Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy in Bladder Cancer Patients: A Multicentre Comparative Effectiveness Study

BackgroundRadical cystectomy with pelvic lymph node dissection (PLND) and urinary diversion in patients with bladder cancer is known for its high risk of complications. Although open radical cystectomy (ORC) is regarded as the standard treatment, robot-assisted radical cystectomy (RARC) is increasingly used in practice, despite the fact that high-quality evidence comparing the effectiveness of both techniques is lacking.ObjectiveTo study the effectiveness of RARC compared with that of ORC, in terms of 90 d complications (Clavien-Dindo), health-related quality of life (HRQOL), and clinical outcomes.Design, setting, and participantsA prospective comparative effectiveness study was conducted in 19 Dutch centres, expert in either ORC or RARC. Follow-up visits were scheduled at 30, 90, and 365 d.InterventionStandard ORC or RARC with PLND, using a standardised perioperative protocol.Outcome measurements and statistical analysisThe primary outcome was any-grade complications after 90 d. Secondary outcomes included HRQOL, complications (minor, major, 30 d, and 365 d), and clinical outcomes. Differences were calculated as risk differences (RDs) between the groups with 95% confidence intervals (CIs), adjusted for potential baseline differences by means of propensity score–based inverse probability of treatment weighting.Results and limitationsBetween March 2016 and November 2018, 348 patients were included (n = 168 for ORC, n = 180 for RARC). At 90 d, any-grade complication rates were 63% for ORC and 56% for RARC (RD –6.4%, 95% CI –17 to 4.5). Major complication rates were 15% for ORC and 16% for RARC (RD 0.9%, 95% CI –7.0 to 8.8). Total minor complication rates were 57% for ORC and 49% for RARC (RD –7.6%, 95% CI –19 to 3.6). Analyses showed no statistically significant differences in HRQOL between ORC and RARC. Some differences were found in the secondary outcomes in favour of either RARC or ORC. The major drawback inherent to the design comprises residual confounding.ConclusionsThis multicentre comparative effectiveness study showed no statistically significant differences between ORC and RARC in terms of complications and HRQOL.Patient summaryThis multicentre study did not show differences in overall complication rates, health-related quality of life, mortality, and clinical and oncological outcomes between open and robot-assisted radical cystectomy in bladder cancer patients.     

Retrosigmoid Versus Traditional Ileal Conduit for Urinary Diversion After Radical Cystectomy

Background

Ureteroileal anastomotic stricture (UAS) after ileal conduit diversion occurs in a non-negligible proportion of patients undergoing radical cystectomy (RC). Surgical techniques aimed at preventing this potential complication are sought.

ICUD-EAU International Consultation on Bladder Cancer 2012: Radical Cystectomy and Bladder Preservation for Muscle-Invasive Urothelial Carcinoma of the Bladder

Context

New guidelines of the International Consultation on Urological Diseases for the treatment of muscle-invasive bladder cancer (MIBC) have recently been published.

Objective

To provide a comprehensive overview of the current role of radical cystectomy (RC) in MIBC.

Evidence acquisition

A detailed Medline analysis was performed for original articles addressing the role of RC with regard to indication, timing, surgical extent, perioperative morbidity, oncologic outcome, and follow-up. The analysis also included radiation-based bladder-preserving strategies.

Evidence synthesis

The major findings are presented in an evidence-based fashion and are based on large retrospective unicenter and multicenter series with some prospective data.

Conclusions

Open RC is the standard treatment for locoregional control of MIBC. Delay of RC is associated with reduced cancer-specific survival. In males, standard RC includes the removal of the bladder, prostate, seminal vesicles, and distal ureters; in females, RC includes an anterior pelvic exenteration including the bladder, entire urethra and adjacent vagina, uterus, and distal ureters. A procedure sparing the urethra and the urethra-supplying autonomous nerves can be performed in case of a planned orthotopic neobladder. Further technical variations (ie, seminal-sparing or vaginal-sparing techniques) aimed at improving functional outcomes must be weighed against the risk of a positive margin. Laparoscopic surgery is promising, but long-term data are required prior to accepting it as an option equivalent to the open procedure. Lymphadenectomy should remove all lymphatic tissue around the common iliac, external iliac, internal iliac, and obturator region bilaterally. Complications after RC should be reported according to the modified Clavien grading system. In selected patients with MIBC, bladder-preserving therapy with cystectomy reserved for tumor recurrence represents a safe and effective alternative to immediate RC.     

