Perioperative and mid-term oncologic outcomes of robotic assisted radical cystectomy with totally intracorporeal neobladder: Results of a propensity score matched comparison with open cohort from a single-centre series

Impact of diabetes mellitus on oncologic outcomes in patients receiving robot-assisted radical cystectomy for bladder cancer

PURPOSE

Aim of this study is to investigate the association between DM and oncological outcomes among patients with muscle-invasive (MI) or high-risk non-muscle invasive (NMI) bladder cancer (BC) who underwent robot-assisted radical cystectomy with intracorporeal urinary diversion (RARC).

METHODS

An IRB approved multi-institutional BC database was queried, including patients underwent RARC between January 2013 and June 2023. Patients were divided into two groups according to DM status. Baseline, clinical, perioperative, pathologic data were compared. Chi-square and Student t tests were performed to compare categorical and continuous variables, respectively. Kaplan-Meier method and Cox regression analyses were performed to assess the association between DM and oncologic outcomes.

RESULTS

Out of 547 consecutive patients, 97 (17.7%) had DM. The two cohorts showed similar preoperative features, except for ASA score (p = 0.01) and Hypertension rates (p < 0.001). No differences were detected for perioperative complications, pT stage, pN stages and surgical margins status (all p > 0.12). DM patients displayed significantly lower 5-yr disease-free survival (DFS) (44.6% vs. 63.3%, p = 0.007), 5-yr cancer-specific survival (CSS) (45.1% vs. 70.1%, p = 0.001) and 5-yr Overall survival (OS) (39.9% vs. 63.8%, p = 0.001). At Multivariable Cox-regression analyses DM status was identified as independent predictor of worse cancer-specific survival (CSS) (HR 2.1; p = 0.001) and overall survival (OS) (HR 2.05; p < 0.001).

CONCLUSION

Among BC patients who underwent RARC, DM patients showed worse oncologic outcomes than the non-DM patients, with DM status playing an independent negative predicting role in CSS and OS. Future prospective studies are awaited, stimulating basic and translational research to identify possible mechanisms of interaction between DM and BC.

Learning curve for intracorporeal robotic Padua ileal bladder: 10-year functional assessment from a high-volume single-centre series

OBJECTIVES

To assess the impact of the learning curve (LC) on perioperative and long-term functional outcomes of a consecutive single-centre series of robot-assisted radical cystectomy with Padua intracorporeal orthotopic neobladder.

PATIENTS AND METHODS

Patients treated between 2013 and 2022 were included, with ≥1 year of follow-up. The entire cohort was divided in tertiles. Categorical and continuous variables were compared. Joinpoint regression analysis was used to identify significant changes over the decade in linear slope of the 1-year day- and night-time continence. Uni- and multivariable Cox regression analyses identified predictors of day- and night-time continence recovery. Day-time continence was defined as 'totally dry' (no pads), night-time continence as pad wetness ≤50 mL (one safety pad).

RESULTS

Overall, 200 patients were included. The mean hospital stay (P = 0.002) and 30-day complications (P = 0.04) significantly reduced over time; the LC significantly impacted on Trifecta achievement (P < 0.001). The 1-year day- and night-time continence probabilities displayed a significant improving trend (day-time continence annual average percentage change [AAPC] 11.45%, P < 0.001; night-time continence AAPC 10.05%, P = 0.009). The LC was an independent predictor of day- (hazard ratio [HR] 1.008; P < 0.001) and night-time continence (HR 1.004; P = 0.03) over time.

CONCLUSION

Patients at the beginning of the LC had significantly longer hospitalisations, more postoperative complications, and lower Trifecta rates. At the 10-year analyses, we observed a significant improving trend for both the 1-year day- and night-time continence probabilities, highlighting the crucial role of the LC. However, we are unable to assess the case volume needed to achieve a plateau in terms of day- and night-time continence rates.

Robot-assisted Radical Cystectomy with Totally Intracorporeal Urinary Diversion Versus Open Radical Cystectomy: 3-Year Outcomes from a Randomised Controlled Trial

BACKGROUND AND OBJECTIVE

Randomised controlled trials (RCTs) comparing open radical cystectomy (ORC) and robot-assisted RC (RARC) have involved an extracorporeal approach for urinary diversion (UD), undermining the potential benefits of a totally robotic procedure. Our objective was to compare 3-yr outcomes from a RCT comparing ORC to RARC with totally intracorporeal UD (iUD).

METHODS

Patients with cT2-4 N0 M0 or bacillus Calmette-Guérin-failed high-grade non-muscle-invasive urothelial carcinoma who were candidates for RC without absolute contraindications to robotic surgery were included. A covariate adaptive randomisation process based on body mass index, American Society of Anesthesiologists score, preoperative haemoglobin, type of UD, neoadjuvant chemotherapy, and cT stage was used. The primary endpoint was to investigate the superiority of RARC with iUD in terms of a 50% reduction in transfusion rate. Secondary outcomes included adherence to an early recovery after surgery protocol, perioperative and postoperative outcomes, readmission and complication rates, a cost analysis, and functional, oncological, and health-related quality-of-life outcomes.

KEY FINDINGS AND LIMITATIONS

Overall, 116 patients were enrolled. The primary endpoint was confirmed, as the overall perioperative transfusion rate was significantly lower in the RARC cohort, with an absolute risk reduction of 19% (95% confidence interval 2-36%; p = 0.046). No differences in perioperative and postoperative complications and 3-yr oncological outcomes were observed between the groups. Despite the superiority of ORC on quantitative analysis of night-time pad use, there were no differences in the probabilities of recovery of daytime and night-time continence. Body image was significantly better in the RARC cohort. Cost analysis confirmed that RARC is a more expensive surgical procedure.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our findings support RARC with iUD as a safe surgical option; the transfusion rate was reduced by 50% and the complication rates and 3-yr oncological outcomes were comparable to those with ORC. The minimally invasive nature of RARC was reflected in better body image perception in this cohort. The probabilities of daytime and night-time continence recovery were comparable between the groups. Higher costs remain a drawback of robotic surgery.

PATIENT SUMMARY

This RCT demonstrated a 50% transfusions rate's reduction compared to ORC. We confirmed safety and feasibility of RARC with i-UD providing comparable peri- and postoperative complication rates, as well as, 3yr oncologic outcomes to those of ORC. Patients receiving either RARC-iUD or ORC had comparable probabilities of urinary continence recovery after surgery.

Robot-assisted radical cystectomy with intracorporeal urinary diversion: an updated systematic review and meta-analysis of its differential effect on effectiveness and safety

BACKGROUND

Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion (iRARC) is increasingly being used in recent years. Whether iRARC offers advantages over open radical cystectomy (ORC) remains controversial. This study aimed to compare the difference of perioperative outcomes, oncological outcomes and complications between iRARC and ORC.

METHODS

The PubMed, Embase, Cochrane Library, Web of Science and CNKI databases were searched in July 2023 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement. Studies were identified to be eligible if they compared perioperative outcomes, oncological outcomes and complications in patients who underwent iRARC with ORC.

