Bladder cancer is still one of the most challenging diseases in oncology, with an estimate 80,470 new cases will be diagnosed in the US in 2019 with approximately 17,670 deaths occurring during the same period (1). Radical cystectomy (RC) with bilateral pelvic lymph node dissection (pLND) is the most common treatment option for clinically localized muscle invasive bladder cancer (MIBC) and some non-muscle invasive bladder cancers (NMIBC) (2,3). Open radical cystectomy (ORC) has long been established as an effective primary treatment alternative for patients diagnosed with non-metastatic MIBC, select cases of high-risk non-muscle invasive disease, and recurrent tumors after failed bladder sparing treatments (4-6). However, similar to the conversion from open to minimally-invasive surgery observed with radical prostatectomies and nephrectomies, uptake of robotic-assisted radical cystectomy (RARC) has been steadily increasing over the last two decades (7). Initial retrospective studies showed significant advantages of RARC over ORC, while most early prospective trials failed to find considerable differences between techniques (8-10). Therefore, critically assessing outcomes and costs between techniques are essential at a time of value-based healthcare. Against this backdrop, we aimed to review the comparative effectiveness of ORC and RARC for key effects including oncologic outcomes, quality of life, postoperative complications, and healthcare costs. We will also discuss how surgical approach might influence early recovery after surgery, the potential implications of publication bias on reported robotic series, and future directions in the surgical management of bladder cancer. We present the following article in accordance with the Narrative reporting checklist (available at http://dx.doi.org/10.21037/amj-20-81) (11).
Methodology of literature search
A review of the literature was performed to create this narrative analysis. We searched the PubMed database to identify original articles on comparative analysis between RARC and ORC published through January 2020. We used a range of keywords, including the following search headings: comparative study and bladder cancer or bladder neoplasm and radical cystectomy, ORC, or robot-assisted radical cystectomy. We checked the reference lists for additional relevant manuscripts and used the “related articles” feature on PubMed to obtain further studies of interest. In order to be included in this review, studies were required to compare RARC and ORC for the treatment of localized bladder cancer either on a prospective randomized or retrospective design, include concurrent pLND (irrespective of extension), and urinary diversion (irrespective of type). Only studies reporting at least one outcome were included. Non-comparative studies and those reporting on patients with metastatic disease were excluded.
Narrative results and discussion
A total of 803 articles resulted from the initial search. After removal of duplicates, primary review, and initial screening of 287 abstracts, 37 articles with full texts comparing RARC and ORC outcomes were identified and selected. Three additional manuscripts were added after reference list review. Therefore, a total of 40 articles were included to specifically address the stated purpose. Figure 1 contains the flowchart of study selection. A total of 34 observational [(12-31) and (32-45)], and 6 RCT (9,10,46-49) comparative studies were included in this descriptive analysis and reported on at least one complication and perioperative outcome. Most important characteristics of included studies are depicted in Table 1.
Retrospective reports on oncologic outcomes following RARC were promising but were mostly limited due to significant patient selection bias, short term follow-up, and limited number of patients included in most series (Table 2). Most of these retrospective analyses focused on rate of positive margins and lymph-node yields, with nearly all studies suggesting very similar outcomes for any type (standard vs. extended) of dissection. Positive surgical margins (PSM) has been largely related to stage of disease, with early reports demonstrating no significant increase in risk of PSM following RARC, which could be due to the fact that this might have been the preferred approach for less advanced cancers (50,51).
Long-term follow-up and report on multiple oncologic outcomes are sparse when taking into account all comparative randomized trials published to date (9,10,46,47,49,52). Rate of PSM ranged from 3.6% to 15% and 4.8% and 10% for RARC and ORC, respectively (Table 2). A recent metanalysis grouping all comparative RCT did not find any significant difference between RARC and ORC on either tumor recurrence (RR 0.94, 95% CI, 0.69–1.29, P=0.81) or PSM rates (RR 1.16, 95% CI, 0.56–2.40, P=0.90) (53). Only one well conducted RCT with a median follow-up of 60 months reported on cancer-specific survival (CSS) and overall survival (OS) and did not show any differences between techniques for both outcomes at 5 years of follow-up (52). Finally, recently published results with a 3-year follow-up from the RAZOR trial did not find any difference between techniques in the cumulative incidence rates of recurrence (P=0.80), progression-free survival (68.4%, 95% CI, 60.1–75.3 and 65.4, 95% CI, 56.8–72.7 for RARC and ORC, respectively, P=0.60) or OS (73.9%, 95% CI, 65.5–80.5 and 68.5%, 95% CI, 59.8–75.7 for RARC and ORC, respectively, P=0.33) (54).
