Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial

Minimally invasive versus open radical cystectomy for bladder cancer: A systematic review and meta-analysis

Background

We performed a systematic review and meta-analysis to evaluate the efficacy and safety of minimally invasive radical cystectomy (MIRC) versus open radical cystectomy (ORC) for bladder cancer.

Methods

We searched the EMBASE and MEDLINE databases to identify randomized controlled trials (RCTs) of MIRC versus ORC in the treatment of bladder cancer.

Results

Eight articles describing nine RCTs (803 patients) were analyzed. No significant differences were found between MIRC and ORC in two oncologic outcomes: the recurrence rate and mortality. Additionally, no significant differences were found in three pathologic outcomes: lymph node yield, positive lymph nodes, and positive surgical margins. With respect to perioperative outcomes, however, MIRC showed a significantly longer operating time, less estimated blood loss, lower blood transfusion rate, shorter time to regular diet, and shorter length of hospital stay than ORC. The incidence of complications was similar between the two techniques. We found no statistically significant differences in the above outcomes between robot-assisted radical cystectomy and ORC or between laparoscopic radical cystectomy and ORC with the exception of the complication rate.

Conclusions

MIRC is an effective and safe surgical approach in the treatment of bladder cancer. However, a large-scale multicenter RCT is needed to confirm these findings.

Step-by-step technique for single-port robot-assisted radical cystectomy and pelvic lymph nodes dissection using the da Vinci® SP™ surgical system

OBJECTIVES

To describe a step-by-step technique for robot-assisted radical cystectomy (RARC) with pelvic lymph node dissection (PLND) performed using the da Vinci^® SP™ surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA).

PATIENTS AND METHODS

Four consecutive patients diagnosed with urothelial carcinoma of the bladder were counselled for RARC with PLND and ileal conduit urinary diversion performed using the da Vinci SP surgical system. A 3-cm midline incision was made 5-cm above the umbilicus. Dissection was performed to access the abdominal cavity. Insertion of the GelPOINT^® advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) with the SP Cannula was performed through the incision made. A 12-mm AirSeal^® (SurgiQuest Inc., Milfort, CT, USA) port for the assistant was placed on the pre-marked stoma site, where an ileal conduit urinary diversion was desired. Demographics and perioperative outcomes were collected under Institutional Review Board approval (IRB 13-780). The surgeries were performed by reproducing the steps of the institutional approach for RARC performed with the multi-arm robotic platform.

RESULTS

The surgeries were successfully completed. There was neither conversion to standard multi-arm robotic or open approaches nor the need for additional port placement. The mean (range) operative time was 454 (420-496) min. Blood loss averaged 312 mL. No transfusions were required and no intraoperative complications occurred. All patients had negative surgical margins. All patients were discharged on postoperative day 5.

CONCLUSION

From our preliminary experience, RARC with PLND and ileal conduit urinary diversion is feasible and safe using the da Vinci SP surgical system. Further comparative studies with open and multi-arm robotic approaches are warranted.

Predictors of Recurrence, and Progression-Free and Overall Survival following Open versus Robotic Radical Cystectomy: Analysis from the RAZOR Trial with a 3-Year Followup

PURPOSE

The RAZOR (Randomized Open versus Robotic Cystectomy) trial revealed noninferior 2-year progression-free survival for robotic radical cystectomy. This update was performed with extended followup for 3 years to determine potential differences between the approaches. We also report 3-year overall survival and sought to identify factors predicting recurrence, and progression-free and overall survival.

MATERIALS AND METHODS

We analyzed the per protocol population of 302 patients from the RAZOR study. Cumulative recurrence was estimated using nonbladder cancer death as the competing risk event and the Gray test was applied to assess significance in differences. Progression-free survival and overall survival were estimated by the Kaplan-Meier method and compared with the log rank test. Predictors of outcomes were determined by Cox proportional hazard analysis.

RESULTS

Estimated progression-free survival at 36 months was 68.4% (95% CI 60.1-75.3) and 65.4% (95% CI 56.8-72.7) in the robotic and open groups, respectively (p=0.600). At 36 months overall survival was 73.9% (95% CI 65.5-80.5) and 68.5% (95% CI 59.8-75.7) in the robotic and open groups, respectively (p=0.334). There was no significant difference in the cumulative incidence rates of recurrence (p=0.802). Patient age greater than 70 years, poor performance status and major complications were significant predictors of 36-month progression-free survival. Stage and positive margins were significant predictors of recurrence, and progression-free and overall survival. Surgical approach was not a significant predictor of any outcome.

CONCLUSIONS

This analysis showed no difference in recurrence, 3-year progression-free survival or 3-year overall survival for robotic vs open radical cystectomy. It provides important prospective data on the oncologic efficacy of robotic radical cystectomy and high level data for patient counseling.

Different models for prediction of radical cystectomy postoperative complications and care pathways

Background:

Radical cystectomy for bladder cancer has one of the highest rates of morbidity among urologic surgery, but the ability to predict postoperative complications remains poor. Our study objective was to create machine learning models to predict complications and factors leading to extended length of hospital stay and discharge to a higher level of care after radical cystectomy.

Methods:

Using the American College of Surgeons National Surgical Quality Improvement Program, peri-operative adverse outcome variables for patients undergoing elective radical cystectomy for bladder cancer from 2005 to 2016 were extracted. Variables assessed include occurrence of minor, infectious, serious, or any adverse events, extended length of hospital stay, and discharge to higher-level care. To develop predictive models of radical cystectomy complications, we fit generalized additive model (GAM), least absolute shrinkage and selection operator (LASSO) logistic, neural network, and random forest models to training data using various candidate predictor variables. Each model was evaluated on the test data using receiver operating characteristic curves.

