Robot-assisted laparoscopic vs open radical cystectomy: comparison of complications and perioperative oncological outcomes in 200 patients

Lower bleeding volume contributes to decreasing surgical site infection in radical cystectomy: A propensity score-matched comparison of open versus robot-assisted radical cystectomy

OBJECTIVES

To compare the incidence of surgical site infections (SSI) between robot-assisted and open radical cystectomies and investigate the risk factors for SSI after radical cystectomies.

METHODS

Consecutive patients who underwent radical cystectomy between July 2008 and December 2022 were retrospectively reviewed. The prevalence and characteristics of SSI after open and robot-assisted radical cystectomies were compared, and the risk factors for SSI were investigated using propensity score matching.

RESULTS

This study enrolled 231 patients (open: 145, robot-assisted: 86). In the robot-assisted group, urinary diversion was performed using an intracorporeal approach. SSI occurred in 34 (open: 28, robot-assisted: 6) patients, and the incidence was significantly lower in the robot-assisted group (19.3% vs. 7.0%, p = 0.007). After propensity score matching cohort (open: 34, robot-assisted: 34), increased bleeding volume, blood transfusion, and delayed postoperative oral feeding were significantly associated with SSI. Only increased bleeding volume remained a significant risk factor in the multivariate regression analysis (odds ratio, 1.13 [per 100 mL increase]; 95% confidence interval: 1.02-1.25; p = 0.001). The cutoff bleeding volume for predicting SSI was 1630 mL with an area under the receiver operating characteristic curve, sensitivity, and specificity of 0.773, 0.73, and 0.75, respectively.

CONCLUSIONS

The incidence of SSI after robot-assisted radical cystectomy was significantly lower than that after the open procedure. However, decreased bleeding volume, which was significantly associated with robot-assisted procedures, was an independent and more significant factor for reducing SSI after radical cystectomy than the differences of the surgical procedure even after propensity score matching.

Comparing Bladder Neck Contracture Rate Between Robotic Intracorporeal and Extracorporeal Neobladder Construction

Robot-assisted radical cystectomy (RARC) has become more accessible to surgeons worldwide, and descriptions of intracorporeal urinary diversion techniques, such as orthotopic neobladder construction, have increased. In this study, we aim to compare the rate of bladder neck contracture (BNC) formation between RARC and two different urinary diversion techniques. We retrospectively reviewed our institutional database for patients with bladder cancer who underwent RARC with intracorporeal neobladder (ICNB) construction (n = 11) or extracorporeal neobladder (ECNB) construction (n = 11) between 2012 and 2020. BNC was defined by the need for an additional surgical procedure (e.g., dilatation, urethrotomy). Patients who underwent RARC with ICNB (n = 11) were compared to patients who underwent RARC with ECNB (n = 11) across patient characteristics and postoperative BNC formation rates. Kaplan-Meier curves were generated for freedom from BNC based on the neobladder approach and compared with the log-rank test. For patients who received an ECNB, 73% (8/11) developed a BNC; in comparison, none of the patients in the ICNB group experienced a BNC. Kaplan-Meier survival analysis demonstrates the ECNB group's median probability of freedom from BNC as 1.3 years, while the ICNB group was free of BNC over the study period (p < 0.001). RARC with ICNB creation demonstrated a significantly reduced BNC rate in contrast to RARC with ECNB construction. Longer-term follow-up is needed to assess the durability of this difference in BNC rates.

Morbidity and Days Alive and Out of Hospital Within 90 Days Following Radical Cystectomy for Bladder Cancer

Background

Morbidity after radical cystectomy (RC) is usually quantified in terms of rates of complications, mortality, reoperations, and readmissions, and length of stay (LOS). The overall burden following RC within the first 90 d following RC may be better described using days alive and out of hospital (DAOH), which is a validated, patient-centred proxy for both morbidity and mortality.

Objective

To report short-term morbidity, LOS, and DAOH within 90 d after RC and risk factors associated with these parameters.

Design setting and participants

The study included 729 patients undergoing RC for bladder cancer at a single academic centre from 2009 to 2019. Data were retrieved from national electronic medical charts.

Outcome measurements and statistical analysis

Multivariate analysis was used to investigate variables associated with a major complication, LOS >7 d, and DAOH <80 d.

Results and limitations

The 90-d complication rate was 80%, including major complications in 37% of cases. Median LOS was 7 d (interquartile range (IQR) 6-9) and median DAOH was 80 d (IQR 71-83) days. Body mass index and the Charlson comorbidity index (CCI) predicted major complications. CCI predicted LOS >7 d and DAOH <80 d.

Conclusions

RC was associated with significant short-term morbidity and DAOH was a good marker for cumulative morbidity after RC. We propose that DAOH should be a standard supplement for reporting surgical outcomes following RC for bladder cancer, which may facilitate better comparison of outcomes across treating institutions.

Patient summary

We studied complications after surgical removal of the bladder for bladder cancer. We assessed a novel patient-centred tool that more accurately describes the total burden of complications after surgery than traditional models. We found that patients with a high body mass index and coexisting chronic diseases had a higher risk of a complicated surgical course.

Short-term morbidity and mortality following radical cystectomy: a systematic review

OBJECTIVE

To study short-term (<90 days) morbidity and mortality following radical cystectomy (RC) for bladder cancer and identify modifiable risk factors associated with these.

DESIGN

Systematic review.

METHODS

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE were searched for relevant papers on 11 June 2019 and rerun on 27 May 2020. Studies reporting complications, reoperations, length of stay and mortality within 90 days were included. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine and the quality of evidence was assessed using the Newcastle-Ottawa Scale.

