Open radical cystectomy with lymphadenectomy remains the treatment of choice for invasive bladder cancer

Lymphadenectomy before and after radical cystectomy: does this affect the radicality? A prospective randomized comparative study

PURPOSE

To compare the oncological outcome of performing ePLND before or after RC in 200 patients in a prospective randomized manner.

MATERIALS AND METHODS

From January 2014 to December 2019, 200 patients with T2-T3b N0M0 BCa were included in the current study after signing an informed consent. Patients were divided into two groups, 100 in each one. Group I underwent ePLND before RC, whereas group II underwent ePLND after RC. Postoperative evaluation included clinical, laboratory, and radiographic studies.

RESULTS

Patients' characteristics were comparable between both groups. The mean operative time excluding that of urinary diversion was significantly shorter in group II than in group I (p = 0.01). The mean number of LNs removed was 25 ± 6 in group I and 32 ± 8 in group II (p = 0.141). Intraoperative complications occurred in four patients in the form of external iliac artery and vein injury [two in each group (p = 0. 245)]. Postoperative complications were comparable between both groups with no statistically significant difference (p = 0.375). Oncological failure occurred in 28 patients [16 (17.6%) in group I and 12 (22%) in group II (p = 0.389)].

CONCLUSIONS

EPLND before and after RC has comparable oncological outcomes. The stage of the disease, the time since the first diagnosis till RC and the surgeon experience in performing meticulous ePLND are more important. In absence of oncological superiority, the timing of ePLND should be judged according to the patient-related factors to facilitate safe RC with minimal morbidity.

Mini-laparotomy radical cystectomy with limited bowel externalization during ileal conduit urinary diversion reduces the rate of postoperative complications: a match-paired, single centered analysis

OBJECTIVE

To assess the feasibility and functional outcomes of mini-laparotomy radical cystectomy (RC) in association with limited bowel externalization during ileal conduit urinary diversion.

METHODS

Between January 2018 and March 2020, 53 patients underwent RC plus pelvic lymph node dissection (PLND) for invasive carcinoma of the urinary bladder. This group of patients was intentionally treated utilizing the mini-laparotomy approach, with the addition of limited bowel externalization during conduit preparation and match-paired with 46 examinees from a historical series of patients who underwent conventional open RC plus PLND and ileal conduit diversion. Clinicopathological features and perioperative outcomes were examined from medical records, while postoperative pain was evaluated through the Visual Analog Scale for Pain (VAS). Mean pain scores were evaluated on postoperative days (POD) 1-3.

RESULTS

There was no difference in specific intraoperative complications between groups, with a median (range) incision length of 8 (5-10) cm within the first group and 16.3 (12-22.6) cm within the second group. The first group had less postoperative pain compared with patients in the second group, with mean pain scores significantly lower across POD 1-3, 3.8 (IQR: 0-6) versus 6.7 (IQR: 3.8-8.1) and 2.5 (IQR: 1-3.7) versus 4.6 (IQR: 3-6), respectively (p = .012 and .002).

CONCLUSIONS

By using this technique, we were able to significantly reduce patients' postoperative pain, time to bowel restitution, and hospital stay, which are major issues in minimizing short-term postoperative complications of conventional open surgery.

Contemporary Outcomes of Open Radical Cystectomy: a 5-Year Experience from a Tertiary Care Center

To evaluate the perioperative outcomes of patients undergoing open radical cystectomy for carcinoma bladder in a tertiary care center. A retrospective analysis of a prospectively maintained database of all patients undergoing open radical cystectomy with a urinary diversion from July 2014 to August 2019 was done. A total of 195 patients were included. A total of 172 patients (88.2%) underwent radical cystectomy with ileal or sigmoid conduit, 6 patients underwent orthotopic neobladder, and 17 patients underwent cutaneous ureterostomy. The mean American Society of Anaesthesiology (ASA) score was 1.4. On preoperative histopathology, 125 patients had the muscle-invasive disease. The mean operative time (± SD) was 303.6 ± 53.4 min and the operative time was significantly longer for neobladder (p = 0.033). The mean blood loss (± SD) was 977.5 ± 346.5 ml. Among the complications, a total of 350 events occurred in 96 patients (49.3%). Thirty-nine patients (20%) suffered grade I complications, 12 patients (6.2%) suffered grade II complications, 26 patients (13.3%) suffered grade III complications, and 9 patients (4.6%) suffered grade IV complications. Grade III, IV, and V complications were considered major complications and 46 patients (23.5%) had major complications. Among the grade III complications, the majority included fascial dehiscence (burst abdomen), i.e., 13.3%, and uretero-ileal leak, i.e., 2.6%. The overall 30-day mortality rate was 5.2% (10/195). On multivariate analysis, the presence of diabetes mellitus (p = 0.047), operative time (p = 0.003), and low preoperative albumin (p = 0.009) were significant predictors for major preoperative complications. Diabetes mellitus, serum albumin, and operative time are significant predictors of postoperative complications. The ASA score, low preoperative hemoglobin, and blood loss are significant predictors of perioperative mortality. Though radical cystectomy has been associated with significant perioperative morbidity and mortality, the advancements in surgical techniques and intensive care tools have led to a significant decrease in morbidity and mortality in the contemporary era.

Impact of clinical stage on the outcome of laparoscopic radical cystectomy: a prospective cohort study

Background

Some authors recommend not to perform laparoscopic radical cystectomy (LRC) for large bulky bladder cancer (BC) as the laparoscopic manipulation will be difficult. As there were no prospective studies focusing on the effect of the tumor stage of BC on the outcome of LRC, the aim of this prospective cohort study was to evaluate the effect of tumor stage on the outcome of LRC.

Results

LRC was completed for 47 patients. All patients were followed for at least 1 year, and there was no recurrence. COPD, DM, hypertension and renal impairment were detected, respectively, in 57.4%, 36.2%, 44.7% and 10.6% of patients. Transitional cell carcinoma and squamous cell carcinoma were found, respectively, in 91.5% and 8.5% of patients. Complications were reported in 29.78% including 29.78% Clavien grade 1, 17.02% grade 2 and 6.38% grade 3. There was no significant difference between cT2 and cT3 in perioperative criteria including demographic features, operative time, estimated blood loss, blood transfusion, pain score, hospital stay and complications. Upon final pathological assessment, 44.68% of patients were upgraded to higher pathological stages. Additional comparison was performed according to pathological stage and revealed no significant difference in the outcome of LRC between pT2 and higher stages except the pain score at first postoperative day which was higher in patients with pT3 stage.

