NARUS 2018: A Contemporary Analysis of Robotic and Open Radical Cystectomy in Octogenarians

Las Vegas, NV ( The risk of invasive bladder cancer is known to increase with age. Bladder cancer is the fourth leading cause of cancer-related mortality in octogenarian men. Radical cystectomy is the gold standard treatment for localized muscle-invasive bladder cancer. Despite the known survival benefit provided by radical cystectomy, previous studies have shown that older patients may receive less aggressive treatment due to concerns regarding perioperative morbidity. Robotic-assisted radical cystectomy has the potential to reduce perioperative morbidity in the elderly patients. In this study, the authors aimed to compare perioperative, pathological and early oncological outcomes of robotic-assisted radical cystectomy (RRC) with intracorporal urinary diversion (ICUD) versus open radical cystectomy (ORC) in octogenarians.


The authors queried their institutional-review board approved bladder cancer database. A total of 175 patients aged 80 years or older undergoing radical cystectomy for localized bladder cancer between 2010 and 2016 were identified. Patients were divided into 2 groups by surgical approach: RRC and ORC. Demographic and clinicopathological information were collected, and perioperative, pathological and early oncological outcomes were compared. Kaplan Meier and Cox regression analysis were performed to evaluate recurrence-free and overall survival by surgical approach.


Mean age was 84.1 years, with a mean BMI of 25.5 kg/m2. A total of 43 patients had RRC while 132 had ORC. All patients undergoing RRC had intracorporal urinary diversion (ICUD). Patient characteristics were similar between RRC and ORC with respect to age, sex, race, smoking history, BMI, Charlson Comorbidity Score, and preoperative hemoglobin. Tumour and treatment characteristics were similar  as well, with respect to clinical stage, receipt of neoadjuvant chemotherapy, and adjuvant chemotherapy. Patients undergoing RRC were more likely to have ileal conduit urinary diversion (91% vs 66%, p<0.01).

Pathological findings were similar with respect to pathological T stage (pT3/T4 51% vs 43%), variant histology (12% vs 8%), lymphovascular invasion (40% vs 39%), carcinoma-in-situ (44% vs 55%), total resected nodes (38 vs 43), node-positive disease (26% vs 26%), positive surgical margins (9% vs 8%). RRC was associated with significantly lower estimated blood loss (265mL vs 575mL, p<0.01), and transfusion rate (12% vs 39%, p<0.01). RRC and ORC were similar in terms of operating time, length of stay, 90-day complications rate, and perioperative mortality (all p>0.05). Multivariable logistic regression analysis was performed adjusting for age, preoperative hemoglobin, neoadjuvant chemotherapy status, and type of diversion.

Patients undergoing ORC were at a substantially increased risk of needing perioperative transfusion compared to RRC (OR 4.6, CI 1.6-12.7, p=0.004). Median follow up for the cohort was 13 months. There was no difference in recurrence free survival (p=0.45) and overall survival (p=0.65) between RRC and ORC, and surgical approach was not a predictor of recurrence-free or overall survival.


The authors conclude that robotic RRC with intracorporal urinary diversion is safe and feasible in the octogenarian population. Compared to ORC, RRC was associated with significantly lower estimated blood loss and perioperative transfusions  with equivalent pathological and oncological outcomes. RRC was an independent protective predictor for needing a transfusion after controlling for confounders.

Presented By: Akbar N. Ashrafi, USC institute of Urology, Keck School of Medicine of USC University of Southern California, USA

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV