Robot-assisted Radical Cystectomy Group Research Articles

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.

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.

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.

Robot-assisted, laparoscopic and open radical cystectomy for bladder cancer: A systematic review and network meta-analysis.

To evaluate the safety and effectiveness of robot-assisted radical cystectomy (RARC), laparoscopic radical cystectomy (LRC), and open radical cystectomy (ORC) in bladder cancer. A literature search for network meta-analysis was conducted using international databases up to February 29, 2024. Outcomes of interest included baseline characteristics, perioperative outcomes and oncological outcomes. Forty articles were finally selected for inclusion in the network meta-analysis. Both LRC and RARC were associated with longer operative time, smaller amount of estimated blood loss, lower transfusion rate, shorter time to regular diet, fewer incidences of complications, and fewer positive surgical margin compared to ORC. LRC had a shorter time to flatus than ORC, while no difference between RARC and ORC was observed. Considering lymph node yield, there were no differences among LRC, RARC and ORC. In addition, there were statistically significant lower transfusion rates (OR=-0.15, 95% CI=-0.47 to 0.17), fewer overall complication rates (OR=-0.39, 95% CI=-0.79 to 0.00), fewer minor complication rates (OR=-0.23, 95% CI=-0.48 to 0.02), fewer major complication rates (OR=-0.23, 95% CI=-0.68 to 0.21), fewer positive surgical margin rates (OR=0.22, 95% CI=-0.27 to 0.68) in RARC group compared with LRC group. LRC and RARC could be considered as a feasible and safe alternative to ORC for bladder cancer. Notably, compared with LRC, RARC may benefit from significantly lower transfusion rates, fewer complications and lower positive surgical margin rates. These data thus showed that RARC might improve the management of patients with muscle invasive or high-risk non-muscle invasive bladder cancer.

Comparison of Robotic vs Open Cystectomy: A Systematic Review.

The benefits of a robot-assisted radical cystectomy (RARC) compared to an open approach is still under debate. Initial data on RARC were from trials where urinary diversion was performed by an extracorporeal approach, which does not represent a completely minimally invasive procedure. There are now updated data for RARC with intracorporeal urinary diversion that add to the evidence profile of RARC. To perform a systematic review and meta-analysis of the effectiveness of RARC compared with open radical cystectomy (ORC). Multiple databases were searched up to May 2022. We included randomised trials in which patients underwent RARC and ORC. Oncological and safety outcomes were assessed. Seven trials of 907 participants were included. There were no differences seen in primary outcomes: disease progression [RR 0.98, 95% CI 0.78 to 1.23], major complications [RR 0.95, 95% CI 0.72 to 1.24] and quality of life [SMD 0.05, 95% CI -0.13 to 0.38]. RARC resulted in a decreased risk of perioperative blood transfusion [RR 0.57, 95% CI 0.43 to 0.76], wound complications [RR 0.34, 95% CI 0.21 to 0.55] and reduced length of hospital stay [MD -0.62 days, 95% CI -1.11 to -0.13]. However, there was an increased risk of developing a ureteric stricture [RR 4.21, 95% CI 1.07 to 16.53] in the RARC group and a prolonged operative time [MD 70.4 minutes, 95% CI 34.1 to 106.7]. The approach for urinary diversion did not impact outcomes. RARC is an oncologically safe procedure compared to ORC and provides the benefits of a minimally invasive approach. There was an increased risk of developing a ureteric stricture in patients undergoing RARC that warrants further investigation. There was no difference in oncological outcomes between approaches.

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.

