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.

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

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

Comparison of Perioperative Outcomes Between Open and Robotic Radical Cystectomy: A Population-Based Analysis

INTRODUCTION

Radical cystectomy represents the standard of care for muscle-invasive bladder cancer (MIBC). Due to its novelty the use of robotic radical cystectomy (RARC) is still under debate. We examined intraoperative and postoperative morbidity and mortality in addition to impact on length of stay (LOS) and total hospital charges (THCGs) of RARC compared with open radical cystectomy (ORC).

MATERIALS AND METHODS

Within National Inpatient Sample (2008-2013), we identified patients with nonmetastatic bladder cancer treated with either ORC or RARC. We relied on inverse probability of treatment weighting to reduce the effect of inherent differences between ORC vs RARC. Multivariable logistic regression (MLR) and multivariable Poisson regression (MPR) models were used.

RESULTS

Of all 10,027 patients, 12.6% underwent RARC. Between 2008 and 2013, RARC rates increased from 0.8% to 20.4% [estimated annual percentage change (EAPC): +26.5%, 95% confidence interval (CI): +11.1 to +48.3; p = 0.035] and RARC THCGs decreased from 45,981 to 31,749 United States dollars (EAPC: -6.8%, 95% CI: -9.6 to -3.9; p = 0.01). In MLR models RARC resulted in lower rates of overall complications [odds ratio (OR): 0.6; p < 0.001] and transfusions (OR: 0.44; p < 0.001). In MPR models, RARC was associated with shorter LOS (relative risk 0.91; p < 0.001). Finally, higher THCGs (OR: 1.09; p < 0.001) were recorded for RARC. Data are retrospective and no tumor characteristics were available.

CONCLUSION

RARC is related to lower rates of overall complications and transfusions rates. In consequence, RARC is a safe and feasible technique in select MIBC patients. Moreover, RARC is associated with shorter LOS, although higher THCGs.