Conclusion

LRC is a feasible and safe technique for both T2 and T3 clinical and pathological stages.

Timing of lymphadenectomy during robot-assisted radical cystectomy: before or after cystectomy? Fifteen cases with totally intracorporeal urinary diversions

Introduction

Many publications detail the level and number of lymphadenectomies, whereas the timing of pelvic lymph node dissection (PLND) is infrequently discussed in the robot-assisted radical cystectomy (RARC) series.

Aim

To determine the effects of performing PLND before or after cystectomy in totally intracorporeal RARC on operative outcomes.

Material and methods

A total of 15 patients included in the study underwent RARC and intracorporeal orthotopic neobladder. Of these, 8 patients underwent PLND before cystectomy (group 1), whereas 7 underwent PLND after cystectomy (group 2). Demographic information, intraoperative data, and post-operative outcomes were recorded for each patient.

Results

The mean ± SD age was 61.87 ±6.76 years. Overall mean operation time (OT) was 537.33 ±63.07 min. The mean EBL and hospitalization time were 322.33 ±69.92 ml and 13.87 ±5.2 days. The number of LN removed was 23.75 ±3.454 for group 1 and 13.71 ±6.873 for group 2 (p = 0.007). The postoperative pathological stages were: pT2(5), pT3(2), pT4(1) for group 1, pT2(4), pT3(2), pT4(1) for group 2. Surgical margins were negative in all patient. Overall complications occurred in 7 (46.6%) patients. Only the number of LN removed was statistically significant in favor of group 1 (p = 0.007). Mean follow-up was 15.87 months.

Conclusions

Our initial experience with performing extended PLND (ePLND) before or after cystectomy in totally intracorporeal RARC appears to be favorable, with similar oncological results and acceptable complication rates. However, although the number of cases is too low for statistical evaluation, it seems to be advantageous to perform ePLND before cystectomy in terms of LN number and operation time.

Single-center experience of robot-assisted radical cystectomy (RARC) and extended pelvic lymph node dissection

OBJECTIVE

To report the outcomes of robot-assisted radical cystectomy (RARC) and extended pelvic lymph node dissection (ePLND) series for bladder cancer.

MATERIAL AND METHODS

Between October 2016 and June 2019, overall 57 patients (50 men, 7 women) were included in the study. Patient demographics, operative data, and postoperative pathological outcomes were evaluated. Patients who had a history of pelvic or Professional surgery due to other concurrent malignancy, radiation therapy, or lacked data were excluded from the study.

RESULTS

The mean age of the patients was 64.72±9.09 years. The mean operation time, intraoperative estimated blood loss, and hospitalization time were 418.58±85.66 minutes, 313.00±79.16mL, and 13.44±5.25 days, respectively. The postoperative pathological stages were reported as pT0 (n=8), pTis (n=4), pT1 (n=4), pT2 (n=22), pT3a (n=11), pT3b (n=2), pT4a (n=4), pT4b (n=1), and other (n=1). The mean lymph node (LN) yield was 23.45±9.43. Positive LNs were found in 16 (28.1%) patients. Surgical margins were positive in 3 (5.26%) patients. The mean follow-up period was 15.42±8.31 months. According to the modified Clavien-Dindo system, minor (Clavien 1-2) and major (Clavien 3-5) complications occurred in 18 (31.58%) and 9 (15.78%) patients during the early (0-30 days) period and in 4 (7.02%) and 5 (8.77%) patients in the late (31-90 days) period.

CONCLUSION

RARC and ePLND are complex but safe procedures with acceptable morbidity and excellent surgical and oncologic outcomes in muscle-invasive or high-risk bladder tumors.

Elderly patients undergoing cystectomy, comparing preoperative American Society of Anesthesiology and Eastern Cooperative Oncology Group scores and operative approaches

Objective:

To evaluate preoperative scoring systems and operative management and their relation to complications in patients older than 75 years undergoing cystectomy at two academic institutions.

Methods:

In total, 212 patients aged 75–95 years with muscle invasive bladder cancer underwent cystectomy at the University of Utah and Central Hospital of Bolzano, Italy. The rates of Grade 3 Clavien-Dindo complications and above in radical cystectomy patients (n = 199) were compared using Eastern Cooperative Oncology Group Scores and American Society of Anesthesiologists Physical Status Classification. The rates of Grade 3 Clavien-Dindo complications and above were also compared by urinary diversion type. Logistic regression was used to control for source institution.

Results:

In total, 199 cases were included in the primary analysis. Neither of the preoperative scoring systems were predictive for identification of radical cystectomy patients with ⩾Grade 3 Clavien-Dindo complications. In secondary analysis (n = 212, including partial cystectomy), none of the urinary diversion types associated with radical cystectomy had a significantly different rate of complications. However, partial cystectomy (n = 13) had a significantly lower rate of complications.

Conclusion:

Complication rates among elderly patients undergoing cystectomy for muscle invasive bladder cancer were very high. For patients who are approved for surgery after the history and physical exam, none of our objective metrics adequately predicted operative risk. A unique diversion procedure described by the Bolzano group, uretero-ureterocutaneostomy, had equivalent complication rates to the more common diversion procedures. It also appears based on outcomes in this cohort that partial cystectomy is a particularly favorable option within the elderly population in terms of perioperative morbidity.

Reasons why not all Danish patients with muscle invasive bladder cancer receive neoadjuvant chemotherapy before radical cystectomy

Background: Danish guidelines on muscle invasive bladder cancer (MIBC) recommend neoadjuvant chemotherapy (NAC) for non-metastatic patients fit for cisplatin-based chemotherapy. The current indication is urothelial MIBC in patients less than 75 years old with no metastasis on imaging and normal renal function (GFR ≥ 60 ml/min). Data from the Danish Bladder Cancer Database (DaBlaCa-Data) reveals that only 40-50% of MIBC patients below 75 years of age receive NAC prior to cystectomy. The aim of this study was to clarify the reasons why the remaining patients do not receive NAC.Methods: Individual patient data were collected retrospectively from all five Danish urologic departments performing cystectomies. Patients fulfilling the inclusion criteria: MIBC at TURBT, age less than 75 years old and subsequent cystectomy were included and registered by the specific reason why NAC was not given. In total, 449 patients met the age- and T-stage criteria for NAC in the period September 2014 through August 2017.Results: In total, 274 patients (61.0%) received chemotherapy. Of the 175 patients who did not receive NAC, 140 patients (80%) were not fit for cisplatin and 35 patients did not receive NAC and had no specific contraindication. This ranged from 0-18% of included patients in the different centres. The main reason was patient refusal (97%). Interestingly, this ranged from 0-50% of patients not receiving NAC when comparing the five centres.Conclusion: These findings underline the need for proper patient information in order to get a uniform treatment strategy between centres.

