Open Radical Cystectomy Research Articles

The Role of Robotic Cystectomy in the Salvage and Palliative Setting: A Retrospective, Single-Center, Cohort Study

Introduction: This article compares surgical and survival outcomes of robot-assisted and open radical cystectomy with cutaneous ureterostomy for the treatment of frail bladder cancer patients with limited life expectancy. Methods: The institutional database was searched for cystectomy cases with cutaneous ureterostomy, from 1 June 2016 to 31 August 2022. The study population was split into two groups, according to the surgical approach. The baseline characteristics and surgical outcomes were compared. Logistic regression analyses identified predictors of major bleeding events (hemoglobin loss ≥ 3.5 g/dL or blood transfusion) and re-operation within 30 days from surgery. The Kaplan–Meier method estimated the impact of the robotic approach on overall survival and Cox regression analysis assessed its predictors. Results: A total of 145 patients were included: 30% (n = 43) underwent robotic cystectomy. Patients’ characteristics and tumor stages distribution were comparable in the two groups but those receiving a minimally invasive treatment showed significantly reduced times to flatus, bowel and hospital discharge (all p < 0.001). Although operation times were longer in this cohort, major bleeding events (60% vs. 89%) and postoperative severe complications (0 vs. 8%) (both p < 0.001) were less frequent compared to the open approach. A logistic regression showed that robotic surgery independently predicted major bleeding events (OR: 0.26; 95%CI 0.09–0.72; p = 0.02) but not the need for re-intervention. A Kaplan–Meier analysis showed that robotic cystectomy was associated with a significant advantage in terms of overall survival (LogRank = 0.03), and this result was confirmed by Cox regression analysis (HR: 0.39; 95%CI 0.14–0.94; p = 0.04). Conclusions: Robotic cystectomy with cutaneous ureterostomy may represent a viable option to treat frail bladder cancer patients, as the minimally invasive approach reduces the risk of bleeding and serious complications and provides a prompt restoration of bowel function and a shorter hospital stay compared to open surgery.

P271 Robotic versus open radical cystectomy: Factors in approach selection, conversion predictors, and survival outcomes

P271 Robotic versus open radical cystectomy: Factors in approach selection, conversion predictors, and survival outcomes

Comparative effectiveness of robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy for bladder cancer.

To assess the comparative effectiveness of robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) vs open radical cystectomy(ORC) for bladder cancer (BC). We conducted a real-life monocentric study including all consecutive patients who underwent RARC with ICUD or ORC for BC at our institution from 2014 to 2023. Uni- and multivariable logistic and Cox regression analyses were used to compare perioperative, oncological and stricture outcomes between both groups by calculating odds (ORs) and hazard (HRs) ratios with their corresponding 95% confidence intervals (CIs), respectively. Overall, 316 patients underwent either RARC with ICUD (n = 228 [72.2%]) or ORC (n = 88 [27.8%]). The perioperative benefits of RARC vs ORC included decreased risks of major blood loss (OR 0.10, 95% CI 0.04-0.23; P < 0.001), perioperative transfusion (OR 0.30, 95% CI 0.16-0.57; P < 0.001), 90-day major complications (OR 0.56, 95% CI 0.29-0.99; P = 0.04), and prolonged initial length of hospital stay (OR 0.20, 95% CI 0.09-0.35; P < 0.001), as well as more days alive and out of the hospital within 90 days of surgery (OR 2.56, 95% CI 1.46-4.6; P < 0.01). In addition, the use of RARC vs ORC was associated with a higher lymph node (LN) count (OR 3.35, 95% CI 1.83-6.30; P < 0.001), while there was no significant difference in recurrence-free (HR 0.72, 95% CI 0.49-1.07; P = 0.1), cancer-specific (HR 0.69, 95% CI 0.43-1.10; P = 0.1), overall (HR 0.76, 95% CI 0.47-1.20; P = 0.3) and uretero-ileal stricture-free (HR 1.18, 95% CI 0.62-2.25; P = 0.6) survival between both groups after a median (interquartile range) follow-up of 42.3 (16.4-73.8) months. Our real-world study supports the effectiveness of RARC with ICUD vs ORC for BC. We generally observed better perioperative outcomes, as well as similar oncological-except for higher LN count-and uretero-ileal stricture outcomes after RARC with ICUD vs ORC.