RESULTS

Twenty-two studies involving 7,020 patients were included. Compared to ORC, iRARC was superior for estimated blood loss [EBL WMD: -555.52; 95% CI, -681.64 to -429.39; P<0.001], blood transfusion rate [OR: 0.16; 95% CI, 0.09 to 0.28; P<0.001], length of hospital stay [LOS WMD: -2.05; 95% CI, -2.93 to -1.17; P<0.001], Clavien-Dindo grades ≥III complication rate [30d: OR: 0.57; 95% CI 0.44 to 0.75; P<0.001; 90d: OR: 0.71; 95% CI 0.60 to 0.84; P<0.001], and positive surgical margin [PSM OR: 0.65; 95% CI 0.49 to 0.85; P=0.002]. However, iRARC had a longer operative time [OT WMD: 68.54; 95%CI 47.41 to 89.67; P<0.001] and a higher rate of ureteroenteric stricture [ UES OR: 1.56; 95% CI 1.16 to 2.11; P=0.003]. Time to flatus, time to bowel, time to regular diet, readmission rate, Clavien-Dindo grades

CONCLUSION

Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion appears to be superior to open radical cystectomy in terms of effectiveness and safety. However, attention should be paid to the occurrence of ureteroenteric stricture during follow-up.

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Affiliation(s)

Shi Fu Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
HongJin Shi Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Zhinan Fan Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China Department of Urology, Meishan People's Hospital, Meishan, China
Jinze Li Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
Ting Luan Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Haonan Dong Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Jincheng Wang Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Shuwen Chen Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Jinsong Zhang Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Jiansong Wang Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Mingxia Ding Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Haifeng Wang Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China

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Open versus robot-assisted radical cystectomy: pentafecta and trifecta achievement comparison from a randomised controlled trial

OBJECTIVES

To compare University of Southern California (USC) Institute of Urology pentafecta and trifecta achievement comparing open radical cystectomy (ORC) vs robot-assisted RC (RARC) with totally intracorporeal urinary diversion (iUD) from a randomised controlled trial (RCT).

PATIENTS AND METHODS

Patients were eligible for randomisation if they had a diagnostic transurethral resection of bladder tumour with clinical T stage (cT)2-4, cN0, cM0, or recurrent high-grade non-muscle-invasive bladder cancer and no anaesthesia contraindications to robotic surgery. Patients were enrolled with a covariate adaptive randomisation process based on the following variables: body mass index, American Society of Anesthesiologists score, preoperative haemoglobin, planned UD, neoadjuvant chemotherapy, and cT stage. USC pentafecta was defined as the combination at 1 year after surgery of: negative soft tissue surgical margins, ≥16 lymph node (LN) yield, absence of major (Clavien-Dindo Grade ≥III) complications at 90 days, absence of UD-related long-term sequalae, and absence of clinical recurrence. Trifecta was defined as the coexistence of daytime urinary continence, absence of major complications and recurrence-free status, all assessed at 1 year. Continuous and categorical variables were compared using Student's t-test and chi-square test, respectively. Univariable logistic regression analysis was performed to assess the role of USC pentafecta and trifecta achievement on health-related quality of life (HRQoL).

RESULTS

There was no statistically significant difference in USC pentafecta and trifecta achievement between groups. Among secondary outcomes, univariable logistic regression analysis was performed and both 1-year USC pentafecta and trifecta achievement were predictors of 2-year unmodified global HRQoL.

CONCLUSIONS

This study supports equivalence of RARC-iUD and ORC with regard to surgical quality as described by the USC pentafecta and trifecta. We described a significant impact of USC pentafecta and trifecta achievement on global health status/HRQoL, providing a strict correlation between objective evaluation of surgical outcomes and self-reported HRQoL.

Laparoscopic Radical Cystectomy with Ileal Orthotopic Neobladder for Bladder Cancer: Current Indications and Outcomes

BACKGROUND

Laparoscopic radical cystectomy (LRC) with ileal orthotopic neobladder (IONB) reconstruction is one of the most promising methods for bladder cancer treatment; its advantages include a small incision size, less blood loss, improved perioperative outcome and tumor prognosis, and a positive self-image postoperatively. The short-term benefits of various IONB reconstruction procedures reported thus far include a simple process, short operative time, less intraoperative bleeding, few postoperative complications, and good postoperative neobladder function; in the long term, these benefits engender good quality of life of the patients. Here, we explored and summarized the more novel and available IONB reconstruction procedures to identify the safest, most efficient, and simplest IONB reconstruction techniques for patients with bladder cancer.

SUMMARY

LRC with IONB reconstruction is technically feasible; however, most of the relevant studies have been short, employing a small sample size and a retrospective design. However, long-term, large-scale, prospective studies identifying the most appropriate bowel segments for IONB reconstruction, comparing intracorporeal and extracorporeal IONB reconstruction, assessing currently available IONBs, and resolving relevant postoperative complications further, with a focus on patients with bladder cancer, are warranted.

KEY MESSAGE

Several procedures for LRC with IONB reconstruction have been reported thus far. However, there is no consensus regarding the IONB reconstruction procedures most beneficial to patients with bladder cancer. Our review may aid researchers in developing a simple, safe, and efficient LRC with IONB reconstruction procedure for patients with bladder cancer.

Long-term oncologic and functional outcomes following robot-assisted radical cystectomy and intracorporeal Padua ileal bladder: results from a single high-volume center

PURPOSE

To report long-term oncologic and functional outcomes of a large consecutive single center series of Robot-assisted radical cystectomy (RARC)- intracorporeal (IC) Urinary Diversion (UD), identifying their predicting factors.

METHODS

A single center Bladder cancer (BC) database was queried for "RARC" and "ICUD", including patients treated between January 2012 and September 2020. Kaplan-Meier curves were assessed disease-free (DFS), cancer-specific (CSS) and overall survival (OS) probability. Univariable (UV) and multivariable (MV) analysis were adopted to identify predictors of DFS, CSS and OS. Kaplan-Meier method evaluated day- and night-time continence recovery probabilities; UV and MV analysis were adopted to identify predictors of Day-time continence.

RESULTS

Overall, 251 patients were included. Among them, 192 patients underwent intracorporeal ileal orthotopic neobladder (ION) (76.5%). Five-year DFS, CSS and OS rates were 66.5%, 65.4% and 61.5%; pT stage ≥ 3 and pathologic nodal involvement were identified as negative independent predictors of DFS (HR 2.39, p = 0.001, HR 4.64, p ≤  0.001), CSS (HR 2.20, p = 0.01, HR 3.97, p < 0.001) and OS (HR 2.25, p = 0.005, HR 3.95, p < 0.001). In RARC-ION patients, Trifecta rate was 64.1%. One-year day- and night-time continence rates were 78.6% and 48.3%. Age (HR 0.98, p = 0.03), female gender (HR 0.57, p = 0.008) and complications Clavien grade ≥ 3 (HR 0.55, p = 0.03) were identified as independent predictors of day-time incontinence.

CONCLUSIONS

Long-term oncologic outcomes and their predicting factors seem aligned to the largest historical open series and multi-institutional robotic series data. According to the identified predicting factors undermining a proper achievement of day-time continence, this represents an objective support, in order to properly advice specific sub-group of patients.

