Intracorporeal robot-assisted radical cystectomy trumps extracorporeal approach, open surgery

Robot-assisted radical cystectomy with intracorporeal urinary diversion results in better perioperative outcomes and lower major complications compared to extracorporeal urinary diversion and open radical cystectomy in patients with bladder cancer, a study has shown.

“The existing literature shows no difference in the major complication rate between open radical cystectomy and extracorporeal urinary diversion,” the investigators said. “However, the emerging popularity of intracorporeal urinary diversion has exposed the need to compare a completely intracorporeal method to alternative approaches.”

Analysis was performed using a prospectively maintained database for patients treated with radical cystectomy from 2011 to 2018 for an oncologic indication. The investigators assessed perioperative and pathological outcomes, as well as 30- and 90-day major complications. They also performed statistical analysis using Pearson chi-square, Kruskal-Wallis and Kaplan-Meier tests, and multivariable regression.

Of the 948 patients who were eligible for analysis, 272 underwent open surgery, 301 intracorporeal urinary diversion and 375 extracorporeal urinary diversion. Over a median follow-up of 26 months, intracorporeal urinary diversion patients demonstrated lower estimated blood loss (p<0.001), shorter hospitalization (p<0.001) and lower ileus rate (p=0.023) than extracorporeal urinary diversion and open surgery patients.

In addition, intracorporeal urinary diversion correlated with lower 30- and 90-day major complication rates as compared to extracorporeal urinary diversion and open surgery (90-day Clavien-Dindo III-V 16.9 percent vs 24.8 percent and 26.1 percent, respectively; p=0.015). No significant difference was found in readmission rates between surgical approaches.

Patient age, Charlson Comorbidity Index and operative time significantly predicted increased 90-day major complications. Moreover, multivariable analysis revealed an association between intracorporeal urinary diversion and reduced 90-day major complications (odds ratio, 0.58; p=0.037).