RESULTS

The search retrieved 1957 articles. Sixty-six articles were included. The quality of evidence was poor to good. Most studies were retrospective, and no randomised clinical trials were identified. Of included studies a median of 6 Martin criteria for reporting complications after surgery were fulfilled. The Clavien-Dindo classification for grading complications was most frequently used. The weighted overall complication rate after RC was 34.9% (range 28.8-68.8) for in-house complications, 39.0% (range 27.3-80.0) for 30-day complications and 58.5% (range 36.1-80.5) for 90-day complications. The most common types of complications reported were gastrointestinal (29.0%) and infectious (26.4%). The weighted mortality rate was 2.4% (range 0.9-4.7) for in-house mortality, 2.1% (0.0-3.7) for 30-day mortality and 4.7% (range 0.0-7.0) for 90-day mortality. Age and comorbidity were identified as the best predictors for complications following RC.

CONCLUSION

Short-term morbidity and mortality are high following RC. Reporting of complications is heterogeneous and the quality of evidence is generally low. There is a continuous need for randomised studies to address any intervention that can reduce morbidity and mortality following RC.

PROSPERO REGISTRATION NUMBER

104937.

Lung protective ventilation strategy to reduce postoperative pulmonary complications (PPCs) in patients undergoing robot-assisted laparoscopic radical cystectomy for bladder cancer: A randomized double blinded clinical trial

STUDY OBJECTIVE

To evaluate the effects of ventilation with low tidal volume and positive end-expiratory pressure (PEEP) on postoperative pulmonary complications in patients undergoing robot-assisted laparoscopic radical cystectomy (RARC) for bladder cancer.

DESIGN

A prospective randomized double-blinded study.

SETTING

A single center trial in a comprehensive tertiary hospital from January 2017 to January 2019.

PATIENTS

A total of 258 patients undergoing RARC for bladder cancer.

INTERVENTIONS

Patients were randomly assigned to receive either lung-protective ventilation (LPV group) [tidal volume 6 ml/ kg predicated body weight (PBW) + PEEP 7 cmH₂O] or nonprotective ventilation (control group) (tidal volume 9 ml/ kg PBW without PEEP) during anesthesia.

MEASUREMENTS

The primary outcome was the occurrence of postoperative pulmonary complications (PPCs) during the first 90 days after surgery. The secondary outcomes were extubation time, oxygenation index (OI) after extubation and at postoperative day 1 in blood gas.

MAIN RESULTS

The incidence of PPCs at postoperative day1, 2 and 3 were lower in LPV group [26.8% vs. 47.2%, odds ratio (OR) 0.41, 95% confidence interval (CI), 0.24-0.69, P = 0.0007, 21.3% vs. 43.3%, OR 0.36, 95% CI, 0.20-0.61, P = 0.0002, 14.2% vs. 27.5%, OR0.43, 95%CI, 0.23-0.82, P = 0.0087, respectively], while no differences were observed at day 7 and 28 (3.9% vs. 9.4%, P = 0.0788, 0% vs. 1.6%, P = 0.4980, respectively). No PPCs were observed at postoperative day 90 in both groups. Furthermore, immediately after extubating and at postoperative day 1, OI was significantly higher in LPV group compared with control group [390(337-467) vs. 343(303-420), P = 0.0005, 406.7(73.0) vs. 425.5(74.7), P = 0.0440, respectively]. Patients in LPV group had a significant shorter extubation time after operation compared with control group [38(33-54) vs. 35(25-46), P = 0.0012].

CONCLUSION

LPV combining low tidal volume and PEEP during anesthesia for RARC may decrease the incidence of postoperative pulmonary complications.

The Impact of Previous Prostate Surgery on Surgical Outcomes for Patients Treated with Robot-assisted Radical Cystectomy for Bladder Cancer

BACKGROUND

The feasibility and safety of robot-assisted radical cystectomy (RARC) may be undermined by unfavorable preoperative surgical characteristics such as previous prostate surgery (PPS).

OBJECTIVE

To compare perioperative outcomes for patients undergoing RARC with versus without a history of PPS.

DESIGN, SETTING, AND PARTICIPANTS

The study included 220 consecutive patients treated with RARC and pelvic lymph node dissection for bladder cancer at a single European tertiary centre. Of these, 43 had previously undergone PPS, defined as transurethral resection of the prostate/holmium laser enucleation of the prostate (n=21) or robot-assisted radical prostatectomy (n=22).

SURGICAL PROCEDURE

RARC in patients with a history of PPS.

MEASUREMENTS

Data on postoperative complications were collected according to the quality criteria for accurate and comprehensive reporting of surgical outcomes recommended by the European Association of Urology guidelines. Multivariable logistic, linear, and Poisson regression analyses were performed to test the effect of PPS on surgical outcomes.

RESULTS AND LIMITATIONS

Overall, 43 patients (20%) were treated with RARC after PPS. Operative time (OT) was longer in the PPS group (360 vs 330min; p<0.001). Patients with PPS experienced higher rates of intraoperative complications (19% vs 6.8%) and higher rates of 30-d (67% vs 39%), and Clavien-Dindo >3 (33% vs 16%) postoperative complications (all p<0.05). Moreover, the positive surgical margin (PSM) rate after RARC was higher in the PPS group (14% vs 4%; p=0.03). On multivariable analyses, PPS at RARC independently predicted higher risk of intraoperative (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.04-6.21; p=0.01) and 30-d complications (OR 2.26, 95% CI 1.05-5.22; p=0.02), as well as longer OT (relative risk [RR] 1.03, 95% CI 1.00-1.05; p=0.02) and length of stay (RR 1.13, 95% CI 1.02-1.26; p=0.02). Lack of randomization represents the main limitation.

CONCLUSIONS

RARC in patients with a history of PPS is feasible, but it is associated with a higher risk of complications and longer OT and length of stay. Moreover, higher PSM rates have been reported for these patients. Thus, measures aimed at improving surgical outcomes appear to be warranted.

