Does the use of the robot decrease the complication rate adherent to radical cystectomy? A systematic review and meta-analysis of studies comparing open to robotic counterparts.

Abstract

Introduction Radical cystectomy (RC) is the mainstay of treatment for muscle invasive bladder cancer (MIBC). In 2003 the first robotic RC (RARC) was performed and since then many studies, mainly observational, were conducted to compare robotic and open method. This study aims to assess perioperative outcomes between the two methods, based on pooled data from existing literature. Methods A literature search of articles in English and French language was performed in three databases (Medline, Embase, Cochrane) until 30th of June 2018, as well as in Urology conference programs and reference lists of included studies. Study protocol was registered to PROSPERO (CRD42018103063). Terms robotic, open, radical cystectomy and synonyms were used for searching algorithm. Primary outcome was number of minor and major post-operative complications (Clavien grading system). Risk of bias was assessed with Cochrane tool and Newcastle-Ottava scale. Comparison of continuous outcomes was performed with weighted mean differences, while for dichotomous with odds ratios (OR). Review Manager 5.3 was used. Results 54 studies (5 randomized trials and 49 observational) were eligible, including 29697 patients (6500 in RARC and 23197 in ORC group). Minor complications (grade 1-2) in pooled data of 29 studies were less in RARC group (OR=0.54, 95% C.I.:0.38-0.76, p<0.001), a difference persisting after sensitivity analysis for 30 and 90 days. Major complications (grade 3-5) in 31 studies were less in RARC group (OR=0.78, 95% C.I.:0.65-0.94, p=0.009) but this difference disappeared in 30 days sub analysis. RARC was associated with lower blood transfusion rates (p<0.001), less length of stay (p<0.001), faster return to regular diet (p<0.001) and lower postoperative mortality (p<0.001), but longer operating time. Conclusions RARC appears to be associated with less complications and favoring perioperative outcomes in comparison to open method. Due to the observational nature of most studies, larger randomized trials are needed to confirm these findings.