Urologic oncology case volume among early career urologists: An analysis of certification data from the American board of urology between 2003 and 2019

IntroductionThe incidence of urologic cancer is expected to increase as the U.S. population ages, but the size of the urologic workforce is not expected to increase at a commensurate rate. To understand this growing imbalance, we explored the extent to which early career urologists performed oncology cases, particularly open surgical cases, between 2003 and 2019. Materials and MethodsWe examined case logs submitted by early career urologists applying for their oral American Board of Urology Certifying Examination (Part 2) between 2003 and 2019. We included case logs spanning at least 120 days between the first and last record. We used CPT® codes to identify urologists who performed an open radical cystectomy, nephrectomy, or prostatectomy, as well as those who performed a minimally invasive (MIS) radical nephrectomy or prostatectomy. We calculated the annual percentage of urologists who performed each procedure. Multivariable logistic regression analysis analyzed the association between performing each procedure and specialization or fellowship training in oncology, adjusting for gender, practice type, and year of case log submission. ResultsWe identified 4,166 unique urologists submitting case logs between 2003 and 2019. Their average age was 34.9 years, 81.3% were male, 14.2% specialized in oncology, and 8.2% reported oncology fellowship training. From 2003 to 2019, the percentage of urologists who performed open oncologic procedures decreased, while the percentage who performed MIS oncologic procedures increased. Fellowship training in oncology significantly increased the odds of performing the following procedures: open radical cystectomy (72.5% with fellowship training vs. 30.0% without fellowship training, OR 2.51, 95% CI 0.63–0.92, P < 0.001), open radical nephrectomy (74.3% with fellowship training vs 42.4% without fellowship training, OR 2.02, 95% CI 1.48–2.78, P < 0.001), open radical prostatectomy (42.1% with fellowship training vs. 26.9% without fellowship training, OR 1.86, 95% CI 1.34–2.58, P < 0.001) and MIS radical prostatectomy (80.4% with fellowship training vs. 45.0% without fellowship training, OR 1.69, 95% CI 1.16–2.48, P = 0.006). When comparing those with solely oncology specialization to those with both oncology specialization and fellowship training, we found that those with oncology fellowship training had over 2 times higher odds of performing open radical cystectomy (OR 2.58, CI 1.78–3.74, P < 0.001), open radical nephrectomy (OR 2.06, CI 1.42–2.99, P < 0.001) and open radical prostatectomy (OR 2.12, CI 1.44–3.12, P < 0.001). Female urologists had significantly lower odds of performing each oncologic procedure. ConclusionsIn this analysis of early career urologist case logs, the proportion of urologists performing a radical cystectomy, radical nephrectomy, and open prostatectomy declined between 2003 and 2019. Oncology specialization or fellowship training, however, significantly increased the odds of performing the procedures. Specifically, oncology fellowship alone was associated with over 2 times the odds of performing major open oncologic procedures. These findings reflect ongoing specialization among early career urologists, such that an oncology fellowship or practice focus has likely become necessary for access to open urologic procedures and to become a high-volume urologic oncology surgeon.

Effects of Intraoperative Opioid Use and a Combined Anesthesia Protocol in Patients Undergoing Radical Cystectomy for Urothelial Carcinoma of the Bladder—A Single-Center Experience