PATIENT SUMMARY

We investigated the effect of previous prostate surgery (PPS) on surgical outcomes after robot-assisted removal of the bladder. We found that patients with PPS have a higher risk of complications and longer hospitalization after bladder removal. These patients deserve closer evaluation before this type of bladder operation.

Partial cystectomy for muscle-invasive bladder cancer: a review of the literature

The radical cystectomy (RC) for muscle-invasive bladder cancer is one of the most morbid and complex urologic procedures performed today. To avoid these complications, the partial cystectomy (PC) has been offered as an alternative in carefully selected patients as a means of achieving equal oncologic efficacy with less morbidity. Selection criteria should include solitary tumors without concomitant carcinoma in situ (CIS) and amenable to resection with 1–2 cm margins in a normally functioning bladder. In addition to the standard work-up, random bladder and prostatic biopsies may be performed. The PC can be performed through an open, laparoscopic, or robot-assisted approach, each with acceptable outcomes. A number of techniques have been developed to identify and resect the tumor completely with negative margins, while preventing tumor spillage within the abdomen. While there are no randomized trials, single institution series have demonstrated acceptable oncologic outcomes in appropriately selected patients. Therefore, offering PC in the appropriate candidate, including those patients who do not accept or are unfit for the associated morbidity of a RC, represents an acceptable alternative.

Bayesian network analysis of open, laparoscopic, and robot-assisted radical cystectomy for bladder cancer

BACKGROUND

We have performed the direct and network meta-analysis to evaluate the safety and efficacy of robot-assisted (RARC) versus laparoscopic (LRC) versus open radical cystectomy (ORC) for bladder cancer (BCa).

METHODS

A systematic search of PubMed, Cochrane Library, and Embase was performed up until Dec 20, 2019. Outcome indexes include oncologic outcomes (the recurrence rate, mortality), pathologic outcomes (lymph node yield (LNY), positive lymph node (PLN), positive surgical margins (PSM)), perioperative outcomes (operating time (OP), estimated blood loss (EBL), blood transfusion rate, the length of hospital stay (LOS) and the time to regular diet) and postoperative 90-day complications.

RESULTS

We have analyzed 6 RCTs, 23 prospective studies, and 25 retrospective studies (54 articles: 6382 patients). On one hand, the direct meta-analysis shows RARC is better than LRC or ORC. On the other hand, the clinical effects of the recurrence rate, Morbidity, PSM, LNY, PLN, and postoperative 90-day complications of RARC, LRC and ORC are all no statistical significance by network meta-analysis. Moreover, the probability rank shows that the comprehensive rank of RARC is better than LRC or ORC. The clinical effects of OP, EBL, LOS, blood transfusion rate and the time to regular diet are all statistical significance by network meta-analysis. There are ORC > LRC > RARC in the EBL ranking. Patients with RARC exhibited a decrease of LOS compared to those with LRC or ORC. Patients with RARC exhibited a decrease in blood transfusion rate and the time to regular diet compared to those with ORC. Patients with ORC exhibited an increase of OP compared to those with RARC or LRC. The heterogeneity tests of most studies are < 50%. Most studies have no publication bias and the quality of the selected studies is good.

CONCLUSION

The direct meta-analysis and network meta-analysis suggest that RARC is better than LRC or ORC according to comprehensive analysis. However, we need a large sample size and more high-quality studies to verify and improve in the further.

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.

A novel Bayesian continuous piecewise linear log-hazard model, with estimation and inference via reversible jump Markov chain Monte Carlo

We present a reversible jump Bayesian piecewise log-linear hazard model that extends the Bayesian piecewise exponential hazard to a continuous function of piecewise linear log hazards. A simulation study encompassing several different hazard shapes, accrual rates, censoring proportion, and sample sizes showed that the Bayesian piecewise linear log-hazard model estimated the true mean survival time and survival distributions better than the piecewsie exponential hazard. Survival data from Wake Forest Baptist Medical Center is analyzed by both methods and the posterior results are compared.

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.

Postoperative cognitive dysfunction after robot-assisted radical cystectomy (RARC) with cerebral oxygen monitoring an observational prospective cohort pilot study

Background

The incidence and risk factors of postoperative cognitive dysfunction (POCD) during robot-assisted radical cystectomy (RARC) in extreme Trendelenburg positioning and pneumoperitoneum are still controversial. The aim of this prospective observational study was to find the incidence rate as well as possible risk factors of POCD in RARC with cerebral oxygen monitoring.

Methods

Patients who underwent RARC and open abdominal surgery in horizontal positioning were included. Preoperative and postoperative arterial blood gas (ABG), S-100β, C-reactive protein (CRP), and cognitive dysfunction scales were tested. Also, we used Z score to analyze and comprehensively evaluate POCD. Measurements of heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), end-tidal CO₂ (etCO₂), and cerebral oxygen were immediately obtained after different time points during the surgery.

Results

Here, 24 and 23 patients were included in the RARC group and in the control group, respectively. The incidence of POCD didn’t have significant difference in RARC group (45.8%), in contrast to the control group (26.1%). The laboratory tests of s100β and CRP between two groups didn’t contain significant difference as well. As duration of Trendelenburg and pneumoperitoneum prolonged, the cerebral oxygen saturation in the RARC group increased, which didn’t cause excessive perfusion nevertheless (rSO₂<75%). We compared laboratory tests, age, education status, blood loss, and fluid input between POCD and non-POCD patients. A significant difference was found in the serum concentrations of CRP (72.59 ± 42.09 vs. 48.50 ± 26.53, P = 0.025) and age (69.20 ± 7.033 vs. 65.34 ± 5.228, P = 0.041).

