Perioperative Outcomes and Safety of Robotic vs Open Cystectomy: A Systematic Review and Meta-Analysis of 12,640 Cases - Beyond the Abstract

Bladder cancer is the ninth most common malignancy worldwide with over 330,000 cases diagnosed every year. The standard surgical treatment offered to patients diagnosed with muscle-invasive bladder cancer or high-risk non-muscle-invasive bladder cancer is radical cystectomy with pelvic lymph node dissection. This can be performed laparoscopically, robotically, or in an open fashion. Open radical cystectomy (ORC) is considered a highly morbid procedure with an overall complication rate of 60% and a major complication rate of 13-40%. In an attempt to reduce morbidity and mortality, alternative operative technologies have been explored by surgeons worldwide. This has led to an increase in patients undergoing robotic radical cystectomy (RRC). Our recently published paper examines the early surgical outcomes and complications of patients undergoing RRC compared to those undergoing ORC.


A systematic literature review was undertaken in April 2020. Pubmed, Embase, and the Cochrane Controlled Register of Trials were searched for comparative studies investigating the perioperative outcomes associated with RRC vs ORC from 2000-2020. 5 randomised control studies and 42 non-randomised comparative studies were included. 

Data extracted from the included studies included but was not limited to; pre-operative cancer staging, post-operative nodal status, presence of positive surgical margins, operative time, blood loss, need for transfusion, and number of patients with Clavien-Dindo grade I/II/III/IV/V complications. Randomised controlled trials were assessed for risk of bias and quality using the Cochrane Risk of Bias tool. Non-randomised studies were assessed using the Newcastle-Ottawa score. 

A total of 6572 open radical cystectomies and 6068 robotic radical cystectomies were included for analysis. No significant differences in patient characteristics were identified. Patients undergoing RRC were more likely to have muscle-invasive disease on pre-operative staging whilst those undergoing ORC were more likely to have superficial disease. Operative time was significantly shorter in patients undergoing ORC. Blood loss and the requirement for subsequent blood transfusion was significantly lower in patients undergoing RRC.  There was no significant difference between groups with regard to low-grade Clavien-Dindo complications (I/II) or mortality, however, patients undergoing RRC had significantly fewer high-grade Clavien-Dindo complications (III/IV) and overall complications. There was no significant difference in post-operative nodal status and presence of positive surgical margins between groups.

In conclusion, our systematic review and meta-analysis reinforce the perioperative benefits of RRC when compared to ORC, however, the evidence must be interpreted with caution given the small numbers of randomised control trials available. Further high quality, large randomised trials are required.

Written by: Keiran D. Clement, Department of Urology, Royal Alexandra Hospital, Castlehead, UK & Emily Pearce, Department of Paediatric Surgery, Royal Hospital for Children, Glasgow, UK

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