Background: An increased intraoperative opioid dose seems to lead to worse outcomes in several types of cancer. We assessed the effect of intraoperatively administered opioids as well as the type of anesthesia on survival, recurrence rates and major perioperative outcomes in patients who underwent radical cystectomy (RC) for urothelial carcinoma of the urinary bladder. Methods: We included patients who underwent open RC at our center between 2015 and 2022. The role of the type and dosage of intraoperative opioid agents, such as remifentanil, sufentanil and morphine milligram equivalents (MME), as well as the type of anesthesia (intravenous only versus intravenous/epidural), was assessed regarding perioperative and long-term outcomes after RC. Results: A total of 508 patients with a median age of 73 years (IQR: 64–78) were included. Overall, 92 (18%) patients received intravenous anesthesia, whereas 416 (82%) received combined anesthesia. At a median follow-up of 270 days (IQR: 98–808), 108 (21%) deaths and 106 (21%) recurrences occurred. Combined anesthesia was associated with better survival (HR:0.63, 95% CI: 0.4–0.97, p = 0.037) and lower intensive care unit admission rates (OR: 0.49, 95% CI: 0.31–0.77, p = 0.002) in the univariate analysis (unadjusted). The type and dosage of intraoperative opioid agents did not affect long-term survival and recurrence rates, as well as major perioperative outcomes. Nevertheless, the findings of our study were limited by its single-center, retrospective design. Conclusion: The use of intraoperative opioids was not associated with worse outcomes in our cohort, while the use of additional epidural anesthesia seems to be beneficial in terms of overall survival and intensive care unit admissions. Nevertheless, further research is mandatory to validate the safety of opioids in patients undergoing RC.

Tranexamic Acid During Radical Cystectomy

Among cancer surgeries, patients requiring open radical cystectomy have the highest risk of red blood cell (RBC) transfusion. Prophylactic tranexamic acid (TXA) reduces blood loss during cardiac and orthopedic surgery, and it is possible that similar effects of TXA would be observed during radical cystectomy. To determine whether TXA, administered before incision and for the duration of radical cystectomy, reduced the number of RBC transfusions received by patients up to 30 days after surgery. The Tranexamic Acid During Cystectomy Trial (TACT) was a double-blind, placebo-controlled, randomized clinical trial with enrollment between June 2013 and January 2021. This multicenter trial was conducted in 10 academic centers. A consecutive sample of patients was eligible if the patients had a planned open radical cystectomy for the treatment of bladder cancer. Before incision, patients in the intervention arm received a loading dose of intravenous TXA, 10 mg/kg, followed by a maintenance infusion of 5 mg/kg per hour for the duration of the surgery. In the control arm, patients received indistinguishable matching placebo. The primary outcome was receipt of RBC transfusion up to 30 days after surgery. A total of 386 patients were assessed for eligibility, and 33 did not meet eligibility. Of 353 randomized patients (median [IQR] age, 69 [62-75] years; 263 male [74.5%]), 344 were included in the intention-to-treat analysis. RBC transfusion up to 30 days occurred in 64 of 173 patients (37.0%) in the TXA group and 64 of 171 patients (37.4%) in the placebo group (relative risk, 0.99; 95% CI, 0.83-1.18). There were no differences in secondary outcomes among the TXA group vs placebo group including mean (SD) number of RBC units transfused (0.9 [1.5] U vs 1.1 [1.8] U; P = .43), estimated blood loss (927 [733] mL vs 963 [624] mL; P = .52), intraoperative transfusion (28.3% [49 of 173] vs 24.0% [41 of 171]; P = .08), or venous thromboembolic events (3.5% [6 of 173] vs 2.9% [5 of 171]; P = .57). Non-transfusion-related adverse events were similar between groups. Results of this randomized clinical trial reveal that TXA did not reduce blood transfusion in patients undergoing open radical cystectomy for bladder cancer. Based on this trial, routine use of TXA during open radical cystectomy is not recommended. ClinicalTrials.gov Identifier: NCT01869413.

Retroperitoneal cutaneous ureterostomy following radical cystectomy: A multicenter comparative study of robotic versus open surgery.