Peri-operative efficacy and long-term survival benefit of robotic-assisted radical cystectomy in septuagenarian patients compared with younger patients: a nationwide multi-institutional study in Japan

BACKGROUND

To determine the peri-operative safety and oncological value of robotic-assisted radical cystectomy (RARC) for older and younger patients in an initial Japanese RARC series.

METHODS

We retrospectively analyzed the demographics, complications, peri-operative and oncological outcomes of 253 consecutive patients with bladder cancer who underwent RARC at 34 institutions in Japan between April 2009 and March 2017. The patients were assigned to groups according to ages at surgery of < 70 (younger; n = 125) and ≥ 70 (older; n = 128) years.

RESULTS

Mean Charlson comorbidity index (p = 0.045) and the incidence of a history of previous abdominal surgery (p = 0.002) were significantly higher, whereas a history of neoadjuvant chemotherapy (p = 0.028) and neobladder (p < 0.001) were significantly lower in the older group. Mean total operative time was significantly shorter (p = 0.019) and mean estimated blood loss (p = 0.013) was significantly lower in the older group. Post-operative Grade ≥ II complications were comparable at 0-30, 31-90 and 91 days after surgery despite urinary tract associations. Rates of positive surgical margins and mean numbers of removed lymph nodes were comparable between the two groups. Although 5-year overall survival rates were significantly lower (p = 0.03) for older patients, 5-year cancer-specific (p = 0.10) and recurrence-free survival rates were comparable (p = 0.20) between the groups.

CONCLUSION

Using RARC potentially allows the application of less invasive procedures and cancer control for septuagenarian patients that are equivalent to those for younger patients.

Role of Percutaneous Nephrostomy in Bladder Carcinoma with Obstructive Uropathy: A Story Revisited

Objective:

To evaluate the role of percutaneous nephrostomy (PCN) in patients of carcinoma bladder presenting with obstructive uropathy.

Material and Methods:

We evaluated medical records of 33 patients of bladder cancer with obstructive uropathy that presented to a tertiary care hospital in north India from January 2015 to December 2016. Outcome measures included technical success rates, change in blood urea and serum creatinine (measured on Day 1, 7, and 14); and complications of PCN according to Society of Interventional Radiology Guidelines for Percutaneous Nephrostomy.

Results:

PCN was done in 30 patients. The mean age of patients was 51 years (range 42-67). 24 patients were male and 6 patients were female. The technical success rates for PCN placement were 93.33%. In 12 patients there was no improvement after PCN insertion. Improvement in clinical condition/kidney function occurred in 18 patients. Out of these 6 patients underwent radical cystectomy with ileal conduit formation and palliative radiotherapy/chemotherapy was given to 5 cases. In the remaining 7 patients, after an initial improvement that lasted for 2 weeks after PCN progressive renal dysfunction developed due to malignancy. Minor complications of PCN were seen in 16.6% of patients and major complications were seen in 10 % of cases.

Conclusion:

In selected patients with bladder carcinoma with obstructive uropathy, PCN insertion may improve kidney function tests to normal levels and enable them to receive tumor-specific curative/palliative treatment.

Robotic radical cystectomy for the management of bladder cancer: Analysis of operative and pathological outcomes of eighteen patient

OBJECTIVE

To present the surgical and pathological results of robotic radical cystectomy (RRC) operations performed in our clinic.

MATERIAL AND METHODS

A total of 18 patients, who underwent RRC and intracorporeal urinary diversion between October 2016 and September 2017 for clinically localized bladder cancer in our clinic, were included in the study. The results were evaluated under three headings. 1. operative outcomes (total operation time, perioperative blood loss, postoperative hematocrit decrease) 2. recovery period (pull-off drain day, hospitalization time) 3. oncological results (pathologic stage, surgical margin, number, and characteristics of lymph nodes removed). Complications within the postoperative 30-day period, were evaluated and the Clavien classification system was used to classify the complications.

RESULTS

The mean age of the patients was 64.4 (52-80) years. Seventeen male patients and one female patient underwent robotic cystectomy. At the operative outcomes, the mean blood loss was 325 mL, and the mean hematocrit decrease was 3.15%. The mean duration of the surgery was 471 minutes (330-630), while the median operative time was 450 minutes. Complications occured in 6 patients during the early postoperative period. Six of them (75%) had minor complications (Clavien grade 1), two patients (25%) had major complications (Clavien grade 4).

CONCLUSION

Our initial experience with RRC is that, this surgical technique has acceptable operative, oncological and short-term clinical outcomes. However, prospective randomized studies are needed to assess whether there is a clear advantage compared to open surgery.

Robot-assisted laparoscopic radical cystectomy with extracorporeal urinary diversion: Initial experience and outcomes

INTRODUCTION

Open radical cystectomy (ORC) is the most common surgical approach for invasive carcinoma of the urinary bladder, but robot-assisted radical cystectomy (RARC) has recently gained popularity. There is limited data from the Indian subcontinent on RARC. The aim of this study was to assess the perioperative, pathological, and oncological outcomes of RARC and follow-up in our initial 63 cases.

MATERIALS AND METHODS

A retrospective analysis of prospectively maintained data of 63 RARC procedures performed in our tertiary care institute from July 2006 to January 2016 was done. All patients underwent RARC with extracorporeal urinary diversion. We analyzed perioperative parameters, length of hospital stay, pathological and oncological outcomes, and rate of complications. Follow-up data were analyzed for disease recurrence and survival.

RESULTS

The mean age of the patients was 58 years. The mean American Society of Anesthesiologists (ASA) score was 1.66. Mean operative time was 348.6 min and mean blood loss was 868.2 ml. Mean hospital stay was 10.4 days (±5.4 days). 42.8% patients had pT2 disease, 49.2% pT3, 1.58% pT1, and 6.34% had pT4 disease. Mean lymph node yield was 12.4 (3-25). One patient had positive surgical margins. Twenty-four patients had postoperative complications of which four were major complications (Clavien-Dindo 3 or higher). At a median follow-up of 60 months (range: 3-108 months), 11 patients were lost to follow-up 10 patients developed metastasis, out of which 4 died. Four had recurrence, two died and two are receiving chemotherapy.

