ESOU: Debating the best approach to radical prostatectomy and cystectomy

One of the biggest themes during the meeting of the EAU Section of Oncological Urology (ESOU) was the comparison between robot-assisted radical prostatectomy and cystectomy to open surgery. Cost-effectiveness was an important factor in the discussion.

Dr. Bernardo Rocco (Milan, IT) made a case for robot-assisted radical prostatectomy (RARP) in high-risk prostate cancer patients. He argued that RARP can prevent follow-up treatment and, with that, can be cost-effective. Stressing that it is important to take possible indirect costs into account next to direct costs, he showed that high-volume centres can reduce the costs of RARP.

Asst. Prof. Declan Murphy (Melbourne, AU) shared the experiences in Australia with RARP, as the incidence of prostate cancer in Australia and New Zealand is among the highest in the world. He noted a shift in the role of surgery in high-risk prostate cancer.

On the one hand it is becoming clearer that patients with localised disease do not benefit from prostatectomy and are recommended active surveillance or focal treatment, while on the other hand more high-risk patients are undergoing robot-assisted surgery.

Prof. Axel Heidenreich (Aachen, DE) took on the challenging task of tempering the enthusiasm for robot-assisted surgery. By pointing out that there are still no long-term data on RARP, no clear benefits to its effectiveness, no significant differences in quality of life of patients, and that it is not a cost-effective type of surgery, he argued in favour of open radical prostatectomy.In the session about radical cystectomy, Prof. Richard Gaston (Bordeaux, FR) showed that robot-assisted radical cystectomy (RARC) can be performed safely because there is a lower risk of complications and patients generally have less blood loss. He further pointed out that the expertise of the surgical team is of utmost importance in any surgery.

Prof. Maurizio Brausi (Modena, IT) defended open radical cystectomy and proposed developing new techniques to make the procedure less invasive and comparable to robot-assisted surgeries. As radical cystectomy is mainly performed on older patients, it is important to minimise complications.

He went on to point out that there still is a lack of long-term data on RARC. Operating time is longer and there are complications inherent to this type of surgery, mainly equipment malfunction. As there is no significantly superior outcome and the costs of RARC are higher, Brausi stated that open radical cystectomy remains the golden standard for muscle-invasive bladder cancer.