Open vs robotic intracorporeal Padua ileal bladder: functional outcomes of a single-centre RCT

PURPOSE

Functional outcomes of robot-assisted (RA) radical cystectomy (RC) with intracorporeal orthotopic neobladder (i-ON) have been poorly investigated. The study aimed to report functional outcomes of a prospective randomized controlled trial (RCT) comparing open RC (ORC) and RARC with i-ON.

METHODS

Inclusion criteria were cT2-4/N0/M0, or BCG-failure high-grade urothelial carcinoma, candidate to RC with curative intent. A covariate adaptive randomization process was used, based on the following variables: BMI, ASA score, haemoglobin levels, cT-stage, neoadjuvant chemotherapy, urinary diversion. Day-time continence was defined as "totally dryness", nigh-time continence as pad wetness ≤ 50 cc. Continence recovery probabilities were compared between arms with Kaplan-Meier method and Cox regression analysis was performed to identify predictors of continence recovery. HRQoL outcomes analysis was assessed with a generalized linear mixed effect regression (GLMER) model.

RESULTS

Out of 116 patients randomized, 88 received ON. Quantitative analysis of functional outcomes reported similar results in terms of day continence, while a better night continence status in ORC cohort was observed. However, 1-yr day- and night-time continence recovery probabilities were comparable. Night-time micturition frequency < 3 h was the only predictor of nigh-time continence recovery. At GLMER, 1-yr body image and sexual functioning were significantly better in RARC cohort, while urinary symptoms were comparable between arms.

CONCLUSION

Despite superiority of ORC at quantitative night-time pad use analysis, we showed comparable day- and night-time continence recovery probabilities. At 1-yr analysis of HRQoL outcomes, urinary symptoms were comparable between arms, while RARC patients reported lower body image and sexual functioning worsening.

The CUSUM curve combined with comprehensive complication index for assessing short-term complications of radical cystectomy

Objective

To evaluate the comprehensive complication index(CCI) and Clavien‐Dindo classification(CDC) for short‐term postoperative complications in radical cystectomy and assess cumulative surgical morbidity to compare sufficient surgical skill.

Methods

From September 30, 2010, to October 1, 2020, clinical data of patients with urothelial carcinoma who underwent radical cystectomy with urinary diversion were gathered, patients who had only a urinary diversion, bladder sparing surgery, additional abdominal surgeries at the same time were all excluded. The CDC and CCI were utilized to evaluate 30‐d complications after radical cystectomy and the relevance of hospital stay was compared between CCI and CDC. The cumulative sum control models (CUSUM) were used to evaluate the overall surgical morbidity of radical cystectomy in our facility and for comparisons between surgeons.

Results

This study enrolled a total of 635 individuals, 548 (86.3%) of whom had 1124 problems. The incidence of severe complications (CDC≥ Grade III) was 10.2%. The average CCI was 20.2 ± 14.7. Gender, urinary diversion subtype, procedure method, and surgeon were significantly correlated with the increase of CCI (p < 0.05). The CCI demonstrated a better relationship with hospital stay (R² = 0.429) than the CDC (R² = 0.361). The CUSUM‐CCI model demonstrated a difference and growth distribution in dynamic time between individual surgeons.

Conclusions

CCI can better reflect the incidence of complications for radical cystectomy than CDC, and CCI is more strongly correlated with postoperative hospital stay. The CUSUM‐CCI model can reflect the quality of surgical skill for each surgeon instantaneously.

The View Outside of the Box: Reporting Outcomes Following Radical Cystectomy Using Pentafecta From a Multicenter Retrospective Analysis

We aimed at characterization of the patients undergoing radical cystectomy (RC) using the prognostic model (a modified pentafecta). In the multicenter retrospective study, we enrolled 304 patients with bladder cancer (pTis-4N0-2M0) who underwent RC between 2015 and 2020 in experienced centers. The definition of the pentafecta was as follows: no Clavien–Dindo grade III–V complications at 90 days and no long-term complications related to urinary diversion <12 months, negative surgical margins, ≥10 lymph nodes (LNs) resected, and no recurrence ≤12 months. RC-pentafecta achievement rate was 22% (n = 67), varying from 47% to 88% attainment rate for different pentafecta components, and was the lowest for sufficient LN yield. Both 12-month recurrence-free survival (RFS) and cancer-specific mortality were compromised in pentafecta failers compared with achievers (57.8% vs. 100% and 33.8% vs. 1.5%, respectively). The following were identified as crucial predictors of RC pentafecta achievement: modality of the surgery, type of urinary diversion, histological type of bladder cancer, advanced staging, and elevated preoperative serum creatinine. In conclusion, we found that the pentafecta achievement rate was low even in high-volume centers in patients undergoing cystectomy. The complexity of the procedure directly influenced the attainment rate, which in turn led to an increase in cancer-specific mortality rate among the pentafecta failers.

Gender-related outcomes in robot-assisted radical cystectomy: A multi-institutional study

Purpose

Robot-assisted radical cystectomy (RARC) optimizes patient recovery and has outcomes comparable with those of open surgery. This study aimed to compare the perioperative and oncologic outcomes of RARC in female and male patients.

Materials and Methods

A retrospective cohort study of the Korean Robot-Assisted Radical Cystectomy Study Group database from 2007 to 2019 identified 749 patients (111 females and 638 males). Female were matched 1:1 to male by propensity score matching using a logistic regression. We compared perioperative outcomes, oncologic outcomes, and complications between the two groups.

Results

The female group had comparable perioperative outcomes to the male group in terms of operation time, lymph node yield, positive surgical margin, blood transfusion rate, and hospitalization days. Complication rate and grade were not significantly different between the two groups. The most common complication was infection in female and gastrointestinal complications in male. We compared the 5-year overall, disease-specific, and recurrence-free survival of female and male: 58.2% vs. 68.0% (p=0.495), 75.7% vs. 79.3% (p=0.645), and 40.8% vs. 53.5% (p=0.913), respectively. On multivariable analysis, T stage (>T2), postoperative complications, and positive surgical margin were prognostic factors of poor outcome. Sex was not an independent predictor of the three survivals.

Conclusions

The current study suggests that RARC in female has comparable perioperative and oncologic outcomes to those in male. The complication rate of RARC in female was comparable to that in male, but the type of complications differed by sex.

