Open vs. robot-assisted radical cystectomy with extracorporeal or intracorporeal urinary diversion for bladder cancer: A pairwise meta-analysis of outcomes and a network meta-analysis of complications by urinary diversion approach

Introduction: There are no meta-analyses of randomized controlled trials (RCTs) comparing open radical cystectomy (ORC) with robot-assisted radical cystectomy (RARC), inclusive of both intracorporeal (iRARC) and extracorporeal (hybrid RARC, hRARC) urinary reconstruction. Methods: MEDLINE, Embase, Scopus, the International Clinical Trials Registry Platform and ClinicalTrials.gov registries were searched in May 2022. Outcomes of interest included recurrence- or progression-free survival (RFS/PFS), margin status and lymph node yield, mean estimated blood loss (EBL) and operating room time (ORT), hospital length of stay (LOS), 90-day complications and readmissions, and quality of life (QoL). Pairwise meta-analyses and network meta-analyses were performed using random-effects models and Bayesian hierarchical random-effects models, respectively. Results: We found no significant differences between RARC and ORC for oncological and most perioperative outcomes: RFS/PFS (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.67–1.23); positive surgical margins (odds ratio [OR] 1.05, 95% CI 0.60–1.85); lymph node yield (mean difference [MD] -0.63, 95% CI -2.63–1.37); LOS (MD -0.22, 95% CI -1.10–0.65); overall complications (OR 0.81, 95% CI 0.61–1.07); major complications (OR 0.94, 95% CI 0.69–1.30); readmissions (OR 0.90, 95% CI 0.60–1.35); and QoL (standardized MD -0.02, 95% CI -0.17–0.14). We found significantly lower EBL for RARC compared to ORC (MD -312.61, 95% CI - 447 to -178.22) at the expense of significantly prolonged ORT (MD 82.34 minutes, 95% CI 44.82–119.86). Network meta-analysis did not find significant differences in complications between hRARC and iRARC. Conclusions: This meta-analysis confirms the equivalence of RARC and ORC with respect to oncological outcomes.