Urology

Extracorporeal

Urinary system

Perioperative

Cancer

Bladder cancer

Urinary diversion

Internal medicine

Surgery

Cystectomy

Medicine

The Journal of Urology

No AccessJournal of UrologyAdult Urology1 Mar 2020Large Single Institution Comparison of Perioperative Outcomes and Complications of Open Radical Cystectomy, Intracorporeal Robot-Assisted Radical Cystectomy and Robotic Extracorporeal ApproachThis article is commented on by the following:Editorial CommentEditorial Comment JJ 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, and Byron Lee JJ H. ZhangJJ H. Zhang *Correspondence: Cleveland Clinic Foundation, 9500 Euclid Ave., Q10-1, Cleveland, Ohio 44195 telephone: 858-705-0621; E-mail Address: [email protected] Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author , Kyle J. EricsonKyle J. Ericson Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author , Lewis J. ThomasLewis J. Thomas Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author , Jacob KnorrJacob Knorr Cleveland Clinic Lerner School of Medicine, Cleveland, Ohio More articles by this author , Abhinav KhannaAbhinav Khanna Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author , Alice CraneAlice Crane Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author , Ria MittalRia Mittal Case Western Reserve University, Cleveland, Ohio More articles by this author , Anna ZampiniAnna Zampini Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author , Michele FascelliMichele Fascelli Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author , Prithvi B. MurthyPrithvi B. Murthy Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author , Georges-Pascal HaberGeorges-Pascal Haber Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author , and Byron LeeByron Lee Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000570AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: Bladder cancer management options include open radical cystectomy and robot-assisted radical cystectomy with intracorporeal or extracorporeal urinary diversion. The existing literature shows no difference in the major complication rate between open radical cystectomy and extracorporeal urinary diversion. However, the emerging popularity of intracorporeal urinary diversion has exposed the need to compare a completely intracorporeal method to alternative approaches. To our knowledge the robotic intracorporeal advantage regarding major complications has not yet been established in an evaluation of all 3 modalities. We compared outcomes and complications of open, intracorporeal and extracorporeal cystectomy techniques at a high volume institution. Materials and Methods: We queried a prospectively maintained database for patients who underwent radical cystectomy from 2011 to 2018 for an oncologic indication. Perioperative and pathological outcomes, and 30 and 90-day major complications were assessed. Statistical analyses were done using the Pearson chi-square, Kruskal-Wallis and Kaplan-Meier tests, and multivariable regression. Results: A total of 948 patients met the study criteria, including 272, 301 and 375 treated with open radical cystectomy, intracorporeal urinary diversion and extracorporeal urinary diversion, respectively. Median followup was 26 months. Intracorporeal urinary diversion cases had lower estimated blood loss (p <0.001), shorter hospitalization (p <0.001) and a lower ileus rate (p=0.023) than extracorporeal urinary diversion and open radical cystectomy cases. Importantly, intracorporeal urinary diversion was associated with lower 30 and 90-day major complication rates vs extracorporeal urinary diversion and open radical cystectomy (90-day Clavien-Dindo III-V 16.9% vs 24.8% and 26.1%, respectively, p=0.015). There was no significant difference in the readmission rate according to the surgical approach. Multivariable predictors of increased 90-day major complications were patient age, the Charlson Comorbidity Index and operative time. On multivariable analysis intracorporeal urinary diversion was associated with reduced 90-day major complications (OR 0.58, p=0.037). Conclusions: In a 3-way comparison intracorporeal urinary diversion demonstrated a lower major complication rate and perioperative benefits compared to extracorporeal urinary diversion and open radical cystectomy. References 1. : Cancer statistics, 2019. CA Cancer J Clin 2019; 69: 7. Google Scholar 2. : The changing face of urologic oncologic surgery from 2000-2018 (63 141 patients)—impact of robotics. Eur Urol, suppl., 2019; 18: e656. Google Scholar 3. : Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet 2018; 391: 2525. Google Scholar 4. : The role of robotics in the invasive management of bladder cancer. Curr Urol Rep 2017; 18: 16. Google Scholar 5. : Robot-assisted radical cystectomy with intracorporeal urinary diversion versus open radical cystectomy (iROC): protocol for a randomised controlled trial with internal feasibility study. BMJ Open 2018; 8: 1. 