The report is a product of the VA/HSR Evidence Synthesis Program.

Robotic-Assisted Surgery in Partial Nephrectomy and Cystectomy: Systematic Review

The robotic surgical platform was introduced in 1999. By the end of 2017, more than 750,000 robotic procedures were being performed in the United States annually, including over 125,000 urologic robotic procedures. Due to recent evidence questioning the utility of the robotic platform, the use of it in urologic surgery must be revisited, especially in regard to long-term clinical and oncologic outcomes. While the robotic approach has become the standard approach to prostatectomy, there are other urologic procedures (i.e., partial nephrectomy and cystectomy) in which the robotic approach is being introduced. In addition, the robotic platform requires a significant economic investment. If the robotic platform can reduce length of stay, complications, readmissions, or improve oncologic outcomes, then costs may be more than recuperated, but this needs to be determined.

To help clinicians, patients, and policymakers decide between robotic and other surgical approaches in patients undergoing partial nephrectomy and cystectomy, VA’s Evidence Synthesis Program (ESP) in West Los Angeles, CA reviewed the literature in PubMed from 1/1/2010 through 6/29/2019 and Cochrane (all databases) from 1/1/2010 through 6/29/2019. Investigators identified 556 articles for abstract screening. From these, 42 publications met inclusion criteria including: 4 cost-effectiveness analyses, 4 cost-only studies, 7 nephrectomy observational studies, and 16 articles describing 5 cystectomy randomized controlled trials (RCTs), and 11 cystectomy observational studies.

Summary of Findings

Robotic-assisted surgery for partial nephrectomy and cystectomy have a few documented short-term benefits over open or laparoscopic approaches, but the cost effectiveness is unknown, and long-term functional and oncologic outcomes are inadequately studied. Findings and certainty of the evidence include:

• Robot-assisted surgery probably results in less blood loss than open or laparoscopic approaches, for both partial nephrectomy and cystectomy procedures. Most other differences in outcomes probably may be small or non-existent (i.e., complications, lymph node sampling [for cystectomy], warm ischemia time [for partial nephrectomy], etc.); however, the certainty of evidence is low or very low.
• There is a signal that length-of-stay may be shorter and major complications may be fewer for robot-assisted cases of partial nephrectomy, but again the certainty of evidence is low.
• Operating room time in cystectomy was judged to have moderate certainty that robot-assisted procedures take more time.
• On the crucial issues of long-term functional or oncologic outcomes, data are too sparse and imprecise to reach any conclusions. Likewise, cost effectiveness has not been estimated with high certainty of evidence.

Limitations

The data comparing robot-assisted partial nephrectomy and cystectomy to other approaches have underlying methodologic limitations and long-term studies are sparse. Also, no studies were specific to VA populations. However, the benefits for robotic approach may still be realized despite patient-level differences (VA patient population has greater burden of comorbidities than the general population), which will need to be confirmed in future studies.

Future Research

Two research gaps are apparent. The first is randomized data for patients undergoing partial nephrectomy, in terms of short-term outcomes. The second is high-quality evidence with adequate long-term follow-up to assess cancer outcomes between the operative approaches for either partial nephrectomy or cystectomy. Only 40 patients have been enrolled in RCTs with five-year follow-up for either of these procedures. Acceptable cancer and functional outcomes need to be confirmed. Specifically, studies should assess ongoing kidney function for partial nephrectomy patients and the functional quality of life outcomes for bladder cancer patients.

Implications for VHA Policy/Practice

The findings of this ESP report suggest that robotic surgery for partial nephrectomy and cystectomy procedures is likely to be at least equivalent to open or laparoscopic approaches for most short-term outcomes. Robot-assisted cases of partial nephrectomy may have a shorter post-operative in-hospital length-of-stay and fewer major complications, but certainty of evidence is low. Blood loss for both procedures may be lower with robot-assistance. There are inadequate data to define comparative long-term functional or oncologic outcomes, or to assess cost-effectiveness.

Per VA’s National Surgery Office (10NC2), robotic assistance for partial nephrectomy and cystectomy is an appropriate consideration for VA urologists with access to robotic surgery and technical expertise. Projected volumes of these procedures may be included in business plans to support the addition of robotic surgery at VA surgery programs. Patients are ideally monitored long-term so that oncologic outcomes may be assessed.

Maggard-Gibbons M, Childers CP, Girgis M, Lamaina M, Tang A, Ruan Q, Mak SS. Begashaw M, Booth MS, and Shekelle PG. Robotic-Assisted Surgery in Partial Nephrectomy and Cystectomy. Los Angeles: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226; 2019. 

To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/robot-asst-surg.cfm
(Intranet only, copy and paste the URL into your browser if you have intranet access).

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

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This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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