Benchmarking PASADENA Consensus along the Learning Curve of Robotic Radical Cystectomy with Intracorporeal Neobladder: CUSUM Based Assessment

(1) Aim: Robot assisted radical cystectomy (RARC) with intacorporeal neobladder (iN) is a challenging procedure. There is a paucity of reports on RARC-iN, the extracorporeal approach being the most used. The aim of our study was to assess the learning curve of RARC-iN and to test its performance in benchmarking Pasadena consensus outcomes. (2) Material and methods: The single-institution learning curve of RARC-iN was retrospectively evaluated. Demographic, clinical and pathologic data of all patients were recorded. Indications to radical cystectomy included muscle invasive bladder cancer (pT ≥ 2) or recurrent high grade non muscle invasive bladder cancer. The cumulative sum (CUSUM) technique, one of the methods developed to monitor the performance and quality of the industrial sector, was adopted by the medical field in the 1970s to analyze learning curves for surgical procedures. The learning curve was evaluated using the following criteria: 1. operative time (OT) <5 h; 2. 24-h Hemoglobin (Hb) drop <2 g/dl; 3. severe complications (according to the Clavien classification system) <30%; 4. positive surgical margins <5%; and 5. complete lymph-node dissection defined as more than 16 nodes. Benchmarking of all five items on quintile analysis was tested, and a failure rate <20% for any outcome was set as threshold. (3) Results: the first 100 consecutive RARC-iN patients were included in the analysis. At CUSUM analysis, RARC required 20 cases to achieve a plateau in terms of operative time (defined as more than 3 consecutive procedures below 300 min). Hemoglobin drop, PSM and number of removed lymph-nodes did not change significantly along the learning curve. Overall, 41% of the patients presented at least one complication. Low-grade and high-grade complication rates were 30% and 17%, respectively. When assessing the benchmarks of all five Pasadena consensus outcomes on quintile analysis, a plateau was achieved after the first 60 cases. (4) Conclusions: RARC-iN is a challenging procedure. The potential impact of the learning curve on significant outcomes, such as high grade complications and positive surgical margins, has played a detrimental effect on its widespread adoption. According to this study, in tertiary referral centers, 60 procedures are sufficient to benchmark all outcomes defined in Pasadena RARC consensus.

Perioperative outcomes of intracorporeal robot-assisted radical cystectomy versus open radical cystectomy: A systematic review and meta-analysis of comparative studies

PURPOSE

To systematically review studies comparing the perioperative outcomes of intracorporeal robot-assisted radical cystectomy (iRARC) and open radical cystectomy (ORC).

METHODS

Systematic searches of PubMed, Web of Science and the Cochrane Library were performed in June 2020. Studies with data comparing iRARC and ORC were included in our review, and a pooled meta-analysis was completed.

RESULTS

In total, 8 studies (7 prospective studies, 1 retrospective study) comparing 1193 patients were included for our review and meta-analysis. Compared with ORC, iRARC demonstrated lower estimated blood loss (weighted mean difference (WMD): -449.25; 95% CI -566.47 - -332.03; p < 0.01), lower blood transfusion rates (OR: 0.31; 95% CI 0.22 - 0.46; p < 0.01), and lower postoperative complication rates with Clavien-Dindo grades III-IV (30 days: OR: 0.65; 95% CI 0.47 - 0.90; p = 0.01; 90 days: OR: 0.72; 95% CI 0.53 - 0.98; p = 0.04), but a longer operative time (WMD: 78.82; 95% CI 52.77 - 104.87; P < 0.01). Furthermore, there was no significant difference between iRARC and ORC in terms of postoperative complication rates with Clavien-Dindo grades Ⅰ-Ⅱ (30 days: OR: 0.71; 95% CI 0.36 - 1.40; p = 0.32; 90 days: OR: 0.98; 95% CI 0.74 - 1.30; p = 0.89), length of stay (WMD: -1.18; 95% CI -3.33 - -2.07; p = 0.06) and positive surgical margins (OR: 0.78; 95% CI 0.0.45 - 1.36; p = 0.38).

CONCLUSION

iRARC was associated with a significantly lower estimated blood loss and a lower blood transfusion rate and major postoperative complication rate than ORC.

Computed-tomography based scoring system predicts outcome for clinical lymph node-positive patients undergoing radical cystectomy

Purpose:

Contrast-enhanced CT scan is the standard staging modality for patients with bladder cancer undergoing radical cystectomy (RC). Involvement of lymph nodes (LN) determines prognosis of patients with bladder cancer. The detection of LN metastasis by CT scan is still insufficient. Therefore, we investigated various CT scan characteristics to predict lymph node ratio (LNR) and its impact on survival. Also, pre-operative CT scan characteristics might hold potential to risk stratify cN+ patients.

Materials and Methods:

We analyzed preoperative CT scans of patients undergoing RC in a tertiary high volume center. Retrospectively, local tumor stage and LN characteristics such as size, morphology (MLN) and number of loco-regional LN (NLN) were investigated and correlation to LNR and survival was analyzed. CT scan characteristics were used to develop a risk stratification using Kaplan-Maier and multivariate analysis.

Results:

764 cN0 and 166 cN+ patients with complete follow-up and imaging data were included in the study. Accuracy to detect LN metastasis and locally advanced tumor stage in CT scan was 72% and 62%. LN larger than 15mm in diameter were significantly associated with higher LNR (p=0.002). Increased NLN correlated with decreased CSS and OS (p=0.001: p=0.002). Furthermore, CT scan based scoring system precisely differentiates low-risk and high-risk profiles to predict oncological outcome (p <0.001).

Conclusion:

In our study, solely LN size >15mm significantly correlated with higher LNR. Identification of increased loco-regional LN was associated with worse survival. For the first time, precise risk stratification based on computed-tomography findings was developed to predict oncological outcome for clinical lymph node-positive patients undergoing RC.

Surgical techniques, oncologic and functional outcomes of two types of modified ileal orthotopic neobladders

Background

In recent years, the construction of orthotopic neobladder has become the focus of research. Our study is aim to illustrate and evaluate surgical techniques, oncologic and functional outcomes of two types of modified ileal orthotopic neobladders (IONB).

Methods

We retrospectively reviewed of 64 patients who underwent laparoscopic radical cystectomy (LRC) + Xing’s neobladder (n=41), Institute of Urology Peking University neobladder (IUPUB) (n=23) at two tertiary referral centers. Then demographic characteristics, operation outcomes were analyzed. In addition, postoperative complication rates, oncologic outcomes, continence, and neobladders’ function were further evaluated.

Results

All LRC + IONB were carried out in 64 patients successfully. Pathological results show that 63 were urothelial carcinoma and 1 was adenocarcinoma. Time to flatus was 3 [1–6] d in Xing’s neobladder group while 3 [2–5] d in IUPUB group (P=0.049). In terms of overall survival (OS), cancer specific survival (CSS) and recurrence-free survival (RFS), there is no statistical difference between the two groups. Overall, grade 1–2 complications were 36%, grade 3–4 complications were 1.6% on the 30th day, and 15.6%, 1.6% respectively on the 90th day. On the whole, daytime and night continence were 96.4%, 83.6% respectively one year after operation.

Conclusions

The two types of modified IONB are safe and feasible. The technical improvements significantly simplify the procedure and decrease the difficulty of the surgery, probably shorten the operative time and reduce blood loss. Furthermore, they take the advantage of less late complications and comparative good functional outcomes without affecting the prognosis of oncology. In addition, Xing’s neobladder is more beneficial to the recovery of postoperative gastrointestinal function.

