Open Radical Cystectomy Group Research Articles

Comparisons of in-hospital fee and surgical outcomes between robot-assisted, laparoscopic, and open radical cystectomy: a Japanese nationwide study.

To evaluate in-hospital fees and surgical outcomes of robot-assisted radical cystectomy (RARC), laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC) using a Japanese nationwide database. All data were obtained from the Diagnosis Procedure Combination database between April 2020 and March 2022. Basic characteristics and perioperative indicators, including in-hospital fees, were compared among the RARC, LRC and ORC groups. Propensity score-matched comparisons were performed to assess the differences between RARC and ORC. During the study period, 2931, 1311 and 2435 cases of RARC, LRC and ORC were identified, respectively. The RARC group had the lowest in-hospital fee (median: 2.38 million yen), the shortest hospital stay (26days) and the lowest blood transfusion rate (29.5%), as well as the lowest complication rate (20.9%), despite having the longest anesthesia time (569min) among the three groups (all P<0.01). The outcomes of LRC were comparable with those of RARC, and the differences in these indicators between the RARC and ORC groups were greater than those between the RARC and LRC groups. In propensity score-matched comparisons between the RARC and ORC groups, the differences in the indicators remained significant (all P<0.01), with an ~50 000 yen difference in in-hospital fees. RARC and LRC were considered to be more cost-effective surgeries than ORC due to their superior surgical outcomes and comparable surgical fees in Japan. The widespread adoption of RARC and LRC is expected to bring economic benefits to Japanese society.

Robotic versus open radical cystectomy for bladder cancer: evaluation of complications, survival, and opioid prescribing patterns.

We aim to compare complications, readmission, survival, and prescribing patterns of opioids for post-operative pain management for Robotic-assisted laparoscopic radical cystectomy (RARC) as compared to open radical cystectomy (ORC). Patients that underwent RARC or ORC for bladder cancer at a tertiary care center from 2005 to 2021 were included. Recurrence-free survival (RFS) and overall survival (OS) were evaluated with Kaplan-Meier curves and multivariable Cox proportional hazards regression models. Comparisons of narcotic usage were completed with oral morphine equivalents (OMEQ). Multivariable linear regression was used to assess predictors of OMEQ utilization. A total of 128 RARC and 461 ORC patients were included. There was no difference in rates of Clavien-Dindo grade ≥ 3 complications between RARC and ORC (36.7 vs 30.1%, p = 0.16). After a mean follow up of 3.4years, RFS (HR 0.96, 95%CI 0.58-1.56) and OS (HR 0.69, 95%CI 0.46-1.05) were comparable between RARC and ORC. There was no difference in the narcotic usage between patients in the RARC and ORC groups during the last 24h of hospitalization (median OMEQ: 0 vs 0, p = 0.33) and upon discharge (median OMEQ: 178 vs 210, p = 0.36). Predictors of higher OMEQ discharge prescriptions included younger age [(- )3.46, 95%CI (-)5.5-(-)0.34], no epidural during hospitalization [- 95.85, 95%CI (- )144.95-(- )107.36], and early time-period of surgery [(- )151.04, 95%CI (- )194.72-(- )107.36]. RARC has comparable 90-day complication rates and early survival outcomes to ORC and remains a viable option for bladder cancer. RARC results in comparable levels of opioid utilization for pain management as ORC.

Comparing Robotic-Assisted to Open Radical Cystectomy in the Management of Non-Muscle-Invasive Bladder Cancer: A Propensity Score Matched-Pair Analysis.

