Widespread Adoption of Laparoscopic Cystectomy May Increase Death Rate

Newswise — Widespread use of laparoscopic cystectomy -- a minimally invasive alternative to traditional bladder-removal surgery for patients with aggressive bladder cancer -- could increase the death rate from bladder cancer, a leading urologic oncologist warned yesterday at the annual meeting of the World Congress on Endourology.

"Laparoscopic cystectomy will not add a single day to the life of a patient with bladder cancer, but if the technique becomes widely used in the next five years, it is likely to increase the mortality from the disease," said Ralph deVere White, professor and chair of urology at the UC Davis School of Medicine and Medical Center and director of the UC Davis Cancer Center. DeVere White made the argument during a debate held as part of the scientific program at the congress.

In a laparoscopic cystectomy, a surgeon makes small "keyhole" incisions in the abdomen. The bladder is removed via an endoscope, a camera-tipped hollow tube through which miniature instruments can be introduced into the body. The laparoscopic procedure is more difficult to perform than a traditional cystectomy, in which the bladder, lymph nodes and surrounding cancerous tissue are removed through a long abdominal incision. In the traditional surgery, the surgeon uses full-sized surgical instruments and sees the surgical field directly, rather than on a video monitor.

Although the first laparoscopic cystectomy was performed in 1992, very few surgeons adopted the technique during the rest of that decade. Over the past three years, however, more and more urologists have reported performing laparoscopic cystectomy.

In arguing against widespread use of the minimally invasive procedure, deVere White cited recent research suggesting that even traditional cystectomy appears to be too demanding for many surgeons. A study presented at a recent meeting of the American Society of Clinical Oncology and reported in Urology Times in August evaluated 268 cystectomies performed by 106 surgeons at 109 institutions between 1987 and 1998. In up to 62 percent of the cases, the surgeons removed fewer than 10 lymph nodes, increasing the risk for recurrence. The study was conducted by Harry W. Herr, a bladder cancer specialist at Memorial Sloan-Kettering Cancer Center in New York.

Patients face more than a five-fold increased risk that their cancer will recur, despite cystectomy, if fewer than 10 lymph nodes are removed. When the cancer does recur, the survival rate is grim -- less than 10 percent of these patients live five years. The surgeons in the study who did the fewest procedures had the worst track record. But even the highest-volume surgeons removed too few lymph nodes in a third of their cases.

"Based on how well even traditional cystectomy, an operation that has been taught for 50 years, is being performed, and based on the skill required to perform laparoscopic cystectomy, widespread adoption of the laparoscopic technique would be unwise," deVere White said.

Some laparoscopic procedures involve shorter operative times and allow a quicker recovery than traditional "open" surgeries, with equivalent outcomes. But a study published last year found that laparoscopic cystectomy, because of its difficulty, involves seven hours in the operating room and a seven-day hospital stay -- no advantage over traditional cystectomy.

The American Cancer Society estimates that 57,400 new cases of bladder cancer will be diagnosed in the United States this year, and 12,500 people will die of the disease.

DeVere White serves on the board of the Society of Urological Oncology and is the immediate past chairman of the U.S. Department of Defense Integrated Panel for Prostate Cancer Research, an advisory body that helps to administer $85 million in federal grants for prostate cancer research.