Intracorporeal versus extracorporeal urinary diversion in robot-assisted radical cystectomy: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to assess and compare the perioperative and oncological outcomes of intracorporeal (ICUD) and extracorporeal (ECUD) urinary diversion following robot-assisted radical cystectomy (RARC). A systematic literature search of articles was performed in PubMed^®, Web of Science^®, and Scopus^® databases according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. We included studies that compared patients who underwent RARC with ICUD to those with ECUD. Twelve studies including 3067 patients met the eligibility criteria. There were no significant differences between ICUD and ECUD in overall and major complications, regardless of the period (short-term [≤ 30 days] or mid-term [> 30 days]). Subgroup analyses demonstrated that ICUD performed by high-volume centers exhibited a significantly reduced risk of major complications (short-term: OR 0.57, 95% CI 0.37–0.86, p = 0.008, mid-term: OR 0.66, 95% CI 0.46–0.94, p = 0.02). Patients who underwent ICUD had lower estimated blood loss (MD -102.3 ml, 95% CI − 132.8 to − 71.8, p < 0.00001), less likely to receive blood transfusion rates (OR 0.36, 95% CI 0.20–0.62, p = 0.00003); and these findings were consistent in subgroup analyses by low-volume centers (MD-121.6 ml, 95% CI − 160.9 to − 82.3, p < 0.00001 and OR 0.36, 95% CI 0.20–0.62, p = 0.00003, respectively). ICUD had a higher lymph node yield (MD 3.68, 95% CI 0.80–6.56, p = 0.01). Patients receiving ICUD provided comparable complications, superior perioperative outcomes, and similar oncological outcomes compared with ECUD. Centralization of patients may contribute to a reduction of postoperative complications, while maintaining the advantages.

Intra-corporeal robot-assisted versus open radical cystectomy: a propensity score-matched analysis comparing perioperative and long-term survival outcomes and recurrence patterns

BACKGROUND

To compare perioperative and long-term oncological outcomes and recurrence patterns between robot-assisted radical cystectomy with intra-corporeal urinary diversion (iRARC) and open radical cystectomy (ORC).

METHODS

We retrospectively analyzed 177 bladder cancer patients who received iRARC or ORC at Fujita Health University between 2008 and 2020. Our primary endpoint was long-term oncological outcomes. As a secondary endpoint, we examined perioperative outcomes, complications, and recurrence patterns. These outcome measures were compared between the propensity score (PS)-matched cohorts.

RESULTS

PS-matched analysis resulted in 60 matched pairs from iRARC and ORC groups. The iRARC cohort was associated with significantly longer operative time (p = 0.02), lower estimated blood loss (p < 0.001), lower blood transfusion rate (p < 0.001), shorter length of hospital stay (p < 0.001), fewer overall complications (p = 0.03), and lower rate of postoperative ileus (p = 0.02). There was no statistically significant difference between iRARC and ORC in 5-year RFS (p = 0.46), CSS (p = 0.63), and OS (p = 0.71). RFS and CSS were also comparable, even in locally advanced (≥ cT3) disease. Multivariate analysis identified lymphovascular invasion as a robust predictor of RFS, CSS, and OS. The number of recurrence was similar between the groups, while extra-pelvic lymph nodes were more frequent in iRARC than that in ORC (22.7% vs. 7.7%).

CONCLUSIONS

iRARC has favorable perioperative outcomes, fewer complications, and comparable long-term survival outcomes, including locally advanced (≥ cT3) disease, compared to that in ORC. Our results need to be validated in prospective randomized clinical trials.

Robot-assisted versus open radical cystectomy: A cohort study on perioperative outcomes accounting for stage selection bias and surgical experience

BACKGROUND

Most comparisons of robot-assisted (RARC) versus open radical cystectomy (ORC) for urothelial carcinoma do not factor the inherent stage selection bias or surgical experience.

METHODS

We compared the perioperative outcomes of 229 RARC and 335 ORC at a single tertiary referral centre with propensity score matching and multiple regression models, when controlling for tumour and patient characteristics, surgeon's experience and type of urinary diversion.

RESULTS

RARC had less major complications (19.8% vs. 34.1%) and ICU admissions (6.6% vs. 19.8%), with lower blood loss (400 vs. 500 ml) and transfusion rates. The operating time was longer (336 vs. 286 min), but decreased with surgeon's experience. RARC had less positive surgical margins (3% vs. 8.4%) and a higher lymph node count (14 vs. 11).

CONCLUSIONS

In this large single centre series comparing RARC with ORC controlling for stage selection bias and surgical experience, RARC proved significantly better outcomes, especially with intracorporeal urinary diversion.

Robotic assisted radical cystectomy versus open radical cystectomy: a review of what we do and don't know

Radical cystectomy (RC) is the gold standard treatment for muscle-invasive and high-risk, noninvasive bladder cancer. Since 2003, robot-assisted radical cystectomy (RARC) has been gaining popularity. Metanalyses show that the primary advantage of RARC is less blood loss and the primary advantage of open radical cystectomy (ORC) is shorter operative times. There do not appear to be significant differences in complications, cancer-related outcomes or survival between the two approaches. Cost analyses comparing RARC and ORC are complicated by the often-ill-defined distinction between the cost to the hospital versus the cost to payors. However, it is likely that for both hospitals and payors, RARC is cost effective at high-volume centers. It is feasible that in the future, increased experience with RARC will lead to improved outcomes and justify the use of RARC over ORC.

Comparison of Oncologic Outcomes Following Open and Robotic-assisted Radical Cystectomy with both Extracorporeal and Intracorporeal Urinary Diversion

OBJECTIVES

To compare oncologic endpoints between open radical cystectomy (ORC) and robotic-assisted radical cystectomy with extracorporeal urinary diversion (eRARC) or intracorporeal urinary diversion (iRARC).

MATERIALS AND METHODS

Retrospective review of all patients undergoing curative-intent radical cystectomy with urinary diversion for urothelial bladder cancer at a single-institution from 2010-2018. Primary outcomes included recurrence location and rates, recurrence-free (RFS) and overall survival (OS). Survival estimates were obtained using the Kaplan-Meier method and compared using log-rank analysis. Cox proportional-hazards model was used to identify predictors of survival.

RESULTS

265, 366 and 285 patients underwent ORC, eRARC, and iRARC, respectively (n = 916). Median follow-up was 52, 40 and 37 months for ORC, eRARC and iRARC, respectively (P < 0.001). Ileal conduit was more commonly performed in iRARC (85%, P < 0.001). Neobladder rates did not vary. Neoadjuvant (p=0.4) or adjuvant therapy use (P = 0.36), pT-stage (P = 0.28) or pN-stage (P = 0.1) did not differ. Positive soft tissue margin rates were higher in ORC (7.2%-ORC, 3.6%-eRARC, 3.2%-iRARC, P = 0.041). Differences in recurrence rates or location were not observed. Surgical approach was not associated with any survival endpoint on proportional-hazards or Kaplan-Meier analysis. Hazard ratios and 95% CI for RFS were 1 (0.72-14) and 0.93 (0.66-1.3) for eRARC and iRARC, respectively, when compared to ORC as the referent.

CONCLUSION

These findings from a large, single-institution in conjunction with randomized-controlled trial data suggest that RARC does not compromise perioperative or long-term oncologic outcomes when compared to ORC.