CONCLUSION

This study shows the feasibility and safety of RARC. The operative time, blood loss, return of bowel activity and hospital stay were higher than those reported in the literature but may reflect the learning curve.

Prospective study comparing laparoscopic and open radical cystectomy: Surgical and oncological results

INTRODUCTION

Laparoscopic radical cystectomy with lymphadenectomy and urinary diversion is an increasingly widespread operation. Studies are needed to support the oncological effectiveness and safety of this minimally invasive approach.

PATIENTS AND METHODS

A nonrandomised, comparative prospective study between open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) was conducted in a university hospital. The main objective was to compare cancer-specific survival. The secondary objective was to compare the surgical results and complications according to the Clavien-Dindo scale.

RESULTS

We treated 156 patients with high-grade invasive bladder cancer with either ORC (n=70) or LRC (n=86). The mean follow-up was 33.5±23.8 (range 12-96) months. The mean age was 66.9+9.4 years, and the male to female ratio was 19:1. Both groups were equivalent in age, stage, positive lymph nodes, in situ carcinoma, preoperative obstructive uropathy, adjuvant chemotherapy and type of urinary diversion. There were no differences between the groups in terms of cancer-specific survival (log-rank; P=.71). The histopathology stage was the only independent variable that predicted the prognosis. The hospital stay (P=.01) and operative transfusion rates (P=.002) were less for LRC. The duration of the surgery was greater for LRC (P<.001). There were no differences in the total complications rate (p=.62) or major complications (P=.69). The risk of evisceration (P=.02), surgical wound infection (P=.005) and pneumonia (P=.017) was greater for ORC. The risk of rectal lesion (P=.017) and urethrorectal fistulae (P=.065) was greater for LRC.

CONCLUSION

LRC is an equivalent treatment to ORC in terms of oncological efficacy and is advantageous in terms of transfusion rates and hospital stays but not in terms of operating room time and overall safety. Studies are needed to better define the specific safety profile for each approach.

Residual tumor micro-foci and overwhelming regulatory T lymphocyte infiltration are the causes of bladder cancer recurrence

Bladder cancer has an unexplained, high recurrence rate. Causes of recurrence might include the presence of sporadic tumor micro-foci in the residual urothelial tissue after surgery associated with an inverted ratio between intratumoral effector and regulatory T cell subsets. Hence, surgical specimens of both tumors and autologous, macroscopically/histologically free-of-tumor tissues were collected from 28 and 20 patients affected by bladder or renal cancer, respectively. The frequencies of effector (IFNγ+ and IL17+ T cells) and regulatory (CD4+CD25hiCD127lo and CD8+CD28-CD127loCD39+ Treg) T cell subpopulations among tumor infiltrating lymphocytes were analyzed by immunofluorescence, while the gene expression of MAGE-A1 and MAGE-A2 tumor-associated antigens was studied by RT-PCR. The results show that both the T cell infiltrate and the frequency of MAGE-A1/A2 gene expression were comparable in tumors and in autologous free-of-tumor tissues in bladder cancer, while the autologous free-of-tumor renal tissues showed reduced T cell infiltrate and frequency of MAGE gene expression as compared to the autologous tumors. Importantly, the intra-tumor T effector/Treg cell ratio was consistently <1 in bladder cancer patients (n. 7) who relapsed within two years, while it was always >1 in patients (n. 6) without recurrence (regardless of tumor stage) (P = 0.0006, Odds ratio = 195). These unprecedented findings clarify the pathogenic mechanism of bladder cancer recurrence and suggest that microscopically undetectable micro-foci of tumor may predispose to recurrence when associated with an inverted intratumoral T effector/Treg cell ratio.

Robot-assisted laparoscopic radical cystectomy with complete intracorporeal urinary diversion

Robot-assisted radical cystectomy with intracorporeal urinary diversion (RARC-ICUD) has only recently been explored as a viable surgical option for patients with muscle-invasive bladder cancer seeking satisfactory oncologic control while benefiting from minimally invasive surgical techniques. Inspired by earlier open and laparoscopic work, initial descriptions of RARC-ICUD were published in 2003, and have since been followed by multiple larger case series which have suggested promising outcomes for our patients. However, the rate of adoption has remained relatively slow when compared to other robot-assisted procedures such as the radical prostatectomy, likely owing to longer operative times, operative complexity, costs, and uncertainty regarding oncologic efficacy. The operative technique for RARC-ICUD has evolved over the past decade and several high-volume centers have shared tips to improve efficiency and make the operation possible for a growing number of urologists. Though there are still questions regarding economic costs, effectiveness, and generalizability of outcomes reported in published data, a growing dataset has brought us ever closer to the answers. Here, we present our current operative technique for RARC-ICUD and discuss the state of the literature so that the urologist may hold an informed discussion with his or her patients.

Open versus robotic radical cystectomy with intracorporeal Studer diversion

Background and Objectives:

To compare open versus totally intracorporeal robotic-assisted radical cystectomy, bilateral extended pelvic lymph node dissection, and Studer urinary diversion in bladder cancer patients.

Methods:

A retrospective comparison of open (n = 42) versus totally intracorporeal (n = 32) robotic-assisted radical cystectomy, bilateral extended pelvic lymph node dissection, and Studer urinary diversion was performed concerning patient demographic data, operative and postoperative parameters, pathologic parameters, complications, and functional outcomes.

Results:

Patient demographic data and the percentages of patients with pT2 disease or lower and pT3–pT4 disease were similar between groups (P > .05). Positive surgical margin rates were similar between the open (n = 1, 2.4%) and robotic (n = 2, 6.3%) groups (P > .05). Minor and major complication rates were similar between groups (P > .05). Mean estimated blood loss was significantly lower in the robotic group (412.5 ± 208.3 mL vs 1314.3 ± 987.1 mL, P < .001). Significantly higher percentages of patients were detected in the robotic group regarding bilateral neurovascular bundle–sparing surgery (93.7% vs 64.3%, P = .004) and bilateral extended pelvic lymph node dissection (100% vs 71.4%, P = .001). The mean lymph node yield was significantly higher in the robotic group (25.4 ± 9.7 vs 17.2 ± 13.5, P = .005). The number of postoperative readmissions for minor complications was significantly lower in the robotic group (0 vs 7, P = .017). Better trends were detected in the robotic group concerning daytime continence with no pad use (84.6% vs 75%, P > .05) and severe daytime incontinence (8.3% vs 16.6%, P > .05). No significant differences were detected regarding postoperative mean International Index of Erectile Function scores between groups (P > .05).