For non-muscle-invasive bladder cancer (NMIBC) requiring radical surgery, limited data are available comparing robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) to open radical cystectomy (ORC). The objective of this study was to compare the two surgical techniques. A multicentric cohort of 593 patients with NMIBC undergoing iRARC or ORC between 2015 and 2020 was prospectively gathered. Perioperative and pathologic outcomes were compared. A total of 143 patients operated on via iRARC were matched to 143 ORC patients. Operative time was longer in the iRARC group (p = 0.034). Blood loss was higher in the ORC group (p < 0.001), with a consequent increased post-operative transfusion rate in the ORC group (p = 0.003). Length of stay was longer in the ORC group (p = 0.007). Post-operative complications did not differ significantly (all p > 0.05). DFS at 60 months was 55.9% in ORC and 75.2% in iRARC with a statistically significant difference (p = 0.033) found in the univariate analysis. We found that iRARC for patients with NMIBC is safe, associated with a lower blood loss, a lower transfusion rate and a shorter hospital stay compared to ORC. Complication rates were similar. No significant differences in survival analyses emerged across the two techniques.

Lymph node dissection during radical cystectomy for bladder cancer: A two-center comparative study of robotic versus open surgery.

This study was performed to evaluate the safety and efficacy of lymph node dissection (LND) during robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC). From October 2003 to December 2021, 122 patients underwent LND during RARC and 103 patients underwent LND during ORC at Tokushima University Hospital and Tokushima Prefectural Central Hospital. We investigated the safety and efficacy of LND during RARC by comparing the surgical and oncological outcomes between the two groups. The patients were significantly older in the RARC than the ORC group. The operative time was significantly shorter and the estimated blood loss was significantly lower in the RARC than the ORC group. Although the lymph node yield was significantly higher in the RARC than the ORC group, there was no significant difference in lymph node positivity between the groups. There was no significant difference in the incidence of local recurrence or distant metastasis between the two groups. The 5-year survival rates (overall survival, cancer-specific survival, and recurrence-free survival) were not different between the RARC and ORC groups. This study suggests that the surgical and oncological safety and efficacy of LND during RARC are greater than those of LND during ORC. We believe that LND during RARC is a higher-quality procedure than LND during ORC.

Surgical outcomes of robot-assisted radical cystectomy in octogenarian or older patients: A Japanese nationwide study.

To evaluate the surgical outcomes of robot-assisted radical cystectomy (RARC) in octogenarian or older patients based on a Japanese nationwide database. The diagnosis procedure combination database was used to extract the data on radical cystectomy cases. Surgical outcomes of RARC in octogenarian or older patients (older group) were initially compared to those of patients younger than 80 years (younger group). Then, the surgical outcomes of RARC in the older group were compared to those of open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) in the same age group. Between 2018 and 2021, 478 RARC cases in the older group and 2257 RARC cases in the younger group were identified. In the older group, ileal conduit, neobladder, and other urinary diversions were carried out in 352 (73.6%), 22 (4.6%), and 104 (21.8%) patients, respectively. In the older group, when compared with the younger group, the complication rate (24.9%), blood transfusion rate (41.4%), and in-hospital mortality (1.4%) were equivalent, while significantly shorter anesthesia time and longer length of stay were observed in the older group (521.0 ± 140.4 min vs. 595.1 ± 141.71 min, p < 0.01, and 32.9 ± 16.8 days vs. 30.6 ± 17.8 days, p = 0.01, respectively). In the comparison of the surgical outcomes of older patients receiving RARC to those receiving ORC (n = 746) and LRC (n = 375), the RARC group had the lowest complication rate and the shortest length of stay, while the shortest anesthesia time was noted in the ORC group. The feasibility of RARC for octogenarian or older patients was demonstrated by the nationwide database study.

Efficiency and Safety of Laparoscopic Radical Cystectomy for Muscle-Invasive Bladder Cancer, and Postoperative Recurrence.