Comparison of Patient-reported Health-related Quality of Life Between Open Radical Cystectomy and Robot-assisted Radical Cystectomy with Intracorporeal Urinary Diversion: Interim Analysis of a Randomised Controlled Trial

BACKGROUND

Open radical cystectomy (ORC) is still considered the reference approach for RC, although robot-assisted RC (RARC) has recently gained in popularity. There are literature reports on perioperative and oncologic outcomes of RARC, but functional outcomes and aspects related to health-related quality of life (HRQoL) remain unexplored.

OBJECTIVE

To report an interim analysis of 1-yr HRQoL outcomes from an ongoing randomised controlled trial comparing ORC and RARC with totally intracorporeal urinary diversion (iUD) (ClinicalTrials.gov NCT03434132).

DESIGN, SETTING, AND PARTICIPANTS

Patients with cT2-4N0M0 non-muscle-invasive bladder cancer or bacillus Calmette-Guérin failure who were candidates for cystectomy with curative intent without absolute contraindications to robotic surgery were included. A covariate adaptive randomisation based on the following variables was used: body mass index, American Society of Anesthesiologists score, preoperative haemoglobin level, cT stage, type of UD, and neoadjuvant chemotherapy.

INTERVENTION

ORC or RARC with iUD.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Data from patient-reported European Organization for Research and Treatment of Cancer QoL questionnaires (QLQ-C30 and QLQ-BLM30) were collected at baseline and 1 yr. Continuous variables were compared using the Student t test.

RESULTS AND LIMITATIONS

At interim analysis, 51 patients (24 RARC, 27 ORC) were analysed. Overall, both groups reported significant worsening of body image and physical and sexual functions (all p ≤ 0.012). Patients receiving ORC were more likely to report significant 1-yr impairment of role functioning, symptoms scales and bowel symptoms (all p ≤ 0.048). Patients receiving RARC reported significant impairment of urinary symptoms and problems (p = 0.018).

CONCLUSIONS

This study suggests equivalence between RARC-iUD and ORC for most HRQoL domains. Notwithstanding, after 1 yr patients receiving ORC were more likely to experience a decline in role functioning and higher symptoms scale, while RARC-iUD patients were more likely to report significant increases in urinary symptoms and problems.

PATIENT SUMMARY

We analysed 1-year data for health-related quality of life from an ongoing trial comparing open and robotic surgery for removal of the bladder in patients with bladder cancer. Robotic surgery seems to provide benefits for most quality-of-life items on patient-reported questionnaires. This trial is registered at ClinicalTrial.gov as NCT03434132.

Outcomes and complications of radical cystectomy with ileal conduit urinary diversion: A comparison between open, semi-robotic and totally robotic surgery

BACKGROUND

It was aimed to compare open versus robotic-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (ICIC), versus RARC with extracorporeal ileal conduit (ECIC) formation for bladder cancer.

MATERIALS AND METHODS

Open, RARC-ECIC and RARC-ICIC groups were compared in terms of patient demographics, operative and postoperative parameters, pathological parameters, complications and functional outcomes.

RESULTS

Mean operative times were lower in the RARC-ECIC group (p = 0.004). Mean estimated blood loss was significantly lower (p < 0.01) in the robotic groups. The blood transfusion was lower in RARC-ICIC groups (p < 0.001). Rates of stage pT3-4 disease were the highest in the RARC-ICIC group (p = 0.004). LOS was significantly shorter in the RARC-ICIC group (p = 0.01). Numbers of Clavien 3-5 complications were lower in the robotic groups (p = 0.012).

CONCLUSIONS

RARC and ICIC is a complex procedure involving an increased operation time but with the advantages of lower estimated blood loss, transfusion rates, complications and hospital stays compared with open surgery.

Robot-assisted radical cystectomy with intracorporeal neobladder: impact of learning curve and long-term assessment of functional outcomes

BACKGROUND

There is paucity of data about functional outcomes of Robot-assisted Radical Cystectomy (RARC) with intracorporeal orthotopic neobladder (ICON), and the impact of learning curve (LC) on those outcomes remains to be addressed. The aim of this study was to report long-term functional outcomes of our single center series of RARC with ICON, assessing the role of LC in their achievement.

METHODS

Patients treated with Robot assisted radical cystectomy with intracorporeal orthotopic neobladder in our center between January 2012 and August 2019 were retrospectively analyzed. Preoperative, clinical, perioperative, pathologic and functional data were reported. The first cases were divided in tertiles, for assessing the impact of learning curve on the outcomes evaluated. Long-term functional outcomes of the whole cohort were evaluated.

RESULTS

Overall, 167 patients were included. Concerning tertiles analysis, operative time (P<0.001), incidence of low (P=0.002) and high grade (P=0.001) complications and hospital stay (P=0.04) decreased significantly over time. Day-time continence recovery probability was significantly lower in the initial case series (1-yr rate 68.4%, 87% and 89.8 for I, II and III tertile, respectively; P=0.04;). Accordingly, Trifecta achievement was significantly higher in II and III tertiles (P=0.01). At a median follow- up of 34 months, the incidence of significant renal function deterioration of the whole cohort was 16.7%. Overall, 12, 24 and 60-mo day-time continence rates were 74.8%, 82.7% and 82.7%.

CONCLUSIONS

Patients treated at the beginning of the learning curve show worse perioperative and functional results. Once standardized the procedure, complications rates, hospital stay, and day-time continence recovery experienced a significant improvement. At a long-term analysis of functional outcomes of our patients, renal function preservation and continence recovery results are encouraging.

Development and Validation of a Model for Predicting Urethral Recurrence in Male Patients with Muscular Invasive Bladder Cancer After Radical Cystectomy Combined with Urinary Diversion

Purpose

Radical cystectomy (RC) is the primary treatment strategy for patients with muscular invasive bladder cancer (MIBC). However, the prognosis is poor and tumor recurrence is not rare, in particular, urethral recurrence (UR) in male patients who underwent RC combined with urinary diversion. Here, we have developed and validated a model for predicting UR in these patients.

Patients and Methods

The development cohort comprised 310 patients who underwent RC combined with urinary diversion at our center between 1 January 2007 and 31 December 2015. Clinicopathologic data of patients were comprehensively recorded. Multivariate Cox proportional hazard regression was used for building a predictive model with regression coefficients and backward stepwise selection applied by utilizing the likelihood ratio test with Akaike’s information criterion as the stopping rule. An independent cohort consisting of 131 consecutive patients treated from 1 January 2016 to 31 December 2017 was used for validation. The performance of this predictive model was assessed with respect to discrimination, calibration, and clinical usefulness.

Results

The predictors of this model included body mass index, history of transurethral resection of bladder tumor, tumor grade, tumor stage, and concomitant carcinoma in situ. In the validation cohort, the model showed good discrimination with a concordance index of 0.777 (95% CI, 0.618 to 0.937) and calibration. Decision curve analysis also demonstrated the clinical utility of the model.

Conclusion

The predictive model facilitated postoperative individualized prediction of UR in male patients with MIBC after RC combined with urinary diversion and it may therefore serve to improve follow-up strategies.