Conclusions:

Robotic surgery has the advantages of decreased blood loss, better preservation of neurovascular bundles, an increased lymph node yield, a decreased rate of hospital readmissions for minor complications, and a better trend for improved daytime continence when compared with the open approach.

Robot-assisted radical cystectomy is a promising alternative to open surgery in the Japanese population with a high rate of octogenarians

BACKGROUND

Japanese patients who undergo radical cystectomy have a unique feature, i.e., the ratio of octogenarians is higher than in Western patients because of the aging Japanese population. The purpose of this study was to compare perioperative outcomes, complications, and oncologic outcomes between robot-assisted radical cystectomy and open radical cystectomy.

METHODS

From 2010-2015, 20 (of which 8 were octogenarians) and 40 (of which 11 were octogenarians) patients underwent robot-assisted radical cystectomy and open radical cystectomy, respectively.

RESULTS

There was no significant difference in terms of patient demographics between the two surgical cohorts, regardless of patient age. In the octogenarian patient cohort, the rates of previous abdominal surgery and the median age-adjusted Charlson comorbidity index were higher. The median estimated blood loss, transfusion rate and the days to resumption of a regular diet were significantly lower in the robot-assisted radical cystectomy cohort, regardless of patient age. Robot-assisted radical cystectomy significantly decreased grade II or higher complications, but there were no significant differences in terms of decreasing grade III or higher complications, regardless of patient age. Positive surgical margin and the mean number of lymph nodes removed were similar between the two surgical cohorts, regardless of patient age.

CONCLUSION

Although robot-assisted radical cystectomy has a short history in Japan, the outcomes were generally comparable to those of previous studies. In a country that is aging rapidly like Japan, robot-assisted radical cystectomy could be a valid option for the management of muscle-invasive and high-risk superficial bladder cancer.

Significance of preoperative butyrylcholinesterase as an independent predictor of biochemical recurrence-free survival in patients with prostate cancer treated with radical prostatectomy

BACKGROUND

Butyrylcholinesterase (BChE) is an alpha-glycoprotein found in the nervous system and liver. Its serum level is reduced in many clinical conditions, such as liver damage, inflammation, injury, infection, malnutrition, and malignant disease. In this study, we analyzed the potential prognostic significance of preoperative BChE levels in patients with prostate cancer (PCa) undergoing radical prostatectomy (RP).

METHODS

We retrospectively evaluated 535 patients with PCa who underwent RP from 1996-2014 at a single institution. Serum BChE was routinely measured in all patients before operation. Covariates included age, preoperative laboratory data [prostate-specific antigen (PSA), hemoglobin, total protein, albumin, BChE, lactate dehydrogenase, C-reactive protein], clinical T, biopsy Gleason score, D'Amico risk classification, and RP with/without neoadjuvant therapy. Univariate and multivariate analyses were performed to identify clinical factors associated with biochemical recurrence-free survival (BRFS). Univariate analyses were performed using the Kaplan-Meier and log-rank methods, and multivariate analysis was performed using a Cox proportional hazard model.

RESULTS

The median BChE level was 255 U/L (normal range 168-470 U/L). The median age of the enrolled patients was 68 years, and the median PSA level at diagnosis of PCa was 8.39 ng/mL. The median follow-up period was 65 months. The 5-year BRFS rate was 72.9 %. The 5-year BRFS rates in the BChE ≥ 168 and ≤ 167 U/L groups were 77.7 and 55.0 %, respectively (P < 0.001). In univariate analysis, BChE, cT, biopsy Gleason score, and D'Amico risk classification were significantly associated with BRFS. Multivariate analysis revealed that BChE was significantly associated with BRFS.

CONCLUSIONS

This study validated preoperative serum BChE levels as an independent prognostic factor for PCa after RP.

Laparo-endoscopic single-site radical cystectomy with orthotopic urinary diversion: Technique, feasibility, and the 3-year follow-up

OBJECTIVES

To assess the feasibility, operative morbidity and oncological outcome of laparoendoscopic single-site (LESS) radical cystectomy.

PATIENTS AND METHODS

Ten patients with clinical stage T1-T2 bladder cancer underwent a LESS radical cystectomy. The mean (SD) age of the patients was 64.8 (8.6) years and their mean body mass index was 25.9 (2.7) kg/m(2). The procedure was done via a single-incision laparoscopic surgery port using a rigid 5-mm 30° long-shaft laparoscope in addition to the two working instruments. A 7-cm Pfannenstiel incision was made to remove the specimens and to allow the creation of an ileal neobladder with hand assistance.

RESULTS

In eight patients the LESS radical cystectomy was completed as scheduled, with the other two requiring a conversion, one to an open procedure due to locally advanced disease, and the other to conventional laparoscopy due to gas leakage. The mean (SD) operative duration was 236 (49) min, with a mean estimated blood loss of 575 (113) mL, and a mean hospital stay of 5.5 (0.7) days. No postoperative analgesic medications were prescribed and patients returned to normal activity after a mean (SD) of 17.6 (2.6) days. The pathological examination showed negative surgical margins for the bladder specimens, with a mean (SD) of 14 (1.9) lymph nodes retrieved. Seven patients were cancer-free within a mean (SD, range) follow-up of 37 (6, 29-44) months.

CONCLUSIONS

LESS radical cystectomy is technically feasible, with a favourable course and convalescence, and it has an acceptable oncological outcome.

Robot-assisted intracorporeal urinary diversion: where do we stand in 2014?

Radical cystectomy can only be considered as minimally invasive when both extirpative and reconstructive part of the procedure are performed with an intracorporeal approach. Robot-assisted radical cystectomy makes it possible to achieve this task, which seemed difficult with conventional laparoscopy. Intracorporeal urinary diversion (ICUD) is associated with better perioperative outcomes. Quality-of-life assessments and functional outcomes from continent ICUD are encouraging. Working in high-volumes center with mentored training can help robotic surgeons to learn the techniques of ICUD in conjunction with robot-assisted radical cystectomy. This article discusses the perioperative and functional outcomes of ICUD with a review of literature.