Perioperative parameters and complications
The majority of the studies provide little information on the specific adverse events patients experienced (Table 3). Several retrospective studies included ORC patients with more comorbidities and advanced stages of disease, which could likely have led to a selection bias when comparing complications between techniques (Table 3). There seems to be an advantage in favor of RARC over ORC when comparing the frequencies of 90d overall complications, 90d higher-grade complications (Clavien ≥3) and 90d mortality between groups within included retrospective series. However, data from most RCT point towards a different scenario when it comes to the incidence of complications between techniques (53). Adverse events occurred in 67% and 69% of patients in RARC and ORC groups, respectively in the RAZOR trial, with similar complication rates within 90 days between groups for both low and higher-grade complications (49). Moreover, a pooled analysis of 3 RCT did not show any difference in the incidence of major complications (Clavien ≥3) between RARC and ORC (RR 1.03, 95% CI, 0.75–1.49, P=0.74) (53).
RARC seems to be consistently associated with lower estimated blood loss (EBL), shorter length of stay (LOS), lower transfusion rates (TR) and longer operative times (OT) among most retrospective studies. When looking exclusively into included RCT, the same seems to be true in regard to EBL, TR, and OT. Similarly, the RAZOR trial found a significant difference in median LOS in favor of RARC compared to ORC (6 days, 5–10 versus 7 days, 6–10, P<0.02) (49). However, a recent metanalysis of 5 RCTs reported on only a marginal diminished LOS in favor of RARC compared to ORC (RR −0.63 days, 95% CI, −1.21 to −0.05, P=0.03) (53). In all, this difference in LOS might be due to recent change in post-operative pathways, as discussed in detail below.
Health-related quality of life (HRQOL) outcomes
The expansion of robotic cystectomy has resulted in a number of studies that have sought to assess if there is any difference between robotic and open techniques with regard to post-operative HRQOL. The studies measuring the HRQOL of RARC vs. ORC problematically used varying instruments at differing follow-up times, thereby making it difficult to compare the two techniques directly. Nevertheless, the five studies analyzed in this review almost universally reported no statistically significant differences between techniques. Differences that were reported were either minimal or transient in nature. One retrospective analysis of 324 patients at a single institution that evaluated HRQOL was unique in using a combination of the Bladder Cancer Index (BCI) for long term post-operative convalescence (1,3,6,12 months) and Convalescence and Recovery Evaluation (CARE) for short term follow-up (2,4,6 weeks) (30). Baseline BCI/CARE scores were comparable between RARC and ORC groups. Post-operative analysis revealed that recovery was comparable across BCI domains and that scores had nearly returned to baseline level at 1 year for all patients. Two other retrospective studies that utilized the BCI and included somewhat smaller cohorts similarly found no significant difference in HRQOL (21,31). Messer et al. conducted a 40 patient RCT utilizing the Functional Assessment of Cancer Therapy-Vanderbilt Index Questionnaire (FACT-VCI) at 3, 6, 9, and 12 months post-operatively (48). They reported no significant differences with regard to physical, social/family, functional, or emotional well-being between RARC and ORC cohorts, with the exception of a slightly lower score in the ORC arm for physical well-being at 6 months. Two other RCTs, one of 302 patients that utilized FACT-VCI and one of 118 patients that utilized the Quality of Life Questionnaire Core 30, also assessed the HRLQ. Assessment at baseline, 3 and 6 months post-operatively yielded no significant differences between either arm in either study (9,49). One major limitation of studies reporting on HRQOL outcomes is the absence of objective independent measures of postoperative pain and return to work outcomes. Moreover, if is often hard to account for differences in surgeon’s expertise. None of these studies provided granular data on differences between type of urinary diversion. Since most of the urinary diversions were carried out using ECUD, it is easy to underestimate potential gains in QOL due to the use of a robotic approach. Finally, on a recent report on HRQOL using data form the RAZOR trial, Becerra et al. showed there was no statistically significant difference between the surgical approaches at any time point, even though attention should be paid to the fact that all diversions were performed extracorporeally in this prospective trial (55). Therefore, definitive comparative HRQOL data will most likely come from large prospective studies comparing RARC with ICUD to either ORC or RARC with ECUD.