To evaluate the efficiency of open radical cystectomy (ORC) in relation to laparoscopic radical cystectomy (LRC) for muscle-invasive bladder cancer, and incidence of postoperative recurrence. A total of 90 patients with muscle-invasive bladder cancer admitted to our urology department from January 2019 to May 2022 were included in this study. Using the random number table, the patients were assigned equally to ORC and LRC groups. The perioperative data of the patients were collected and recorded. The outcome indicators comprised erythrocyte pressure and creatinine levels, blood gas analysis, type of urinary diversion, and histopathology of surgically removed tumors. Operation time of LRC was significantly longer than that of ORC, but other perioperative indices of LRC were better than those of ORC (p < 0.05). Hematocrit levels in LRC group were higher than those in ORC group at postoperative 1 day and before discharge (p < 0.05). However, creatinine levels were lower in LRC group than in ORC group at postoperative 1 day and before discharge (p < 0.05). Moreover, LRC resulted in better blood gas indices than ORC (p < 0.05). There were no significant differences in the type of urinary diversion and histopathological results from surgically removed tumor between the two groups (p > 0.05). Patients who received LRC had a lower incidence of complications than those given ORC (p < 0.05). LRC reduced perioperative complications, decreased mean length of hospital stays, and enhanced recovery of gastrointestinal and renal functions. These data suggest that LRC is safer and more efficient than ORC. However, further studies are required prior to clinical application of this procedure.

Effect of Radical Laparoscopic Surgery and Conventional Open Surgery on Surgical Outcomes, Complications, and Prognosis in Elderly Patients with Bladder Cancer.

Background Bladder cancer is a common malignant tumor of the urinary system in the clinic. It has multiple lesions, easy recurrence, easy metastasis, poor prognosis, and high mortality. Objective The aim of this study is to investigate the impact of laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC) on the surgical outcome, complications, and prognosis of elderly patients with bladder cancer. Materials and Methods One hundred elderly bladder cancer patients who underwent surgery in our hospital from June 2019 to June 2021 were selected for the retrospective study and were divided into 50 cases each in the ORC group and the LRC group according to the different surgical methods. The ORC group was treated with ORC, and the LRC group implemented LRC treatment. The differences in surgery, immune function, recent clinical outcomes, and complications between the two groups were observed and compared. Results The mean operative time, mean intraoperative bleeding, intraoperative and postoperative transfusion rate, and transfusion volume of patients in the LRC group were statistically significant when compared to the ORC group. The differences in the meantime to resume eating, time to get out of bed, mean number of days in hospital after surgery, and the amount of postoperative numbing analgesics used by patients in the LRC group after surgery were statistically significant compared to the ORC group (P < 0.05). There was no statistically significant difference in the comparison of immune function between the two groups before surgery (P > 0.05), while the comparison of CD8+ and B cells 1 week after surgery of the LRC group was significantly better than that of the ORC group (P < 0.05), and the operation time of the LRC group was longer than that of the ORC group (P < 0.05). Statistical analysis of postoperative complications showed that the overall incidence of postoperative complications in the LRC group was significantly lower than that in the ORC group (16.67% vs. 46.67%) (P < 0.05). Conclusion LRC has less surgical trauma and intraoperative bleeding, faster postoperative recovery, and fewer postoperative complications, providing some reference for clinical surgery for elderly bladder cancer patients.

Association of Open vs Robot-Assisted Radical Cystectomy With Mortality and Perioperative Outcomes Among Patients With Bladder Cancer in Sweden

Mortality rates resulting from bladder cancer have remained unchanged for more than 30 years. The surgical community has put hope in robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in an effort to improve surgical outcomes and bladder cancer survival without strong supporting evidence. To evaluate perioperative, safety, and survival outcome differences between RARC with ICUD and open radical cystectomy (ORC). This nationwide population-based cohort study used data from the Swedish National Register of Urinary Bladder Cancer and population-based Cause of Death Register, which includes clinical information on tumor characteristics, treatment, and survival and covers approximately 97% of patients with urinary bladder cancer in Sweden. All patients who underwent radical cystectomy for bladder cancer in any hospital between January 2011 and December 2018 were included. Follow-up data were collected until December 2019. Data analysis was conducted from June to December 2020. RARC or ORC. The main outcomes were all-cause and cancer-specific mortality between RARC and ORC, compared using propensity score matching. Secondary outcomes were differences in perioperative outcomes after the different surgical approaches. Throughout the observation period, 889 patients underwent RARC and 2280 patients underwent ORC at 24 Swedish hospitals. The median (IQR) age was 71 (66-76) years and 2386 patients (75.3%) were men. After a median (IQR) follow-up of 47 (28-71) months, the 5-year cancer-specific mortality rates were 30.2% (variance, 1.59) for ORC and 27.6% (variance, 3.12) for RARC, and the overall survival rates were 57.7% (variance, 2.46) for ORC and 61.4% (variance, 5.11) for RARC. In the propensity score-matched analysis, RARC was associated with a lower all-cause mortality (hazard ratio, 0.71; 95% CI, 0.56-0.89; P = .004). Compared with ORC, RARC was associated with a lower estimated blood loss (median [IQR] 150 [100-300] mL vs 700 [400-1300] mL; P < .001), intraoperative transfusion rate (odds ratio [OR], 0.05; 95% CI, 0.03-0.08; P < .001), and shorter length of stay (median [IQR], 9 [6-13] days vs 13 [10-17] days; P < .001), and with a higher lymph node yield (median [IQR], 20 [15-27] lymph nodes vs 14 [8-24] lymph nodes; P < .001) and 90-day rehospitalization rate (OR, 1.28; 95% CI, 1.02-1.60; P = .03). The RARC group, compared with the ORC group had lower risk of Clavien-Dindo grade III or higher complications (OR, 0.62; 95% CI, 0.43-0.87; P = .009). These findings suggest that compared with ORC, RARC with ICUD was associated with a lower overall mortality rate, fewer high-grade complications, and more favorable perioperative outcomes.

Comparison of open and laparoscopic radical cystectomy as regards long-term oncological outcomes for bladder cancer

Objective: Recently, the laparoscopic technique has become widely accepted as a minimally invasive modality which reduces morbidity and provides similar oncological outcomes to open surgery. However, the number of clinical trials comparing laparoscopic and open radical cystectomy are limited. The objectives of this study are to compare the long-term oncological outcomes between open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) for bladder cancer. Materials and Methods: Out of 144 radical cystectomy patients admitted to our institute from January 2006 to December 2016, 87 patients were categorized as being in the LRC group, and 57 patients in the ORC group. Baseline characteristics, perioperative variables, and pathology results were collected retrospectively. Oncological outcomes including overall survival (OS), recurrence-free survival (RFS) and cancer-specific survival (CSS) were analyzed and compared between the two groups. Results: The mean age of the patients was 64.19 ± 9.89 years in the ORC group and 61.90 ± 10.47 years in the LRC group. The most frequent urinary diversion procedure in both groups was ileal conduit. All pathology results between the LRC group and the ORC group showed no statistical significance. The median follow-up duration was 57.18 ± 44.68 months in the ORC group and 53.96 ± 34.97 months in the LRC group. There was no statistically significant difference in overall survival (OS), recurrence-free survival (RFS) and cancer-specific survival (CSS) between the groups (p = 0.322, 0.946, and 0.528, respectively). Conclusion: Our study demonstrated that the long-term oncological outcome of LRC is comparable to ORC in the management of bladder cancer. LRC is an alternative option to open radical cystectomy and is safe, effective, and feasible. However, further large comparative studies with adequate long-term follow-up are recommended to support our results.

Association between Ureteral Clamping Time and Acute Kidney Injury during Robot-Assisted Radical Cystectomy.