Results:

A total of 7557 patients were identified who met the inclusion criteria, and 2221 complications occurred. LASSO logistic models demonstrated the highest area under curve for predicting any complications (0.63), discharge to a higher level of care (0.75), extended length of stay (0.68), and infectious (0.62) adverse events. This was comparable with random forest in predicting minor (0.60) and serious (0.63) adverse events.

Conclusions:

Our models perform modestly in predicting radical cystectomy complications, highlighting both the complex cystectomy process and the limitations of large healthcare datasets. Identifying the most important variable leading to each type of adverse event may allow for further strategies to model cystectomy complications and target optimization of modifiable variables pre-operative to reduce postoperative adverse events.

Patient-reported outcomes in randomised clinical trials of bladder cancer: an updated systematic review

BACKGROUND

Despite international recommendations of including patient-reported outcomes (PROs) in randomised clinical trials (RCTs), a 2014 review concluded that few RCTs of bladder cancer (BC) report PRO as an outcome. We therefore aimed to update the 2014 review to synthesise current evidence-based knowledge of PROs from RCTs in BC. A secondary objective was to examine whether quality of PRO reporting has improved over time and to provide evidence-based recommendations for future studies in this area.

METHODS

We conducted a systematic literature search using PubMed/Medline, from April 2014 until June 2018. We included the RCTs identified in the previous review as well as newly published RCTs. Studies were evaluated using a predefined electronic-data extraction form that included information on basic trial demographics, clinical and PRO characteristics and standards of PRO reporting based on recommendation from the International Society of Quality of Life Research.

RESULTS

Since April 2014 only eight new RCTs for BC included PROs as a secondary outcome. In terms of methodology, only the proportion of RCTs documenting the extent of missing PRO data (75% vs 11.1%, p = 0.03) and the identification of PROs in trial protocols (50% vs 0%, p = 0.015) improved. Statistical approaches for dealing with missing data were not reported in most new studies (75%).

CONCLUSION

Little improvement into the uptake and assessment of PRO as an outcome in RCTs for BC has been made during recent years. Given the increase in (immunotherapy) drug trials with a potential for severe adverse events, there is urgent need to adopt the recommendations and standards available for PRO use in bladder cancer RCTs.

Translation and validation of two disease-specific patient-reported outcome measures (Bladder Cancer Index and FACT-Bl-Cys) in Dutch bladder cancer patients

BACKGROUND

The Bladder Cancer Index (BCI) and Functional Assessment of Cancer Therapy-Bladder-Cystectomy (FACT-Bl-Cys) were developed to measure disease-specific health-related quality of life (HRQOL) in bladder cancer patients and patients treated with radical cystectomy, respectively. Both patient-reported outcome measures (PROMs) are frequently used in clinical practice, but are not yet validated according to the COSMIN criteria and not yet available in Dutch. Therefore, the aim of this study was to translate the BCI and FACT-Bl-Cys into Dutch and to evaluate their measurement properties according to the COSMIN criteria.

METHODS

The BCI and FACT-Bl-Cys were translated into Dutch using a forward-backward method, and subsequently administered at baseline (pre-operatively) and 3 months post-operatively in bladder cancer patients who received a radical cystectomy. Validity (content and construct), reliability (internal consistency, test-retest reliability, and measurement error), floor and ceiling effects, and responsiveness were assessed according to the COSMIN criteria.

RESULTS

Forward-backward translation encountered no particular linguistic problems. In total 260 patients completed the baseline measurement, while 182 patients completed the three-month measurement. Only a ceiling effect was identified for the BCI. Hypotheses testing for construct validity was satisfying, as 67% and 92% of the hypothesized correlations were confirmed. Structural validity was moderate for both measures, as confirmatory factor analyses showed limited fit. Reliability of both PROMs was good. The intraclass correlation coefficient (ICC) of the BCI domains ranged from 0.47 to 0.93, minimal value of Cronbach's α was 0.70, smallest detectable change on group level (SDC group) ranged from 1.9 to 8.6. The ICC of the FACT-Bl-Cys domains ranged from 0.43 to 0.83, minimal value of Cronbach's α was 0.77, SDC group was around 1. Only the FACT-Bl-Cys total score was found to be responsive to changes in generic quality of life.

CONCLUSIONS

The Dutch versions of the BCI and FACT-Bl-Cys were shown to be reliable and have good content validity. Structural validity was limited for both measures. Only the FACT-Bl-Cys total score was responsive to changes in generic HRQOL. Despite some limitations, both PROMs seem suitable for use in clinical practice and research.

Predicting complications following radical cystectomy with the ACS NSQIP universal surgical risk calculator

INTRODUCTION

Radical cystectomy (RC) is a challenging procedure with significant morbidity, though remains the standard of care treatment for many patients with bladder cancer. There has been debate regarding the utility of universal risk calculators to aid in point-of-care prediction of complications in individual patients preoperatively. We retrospectively evaluated the predictive value of the ACS NSQIP universal surgical risk calculator in our patients who underwent RC.

METHODS

A prospective cohort of patients undergoing RC was retrospectively reviewed between October 2014 and August 2017. Only patients who underwent a RC for genitourinary cancer without significant deviation from NSQIP surgery codes 51590, 51595, and 51596 (n = 29) were included. The accuracy of the risk calculator was assessed by ROC AUC and Brier scores for both NSQIP and Clavien-Dindo defined complications. Additionally, each NSQIP risk factor was individually assessed for association with postoperative complications.

RESULTS

223 patients who underwent open or robotic RC (n = 18) were included for analysis. Determined by AUC C-stat and Brier scores, prediction was good for cardiac complications (0.80 and 0.021), fair for pneumonia (0.75 and 0.017), poor for UTI (0.64 and 0.078), 30-day mortality (0.62 and 0.013), any complication (0.60 and 0.19) and serious complication (0.60 and 0.17). There was a significant discordance between the rate of NSQIP predicted vs. Clavien-Dindo observed any and serious complications: 28.8% vs. 67.3%, and 25.3% vs. 11.7%, respectively.

