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. 2022 Apr 1;5(4):e228959.
doi: 10.1001/jamanetworkopen.2022.8959.

Association of Open vs Robot-Assisted Radical Cystectomy With Mortality and Perioperative Outcomes Among Patients With Bladder Cancer in Sweden

Ashkan Mortezavi  1   2   3 , Alessio Crippa  2 , Maria Ioanna Kotopouli  4 , Olof Akre  3   5 , Peter Wiklund  3   5   6 , Abolfazl Hosseini  3   5
Affiliations

Association of Open vs Robot-Assisted Radical Cystectomy With Mortality and Perioperative Outcomes Among Patients With Bladder Cancer in Sweden

Ashkan Mortezavi et al. JAMA Netw Open. .

Abstract

Importance: Mortality rates resulting from bladder cancer have remained unchanged for more than 30 years. The surgical community has put hope in robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in an effort to improve surgical outcomes and bladder cancer survival without strong supporting evidence.

Objective: To evaluate perioperative, safety, and survival outcome differences between RARC with ICUD and open radical cystectomy (ORC).

Design, setting, and participants: This nationwide population-based cohort study used data from the Swedish National Register of Urinary Bladder Cancer and population-based Cause of Death Register, which includes clinical information on tumor characteristics, treatment, and survival and covers approximately 97% of patients with urinary bladder cancer in Sweden. All patients who underwent radical cystectomy for bladder cancer in any hospital between January 2011 and December 2018 were included. Follow-up data were collected until December 2019. Data analysis was conducted from June to December 2020.

Exposures: RARC or ORC.

Main outcomes and measures: The main outcomes were all-cause and cancer-specific mortality between RARC and ORC, compared using propensity score matching. Secondary outcomes were differences in perioperative outcomes after the different surgical approaches.

Results: Throughout the observation period, 889 patients underwent RARC and 2280 patients underwent ORC at 24 Swedish hospitals. The median (IQR) age was 71 (66-76) years and 2386 patients (75.3%) were men. After a median (IQR) follow-up of 47 (28-71) months, the 5-year cancer-specific mortality rates were 30.2% (variance, 1.59) for ORC and 27.6% (variance, 3.12) for RARC, and the overall survival rates were 57.7% (variance, 2.46) for ORC and 61.4% (variance, 5.11) for RARC. In the propensity score-matched analysis, RARC was associated with a lower all-cause mortality (hazard ratio, 0.71; 95% CI, 0.56-0.89; P = .004). Compared with ORC, RARC was associated with a lower estimated blood loss (median [IQR] 150 [100-300] mL vs 700 [400-1300] mL; P < .001), intraoperative transfusion rate (odds ratio [OR], 0.05; 95% CI, 0.03-0.08; P < .001), and shorter length of stay (median [IQR], 9 [6-13] days vs 13 [10-17] days; P < .001), and with a higher lymph node yield (median [IQR], 20 [15-27] lymph nodes vs 14 [8-24] lymph nodes; P < .001) and 90-day rehospitalization rate (OR, 1.28; 95% CI, 1.02-1.60; P = .03). The RARC group, compared with the ORC group had lower risk of Clavien-Dindo grade III or higher complications (OR, 0.62; 95% CI, 0.43-0.87; P = .009).

Conclusions and relevance: These findings suggest that compared with ORC, RARC with ICUD was associated with a lower overall mortality rate, fewer high-grade complications, and more favorable perioperative outcomes.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Mortezavi reported grants from Krebsliga Schweiz Research during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Propensity Score–Matched Survival Analysis
ORC indicates open radical cystectomy; RARC, robot-assisted radical cystectomy.
Figure 2.
Figure 2.. Sensitivity Survival Analysis including High-Volume Hospitals Only
Analysis restricted to patients who received care in hospitals with a yearly volume of more than 25 procedures. ORC indicates open radical cystectomy; RARC, robot-assisted radical cystectomy.
See this image and copyright information in PMC

References

    1. Witjes JA, Bruins HM, Cathomas R, et al. European Association of Urology guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2020 guidelines. Eur Urol. 2021;79(1):82-104. doi: 10.1016/j.eururo.2020.03.055 - DOI - PubMed
    1. Lowrance WT, Rumohr JA, Chang SS, Clark PE, Smith JA Jr, Cookson MS. Contemporary open radical cystectomy: analysis of perioperative outcomes. J Urol. 2008;179(4):1313-1318. doi: 10.1016/j.juro.2007.11.084 - DOI - PubMed
    1. Zamboni S, Soria F, Mathieu R, et al. ; European Association of Urology - Young Academic Urologists (EAU-YAU), Urothelial carcinoma working group . Differences in trends in the use of robot-assisted and open radical cystectomy and changes over time in peri-operative outcomes among selected centres in North America and Europe: an international multicentre collaboration. BJU Int. 2019;124(4):656-664. doi: 10.1111/bju.14791 - DOI - PubMed
    1. Sathianathen NJ, Kalapara A, Frydenberg M, et al. Robotic assisted radical cystectomy vs open radical cystectomy: systematic review and meta-analysis. J Urol. 2019;201(4):715-720. doi: 10.1016/j.juro.2018.10.006 - DOI - PubMed
    1. Jonsson MN, Adding LC, Hosseini A, et al. Robot-assisted radical cystectomy with intracorporeal urinary diversion in patients with transitional cell carcinoma of the bladder. Eur Urol. 2011;60(5):1066-1073. doi: 10.1016/j.eururo.2011.07.035 - DOI - PubMed