Health-related quality of life from a prospective randomised clinical trial of robot-assisted laparoscopic vs open radical cystectomy

OBJECTIVE

To compare health-related quality-of-life (HRQoL) outcomes for robot-assisted laparoscopic radical cystectomy (RARC) with those of traditional open radical cystectomy (ORC) in a prospective randomised fashion.

PATIENTS AND METHODS

This was a prospective randomised clinical trial evaluating the HRQoL for ORC vs RARC in consecutive patients from July 2009 to June 2011. We administered the Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index questionnaire, validated to assess HRQoL, preoperatively and then at 3, 6, 9 and 12 months postoperatively. Scores for each domain and total scores were compared in terms of deviation from preoperative values for both the RARC and the ORC cohorts. Multivariate linear regression was used to assess the association between the type of radical cystectomy and HRQoL.

RESULTS

At the time of the study, 47 patients had met the inclusion criteria, with 40 patients being randomised for analysis. The cohorts consisted of 20 patients undergoing ORC and 20 undergoing RARC, who were balanced with respect to baseline demographic and clinical features. Univariate analysis showed a return to baseline scores at 3 months postoperatively in all measured domains with no statistically significant difference among the various domains between the RARC and the ORC cohorts. Multivariate analysis showed no difference in HRQoL between the two approaches in any of the various domains, with the exception of a slightly higher physical well-being score in the RARC group at 6 months.

CONCLUSIONS

There were no significant differences in the HRQoL outcomes between ORC and RARC, with a return of quality of life scores to baseline scores 3 months after radical cystectomy in both cohorts.

Significance of preoperative butyrylcholinesterase as an independent predictor of survival in patients with muscle-invasive bladder cancer treated with radical cystectomy

OBJECTIVES

Butyrylcholinesterase (BChE) is an alpha-glycoprotein found in the nervous system and liver. Its serum level is reduced in many clinical conditions, such as liver damage, inflammation, injury, infection, malnutrition, and malignant disease. In this study, we analyzed the potential prognostic significance of preoperative BChE levels in patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC).

METHODS AND MATERIALS

We retrospectively evaluated 327 patients with MIBC who underwent RC from 1996 to 2013 at a single institution. Serum BChE level was routinely measured before operation in all patients. Covariates included age, gender, preoperative laboratory data (anemia, BChE, lactate dehydrogenase, and C-reactive protein), clinical T (cT) and N stage (cN), tumor grade, and RC with/without neoadjuvant chemotherapy. Univariate and multivariate analyses were performed to identify clinical factors associated with overall survival (OS) and disease-free survival (DFS). Univariate analyses were performed using the Kaplan-Meier and log-rank methods, and the multivariate analysis was performed using a Cox proportional hazard model.

RESULTS

The median BChE level was 187 U/l (normal range: 168-470 U/l). The median age of the enrolled patients was 69 years, and the median follow-up period was 51 months. The 5-year OS and DFS rates were 69.6% and 69.3%, respectively. The 5-year OS rates were 90.1% and 51.3% in the BChE ≥ 168 and<168 U/l groups, respectively (P<0.001). The 5-year DFS rates were 83.5% and 55.4% in the BChE ≥ 168 and ≤167 U/l groups, respectively (P<0.001). In the univariate analysis, BChE, cT, cN, and RC with/without neoadjuvant chemotherapy were significantly associated with both OS and DFS. Multivariate analysis revealed that BChE was the factor most significantly associated with OS, and BChE, cT, and cN were significantly associated with DFS.

CONCLUSIONS

This study validated preoperative serum BChE levels as an independent prognostic factor for MIBC after RC.

Long-term evaluation of oncologic and functional outcomes after laparoscopic open-assisted radical cystectomy: a matched-pair analysis

PURPOSE

To evaluate peri- and postoperative morbidity, and long-term oncologic and functional results of our laparoscopic radical cystectomy (LRC) technique, comparing it with our standard open approach.

METHODS

Between 2000 and 2010, 54 patients underwent LRC for urothelial cell carcinoma of the bladder in two academic hospitals. The procedures were performed by two surgeons. Patients were matched 1:1 with patients who underwent open RC in the same years by the same surgical team. Differences in peri- and postoperative complications across the two groups were assessed using Wilcoxon's rank-sum or χ (2) test. Kaplan-Meier curves, log-rank tests and Cox regression models were constructed to assess differences in recurrence-free survival on long-term follow-up between the two groups.

RESULTS

Laparoscopic radical cystectomy was significantly associated with lower blood loss (p < 0.0001) and less frequent postoperative ileus (p = 0.03). Regarding more serious postoperative complications, no difference was found across the two cohorts. Median oncologic follow-up was 42 months (IQR 12-72 months) in the LRC cohort and 18 months (IQR 8-27 months) in patients undergoing open radical cystectomy (ORC). No statistically significant difference in recurrence-free survival was observed between the two groups (log rank p = 0.677). On univariate Cox regression, the surgical approach used was not significantly associated with risk of recurrence.

CONCLUSIONS

We found that LRC is safe and associated with lower blood loss and decreased postoperative ileus compared with ORC. Moreover, on long-term oncologic follow-up, LRC appeared non-inferior to ORC with no significant difference in recurrence-free survival. Nonetheless, these results must be confirmed by larger series and stronger long-term follow-up data are needed.

A prospective randomised controlled trial of laparoscopic vs open radical cystectomy for bladder cancer: perioperative and oncologic outcomes with 5-year follow-upT Lin et al

Background:

Laparoscopic radical cystectomy (LRC) is increasingly being used for muscle-invasive bladder cancer. However, high levels of clinical evidence comparing laparoscopic vs open radical cystectomy (ORC) are lacking.

Methods:

A prospective randomised controlled clinical trial comparing LRC vs ORC in patients undergoing radical cystectomy for bladder cancer. Thirty-five patients were eligible for final analysis in each group.

Results:

The median follow-up was 26 months (range, 4–59 months) for laparoscopic vs 32 months (range, 6–60 months) for ORC. Significant differences were noted in operative time, estimated blood loss (EBL), blood transfusion rate, analgesic requirement, and time to resumption of oral intake. No significant differences were noted in the length of hospital stay, complication rate, lymph node yield (14.1±6.3 for LRC and 15.2±5.9 for ORC), positive surgical margin rate, postoperative pathology, or recurrence rate (7 for LRC and 8 for ORC). The 5-year recurrence-free survival with laparoscopic vs ORC was 78.5% vs 70.9%, respectively (P=0.773). The overall survival with laparoscopic vs ORC was 73.8% vs 67.4%, respectively (P=0.511).

