title: Systematic review and cumulative analysis of oncologic and functional outcomes after robot-assisted radical cystectomy.
abstract: BACKGROUND
  Although open radical cystectomy (ORC) is still the standard approach, laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) are increasingly performed.
  
  
  OBJECTIVE
  To report on a systematic literature review and cumulative analysis of pathologic, oncologic, and functional outcomes of RARC in comparison with ORC and LRC.
  
  
  METHODS
  Medline, Scopus, and Web of Science databases were searched using a free-text protocol including the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy. RARC case series and studies comparing RARC with either ORC or LRC were collected. A cumulative analysis was conducted.
  
  
  RESULTS
  The searches retrieved 105 papers, 87 of which reported on pathologic, oncologic, or functional outcomes. Most series were retrospective and had small case numbers, short follow-up, and potential patient selection bias. The lymph node yield during lymph node dissection was 19 (range: 3-55), with half of the series following an extended template (yield range: 11-55). The lymph node-positive rate was 22%. The performance of lymphadenectomy was correlated with surgeon and institutional volume. Cumulative analyses showed no significant difference in lymph node yield between RARC and ORC. Positive surgical margin (PSM) rates were 5.6% (1-1.5% in pT2 disease and 0-25% in pT3 and higher disease). PSM rates did not appear to decrease with sequential case numbers. Cumulative analyses showed no significant difference in rates of surgical margins between RARC and ORC or RARC and LRC. Neoadjuvant chemotherapy use ranged from 0% to 31%, with adjuvant chemotherapy used in 4-29% of patients. Only six series reported a mean follow-up of >36 mo. Three-year disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) rates were 67-76%, 68-83%, and 61-80%, respectively. The 5-yr DFS, CSS, and OS rates were 53-74%, 66-80%, and 39-66%, respectively. Similar to ORC, disease of higher pathologic stage or evidence of lymph node involvement was associated with worse survival. Very limited data were available with respect to functional outcomes. The 12-mo continence rates with continent diversion were 83-100% in men for daytime continence and 66-76% for nighttime continence. In one series, potency was recovered in 63% of patients who were evaluable at 12 mo.
  
  
  CONCLUSIONS
  Oncologic and functional data from RARC remain immature, and longer-term prospective studies are needed. Cumulative analyses demonstrated that lymph node yields and PSM rates were similar between RARC and ORC. Conclusive long-term survival outcomes for RARC were limited, although oncologic outcomes up to 5 yr were similar to those reported for ORC.
  
  
  RESULTS
  Although open radical cystectomy (RC) is still regarded as the standard treatment for muscle-invasive bladder cancer, laparoscopic and robot-assisted RCs are becoming more popular. Templates of lymph node dissection, lymph node yields, and positive surgical margin rates are acceptable with robot-assisted RC. Although definitive comparisons with open RC with respect to oncologic or functional outcomes are lacking, early results appear comparable.
authors.affiliation: City of Hope National Cancer Center, Duarte, CA, USA. Electronic address: byuh@coh.org.
authors.forename: Bertram
authors.initials: B
authors.lastname: Yuh
authors.affiliation: City of Hope National Cancer Center, Duarte, CA, USA.
authors.forename: Timothy
authors.initials: T
authors.lastname: Wilson
authors.affiliation: Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Bernie
authors.initials: B
authors.lastname: Bochner
authors.affiliation: City of Hope National Cancer Center, Duarte, CA, USA.
authors.forename: Kevin
authors.initials: K
authors.lastname: Chan
authors.affiliation: Fundació Puigvert, Barcelona, Spain.
authors.forename: Joan
authors.initials: J
authors.lastname: Palou
authors.affiliation: Department of Urology, University of Tübingen, Tübingen, Germany.
authors.forename: Arnulf
authors.initials: A
authors.lastname: Stenzl
authors.affiliation: Department of Urology, University Vita-Salute San Raffaele, Milan, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.affiliation: Department of Urology, University of Bern, Bern, Switzerland.
authors.forename: George
authors.initials: G
authors.lastname: Thalmann
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, NY, USA.
authors.forename: Khurshid
authors.initials: K
authors.lastname: Guru
authors.affiliation: Academic Urology Unit, University of Sheffield, Sheffield, UK.
authors.forename: James W F
authors.initials: JW
authors.lastname: Catto
authors.affiliation: Karolinska University Hospital, Urology, Stockholm, Sweden.
authors.forename: Peter N
authors.initials: PN
authors.lastname: Wiklund
authors.affiliation: Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Padua, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
mesh_terms: D017024:Chemotherapy, Adjuvant; D016009:Chi-Square Distribution; D015653:Cystectomy / Q000009:adverse effects / Q000401:mortality; D018450:Disease Progression; D018572:Disease-Free Survival; D006801:Humans; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis; D020360:Neoadjuvant Therapy; D009364:Neoplasm Recurrence, Local; D018365:Neoplasm, Residual; D016017:Odds Ratio; D011183:Postoperative Complications / Q000209:etiology; D012307:Risk Factors; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*
keywords: Laparoscopic radical cystectomy; Radical cystectomy; Robotic radical cystectomy; Robotics