Amidst an evolving health system with limited resources, comparisons of overall, direct, and cost-to-patient between RARC and ORC are of outmost importance in order to improve population health. Robotic surgery has been questioned on most retrospective studies due to concerns regarding higher costs, as demonstrated in two previous population-based retrospective studies (22,56). In the first study, even though there were no differences in 90-d major complications between RARC and ORC, and RARC had 46% decreased odds of minor complications, 77% reduced odds for blood transfusion and shorter length of stay, RARC was associated with higher median 90-d direct hospital costs (ORC: $26,681 vs. RARC: $31,007; P<0.01). Major driver was increased cost of supplies, not board or room costs. Importantly, when restricting the analysis to centers performing ≥19 cases a year, RARC was no longer more costly than ORC for the highest-volume surgeons (22). In the second study, inpatient costs did not differ statistically, but RARC was still associated with higher 30-d ($31,009 vs. $27,947) and 90-d ($36,121 vs. $32,521) costs, likely influenced by a greater use of home health, and less usual discharge to home among RARC patients. Notably, the latter analysis included a fairly small cohort of patients undergoing RARC, and possibly failed to include SEER Medicare patients after 2012, which most likely reflects the beginning of RARC adoption within the general population (56). Besides these early observations, more recent cost outcomes analysis on perioperative and beyond inpatient spending have showed somewhat different results (37,38,57). Interestingly, one of these more recent studies found 90-d spending to be higher for ORC compared with minimally invasive cystectomy (open $38,071 vs. $34,369, P<0.01) (57). In part, the discrepancies in these results may be due to the difference in the period of most recent analysis, with lesser spending driven by increased experience, better postoperative management, and disposition after RARC in more recent years. Moreover, the dollar amount charged to patients for services was significantly reduced in the robotic group in a recent cost-to-patient estimate analysis (37). The explanation for these findings were that more patients underwent imaging studies within 30 days of ORC, and were charged more for room and board and inpatient medications due to prolonged hospitalization (37). Finally, a recent study looked into cost-effectiveness of cystectomy with urinary diversion by comparing both techniques in terms of health utilities and gains in quality-adjusted life years (QALYs) (38). In this latter analysis, even though RARC was still significantly more expensive then ORC, it was associated with increased QALYs and was the preferred approach as long as it could prevent complications and transfusions (38). Unfortunately, the urological community is still awaiting definitive answers on comparative cost analysis between RARC and ORC since most randomized trials to date have failed at delivering such results (53). However, efforts should focus on reducing intra-operative expenditures by judicious use of instruments and by becoming more efficient at decreasing intra-operative time (56-58). Hospitals should adhere to standardized processes in order to decrease LOS, optimize use of postoperative home-health resources, and prioritize discharging patients to home whenever deemed safe.
ERAS and robotic surgery
First introduced in patients undergoing colorectal surgeries, enhanced recovery after surgery (ERAS) are perioperative programs designed to optimize the perioperative care of patients undergoing major surgeries. Eras protocols applied to patients undergoing either open or robotic cystectomy have shown to positively affect rates of multiple outcomes, including a decrease in complication, readmission, transfusion rates, post-operative ileus, and LOS (59). ERAS has had a major impact on ORC outcomes as demonstrated in multiple series based on data later then 2012, with reductions in LOS, postoperative complications, morbidity, and overall health costs (60,61). However, up until recently, there was still debate regarding the benefits of ERAS implementation for patients undergoing RARC (62). Multiple series have lately reported on similar reductions in LOS when ERAS recommendations are utilized in the care of patients undergoing RARC (51,63). Similarly, a recent prospective study on non-opioid pathway for patients undergoing RARC showed reduced oral opioid use, LOS, and median time to regular diet (64). Moreover, cumulative effect of ERAS and RARC lowered 90-d readmission rates and gastrointestinal complications in a recent single-center prospective cohort study (40). A minimally invasive approach aligns itself with the core principles of ERAS, decreasing surgical trauma and stress response, and facilitating quicker patient recovery. In fact, a recent consensus of the European Association of Urology working group on ERAS after RARC has been recently published, acknowledging the benefits of multiple ERAS components in the care of patients undergoing RARC, and giving guidance specifically for this patient population (65). Compared with ORC, ERAS designed for RARC incorporates multiple elements previously described for ORC (patient education, optimization of preoperative nutrition status, thromboembolic prophylaxis, early mobilization, etc.) with special emphasis to avoidance of epidural and reduced postoperative analgesia requirements (65).