Conclusion

RARC in extreme Trendelenburg positioning and pneumoperitoneum did not significantly increase the incidence of POCD and didn’t cause excessive perfusion. The inflammation marker CRP and age might be independent risk factors of POCD.

Trial registration

Clinicaltrials.gov with registration number NCT03372135. Registered 1 November 2017 (retrospectively registered).

Robotic vs. open surgical management of ureteroenteric anastomotic strictures: technical modifications to enhance success

Development of ureteroanastamotic strictures (UAS) after urinary diversion is not uncommon, but is challenging to treat. Poor outcomes are likely with endoscopic and radiologic management, and definitive surgical treatment can cause significant morbidity. The comparative advantages of an operative approach have not yet been fully described in the literature. We retrospectively reviewed the prospectively maintained Tulane University Department of Urology quality assurance database of 12 patients who underwent operative UAS repair between 2012 and 2018. Data were reviewed for operative approach, demographics, baseline disease characteristics, operative variables, and perioperative and pathological outcomes. Of the 12 patients analyzed, 5 underwent open repair (OR) (2 bilateral, 2 right, 1 left) and 7 underwent robotic repair (RR) (3 right, 4 left). One robotic case required conversion to open due to significant intestinal and peri-ureteral adhesions. The median ages were 59 years in OR and 60 years in RR. Two patients in each group had failed previous endoscopic repair. Median time from cystectomy to treatment of enteroanastamotic stricture was 13 months for OR and 10 months for RR (p = 0.25). Median estimated blood loss was 80 mL in both OR and RR (p = 1.0), median operative time was 260 min in OR and 255 min in RR (p = 0.13), and median hospital stay was 8 and 4 days, respectively (p = 0.06). There were two intra-operative and one post-operative complication in the OR group, one of whom required further surgical intervention, and no complications in the robotic cohort. A minimally invasive, robotic approach offers a non-inferior alternative to OR with similar outcomes for appropriately selected patients with UAS. High success rates combined with minimal morbidity may provide definitive therapy at an earlier stage of the stricture state.

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 Laparoscopic and Robot-assisted Radical Cystectomy for Bladder Cancer: Perioperative and Oncologic Outcomes

BACKGROUND

The purpose of this study was to compare perioperative and oncologic outcomes between laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) for bladder cancer (BCa).

MATERIALS AND METHODS

Patients who underwent LRC or RARC with curative intent for BCa between January 2011 and December 2016 were included. Perioperative, pathologic oncologic data were extracted from our database. Disease-free survival, overall survival, and cancer-specific survival were analyzed using Kaplan-Meier survival curves with log-rank tests.

RESULTS

A total of 126 patients underwent LRC and 189 patients underwent RARC during the study period. All the baseline variables were similar between the two groups. Patients undergoing RARC had a significant higher median estimated blood loss (300 mL vs. 200 mL; P = .005), lower rate of 90-day postoperative complications (36.5% vs. 50.0%; P = .017), and higher median direct cost ($15,306 vs. $11,131; P < .001) than LRC. Other perioperative outcomes were similar. No differences were found in pathologic T stage, positive lymph nodes, or positive surgical margin between patients who underwent LRC and RARC. The 5-year disease-free survival, overall survival, and cancer-specific survival rates were 51.9%, 61.0%, and 69.5%, respectively, for all included patients. There were no significant differences in oncologic outcomes between the 2 groups.

CONCLUSION

Patients with BCa can be safely managed with LRC and RARC by experienced surgeons. RARC was associated with a reduced rate of postoperative complication but also with higher median estimated blood loss, and higher median direct cost. These findings could be used to guide patient counseling, and treatment selection.

Predictors of postoperative complications after robot-assisted radical cystectomy with extracorporeal urinary diversion

Purpose: Robot-assisted radical cystectomy (RARC) is known to have less postoperative morbidity and complications than open radical cystectomy. However, various complications not yet have been reported after RARC. In this study, we aimed to identify the predictors of complications following RARC. Patients and methods: From August 2008 to November 2017, we retrospectively reviewed 126 patients who underwent RARC with extracorporeal urinary diversion. Overall perioperative complications were examined, and factors that may affect complications were analyzed using a logistic regression model. Complications were classified according to the Clavien-Dindo system. Results: Overall postoperative complications occurred in 78 (61.9%) of 126 patients. Whereas the rate of minor complications was 58.0% (grade I=15.9% (n=20), grade II=42.1% (n=53)), the rate of major complications was very low (grade IIIa=1.6% (n=2), grade IIIb =2.4% (n=3)). No fatal complications more than grade IV were developed. Notably, transfusions (27.0%), urinary tract infection (15.9%), anastomosis site leakage (14.3%), and ileus (10.3%) were the most common complications after RARC. In the multivariate regression model, previous intravesical instillation (odds ration [OR]=3.374), preoperative hemoglobin (OR=0.751), and estimated blood loss (EBL) (OR=3.949) were identified as the predictors of postoperative complications. Conclusion: In sum, our data showed the rates of major complications were comparable after RARC with extracorporeal urinary diversion compared as reported in previous studies and lower major than minor complications following RARC. Moreover, we identified the independent predictors of postoperative complications, such as preoperative hemoglobin, intravesical instillation, and EBL.

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.

Peri-Operative Outcomes after Open and Robot-Assisted Radical Cystectomy by Using an Advanced Bipolar Seal and Cut Technology (Caiman®): A Prospective, Comparative, and Multi-Institutional Study

Objective

To report and compare the peri-operative outcomes of patients undergoing open (ORC) and robotic-assisted radical cystectomy (RARC) for bladder cancer performed with a radiofrequency seal and cut device (Caiman®).

Materials and Methods

Data of patients undergoing ORC or RARC between January 2015 and March 2016 at 6 Italian institutions were prospectively recorded and analyzed. Thirty-and 90-day complications were stratified according to the Martin's criteria and graded according to the Clavien-Dindo classification. Data on operative time, blood loss, transfusion rate, complications, and length of stay were evaluated and compared between the ORC and RARC groups.

