Elsevier

European Urology

Volume 67, Issue 3, March 2015, Pages 376-401
European Urology

RARC Pasadena Consensus Panel – Review
Editorial by Monish Aron and Inderbir S. Gill on pp. 361–362 of this issue
Systematic Review and Cumulative Analysis of Perioperative Outcomes and Complications After Robot-assisted Radical Cystectomy

https://doi.org/10.1016/j.eururo.2014.12.007Get rights and content

Abstract

Context

Although open radical cystectomy (ORC) is still the standard approach, laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) have gained popularity.

Objective

To report a systematic literature review and cumulative analysis of perioperative outcomes and complications of RARC in comparison with ORC and LRC.

Evidence acquisition

Medline, Scopus, and Web of Science databases were searched using a free-text protocol including the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy. RARC case series and studies comparing RARC with either ORC or LRC were collected. Cumulative analysis was conducted.

Evidence synthesis

The searches retrieved 105 papers. According to the different diversion type, overall mean operative time ranged from 360 to 420 min. Similarly, mean blood loss ranged from 260 to 480 ml. Mean in-hospital stay was about 9 d for all diversion types, with consistently high readmission rates. In series reporting on RARC with either extracorporeal or intracorporeal conduit diversion, overall 90-d complication rates were 59% (high-grade complication: 15%). In series reporting RARC with intracorporeal continent diversion, the overall 30-d complication rate was 45.7% (high-grade complication: 28%). Reported mortality rates were ≤3% for all diversion types. Comparing RARC and ORC, cumulative analyses demonstrated shorter operative time for ORC, whereas blood loss and in-hospital stay were better with RARC (all p values <0.003). Moreover, 90-d complication rates of any-grade and 90-d grade 3 complication rates were lower for RARC (all p values <0.04), whereas high-grade complication and mortality rates were similar.

Conclusions

RARC can be performed safely with acceptable perioperative outcome, although complications are common. Cumulative analyses demonstrated that operative time was shorter with ORC, whereas RARC may provide some advantages in terms of blood loss and transfusion rates and, more limitedly, for postoperative complication rates over ORC and LRC.

Patient summary

Although open radical cystectomy (RC) is still regarded as a standard treatment for muscle-invasive bladder cancer, laparoscopic and robot-assisted RC are becoming more popular. Robotic RC can be safely performed with acceptably low risk of blood loss, transfusion, and intraoperative complications; however, as for open RC, the risk of postoperative complications is high, including a substantial risk of major complication and reoperation.

Introduction

Radical cystectomy (RC) with regional lymph node dissection is the standard surgical treatment for muscle-invasive and high-risk non–muscle-invasive urothelial carcinoma of the bladder [1]. Although open RC (ORC) is still the most commonly adopted surgical approach [2], minimally invasive techniques have gained popularity such that laparoscopic RC (LRC) and robot-assisted RC (RARC) are routinely performed with promising short- and intermediate-term results [3].

Due to increasing evidence in the field of RARC and in preparation for the Pasadena international consensus meeting on best practice in RARC and urinary diversion, we performed a systematic literature review of perioperative, functional, and oncologic outcomes of RARC in comparison with ORC and LRC. We report the findings of this review with a cumulative analysis of perioperative outcomes and postoperative complications.

Section snippets

Evidence acquisition

The systematic literature search was initially performed in September 2013 using the Medline, Scopus, and Web of Science databases. The searches included a free-text protocol using the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy in all fields of the records for PubMed and Scopus searches and in the Title and Topic fields for the Web of Science search. No limits were applied. A full update of the searches was done April 28, 2014.

Two authors

Quality of the studies and level of evidence

The flow of this systematic review of the literature is shown in Fig. 1. In total, 70 surgical series [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74]

Conclusions

RARC can be performed safely with acceptable operative time, little blood loss, and low transfusion rates. The risk of intraoperative complications is low, but postoperative complications and readmission after discharge are common. Cumulative analyses demonstrated that operative time was shorter with ORC, whereas blood loss and transfusion rates were significantly lower with RARC than with ORC. Conversely, rates for any-grade and grade 3 complications at 90 d were slightly lower with RARC than

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