Bladder cancer management options include open radical cystectomy (ORC) and robot-assisted radical cystectomy with intracorporeal (ICUD) or extracorporeal urinary diversion (ECUD). Existing literature establishes no difference in major complication rates between ORC and ECUD, but the emerging popularity of ICUD exposes a necessity for comparisons of a completely intracorporeal method to alternative approaches. Robotic intracorporeal advantage regarding major complications has not yet been established in evaluation of all three modalities. We aim to compare outcomes and complications between open, intracorporeal, and extracorporeal cystectomy techniques at a high-volume institution.
A prospectively-maintained database was queried for patients who underwent radical cystectomy from 2011-2018 for an oncologic indication. Perioperative and pathologic outcomes, 30-day and 90-day major complications were assessed. Statistical analyses utilized Pearson's chi-square, Kruskal-Wallis, multivariable regression, and Kaplan-Meier.
948 patients met criteria: 272 ORC, 301 ICUD, and 375 ECUD (26-month median follow-up). ICUD patients had lower estimated blood loss (p<0.001), shorter hospitalization (p<0.001) and lower ileus rate (p=0.023) compared to ECUD and ORC (p=0.023). Importantly, ICUD was associated with lower 30-day and 90-day major complication rate compared to ECUD and ORC (90-day Clavien-Dindo III-V: 16.9% v 24.8% v 26.1%, p=0.015). There was no significant difference in readmission by surgical approach. Multivariable predictors of increased 90-day major complications were age, Charlson Comorbidity Index, and operative time. On multivariable analysis, ICUD demonstrated reduced 90-day major complications (OR 0.58, p=0.037).
In a three-way comparison, ICUD demonstrated lower major complication rates and perioperative benefits compared to ECUD and ORC.
The Journal of urology. 2019 Oct 03 [Epub ahead of print]
J J H Zhang, Kyle J Ericson, Lewis J Thomas, Jacob Knorr, Abhinav Khanna, Alice Crane, Ria Mittal, Anna Zampini, Michele Fascelli, Prithvi B Murthy, Georges-Pascal Haber, Byron Lee
Cleveland Clinic Foundation., Cleveland Clinic Lerner School of Medicine., Case Western Reserve University.