Robot-assisted radical cystectomy (RARC) is replacing open radical cystectomy (ORC) and requires clamping of the ureters, resulting in a predisposition to postrenal acute kidney injury (AKI). We investigated the association between ureteral clamping or its duration and acute/chronic postoperative kidney function. Patients who underwent radical cystectomy (robotic or open) at two tertiary institutions during 2002–2021 were retrospectively enrolled. In those who underwent RARC, the maximum postoperative percentage serum creatinine level (%sCre) change was plotted against ureteral clamping duration. They were divided into two groups using the median clamping time (210 min), and the maximum %sCre change and percentage estimated glomerular filtration rate (%eGFR) change at 3–6 months (chronic) were compared between the ORC (no clamp), RARC < 210, and RARC ≥ 210 groups. In 44 RARC patients, a weak correlation was observed between the duration of ureteral clamping and %Cre change (R2 = 0.22, p = 0.001). Baseline serum creatinine levels were comparable between the groups. However, %sCre change was significantly larger in the RARC ≥ 210 group (N = 17, +32.1%) than those in the RARC < 210 (N = 27, +6.1%) and ORC (N = 76, +9.5%) groups (both, p < 0.001). Chronic %eGFR change was comparable between the groups. Longer clamping of the ureter during RARC may precipitate AKI; therefore, the clamping duration should be minimized.

Open vs robot-assisted radical cystectomy (BORARC): a double-blinded, randomised feasibility study.

To examine surgical outcomes and feasibility of blinding patients and care providers to the surgical technique of radical cystectomy (RC). Single-centre, parallel-group, double-blinded, randomised feasibility study of open RC (ORC) vs robot-assisted RC with intracorporeal urinary diversion (iRARC) in an 'Enhanced Recovery After Surgery' setup. A total of 50 patients aged ≥18 years with bladder cancer planned for RC with an ileal conduit were included. Patients with previous major abdominal/pelvic surgery, pelvic radiation or anaesthesiological contraindications were excluded. Primary outcomes were proportion of unblinded patients and success of blinding using Bang's Blinding Index. Secondary outcomes included length of stay (LOS), complication rates, blood loss, pain, and opioid consumption. A total of 26% of the patients were unblinded before discharge. We demonstrated that patients and doctors remained blinded for the allocated treatment, but nurses did not. Blood loss was greater in the ORC group as was operative time in the iRARC group. We found no difference in complication rate, LOS, or use of analgesics. The present study demonstrates that blinding of surgical technique in RC is possible. The results of secondary outcomes are consistent with the findings of previous unblinded randomised controlled trials. Our study highlights that it is possible to perform a blinded phase III study to explore the optimal surgical technique in RC.

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

To compare perioperative and long-term oncological outcomes and recurrence patterns between robot-assisted radical cystectomy with intra-corporeal urinary diversion (iRARC) and open radical cystectomy (ORC). We retrospectively analyzed 177 bladder cancer patients who received iRARC or ORC at Fujita Health University between 2008 and 2020. Our primary endpoint was long-term oncological outcomes. As a secondary endpoint, we examined perioperative outcomes, complications, and recurrence patterns. These outcome measures were compared between the propensity score (PS)-matched cohorts. PS-matched analysis resulted in 60 matched pairs from iRARC and ORC groups. The iRARC cohort was associated with significantly longer operative time (p = 0.02), lower estimated blood loss (p < 0.001), lower blood transfusion rate (p < 0.001), shorter length of hospital stay (p < 0.001), fewer overall complications (p = 0.03), and lower rate of postoperative ileus (p = 0.02). There was no statistically significant difference between iRARC and ORC in 5-year RFS (p = 0.46), CSS (p = 0.63), and OS (p = 0.71). RFS and CSS were also comparable, even in locally advanced (≥ cT3) disease. Multivariate analysis identified lymphovascular invasion as a robust predictor of RFS, CSS, and OS. The number of recurrence was similar between the groups, while extra-pelvic lymph nodes were more frequent in iRARC than that in ORC (22.7% vs. 7.7%). iRARC has favorable perioperative outcomes, fewer complications, and comparable long-term survival outcomes, including locally advanced (≥ cT3) disease, compared to that in ORC. Our results need to be validated in prospective randomized clinical trials.

