Open vs Robotic Cystectomy: Case Closed?

Abstract

The best place to hide something is in plain sight, where it's obvious yet overlooked.Edgar Allan Poe, The Purloined LetterCaring for patients using high-level scientific evidence is a guiding principle which all clinicians should espouse. Evidence from randomized controlled surgical trials (RCTs) has provided practice-changing data and led to treatment guidelines across surgical disciplines. In urology, while RCT data are lacking in many important areas of oncology, fortunately for bladder cancer patients, we do have several RCTs evaluating clinical outcomes between open (ORC) and robotic radical cystectomy (RARC). However, not all RCTs are designed equally, and the impact of their results on how they change practice patterns is based on the quality of trial design, the primary question the study was powered to evaluate, the patient populations studied, and the clinical relevance of the observed outcome. Wedand our patientsdwant the trials to answer the following questions: (1) Will our patients find it easier to recover from cystectomy and diversion with RARCdmeaning will complications be less and lead to a shorter hospital stay? (2) Can RARC provide similar or improved cancer outcomes as compared to ORC? (3) Will RARC be able to provide better or at least similar urinary diversion-associated functional outcomes to ORC? (4) Does RARC advance our ability to perform continent diversions compared to ORC so that we can extend this proven option for reconstruction? And finally, (5) will RARC provide benefits in any of the above-listed measures that will justify any increased costs of care, which is a burden that ultimately affects all of us?