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Introduction: We sought to describe the incidence, risk factors, and survival outcomes associated with pathologic upstaging from non-muscle invasive bladder cancer (NMIBC) to muscle invasive bladder cancer (MIBC) after robot-assisted radical cystectomy (RARC). Methods: We reviewed the International Robotic Cystectomy Consortium database between 2004 and 2020. Upstaging was defined as ≥pT 2 or pathologic node positive (pN+) at final pathology analysis from clinical 2 N 0 M 0 . Descriptive statistics were used to summarize data. Cochran-Armitage test was used to depict upstaging trend over time. Multivariate regression models were used to depict variables associated with upstaging. Kaplan-Meier curves were used to describe disease-specific survival (DSS), recurrence-free survival (RFS), and overall survival (OS). Results: A total of 463 patients underwent RARC for NMIBC. Upstaging occurred in 145 (31%) patients. Upstaged patients were older (70 vs 67 years, p  < 0.01), more likely to have American Society of Anesthesiologists (ASA) score (≥3; 55% vs 44%, p  = 0.04), and had higher rate of preoperative hydronephrosis (26% vs 10%, p  < 0.01). They were more likely to have positive surgical margins (10% vs 3%, p  = 0.01), recurrences (28% vs 9%, p  < 0.01), and to receive adjuvant/salvage treatment (26% vs 3%, p  < 0.01). On multivariate analysis, upstaging was associated with older age (odds ratio [OR] 1.04; confidence interval [CI] 1.01-1.07, p  < 0.01), cT 1 vs cTis (OR 4.25; CI 1.57-11.48, p  < 0.01), cT 1 vs cTa (OR 2.92; CI 1.40-6.06, p  < 0.01), and preoperative hydronephrosis (OR 3.18; CI 1.60-6.32, p  < 0.01). Upstaged patients had worse 5-year RFS (53% vs 85%, log rank p  < 0.01), DSS (66% vs 93%, log rank p  < 0.01), and OS (49% vs 74%, log rank p  < 0.01). The rate of upstaging did not significantly change over time (38% in 2004 to 27% in 2019, p  = 0.17). Conclusion: Upstaging to MIBC occurred in a significant proportion of patients after RARC for NMIBC and was associated with worse survival outcomes. Older patients, those with cT 1 disease and hydronephrosis were more likely to upstage.

Objective: To compare the perioperative outcomes of intracorporeal (ICUD) vs extracorporeal urinary diversion (ECUD) after robot-assisted radical cystectomy (RARC)., Patients and Methods: We retrospectively reviewed the prospectively maintained International Robotic Cystectomy Consortium (IRCC) database. A total of 972 patients from 28 institutions who underwent RARC were included. Propensity score matching was used to match patients based on age, gender, body mass index (BMI), American Society of Anesthesiologists Score (ASA) score, Charlson Comorbidity Index (CCI) score, prior radiation and abdominal surgery, receipt of neoadjuvant chemotherapy, and clinical staging. Matched cohorts were compared. Multivariate stepwise logistic and linear regression models were fit to evaluate variables associated with receiving ICUD, operating time, 90-day high-grade complications (Clavien-Dindo Classification Grade ≥III), and 90-day readmissions after RARC., Results: Utilisation of ICUD increased from 0% in 2005 to 95% in 2018. The ICUD patients had more overall complications (66% vs 58%, P = 0.01) and readmissions (27% vs 17%, P = 0.01), but not high-grade complications (21% vs 24%, P = 0.22). A more recent RC era and ileal conduit diversion were associated with receiving an ICUD. Higher BMI, ASA score ≥3, and receiving a neobladder were associated with longer operating times. Shorter operating time was associated with male gender, older age, ICUD, and centres with a larger annual average RC volume. Longer intensive care unit stay was associated with 90-day high-grade complications. Higher CCI score, prior radiation therapy, neoadjuvant chemotherapy, and ICUD were associated with a higher risk of 90-day readmissions., Conclusions: Utilisation of ICUD has increased over the past decade. ICUD was associated with more overall complications and readmissions compared to ECUD, but not high-grade complications., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)

Purpose: We sought to investigate the prevalence and variables associated with early oncologic failure., Materials and Methods: We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot-assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot-assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan-Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival., Results: A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38-5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00-6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21-3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001)., Conclusions: The incidence of early oncologic failure following robot-assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot-assisted radical cystectomy., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the emerging role of robotic-assisted radical cystectomy (RARC) in the management of bladder cancer., Methods: Review of the published literature on robotic-assisted radical cystectomy, including data from our cystectomy series of 30 patients., Results: Nearly 150 procedures have been performed worldwide. The benefits of robotic-assisted operations are similar to those of laparoscopically-performed procedures. RARC appears to be technically safe, oncologically and functionally equivalent to open (ORC) and laparoscopic radical cystectomy (LRC). However, RARC offers superior ergonomics and better vision. These benefits come at extra initial capital expenditure and subsequent higher maintenance costs., Conclusion: With the rapid spread of robotics, it is likely that RARC will become the standard of care in units with access to the technology.

Background: The use of robotic technology for laparoscopic prostatectomy is now well established. The same cannot yet be said of robotic-assisted laparoscopic radical cystectomy (RARC), which is performed in just a few centres worldwide., Objective: We present our technique and experience of this procedure using the da Vinci surgical system., Design, Setting, and Participants: From 2004 to 2007, 23 patients underwent RARC and urinary diversion at our institution., Surgical Procedure: We report the development of our technique for RARC, which involves posterior dissection, lateral pedicle control, anterior dissection, and lymphadenectomy prior to either ileal conduit urinary diversion or Studer pouch reconstruction performed extracorporeally., Measurements: Demographic and perioperative data were recorded prospectively. Oncologic and functional outcomes were assessed at 3- to 6-mo intervals., Results and Limitations: To date, 23 patients have undergone this procedure at our institution. Of those, 19 had ileal loop urinary diversion and 4 were suitable for Studer pouch reconstruction. Mean total operative time plus or minus (+/-) standard deviation (SD) was 397+/-83.8min. Mean blood loss +/-SD was 278+/-229ml with one patient requiring a blood transfusion. Surgical margins were clear in all patients with a median +/-SD of 16+/-8.9 lymph nodes retrieved. The complication rate was 26%. At a mean follow-up +/-SD of 17+/-13 (range 4-40) mo, one patient had died of metastatic disease and one other is alive with metastases. The remaining 21 patients are alive without recurrence., Conclusions: RARC remains a procedure in evolution in the small number of centres carrying out this type of surgery. Our initial experience confirms that it is feasible with acceptable morbidity and good short-term oncologic results.