Robotic versus open radical cystectomy: factors influencing approach Selection, predictors of surgical Conversion and...

BACKGROUND: Robot-assisted radical cystectomy (RARC) use for bladder cancer (BC) treatment is increasing, offering similar oncologic outcomes to open radical cystectomy (ORC) with better perioperative results. We assessed factors driving RARC selection, predictors of conversion to open surgery, and impacts on mortality and morbidity. METHODS: We retrospectively analyzed the National Cancer Database (NCDB) (2010–2021) for patients with localized BC undergoing RARC versus ORC. Proportions in approach use were assessed, and multivariable logistic regression identified predictors of approach selection. RARC conversion rates and conversion predictors were analyzed. 30-/90-day mortality and 30-day readmission were compared between converted and non-converted cases using adjusted odds ratios (aOR) and 95% confidence intervals (CI). RESULTS: Among 29,215 patients with localized BC, 9,954 (34.1%) underwent RARC. Usage rose from 18.1% in 2010 to 48.7% in 2021 (p < 0.001), highest in non-muscle invasive BC (NMIBC) (36.0%; p < 0.001). Predictors of RARC adoption over ORC included NMIBC diagnosis (aOR 1.22, 95% CI 1.10–1.35), neoadjuvant chemotherapy (1.49, 1.34–1.66), and private insurance (1.68, 1.32–2.16). RARC usage was less likely for cN2-3 (0.73, 0.61–0.86) and prior radiation (0.60, 0.43–0.85). Among RARC cases, 288 (2.9%) required intraoperative conversion to open surgery. Low-volume centers (< 10 cases: 2.33, 1.66–3.28; 10–19 cases: 1.89, 1.26–2.83) had higher conversion risk. Converted cases had significantly higher 90-day (11.9% vs. 5.1%; 2.53, 1.72–3.72) mortality and 30-day readmission (14.3% vs. 8.5%; 1.79, 1.28–2.51). CONCLUSIONS: RARC use increased, especially in NMIBC cases. Its adoption was driven by NMIBC diagnosis, neoadjuvant chemotherapy, and insurance; low caseload predicted conversion to open surgery and worse outcomes, informing patient selection.