Impact of Clinical Response to Neoadjuvant Chemotherapy in the Era of Robot Assisted Radical Cystectomy: Results of a Single-Center Experience

BACKGROUND

Response to neoadjuvant chemotherapy (NACT) has been proven to be an established prognostic factor after open radical cystectomy (ORC). We evaluated the impact of NACT on survival outcomes of a single-institution robotic radical cystectomy (RARC) series.

METHODS

From January 2012 to June 2020, 79 patients were identified. Baseline, demographic, perioperative, and pathologic data were described. Kaplan-Meier with the log-rank test was used to compare overall survival (OS) differences between complete, partial, and no-NACT responders, respectively. Univariable and multivariable regression analyses were performed to identify predictors of OS.

RESULTS

Complete, partial, and absent response to NACT were recorded in 43 (54.4%), 21 (19%), and 15 (26.6%) patients, respectively. A complete response to NACT displayed a trend toward significant higher OS (p = 0.03). In univariable analysis, significant predictors of lower OS were hypertension (HR 3.37; CI 95% 1.31-8.62; p = 0.01); advanced nodal involvement (HR 2.41; CI 95% 0.53-10.9; p < 0.001); and incomplete response to NACT (HR 0.41; CI 95% 0.18-0.95; p = 0.039). In multivariable analysis, the only independent predictor of worse OS was advanced pathologic N stages (HR 10.1; CI: 95% CI 2.3-44.3; p = 0.002).

CONCLUSIONS

Complete response to NACT is associated with increased OS probability, but significant nodal residual disease remains the only independent predictor of OS after RARC.

Late complications of robot-assisted radical cystectomy with totally intracorporeal urinary diversion

Introduction and objectives

To evaluate late complications in a large cohort of patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD).

Materials and methods

We prospectively enrolled patients who underwent RARC and ICUD between August 2012 and June 2019. We excluded patients with Ejection fraction < 36%, retinal vasculopathy, ventriculoperitoneal shunts, and those treated without curative intent. All complications and their onset date have been recorded, defined, and graded according to Clavien classification adapted for radical cystectomy.

Results

210 patients were included, 76% of whom were men, with a mean age of 62 years. Urinary diversions used were Padua Ileal Bladder (PIB) in 80% of cases, and ileal conduit (IC) in 20% of patients (generally older and with more comorbidity). The mean follow-up was 30 ± 22 months. The stenosis rate of uretero-ileal anastomosis was 14%, while a reduction in eGFR (≥ 20%) was observed in about half of the cases. UTIs occurred in 37% of the patients, especially in the first 12 months. Only 2% of patients had bowel occlusion, whereas incisional hernia, lymphocele, and systemic events (metabolic acidosis and major cardiovascular events) occurred respectively in 20%, 10%, and 1% of cases.

Conclusions

Our study evaluates first late complications in a cohort of patients who underwent RARC with ICUD. These data are encouraging and in line with findings from a historical series of open radical cystectomy (ORC). This study is a further step in supporting RARC as a safe and effective surgical option for the treatment of muscle-invasive bladder cancer (MIBC) in tertiary referral centers.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03378-7) contains supplementary material, which is available to authorized users.

Perioperative outcomes and safety of robotic vs open cystectomy: a systematic review and meta-analysis of 12,640 cases

PURPOSE

Robotic radical cystectomy (RRC) has become a commonly utilised alternative to open radical cystectomy (ORC). We performed a systematic review and meta-analysis of RRC vs ORC focusing on perioperative outcomes and safety.

METHODS

Medline, EMBASE and CENTRAL were searched from January 2000 to April 2020 following the Preferred Reporting Items for Systematic Review and Meta-analysis Statement for study selection.

RESULTS

In total, 47 studies (5 randomised controlled trials, 42 non-randomised comparative studies) comprising 12,640 patients (6572 ORC, 6068 RRC) were included. There was no difference in baseline demographics between the groups apart from males were more likely to undergo ORC (OR 0.77, 95% CI 0.69-0.85). Those with muscle-invasive disease were more likely to undergo RRC (OR 1.21, 95% CI 1.09-1.34), and those with high-risk non-muscle-invasive bladder cancer were more likely to undergo ORC (OR 0.80, 95% CI 0.72-0.89). RRC had a significantly longer operating time, less blood loss and lower transfusion rate. There was no difference in lymph node yield, rate of positive surgical margins, or Clavien-Dindo Grade I-II complications between the two groups. However, the RRC group were less likely to experience Clavien-Dindo Grade III-IV (OR 1.56, 95% CI 1.30-1.89) and overall complications (OR 1.45, 95% CI 1.26-1.68) than the ORC group. The mortality rate was higher in ORC although this did not reach statistical significance (OR 1.52, 95% CI 0.99-2.35).

CONCLUSION

RRC has significantly lower blood loss, transfusion rate and is associated with fewer high grade and overall complications compared to ORC.

Benefits of robotic cystectomy compared with open cystectomy in an Enhanced Recovery After Surgery program: A propensity-matched analysis

OBJECTIVES

To compare the perioperative and oncological outcomes between robot-assisted radical cystectomy with intracorporeal urinary diversion versus open cystectomy for bladder cancer in a contemporary Enhanced Recovery After Surgery cohort.

METHODS

All consecutive patients who underwent radical cystectomy and managed under an Enhanced Recovery After Surgery protocol, from December 2013 to October 2018, were reviewed. Propensity score adjustment was carried out to reduce biases attributable to covariate imbalances.

RESULTS

There were 19 robot-assisted radical cystectomy with intracorporeal urinary diversion and 21 open cystectomy patients. The robot-assisted radical cystectomy with intracorporeal urinary diversion cohort was associated with lower estimated blood loss (397 vs 787 mL, P = 0.05), with a trend toward shorter duration of ileus and postoperative opioid administration. These benefits were apparent, despite a longer operative time (581 vs 446 mins, P = 0.03), a higher proportion of orthotopic bladder reconstruction (26.3 vs 9.5%, P = 0.08), a more prevalent use of neoadjuvant chemotherapy and a higher number of salvage cystectomies for the robot-assisted radical cystectomy with intracorporeal urinary diversion group. Comparable perioperative complications and length of hospital stay were observed. The pathological and intermediate oncological outcomes were similar in both groups (locally advanced disease: 52.6 vs 47.6%, P = 0.85; lymph node yield: 29 vs 34, P = 0.23). The mean recurrence-free survival and overall survival in the robot-assisted radical cystectomy with intracorporeal urinary diversion group was 37.5 and 43.0 months, respectively, compared with 21.4 (P = 0.09) and 35.5 (P = 0.14) months, respectively, in open cystectomy.

CONCLUSION

Robot-assisted radical cystectomy with intracorporeal urinary diversion has perioperative benefits of lower estimated blood loss, with a trend toward faster bowel recovery and a shorter duration of opioid analgesia when compared with open cystectomy. Robot-assisted radical cystectomy with intracorporeal urinary diversion also achieves similar intermediate-term oncological and survival outcomes.

Totally intracorporeal robot-assisted urinary diversion for bladder cancer (part 2). Review and detailed characterization of the existing intracorporeal orthotopic ileal neobladder

Abstract

To review the most used intracorporeal orthotopic ileal neobladder (ICONB) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new consistent images.