MP52-19 ROBOTIC VERSUS OPEN CYSTECTOMY WITH ILEAL CONDUIT FOR THE MANAGEMENT OF NEUROGENIC BLADDER: A COMPARATIVE STUDY

You have accessJournal of UrologyCME1 Apr 2023MP52-19 ROBOTIC VERSUS OPEN CYSTECTOMY WITH ILEAL CONDUIT FOR THE MANAGEMENT OF NEUROGENIC BLADDER: A COMPARATIVE STUDY Jeanne Beirnaert, Ugo Pinar, Davy Benarroche, Morgan Roupret, Véronique Phé, Christophe Vaessen, Jerome Parra, Emmanuel Chartier-Kastler, and Thomas Seisen Jeanne BeirnaertJeanne Beirnaert More articles by this author , Ugo PinarUgo Pinar More articles by this author , Davy BenarrocheDavy Benarroche More articles by this author , Morgan RoupretMorgan Roupret More articles by this author , Véronique PhéVéronique Phé More articles by this author , Christophe VaessenChristophe Vaessen More articles by this author , Jerome ParraJerome Parra More articles by this author , Emmanuel Chartier-KastlerEmmanuel Chartier-Kastler More articles by this author , and Thomas SeisenThomas Seisen More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003300.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Cystectomy associated with non-continent ileal diversion is a common surgery in patients with neurogenic bladder. Few data are available, especially for the robotic approach. Our purpose was to compare open cystectomy (OC) and robot-assisted radical cystectomy (RARC) with ileal conduit, regarding peri- and postoperative outcomes. METHODS: We included each patient who underwent cystectomy and ileal conduit for neurogenic bladder in a referral-center between January 2017 and November 2021. Datas were retrospectively analysed. Median follow-up was 16.6 months [IQR: 5; 41]. All patients had neurogenic bladder with failure of conservative treatment and/or impacted Quality of Life (QoL). Open cystectomy with non-continent ileal diversion and robot-assisted cystectomy with intra-corporeal non-continent ileal diversion were compared. Primary endpoint were postoperative complications. Secondary endpoints were length of hospital stay (LOS), surgery duration, blood loss and ureteral anastomosis stricture. RESULTS: A total of 123 patients were included, 85 (69.1%) undergoing OC and 38 (30.9%) RARC. Significant differences were observed for: operative time (OC: 266.9±64 vs. RARC: 205.8±55.5 min, p<0.001), blood loss (OC: 737.7±515.8 vs. RARC: 245.8±169.6 ml, p<0.001), delay until feeding resumption (OC: 7.1±4.7 vs. RARC: 5.5±2.9 days, p=0.05) and mean LOS (OC: 21.6±13.9 vs. RARC: 16.2±7.6 days, p=0.03). In RARC group, there were 10.5% complications Clavien-Dindo >2 whereas 23.8% complications underwent in the OC group (p=0.1). With regards to uretero-ileal anastomosis stenosis, 23 (18.7%) events occurred after a median follow-up of 16.6 months [IQR: 5; 41] including 20 (23.5%) and three (7.9%) in the ORC and RARC groups, respectively (p=0.07). Patients who underwent RARC had better ureteral stenosis-free survival rates than those who underwent ORC (log-rank test, p=0.05). CONCLUSIONS: RARC is a safe approach for management of neurological bladder showing significantly better perioperative outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e710 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeanne Beirnaert More articles by this author Ugo Pinar More articles by this author Davy Benarroche More articles by this author Morgan Roupret More articles by this author Véronique Phé More articles by this author Christophe Vaessen More articles by this author Jerome Parra More articles by this author Emmanuel Chartier-Kastler More articles by this author Thomas Seisen More articles by this author Expand All Advertisement PDF downloadLoading ...

Impact of outcomes and costs for implementation of robotic radical cystectomy with full intracorporeal urinary diversion.

Radical cystectomy (RC) remains a surgery with important morbidity despite technical advances. Our aim was to determine the impact on outcomes and costs of robot-assisted radical cystectomy (RARC) with full intracorporeal diversion. We retrospectively included 196 consecutive patients undergone RC for bladder cancer between 2017 and 2022. Comparisons were done between the open radical cystectomy (ORC; n = 166) and RARC with full intracorporeal diversion (n = 30) in the overall cohort and after matched pair analysis. More neobladders were performed in the RARC group (40% vs 18.7%, p = 0.011). Peri-operative parameters continuously improved over time in the RARC cohort despite an increased proportion of elderly patients with higher comorbidity index. RARC patients had lower prolonged stay (33.3% vs 68.3%, p = 0.002), lower grade 1 complication rates (26.7% vs 53.3%, p = 0.016) and blood loss (185 vs 611 ml, p <0.001) than ORC patients. RARC was an independent favorable predictor for prolonged stay (OR 0.199) and complication (OR 0.334). Cost balance favored ORC, with an increase of hospitalization cost at 816 euros for RARC. After matching, RARC with full intracorporeal diversion was associated with improved outcomes and a moderated increase of post-operative costs mainly due to the use of robotic devices.

Robotic versus open cystectomy with ileal conduit for the management of neurogenic bladder: a comparative study.

