[Comparative analysis of robot-assisted and open radical cystectomy with orthotopic urinary diversion]

Robot-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder creation is a complex surgical procedure, which is gradually becoming an alternative to open surgery.

To compare the perioperative, functional and oncological outcomes of open radical cystectomy (ORC) and RARC.

RARC with ileocystoplasty was performed in 25 patients, including 24 men. The average age was 65.5 years. ORC was done in 30 patients (28 men; control group) with the mean age of 67.2 years. In RARC, the ureters were isolated at the level of lower thirds, the bladder was dissected from the rectum on both sides, then the bladder vessels were divided using clips, and the urethra was cut off. After pelvic lymph node dissection, 50 cm of the ileum was resected. Then two distal segments were folded in a U-shape, a 1.5 cm incision was made in the lower part, and an anastomosis with the urethra was carried out. Further, these segments were detubularized and a modified Studer reservoir was created. The ureters were implanted into the tubular part. In ORC, urine diversion was also done using Studer technique. In both groups, the operation time, the volume of blood loss, the number of complications, the duration of hospitalization, the proportion of daytime and nighttime continence were evaluated.

The mean time for RARC and ORC was 380 (320-580) and 260 (220-320) min, respectively (p<0.05). In the group of RARC, the volume of blood loss was 85 (50-250) ml and no blood transfusion was performed, while in ORC, the volume of blood loss was 520 (350-1400) ml, an average of 480 (0-840) ml of blood was transfused (p<0.05). After RARC, 30- and 90- complications rate was 32.0% (n=8) and 24.0% (n=6), respectively, compared to 40.0% (n=12) and 30.0% (n=9) in ORC. One patient died due to myocardial infarction during the 90-day follow-up period after RARC (grade V complication according to Clavien). The average number of removed lymph nodes in the RARC group was 15 (10-18). One patient had lymph node metastases. There were no cases of local recurrence. In ORC, the average number of lymph nodes was 16 (11-20), metastases were detected in 2 patients. One of them was subsequently diagnosed with local recurrence. There was no significant difference in the number of lymph nodes removed between two groups. After RARC, 20 (80.0%) patients had complete urinary continence, while 5 patients (20.0%) used 1-2 pads per day. Night continence was preserved in 15 cases (60.0%). After ORC, complete urinary continence was seen in 23 cases (76.7%). Five patients (20.0%) used 1-2 pads per day and two patients (6.7%) used 2-3 pads per day. Night continence after ORC was preserved in 17 cases (56.7%).

RARC is a minimally invasive method of surgical treatment of patients with muscle-invasive bladder cancer. Compared with ORC, a significantly lower rate of complications and blood transfusions is documented, but RARC requires a longer operation time. Both interventions provide the equivalent oncological and functional outcomes, which are in line with published data.