Clinical Outcomes after Robot-Assisted Radical Cystectomy versus Open Radical - Expert Commentary

Robot-assisted RC (RARC) procedures are popular due to faster recovery times. A recent study by Khetrapal et al. performed a systematic review and meta-analysis of randomized controlled trials (RCTs) – of outcomes in patients with bladder cancer who underwent RARC versus open RC (ORC).

A total of seventeen studies were included in the analysis, which encompassed eight RCTs and 1,024 patients. 509 patents underwent ORC, and 515 underwent RARC. Most patients were male (80%) and had muscle-invasive bladder cancer (57%). In terms of treatment, 67% had not received neoadjuvant chemotherapy. A pooled analysis of eight studies revealed that ORC patients had more extended hospital stays (p = 0.02). There was no significant difference in 90-day complications between the ORC and RARC groups (OR, 1.22; 95% CI, 0.94-1.58; p = 0.14). Pooled estimates across six studies for venous thromboembolic events (VTE) indicated a significantly higher number of VTEs in the ORC group compared to the RARC group (OR 1.84; 95% CI, 1.02–3.31; p = 0.04). There was no significant difference in postoperative ileus (p = 0.8) or time to flatus (p = 0.5) across six and four studies, respectively.

Patients undergoing ORC exhibited significantly higher estimated blood loss than patients who underwent RARC (mean difference, 322 mL; 95% CI, 193–450; p < 0.001). In line with this finding, patients who received ORC received more perioperative blood transfusions than patients who received RARC (OR, 2.35; 95% CI, 1.65–3.36; p < 0.001). A significantly longer operative time was found in the RARC group (mean difference, 76 min; 95% CI, 39–112; p < 0.001). There was no significant difference in the number of patients with positive surgical margin (OR, 0.95; 95% CI, 0.54–1.67; p = 0.9) or number of lymph nodes (mean difference, 1.07; 95% CI, -1.73–3.86; p = 0.5) between the ORC and RARC groups. There were no significant differences in overall survival (p = 0.9) or progression-free survival (p > 0.9) between groups over a median follow-up of 36 months. The investigators subsequently analyzed differences in quality of life (QoL) by separating the outcome into distinct domains. Measures of physical function or well-being domain (p < 0.001) were significantly better in the RARC group than in the ORC group. There were no significant differences in the other domains, such as emotional functioning, cognitive functioning, or social functioning. The overall risk of bias in the selected studies was low, although there were concerns regarding the randomization process in four studies.

Across several important measures, RARC is associated with more favorable patient outcomes than ORC. The limitations of this study are inherent to meta-analyses and include the heterogeneity of patient criteria, clinical definitions, and data collection methods for outcomes across studies.

Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine


  1. Khetrapal P, Wong JKL, Tan WP, et al. Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy: A Systematic Review and Meta-analysis of Perioperative, Oncological, and Quality of Life Outcomes Using Randomized Controlled Trials [published correction appears in Eur Urol. 2023 Aug 8]. Eur Urol. 2023;84(4):393-405. doi:10.1016/j.eururo.2023.04.004
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