Multicenter external validation of the radical cystectomy pentafecta in a European cohort of patients undergoing robot-assisted radical cystectomy with intracorporeal urinary diversion for bladder cancer

Abstract

Objective To perform an external validation of this RC-pentafecta. Method Between January 2014 and December 2019, 104 consecutive patients who underwent RARC with ICUD within 6 urological centers were analyzed retrospectively. Patients who simultaneously demonstrated negative soft tissue surgical margins (STSMs), a lymph node (LN) yield ≥ 16, absence of major (Clavien–Dindo grade III–V) 90-day postoperative complications, absence of UD-related long-term sequelae, and absence of 12-month clinical recurrence were considered to have achieved RC-pentafecta. A multivariable logistic regression model was used to measure predictors for achieving RC-pentafecta. We analyzed the influence of this RC-pentafecta on survival, and the impact ofthe surgical experience. Results Since 2014, 104 patients who had completed at least 12 months of follow-up were included. Over a mean follow-up of 18 months, a LN yield ≥ 16, negative STSMs, absence of major complications at 90 days, and absence of UD-related surgical sequelae and clinical recurrence at ≤ 12 months were observed in 56%, 96%, 85%, 81%, and 91% of patients, respectively, resulting in a RC-pentafecta rate of 39.4%. Multivariate analysis showed that age was an independent predictor of pentafecta achievement (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.90. 0.99; p = 0.04). The surgeon experience had an impact on the validation of the criteria. Conclusion This study confirmed that the RC-pentafecta is reproducible and could be externally used for the outcome assessment after RARC with ICUD. Therefore, the RC-pentafecta could be a useful tool to assess surgical success and its impact on different outcomes.

The View Outside of the Box: Reporting Outcomes Following Radical Cystectomy Using Pentafecta From a Multicenter Retrospective Analysis

“…Similar findings were reported by Laymon et al: only 33.6% of individuals who underwent open RC attained pentafecta, while the main reason for not achieving pentafecta was a low number of resected LNs (i.e., <16) (34). Another corresponding paper with our study by Baron et al revealed that pentafecta protocol in the cohort of patients undergoing robotassisted RC with intracorporeal UD was highly influenced by the number of resected LNs (56% of pentafecta attainment) leading to an overall pentafecta rate as of 39% (22).…”

“…This might reflect the fact that other factors were of more pronounced prognostic value (e.g., surgery modality, pT category, and UD type). Interestingly, other papers also did not directly show the independent prognostic significance of LN staging on trifecta (15) or pentafecta (22). In the recent paper by Oh et al, pentafecta failers were the predominant group, reaching over 71% (23).…”

“…Therefore, a concept of tri-and pentafecta models was proposed by Aziz et al based on the experts' panel, members of which ranked respective variables, of which five are the most commonly selected formed pentafecta criteria (20). The idea was later developed and modified by Cacciamiani et al (21), and other researchers analyzed it in various settings, e.g., in either open (34) or robotic approach (22,23), while mainly single-center data are available except for single papers (22,23).…”

“…Finally, Baron et al hypothesized about incorporation into the existing models' other factors, e.g., LOH, readmission rates, or use of NAC (22). Their utilization might increase the prognostic value of the pentafecta transforming it into heptaor even octafecta tool.…”

“…There were standardized outcome criteria proposed for reporting purposes, i.e., trifecta and/or pentafecta for partial nephrectomy and radical prostatectomy, which focused on both the quality of cancer management and the assessment of surgical complications (18,19). It seems reasonable to promote the idea of incorporating similar scales in the cohort of cystectomized patients in the light of growing interest in the technical quality of the procedure and the changing landscape of open surgery indications (20)(21)(22)(23). RC pentafecta assessment was designed to serve as a standardized tool for the measurement of surgical quality, which directly influences oncological and functional outcomes.…”