Variations in the Costs of Radical Cystectomy for Bladder Cancer in the USA

Background

Radical cystectomy (RC) for muscle-invasive bladder cancer (BCa) has potential for serious complications, prolonged length of stay and readmissions—all of which may increase costs. Although variations in outcomes are well described, less is known about determinants driving variation in costs.

腹腔镜下膀胱根治性切除术(附23例报告)

目的探讨腹腔镜下膀胱根治性切除术的手术方法和临床效果。方法浸润性膀胱癌23例,无远处转移,采用5个trocar,腹腔镜下行膀胱根治性切除术、前列腺切除,下腹正中做7cm切口,取出切除的膀胱、前列腺,尿流改道方式包括17例回肠膀胱术、3例回肠代膀胱术、1例输尿管乙状结肠吻合、2例输尿管皮肤造口。结果手术时间4~10h,平均7.5h。出血量100~800ml,平均311ml,1例输血1000ml,余22例未输血。术后2例麻痹性肠梗阻,经保守治疗痊愈,无其他并发症。术后随访2~32个月,2例因远处转移死亡,21例健在,无瘤生存2~32个月,平均17个月,肾功能正常,B超及IVU检查1例轻度双肾积水。结论腹腔镜下膀胱根治性切除术安全可行,创伤小,出血少,恢复快。     

The Impact of Perioperative Blood Transfusion on Cancer Recurrence and Survival Following Radical Cystectomy

Background

While the receipt of a perioperative blood transfusion (PBT) has been associated with an increased risk of mortality for a number of malignancies, the relationship between PBT and survival following radical cystectomy (RC) for bladder cancer (BCa) has not been well established.

Objective

To evaluate the association of PBT with disease recurrence and mortality following RC.

Design, setting, and participants

We identified 2060 patients who underwent RC at the Mayo Clinic between 1980 and 2005. PBT was defined as transfusion of allogenic red blood cells during RC or postoperative hospitalization.

Outcome measurements and statistical analysis

Survival was estimated using the Kaplan-Meier method and was compared with the log-rank test. Cox proportional hazard regression models were used to evaluate the association of PBT with outcome, controlling for clinicopathologic variables.

Results and limitations

A total of 1279 patients (62%) received PBT. The median number of units transfused was 2 (interquartile range [IQR]: 2–4). Patients receiving PBT were significantly older (median: 69 yr vs 66 yr; p < 0.0001), had a worse Eastern Cooperative Oncology Group performance status (p < 0.0001), and were more likely to have muscle-invasive tumors (56% vs 49%; p = 0.004). Median postoperative follow-up was 10.9 yr (IQR: 7.9–15.7). Receipt of PBT was associated with significantly worse 5-yr recurrence-free survival (58% vs 64%; p = 0.01), cancer-specific survival (59% vs 72%; p < 0.001), and overall survival (45% vs 63%; p < 0.001). On multivariate analyses, PBT remained associated with significantly increased risks of postoperative tumor recurrence (hazard ratio [HR]: 1.20; p = 0.04), death from BCa (HR: 1.31; p = 0.003), and all-cause mortality (HR: 1.27; p = 0.0002). Among patients who received PBT, an increasing number of units transfused was independently associated with increased cancer-specific mortality (HR: 1.07; p < 0.0001) and all-cause mortality (HR: 1.05; p < 0.0001). Limitations include selection bias and lack of standardized transfusion criteria.

Conclusions

We found that PBT is associated with significantly increased risks of cancer recurrence and mortality following RC. While external validation is required, continued efforts to reduce the use of blood products in these patients are warranted.     

Conditional Survival After Radical Cystectomy for Bladder Cancer: Evidence for a Patient Changing Risk Profile over Time

Background

Standard survival statistics do not take into consideration the changes in the weight of individual variables at subsequent times after the diagnosis and initial treatment of bladder cancer.

Objective

To assess the changes in 5-yr conditional survival (CS) rates after radical cystectomy for bladder cancer and to determine how well-established prognostic factors evolve over time.

Design, setting, and participants

We analyzed data from 8141 patients treated with radical cystectomy at 15 international academic centers between 1979 and 2012.

Interventions

Radical cystectomy and pelvic lymph node dissection.

Outcome measurements and statistical analysis

Conditional cancer-specific survival (CSS) and overall survival (OS) estimates were calculated using the Kaplan-Meier method. The multivariable Cox regression model was used to calculate proportional hazard ratios for the prediction of mortality after stratification by clinical characteristics (age, perioperative chemotherapy status) and pathologic characteristics (pT stage, grade, lymphovascular invasion, pN stage, number of nodes removed, margin status). The median follow-up was 32 mo.

