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Journal ArticleDOI

Comparing robotic, laparoscopic and open cystectomy: a systematic review and meta-analysis.

31 Mar 2015-Archivio Italiano di Urologia e Andrologia (Arch Ital Urol Androl)-Vol. 87, Iss: 1, pp 41-48
TL;DR: RARC is comparable to LRC with better surgical results than ORC and LRC has better surgical outcomes than OrC.
Abstract: Objective: To conduct a systematic review and meta-analysis comparing outcomes between Open Radical Cystectomy (ORC), Laparoscopic Radical Cystectomy (LRC) and Robot-assisted Radical Cystectomy (RARC). RARC is to be compared to LRC and ORC and LRC compared to ORC. Material and methods: A systematic review of the literature was conducted, collating studies comparing RARC, LRC and ORC. Surgical and oncological outcome data were extracted and a meta-analysis was performed. Results: Twenty-four studies were selected with total of 2,104 cases analyzed. RARC had a longer operative time (OPT) compared to LRC with no statistical difference between length of stay (LOS) and estimated blood loss (EBL). RARC had a significantly shorter LOS, reduced EBL, lower complication rate and longer OPT compared to ORC. There were no significant differences regarding lymph node yield (LNY) and positive surgical margins (PSM.) LRC had a reduced EBL, shorter LOS and increased OPT compared to ORC. There was no significant difference regarding LNY. Conclusion: RARC is comparable to LRC with better surgical results than ORC. LRC has better surgical outcomes than ORC. With the unique technological features of the robotic surgical system and increasing trend of intra-corporeal reconstruction it is likely that RARC will become the surgical option of choice.

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Citations
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Journal ArticleDOI
TL;DR: There was no difference in 5-yr RFS, CSS, and OS rates of patients who underwent ORC, RARC, and LRC for management of bladder cancer, and minimally invasive techniques achieved equivalent oncological outcomes to the gold standard of ORC.

75 citations

Journal ArticleDOI
07 Nov 2016-PLOS ONE
TL;DR: This study does not provide evidence to support a benefit for RARC compared to ORC in patients with bladder cancer and well-designed trials with appropriate endpoints conducted by equally experienced ORC and RARC surgeons will be needed to address this.
Abstract: 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.

67 citations

Journal ArticleDOI
TL;DR: A multi-disciplinary approach is paramount to achieving optimal outcomes for MIBC patients, irrespective of their age, performance and nutritional status, fitness/frailty, renal and other organ function, or disease severity.
Abstract: To provide a comprehensive overview and update of the Joint Societe Internationale d’Urologie–International Consultation on Urological Diseases (SIU–ICUD) Consultation on Bladder Cancer for muscle-invasive presumably node-negative bladder cancer (MIBC). Contemporary literature was analyzed for the latest evidence in treatment options, outcomes, including radical surgery, neoadjuvant and adjuvant treatment modalities, and bladder-sparing approaches. An international multi-disciplinary expert panel evaluated and graded the data according to guidelines from the Oxford Centre for Evidence-Based Medicine. Radical cystectomy (RC) is the standard of care for MIBC patients considered to be surgical candidates. While associated with substantial morbidity and mortality, this has been mitigated with improved technique, minimally invasive technology, and better perioperative care pathways (e.g., enhanced recovery after surgery). Neoadjuvant (NA) cisplatin-based combination chemotherapy improves overall survival and should be offered to eligible ≥ cT2N0 patients. Adjuvant (Adj) cisplatin-based combination chemotherapy may be considered, particularly for pT3–4 and/or pN+ disease without prior NA chemotherapy. Trimodal bladder-preserving treatment via maximum transurethral resection of bladder tumor followed by concurrent chemoradiation is safe and, when combined with early salvage RC for recurrence, offers long-term survival rates in selected patients comparable to RC. Immunotherapy is still experimental and is given either alone or in combination with chemotherapy and/or radiation. A multi-disciplinary approach is paramount to achieving optimal outcomes for MIBC patients, irrespective of their age, performance and nutritional status, fitness/frailty, renal and other organ function, or disease severity.

38 citations

Journal ArticleDOI
TL;DR: The findings indicate that the type of surgical approach is not associated with RFS, CSS, and OS in patients with bladder cancer.
Abstract: Purpose: To investigate oncological outcomes in patients with muscle-invasive bladder cancer who underwent open radical cystectomy (ORC), laparoscopic radical cystectomy (LRC), or robot-assisted radical cystectomy (RARC). Patients and Methods: A retrospective analysis was performed on 230 patients who underwent ORC (n = 150), LRC (n = 22), or RARC (n = 58) between September 2009 and June 2012. Perioperative outcomes were compared between the three surgical approaches. The influence of the type of surgical approach on recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) was analyzed using the Kaplan–Meier method, and differences were assessed with the log-rank test. Predictors of RFS, CSS, and OS were also analyzed with a Cox regression model. Results: The median patient age for ORC, LRC, and RARC groups was 68.0 (interquartile range [IQR]: 60.0–73.0), 65.0 (IQR: 62.8–74.0), and 61.5 (IQR: 54.8–72.0) years, respectively (p = 0.017), and the median follow-up dur...

