DR GOMELLA: Unfortunately, when you look at national statistics it’s really very low, depending on which paper you look at. Only 10% to 20% of patients nationally are offered a neoadjuvant strategy. We consider that really to be our standard of care and approach with patients who have muscle-invasive disease.

However, to be fair, for the older patient, being a referral center, we tend to get a lot of very, very senior patients who come in the door, often above the age of 80, with a little bit of baseline renal insufficiency. So we’ll sometimes say, “Look. Maybe, Mr Jones, it’s better to just go right to the surgery. Let’s see what things look like afterward.”

DR LOVE: So anything new in terms of cystectomy, robotic cystectomy, partial cystectomy?

DR GOMELLA: Organ preservation is out there. The issue with organ preservation, there are protocols out there. If you’re going to do organ preservation in an older person, it’s very important to understand the success of organ preservation in muscle-invasive bladder cancer using chemotherapy and radiation is an intermediate-point TUR. If that intermediate-point TUR has persistent muscle-invasive, high-grade bladder cancer, you need to do a cystectomy.

And this is where you kind of get into a little bit of a rub with patients, because a lot of these patients are either felt to be intolerant, don’t want a radical cystectomy, they’re too old or they’re too ill. So bladder preservation, we talk a lot about it, but it’s really not executed as much as you might otherwise believe.

Concerning the issue of robotic versus standard radical prostatectomy, I will say that that is really highly controversial right now. I think we generally accept it in urologic oncology in the management of prostate cancer that robotic prostatectomy is probably reasonable for the majority of patients who can’t tolerate a pneumoperitoneum and tolerate the positioning and have not had extensive lower abdominal surgery. It’s probably reasonable.

All of the data that we really have right now with robotic versus standard radical cystectomy is that it’s equivalent. There’s really no apparent additional advantage when it comes to recovery, postop complications, length of stay in the hospital with the robot versus the standard. So that’s still an evolving concept. I could say that the studies internationally have really not shown a clear advantage. At best, they’ve shown equivalence.

DR LOVE: Is that your clinical impression also?

DR GOMELLA: Oh, my clinical impression, absolutely. I am not a robotic surgeon. I am trained in robotic surgery, but my department, I brought in fellowship-trained robotic surgeons. And I can say that watching the recovery of the robotic cystectomies that are done compared to a standard cystectomy, it doesn’t impress you. It really does not impress you.

DR LOVE: And do we know to what extent robotic surgery is being used, say, in the United States?

DR GOMELLA: Certainly for robotic radical prostatectomy, it’s kind of become the de facto norm, probably at least 80% to 85% of radical prostatectomies are done robotically today. Kidney’s coming on fairly strong as people get more experience with vascular control and understanding how you can do a partial nephrectomy. There’s absolutely no role for a radical nephrectomy, to use a robot. The cost, the inconvenience is not worth it. A regular laparoscopic nephrectomy is just fine. But the robot, the advantage of it is reconstruction, is potentially partial nephrectomy. You can do suturing of the collecting system. You can selectively perform arterial control, venous control.

So for renal partial nephrectomy, the robot is coming on. But for radical cystectomy right now, again, a lot of controversy, and it does not appear that there’s a lot of benefit at this point. So fewer and fewer places are doing robotic cystectomy as a standard of care.

Bladder cancer

Prostate cancer

Renal cell carcinoma

Checkpoint inhibitors