Results and limitations

The 5-yr CSS and OS rates were 67.7% and 57.5%, respectively. Given a 1-, 2-, 3-, 5- and 10-yr survivorship, the 5-yr conditional OS rates improved by +5.6 (60.7%), +8.4 (65.8%), +7.6 (70.8%), +3.0 (72.9%), and +1.9% (74.3%), respectively. The 5-yr conditional CSS rates improved by +5.6 (71.5%), +9.8 (78.5%), +7.9 (84.7%), +7.2 (90.8%), and 5.6% (95.9%), respectively. The 5- and 10-yr CS improvement was primarily noted among surviving patients with advanced stage disease. The impact of pathologic parameters on CS estimates decreased over time for both CSS and OS. Findings were confirmed on multivariable analyses. The main limitation was the retrospective design.

Conclusions

CS analysis demonstrates that the patient risk profile changes over time. The risk of mortality decreases with increasing survivorship. The CS rates improve mainly in the case of advanced stage disease. The impact of prognostic pathologic features decreases over time and can disappear for long-term CS.     

Lymphadenectomy for Bladder Cancer at the Time of Radical Cystectomy

Context

Although the importance of lymphadenectomy during radical cystectomy (RC) in high-risk non–muscle-invasive and muscle-invasive bladder cancer (BCa) is well accepted, the optimal extent of lymphadenectomy, number of lymph nodes (LNs) to be retrieved, and prognostic and therapeutic role of lymphadenectomy remain debated issues.

Objective

In this review, we summarize the existing data on the value of lymphadenectomy for staging and outcome of BCa patients undergoing RC and lymphadenectomy.

Evidence acquisition

A systematic Medline/PubMed literature search of peer-reviewed scientific articles published from 1998 and 2012, concerning the role of lymphadenectomy in BCa patients, was carried out. The terms and permutations used were lymphadenectomy, bladder cancer/carcinoma, urothelial carcinomas, radical cystectomy, lymph node metastasis, lymph node dissection, bladder, recurrence, and survival. Selective older articles were included.

Evidence synthesis

Bilateral pelvic lymphadenectomy is an integral part of RC for BCa. The literature regarding the role of lymphadenectomy in BCa patients in general is retrospective, nonstandardized, and of low-level quality in regard to evidence. Prospective randomized trials designed to define the optimal template of lymphadenectomy and its impact on oncologic outcome are advocated. Some of these studies are ongoing, and their completion and analyses are necessary to resolve controversies.

Conclusions

Many consistent and concordant observations, although of low level of evidence, document that the extent of lymphadenectomy may influence disease-free survival after RC independent of the status of LNs and the pathologic stage of BCa. Lymphadenectomy standardization at the time of RC to create evidence-based guidelines is essential for further improvement of surgical quality and BCa patient survival.     

Differential Complication Rates Following Radical Cystectomy in the Irradiated and Nonirradiated Pelvis

Background

Reports suggest that cystectomy following pelvic irradiation is associated with a higher morbidity and mortality than in primary cases. However, such reports are from an era when postcystectomy complication rates were higher than are currently reported.

Objective

This study evaluates perioperative complications and mortality in primary radical and postradiation salvage cystectomy.

Design, setting, and participants

Patients treated with cystectomy for bladder cancer or advanced pelvic malignancies involving the bladder were studied.

Measurements

Perioperative complications and mortality were analysed for 426 primary and 420 salvage cystectomies performed at a single institution between 1970 and 2005.

Results and limitations

The 30- and 60-d mortality in the 2000–2005 cohort were 0% and 1.2%, respectively, in the primary group and 1.4% and 4.3%, respectively, in the salvage cystectomy group. Thirty-day mortality between 1970 and 2005 was not statistically significant in the primary and salvage groups (4.2% and 7.1%, respectively).

Conclusions

This large series from a high-volume centre demonstrates no difference in perioperative mortality in primary or postradiation salvage radical cystectomy. Similarly, there was no significant difference in the incidence of most of the surgical or medical complications in either group, although the stomal stenosis rate was higher postradiation.     

Prevention and Management of Complications Following Radical Cystectomy for Bladder Cancer

Context

This review focuses on the prevention and management of complications following radical cystectomy (RC) for bladder cancer (BCa).

Objective

We review the current literature and perform an analysis of the frequency, treatment, and prevention of complications related to RC for BCa.