Comparative analysis between surgical approaches should be interpreted with caution, especially when it entails evaluating the efficacy of the da Vinci robotic platform on clinical outcomes. One important comment to make is that the most recent randomized trial comparing both techniques has not found any significant differences in overall complications or major complication rates between techniques (49). Moreover, on a recent update of results, there hasn’t been any differences between techniques for progression-free survival, cumulative incidence rates of recurrence, or overall survival with a 3-year follow-up (54). Moreover, it should be pointed out that ERAS protocols had not been implemented prior to 2012, which might have flawed some retrospective studies included here, incorporating more modern RARC and relatively older ORC series.
Another important aspect to consider is the influence of industry funding of research on reported outcomes (66,67). A large well-conducted review found that funded studies were more likely to have favorable efficacy results and conclusions compared with non-sponsored ones (67). Moreover, even though authors are expected to declare pertinent financial conflicts of interest (COI) when publishing their results, a recent analysis comparing COI with industry registered payments found that it was very common for payments to go undeclared in robotic surgery manuscripts (66). This is important because accepting corporate payments have been shown to impact the chance of reporting a benefit in favor of robotic surgery (68). Financial cooperation between industry and academic institutions will continue to occur, since this partnership is important for the conduction of multiple studies. However, liability processes should be implemented in order to guarantee transparency to journal readers. Moreover, class associations and journals might want to include a statement on the dollar amount payed to authors, because this seems to drive the inclination to report more favorable results on articles submitted for publication.
Minimally invasive and robotic urologic surgery continues to evolve and has recently added a new platform specifically designed for single-port (SP) procedures (69). The da Vinci SP allows for three articulating instruments and a camera to be inserted into the patient through a SP (70). A recent series was published to evaluate and determine the feasibility and safety of this new platform (69). Nine patients, including one simple cystectomy with intracorporeal ileal conduit diversion, were operated on at a center of excellence with no reported intraoperative complications, even though operative time was noted to be longer compared to the equivalent multi-arm approaches (69). This is particularly attractive for RC since it decreases surgical trauma and allows for intracorporeal urinary diversions. However, large-scale head-to-head comparisons between the novel and the multi-arm platforms are still needed in order to better define indications and use of this new technology.
Although most prospective comparative data between RARC and ORC have failed to demonstrate big differences in complications, the attention has now shifted to the assessment of outcomes of the different types of urinary diversion utilized after removal of the bladder (71). Particularly in regard to the extension of required ureteral dissection when performing either ICUD or ECUD, intraoperative use of indocyanine green (ICG) has been shown to improve real-time assessment of ureteral blood supply, and significantly reduced the rates of ureteroenteric strictures in a group of patients undergoing RARC with ICUD (72). This is a technology that is becoming standard on latest generations of the robot and could potentially have a positive impact on decreasing the incidence of delayed urinary complications after RARC.
Comparative effectiveness investigation is an important part in assessing health care delivery. In this narrative review of contemporary studies RARC was consistently found to be associated with decreased blood loss and lower transfusion rates compared with ORC. Despite multiple advantages reported for RARC in regard to LOS, mortality within 90 days, and higher-grade complications within 90 days on retrospective series, no significant differences were encountered between techniques in regard to postoperative complications, rates of recurrence and PSM, overall survival, and HRQOL outcomes in prospective studies. Further comparisons between RARC with ICUD and either ORC or RARC with ECUD, with special attention to costs and improvement in quality of care are necessary in order to better delineate future management of this common disease.