Results

Thirty-three (66%) and 17 (34%) patients were treated with ORC and RARC, respectively. The median age was 72 (64-78) years. Overall operative time was longer in RARC compared to ORC (389 ± 80.1 vs. 242 ± 62.2 min, p < 0.001), while the estimated blood loss during cystectomy was higher after ORC (370 ± 126.8 vs. 243.3 ± 201.6 ml, p = 0.03). The transfusion rate was significantly higher in the ORC compared to RARC (24.2 vs. 5.9%, p = 0.04). Eight (19%) and 7 (16.7%) patients experienced 30- and 90-day post-operative complications, with no significant difference between ORC and RARC. Length of stay was significantly shorter in RARC group (median 7 vs. 14 days, p < 0.001).

Conclusion

Open and robot-assisted procedures were safely performed by using a new advanced bipolar seal and cut technology (Caiman®). RARC demonstrated to be superior to ORC in terms of bleeding, transfusion rates and length of hospital stay, despite longer operative time.

Comparative Effectiveness in Perioperative Outcomes of Robotic versus Open Radical Cystectomy: Results from a Multicenter Contemporary Retrospective Cohort Study

BACKGROUND

The comparative effectiveness of robotic-assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) in terms of perioperative outcomes is still a matter of debate affecting payors, physicians, and patients.

OBJECTIVE

To evaluate comparative perioperative and longer-term morbidity of RARC versus ORC in a multicenter contemporary retrospective cohort of patients.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective multicenter study included patients with bladder cancer treated with radical cystectomy at 10 academic centers between 2000 and 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Intraoperative outcomes including blood loss and operative time as well as postoperative outcomes including time to discharge, complication, readmission, reoperation, and mortality rates at 30 and 90 d were assessed. Multiple imputation and inverse probability of treatment weighting (IPTW) were used. IPTW-multivariable-adjusted regression and logistic analyses were performed to evaluate the associations of RARC versus ORC with perioperative outcomes at 30 and 90 d.

RESULTS AND LIMITATIONS

Overall, 1887 patients (1197 RARC and 690 ORC) were included in the study. After IPTW-adjusted analysis, no differences between the groups in terms of preoperative characteristics were observed. RARC was associated with lower blood loss (p<0.001), shorter length of stay (p<0.001), and longer operative time (p=0.007). On IPTW-adjusted multivariable logistic regression analyses, no differences in terms of 30- and 90-d complications, reoperation, and mortality rates were observed. RARC was independently associated with a higher readmission rate at both 30 and 90 d. Limitations are mainly related to the retrospective nature of the study.

CONCLUSIONS

While RARC was associated with less blood loss and shorter hospital stay, it also led to longer operation times and more readmissions. There were no differences in 30- and 90-d complications. Because there are no apparent differences in safety between ORC and RARC in expert centers, differences in oncologic and cost-effectiveness outcomes are likely to drive decision making regarding RARC utilization.

PATIENT SUMMARY

In this study we investigated the differences between RARC and ORC in terms of perioperative outcomes. We found no difference in early and late complications. We concluded that, to date, differences in oncologic and cost-effectiveness outcomes should drive decision making regarding RARC utilization.

Semi-competing risk model to predict perioperative and oncologic outcomes after radical cystectomy

Background

To utilize a semi-competing risk model to predict perioperative and oncologic outcomes after radical cystectomy and to compare the findings with the univariate Cox regression model.

Methods

We reviewed the Institutional Review Board approved database of radical cystectomy of 316 patients who had undergone robot-assisted radical cystectomy (RARC) or open radical cystectomy between 2006 and 2016. Demographic data, perioperative outcomes, complications, metastasis, and survival were analyzed. The Bayesian variable selection method was utilized to obtain models for each hazard function in the semi-competing risks.

Results

Of 316 patients treated, 48% and 18% experienced any or major complication respectively within 30 days. Intracorporeal RARC was associated with decreased metastasis risk. Extracorporeal RARC was associated with marginally decreased risks of overall complications or major complications. Patients with advanced cancer had an increased risk of metastasis, death after metastasis and death after complication. Positive nodes were associated with an increased risk of death without overall or major complications and increased risk of death after metastasis occurs. When a serious complication was taken into account there was no significant difference in mortality, irrespective of disease stage.

Conclusions

A semi-competing risk model provides relatively more accurate information in comparison to Cox regression analysis in predicting risk factors for complications and metastasis in patients undergoing radical cystectomy.

Surgical techniques for facilitating laparoscopic intracorporeal orthotopic neobladder: initial experience

PURPOSE

To describe our technique and outcomes for laparoscopic intracorporeal ileal neobladder (ICNB) reconstruction.

MATERIALS AND METHODS

From April 2014 to November 2016, 21 patients underwent laparoscopic ICNB at our tertiary referral centre. ICNB with bilateral isoperistaltic afferent limbs and several technique improvements were introduced. Demographics, clinical, and pathological data were collected. Perioperative, 1-year oncologic, 1-year Quality of life and 1-year functional outcomes were reported.

RESULTS

ICNB was successfully performed in all 21 patients without open conversion and transfusion. Mean operative time was 345.6±66.9 min, including 106±22 min for LRC and PLND and 204±46.4 min for ICNB, respectively. Mean established blood loss was 192±146 mL. The overall incidence of 90-d complication was 33.3%, while major complication occurred in 4.8%. One-year daytime and night-time continence rates were 85.7% and 57.1%, respectively. One patient died from myocardial infarction six months postoperatively, and two patients had lung metastasis five months and six months respectively.