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Google Scholar 12. : Robotic assisted radical cystectomy vs open radical cystectomy: systematic review and meta-analysis. J Urol 2019; 201: 715. Link, Google Scholar 13. : Comparative effectiveness in perioperative outcomes of robotic versus open radical cystectomy: results from a multicenter contemporary retrospective cohort study. Eur Urol Focus 2018; doi: 10.1016/j.euf.2018.11.002. Crossref, Google Scholar 14. : Perioperative and oncologic outcomes of robot-assisted vs. open radical cystectomy in bladder cancer patients: a comparison of two high-volume referral centers. Eur J Surg Oncol 2016; 42: 1736. Google Scholar 15. : Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol 2015; 67: 1042. Google Scholar 16. : Intracorporeal robot-assisted radical cystectomy, together with an enhanced recovery programme, improves postoperative outcomes by aggregating marginal gains. BJU Int 2018; 121: 632. 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Google Scholar 26. : Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 2015; 67: 376. Google Scholar 27. : Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder—what is the effect of the learning curve on outcomes?BJU Int 2014; 113: 100. Google Scholar 28. : Surgery-related complications of robot-assisted radical cystectomy with intracorporeal urinary diversion. Urology 2011; 77: 871. Google Scholar 29. : Comparison of long-term oncologic outcomes among historical open and minimally invasive retrospective studies. J Urol 2019; 202: 1. Google Scholar 30. : Recurrence patterns after open and robot-assisted radical cystectomy for bladder cancer. Eur Urol 2015; 68: 399. Google Scholar The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article. Editor's Note: This article is the second of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 627 and 628. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited ByChang S (2020) Re: Spillover Effects of the Hospital Readmissions Reduction Program on Radical Cystectomy ReadmissionsJournal of Urology, VOL. 204, NO. 4, (876-876), Online publication date: 1-Oct-2020.Related articlesJournal of UrologyNov 27, 2019, 12:00:00 AMEditorial CommentJournal of UrologyNov 27, 2019, 12:00:00 AMEditorial Comment Volume 203Issue 3March 2020Page: 512-521Supplementary Materials Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.Keywordsminimally invasive surgical procedurespostoperative complicationsurinary bladder neoplasmsurinary diversionrobotic surgical proceduresMetricsAuthor Information JJ H. Zhang Cleveland Clinic Foundation, Cleveland, Ohio *Correspondence: Cleveland Clinic Foundation, 9500 Euclid Ave., Q10-1, Cleveland, Ohio 44195 telephone: 858-705-0621; E-mail Address: [email protected] More articles by this author Kyle J. Ericson Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author Lewis J. Thomas Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author Jacob Knorr Cleveland Clinic Lerner School of Medicine, Cleveland, Ohio More articles by this author Abhinav Khanna Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author Alice Crane Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author Ria Mittal Case Western Reserve University, Cleveland, Ohio More articles by this author Anna Zampini Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author Michele Fascelli Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author Prithvi B. Murthy Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author Georges-Pascal Haber Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author Byron Lee Cleveland Clinic Foundation, Cleveland, Ohio More articles by this author Expand All The corresponding author certifies that, when applicable, a statement(s) has been included in the manuscript documenting institutional review board, ethics committee or ethical review board study approval; principles of Helsinki Declaration were followed in lieu of formal ethics committee approval; institutional animal care and use committee approval; all human subjects provided written informed consent with guarantees of confidentiality; IRB approved protocol number; animal approved project number. No direct or indirect commercial, personal, academic, political, religious or ethical incentive is associated with publishing this article. Editor's Note: This article is the second of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 627 and 628. Advertisement Loading ...

Large Single Institution Comparison of Perioperative Outcomes and Complications of Open Radical Cystectomy, Intracorporeal Robot-Assisted Radical Cystectomy and Robotic Extracorporeal Approach