34 citations


Cites result from "Comparing robotic, laparoscopic and..."

  • ...Longer operative times and lower transfusion rates for LRC or RARC compared with ORC have been demonstrated in most previous surgical series.(5,18,19) Aboumarzouk et al....

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Journal ArticleDOI
TL;DR: Evidence is presented for RARC not being superior to ORC regarding complications, LOS and HRQoL and high-quality studies with consistent registration of complications and patient-related outcomes are warranted.
Abstract: Radical cystectomy is associated with high rates of perioperative morbidity. Robotic-assisted radical cystectomy (RARC) is widely used today despite limited evidence for clinical superiority. The aim of this review was to evaluate the effect of RARC compared to open radical cystectomy (ORC) on complications and secondary on length of stay, time back to work and health-related quality of life (HRQoL). The databases PubMed, The Cochrane Library, Embase and CINAHL were searched. A systematic review according to the PRISMA guidelines and cumulative analysis was conducted. Randomized controlled trials (RCTs) that examined RARC compared to ORC were included in this review. We assessed the quality of evidence using the Cochrane Collaboration’s ‘Risk of bias’ tool and Grading of Recommendations Assessment, Development and Evaluation approach. Data were extracted and analysed. The search retrieved 273 articles. Four RCTs were included involving overall 239 patients. The quality of the evidence was of low to moderate quality. There was no significant difference between RARC and ORC in the number of patients developing complications within 30 or 90 days postoperatively or in overall grade 3–5 complications within 30 or 90 days postoperatively. Types of complications differed between the RARC and the ORC group. Likewise, length of stay and HRQoL at 3 and 6 months did not differ. Our review presents evidence for RARC not being superior to ORC regarding complications, LOS and HRQoL. High-quality studies with consistent registration of complications and patient-related outcomes are warranted. PROSPERO CRD42016038232

34 citations


Cites result from "Comparing robotic, laparoscopic and..."

  • ...In systematic reviews including both randomized controlled trials (RCTs), retrospective and prospective comparative study designs, RARC has similar oncological outcomes compared to ORC [10, 11], however with lower perioperative blood loss, fewer transfusions and shorter postoperative length of stay (LOS)....

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References
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Journal ArticleDOI
TL;DR: The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
Abstract: Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4 Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature. The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification. Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.

23,435 citations


"Comparing robotic, laparoscopic and..." refers methods in this paper

  • ...Complications were assessed using the Clavien-Dindo grading system (3)....

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Journal ArticleDOI
TL;DR: This report hopes this report will generate further thought about ways to improve the quality of reports of meta-analyses of RCTs and that interested readers, reviewers, researchers, and editors will use the QUOROM statement and generate ideas for its improvement.

4,767 citations


"Comparing robotic, laparoscopic and..." refers methods in this paper

  • ...Synthesis of results Guidance was sought from the Cochrane Collaboration as well as information from the QUORUM guidelines (5) to provide the framework of the statistical analysis....

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Journal ArticleDOI
TL;DR: High levels of clinical evidence with regard to the benefits of robotic cystectomy are absent, and the current experiences represent case series with limited comparisons to historical controls at best, demonstrating the robotic approach to be noninferior to the open approach.

473 citations


"Comparing robotic, laparoscopic and..." refers background in this paper

  • ...Study characteristics Characteristics of all 24 studies included in the analysis are summarized in Table 1 (6-29)....

    [...]

  • ...Thus 24 studies were included in the final quantitative and qualitative analysis (Figure 1) (6-29)....

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Journal ArticleDOI
TL;DR: Patients undergoing robotic Cystectomy experienced fewer postoperative complications than those undergoing open cystectomy and high American Society of Anesthesiologists (ASA) score and longer surgical time were independent predictors of major complications.

271 citations


"Comparing robotic, laparoscopic and..." refers background in this paper

  • ...Study characteristics Characteristics of all 24 studies included in the analysis are summarized in Table 1 (6-29)....

    [...]

  • ...Thus 24 studies were included in the final quantitative and qualitative analysis (Figure 1) (6-29)....

    [...]

Journal ArticleDOI
TL;DR: This study validates the concept of randomizing patients with bladder cancer undergoing radical cystectomy to an open or robotic approach and demonstrates potential benefits of decreased estimated blood loss and decreased hospital stay compared to open radical cyStectomy.

244 citations


"Comparing robotic, laparoscopic and..." refers background in this paper

  • ...Study characteristics Characteristics of all 24 studies included in the analysis are summarized in Table 1 (6-29)....

    [...]

  • ...Thus 24 studies were included in the final quantitative and qualitative analysis (Figure 1) (6-29)....

    [...]

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