Provenance and Peer Review: This article was commissioned by the Guest Editor (Simon P. Kim) for the series “Surgical Management of Genitourinary Malignancies” published in AME Medical Journal. The article has undergone external peer review.
Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at http://dx.doi.org/10.21037/amj-20-81
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/amj-20-81). The series “Surgical Management of Genitourinary Malignancies” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
- Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin 2019;69:7-34. [Crossref] [PubMed]
- Chang SS, Boorjian SA, Chou R, et al. Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline. J Urol 2016;196:1021-9. [Crossref] [PubMed]
- Chang SS, Bochner BH, Chou R, et al. Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline. J Urol 2017;198:552-9. [Crossref] [PubMed]
- Borden LS Jr, Clark PE, Hall MC. Bladder cancer. Curr Opin Oncol 2005;17:275-80. [Crossref] [PubMed]
- Herr HW, Dotan Z, Donat SM, et al. Defining optimal therapy for muscle invasive bladder cancer. J Urol 2007;177:437-43. [Crossref] [PubMed]
- Huang GJ, Stein JP. Open radical cystectomy with lymphadenectomy remains the treatment of choice for invasive bladder cancer. Curr Opin Urol 2007;17:369-75. [Crossref] [PubMed]
- Pak JS, Lee JJ, Bilal K, et al. Utilization Trends and Short-term Outcomes of Robotic Versus Open Radical Cystectomy for Bladder Cancer. Urology 2017;103:117-23. [Crossref] [PubMed]
- Rhee JJ, Lebeau S, Smolkin M, et al. Radical cystectomy with ileal conduit diversion: early prospective evaluation of the impact of robotic assistance. BJU Int 2006;98:1059-63. [Crossref] [PubMed]
- Bochner BH, Dalbagni G, Sjoberg DD, et al. Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial. Eur Urol 2015;67:1042-50. [Crossref] [PubMed]
- Khan MS, Gan C, Ahmed K, et al. A Single-centre Early Phase Randomised Controlled Three-arm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL). Eur Urol 2016;69:613-21. [Crossref] [PubMed]
- Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Chiropr Med 2006;5:101-17. [Crossref] [PubMed]
- Ng CK, Kauffman EC, Lee MM, et al. A comparison of postoperative complications in open versus robotic cystectomy. Eur Urol 2010;57:274-81. [Crossref] [PubMed]
- Richards KA, Hemal AK, Kader AK, et al. Robot assisted laparoscopic pelvic lymphadenectomy at the time of radical cystectomy rivals that of open surgery: single institution report. Urology 2010;76:1400-4. [Crossref] [PubMed]
- Gondo T, Yoshioka K, Nakagami Y, et al. Robotic versus open radical cystectomy: prospective comparison of perioperative and pathologic outcomes in Japan. Jpn J Clin Oncol 2012;42:625-31. [Crossref] [PubMed]
- Khan MS, Challacombe B, Elhage O, et al. A dual-centre, cohort comparison of open, laparoscopic and robotic-assisted radical cystectomy. Int J Clin Pract 2012;66:656-62. [Crossref] [PubMed]
- Styn NR, Montgomery JS, Wood DP, et al. Matched comparison of robotic-assisted and open radical cystectomy. Urology 2012;79:1303-8. [Crossref] [PubMed]
- Sung HH, Ahn JS, Seo SI, et al. A comparison of early complications between open and robot-assisted radical cystectomy. J Endourol 2012;26:670-5. [Crossref] [PubMed]
- Kader AK, Richards KA, Krane LS, et al. Robot-assisted laparoscopic vs open radical cystectomy: comparison of complications and perioperative oncological outcomes in 200 patients. BJU Int 2013;112:E290-4. [Crossref] [PubMed]
- Knox ML, El-Galley R, Busby JE. Robotic versus open radical cystectomy: identification of patients who benefit from the robotic approach. J Endourol 2013;27:40-4. [Crossref] [PubMed]
