Oncologic Outcomes for Robotic Vs. Open Radical Cystectomy Among Locally Advanced and Node-Positive Patients: Analysis of The National Cancer Database

The use of robotic assisted radical cystectomy has not been widely adopted for particularly advanced disease. Using the National Cancer Database, this study examined the oncologic and surgical outcomes in node positive and/or pathologic stage T3-4 disease. Compared to open, there were no significant differences in survival outcomes with use of the robotic approach, which may confer certain perioperative benefits. Introduction: Despite concerns of atypical recurrence following robotic-assisted radical cystectomy (RARC), utilization of the modality is increasing. The presumed mechanisms of peritoneal immunomodulation and pneumoperitoneum-induced tumor cell intravasation are especially relevant for higher stage, locally advanced disease, where intrinsic metastatic potential of tumor cells may be greater. This study aims to compare the oncologic outcomes and survival after RARC compared to open radical cystectomy (ORC) among patients with stage pT3-4 or node-positive muscle-invasive bladder cancer. Patients and Methods: Retrospective cohort analysis of pT3-4N0-3 and pT(any)N1-3 patients who underwent RARC or ORC was performed using the National Cancer Database (2010-2016) to investigate perioperative and oncologic outcomes. Results: 9,062 ORC cases and 2,544 RARC cases met inclusion cr iteria. The robotic approach was significantly associated with superior unadjusted survival compared to open as well as lower proportions of unadjusted 30- and 90-day mortality, lower positive margin status, and shorter surgical inpatient stay (all respective P <.05). However, after adjusting for confounding covariates, multivariable analysis revealed no difference in mortality hazard or odds of any of the above secondary outcomes with the exception of shorter inpatient stay and higher lymph node yield. Patients treated with RARC were more likely to have neoadjuvant chemotherapy. Conclusions: RARC is no less safe than ORC for patients with locally advanced bladder cancer on the basis of overall, 30- and 90-day survival. Unadjusted mortality and surgical outcomes demonstrate advantages to RARC, which are attenuated after multivariate analysis. Perioperative benefits may favor the robotic approach, consistent with previous randomized control studies. (C) 2021 Elsevier Inc. All rights reserved.