CONCLUSION

The NSQIP universal surgical risk calculator did not perform with enough accuracy to consider adoption into clinical practice.

Open Versus Robotic Cystectomy: A Propensity Score Matched Analysis Comparing Survival Outcomes

Background: To assess the differential effect of robotic assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) on survival outcomes in matched analyses performed on a large multicentric cohort. Methods: The study included 9757 patients with urothelial bladder cancer (BCa) treated in a consecutive manner at each of 25 institutions. All patients underwent radical cystectomy with bilateral pelvic lymphadenectomy. To adjust for potential selection bias, propensity score matching 2:1 was performed with two ORC patients matched to one RARC patient. The propensity-matched cohort included 1374 patients. Multivariable competing risk analyses accounting for death of other causes, tested association of surgical technique with recurrence and cancer specific mortality (CSM), before and after propensity score matching. Results: Overall, 767 (7.8%) patients underwent RARC and 8990 (92.2%) ORC. The median follow-up before and after propensity matching was 81 and 102 months, respectively. In the overall population, the 3-year recurrence rates and CSM were 37% vs. 26% and 34% vs. 24% for ORC vs. RARC (all p values > 0.1), respectively. On multivariable Cox regression analyses, RARC and ORC had similar recurrence and CSM rates before and after matching (all p values > 0.1). Conclusions: Patients treated with RARC and ORC have similar survival outcomes. This data is helpful in consulting patients until long term survival outcomes of level one evidence is available.

Current status and future perspective of robot-assisted radical cystectomy for invasive bladder cancer

The current status of robot-assisted radical cystectomy was reviewed 16 years after the initial robot-assisted radical cystectomy for the treatment of invasive bladder cancer. Articles associated with robot-assisted radical cystectomy and written in English were selected from the PubMed database from January 2003 to February 2019. The present review article focused on the distribution of robot-assisted radical cystectomy, patient selection, preoperative management, surgical technique, lymph node dissection, urinary diversion, recurrence pattern, oncological outcomes, cost, learning curve, complications and educational programs. A total of 400 articles were divided according to the country of the first author's affiliation. The USA was the most dominant at 198 (50%), whereas the number of articles from the countries belonging to the Urological Association of Asia was 15 (3.8%) for China, 17 (4.3%) for South Korea, 10 (2.5%) for Japan, eight (2%) for Taiwan, eight (2%) for Turkey and one (0.2%) for Iran. The percentage of robot-assisted radical cystectomy carried out is increasing, and intracorporeal urinary diversion and ileal neobladder are also frequently carried out. With a refined technique being performed in high-volume centers, robot-assisted radical cystectomy has contributed to the reduction in transfusion rate, length of stay and severe complications; however, it has not yet shown any cancer-specific survival benefits. Robot-assisted radical cystectomy is not fully spread throughout the Urological Association of Asia. Further investigation with respect to worldwide results is needed to prove the real benefit of robot-assisted radical cystectomy regarding low morbidity, reduced total medical cost, and survival benefit. In the era of precision medicine, appropriate drug and surgery will be given based on each genetic profile.

Does the Use of a Robot Decrease the Complication Rate Adherent to Radical Cystectomy? A Systematic Review and Meta-Analysis of Studies Comparing Open with Robotic Counterparts

Introduction: Radical cystectomy (RC) is the mainstay of treatment for muscle-invasive bladder cancer. In 2003, the first robot-assisted radical cystectomy (RARC) was performed and since then many studies, mainly observational, were conducted to compare robotic and open methods. This study aims to assess perioperative outcomes between the two methods based on pooled data from existing literature. Methods: A literature search of articles in English and French languages was performed in three databases (Medline, Embase, and Cochrane) until 30th of June 2018, as well as in urology conference programs and reference lists of included studies. The study protocol was registered at PROSPERO (CRD42018103063). Terms such as "robotic," "open," and "radical cystectomy" and synonyms were used for the searching algorithm. The primary outcome was the number of minor and major postoperative complications (Clavien grading system). Risk of bias was assessed with the Cochrane tool and Newcastle-Ottawa scale. Comparison of continuous outcomes was performed with weighted mean differences, while for dichotomous outcomes, odds ratios (ORs) were used. Review Manager 5.3 was used. Results: Fifty-four studies (5 randomized trials and 49 observational) were eligible, including 29,697 patients (6500 in the RARC group and 23,197 in the open radical cystectomy group). Minor complications (grade 1-2) in pooled data of 29 studies were fewer in the RARC group (OR = 0.54, 95% confidence interval [CI]: 0.38-0.76, p < 0.001), a difference persisting after sensitivity analysis for 30 and 90 days. Major complications (grade 3-5) in 31 studies were fewer in the RARC group (OR = 0.78, 95% CI: 0.65-0.94, p = 0.009), but this difference disappeared in the 30-day subanalysis. RARC was associated with lower blood transfusion rates (p < 0.001), lower length of stay (p < 0.001), faster return to regular diet (p < 0.001), and lower postoperative mortality rates (p < 0.001), but longer operating time. Conclusions: RARC appears to be associated with fewer complications and favoring perioperative outcomes in comparison with the open method. Due to the observational nature of most studies, larger randomized trials are needed to confirm these findings.

Robot-assisted vs open radical cystectomy for bladder cancer in adults

BACKGROUND

It has been suggested that, in comparison with open radical cystectomy (ORC), robot-assisted radical cystectomy (RARC) results in less blood loss, shorter convalescence and fewer complications, with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits.