Cystectomy associated with non-continent ileal diversion is a common surgery in patients with neurogenic bladder. Few data are available, especially for the robotic approach. Our purpose was to compare open cystectomy (OC) and robot-assisted radical cystectomy (RARC) with ileal conduit, regarding peri- and post-operative outcomes. We included each patient who underwent cystectomy and ileal conduit for neurogenic bladder in a referral-center between January 2017 and November 2021. Data were retrospectively analyzed. Median follow-up was 16.6months [IQR: 5; 41]. All patients had neurogenic bladder with failure of conservative treatment and/or impacted Quality of Life (QoL). Open cystectomy with non-continent ileal diversion and robot-assisted cystectomy with intra-corporeal non-continent ileal diversion were compared. Primary endpoint was postoperative complications. Secondary endpoints were length of hospital stay (LOS), surgery duration, blood loss and ureteral anastomosis stricture. A total of 123 patients were included, n = 85 (69.1%) undergoing OC and n = 38 (30.9%) RARC. Significant differences were observed for: operative time (OC 266.9 ± 64 vs. RARC 205.8 ± 55.5min, p < 0.001), blood loss (OC 737.7 ± 515.8 vs. RARC 245.8 ± 169.6ml, p < 0.001), delay until feeding resumption (OC 7.1 ± 4.7 vs. RARC 5.5 ± 2.9days, p = 0.05) and mean LOS (OC 21.6 ± 13.9 vs. RARC 16.2 ± 7.6days, p = 0.03). In RARC group, there were 10.5% complications Clavien-Dindo > 2 whereas 23.8% complications underwent in the OC group (p = 0.1). RARC is a safe approach for management of neurological bladder showing significantly better perioperative outcomes.

Сравнительный анализ робот-ассистированной и открытой радикальной цистэктомии с ортотопической деривацией мочи

Robot-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder creation is a complex surgical procedure, which is gradually becoming an alternative to open surgery.To compare the perioperative, functional and oncological outcomes of open radical cystectomy (ORC) and RARC.RARC with ileocystoplasty was performed in 25 patients, including 24 men. The average age was 65.5 years. ORC was done in 30 patients (28 men; control group) with the mean age of 67.2 years. In RARC, the ureters were isolated at the level of lower thirds, the bladder was dissected from the rectum on both sides, then the bladder vessels were divided using clips, and the urethra was cut off. After pelvic lymph node dissection, 50 cm of the ileum was resected. Then two distal segments were folded in a U-shape, a 1.5 cm incision was made in the lower part, and an anastomosis with the urethra was carried out. Further, these segments were detubularized and a modified Studer reservoir was created. The ureters were implanted into the tubular part. In ORC, urine diversion was also done using Studer technique. In both groups, the operation time, the volume of blood loss, the number of complications, the duration of hospitalization, the proportion of daytime and nighttime continence were evaluated.The mean time for RARC and ORC was 380 (320-580) and 260 (220-320) min, respectively (p<0.05). In the group of RARC, the volume of blood loss was 85 (50-250) ml and no blood transfusion was performed, while in ORC, the volume of blood loss was 520 (350-1400) ml, an average of 480 (0-840) ml of blood was transfused (p<0.05). After RARC, 30- and 90- complications rate was 32.0% (n=8) and 24.0% (n=6), respectively, compared to 40.0% (n=12) and 30.0% (n=9) in ORC. One patient died due to myocardial infarction during the 90-day follow-up period after RARC (grade V complication according to Clavien). The average number of removed lymph nodes in the RARC group was 15 (10-18). One patient had lymph node metastases. There were no cases of local recurrence. In ORC, the average number of lymph nodes was 16 (11-20), metastases were detected in 2 patients. One of them was subsequently diagnosed with local recurrence. There was no significant difference in the number of lymph nodes removed between two groups. After RARC, 20 (80.0%) patients had complete urinary continence, while 5 patients (20.0%) used 1-2 pads per day. Night continence was preserved in 15 cases (60.0%). After ORC, complete urinary continence was seen in 23 cases (76.7%). Five patients (20.0%) used 1-2 pads per day and two patients (6.7%) used 2-3 pads per day. Night continence after ORC was preserved in 17 cases (56.7%).RARC is a minimally invasive method of surgical treatment of patients with muscle-invasive bladder cancer. Compared with ORC, a significantly lower rate of complications and blood transfusions is documented, but RARC requires a longer operation time. Both interventions provide the equivalent oncological and functional outcomes, which are in line with published data.