The aim of this study was to evaluate the differences in perioperative outcomes of cutaneous ureterostomy (CUS) between open surgery (open radical cystectomy, ORC) and robot-assisted surgery (robot-assisted radical cystectomy, RARC), including the stent-free rate, readmission rates due to urinary tract infection (UTI), and changes in renal function. Between 2005 and 2023, a total of 37 patients underwent CUS following ORC, while 24 patients underwent CUS following RARC. Perioperative outcomes were compared between these two groups. The patients in the RARC group were significantly older (p = 0.007) and had a significantly higher proportion of high-risk cases with ASA-PS ≥3 (p = 0.002). In addition, RARC was associated with a significantly lower estimated blood loss (p < 0.001) and a reduced transfusion rate (p = 0.003). Postoperative complication rates and the stent-free rate were comparable between the ORC and RARC groups. Throughout a median follow-up period of 2.6 years, rates of readmission due to UTI did not differ significantly between the two groups. Moreover, there were no differences in the change in estimated glomerular filtration rate before and after surgery and the 3-year survival rates were similar across both groups. CUS following RARC appears to offer a safer alternative compared with CUS following ORC, and the stent-free rates are comparable. The significantly lower estimated blood loss and transfusion rate associated with RARC are particularly favorable for elderly patients, those who are frail, and individuals with multiple comorbidities.

PE085 Single-center comparative analysis of open vs robotic radical cystectomy with elective indication to cutaneous ureterostomy

PE085 Single-center comparative analysis of open vs robotic radical cystectomy with elective indication to cutaneous ureterostomy

Surgical cystectomy training using human cadavers embalmed using Thiel's method: a pilot study.

To develop the use of Thiel soft embalmed human cadavers (TeC) in open radical cystectomy (ORC) training for the first time, to investigate the effect of cadaveric training on surgical trainees' technical skills/performance and to determine how trainees perceive the use of cadaveric workshops. A 3-day hands-on workshop was organised. Ten trainees performed ORC on five TeC, supervised by five experts. Feedback from trainees and mentors was evaluated on a five-point Likert scale. All procedures were completed in a fully equipped surgical environment and complied with the principles outlined in the Declaration of Helsinki. The workshop participants evaluated the anatomical and manipulation characteristics of the TeC as similar to real-life conditions. The colour and consistency of the urethra and ureter differed little from those in live patients. The trainees stated that the TeC were beneficial for learning the stages of ORC and urinary diversion (UD), while their self-confidence increased. In terms of realism, all steps of radical cystectomy (RC) were rated 4 out of 5 or higher on the Likert scale by both trainees and faculty. The use of TeC for RC und UD was perceived as favourable by trainees and faculty. The TeC demonstrated a surprising ability to mimic real-life anatomy and represent a new and effective surgical training tool.

Tranexamic acid reduces perioperative blood transfusions following open radical cystectomy – a propensity-score matched analysis

PurposeRadical cystectomy is associated with bleeding and high transfusion rates, presenting challenges in patient management. This study investigated the prophylactic use of tranexamic acid during radical cystectomy.MethodsAll consecutive patients treated with radical cystectomy at a tertiary care university center were included from a prospectively maintained database. After an institutional change in the cystectomy protocol patients received 1 g of intravenous bolus of tranexamic acid as prophylaxis. To prevent bias, propensity score matching was applied, accounting for differences in preoperative hemoglobin, neoadjuvant chemotherapy, tumor stage, and surgeon experience. Key outcomes included transfusion rates, complications, and occurrence of venous thromboembolism.ResultsIn total, 420 patients were included in the analysis, of whom 35 received tranexamic acid. After propensity score matching, 32 patients and 32 controls were matched with regard to clinicopathologic characteristics. Tranexamic acid significantly reduced the number of patients who received transfusions compared to controls (19% [95%-Confidence interval = 8.3; 37.1] vs. 47% [29.8; 64.8]; p = 0.033). Intraoperative and postoperative transfusion rates were lower with tranexamic acid, though not statistically significant (6% [1.5; 23.2] vs. 19% [8.3; 37.1], and 16% [6.3; 33.7] vs. 38% [21.9; 56.1]; p = 0.257 and p = 0.089, respectively). The occurrence of venous thromboembolism did not differ significantly between the groups (9% [2.9; 26.7] vs. 3% [0.4; 20.9]; p = 0.606).ConclusionProphylactic tranexamic administration, using a simplified preoperative dosing regimen of 1 g as a bolus, significantly lowered the rate of blood transfusion after cystectomy. This exploratory study indicates the potential of tranexamic acid in enhancing outcomes of open radical cystectomy.