OBJECTIVES

To assess the effects of RARC vs ORC in adults with bladder cancer.

SEARCH METHODS

We conducted a comprehensive search, with no restrictions on language of publication or publication status, for randomized controlled trials (RCTs) that compared RARC with ORC. The date of the last search was 1 July 2018. Databases searched included the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We also searched the following trial registers: ClinicalTrials.gov (clinicaltrials.gov/); BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com); and the World Health Organization International Clinical Trials Registry Platform. The review was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (Clavien grade III to V). Secondary outcomes were minor postoperative complications (Clavien grades I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive surgical margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk-of-bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data.

RESULTS

We included in the review five RCTs comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively. We found that RARC and ORC may result in a similar time to recurrence (hazard ratio 1.05, 95% confidence interval [CI] 0.77 to 1.43; two trials, low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar rates of major complications (risk ratio [RR] 1.06, 95% CI 0.76 to 1.48; five trials, low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence because of study limitations and imprecision. We were very uncertain whether RARC reduces minor complications (very-low-certainty evidence). We downgraded the certainty of evidence because of study limitations and very serious imprecision. RARC probably results in substantially fewer transfusions than ORC (RR 0.58, 95% CI 0.43 to 0.80; two trials, moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations. RARC may result in a slightly shorter hospital stay than ORC (mean difference -0.67, 95% CI -1.22 to -0.12; five trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in a similar quality of life (standardized mean difference 0.08, 95% CI 0.32 lower to 0.16 higher; three trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar positive surgical margin rates (RR 1.16, 95% CI 0.56 to 2.40; five trials, low-certainty evidence). This corresponds to eight more (95% CI 21 fewer to 67 more) positive surgical margins per 1000 participants, based on 48 positive surgical margins per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision.

CONCLUSIONS

We conclude that RARC and ORC may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive surgical margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very-low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness.

Comparison of perioperative outcomes and complications of robot assisted radical cystectomy with extracorporeal vs intracorporeal urinary diversion

OBJECTIVES

To compare perioperative outcomes and complications of robot assisted radical cystectomy (RARC) with extracorporeal (ECUD) vs. intracorporeal urinary diversion (ICUD) for bladder cancer.

MATERIAL AND METHODS

Retrospective revision of 43 patients who underwent RARC for bladder cancer between 2015-2018 with at least 3 months of follow-up. The analysis included the initial series of RARC performed by one surgeon with extensive experience in open radical cystectomy.

RESULTS

Forty-three patients, 40 men (93%) and 3 women (7%), with a median age of 65 years (44-83) and mean follow-up of 27.7 months (±20.1) underwent RARC. A ECUD was performed in 22 cases (51%), of whom 10 were ileal conduits (45.5%) and 12 neobladders (54.5), and ICUD in 21 cases (49%), of whom 14 were ileal conduits (66.7%) and 7 neobladders (33.3%). Clinical and preoperative characteristics were similar in both groups. The median operative time was 360 minutes (240-540) and length of hospital stay was 12 days (7-73). Thirty-five patients (81%) had postoperative complications, of whom 10 (23%) were major. Operative time, peroperative complications, pathological stage, positive margins, and number of lymph nodes removed did not significantly differ among groups. Patients who underwent ECUD had a higher rate of uretero-ileal strictures than those with ICUD (45.5% vs. 14.3%, P=.026). Among the neobladders, the ECUD developed a higher rate of urethro-neobladder stricture than the ICUD (33% vs. 0%, P=.044).

CONCLUSIONS

RARC with ICUD achieved peroperative outcomes and complication rates comparable than those with ECUD. The ICUD could reduce the risk of developing uretero-ileal and urethro-neobladder strictures.

[Orthotopic neobladder reconstruction for bladder cancer: robotic-assisted versus open-radical cystectomy for perioperative outcomes, functional results and quality of life]

INTRODUCTION

Open radical cystectomy (ORC) is the gold standard technique for carcinologic cystectomies. Robotic-assisted radical cystectomy (RARC) was introduced in 2003 and its development is booming.

OBJECTIVE

To compare ORC and RARC with totally intracorporal (IC) orthotopic neobladder (ONB) reconstruction, in terms of perioperative outcomes, morbidity, functional results and quality of life (Qol).

PATIENTS AND METHODS

From February 2010 to February 2017, a French multicentric, prospective study on patients who had a RC and ONB reconstruction for bladder cancer was performed. All patients completed the following questionnaires: the European Organization for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and the bladder cancer specific instruments (QLQ-BLM30). To assess urinary symptoms, patients also completed the Urinary Symptom Profile questionnaire (USP) and a three-day voiding diary. Patients were divided in two groups: ORC and RARC.

RESULTS

We included 72 patients: 55 in the ORC group (76,4%) and 17 (33,6%) in the RARC group. Operative time was longer in RARC group (median 360 vs 300min; P<0.001) but length of stay was 5 days shorter (median 12 vs 17 days; P<0,05). Patients in RARC group had less blood transfusion (0 vs 23.6%; P<0.05), but a higher rate of uretero-ileal anastomosis stenosis and eventration at long term (respectively 25.5 vs 3.6% et 23 vs 2%; P<0.05). No statistical differences were found concerning quality of life items and functional results between the groups.

CONCLUSION

RARC with totally IC ONB reconstruction lead to less perioperative morbidity with a reduced rate of blood transfusion and a reduced hospital length of stay. At long term, RARC could provide higher rates of uretero-ileal stenosis and eventration. RARC and ORC do not have any differences in terms of functional outcomes and Qol at long term after ONB reconstruction.

LEVEL OF EVIDENCE

3.

