title: Robotic or open radical cystectomy, which is safer? A systematic review and meta-analysis of comparative studies.
abstract: Robotic radical cystectomy (RRC) has been growing in popularity across the world as a treatment option for bladder cancer.
  
  
  OBJECTIVE
  To compare early surgical outcomes for RRC and open radical cystectomy (ORC) with an emphasis on complications and postoperative mortality rates.
  
  
  METHODS
  
  
  
  METHODS
  A literature review was conducted from 2000 to 2013, including studies comparing RRC and ORC. The main outcome measures analyzed were the complications and mortality rates, in addition to patient demographics, pathological parameters, operating time, estimated blood loss (EBL), transfusion rates, and type of urinary diversion. A meta-analysis was conducted. For continuous data, the Mantel-Haenszel chi-square test was used, and for dichotomous data, inverse variance was used and each expressed as risk ratio with 95% CI.
  
  
  RESULTS
  In total, 748 patients were included, 461 patients in the robotic group and 287 patients in the open group (seven studies). There were no significant differences in the demographic parameters of the two groups, except for age (age: p=0.03). There was no difference in the number of muscle-invasive diseases: p=0.47. No difference in positive surgical margin rates (p=0.21).
  
  
  METHODS
  The overall (p=0.32) and lower grade (Clavien I-II) (p=0.10) complication rates between the two cohorts did not achieve statistical significance. The high-grade (Clavien III-IV) (p=0.007) complication rates in the ORC group were significantly higher. The mortality rate (Clavien V) was higher in the ORC group (2.2%) compared with the RRC group (0.35%) and this did achieve statistical significance on a meta-analysis (p=0.04).
  
  
  RESULTS
  The EBL and transfusion rates were statistically significantly lower in the RRC cohort (p<0.00001). The operating time was statistically significantly higher in the RRC cohort (p<0.00001). There was no statistically significant difference in the margin positivity between the two cohorts (p=0.08).
  
  
  CONCLUSIONS
  In early experience, RRC appears to be feasible and a safe alternative to the ORC. RRC appears to have lower high-grade complications and mortality rates compared with the open approach. Although these results are promising, the authors would suggest caution while interpreting these results due to concerns with methodological flaws in the included studies in this review.
authors.affiliation: 1 Department of Urology, University Hospitals Southampton NHS Trust , Southampton, United Kingdom .
authors.forename: Hiro
authors.initials: H
authors.lastname: Ishii
authors.forename: Bhavan Prasad
authors.initials: BP
authors.lastname: Rai
authors.forename: Jens-Uwe
authors.initials: JU
authors.lastname: Stolzenburg
authors.forename: Pradeep
authors.initials: P
authors.lastname: Bose
authors.forename: Piotr L
authors.initials: PL
authors.lastname: Chlosta
authors.forename: Bhaskar K
authors.initials: BK
authors.lastname: Somani
authors.forename: Ghulam
authors.initials: G
authors.lastname: Nabi
authors.forename: Hasan Abdur Rahman
authors.initials: HA
authors.lastname: Qazi
authors.forename: Krishnamoorthy
authors.initials: K
authors.lastname: Rajbabu
authors.forename: Howard
authors.initials: H
authors.lastname: Kynaston
authors.forename: Omar M
authors.initials: OM
authors.lastname: Aboumarzouk
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002295:Carcinoma, Transitional Cell / Q000601:surgery*; D015653:Cystectomy / Q000379:methods* / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications; D065287:Robotic Surgical Procedures / Q000379:methods*; D012449:Safety; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000601:surgery*; D014547:Urinary Diversion