Estimation of Physiologic Ability and Surgical Stress (E-PASS) predicts postoperative complications after radical cystectomy.

This study evaluates the effectiveness of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system in predicting postoperative complications following radical cystectomy (RC). In this single-center retrospective study, we analyzed data from patients who underwent open RC for muscle-invasive bladder cancer by a single surgeon between 2008 and 2023. Cases involving cystectomy for non-urothelial carcinoma or urinary diversion other than ileal conduit were excluded. We recorded patient demographics, body mass index (BMI), history of abdominal/retroperitoneal surgery, ASA score, performance status (PS), and pre-existing conditions, such as hypertension (HT), coronary artery disease (CAD), diabetes mellitus (DM), and chronic kidney disease (CKD). Intraoperative data included surgery duration, blood loss, and need for blood transfusion. Post-operative complications were classified using the Clavien-Dindo system. E-PASS score was calculated using the Preoperative Risk Score (PRS), Surgical Stress Score (SSS), and Comprehensive Risk Score (CRS). The study included 252 patients. Patients who experienced postoperative complications had higher age, BMI, prior surgical history, ASA score, PS, and rates of CAD, HT, DM, and CKD compared to those who did not. Surgery duration, blood loss, blood transfusion requirement, and E-PASS scores (PRS, SSS, CRS) were also higher in this group. The ROC curve for CRS revealed a predictive cutoff of 0.4911 (AUC = 0.905, p < 0.001). Independent risk factors for postoperative complications included high BMI (p = 0.031), longer surgery duration (p < 0.001), HT (p = 0.042), CKD (p = 0.017), and CRS > 0.4911 (p < 0.001). E-PASS system effectively predicts postoperative complications in RC patients.

Evaluating the Differences of Wound Related Complications in Robotically Assisted Radical Cystectomy vs Open Radical Cystectomy

ObjectiveTo determine whether robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) compared to open radical cystectomy (ORC) or RARC with extracorporeal urinary diversion (ECUD) would result in a decreased rate of surgical site complications. RARC has been shown to be non-inferior to ORC. Both RARC and ORC are complicated by a high rate of perioperative morbidity, including wound related complications, which may be decreased by a robotic approach with intracorporeal diversion. MethodsA retrospective review of our bladder cancer database for patients undergoing radical cystectomy from 2013 to 2021. Patients were stratified by surgical technique as RARC with ICUD vs. ORC vs. RARC with ECUD. Surgical site complications were measured at both 30 and 90-day intervals. ResultsOf the 269 patients, 127 (47.2%) had RARC with ICUD, 118 (43.7%) had ORC, and 24 (8.9%) had RARC with ECUD (mean ages 71.0, 69.5, 67.5 respectively). A comparison of the three groups demonstrated statistical significance at both the 30-day (p<0.001) and 90-day (p<0.001) timeframes for total surgical site complications, with RARC with ICUD having the fewest amount of patients experience a surgical site complication (0.8%) followed by ORC (25.4%) and RARC with ECUD (29.2%). ConclusionOverall, we observed lower surgical site complication rates among patients undergoing RARC with ICUD compared to patients who underwent ORC or RARC with ECUD. This study suggests that decreased surgical site complications may be one benefit of the minimally invasive approach particularly in patients at high risk for surgical site complications after radical cystectomy.

The impact of venous thromboembolism before open or minimally-invasive radical cystectomy in the USA: insurance claims data on perioperative outcomes and healthcare costs.