Treatment Options and Outcomes in Nonmetastatic Muscle Invasive Bladder Cancer

Muscle-invasive bladder cancer (MIBC) represents 25% of newly diagnosed bladder cancer. MIBC is aggressive and requires timely management. The current standard of care is neoadjuvant chemotherapy followed by radical cystectomy, an approach that could result in significant morbidities. Modifications in the chemotherapy regimens, as well as in perioperative care and surgical approach, have resulted in better overall toxicity profile and faster recovery. However, bladder-preservation in carefully selected patients can lead to acceptable oncological outcomes and better quality of life. Optimization of bladder-preservation protocols and proper identification of patients who tolerate and respond to various treatment modalities will significantly impact patient survival in the coming future.

Long-term oncologic outcomes of robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD): a multi-center study

PURPOSE

To report survival outcomes after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) for recurrent/muscle-invasive non-metastatic bladder cancer.

METHODS

Prospectively maintained databases were queried for "robotic cystectomy AND ICUD". Patients treated after October 2013 and those treated without curative intent were excluded. Kaplan-Meier method was used to plot stage-specific survival outcomes, computed at 1, 2, and 5 years after surgery. Univariable and multivariable Cox analyses assessed predictors of recurrence-free (RFS), cancer-specific (CSS) and overall (OS) survival.

RESULTS

113 consecutive patients were included, mostly men (82%). Neoadjuvant chemotherapy was performed in 23% of cases, median lymph node (LN) yield was 36 (IQR 28-45) and the rate of positive surgical margins (PSM) was 8%. Orthotopic ileal neobladder was the preferred ICUD type (57%). An organ-confined disease was observed in 51% of cases and 21% were pT0 on final histology. Overall, 5-year RFS, CSS and OS probabilities were 58 ± 5%, 61 ± 5% and 54 ± 5%, respectively. At Kaplan-Meier method, tumor stage group was a significant predictor of survival probabilities (all p < 0.001) and this was confirmed at multivariable Cox regression analysis (RFS-OR 2.29; 95% CI 1.58-3.32; p < 0.001) (CSS-OR 1.82; 95% CI 1.3-2.53; p < 0.001) (OS-OR 2.14; 95% CI 1.46-3.14; p < 0.001). PSM status was associated to CSS (OR 2.54; 95% CI 1.13-5.69; p = 0.024) and OS (OR 2.82; 95% CI 1.17-6.77; p = 0.021), but did not predict RFS (p = 0.062).

CONCLUSIONS

Long-term oncologic outcomes after RARC with ICUD appear similar to recent robotic series with extracorporeal diversion and historical open experiences.

Robot-assisted radical cystectomy with totally intracorporeal urinary diversion: surgical and early functional outcomes through the learning curve in a single high-volume center

The aim of the study is to report surgical and early functional outcomes of first 100 patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD) in a single center. The main surgeon (A.P.) attended a modular training program at a referring center mentored by a worldwide-recognized robotic surgeon (P.W.). The program consisted of: (a) 10 h of theoretical lessons; (b) video session (c) step-by-step in vivo modular training. Each procedure was performed as taught, without any technique variation. Demographics, intra-operative data and post-operative complications, along with early functional outcomes, were recorded for each patient. We retrospectively evaluated the first consecutive 100 patients submitted to RARC with totally ICUD from July 2015 to December 2018. Median age at surgery was 69 years (IQR 60-74). 52 (52%), 32 (32%), and 17 (17%) patients received orthotopic neobladder, ileal conduit and uretero-cutaneostomy, respectively. Median operative time was 410 min. A median number of lymph nodes retrieved were 27 and median estimated blood loss was 240 mL with median hospitalization time of 7 days. All procedures were completed successfully without open conversion. A statistically significant improvement was found in the late (30-90 post-operative days) post-operative complications (p = 0.02) and operative time for urinary derivation. At multivariate logistic regression model ASA score ≥ 3 (OR = 4.2, p = 0.002) and number of lymph nodes retrieved (OR = 1.16, p = 0.02) were found to be predictors of 90-day complications. An adequate modular training is paramount to obtain successful results and reduce the learning curve of RARC, as demonstrated by our experience.

Comparison of perioperative complications and health-related quality of life between robot-assisted and open radical cystectomy: A systematic review and meta-analysis

To compare postoperative complications and health‐related quality of life of patients undergoing robot‐assisted radical cystectomy with those of patients undergoing open radical cystectomy. A systematic search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement. A pooled meta‐analysis was carried out to assess the differences between robot‐assisted radical cystectomy and open radical cystectomy according to randomized and non‐randomized comparative studies, respectively. We identified six randomized comparative studies and 31 non‐randomized comparative studies. Most robot‐assisted radical cystectomy patients were treated with extracorporeal urinary diversion. Robot‐assisted radical cystectomy was associated with longer operative times, and lower blood loss and transfusion rates compared with open radical cystectomy in both randomized comparative studies and non‐randomized comparative studies. There was no significant difference between robot‐assisted radical cystectomy and open radical cystectomy in the rate of patients with any or major complications within 90 days both in randomized comparative studies and non‐randomized comparative studies. Non‐randomized comparative studies reported a lower rate of complications at 30 days, mortality at 90 days and length of stay for patients treated with robot‐assisted radical cystectomy, which were not confirmed in randomized comparative studies. Additionally, there were no differences in postoperative quality of life score assessment at 3 and 6 months between robot‐assisted radical cystectomy and open radical cystectomy. Robot‐assisted radical cystectomy is associated with less blood loss and lower transfusion rates. There is no difference in complications, length of stay, mortality, and quality of life between robot‐assisted radical cystectomy and open radical cystectomy. Data from non‐randomized comparative studies favor perioperative outcomes in robot‐assisted radical cystectomy patients, the failure to confirm in randomized comparative studies, likely due to bias in study design and reporting. Further randomized comparative studies comparing postoperative complications and quality of life between robot‐assisted radical cystectomy with intracorporeal urinary diversion and open radical cystectomy are required to assess potential differences between these two surgical approaches.