CONCLUSIONS

We described our experience of 3D LRC with a novel intracorporeal orthotopic ileal neobladder, and the technique improvements facilitate the procedure. However, further studies are required to evaluate long-term outcomes of the intracorporeal neobladder with bilateral isoperistaltic afferent limbs.

A cost-effectiveness modeling study of robot-assisted (RARC) versus open radical cystectomy (ORC) for bladder cancer to inform future research

BACKGROUND

Open radical cystectomy (ORC) is regarded the standard treatment for muscle-invasive bladder cancer, but robot-assisted radical cystectomy (RARC) is increasingly used in practice. However, it is unclear whether RARC provides value for money.

OBJECTIVE

To identify the main evidence gaps and main drivers of cost-effectiveness, comparing RARC to ORC.

DESIGN, SETTING, AND PARTICIPANTS

A decision analytical model was developed to study the 30d and 90d postoperative complications with RARC versus ORC and their related cost in bladder cancer patients. Input data were derived from systematic literature searches, meta-analyses, internal databases and expert opinion.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cost per saved complication (in Clavien-Dindo grading) was determined. Deterministic sensitivity analyses was performed to search for threshold values for RARC to become cost saving. Uncertainty was addressed using probabilistic sensitivity analyses.

RESULTS

The expected 30d and 90d risk for a minor complication was lower for RARC than ORC (37% vs. 45% and 32% vs. 36%). The expected 30d and 90d risk of RARC versus ORC for a major complication was 18% vs. 23% and 16% vs. 25%. The 30d and 90d extra costs needed to prevent one major complication were €62,582 and €37,007, respectively. Data on the impact of complications on quality of life were lacking. Three scenarios resulted in cost savings for RARC: operating time (threshold: ≤175min), length of stay (≤4d), and RARC equipment (≤€281).

CONCLUSION

Current evidence suggests that it is unlikely that RARC will become less expensive than ORC. However, RARC might result in fewer complications. To determine value for money, research is needed into the consequences of these complications in terms of quality of life.

PATIENT SUMMARY

Economic modeling showed that RARC might result in fewer complications, but is more expensive than ORC. Future research should focus on the impact on quality of life.

Robotic-assisted radical cystectomy with intracorporeal urinary diversion versus open: early Australian experience

BACKGROUND

The aim of this study was to describe our initial Australian single surgeon experience with robotic-assisted radical cystectomy (RARC) and intracorporeal urinary diversion (ICUD) and to compare the outcomes with open radical cystectomy (ORC).

METHODS

Between January 2014 and June 2016, consecutive patients diagnosed with muscle invasive and high-risk non-muscle invasive bladder cancer undergoing radical cystectomy were included. Treatment modalities included either RARC with ICUD or ORC. ICUD consisted of either intracorporeal ileal conduit or orthotopic neobladder formation. Prospectively collected perioperative and oncological outcomes were analysed.

RESULTS

Twenty-six RARC and 13 ORC were performed. Median operating times were 362 and 240 min for RARC and ORC, respectively (P < 0.001). Estimated blood loss for RARC was 300 mL compared with 500 mL for ORC (P = 0.01). Post-operative haemoglobin drop was less in the RARC cohort (20% versus 24%, P = 0.03). There was no statistical difference in overall 90-day complication rates (81% versus 62%, P = 0.25) and 90-day major complication rates (19% versus 23%, P = 0.67) between the RARC and ORC groups, respectively. Positive surgical margins for RARC were 4% and 8% for ORC (P = 1.0).

CONCLUSION

Early results demonstrate that the safe introduction of RARC with ICUD in Australia is potentially feasible without compromising perioperative and oncological outcomes. Future randomized trial with larger numbers will be required for further analysis in the Australian setting.

The current status of robot-assisted cystectomy

Robot-assistance is being increasingly used for radical cystectomy (RC). Fifteen years of surgical evolution might be considered a short period for a radical procedure to be established as the treatment of choice, but robot assisted radical cystectomy (RARC) is showing promising results when compared with the current gold standard, open RC (ORC). In this review, we describe the current status of RARC and continue the discussion on the on-going RARC versus ORC debate.

Is the open cystectomy era over? An update on the available evidence

In 2018, robot-assisted radical cystectomy will enter its 15th year. In an era where an effort is being made to standardize complication reporting and videos of the procedure are readily available, it is inevitable and justified that like everything novel, robot-assisted radical cystectomy should be scrutinized against the gold standard, open radical cystectomy. The present comparison is focused on several parameters: oncological, functional and complication outcomes, and direct and indirect costs. Meta-analysis and prospective randomized trials comparing robot-assisted radical cystectomy versus open radical cystectomy have been published, showing an oncological equivalence and in some cases an advantage of robot-assisted radical cystectomy in terms of postoperative morbidity. In the present review, we attempt to update the available knowledge on this debate and discuss the limitations of the current evidence that prevent us from drawing safe conclusions.

A preliminary oncologic outcome and postoperative complications in patients undergoing robot-assisted radical cystectomy: Initial experience

PURPOSE

Robot-assisted radical cystectomy (RARC) was originally intended to replace open radical cystectomy (ORC) as a minimally invasive surgery for patients with invasive bladder cancer. The purpose of this study was to evaluate the advantages of robotic surgery, comparing perioperative and oncologic outcomes between RARC and ORC.

MATERIALS AND METHODS

Between June 2012 and August 2016, 49 bladder cancer patients were given a radical cystectomy, 21 robotically and 28 by open procedure. We compared the clinical variables between the RARC and ORC groups.

RESULTS

In the RARC group, the median estimated blood loss (EBL) during cystectomy, total EBL, operative time during cystectomy, and total operative time were 0 mL, 457.5 mL, 199 minutes, and 561 minutes, respectively. EBL during cystectomy (p<0.001), total EBL (p<0.001), and operative time during cystectomy (p=0.003) in the RARC group were significantly lower compared with the ORC group. Time to resumption of a regular diet (p<0.001) and length of stay (p=0.017) were also significantly shorter compared with the ORC group. However, total operative time in the RARC group (median, 561 minutes) was significantly longer compared with the ORC group (median, 492.5 minutes; p=0.015).

