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

Purpose of review Recently, several trials as well as registry-data analyses investigating the role of robot-assisted radical cystectomy with extra or intracorporal urinary diversion were completed and follow up matured. This review aims to comment on the current evidence-based findings and interpret the future role of the robotic approach as a part of the treatment of bladder cancer. Recent findings Numerous trials and registry-data analyses revealed no significant differences in progression-free and overall survival after open radical cystectomy or robot-assisted radical cystectomy irrespective of urinary diversion. Perioperative parameters, especially intraoperative blood loss, transfusions, thromboembolic events, wound infections and hospitalization were significantly increased in open radical cystectomy. Patients’ convalescence, and especially early postsurgical quality of life, was improved by the robotic approach. The highly demanding surgery itself displayed by a flat learning curve required more than 130 surgeries per institution to reach a stable plateau of complications. The performance of high-quality radical cystectomy irrespective of the approach was significantly increased in high-volume centres. Local recurrence occurs in 11% after radical cystectomy. Current research focuses on intraoperatively usable detection methods and instruments to minimize the risk of residual tumour cells. Summary Taken together, the total intracorporal approach in radical cystectomy holds the potential to improve perioperative parameters and reduces hospitalization without impairing oncological performance of the procedure. To provide best results for the patient radical cystectomy and especially the technically challenging total intracorporal procedure will gain importance in bladder cancer treatment but should be limited to high-volume centres.

Section: Interpreting Current Datamentioning

confidence: 99%

Robotic radical cystectomy – more precision needed?

Walz

Aslani

Sawodny

et al. 2022

“…Though, the eRARC group had shorter operative times (7 vs 6 h, P = .0004). Several retrospective studies comparing iRARC to either open, laparoscopic, and eRARC have recently been published [25 ▪▪ ,26–33].…”

Section: Intracorporeal Urinary Diversionmentioning

confidence: 99%

“…In the second largest ( n = 916), Murthy et al compared oncological outcomes in ORC, iRARC, and eRARC and found no differences in recurrence rates or any survival endpoint [26]. In a retrospective analysis of 177 bladder cancer patients, Zennami et al compared iRARC to open surgery via a propensity score-match analysis in terms of oncological and perioperative outcomes [27], They report no difference in five-year recurrence-free survival ( P = 0.46), cancer-specific survival ( P = 0.63), and overall survival ( P = 0.71). The iRARC cohort was associated with significantly longer operative time ( P = 0.02), lower EBL ( 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).…”

Section: Intracorporeal Urinary Diversionmentioning

confidence: 99%

Update on robotic cystectomy

Grauer

Wiklund

2021

Purpose of reviewThis article aims to discuss recently published (2019–2021) studies on robot-assisted radical cystectomy (RARC) with attention to evidence comparing intracorporeal (ICUD) and extracorporeal urinary diversion (ECUD) in terms of intraoperative and perioperative metrics.Recent findingsRARC produces equivalent oncological outcomes compared to open radical cystectomy (ORC). The benefits of RARC are most pronounced perioperatively. ICUD has been increasingly used at centers of excellence as it reduces intestinal exposure, which may incrementally minimize morbidity compared to ECUD or ORC. As the learning curve for ICUD diversion has flattened, retrospective analyses have emerged that suggest this technique may hold benefit over both ORC and RARC with ECUD, though current data is conflicting, and a randomized controlled study is forthcoming.SummaryORC is the current ‘gold standard’ management for muscle-invasive bladder cancer. Based on the premise of the minimization of perioperative morbidity, the development of RARC, most recently with ICUD, seeks to improve patient outcomes. Despite a protracted learning curve, many expert bladder cancer centers have adopted an intracorporeal approach. As more centers adopt, refine, and climb the learning curve for ICUD, a clearer insight of its effect on morbidity will be revealed—informing further adoption of the technique.

“…There is still no available randomized comparison of this technique and ORC, hence the results from the robot assisted radical cystectomy with intracorporeal urinary diversion versus open radical cystectomy (iROC-study)) are much anticipated [43]. In the meantime, an observational cohort with propensity score matching consisting of 60 patients in each group evaluated complications in intra-corporeal RARC vs ORC [44 ▪ ]. Apart from confirming a pattern of longer operating time, lower blood loss and shorter hospital stay, the patients in the RARC group also had fewer overall complications and a lower rate of postoperative ileus.…”

Section: Robotic-assisted Vs Open Surgical Techniquementioning

confidence: 99%

Urinary diversions for benign and oncologic indications: what did we learn about short term complications in the last 24 months?

Bobjer

2021

Purpose of reviewUrinary diversion (UD) with or without cystectomy is a procedure with high short term complication rates. In this review, we summarize the most relevant findings of the last 2 years.Recent findingsThe use of a prophylactic mesh decreases the risk of parastomal hernia after ileal conduit (IC) surgery without adding mesh-related complications according to a recent randomized multicentre trial. Robot-assisted surgery is increasingly applied for UD and is evolving from extra- to intra-corporeal reconstruction in both continent and incontinent diversions, but there is still a need for appropriately designed studies assessing both short- and long-term complications. Promising techniques to decrease ureterointestinal stricture rates have been reported from small series, such as retrosigmoid placement of the proximal IC to avoid transpositioning of the left ureter, or in robot-assisted surgery the use of indocyanine green with near-infrared light to improve visualisation of distal ureteral viability.SummaryMost recent reports derive from observational data. Appropriate randomized studies are warranted for the evaluation of new techniques to be implemented in a surgical area that still is associated with high complication rates.