Editorial Comment: Extending the Domain of Minimally Invasive Surgery: Bladder Cancer

Abstract

INEVER THOUGHT OF MYSELF as either becoming actively involved with the Endourological Society or of contributing to the Journal of Endourology. At the Annual Meeting of the Endourological Society several years ago, however, I was asked to participate in a debate on the merits of endourologic treatment of upper tract urothelial cancers. Although asked to defend open surgery and realizing that the outcome of treatment of these cancers is largely contingent on the biology of the disease, I couldn’t help but be impressed with the success that has been achieved with endourologic approaches in selected situations, given the many advances in instrumentation and growth in expertise of those who have been courageous enough to implement the new technologies. Since then, I have been witness to the tremendous growth in endourologic and laparoscopic techniques in the treatment of an ever-growing variety of urologic conditions. Although I have not performed laparoscopic procedures and have limited my endourologic expertise to the simplest of endoscopic procedures, I have not been deterred from encouraging an increasingly extensive application of such techniques, sending my residents for fellowships in minimally invasive surgery and then bringing them back as faculty members to expand this area to as many aspects of the diagnosis and treatment of urologic conditions as their imagination permits. I still was surprised when Dr. Arthur Smith asked me to write an editorial for this special issue on endourologic oncology for the Journal of Endourology. I suspect that in his own subtle way he was telling me, “Well, there you are. You’d better start to change your way of thinking, since we can accomplish the same effective treatment with endourologic and laparoscopic approaches as can be done with open surgery and minimize treatment effects on quality of life.” In many respects, I agree. However, we are not yet at the finish line in treating many of these conditions even though good technology is available. To a large extent, this is probably attributable both to our inability to predict the intrinsic biologic potential of many of these conditions and the limitations in therapeutic options that might otherwise make the application of some of these new technologies more effective. The articles I have been asked to review are illustrative of this. The articles by Pietrow and Smith1 and by Grob and Macchia2 describe transurethral approaches in treating muscle-invasive bladder cancers without resorting to the more traditional cystectomy. Using techniques incorporating either laser or extensive transurethral resection of the tumor, respectively, these authors are able to preserve the bladder and, presumably, normal voiding function. The caveat for each of these ideas is that tumors subjected to these approaches must be highly selected. Although they are muscle invasive, all cancer cells must be eradicated, as confirmed histologically on repeat TUR (a requirement even when laser is the primary treatment). Moreover, success is predicted on the assumption that the treatments themselves do not result in voiding dysfunction, which would make retention of the bladder (with the concomitant risk of tumor recurrence and progression) an unproductive exercise. Neither of these considerations, though of substantial importance, has as yet been effectively and unequivocally addressed. In all of the studies reviewed by Grob and Macchia,2 the initial apparently successful treatment of muscle-invasive tumors by transurethral resection did not necessarily translate into durable tumor-free survival. Generally, one third of such patients had tumor recurrence and required salvage cystectomy, and 10% to 20% of such patients had tumor progression with metastases and succumbed to their disease. Of those who retained their bladders, characterization of voiding function was often not discussed. Although many of these patients had no evidence of cancer on second transurethral resection, supporting the impression that no residual tumor was present, many would develop cancer elsewhere in their bladder and require adjunctive therapies or bladder removal. Often, the adjunctive therapies themselves (radiation, local or systemic chemotherapy, repetitive laser treatment, or transurethral resection) would lead to substantive local or systemic side effects, compromise voiding function or other measures of quality of life, and still not result in cure or durable tumor-free survival. The question that remains is whether such patients were better served by undergoing multiple diagnostic and treatment procedures when they presumably might have been at a curable phase of their disease such that definitive treatment (cystectomy) and continent and possible orthotopic diversion could have been done and a reasonable, if not perfect, quality of ex-