Current role of robotic bladder cancer surgery

INTRODUCTION

Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in urology, that is not devoid of postoperative complications. Minimally invasive surgery, and especially robot-assisted RC (RARC) has emerged as an alternative to open RC (ORC) in an attempt to minimize surgical morbidity and facilitate the surgical approach. The aim of this paper was to present the current knowledge on the oncological efficacy and complication outcomes of RARC.

EVIDENCE ACQUISITION

A non-systematic review on all relevant studies with the keywords "Radical cystectomy," "Open," "Robot-assisted," "Complications," "Recurrence," "Survival," "Neobladder," "Potency," "Continence" and "Intracorporeal" was performed using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) Guidelines.

EVIDENCE SYNTHESIS

RARC shows similar lymph node yields and positive surgical margin rates as well as perioperative complication outcomes compared with ORC. RARC exhibits significantly less blood loss and less intra- and postoperative blood transfusion. Moreover, survival and recurrence rates are not related to the surgical approach. Finally, RARC seems to be more expensive and has a longer operating time compared to the open technique.

CONCLUSIONS

As current evidence shows, RARC seems as a technically feasible and safe procedure, providing equivalent perioperative and oncological results compared to ORC. More prospective, randomized-controlled trials are necessary to draw definitive conclusions on all comparative aspects.

Impact of Anaesthetist Volume on Radical Cystectomy Outcomes

BACKGROUND

Radical cystectomy (RC) is a gold standard treatment for aggressive bladder cancer. Higher surgical volumes through centralisation are associated with improved RC outcomes. The impact of anaesthetist experience and RC volume on outcomes is less clear.

OBJECTIVE

We sought to examine RC outcomes stratified by anaesthetist volume using a contemporary homogenous series.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of a prospectively collected, single-surgeon database of RC patients over a 10-yr period.

INTERVENTION

Four hundred and fifty-three consecutive patients underwent RC, including 430 (95%) with anaesthetist annotation.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Anaesthetists were stratified into low- (<10 cases) and high-volume (≥10 cases) classes. Primary outcomes were blood loss, transfusion rates, length of stay (LOS), and postoperative mortality.

RESULTS AND LIMITATIONS

In total, 63 anaesthetists were included for analysis (median two RCs per anaesthetist). Of 63 anaesthetists, 56 (88.9%) and seven (11.1%) were classified, respectively, into low and high volume, and these provided cover for 110 (25.6%) and 320 (74.4%) patients, respectively. When comparing high- versus low-volume anaesthetists, there were shorter LOS (median [interquartile range {IQR}]: 10 [6-14] vs 12 [7-19] d, p =  0.008), lower blood loss (median [IQR]: 600 [384-1000] vs 800 [500-1275] ml, p<0.001), and lower transfusion rate (23/320, 7.2% vs 22/110, 20%; p <  0.001). There was no difference in disease-specific mortality, overall mortality, or readmission rates. In multivariable analysis, a high anaesthetist volume was independently associated with transfusion rate (odds ratio 0.24 [0.07-0.83], p =  0.02).

CONCLUSIONS

Higher-volume anaesthetists have lower transfusion rates for RC patients. Whilst LOS and blood loss may also differ with experience, there is no difference in mortality after RC.

PATIENT SUMMARY

Radical cystectomy is a major operation. Experienced anaesthetists give fewer blood products to patients undergoing this operation. They may also help reduce blood loss and speed recovery. However, all other recovery measures were similar.

Requiem for Open Radical Cystectomy in Bladder Cancer Patients

In the hands of experienced surgeons at referral centers, robotic surgery with an intracorporeal urinary diversion has the potential to provide better perioperative outcomes without affecting cancer control when compared to open surgery for radical cystectomy.

Is robotic approach useful to palliate advanced bladder cancer? A monocentric single surgeon experience

Introduction

The aim of this study was to assess surgical and functional outcomes of 17 consecutive patients undergoing robot- assisted radical cystectomy (RARC) with palliative intent in a monocentric single surgeon series.

Material and methods

We collected data from 17 consecutive patients who underwent RARC with palliative intent performed by a single surgeon at our institution. Patients undergoing palliative RARC were those with advanced bladder cancer (BC) or advanced comorbidities. Clinical, surgical and functional outcomes were prospectively collected. Patients completed a specific questionnaire (Functional Assessment of Cancer Therapy-Bladder Cancer, FACT-BL) before and after surgery to assess the role of palliative RARC in terms of quality of life improvement.

Results

Median age at surgery was 78 years, with median Charlson Comorbidity Index (CCI) and age-adjusted CCI of 3 and 7, respectively. Clinical stage was T2, T3 or T4 in 7, 8 and 2 patients respectively, with 52.9% and 29.4% with cN+ and cM+ disease. Median estimated blood loss was 200 ml, with 1 patient requiring intra-operative blood transfusion. Median hospital stay was 7 days. A total of 3 and 2 patients were re-hospitalized during the first 30 and 30–90 post-operative days, respectively. One major Clavien grade complication was recorded.

At median follow-up of 8 months, 9 and 2 patients succumbed due to tumor progression and other causes. Pre-operative and post-operative FACT-BL scores improved significantly in each domain.

Conclusions

A RARC is a safe and feasible technique which could be offered as part of palliative care in patients with advanced BC or comorbidities. Precise guidelines for palliating BC patients should be better.

Robotic versus open radical cystectomy for bladder cancer in adults

BACKGROUND

It has been suggested that in comparison with open radical cystectomy, robotic-assisted radical cystectomy results in less blood loss, shorter convalescence, and fewer complications with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits.