The Utility and Efficacy of Laparoscopic Radical Cystectomy in Patients with Muscle-Invasive Bladder Cancer at a Single Institution

Background: The aim of this study was to compare the surgical and oncological outcomes and complications of laparoscopic radical cystectomy (LRC) to those of open radical cystectomy (ORC) in patients with muscle-invasive bladder cancer (MIBC). Methods: Our study focused on patients with histologically confirmed stage T2–T4a urothelial carcinoma of the bladder without distant metastases, who underwent LRC (LRC group) or ORC (ORC group). The primary endpoints in this study were the overall survival (OS) and recurrence-free survival (RFS) rates. Results: In this study, 59 patients, 17 underwent LRC and 42 underwent ORC, were enrolled. The 2-year OS rate was 100% in the LRC group and 88.0% in the ORC group (p = 0.85). The 2-year RFS rate was 63.5% in the LRC group and 69.5% in the ORC group (p = 0.321). On multivariate analysis, the histological type, positive lymph node, and positive resection margin were significantly associated with the OS rates. Conclusions: This study suggested that LRC may achieve similar oncological outcomes and fewer perioperative complications and less blood loss compared to ORC. Therefore, LRC should be considered as one of the treatment options for patients with MIBC.

Atypical oncologic failure after laparoscopic and robot-assisted radical cystectomy at a single institution.

The incidence of atypical oncologic failure in patients with bladder cancer, including peritoneal carcinomatosis, and recurrences at the port site and soft tissue after laparoscopic and robot-assisted radical cystectomy are not well characterized. We retrospectively reviewed the records of 52, 51, and 12 patients who underwent open, laparoscopic, and robot-assisted radical cystectomy, respectively, for bladder cancer from 2007 to 2018 at our institution. We identified techniques associated with atypical oncologic failure. The median follow-up period was 29months. Among the 115 patients, 29 (25%) experienced oncological recurrences, and 7 (6%), 12 (10%), and 23 (20%) had atypical, local, and distant recurrences, respectively. The laparoscopic and robot-assisted radical cystectomy groups had significantly higher incidences of total atypical oncologic failure than the open radical cystectomy group (p = 0.013), including six, one, and two patients with peritoneal carcinomatosis, port site carcinomatosis, and soft tissue involvement, respectively. All 7 patients with atypical oncologic failure died of cancer; the median time from surgery to death was 9.3months. All these patients were cT≧3 and had grade 3 disease. In three patients (43%), the pathological tissue contained variants other than urothelial carcinoma. Five (71%) were among the initial twenty patients. Four patients (57%) had histories of intraoperative urine spillage or bladder perforation during transurethral resection. Patients with cT≧3 stage, with pathological variants other than urothelial carcinoma, and those undergoing procedures that lead to extravesical dissemination should avoid laparoscopic radical cystectomy when the procedures are first introduced.

Laparoscopic versus open radical cystectomy in the treatment of locally advanced T3 and T4 bladder cancer: Perioperative and Mid-term oncological outcomes

In this study, we aim to compare the perioperative and midterm oncological outcomes in patients with advanced bladder cancer and those who had laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC). We retrospectively reviewed medical records of patients who underwent LRC or ORC in a single center between 2008 and 2014 with a pathological diagnosis of pT3 and pT4 bladder cancer. Thirty-five and 39 patients were included in the study as part of the LRC and ORC groups, respectively. There was no statistically significant difference between the two groups in terms of disease-free survival (LRC, 39.8±4.86 months; ORC, 45.47±8.92 months, P=0.896). Average estimated blood loss and length of hospitalization were significantly less in the LRC group. The overall survival rates of patients at 1, 2, and 3 years were 73%, 46%, and 46% in the ORC group and 78%, 65%, and 40% in the LRC group, respectively, and there was no statistically significant difference between the two groups. One patient in the ORC group experienced rectal injury in the form of a serosal tear, which was repaired primarily without any postoperative sequelae. There were no conversions in the laparoscopic group. Similarly, in 1 patient, rectal serosal tear was repaired preoperatively. Our study showed that LRC provides midterm oncological outcomes similar to ORC in the treatment of locally advanced T3 and T4 bladder cancer. However, long-term oncological and functional outcomes are required.