Evidence acquisition

A Medline search was conducted to identify original articles, reviews, and editorials addressing the relationship between RC and short- and long-term complications. Series examined were published within the past decade. Large series reported on multiple occasions (Lee [1], Meyer [2], and Chang and Cookson [3]) with the same cohorts are recorded only once. Quality of life (QoL) and sexual function were excluded.

Evidence synthesis

The literature regarding prophylaxis, prevention, and treatment of complications of RC in general is retrospective, not standardised. In general, it is of poor quality when it comes to evidence and is thus difficult to synthesise.

Conclusions

Progress has been made in reducing mortality and preventing complications of RC. Postoperative morbidity remains high, partly because of the complexity of the procedures. The issues of surgical volume and standardised prospective reporting of RC morbidity to create evidence-based guidelines are essential for further reducing morbidity and improving patients’ QoL.     

Laparoscopic Radical Cystectomy with Orthotopic Ileal Neobladder for Bladder Cancer: Oncologic Results of 171 Cases With a Median 3-Year Follow-up

Background

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) is the standard treatment for muscle-invasive and high-risk non–muscle-invasive bladder cancer (BCa). Large series with long-term oncologic data after laparoscopic RC (LRC) are rare.

Objective

To report oncologic outcomes of LRC for 171 cases with a median 3-yr follow-up.

Design, setting, and participants

From December 2002 to June 2009, 171 consecutive patients with BCa who underwent LRC with orthotopic ileal neobladder (OIN) at our institution were enrolled in this retrospective study.

Intervention

All patients underwent LRC OIN. Adjuvant chemotherapy was administered to patients with non–organ-confined disease or positive lymph nodes.

Measurements

The demographic, perioperative, complication, pathologic, and survival data were collected and analysed.

Results and limitations

Most tumours were transitional cell carcinoma (TCC; 160, 93.6%). Tumours were organ confined in 113 patients (pT1–T2; 66.1%) and non–organ confined in 58 patients (pT3–T4a; 33.9%). There was involvement of the lymph nodes in 38 patients (22.2%). Surgical margins were all tumour free. The mean number of removed lymph nodes was 16 (5–46). Follow-up ranged from 3 to 83 mo, and 54 (31.6%) patients completed 5-yr follow-up. Two patients (1.2%) had local recurrence and distant metastasis, 9 patients (5.3%) had local recurrence alone, and 23 patients (13.5%) had distant metastasis. One patient (0.6%) had port-site seeding. One hundred twenty-four patients (72.5%) were alive with no evidence of recurrence; 28 patients (16.4%) died, 20 from metastasis and 8 from tumour-unrelated causes. The estimated 5-yr overall survival, cancer-specific survival, and recurrence-free survival rates were 73.7%, 81.3%, and 72.6%, respectively. The relatively low percentage of patients reaching 5-yr follow-up is a limitation of this retrospective study.

Conclusions

Surgical technique of LRC with OIN can achieve the established oncologic criteria of open surgery, and our oncologic outcome is encouraging. Long-term follow-up is needed for further confirmation.     

Robotic and Laparoscopic Radical Cystectomy for Bladder Cancer: Long-term Oncologic Outcomes

Background

Extended oncologic outcomes after minimally invasive cystectomy have not been previously reported.

Objective

To report outcomes of robot-assisted radical cystectomy (RARC) and laparoscopic radical cystectomy (LRC) for bladder cancer (BCa) at up to 12-yr follow-up.

Design, setting, and participants

All 121 patients undergoing RARC or LRC for BCa between December 1999 and September 2008 at a tertiary referral center were retrospectively evaluated from a prospectively maintained database.

Intervention

RARC or LRC.

Outcome measurements and statistical analysis

Primary end points were overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) calculated using Kaplan-Meier curves. Secondary end points were survival analysis by number of lymph nodes (LNs) and type of procedure. Surgical outcomes, including complications, were analyzed.

