Robotic-assisted, laparoscopic, and open radical cystectomy: surgical data of 1400 patients from The Italian Radical Cystectomy Registry on intraoperative outcomes

In selected cases of high-risk non-muscle invasive bladder cancer (NMIBC) or muscle invasive bladder cancer (MIBC) the optimal oncological is reached with radical cystectomy (RC) : moreover, it is considered the gold standard. This surgery is complex, with significant morbidity, and it essentially consists of two phases, the destructive phase (removal of the bladder and the lymph nodes) and the reconstructive phase (urinary diversion), and each step is prone to complications. Therefore, RC is preferably performed in referral centers where the experience of the surgeon and the facilities allow to minimize the burden of this complex surgery. Open RC (ORC) has represented the gold standard approach for a long time; recently, the increased introduction of new technologies has led to minimally invasive approaches such as laparoscopic RC (LRC), and robotic-assisted RC (RARC) becoming more and more applied in this field. Surely, RARC represents a challenging procedure that can be improved with specific training and a skilled robotic team. However, RARC is a suitable technique for both older and younger patients and has shown promising rates of peri-operative and short-term outcomes compared to ORC: lower rates of minor perioperative complications, decreased blood loss and transfusion rate, faster gastrointestinal recovery, and shorter length of stay. Despite several studies reporting comparable long-term oncological outcomes for RARC versus ORC, data on the long-term functional outcomes is sparse. No studies have directly compared urinary continence or sexual potency in patients receiving neobladder after RARC versus ORC. Not least, the economic burden of RARC is heavier than open surgery due to higher supply costs, but an effective cost-effective analysis is lacking to date. In a systematic review, Novara et al. demonstrated the safety, acceptable operative time other than relatively lower estimated blood loss (EBL), and relatively low transfusion rate for RARC compared to ORC and LRC. Most intra-abdominal surgical procedures in urology are now performed robotically worldwide. The transition is gradual due to the high cost of the technology and the associated learning curve. The hope is that with more competition in the robotic technology space, the advent of new robotic companies will bring the overall costs down and will reduce the robotic technology healthcare disparities. The Italian Radical Cystectomy Registry (Registro Italiano Cistectomie – RIC) Protocol aimed to accurately and comprehensively assess the outcomes of RC in order to improve current clinical knowledge. The aim of this study was to analyse intraoperative outcomes of a multicenter series of patients treated with RC for bladder cancer