The relationship between venous thromboembolism (VTE) and solid malignancy has been established over the decades. With rising projected rates of bladder cancer (BCa) worldwide as well as increasing number of patients experiencing BCa and VTE, our aim is to assess the impact of a preoperative VTE diagnosis on perioperative outcomes and health-care costs in BCa cases undergoing radical cystectomy (RC). Patients ≥18 years of age with BCa diagnosis and undergoing open or minimally invasive (MIS) RC were identified in the Merative™ Marketscan® Research Databases between 2007 and 2021. The association of previous VTE history with 90-day complication rates, postoperative VTE events, rehospitalization, and total hospital costs (2021 USA dollars) was determined by multivariable logistic regression modeling adjusted for patient and perioperative confounders. Sensitivity analysis on VTE degree of severity (i.e., pulmonary embolism [PE] and/or peripheral deep venous thrombosis [DVT]) was also examined. Out of 8759 RC procedures, 743 (8.48%) had a previous positive history for any VTE including 245 (32.97%) PE, 339 (45.63%) DVT and 159 (21.40%) superficial VTE. Overall, history of VTE before RC was strongly associated with almost any worse postoperative outcomes including higher risk for any and apparatus-specific 90-days postoperative complications (odds ratio [OR]: 1.21, 95% CI, 1.02-1.44). Subsequent incidence of new VTE events (OR: 7.02, 95% CI: 5.93-8.31), rehospitalization (OR: 1.25, 95% CI: 1.06-1.48), other than home/self-care discharge status (OR: 1.53, 95% CI: 1.28-1.82), and higher health-care costs related to the RC procedure (OR: 1.43, 95% CI: 1.22-1.68) were significantly associated with a history of VTE. Preoperative VTE in patients undergoing RC significantly increases morbidity, post-procedure VTE events, hospital length of stay, rehospitalizations, and increased hospital costs. These findings may help during the BCa counseling on risks of surgery and hopefully improve our ability to mitigate such risks.

The Prognostic Value of Perioperative Platelet and Leukocyte Values in Patients Undergoing Radical Cystectomy: A Prospective Long-Term Cohort Study

Introduction: Studies assessing the impact of preoperative and first-day postoperative values of leukocytes, thrombocytes, and platelet/leukocyte ratio (PLR) after radical cystectomy (RC) are sparse. We aimed to assess the impact of these factors on long-term survival after RC. Methods: An analysis of patients undergoing open RC from 2004 to 2023 at our center was performed. Leukocytosis was defined as ≥8,000 leukocytes/μL and thrombocytosis as ≥400,000 thrombocytes/μL. Similarly, the cutoff for PLR was set at 28. A multivariable Cox regression analysis was performed to assess the role of leukocytosis, thrombocytosis, and PLR on long-term survival after RC. For all analyses, hazard ratios (HRs) with the corresponding 95% confidence intervals (CIs) were estimated. Results: A total of 1,817 patients with a median age of 70 years (interquartile range [IQR]: 62–77) were included. Overall, 804 (44%), 175 (10%), and 1,296 (71%) patients presented with leukocytosis, thrombocytosis, and PLR ≥28 preoperatively. Accordingly, 1,414 (78%), 37 (2%), and 249 (14%) patients presented with leukocytosis, thrombocytosis, and PLR ≥28 on the first day after RC. At a median follow-up of 26 months (IQR: 8–68) after RC, 896 (49%) patients died. In the multivariate Cox regression analysis after adjusting for major perioperative risk factors, only preoperative leukocytosis (HR: 1.3, 95% CI: 1.1–1.6, p = 0.01), as well as both preoperative and first-day thrombocytosis (HR: 2.1, 95% CI: 1.5–2.9, and HR: 2.8, 95% CI: 1.6–5.1, p < 0.001, accordingly) were associated with worse overall survival. Conclusion: PLR should not be used as a prognostic marker for survival after RC. On the contrary, preoperative leukocytosis, as well as preoperative and first-day thrombocytosis should raise awareness among clinicians performing RC since they were independently associated with worse survival after RC.

