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.
BACKGROUND
The 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.


METHODS
Literature 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.


RESULTS
Four 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.


CONCLUSIONS
This 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.
Division of Surgery and Interventional Science, University College London, London, United Kingdom.|Department of Urology, University College London Hospital, London, United Kingdom.
Wei Shen
http://orcid.org/0000-0002-6119-4043
WS
Tan
Division of Surgery and Interventional Science, University College London, London, United Kingdom.|Department of Urology, University College London Hospital, London, United Kingdom.
Pramit
P
Khetrapal
Department of Urology, Rush University Medical Center, Chicago, Illinois, United States of America.
Wei Phin
WP
Tan
Division of Surgery and Interventional Science, University College London, London, United Kingdom.|Department of Urology, University College London Hospital, London, United Kingdom.
Simon
S
Rodney
Division of Surgery and Interventional Science, University College London, London, United Kingdom.
Marisa
M
Chau
Division of Surgery and Interventional Science, University College London, London, United Kingdom.|Department of Urology, University College London Hospital, London, United Kingdom.
John D
JD
Kelly
D000368:Aged; D016063:Blood Loss, Surgical; D015653:Cystectomy / Q000009:adverse effects* / Q000379:methods*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D065287:Robotic Surgical Procedures / Q000009:adverse effects* / Q000379:methods*; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000601:surgery*; D001749:Urinary Bladder Neoplasms / Q000601:surgery; D014547:Urinary Diversion / Q000009:adverse effects* / Q000379:methods*