OBJECTIVES

To assess the effects of robotic-assisted radical cystectomy versus open radical cystectomy in adults with bladder cancer.

SEARCH METHODS

Review authors conducted a comprehensive search with no restrictions on language of publication or publication status for studies comparing open radical cystectomy and robotic-assisted radical cystectomy. The date of the last search was 1 July 2018 for the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We searched the following trials registers: ClinicalTrials.gov (clinicaltrials.gov/), BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com), and the World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

We searched for randomised controlled trials that compared robotic-assisted radical cystectomy (RARC) with open radical cystectomy (ORC).

DATA COLLECTION AND ANALYSIS

This study was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (class III to V). Secondary outcomes were minor postoperative complications (class I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk of bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data.

MAIN RESULTS

We included in the review five randomised controlled trials comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively.Primary outomesTime-to-recurrence: Robotic cystectomy and open cystectomy may result in a similar time to recurrence (hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.77 to 1.43); 2 trials; low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision.Major complications (Clavien grades 3 to 5): Robotic cystectomy and open cystectomy may result in similar rates of major complications (risk ratio (RR) 1.06, 95% CI 0.76 to 1.48); 5 trials; low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence for study limitations and imprecision.Secondary outcomesMinor complications (Clavien grades 1 and 2): We are very uncertain whether robotic cystectomy may reduce minor complications (very low-certainty evidence). We downgraded the certainty of evidence for study limitations and for very serious imprecision.Transfusion rate: Robotic cystectomy probably results in substantially fewer transfusions than open cystectomy (RR 0.58, 95% CI 0.43 to 0.80; 2 trials; moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations.Hospital stay: Robotic cystectomy may result in a slightly shorter hospital stay than open cystectomy (mean difference (MD) -0.67, 95% CI -1.22 to -0.12); 5 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision.Quality of life: Robotic cystectomy and open cystectomy may result in a similar quality of life (standard mean difference (SMD) 0.08, 95% CI 0.32 lower to 0.16 higher; 3 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision.Positive margin rates: Robotic cystectomy and open cystectomy may result in similar positive margin rates (RR 1.16, 95% CI 0.56 to 2.40; 5 trials; low-certainty evidence). This corresponds to 8 more (95% CI 21 fewer to 67 more) positive margins per 1000 participants based on 48 positive margins per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision.

AUTHORS' CONCLUSIONS

Robotic cystectomy and open cystectomy may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness.

Robot-assisted urological surgery in the Middle East: Where are we and how far can we go?

Objectives: To evaluate robot-assisted surgery (RAS) in Urology in the Middle East, and its status and future perspectives.

Methods: A Medical Literature Analysis and Retrieval System Online (MEDLINE) search was performed using the following keywords: ‘robotics’, ‘robot-assisted surgery’, ‘laparoscopy’, at first with each specific procedure name, such as radical cystectomy, followed by ‘Middle East’ and country names. All abstracts and articles in English that adhered to the scope of the current issue were selected, giving special consideration to relevant landmark articles and those describing trends and the future of RAS in Urology.

Results: Only a few index case reports characterised RAS in the Middle East. The Middle East possess only 1% of the da Vinci® Surgical Systems (Intuitive Surgical Inc., Sunnyvale, CA, USA) installed worldwide, including 19 in Saudi Arabia; six in Qatar; two in each of Kuwait and Lebanon; three in the United Arab Emirates; and only one in Egypt. The total number of RAS performed in the Middle East is low compared to Europe and the USA. Many countries in the Middle East still lack surgical robots despite having the expertise and appropriate caseload, whilst others seem not to utilise the surgical robot at a suitable rate, as reflected by the sparse number of operated cases and outgoing publications. There are major differences in RAS availability, usage, and perception according to the geographical place of practice and acceptance of robots by surgeons and patients.

Conclusion: RAS in Urology continues to grow in the Middle East, with increasing caseloads and diversity of operated cases. Acceptance of robots by Middle East surgeons is significantly increasing.

Abbreviations: 3D: three-dimensional; KSA: Kingdom Saudi Arabia;MIS: minimally invasive surgery; RAA: robot-assisted adrenalectomy; RAP: robot-assisted pyeloplasty; (O)(RA)PN: (open) (robot-assisted) partial nephrectomy; RAS: robot-assisted surgery; (O)(RA)RC: (open) (robot-assisted) radical cystectomy; (RA)RP: (robot-assisted) radical prostatectomy; SAUC: Sabah Al-Ahmad Urology Center

Oncologic outcomes after robot-assisted versus open radical cystectomy: a systematic review and meta-analysis

PURPOSE

The efficacy of RARC in oncologic outcomes compared ORC is controversial. We assess potential differences in oncologic outcomes between robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC).

METHODS

We performed the literature search systematically according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. A pooled meta-analysis was performed to assess the difference in oncologic outcomes between RARC and ORC, separately in randomized controlled trials (RCTs) and non-randomized studies (NRCTs).

RESULTS

Five RCTs and 28 NRCTs were included in this systematic review and meta-analysis. There was no difference in the rate of overall positive surgical margin (PSM) in RCTs, while NRCTs showed a lower rate for RARC. There was no difference in the soft tissue PSM rate between RARC and ORC in both RCTs and NRCTs. There was no difference in the lymph node yield by standard and extended lymph node dissection between RARC and ORC in both RCTs and NRCTs. There was no significant difference in survival outcomes between RARC and ORC in both RCTs and NRCTs.

CONCLUSIONS

Based on the current evidence, there is no difference in the rate of PSMs, lymph node yield, recurrence rate and location as well as short-term survival outcomes between RARC and ORC in RCTs. In NRCTs, only PSM rates were better for RARC compared to ORC, but this was likely due to selection and reporting bias which are inherent to retrospective study designs.