Results and limitations

Most tumors were muscle invasive (≥pT2; n = 81; 67%) urothelial carcinomas (n = 102; 84%). Extended LN dissection was performed in 98 patients (81%), with a median of 14 nodes removed (interquartile range [IQR]: 8–18). Twenty-four patients (20%) had node-positive disease (N1: 10 [8%]; N2: 14 [12%]). Eight patients (6.6%) had positive soft tissue margins. Median follow-up was 5.5 yr (mean: 5.9; IQR: 4.2–8.2; range: 0.13–12.1). At last follow-up, 58 patients (48%) had no evidence of disease, 3 (2%) were alive with recurrence, 59 (49%) had died, and status was unknown in 1. Twenty-eight patients (23%) died from cancer-specific causes, 20 (17%) from unrelated causes, and 11 (9%) from unknown causes. The 10-yr actuarial OS, CSS, and RFS rates were 35%, 63%, and 54%, respectively. At last follow-up, OS for pT0, pTis/a, pT1, pT2, and pT3 versus pT4 was 67%, 73%, 53%, 50%, and 16% versus 0%, respectively (p = 0.02). At last follow-up, CSS for pT0, pTis/a, pT1, pT2, and pT3 versus pT4 was 100%, 91%, 74%, 77%, and 56% versus 0%, respectively (p = 0.03).

Conclusions

The longest oncologic outcomes following RARC and LRC for BCa reported demonstrates results similar to those reported for open RC. Continued analysis and direct randomized comparison between techniques is necessary.     

The Effect of Neoadjuvant Chemotherapy on Perioperative Outcomes in Patients Who Have Bladder Cancer Treated with Radical Cystectomy: A Population-based Study

Background

Although therapeutic guidelines recommend the use of neoadjuvant chemotherapy before radical cystectomy (RC) in patients who have muscle-invasive bladder cancer (MIBC), this approach remains largely underused. One of the main reasons for this phenomenon might reside in concerns regarding the risk of morbidity and mortality associated with neoadjuvant chemotherapy.

Objective

To compare perioperative outcomes between patients receiving neoadjuvant chemotherapy and those treated with RC alone.

Design, setting, and participants

Relying on the Surveillance Epidemiology and End Results–Medicare-linked database, 3760 patients diagnosed with MIBC between 2000 and 2009 were evaluated.

Intervention

RC alone or RC plus neoadjuvant chemotherapy.

Outcome measurements and statistical analysis

Complications occurred within 30 and 90 d after surgery. Heterologous blood transfusions (HBTs), length of stay (LoS), readmission, and perioperative mortality were compared. To decrease the effect of unmeasured confounders associated with treatment selection, propensity score–matched analyses were performed.

Results and limitations

Overall, 416 (11.1%) of patients received neoadjuvant chemotherapy. Following propensity score matching, 416 (20%) and 1664 (80%) patients treated with RC plus neoadjuvant chemotherapy and RC alone remained, respectively. The 30-d complication, readmission, and mortality rates were 66.0%, 32.2%, and 5.3%, respectively. The 90-d complication, readmission, and mortality rates were 72.5%, 46.6%, and 8.2%, respectively. When patients were stratified according to neoadjuvant chemotherapy status, no significant differences were observed in the rates of complications, HBT, prolonged LoS, readmission, and mortality between the two groups (all p ≥ 0.1). These results were confirmed in multivariate analyses, where the use of neoadjuvant chemotherapy was not associated with higher risk of 30- and 90-d complications, HBT, prolonged LoS, readmission, and mortality (all p ≥ 0.1). Our study is limited by its retrospective nature.

Conclusions

The use of neoadjuvant chemotherapy is not associated with higher perioperative morbidity or mortality. These results should encourage wider use of neoadjuvant chemotherapy when clinically indicated.

Patient summary

Chemotherapy before radical cystectomy in patients with muscle-invasive bladder cancer does not increase the risk of complications or death. The use of chemotherapy should be strongly encouraged, as recommended by clinical guidelines, given its benefits.     

A Comparison of Postoperative Complications in Open versus Robotic Cystectomy

Background

Robotic cystectomy is an emerging alternative for treatment of invasive bladder cancer (BCa). However, reduction in postoperative morbidity relative to the open approach has not been demonstrated.

Objective

To compare complication rates in patients undergoing robotic versus open radical cystectomy (RC).

Design, setting, and participants

A prospective cohort study of 187 consecutive patients undergoing RC at our institution—104 open RC, 83 robotic RC.

Intervention

Open or robotic RC with urinary diversion.

Measurements

Demographic, perioperative, and complication data were recorded prospectively. Thirty-day and 90-d complication rates were assessed using the modified Clavien complication scale. Data were evaluated using χ² and multivariate logistic regression analyses.

Results and limitations

At 30 d, the open group demonstrated a higher overall complication rate (59% vs 41%; p = 0.04) as well as more major complications (30% vs 10%; p = 0.007). At 90 d, the overall complication rate was greater in the open group, but this was not statistically significant (62% vs 48%; p = 0.07). However, there was a significantly higher major complication rate in the open cohort (31% vs 17%; p = 0.03). When subjected to logistic regression analysis, robotic cystectomy was an independent predictor of fewer overall and major complications at 30 and 90 d. High American Society of Anesthesiologists (ASA) score (3–4) and longer surgical time were independent predictors of major complications. Though this is one of the largest published RC series, the sample size is relatively small. Moreover, despite the two patient cohorts being similarly matched, the study was not performed in a randomized fashion.

