Introduction:

Utilizing advances in multimodal treatment paradigms and minimally invasive surgical techniques, we investigated the role of robotic-assisted partial cystectomy (RAPC) as an alternative to radical cystectomy in a select cohort of patients with muscle-invasive bladder cancer (MIBC). Along with standard-of-care neoadjuvant platinum-based chemotherapy, we sought to assess whether RAPC provides similar oncologic efficacy as radical cystectomy with reduced rates of associated morbidity.

Methods:

A retrospective review was conducted of all patients with MIBC of primarily urothelial origin who underwent platinum-based neoadjuvant chemotherapy (NAC) and RAPC at our institution between 2018-2023. Patients with MIBC and unifocal tumors at the anterior, anterolateral bladder, or bladder dome were considered for RAPC. Biopsy and restaging was performed with transurethral resection of bladder tumor (TURBT). Immediately prior to RAPC, intravesical chemotherapy was administered. A robotic transperitoneal approach was used with concurrent cystoscopy to guide bladder resection. Bilateral pelvic lymph node dissection was performed. Pathology data was collected after each surgical episode. Primary endpoint was 30-day complications. Secondary endpoints included intravesical recurrences, disease progression to metastasis, systemic chemotherapy/immunotherapy, and/or death.

Results:

Seventeen patients met inclusion criteria. Median operative time was 289 minutes (IQR 229-312) and EBL was 100 mL (IQR 75-150). No patients experienced intraoperative complications, 11/17 (65%) were discharged on postoperative day 1. There was one 30-day complication: pelvic abscess requiring percutaneous drain placement and IV antibiotics.

Eight patients were ypT0 (47%) after RAPC. Of the seven patients who had no malignancy on post-NAC TURBT, 6/7 (86%) were ypT0 and one was ypTIS. Seven patients (41%) had MIBC on final pathology. No patients had positive margins.

Median follow-up was 6.8 months (IQR 3.7-20.3) with 7 patients having follow-up >12 months. Three (19%) had intravesical recurrences: CIS (x2) and MIBC with CIS (x1). Time to recurrence ranged 7.2-12.5 months. No patients required salvage cystectomy. One patient developed metastatic progression; he was ypT0 after RAPC. Two patients died; neither had evidence of disease at times of death. 

Conclusion:

While the gold standard treatment for MIBC remains platinum-based chemotherapy followed by radical cystectomy, there is significant morbidity associated with this surgical intervention. In a selected patient population, RAPC may serve as a less toxic surgical alternative. In this study population, RAPC is shown to be a safe procedure with minimal long-term morbidity. In the short term, response to NAC predicted pathologic complete response after RAPC. Durability of response is an ongoing focus of this study, but only one patient developed new metastatic disease and no patients required salvage cystectomy. Our study represents an initial effort to assess this treatment paradigm and serves as a foundation for further efforts to evaluate its role in management of MIBC.

Funding: N/A