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 Robot-Assisted and Open Radical Cystectomy in Recovery of Patient-Reported and Performance-Related Measures of Independence

No data exist on time to recovery of patient-reported and performance-related measures of functional independence after radical cystectomy (open or robotic). To determine recovery of functional independence after radical cystectomy and whether robot-assisted radical cystectomy (RARC) is associated with any advantage over open procedures. Data for this secondary analysis from the RAZOR (Randomized Open vs Robotic Cystectomy) trial were used. RAZOR was a phase 3 multicenter noninferiority trial across 15 academic medical centers in the US from July 1, 2011, to November 18, 2014, with a median follow-up of 2 years. Participants included the per-protocol population (n = 302). Data were analyzed from February 1, 2017, to May 1, 2021. Robot-assisted radical cystectomy or open radical cystectomy (ORC). Patient-reported (activities of daily living [ADL] and independent ADL [iADL]) and performance-related (hand grip strength [HGS] and Timed Up & Go walking test [TUGWT]) measures of independence were assessed. Patterns of postoperative recovery for the entire cohort and comparisons between RARC and ORC were performed. Exploratory analyses to assess measures of independence across diversion type and to determine whether baseline impairments were associated with 90-day complications or 1-year mortality were performed. Of the 302 patients included in the analysis (254 men [84.1%]; mean [SD] age at consent, 68.0 [9.7] years), 150 underwent RARC and 152 underwent ORC. Baseline characteristics were similar in both groups. For the entire cohort, ADL, iADL, and TUGWT recovered to baseline by 3 postoperative months, whereas HGS recovered by 6 months. There was no difference between RARC and ORC for ADL, iADL, TUGWT, or HGS scores at any time. Activities of daily living recovered 1 month after RARC (mean estimated score, 7.7 [95% CI, 7.3-8.0]) vs 3 months after ORC (mean estimated score, 7.5 [95% CI, 7.2-7.8]). Hand grip strength recovered by 3 months after RARC (mean estimated HGS, 29.0 [95% CI, 26.3-31.7] kg) vs 6 months after ORC (mean estimated HGS, 31.2 [95% CI, 28.8-34.2] kg). In the RARC group, 32 of 90 patients (35.6%) showed a recovery in HGS at 3 months vs 32 of 88 (36.4%) in the ORC group (P = .91), indicating a rejection of the primary study hypothesis for HGS. Independent ADL and TUGWT recovered in 3 months for both approaches. Hand grip strength showed earlier recovery in patients undergoing continent urinary diversion (mean HGS at 3 months, 31.3 [95% CI, 27.7-34.8] vs 33.9 [95% CI, 30.5-37.3] at baseline; P = .09) than noncontinent urinary diversion (mean HGS at 6 months, 27.4 [95% CI, 24.9-30.0] vs 29.5 [95% CI, 27.2-31.9] kg at baseline; P = .02), with no differences in other parameters. Baseline impairments in any parameter were not associated with 90-day complications or 1-year mortality. The results of this secondary analysis suggest that patients require 3 to 6 months to recover baseline levels after radical cystectomy irrespective of surgical approach. These data will be invaluable in patient counseling and preparation. Hand grip strength and ADL tended to recover to baseline earlier after RARC; however, there was no difference in the percentage of patients recovering when compared with ORC. Further study is needed to assess the clinical significance of these findings. ClinicalTrials.gov Identifier: NCT01157676.

Assessment of Feasibility of Robot-assisted Radical Cystectomy in Patients With Advanced Bladder Cancer Treated With Maintenance Hemodialysis Therapy.

To clarify the perioperative and oncological outcomes of robot-assisted radical cystectomy (RARC) in advanced bladder cancer (BC) patients treated with maintenance hemodialysis (HD) therapy. We retrospectively evaluated patients receiving HD therapy who had undergone RARC or open radical cystectomy (ORC) for BC between April 1988 and December 2021 at two affiliated institutions. We compared the surgical outcomes and survival after radical cystectomy between patients treated with RARC and those treated with ORC. Thirty-six patients were evaluated, and eight (22%) and 28 (78%) received RARC and ORC, respectively. RARC was more frequently conducted than ORC in elderly patients (median: 75.5 vs. 68.2 years, p<0.05). Regarding postoperative surgical outcomes, the estimated blood loss volume (median: 75 ml vs. 627 ml, p<0.05) was significantly lower in the RARC group than that in the ORC group. A lower blood transfusion rate (25% vs. 67%, p=0.170) was observed. Moreover, there were no differences in operative time (median: 255 vs. 294 min, p=0.232) or complication rate (Clavien-Dindo grade, any grade: 50% vs. 46%, p=0.858; grade 3 or more: 13% vs. 14%, p=0.897). The 11-year overall survival rate did not differ between the two groups (88% vs. 74%, p=0.365). The perioperative outcomes of RARC in patients undergoing HD therapy were comparable to those of ORC. RARC is a potentially feasible surgical option even in patients with high comorbidities.