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.

Surgical approach as a determinant factor of clinical outcome following radical cystectomy: Does Enhanced Recovery After Surgery (ERAS) level the playing field?

PurposeTo determine whether surgical approach is a determinant of clinical outcomes following radical cystectomy (RC) and urinary diversion when using an Enhanced Recovery After Surgery (ERAS) protocol. Materials and MethodsWe studied all patients undergoing both open radical cystectomy (ORC) and robotic-assisted radical cystectomy (RARC) and urinary diversion with ERAS for bladder urothelial carcinoma from May 2012 to December 2016. Surgical and clinical outcomes within 90 days after surgery were compared between ORC and RARC, including readmission and major complication rates (Clavien-Dindo grade ≥III). Multivariable logistic regression modeling was used to determine factors that predict readmission and major complications. ResultsA total of 345 and 143 patients underwent ORC and RARC, respectively. The ORC group had a greater proportion of continent urinary diversion (71.9 vs. 40.6%, P< 0.001), shorter operative time (5.4 vs. 7.3 hours, P< 0.001), higher estimated blood loss (500 vs. 200 ml, P< 0.001), and higher intraoperative and postoperative transfusion rates (20.9 vs. 9.1%, P= 0.002 and 20 vs. 11.9%, P= 0.04, respectively). Median length of stay was 4 days for ORC (interquartile range 4–6 days) and 6 days for RARC (interquartile range 4–7 days; P< 0.001). There was no significant difference between ORC and RARC groups in major complication rates (20 vs. 23.8%, P= 0.51) or readmission rates (32.2 vs. 36.4%, P= 0.4) within 90 days after surgery. Multivariable logistic regression analysis showed that surgical approach was not an independent factor predictive of readmission (P= 0.33) or major complications (P= 0.76). ConclusionsSurgical approach is not a determinant of readmission or major complications following RC in the context of an ERAS protocol.

Morbidité, résultat fonctionnel, et qualité de vie des néovessies après cystectomie pour cancer : comparaison de la voie ouverte vs robotique

Open radical cystectomy (ORC) is the gold standard technique for carcinologic cystectomies. Robotic-assisted radical cystectomy (RARC) was introduced in 2003 and its development is booming. To compare ORC and RARC with totally intracorporal (IC) orthotopic neobladder (ONB) reconstruction, in terms of perioperative outcomes, morbidity, functional results and quality of life (Qol). From February 2010 to February 2017, a French multicentric, prospective study on patients who had a RC and ONB reconstruction for bladder cancer was performed. All patients completed the following questionnaires: the European Organization for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and the bladder cancer specific instruments (QLQ-BLM30). To assess urinary symptoms, patients also completed the Urinary Symptom Profile questionnaire (USP) and a three-day voiding diary. Patients were divided in two groups: ORC and RARC. We included 72 patients: 55 in the ORC group (76,4%) and 17 (33,6%) in the RARC group. Operative time was longer in RARC group (median 360 vs 300min; P<0.001) but length of stay was 5 days shorter (median 12 vs 17 days; P<0,05). Patients in RARC group had less blood transfusion (0 vs 23.6%; P<0.05), but a higher rate of uretero-ileal anastomosis stenosis and eventration at long term (respectively 25.5 vs 3.6% et 23 vs 2%; P<0.05). No statistical differences were found concerning quality of life items and functional results between the groups. RARC with totally IC ONB reconstruction lead to less perioperative morbidity with a reduced rate of blood transfusion and a reduced hospital length of stay. At long term, RARC could provide higher rates of uretero-ileal stenosis and eventration. RARC and ORC do not have any differences in terms of functional outcomes and Qol at long term after ONB reconstruction. 3.