- Maes AA, Brunkhorst LW, Gavin PW, et al. Comparison of robotic-assisted and open radical cystectomy in a community-based, non-tertiary health care setting. J Robot Surg 2013;7:359-63. [Crossref] [PubMed]
- Aboumohamed AA, Raza SJ, Al-Daghmin A, et al. Health-related quality of life outcomes after robot-assisted and open radical cystectomy using a validated bladder-specific instrument: a multi-institutional study. Urology 2014;83:1300-8. [Crossref] [PubMed]
- Leow JJ, Reese SW, Jiang W, et al. Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: a contemporary population-based analysis in the United States. Eur Urol 2014;66:569-76. [Crossref] [PubMed]
- Musch M, Janowski M, Steves A, et al. Comparison of early postoperative morbidity after robot-assisted and open radical cystectomy: results of a prospective observational study. BJU Int 2014;113:458-67. [Crossref] [PubMed]
- Niegisch G, Albers P, Rabenalt R. Perioperative complications and oncological safety of robot-assisted (RARC) vs. open radical cystectomy (ORC). Urol Oncol 2014;32:966-74. [Crossref] [PubMed]
- Koupparis A, Villeda-Sandoval C, Weale N, et al. Robot-assisted radical cystectomy with intracorporeal urinary diversion: impact on an established enhanced recovery protocol. BJU Int 2015;116:924-31. [Crossref] [PubMed]
- Bak DJ, Lee YJ, Woo MJ, et al. Complications and oncologic outcomes following robot-assisted radical cystectomy: What is the real benefit? Investig Clin Urol 2016;57:260-7. [Crossref] [PubMed]
- Cusano A, Haddock P Jr, Jackson M, et al. A comparison of preliminary oncologic outcome and postoperative complications between patients undergoing either open or robotic radical cystectomy. Int Braz J Urol 2016;42:663-70. [Crossref] [PubMed]
- Gandaglia G, Karl A, Novara G, et al. Perioperative and oncologic outcomes of robot-assisted vs. open radical cystectomy in bladder cancer patients: A comparison of two high-volume referral centers. Eur J Surg Oncol 2016;42:1736-43. [Crossref] [PubMed]
- Iwamoto H, Yumioka T, Yamaguchi N, et al. Robot-assisted radical cystectomy is a promising alternative to open surgery in the Japanese population with a high rate of octogenarians. Int J Clin Oncol 2016;21:756-63. [Crossref] [PubMed]
- Li AY, Filson CP, Hollingsworth JM, et al. Patient-Reported Convalescence and Quality of Life Recovery: A Comparison of Open and Robotic-Assisted Radical Cystectomy. Surg Innov 2016;23:598-605. [Crossref] [PubMed]
- Satkunasivam R, Santomauro M, Chopra S, et al. Robotic Intracorporeal Orthotopic Neobladder: Urodynamic Outcomes, Urinary Function, and Health-related Quality of Life. Eur Urol 2016;69:247-53. [Crossref] [PubMed]
- Winters BR, Bremjit PJ, Gore JL, et al. Preliminary Comparative Effectiveness of Robotic Versus Open Radical Cystectomy in Elderly Patients. J Endourol 2016;30:212-7. [Crossref] [PubMed]
- Kingo PS, Norregaard R, Borre M, et al. Postoperative C-reactive protein concentration and clinical outcome: comparison of open cystectomy to robot-assisted laparoscopic cystectomy with extracorporeal or intracorporeal urinary diversion in a prospective study. Scand J Urol 2017;51:381-7. [Crossref] [PubMed]
- Koie T, Ohyama C, Yamamoto H, et al. The feasibility and effectiveness of robot-assisted radical cystectomy after neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer. Jpn J Clin Oncol 2017;47:252-6. [Crossref] [PubMed]
- Muto S, Kitamura K, Ieda T, et al. A preliminary oncologic outcome and postoperative complications in patients undergoing robot-assisted radical cystectomy: Initial experience. Investig Clin Urol 2017;58:171-8. [Crossref] [PubMed]
