assessed by daily steps tracked on a wearable smart sensor), stamina, and quality of life also increased.

Hope for robotic surgery to be offered more widely

About 10,000 people are diagnosed with bladder cancer in the UK every year and over 3000 bladder removals and reconstructions are performed. It is one of the most expensive cancers to manage, said the authors.

Co-Chief Investigator Professor James Catto, Professor of Urological Surgery at the Department of Oncology and Metabolism, University of Sheffield, said: ‘Time in hospital is reduced and recovery is faster when using this advanced surgery.

‘Ultimately, this will reduce bed pressures on the NHS and allow patients to return home more quickly. We see fewer complications from the improved mobility and less time spent in bed.’

Open surgery remains NICE’s ‘gold standard’ recommendation for highly complex surgeries, though the research team hope this could change.  

Professor Kelly added: ‘In light of the positive findings, the perception of open surgery as the gold standard for major surgeries is now being challenged for the first time.’

The researchers said that the findings provide the strongest evidence so far of the patient benefit of robot-assisted surgery. They are now urging NICE to make it available as a clinical option across the UK for all major abdominal surgeries including colorectal, gastrointestinal, and gynaecological.

Professor Catto highlighted that the study also points to future trends in healthcare. He explained: ‘Soon, we may be able to monitor recovery after discharge, to find those developing problems. It is possible that tracking walking levels would highlight those who need a district nurse visit or perhaps a checkup sooner in the hospital.’

Professor Kelly concluded: ‘In this study we wanted to establish if robot-assisted surgery, when compared with open surgery, reduced time spent in hospital, reduced re-admissions, and led to better levels of fitness and a quality of life—on all counts this was shown.’

He expressed his hope that in the future all eligible patients needing major abdominal operations would be offered the option of having robotic surgery.

This article was originally publised on Medscape, part of the Medscape Professional Network.

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