Comparative Outcomes of Open Radical Cystectomy vs. Robot-Assisted Approaches with Intracorporeal and Extracorporeal Urinary Diversion: A Meta-Analysis and Network Meta-Analysis of Perioperative and Quality of Life Outcomes.

Background: To conduct a comprehensive systematic review and network meta-analysis of RCTs that compare outcomes of robot-assisted radical cystectomy (RARC) with intra- or extracorporeal urinary diversion (ICUD or ECUD) and the standard open approach (oRC). Methods: A systematic review identified RCTs including patients aged >18 years with non-metastatic bladder cancer treated with RARC (ICUD or ECUD) vs. oRC and reporting peri- and post-operative outcomes and quality of life (QoL) assessment. Standard and network metanalyses were performed. Results: Data from 1024 patients included in eight RCTs were analyzed. The standard meta-analysis found that RARC had longer OT, lower EBL, and a lower transfusion rate compared to oRC (all p < 0.001). No significant differences in terms of LOS between the ICUD vs. ECUD vs. ORC were recorded. RARC patients demonstrated better scores in fatigue, insomnia, pain, physical functioning, and role functioning-according to QoL assessment-compared to ORC at early follow-up, despite no difference at baselines. Finally, at network metanalysis, ICUD (OR = 0.74, p < 0.001) but not ECUD (OR = 0.92, p < 0.08) yielded a lower rate of high-grade 90-day complications compared to ORC despite longer OT (MD = 89.56, p = 0.0351). Conclusions: RARC represents a safe and feasible option to reduce perioperative bleeding with no definitive impact on LOS compared to ORC. Interestingly, ICUD may reduce the burden of 90-day complications to a greater extent than ECUD. Nonetheless, surgeons should be aware of the extended OT and steep learning curve of ICUD. Finally, RARC may provide some short-term benefits in terms of QoL, but more research is needed to determine its long-term effects.

Perioperative complications and oncological outcomes of open versus robotic-assisted radical cystectomy: a propensity score-matched study.

To conduct a comparative effectiveness analysis between robot-assisted radical cystectomy (RARC) and open approach (ORC). A retrospective cohort study was conducted involving all patients undergoing radical cystectomy and urinary diversion for invasive bladder cancer at our institution from 2010 to 2018. Of a total 296 patients, we matched ORC and RARC cases based on age, BMI, Charlson comorbidity index, pathological TN staging of the tumor, prior radiotherapy, and type of diversion. The perioperative complications and oncological outcomes were compared. Eighty-nine patients were matched in the ORC and RARC groups. The median operative time was longer in RARC group (430min) than that of ORC group (372min) (p = 0.03); however, the median estimated blood loss (EBL) was significantly lower in RARC group (500ml) than that of ORC (700ml) (p < 0.0001). The median length of hospital stay (LOS) was significantly reduced in the RARC group (7days) compared to the ORC group (8days) (p = 0.02). There were no significant differences between both groups in 30- and 90-day postoperative complications (p = 0.3 and p = 0.2, respectively). A total of 68 deaths (38.2%) were observed, of which 36 (40.4%) were in ORC group while 32 (36%) were in RARC group (p = 0.5). The results were comparable in both groups regarding 5-year survival rate and cancer-specific survival (p = 0.3 and p = 0.1, respectively). RARC showed better perioperative outcomes in the form of less EBL and shortened LOS compared to ORC group. However, both RARC and ORC provide similar postoperative oncologic control, in terms of similar positive surgical margins, cancer-specific rates, and 5-year survival rates.

Near-infrared fluorescence lymph node template region dissection plus backup lymphadenectomy in open radical cystectomy for bladder cancer using an innovative handheld device: A single center experience.