CONCLUSIONS

This Japanese study presented evidence that RARC yields benefits in terms of BL and time to regular diet, while consuming greater total operative time. RARC may be a minimally invasive surgical alternative to ORC with less EBL and shorter length of stay.

Safety and Effectiveness of Robot-Assisted Versus Open Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the safety and effectiveness of robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC) in bladder cancer.

METHODS

A literature search for the systematic review was conducted using international databases as well as domestic databases up to April 2015. Outcomes of interest included baseline characteristics, complication rates, perioperative, and oncologic outcomes.

RESULTS

Twenty-four articles were finally selected for inclusion in the meta-analysis. Complication rates of RARC were similar to those of ORC, except for 90-day overall complication rate, wound dehiscence, abscess, pneumonia, respiratory failure, and sepsis, which was lower after RARC. RARC was also associated with a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield, whereas ORC was associated with a shorter operation time and lower rate of stricture. Considering oncologic outcomes, there were no differences between RARC and ORC.

CONCLUSIONS

RARC seems to be associated with equivalent complication rates, a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield. Randomized controlled trials with a large sample size and comparative studies with long-term follow-up data are warranted to assess our findings and the oncologic effectiveness of RARC.

Systematic review and meta-analysis of randomised trials of perioperative outcomes comparing robot-assisted versus open radical cystectomy

Background

With the introduction of robotic surgery, whether the robot-assisted radical cystectomy (RARC) could reduce the perioperative morbidity compared with Open radical cystectomy (ORC) was unknown.

Methods

Studies reported RARC were reviewed based on all randomized controlled trials (RCTs), which focused on the efficacy of RARC versus ORC.

Results

Of the 201 studies from preliminary screening, four RCTs were included. By pooling these studies, there were significant differences in comparison of operative time (p = 0.007), estimated blood loss (EBL) (p < 0.001) and time to diet (p < 0.001) between the RARC group and ORC groups. There was no significant difference regarding perioperative complications (Clavien 2–5, Clavien 3–5), length of stay (LOS), positive surgical margins (PSM) and lymph node positive.

Conclusion

This meta-analysis presented evidence for a benefit of EBL, time to diet, similar perioperative complications and oncological outcomes, but a longer operative time in RARC. It is noted that RARC was considered as a comparable surgical procedure to ORC.

[Radical cystectomy with orthotopic neobladder replacement: Comparison of robotic assisted and open surgical route]

INTRODUCTION

Radical cystectomy remains the referent treatment of non-metastatic muscle-invasive bladder cancer (MIBC). The fast development of robotic surgery has led some teams to use it for the surgical treatment of the MIBC, in the hope of reducing postoperative morbidity. Urinary diversion by bladder substitution is a bypass option. The aim of our study was to compare the robot-assisted cystectomy with open cystectomy, with urinary diversion by bladder substitution.

PATIENTS AND METHODS

Over a two-year period, all the patients who underwent a robot-assisted laparoscopic or open cystectomy with urinary diversion by bladder substitution have been included. The urinary diversion performed was extra-corporeal.

RESULTS

The study concerned were 26 men, 15 of them underwent robot-assisted cystectomy, and 11 open cystectomy. There was no significant difference in the median operating time or duration of stay (300 vs 314min and 14 vs 18 days). However, there were less blood loss and more lymph nodes collected in the cystectomies robot-assisted group (median: 400 vs 800mL, P=0.016; 15 vs 10, P=0.01). Three grade III complications of the Clavien-Dindo classification have been described in the robot-assisted group, and none in the open group. No robot-assisted procedure required a conversion to laparotomy. Within 90 postoperative days, complications are basically low grades and results are consistent with the literature.

CONCLUSION

In our series, robot-assisted cystectomies with extracorporeal bladder substitution is technically feasible, with best results on blood loss and the number of lymph nodes removed, without impact on the length of stay.

LEVEL OF EVIDENCE

4.

Robotic-Assisted Radical Cystectomy

BACKGROUND

The application and use of robotics during radical cystectomy for the treatment of bladder cancer are still being defined.

METHODS

A systematic literature search was conducted, with an emphasis on studies published within the previous 5 years. Areas of interest included patient selection, outcomes, cost, and comparisons of robotic-assisted radical cystectomy to open surgery.

RESULTS

Although data are lacking in this field, using robotic assistance for radical cystectomy may lead to improvements in estimated blood loss, time to bowel activity, and reduced hospital stay; however, these improvements come at the cost of increased operative time and have a learning curve.

CONCLUSIONS

The widespread adoption of robotic-assisted radical cystectomy has not gained acceptance due to lack of evidence and clinical trials showing superiority over open surgery.

Complications and oncologic outcomes following robot-assisted radical cystectomy: What is the real benefit?

PURPOSE

The aim of this study was to assess the advantages of robotic surgery, comparing perioperative and oncological outcomes between robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC).

MATERIALS AND METHODS

Between August 2008 and May 2014, 112 radical cystectomies (42 RARCs and 70 ORCs) were performed at a single academic institution following Institutional Review Board approval. Patient demographics, perioperative variables (e.g., complications), and oncologic outcomes including metastasis-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS) were reported using the Kaplan-Meier analyses.