Conclusion:

Our study demonstrated that LRC is superior to ORC in perioperative outcomes, including EBL, blood transfusion rate, and analgesic requirement. We found no major difference in oncologic outcomes. The number of patients is too small to allow for a final conclusion.

Robotics in uro-oncologic surgery

In urology, the main use for the robotic technique has been in radical prostatectomy for prostate cancer. Robotic surgery for other organs, such as the kidneys and bladder, has been less explored. However, partial nephrectomy or radical nephroureterectomy can be difficult for inexperienced laparoscopic surgeons. The advent of the da Vinci robot, with multijointed endowristed instruments and stereoscopic vision, decreases the technical difficulty of intracorporeal suturing and improves the reconstructive steps. The objective of this article is to offer an overview of all robotic procedures recently developed in the field of urology. We evaluate the feasibility of these procedures and their potential advantages and disadvantages. We also describe perioperative, postoperative, and oncologic outcomes of robot-assisted surgery as well as perform a comparison with open and laparoscopic techniques. Comparative data and an adequate follow-up are needed to demonstrate equivalent oncologic outcomes in comparison with traditional open or laparoscopic procedures.

Laparoscopic versus open radical cystectomy for muscle-invasive bladder cancer: a single institute comparative analysis

BACKGROUND

Open radical cystectomy (ORC) is the gold standard of treatment for muscle-invasive bladder cancer. Laparoscopic radical cystectomy (LRC) has emerged to provide an alternative.

METHODS

Between 2006 and 2012, 155 patients who underwent LRC or ORC were compared (mean follow-up 53 months).

RESULTS

The ORC group had shorter operative times (p < 0.0001), more blood loss (p < 0.00001), more transfusion requirement (p < 0.00001), longer postoperative length of hospital stay (p < 0.00001) and more morphine requirement (p = 0.02). No difference was found regarding lymph node yield (p = 0.07), positive margins (p = 0.11), cystectomy pathology results (p > 0.05) and positive lymph nodes (p = 0.02). The ORC group had less intraoperative complications (p = 0.03). No difference was found between the two groups regarding 5-year overall survival (p = 0.93), cancer-specific survival (p = 0.7) and recurrence-free survival (p = 0.62).

CONCLUSION

LRC can be considered as an alternative to ORC with good operative and postoperative results in addition to comparable 5-year survival results.

Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy

PURPOSE

Robotic assisted laparoscopic radical cystectomy for bladder cancer has been reported with potential for improvement in perioperative morbidity compared to the open approach. However, most studies are retrospective with significant selection bias.

MATERIALS AND METHODS

A pilot prospective randomized trial evaluating perioperative outcomes and oncologic efficacy of open vs robotic assisted laparoscopic radical cystectomy for consecutive patients was performed from July 2009 to June 2011.

RESULTS

To date 47 patients have been randomized with data available on 40 patients for analysis. Each group was similar with regard to age, gender, race, body mass index and comorbidities, as well as previous surgeries, operative time, postoperative complications and final pathological stage. We observed no significant differences between oncologic outcomes of positive margins (5% each, p = 0.50) or number of lymph nodes removed for open radical cystectomy (23, IQR 15-28) vs robotic assisted laparoscopic radical cystectomy (11, IQR 8.75-21.5) groups (p = 0.135). The robotic assisted laparoscopic radical cystectomy group (400 ml, IQR 300-762.5) was noted to have decreased estimated blood loss compared to the open radical cystectomy group (800 ml, IQR 400-1,100) and trended toward a decreased rate of excessive length of stay (greater than 5 days) (65% vs 90%, p = 0.11) compared to the open radical cystectomy group. The robotic group also trended toward fewer transfusions (40% vs 50%, p = 0.26).

CONCLUSIONS

Our study validates the concept of randomizing patients with bladder cancer undergoing radical cystectomy to an open or robotic approach. Our results suggest no significant differences in surrogates of oncologic efficacy. Robotic assisted laparoscopic radical cystectomy demonstrates potential benefits of decreased estimated blood loss and decreased hospital stay compared to open radical cystectomy. Our results need to be validated in a larger multicenter prospective randomized clinical trial.

Ureteric duplication is not a contraindication for robot-assisted laparoscopic radical cystoprostatectomy and intracorporeal Studer pouch formation

The authors found that duplicated ureters was not a contraindication to robot-assisted laparoscopic radical cystoprostatectomy in this case.

Objectives:

Ureteric duplication is a rarely seen malformation of the urinary tract more commonly seen in females.

Materials and Methods:

We report 2 cases of robot-assisted laparoscopic radical cystoprostatectomy (RALRCP) with bilateral extended pelvic lymph node dissection and intracorporeal Studer pouch formation in patients with duplicated right ureters.

Results:

Two male patients (53 and 68 years old) underwent transurethral resection of a bladder tumor that revealed high-grade muscle invasive transitional cell carcinoma, with no metastases. We performed RALRCP and intracorporeal Studer pouch formation. A duplicated right ureter was observed during the procedures in both patients. Left ureter distal segment was spatulated 2cm long and anastomosed using running 4/0 Vicryl to the right ureter at its bifurcation where it forms a single lumen without spatulation. All 3 ureters were catheterized individually. A Wallace type uretero-ileal anastomosis was performed between the ureters and the proximal part of the Studer pouch chimney. Although ureteric frozen section analysis suggested ureteric carcinoma in situ in patient 1, postoperative pathologic evaluation was normal. Frozen section and final postoperative pathologic evaluations were normal in patient 2.

Conclusions:

Duplicated ureters might be underdiagnosed on CT. The presence of a duplicated ureter is not a contraindication to RALRCP and intracorporeal Studer pouch formation. The da Vinci-S surgical robot is very safe for performing this complicated procedure. Frozen section analysis of ureters during radical cystectomy for bladder cancer might not reliably diagnose the pathologic condition and might overestimate the disease in the ureters.

Extended pelvic lymph node dissection: before or after radical cystectomy? A multicenter study of the Turkish society of urooncology

Purpose

We aimed to ascertain the effects of performing extended pelvic lymph node dissection (PLND) on the duration of surgery, morbidity, and the number of lymph nodes removed when the dissection was performed before or after radical cystectomy (RC).