The extent of pelvic lymphadenectomy (PLND) as part of radical cystectomy (RC) for bladder cancer (BC) remains unclear. Sentinel-based and lymphangiographic approaches could lead to reduced morbidity without sacrificing oncologic safety. To evaluate the feasibility and diagnostic value of fluorescence-guided template sentinel region dissection (FTD) using a handheld near-infrared fluorescence (NIRF) camera in open radical cystectomy. After peritumoral cystoscopic injection of indocyanine green (ICG) 21 patients underwent open RC with FTD due to BC between June 2019 and June 2021. Intraoperatively, the FIS-00 Hamamatsu Photonics® NIRF camera was used to identify and resect fluorescent template sentinel regions (FTRs) followed by extended pelvic lymphadenectomy (ePLND) as oncological back-up. Descriptive analysis of positive and negative results per template region. FTRs were identified in all 21 cases. Median time (range) from ICG injection to fluorescence detection was 75 (55-125) minutes. On average (SD), 33.4 (9.6) lymph nodes were dissected per patient. Considering template regions as the basis of analysis, 67 (38.3%) of 175 resected regions were NIRF-positive, with 13 (7.4%) regions harboring lymph node metastases. We found no metastatic lymph nodes in NIRF-negative template regions. Outside the standard template, two NIRF-positive benign nodes were identified. The concept of NIRF-guided FTD proved for this group all lymph node metastases to be found in NIRF-positive template regions. Pending validation in a larger collective, resection of approximately 40% of standard regions may be sufficient and may result in less morbidity.

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.

Open versus Robot-Assisted Radical Cystectomy for the Treatment of pT4a Bladder Cancer: Comparison of Perioperative Outcomes.

We compared the perioperative outcomes of open (ORC) vs. robot-assisted (RARC) radical cystectomy in the treatment of pT4a MIBC. In total, 212 patients underwent ORC (102 patients, Group A) vs. RARC (110 patients, Group B) for pT4a bladder cancer. Patients were prospectively followed and retrospectively reviewed. We assessed operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of stay, transfusion rate, and oncological outcomes. Preoperative features were comparable. The mean operative time was 232.8 vs. 189.2 min (p = 0.04), and mean EBL was 832.8 vs. 523.7 mL in Group A vs. B (p = 0.04). An intraoperative transfusion was performed in 32 (31.4%) vs. 11 (10.0%) cases during ORC vs. RARC (p = 0.03). The intraoperative complications rate was comparable. The mean length of stay was shorter after RARC (12.6 vs. 7.2 days, p = 0.02). Postoperative transfusions were performed in 36 (35.3%) vs. 13 (11.8%) cases (p = 0.03), and postoperative complications occurred in 37 (36.3%) vs. 29 (26.4%) patients in Groups A vs. B (p = 0.05). The positive surgical margin (PSM) rate was lower after RARC. No differences were recorded according to the oncological outcomes. ORC and RARC are feasible treatments for the management of pT4a bladder tumors. Minimally invasive surgery provides shorter operative time, bleeding, transfusion rate, postoperative complications, length of stay, and PSM rate.

Assessing Trifecta and Pentafecta Success Rates between Robot-Assisted vs. Open Radical Cystectomy: A Propensity Score-Matched Analysis.

This study aimed to evaluate the surgical and oncological outcomes of robot-assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) using trifecta and pentafecta parameters. The clinical data of 41 patients who underwent RARC between 2018 and 2022 were prospectively collected and retrospectively compared to those of 330 patients undergoing ORC using 1:1 propensity score matching. Trifecta was defined as simultaneous negative surgical margins (SMs), a lymph node (LN) yield ≥ 16, and the absence of major complications (Clavien-Dindo grade III-V) within 90 days postoperatively. Pentafecta additionally included a 12-month recurrence-free rate and a time between the transurethral resection of a bladder tumor (TURBT) and radical cystectomy (RC) ≤ 3 months. The continuous variables were compared using the Mann-Whitney U test, and the categorical variables were analyzed using the chi-squared test. No statistically significant differences in trifecta and pentafecta success rates were observed between the RARC and ORC cohorts after propensity score matching. However, the RARC group exhibited significantly reduced blood loss (RARC: 317 mL vs. ORC: 525 mL, p = 0.01). RARC offers distinct advantages over ORC in terms of reduced blood loss, while trifecta and pentafecta success rates do not differ significantly between the two surgical approaches.