RESULTS

The median follow-up period was 40 months (range, 0-70 months) vs. 42 months (range, 0-74 months) in RARC and ORC, respectively. Baseline characteristics of both groups were balanced. Blood loss (median, [range]; 300 mL [125-925 mL] vs. 598 mL [150-2,000 mL], p=0.001) and perioperative transfusion rates (23.8% vs. 45.7%, p=0.020) were significantly lower in the RARC group than in the ORC group. The overall complication rates were greater in the ORC group, but this was not statistically significant (65.7% vs. 64.3%, p=0.878). However, there were significantly higher major complication rates in the ORC group (45.7% vs. 26.2%, p=0.040). No significant differences were found with regards to MFS, CSS, and OS.

CONCLUSIONS

While histopathological findings, overall complications, and survival rates do not reveal definite differences, RARC has more advantages compared to ORC in terms of estimated blood loss, perioperative transfusion rates and fewer perioperative major complications. We propose that RARC is a safer treatment modality with equivalent oncological outcomes compared to ORC.

Oncological Outcomes in Patients Treated with Radical Cystectomy for Bladder Cancer: Comparison Between Open, Laparoscopic, and Robot-Assisted Approaches

PURPOSE

To investigate oncological outcomes in patients with muscle-invasive bladder cancer who underwent open radical cystectomy (ORC), laparoscopic radical cystectomy (LRC), or robot-assisted radical cystectomy (RARC).

PATIENTS AND METHODS

A retrospective analysis was performed on 230 patients who underwent ORC (n = 150), LRC (n = 22), or RARC (n = 58) between September 2009 and June 2012. Perioperative outcomes were compared between the three surgical approaches. The influence of the type of surgical approach on recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) was analyzed using the Kaplan-Meier method, and differences were assessed with the log-rank test. Predictors of RFS, CSS, and OS were also analyzed with a Cox regression model.

RESULTS

The median patient age for ORC, LRC, and RARC groups was 68.0 (interquartile range [IQR]: 60.0-73.0), 65.0 (IQR: 62.8-74.0), and 61.5 (IQR: 54.8-72.0) years, respectively (p = 0.017), and the median follow-up duration was 27.9 (IQR: 14.7-47.9), 28.8 (IQR: 15.7-41.8), and 32.0 (IQR: 15.5-45.4) months, respectively (p = 0.955). There was no significant difference in RFS, CSS, and OS according to the surgical approach (p = 0.253, p = 0.431, and p = 0.527, respectively). Subgroup analysis revealed that RFS, CSS, and OS were not significantly different in both subgroups with stage ≤pT2 or ≥pT3. Multivariable Cox regression analyses showed that the surgical approach was not a significant predictor of RFS, CSS, and OS.

CONCLUSION

Our findings indicate that the type of surgical approach is not associated with RFS, CSS, and OS in patients with bladder cancer.

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.

Critical Review of Outcomes from Radical Cystectomy: Can Complications from Radical Cystectomy Be Reduced by Surgical Volume and Robotic Surgery?

CONTEXT

Radical cystectomy (RC) is a highly complex procedure with multiple risks for perioperative complications.

OBJECTIVE

We reviewed the literature to report perioperative outcomes and the incidence of complications in contemporary RC series. We focused on the potential impact of surgical approach and surgeon volume on these outcomes.

EVIDENCE ACQUISITION

A systematic literature search was performed in December 2015 using the Medline, Embase, and Web of Science databases for articles published in English between 2005 and 2015. The search strategy included the terms complications, cystectomy, robotic assisted radical cystectomy, and surgical volume, alone or in combination. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed.

EVIDENCE SYNTHESIS

Our searches retrieved 49 papers. Open RC (ORC) and robot-assisted RC (RARC) are morbid procedures with consistent risk of perioperative complications (mean weighted incidence: 48.7%; range: 27.0-72.5%). Higher hospital and surgeon volumes were associated with reduced risks of perioperative complications. Prior robotic expertise in radical prostatectomy showed a beneficial protective risk on development of complications after RARC. Surgical volume appears to be a good predictor of safety in ORC and RARC. RARC is associated with reduced estimated blood loss and lower perioperative transfusion rates compared with ORC. Further evidence is needed to support the reproducibility of intracorporeal diversion during RARC, beyond large tertiary referral centers. Several strategies have been demonstrated to be effective for reducing the risk of incurring perioperative complications and should be pursued by physicians.

CONCLUSIONS

Despite improvements in quality of care, RC remains a challenging procedure with high morbidity, regardless of surgical approach. RARC is a safe procedure with potential advantages in terms of reduced blood loss and transfusion rates. Surgical volume appears to be related to the improvement of perioperative outcomes and complications.

PATIENT SUMMARY

Radical cystectomy is a challenging and morbid procedure. The robotic approach has gained popularity and proved to be safe and effective in tertiary referral centers, although further studies are needed to confirm its wide reproducibility. Centers with higher surgical volume have lower incidence of perioperative complications.

Chemotherapy for Invasive Bladder Cancer: Five Simple Rules Learned Over 30 Years

Invasive, clinically non-metastatic bladder cancer has a cure rate of only 50% , when all T stages are considered. The pattern of relapse is dominated by systemic spread, provided that optimal surgery is practiced. Occult metastases are thus most likely to be present at first presentation. For more than 30 years, therapeutic strategies have focused on the use of systemic chemotherapy before, during or after loco-regional therapy to produce cure. More aggressive surgery and more precise radiation techniques in addition to improved chemotherapy have also been tested to improve cure rates. Genetic analysis has focused on prediction and prognostication, without yet having a major impact on outcomes. New agents have been tested in the neoadjuvant and adjuvant setting, but have not yet proven superior to standard algorithms, such as neoadjuvant MVAC chemotherapy. Many studies have tested ineffective metastatic regimens in the neoadjuvant setting without success, giving rise to the maxim that ignoring logical rules of investigation will not advance clinical practice. Leveraging molecular prognostication and immune responsiveness of urothelial cancer may produce the next era of progress. Five simple rules are proposed to guide the development of future studies.