Single-port Robotic Intracorporeal Ileal Conduit Urinary Diversion During Radical Cystectomy Using the SP Surgical System: Step-by-step Technique

OBJECTIVE

To describe the step-by-step technique for robotic intracorporeal ileal conduit urinary diversion (ICUD) following radical cystectomy performed by using the novel da Vinci SP surgical system (Intuitive Surgical, Sunnyvale, CA).

METHODS

Four consecutive patients (2 males and 2 females) were initially counseled for robotic cystectomy with ICUD performed by using the da Vinci SP surgical system. Surgeries were performed by duplicating the steps of the institutional approach for intracorporeal ICUD performed with the multiarms robotic platform. Perioperative outcomes were analyzed. Data were collected under institutional review board approval (IRB 13-780).

RESULTS

Single-port robot-assisted radical cystectomy with ICUD was successfully completed in 3 patients (2 males and 1 female). Mean robotic operative time for ICUD was 75 minutes (range 67-90). There was no conversion to standard multiarms robotic approach. One patient needed to be converted to extracorporeal urinary diversion due to severe adhesions of small bowels. No additional ports were placed. Neither transfusions nor intraoperative complications occurred. All patients were discharged on postoperative day 5. One patient reported self-limited nausea and vomiting after discharge (Clavien grade I).

CONCLUSION

In our preliminary experience, ICUD after robot-assisted radical cystectomy is feasible using the da Vinci SP surgical system. Further comparative studies with open and multiarms robotic approaches are warranted.

When the Evidence Basis Breeds Controversies: Exploring the Value Profile of Robotic Surgery Beyond the Early Introduction Phase

This article investigates qualitatively the value profile of the da Vinci® surgical robot after almost two decades of extensive clinical use and research. We aimed to understand whether the swiftly growing body of published studies on robotic prostate surgery can now, that is, beyond an early stage, guide decisions on the acquisition, procurement, and public provision of this innovation. We explored both published studies and the perspectives of diverse stakeholders in the Netherlands. Both arenas represent conflicting, often polarised arguments on the (added) value of da Vinci surgery. What was unclear a decade ago due to lack of evidence is now unclear because of controversies about evidence. The article outlines controversial value issues and indicates the unlikelihood that awaiting more research - amid the mantra "further studies are needed" - will resolve the controversy. The study underscores multi-stakeholder deliberation to resolve controversies regarding the value of advanced medical innovations.

Prospective implementation of a nonopioid protocol for patients undergoing robot-assisted radical cystectomy with extracorporeal urinary diversion

OBJECTIVES

To evaluate the feasibility and outcomes of a nonopioid (NOP) perioperative pain management protocol for patients undergoing robot-assisted radical cystectomy (RARC).

MATERIALS AND METHODS

We prospectively included 52 consecutive patients undergoing RARC at our institution for bladder cancer. Patients received a multimodal pain management protocol, including a combination of nonopioid pain medications and regional anesthesia. For comparison, we retrospectively included 41 consecutive patients who received the same procedure before implementation of the NOP protocol.

RESULTS

There was no significant difference in demographic and perioperative characteristics between the two groups. Patients included in the NOP protocol received a much lower dose of postoperative morphine milligram equivalents (2.5 [IQR: 0-23] vs. 44 [14.5-128], P < 0.001), with no difference in pain scores. In the NOP protocol, the median time to regular diet was significantly shorter (4days [IQR: 3-5] vs. 5days [IQR: 4-8], P = 0.002) and the length of stay was 2days shorter compared to the control group (5days [IQR: 4-7] vs. 7days [IQR: 6-11], P < 0.001). When evaluating the direct costs within 30days after initial surgery, the NOP protocol was associated with an 8.6% reduction as compared to the control group (P = 0.032). In multivariate analysis, the receipt of the NOP protocol was a significant predictor of a length of stay <7days after RARC (OR: 12.09; 95% CI: 1.70-140; P = 0.023).

CONCLUSIONS

The prospective implementation of a NOP protocol for patients undergoing RARC is feasible, allowing for minimal narcotic usage and provides benefits to patients, institutions, and population.

Robotic vs. open cystectomy: How length-of-stay differences relate conditionally to age

OBJECTIVES

The length-of-stay (LOS) benefit of minimally invasive cystectomy varies in the published literature, potentially because of subgroup effects. Here, we investigated the effect of minimally invasive cystectomy on LOS among different age groups.

METHODS AND MATERIALS

Adult patients who underwent cystectomy (open or minimally invasive) from January 1, 2012, to December 31, 2016, were identified from the National Surgical Quality Improvement Program database. Multivariable linear regression was used to evaluate the adjusted association between the surgical approach and LOS after stratifying patients by age (40-64, 65-79, and ≥80 years). A sensitivity analysis was performed after multiple imputation by using age as a continuous variable with a third-order polynomial term.

RESULTS

Of the 5,561 patients identified, 640 underwent minimally invasive cystectomy and 4,921 had open cystectomy. The unadjusted analysis showed that minimally invasive cystectomy was associated with a shorter mean LOS compared with the open approach (8.0 vs. 9.7 days; P < 0.001). The predicted difference in LOS between the 2 approaches was 0.72 days (95% confidence interval (CI), -0.28 to 1.72; P = 0.16) for patients aged 40 to 64 years, 1.48 days (95% CI, 0.73-2.23; P < 0.001) for 65 to 79 years, and 2.56 days (95% CI, 0.84-4.29; P = 0.01) for ≥80 years favoring the minimally invasive approach. The sensitivity analysis did not materially change the results.

CONCLUSIONS

Older patients may derive more LOS benefit from minimally invasive approaches than younger patients. Given the greater expense associated with the minimally invasive approach, an age-adapted strategy to using this technology may be reasonable.