Materials and Methods

We used the database of our previous prospective multicenter study. A total of 118 patients underwent RC and extended PLND. Of the 118 patients, 48 (40.7%) underwent extended PLND before RC (group 1) and 70 (59.3%) underwent extended PLND after RC (group 2). The two groups were compared for extended PLND time, RC time, and total operation times, per operative morbidity, and the total numbers of lymph nodes removed.

Results

Clinical and pathologic characteristics were comparable in the two groups (p>0.05). The mean RC time and mean total operation times were significantly shorter in group 1 than in group 2 (p<0.001). The mean number of lymph nodes removed was 27.31±10.36 in group 1 and 30.87±8.3 in group 2 (p=0.041). Only at the presacral region was the mean number of lymph nodes removed significantly fewer in group 1 than in group 2 (p=0.001). Intraoperative and postoperative complications and drain withdrawal time were similar in both groups (p=0.058, p=0.391, p=0.613, respectively).

Conclusions

When extended PLND was performed before RC, the duration of RC and consequently the total duration of the operation were significantly shorter than when extended PLND was performed after RC. Practitioners may consider performing extended PLND before RC and rechecking the presacral area for additional lymph nodes after RC, particularly in elderly patients with high co-morbidity for whom the duration of surgery matters.

Conservative treatment of invasive bladder cancer

The concept of organ-preserving therapies is a trend in modern oncology, and several tumour types are now treated in this fashion. Trimodality therapy consisting of as thorough a transurethral resection of the bladder tumour as is judged safe, followed by concomitant chemoradiation therapy, is emerging as an attractive alternative for bladder preservation in selected patients with muscle-invasive bladder cancer. Long-term data from multiple institutional and cooperative group studies have shown that this approach is safe and effective and that it provides patients with the opportunity to maintain an intact and functional bladder with a survival rate similar to that for modern radical cystectomy.

Therapeutic interventions targeting organ preservation in muscle-invasive bladder cancer: a review

Nowadays in modern oncology there is a tendency towards therapies that target organ preservation. Organ preservation protocols have become standard in the treatment of laryngeal carcinoma, oesophageal cancer, breast carcinoma and soft tissue sarcomas. The three-combined therapy consisting of a transurethral resection of the bladder tumour followed by concomitant chemoradiotherapy has been shown to be an attractive alternative for bladder preservation in selected patients with muscle-invasive bladder cancer. In order to evaluate the organ preservation approaches in muscle-invasive bladder cancer we have conducted a comprehensive literature review. Data reported from the studies have shown that bladder preservation therapy with a trimodality approach is safe and effective. Moreover, such an approach provides patients with the opportunity to maintain an intact and functional bladder with a survival rate similar to that of radical cystectomy.

Mid-term oncological control after laparoscopic radical cystectomy in men: a single-centre experience

OBJECTIVE

• To assess the mid-term (3 years of follow-up) oncological control of laparoscopic radical cystectomy (LRC) for high-grade muscle-invasive bladder cancer in a well studied male population.

PATIENTS AND METHODS

• We assessed 40 men with bladder cancer (mean [range] age 66.5 [50-75] years) who underwent LRC and extended pelvic lymphadenectomy at our institution between April 2004 and September 2008. • Of the 40 patients, 13 (32.5%) had a complete laparoscopic procedure (ileal conduit: seven patients; neobladder: five patients; bilateral ureterostomy: one patient) and 27 (67.5%) had an LRC procedure only (ileal conduit: 15 patients; neobladder: 12 patients).

RESULTS

• No major complications were observed intraoperatively. • The mean operating time was 407 min and the mean blood loss was 720 mL. Four patients (10%) required conversion to open surgery. The mean (range) hospital stay was 10.2 (7-25) days. One patient died of myocardial infarction in the postoperative period. • Pathological analysis showed organ-confined tumours (stage pT0/pT1/pT2/pT3a) in 22 patients (55%) and extravesical disease (pT3/pT4) in 18 (45%). Of the 40 patients, six (15%) had lymph node involvement. The mean (range) number of nodes removed was 19.9 (5-40). • At a mean (range) follow-up period of 36 (0-72) months, 26 patients were alive with no evidence of disease (disease-free survival rate 67%).

CONCLUSION

• Laparoscopic radical cystectomy is a safe, feasible, and effective alternative to open radical cystectomy (ORC). The 3-year oncological efficacy was comparable with that of ORC.

Major urologic problems in geriatrics: assessment and management

Elderly urologic patients require the same cautions as used in development of treatment programs for them in other disciplines. Because of potential interference with poor renal function or crossover effects with central or peripheral nervous system, however, many urologic drugs must be titrated appropriately. In treating cancer, erectile dysfunction, incontinence or urinary infection, patient quality of life and life span become dominant factors in making therapeutic decisions, by behavioral change, medication, or surgical intervention.

Is patient outcome compromised during the initial experience with robot-assisted radical cystectomy? Results of 164 consecutive cases

OBJECTIVE

• Robot-assisted radical cystectomy (RARC) remains controversial in terms of oncologic outcomes, especially during the initial experience. The purpose of this study was to evaluate the impact of initial experience of robotic cystectomy programs on oncologic outcomes and overall survival.

PATIENTS AND METHODS

• Utilizing a prospectively maintained, single institution robotic cystectomy database, we identified 164 consecutive patients who underwent RARC since November 2005. • After stratification by age group, gender, pathologic T stage, lymph node status, surgical margin status, and sequential case number; we used chi-squared analyses to correlate sequential case number to operative time, surgical blood loss, lymph node yield, and surgical margin status. • We also addressed the relationship between complications and sequential case number. We then utilized Cox proportional hazard modeling and Kaplan-Meier survival analyses to correlate variables to overall mortality.

RESULTS

• Sequential case number was not significantly associated with increased incidence of complications, surgical blood loss, or positive surgical margins (P= 0.780, P= 0.548, P= 0.545). Case number was, however, significantly associated with shorter operative time and mean number of lymph nodes retrieved (P < 0.001, P < 0.001). • Sequential case number was not significantly associated with survival; however, tumour stage, the presence of lymph node metastases, and positive surgical margins were significantly associated with death. • Although being the largest of its kind, this was a small study with short follow-up when compared to open cystectomy series.

CONCLUSION

• Initial experience with RARC did not affect the incidence of positive surgical margins, operative/postoperative complications, or overall survival in a single-institution series.