Conclusions

Patients undergoing robotic cystectomy experienced fewer postoperative complications than those undergoing open cystectomy. Robotic cystectomy is an independent predictor of fewer overall and major complications. Until long-term oncologic results are available, robotic cystectomy should still be considered investigational.     

Pathologic Nodal Staging Score for Bladder Cancer: A Decision Tool for Adjuvant Therapy After Radical Cystectomy

Background

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) is the standard of care for high-risk non–muscle-invasive and muscle-invasive bladder cancer (BCa).

Objective

To develop a model that allows quantification of the likelihood that a pathologically node-negative patient has, indeed, no positive nodes.

Design, setting, and participants

We analyzed data from 4335 patients treated with RC and PLND without neoadjuvant chemotherapy at 12 international academic centers.

Interventions

Patients underwent RC and PLND.

Outcome measurements and statistical analysis

We estimated the sensitivity of pathologic nodal staging using a beta-binomial model and developed a pathologic (postoperative) nodal staging score (pNSS) that represents the probability that a patient is correctly staged as node negative as a function of the number of examined nodes.

Results and limitations

Overall, the probability of missing a positive node decreases with the increasing number of nodes examined (52% if 3 nodes are examined, 40% if 5 are examined, and 26% if 10 are examined). The proportion of having a positive node increased proportionally with advancing pathologic T stage and lymphovascular invasion (LVI). Patients with LVI who had 25 examined nodes would have a pNSS of 80% (pT1), 88% (pT2), and 66% (pT3–T4), whereas 10 examined nodes were sufficient for pNSS exceeding 90% in patients without LVI and pT0–T2 tumors. This study is limited because of its retrospective design and multicenter nature.

Conclusions

We developed a tool that estimates the likelihood of lymph node (LN) metastasis in BCa patients treated with RC by evaluating the number of examined nodes, the pathologic T stage, and LVI. The pNSS indicates the adequacy of nodal staging in LN-negative patients. This tool could help to refine clinical decision making regarding adjuvant chemotherapy, follow-up scheduling, and inclusion in clinical trials.     

Laparoscopic and Robotic Assisted Radical Cystectomy for Bladder Cancer: A Critical Analysis

Context and Objectives

Interest in laparoscopic assisted radical cystectomy (LRC) and robotic assisted radical cystectomy (RRC) is increasing at select centers worldwide. In this update we present the recent worldwide experience and critically evaluate the role of minimally invasive radical surgery for patients with bladder cancer.

Evidence Acquisition

English-language literature between 1992 and 2007 was reviewed using the National Library of Medicine database and the following key words: laparoscopic, laparoscopic-assisted, robotic, robotic-assisted, and radical cystectomy. Over 102 papers were identified, 48 of which were selected for this review on the basis of their contribution to advancing the field with regard to three criteria: (1) evolution of concepts, (2) development and refinement of techniques, and (3) intermediate- and long-term clinical outcomes. These were evaluated with respect to current techniques and perioperative, functional, and oncological outcomes. Our initial experience is also reported.

Evidence Synthesis

Minimally invasive techniques can adequately achieve the extirpative aspects of LRC and extended template lymphadenectomy. At most institutions the reconstructive urinary diversion is now typically being performed extracorporeally through a minilaparotomy. Perioperative data indicate that minimally invasive techniques are associated with reduced blood loss, slightly increased operating time, and shorter hospital stay without any significant difference in postoperative complications compared with open surgery. Intermediate-term oncological outcomes appear to be comparable with the open approach. Worldwide experience continues to increase; >700 surgeries have already been performed.

Conclusion

LRC or RRC with extracorporeally constructed urinary diversion is a safe and effective operation for appropriate patients with bladder cancer. Perioperative and functional outcomes are comparable with open surgery. More focus on extended lymphadenectomy is necessary to routinely achieve higher node yields. Surrogate and intermediate oncological outcomes are encouraging, and long-term assessment is ongoing.     

Prospective Implementation of Enhanced Recovery After Surgery Protocols to Radical Cystectomy

Background

Multimodal enhanced recovery after surgery (ERAS) regimens have improved outcomes from colorectal surgery.