- Sharma P, Zargar-Shoshtari K, Poch MA, et al. Surgical control and margin status after robotic and open cystectomy in high-risk cases: Caution or equivalence? World J Urol 2017;35:657-63. [Crossref] [PubMed]
- Flamiatos JF, Chen Y, Lambert WE, et al. Open versus robot-assisted radical cystectomy: 30-day perioperative comparison and predictors for cost-to-patient, complication, and readmission. J Robot Surg 2019;13:129-40. [Crossref] [PubMed]
- Kukreja JB, Metcalfe MJ, Qiao W, et al. Cost-Effectiveness of Robot-assisted Radical Cystectomy Using a Propensity-matched Cohort. Eur Urol Focus 2020;6:88-94. [Crossref] [PubMed]
- Simone G, Tuderti G, Misuraca L, et al. Perioperative and mid-term oncologic outcomes of robotic assisted radical cystectomy with totally intracorporeal neobladder: Results of a propensity score matched comparison with open cohort from a single-centre series. Eur J Surg Oncol 2018;44:1432-8. [Crossref] [PubMed]
- Tan WS, Tan MY, Lamb BW, et al. Intracorporeal robot-assisted radical cystectomy, together with an enhanced recovery programme, improves postoperative outcomes by aggregating marginal gains. BJU Int 2018;121:632-9. [Crossref] [PubMed]
- Panwar P, Mavuduru RS, Mete UK, et al. Perioperative outcomes of minimally invasive versus open radical cystectomy: A single-center experience. Indian J Urol 2018;34:115-21. [Crossref] [PubMed]
- Ram D, Rajappa SK, Rawal S, et al. Is robot-assisted radical cystectomy superior to standard open radical cystectomy? An Indian perspective. J Minim Access Surg 2018;14:298-303. [Crossref] [PubMed]
- Faraj KS, Abdul-Muhsin HM, Rose KM, et al. Robot Assisted Radical Cystectomy vs Open Radical Cystectomy: Over 10 years of the Mayo Clinic Experience. Urol Oncol 2019;37:862-9. [Crossref] [PubMed]
- Hanna N, Leow JJ, Sun M, et al. Comparative effectiveness of robot-assisted vs. open radical cystectomy. Urol Oncol 2018;36:88 e1- e9.
- Moschini M, Zamboni S, Soria F, et al. Open Versus Robotic Cystectomy: A Propensity Score Matched Analysis Comparing Survival Outcomes. J Clin Med 2019;8:1192. [Crossref] [PubMed]
- Nix J, Smith A, Kurpad R, et al. Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur Urol 2010;57:196-201. [Crossref] [PubMed]
- Parekh DJ, Messer J, Fitzgerald J, et al. Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. J Urol 2013;189:474-9. [Crossref] [PubMed]
- Messer JC, Punnen S, Fitzgerald J, et al. Health-related quality of life from a prospective randomised clinical trial of robot-assisted laparoscopic vs open radical cystectomy. BJU Int 2014;114:896-902. [Crossref] [PubMed]
- Parekh DJ, Reis IM, Castle EP, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet 2018;391:2525-36. [Crossref] [PubMed]
- Yuh B, Wilson T, Bochner B, et al. Systematic review and cumulative analysis of oncologic and functional outcomes after robot-assisted radical cystectomy. Eur Urol 2015;67:402-22. [Crossref] [PubMed]
- Raza SJ, Wilson T, Peabody JO, et al. Long-term oncologic outcomes following robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol 2015;68:721-8. [Crossref] [PubMed]
- Bochner BH, Dalbagni G, Marzouk KH, et al. Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: Oncologic Outcomes. Eur Urol 2018;74:465-71. [Crossref] [PubMed]
- Sathianathen NJ, Kalapara A, Frydenberg M, et al. Robotic Assisted Radical Cystectomy vs Open Radical Cystectomy: Systematic Review and Meta-Analysis. J Urol 2019;201:715-20. [Crossref] [PubMed]
- Venkatramani V, Reis IM, Castle EP, et al. Predictors of Recurrence, and Progression-Free and Overall Survival following Open versus Robotic Radical Cystectomy: Analysis from the RAZOR Trial with a 3-Year Followup. J Urol 2020;203:522-9. [Crossref] [PubMed]