Methods

We performed a non-systematic review of the literature with the keywords “bladder cancer”, “urinary diversion”, “radical cystectomy”, and “neobladder”.

Results

Forty studies were included in the analysis. The most frequent type of ICONB was the modified Studer “U” neobladder (70%) followed by the Hautmann “W” modified neobladder (7.5%), the “Y” neobladder (5%), and the Padua neobladder (5%). The operative time to perform a urinary diversion ranged from 124 to 553 min. The total estimated blood loss ranged from 200 to 900 mL. The rate of positive surgical margins ranged from 0% to 8.1%. Early minor and major complication rates ranged from 0% to 100% and from 0% to 33%, respectively. Late minor and major complication rates ranged from 0% to 70% and from 0% to 25%, respectively.

Conclusion

The most frequent types of ICONB are Studer “U” neobladder, Hautmann “W” neobladder, “Y” neobladder, and the Padua neobladder. Randomized studies comparing the performance of the different types of ICONB, the performance in an intra or extracorporeal manner, or the performance of an ICONB versus ICIC are lacking in the literature. To this day, there are not sufficient quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used ICONB with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images of each technique.

Robot-assisted intracorporeal orthotopic bladder substitution after radical cystectomy: perioperative morbidity and oncological outcomes - a single-institution experience

OBJECTIVE

To report a single-institution experience with totally intracorporeal neobladder urinary diversion (UD) after robot-assisted laparoscopic radical cystectomy (RARC).

PATIENTS AND METHODS

A total of 158 patients underwent totally intracorporeal neobladder UD after RARC between 2003 and 2016. Patient demographics, intraoperative and pathological data, 30- and 90-day perioperative mortality and complications were recorded. Complications were classified according to the modified Clavien-Dindo classification. The 5-year overall (OS) and cancer-specific survival (CSS) rates were estimated by Kaplan-Meier plots.

RESULTS

Most of the patients were male (84%) and had clinical T Stage ≤2 (87%). The mean operation time was 359 (SD ±98) min, with a median (range) estimated blood loss of 300 (50-2200) mL. Most of the men (86%) received a nerve-sparing procedure and 38% of the females an organ-sparing approach. A lymph node dissection was performed in 156 (99%) patients, with a median (range) yield of 23 (7-48) nodes. Conversion to open surgery occurred in five patients (3%). We recorded negative margins in 156 patients (99%). The median (range) follow-up was 34 (1-170) months, with 30- and 90-day mortality rates of 0%. Clavien-Dindo Grade III-IV complications occurred in 29 of 158 (18%) patients at 30-days and in eight of 158 (5%) between 30-90 days, resulting into a 90-day overall high-grade complication rate of 23%. The unadjusted estimated 5-years recurrence-free survival, CSS and OS rates were 70%, 72%, and 71%, respectively.

CONCLUSION

In our present series the complication and oncological results were similar to open RC series, suggesting that RARC followed by totally intracorporeal neobladder UD is a safe and feasible alternative.

Sex-Sparing Robot-Assisted Radical Cystectomy with Intracorporeal Padua Ileal Neobladder in Female: Surgical Technique, Perioperative, Oncologic and Functional Outcomes

Our aim was to illustrate our technique of sex-sparing (SS)-robot-assisted radical cystectomy (RARC) in female patients receiving an intracorporeal neobladder (iN). From January 2013 to June 2018, 11 female patients underwent SS-RARC-iN at a single tertiary referral center. Inclusion criteria were a cT ≤ 2 N0 M0 bladder tumor at baseline imaging (CT or MRI) and an absence of tumors in the bladder neck, trigone and urethra at TURB. Baseline, perioperative, and outcomes at one year were reported. The median operative time was 255 min and the median hospital stay was seven days. Low-grade Clavien complications occurred in four patients (36.3%), while high-grade complications were not observed in any. Seven patients (63.7%) had an organ-confined disease at the pathologic specimen; nodal involvement and positive surgical margins were not detected in any of the cases. At a median follow-up of 28 months (IQR 14–51), no patients developed new onset of chronic kidney disease stage 3b. After one year, daytime and nighttime continence rates were 90.9% and 86.4% respectively. Quality of life as well as physical and emotional functioning improved significantly over time (all p ≤ 0.04), while urinary symptoms and sexual function worsened at three months with a significant recovery taking place at one year (all p ≤ 0.04). Overall, 8 out of 11 patients (72.7%) were sexually active at the 12-month evaluation. In select female patients, SS-RARC-iN is an oncologically sound procedure associated with favorable perioperative and functional outcomes.

Orthotopic Neobladder Reconstruction: Patient Selection And Perspectives

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure that may be performed in a patient with bladder cancer following a radical cystectomy. The selection of a patient for an ONB reconstruction is strict as not everyone may be suitable to undergo this complex surgery. Patients must be not only mentally competent but also physically dexterous enough to allow for appropriate neobladder training post-procedure, to achieve best urinary function. However, even with a carefully chosen patient population, various complications specific to ONB reconstruction may result. Metabolic acidosis may result from electrolyte shifts, resulting in secondary complications such as bone demineralization and urinary calculi. In addition, nutritional deficiencies may result from the use of a transposed intestinal segment for the fashioning of the reservoir. A widely used outcome measure when assessing for ONB reconstruction is continence. With a strict neobladder training regimen, daytime continence may be achieved in roughly 70% of patients post-ONB procedure. This number may increase over the course of several years, although may decrease in up to 20 years of follow-up. Similarly, quality of life (QoL) measures have been widely studied, and current literature suggests slightly better QoL achieved with ONB compared to other urinary diversion procedures. Of note, the tools used to assess continence and QoL vary between studies, limiting the interpretability of the summarized data. Nevertheless, ONB reconstruction is a procedure that is still evolving, with ongoing modifications that can reduce complications and improve patient urinary function.

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.

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.

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.

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.

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.

Utility of robot-assisted radical cystectomy with intracorporeal urinary diversion for muscle-invasive bladder cancer

Radical cystectomy remains the gold standard for treatment of muscle‐invasive bladder cancer. Robot‐assisted radical cystectomy has technical advantages over laparoscopic radical cystectomy and has emerged as an alternative to open radical cystectomy. Despite the advancements in robotic surgery, experience with total intracorporeal reconstruction of urinary diversion remains limited. Most surgeons have carried out the hybrid approach of robot‐assisted radical cystectomy and extracorporeal reconstruction of urinary diversion, as intracorporeal reconstruction of urinary diversion remains technically challenging. However, intracorporeal reconstruction of urinary diversion might potentially proffer additional benefits, such as decreased fluid loss, reduction in estimated blood loss and a quicker return of bowel function. The adoption of intracorporeal ileal neobladder reconstruction has hitherto been limited to high‐volume academic institutions. In the present review, we compare the totally intracorporeal robot‐assisted radical cystectomy approach with open radical cystectomy and robot‐assisted radical cystectomy + extracorporeal reconstruction of urinary diversion in muscle‐invasive bladder cancer patients.