The role of robotic cystectomy in the salvage and palliative setting as new standard of care

Objective: To compare surgical and survival outcomes of robot-assisted (RARC) vs open (ORC) radical cystectomy with cutaneous ureterostomy (CU) for the treatment of frail patients with limited life expectancy diagnosed with bladder cancer (BC). Methods: Our prospectively maintained database was searched for cystectomy cases with CU, from June 2016 onwards. The study population was split into two groups, according to surgical approach. Baseline characteristics and surgical outcomes were compared: Mann-Whitney and Kruskal-Wallis tests were used for categorical variables, the χ²-test for continuous ones. Logistic regression analyses (LRA) identified predictors of major bleeding events (MBE) (which either caused a hemoglobin loss ≧ 3.5 g/dl or required blood transfusion) and re-operation within 30 days from surgery. Kaplan-Meier (KM) method estimated the impact of the robotic approach on overall survival (OS) and Cox regression analysis (CRA) assessed its predictors. Results: overall, 145 patients were included: 30% (n=43) underwent RARC. Baseline characteristics and tumor stages distribution were comparable in the two groups but those receiving a robot-assisted approach showed significantly reduced times to flatus, bowel and hospital discharge (all p < 0.001). Although operation time was longer in this cohort, MBE (60% vs 89%) and postoperative severe complications (0 vs 8%) (both p <0.001) were less frequent, compared to ORC. At LRA, RARC independently predicted MBE (OR: 0.26; 95%CI 0.09-0.72; p=0.02) but not the need for reintervention. At KM analysis, the minimally-invasive approach was associated with a significant advantage in terms of OS (LogRank = 0.03) and this result was confirmed at CRA (HR: 0.39; 95%CI 0.14-0.94; p=0.04). Conclusions: RARC with CU may represent the nove standard of care to treat highly comorbid patients with advanced BC as, compared to ORC, it provides significant advantages in terms of transfusion rate and severe post-operative complications while ensuring a prompt recovery and discharge.