title: Multi-institutional analysis of robotic radical cystectomy for bladder cancer: perioperative outcomes and complications in 227 patients.
abstract: OBJECTIVE
  Recently, some surgeons have begun to describe single-institution case series with less invasive surgical approaches to bladder cancer such as laparoscopic or robotic-assisted techniques. We report on a multi-institutional, multi-surgeon experience with robotic radical cystectomy with regard to operative and pathologic outcomes and complications to evaluate the feasibility and reproducibility of this technique in a large cohort of patients.
  
  
  METHODS
  Two hundred twenty-seven patients (178 males and 49 females) underwent a robotic cystectomy and urinary diversion at one of four institutions. Operative outcomes, pathological results, and complications of this combined case series are herein reported.
  
  
  RESULTS
  Mean age of this cohort was 67.1 years (range, 33-86 years) with a mean American Society of Anesthesiologists score of 2.7 (range, 2-4). One hundred sixty-eight patients (74%) underwent ileal conduit diversion, 58 (26%) underwent orthotopic ileal neobladder, and 1 patient (<1%) had no diversion (end-stage renal disease). The urinary diversion was performed extracorporeally in 97% cases, with 7 patients (3%) undergoing an intracorporeal diversion. Mean operating room time of all patients was 5.5 hours, and mean surgical blood loss was 256 mL. On surgical pathology, 120 (53%) patients had pT2 or less disease, 35 (15%) had pT3/T4 disease, and 46 (20%) had N+ disease. The mean number of lymph nodes removed was 18 (range, 3-52). There was a positive surgical margin in 5 cases--all with pT3-4 disease. Mean time to discharge was 5.5 days (median, 5 days), with 70% of patients discharged on postoperative day 5 or sooner. Sixty-eight patients (30%) experienced complications, with 7% having Clavien grade 3 or higher. On multivariate analysis, decreased age and increased American Society of Anesthesiologists score were predictors of higher Clavien complication score, with younger patients more likely to undergo neoadjuvant chemotherapy prior to surgery.
  
  
  CONCLUSIONS
  A multi-institutional experience with robotic radical cystectomy appears to demonstrate acceptable operative and pathologic outcomes, thus helping to validate the previously reported single-institution case series. Ultimately, oncologic follow-up of these patients will remain as the most important measure of therapeutic success.
authors.affiliation: Division of Urologic Surgery, The University of North Carolina, Chapel Hill, North Carolina, USA.
authors.forename: Angela B
authors.initials: AB
authors.lastname: Smith
authors.forename: Mathew
authors.initials: M
authors.lastname: Raynor
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Amling
authors.forename: J Erik
authors.initials: JE
authors.lastname: Busby
authors.forename: Erik
authors.initials: E
authors.lastname: Castle
authors.forename: Rodney
authors.initials: R
authors.lastname: Davis
authors.forename: Matthew
authors.initials: M
authors.lastname: Nielsen
authors.forename: Raju
authors.initials: R
authors.lastname: Thomas
authors.forename: Eric M
authors.initials: EM
authors.lastname: Wallen
authors.forename: Michael
authors.initials: M
authors.lastname: Woods
authors.forename: Raj S
authors.initials: RS
authors.lastname: Pruthi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015653:Cystectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology; D012371:Robotics; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000601:surgery*; D014547:Urinary Diversion / Q000379:methods