Clinical outcome of laparoscopic versus robot-assisted radical cystectomy for patients with bladder cancer: a retrospective study

BackgroundWith the development of minimally invasive surgery technology, patients with bladder cancer are increasingly receiving laparoscopic radical cystectomy (LRC) or robotic-assisted radical cystectomy (RARC) treatment. The main purpose of this study was to compare the long-term outcomes of bladder cancer patients treated with LRC versus RARC.MethodsA retrospective study to identify patients with clinical stage Ta/T1/Tis to T3 bladder cancer who underwent RARC or LRC has been performed. The perioperative outcome, recurrence, and overall survival (OS) of the two surgical methods were compared.Results218 patients were identified from March 2010 to December 2019 in our department, which including 82 (38%) patients who received LRC and 136 (62%) patients who received RARC. There was no significant difference between the two groups in terms of lymph node collection, lymph node positive rate, resection margin positive rate, and postoperative pathological staging. Compared with the LRC group, patients in the RARC group had a median estimated blood loss (180 vs. 250 ml; P = 0.02) and reduced complications at 90 days postoperatively (30.8% vs. 46.3%; P = 0.01). Recurrence, all-cause death, and cancer-specific death occurred in 77 (35%), 55 (25%), and 39 (18%) patients, respectively. The 5-year OS rate was 54.63% and 54.65% in the RARC and LRC group (P > 0.05). The 5-year cancer-specific survival (CSS) rate was 73.32% and 61.55% in RARC and LRC group (P > 0.05). There was no significant difference in OS [hazard ratio (HR) 1.083, 95% confidence interval (CI) 0.626–1.874; P = 0.78], and CSS (HR 0.789, 95%CI 0.411–1.515; P = 0.61) between two groups.ConclusionsBoth RARC and LRC were safe and effective with a similar long-term clinical outcomes. Moreover, RARC had significantly lower median estimated blood loss and reduced postoperative complications.

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

BackgroundThe 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.MethodsPatients 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.ResultsHere, 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).ConclusionRARC 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 registrationClinicaltrials.gov with registration number NCT03372135. Registered 1 November 2017 (retrospectively registered).

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.

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.

Cost-Effectiveness of Robot-assisted Radical Cystectomy Using a Propensity-matched Cohort

BackgroundHealth-related quality of life is important for patients undergoing radical cystectomy (RC). ObjectiveTo determine the cost-effectiveness of robotic-assisted RC (RARC) compared to open cystectomy (OC) for bladder cancer and factors that contribute to cost-effectiveness. Design, setting, and participantsA decision analytic model was used to compare health-related quality of life and medical costs for RARCs with intracorporeal urinary diversion and OCs performed between 2007 and 2015. Outcome measurements and statistical analysisPropensity matching was performed among 1322 cases to yield a final cohort of 100 RARC and 96 ORC cases. Probabilities were obtained from the clinical study data, while quality-adjusted life years (QALYs) and health utility values were derived from the literature. A complication, readmission, or transfusion was included in the 90-d time horizon model. Results and limitationsThere were no differences between the groups in patient demographics, pathologic staging, or length of stay. Multivariable analysis revealed that the RARC group had fewer transfusions and complications compared to the OC group. The incremental cost-effectiveness ratio was $2969. RARC cost $2969 less per QALY when compared to OC. While RARC was $17000 more expensive, it also associated with an increase of 0.32 QALYs. One-way sensitivity analysis identified RARC as the preferred strategy if a complication can be prevented 74% of the time. RARC is preferred as long as it is 70% effective in preventing a transfusion. Two-way sensitivity analysis showed that as long as RARC can prevent complications and transfusions, it is the preferred cost-effective treatment when compared to OC. The study is limited by the omission of a societal perspective and the lack of health utility values for RC. ConclusionsRARC is cost-effective compared to OC when the rates of complications and transfusions are significantly lower. Patient summaryBladder removal via a robotic approach is more expensive, but it improves health-related quality of life. Robotic surgery is cost-effective compared to an open approach for bladder removal if there are low rates of complications and blood transfusion.