- Becerra MF, Venkatramani V, Reis IM, et al. Health Related Quality of Life of Patients with Bladder Cancer in the RAZOR Trial - A Multi-Institutional Randomized Trial Comparing Robot versus Open Radical Cystectomy. J Urol 2020;204:450-9. [Crossref] [PubMed]
- Hu JC, Chughtai B, O'Malley P, et al. Perioperative Outcomes, Health Care Costs, and Survival After Robotic-assisted Versus Open Radical Cystectomy: A National Comparative Effectiveness Study. Eur Urol 2016;70:195-202. [Crossref] [PubMed]
- Modi PK, Hollenbeck BK, Oerline M, et al. Real-World Impact of Minimally Invasive Versus Open Radical Cystectomy on Perioperative Outcomes and Spending. Urology 2019;125:86-91. [Crossref] [PubMed]
- Leow JJ, Chang SL, Meyer CP, et al. Robot-assisted Versus Open Radical Prostatectomy: A Contemporary Analysis of an All-payer Discharge Database. Eur Urol 2016;70:837-45. [Crossref] [PubMed]
- Tyson MD, Chang SS. Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes. Eur Urol 2016;70:995-1003. [Crossref] [PubMed]
- Pang KH, Groves R, Venugopal S, et al. Prospective Implementation of Enhanced Recovery After Surgery Protocols to Radical Cystectomy. Eur Urol 2018;73:363-71. [Crossref] [PubMed]
- Nabhani J, Ahmadi H, Schuckman AK, et al. Cost Analysis of the Enhanced Recovery After Surgery Protocol in Patients Undergoing Radical Cystectomy for Bladder Cancer. Eur Urol Focus 2016;2:92-6. [Crossref] [PubMed]
- Chen J, Djaladat H, Schuckman AK, et al. Surgical approach as a determinant factor of clinical outcome following radical cystectomy: Does Enhanced Recovery After Surgery (ERAS) level the playing field? Urol Oncol 2019;37:765-73. [Crossref] [PubMed]
- Baack Kukreja JE, Kiernan M, Schempp B, et al. Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study. BJU Int 2017;119:38-49. [Crossref] [PubMed]
- Audenet F, Attalla K, Giordano M, et al. Prospective implementation of a nonopioid protocol for patients undergoing robot-assisted radical cystectomy with extracorporeal urinary diversion. Urol Oncol 2019;37:300.e17-23. [Crossref] [PubMed]
- Collins JW, Patel H, Adding C, et al. Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View. Eur Urol 2016;70:649-60. [Crossref] [PubMed]
- Patel SV, Yu D, Elsolh B, et al. Assessment of Conflicts of Interest in Robotic Surgical Studies: Validating Author's Declarations With the Open Payments Database. Ann Surg 2018;268:86-92. [Crossref] [PubMed]
- Lundh A, Lexchin J, Mintzes B, et al. Industry sponsorship and research outcome. Cochrane Database Syst Rev 2017;2:MR000033 [PubMed]
- Criss CN, MacEachern MP, Matusko N, et al. The Impact of Corporate Payments on Robotic Surgery Research: A Systematic Review. Ann Surg 2019;269:389-96. [Crossref] [PubMed]
- Kaouk J, Garisto J, Bertolo R. Robotic Urologic Surgical Interventions Performed with the Single Port Dedicated Platform: First Clinical Investigation. Eur Urol 2019;75:684-91. [Crossref] [PubMed]
- Bertolo R, Garisto J, Gettman M, et al. Novel System for Robotic Single-port Surgery: Feasibility and State of the Art in Urology. Eur Urol Focus 2018;4:669-73. [Crossref] [PubMed]
- Bertolo R, Agudelo J, Garisto J, et al. Perioperative Outcomes and Complications after Robotic Radical Cystectomy With Intracorporeal or Extracorporeal Ileal Conduit Urinary Diversion: Head-to-head Comparison From a Single-Institutional Prospective Study. Urology 2019;129:98-105. [Crossref] [PubMed]
- Ahmadi N, Ashrafi AN, Hartman N, et al. Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy. BJU Int 2019;124:302-7. [Crossref] [PubMed]
Cite this article as: Pessoa RR, Boxley P, Kukreja JB. Narrative review on the comparative effectiveness of robotic and open radical cystectomy for bladder cancer. AME Med J 2021;6:6.