Robotic Assisted Radical Cystectomy with Extracorporeal Urinary Diversion Does Not Show a Benefit over Open Radical Cystectomy: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Abstract

BackgroundThe number of robotic assisted radical cystectomy (RARC) procedures is increasing despite the lack of Level I evidence showing any advantages over open radical cystectomy (ORC). However, several systematic reviews with meta-analyses including non-randomised studies, suggest an overall benefit for RARC compared to ORC. We performed a systematic review with meta-analysis of randomised controlled trials (RCTs) to evaluate the perioperative morbidity and efficacy of RARC compared to ORC in patients with bladder cancer.MethodsLiterature searches of Medline/Pubmed, Embase, Web of Science and clinicaltrials.gov databases up to 10th March 2016 were performed. The inclusion criteria for eligible studies were RCTs which compared perioperative outcomes of ORC and RARC for bladder cancer. Primary objective was perioperative and histopathological outcomes of RARC versus ORC while the secondary objective was quality of life assessment (QoL), oncological outcomes and cost analysis.ResultsFour RCTs (from 5 articles) met the inclusion criteria, with a total of 239 patients all with extracorporeal urinary diversion. Patient demographics and clinical characteristics of RARC and ORC patients were evenly matched. There was no significant difference between groups in perioperative morbidity, length of stay, positive surgical margin, lymph node yield and positive lymph node status. RARC group had significantly lower estimated blood loss (p<0.001) and wound complications (p = 0.03) but required significantly longer operating time (p<0.001). QoL was not measured uniformly across trials and cost analysis was reported in one RCTs. A test for heterogeneity did highlight differences across operating time of trials suggesting that surgeon experience may influence outcomes.ConclusionsThis study does not provide evidence to support a benefit for RARC compared to ORC. These results may not have inference for RARC with intracorporeal urinary diversion. Well-designed trials with appropriate endpoints conducted by equally experienced ORC and RARC surgeons will be needed to address this.

Does the robot have a role in radical cystectomy?

“…In line with contemporary reports , RAZOR reported that RARC had significantly reduced blood loss and transfusion rates, but longer operating times. RAZOR did not provide a cost analysis for RARC vs ORC due to varying costs of RC across centres, but they reported a small albeit significant difference in length of stay between RARC and ORC (6 and 7 days, P = 0.022).…”

“…ORC is less expensive, whereas RARC offers reduced blood loss and a potentially quicker recovery. Small randomised studies have shown similar complication rates and perioperative morbidity , and questioned the oncological efficacy of RARC. The health economics of robotic surgery is another key concern, as benefits from RARC are needed to offset the significantly higher operating costs.…”

Robot‐assisted radical cystectomy: Review of surgical technique, and perioperative, oncological and functional outcomes

“…Recently published RCT between RARC and ORC showed a similar PSM rates (3.6% vs 4.8%, P = 0.7), and (6% vs 5%, P = 0.59) for RARC versus ORC, respectively . Also a met‐analysis have shown no difference between RARC and ORC in regards to margin rates …”

Is the open cystectomy era over? An update on the available evidence

“…The four RCTs have published their early outcomes, and the recent meta‐analysis by Tan et al . of those RCTs concluded that RARC is better for blood loss and wound complications, and worse for operation time . No other difference in terms of postoperative morbidity, PSM, lymph node yield, and LOS was found between RARC and ORC.…”

“…Since 2013, we have found 14 such analyses . Two of them are actually meta‐analyses of the four published RCTs . Table summarizes their results in a better or worse fashion, which represents a statistically significant difference between RARC and ORC.…”