Robot-assisted radical cystectomy (RARC) versus open radical cystectomy (ORC): Oncological outcomes in 469 patients with a mean follow-up of five years.

492 Background: There is scant information about intermediate and long-term comparative outcomes between RARC and ORC, with the exception of a recent, small randomized-trial. We present our experience with RARC and ORC in managing bladder cancer patients who require cystectomy. Methods: A query of all patients who underwent radical cystectomy for a primary bladder tumor between 01/2007 and 6/2017 at our institution yield 469 patients. Data was collected on patient demographics, pre-operative information, operative details, pathology, and follow-up. Most RARCs were performed by a high-volume robotic surgeon who preferentially used the robotic approach at the start of all cases. Statistical analyses were generated using SPSS 22.0. Any open conversions were analyzed in the RARC cohort. Results: In 469 total patients, 197 (42.0%) and 272 (58.0%) underwent RARC and ORC, respectively. There were 163 (82.7%) and 224 (82.4%) males in each group and the mean ages (SD) were 71.5 (8.6) and 70.2 (10.5) years. Mean follow-up (SD) was 75 (37.7) and 61 (35.7) months, respectively. There were 130 (66.0%) and 172 (63.2%) patients who presented with T2 or greater disease (p=0.605). Soft-tissue margin rates were 4.1% for RARC and 6.7% for ORC patients (p=0.232). Neoadjuvant chemotherapy was used in 56.9% of RARC and 45.9% of ORC patients with ≥ cT2 disease (p=0.058). The 5-year overall survival was 60.0% vs 57.0% and the 10-year overall survival was 40.3% vs 44.8% for RARC vs. ORC patients, respectively (p=0.283). The 5-year recurrence-free survival was survival (RFS) was 71.7% vs 65.7% and the 10-year RFS was 70.5% vs 62.3% for the RARC vs. open groups, respectively (p=0.078). Aggressive histological variants, which were associated with greater likelihood for recurrence, were more common in the ORC group (13.7 vs. 22.4% p=0.013). Atypical recurrences (i.e. peritoneal, extrapelvic nodes) occurred in 6 (3.0%) and 14 (5.1%) RARC and ORC patients, respectively (p=0.266). Conclusions: In experienced hands, intermediate and long-term outcomes of RARC appear equivalent to ORC with regards to recurrence free survival, overall survival, and risk of atypical recurrences.

Propensity-score-matched comparison of soft tissue surgical margins status between open and robotic-assisted radical cystectomy

IntroductionThe use of robotic-assisted radical cystectomy (RARC) is becoming more widespread. While its safety is accepted, its oncological efficacy as compared to the current standard, open radical cystectomy (ORC), remains debatable. Materials and methodsThe aim of this study is to compare the rates of positive soft tissue surgical margins (STSM), between patients treated with RARC or ORC, using a large contemporaneous collaborative database. We included 2,536 patients with urothelial carcinoma of the bladder treated at 26 institutions. A propensity-score matching 1:1 was performed with 3 ORC patients matched to 1 RARC patient. The final cohort included 1,614 patients. Uni- and multivariable logistic regression analyses tested the impact of surgical technique on STSM status, before and after propensity-score matching. ResultsOverall, 870 (34%) patients underwent RARC and 1,666 (66%) ORC. The overall STSM rate was 11%; 10% in the ORC group and 13% in the RARC group. Within the propensity-score-matched cohort, the positive STSM rate were 14% and 13% in the ORC and RARC group, respectively (P = 0.1). In multivariable analysis, after propensity match RARC approach was not associated with the risk of a positive STSM (P = 0.1). These results were confirmed in the subgroup of patients with pathologic non–organ-confined or organ-confined diseases. ConclusionsWhile treatment with RARC is associated with a higher absolute rate of STSM, the difference did not remain after adjustment for the effects of other established prognostic factors. Results from ongoing trials are awaited to assess the validity of these findings.