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BackgroundTo evaluate the perioperative, oncological, and functional outcomes of reproductive organ-preserving radical cystectomy (ROPRC) compared to standard radical cystectomy (SRC) in the treatment of female bladder cancer.MethodsA systematic search was conducted in November 2023 across several scientific databases. We executed a systematic review and cumulative meta-analysis of the primary outcomes of interest, adhering to the PRISMA and AMSTAR guidelines. The study was registered in PROSPERO (CRD42024501522).ResultsThe meta-analysis included 10 studies with a total of 2015 participants. ROPRC showed a significant reduction in operative time and postoperative fasting period compared to SRC (MD − 45.69, 95% CI − 78.91 ~ − 12.47, p = 0.007, and MD − 0.69, 95% CI − 1.25 ~ − 0.13, p = 0.02, respectively). Functional outcomes, both daytime continence rate (OR 4.94, 95% CI 1.53 ~ 15.91, p = 0.008) and nighttime continence rate (OR 5.91, 95% CI 1.94 ~ 18.01, p = 0.002), and sexual function measured by the Female Sexual Function Index (MD 5.72, 95% CI 0.19 ~ 11.26, p = 0.04), were significantly improved in the ROPRC group. There were no significant differences between ROPRC and SRC in terms of estimated blood loss, length of hospital stay, overall postoperative complications, minor complications or major complications. Oncologically, both procedures showed comparable outcomes with no significant differences in positive surgical margins, tumor recurrence rates, overall survival, cancer-specific survival, recurrence-free survival, or progression-free survival.ConclusionsROPRC is a viable and effective alternative to SRC in female bladder cancer patients, offering enhanced functional outcomes and similar oncological safety. These findings suggest that ROPRC can improve the quality of life in female bladder cancer patients without compromising the efficacy of cancer treatment.

Background Accurately assessing the prognosis of bladder cancer patients after radical cystectomy has important clinical and research implications. Current models, based on traditional statistical approaches and complex variables, have limited performance. We aimed to develop a machine learning (ML)-based prognostic model to predict 5-year cancer-specific mortality (CSM) in bladder cancer patients undergoing radical cystectomy, and compare its performance with current validated models. Methods Patients were selected from the Surveillance, Epidemiology, and End Results database and the First Affiliated Hospital of Sun Yat-sen University for model construction and validation. We used univariate and multivariate Cox regression to select variables with independent prognostic significance for inclusion in the model’s construction. Six ML algorithms and Cox proportional hazards regression were used to construct prediction models. Concordance index (C-index) and Brier scores were used to compare the discrimination and calibration of these models. The Shapley additive explanation method was used to explain the best-performing model. Finally, we compared this model with three existing prognostic models in urothelial carcinoma patients using C-index, area under the receiver operating characteristic curve (AUC), Brier scores, calibration curves, and decision curve analysis (DCA). Results This study included 8,380 patients, with 6,656 in the training set, 1,664 in the internal validation set, and 60 in the external validation set. Eight features were ultimately identified to build models. The Light Gradient Boosting Machine (LightGBM) model showed the best performance in predicting 5-year CSM in bladder cancer patients undergoing radical cystectomy (internal validation: C-index = 0.723, Brier score = 0.191; external validation: C-index = 0.791, Brier score = 0.134). The lymph node density and tumor stage have the most significant impact on the prediction. In comparison with current validated models, our model also demonstrated the best discrimination and calibration (internal validation: C-index = 0.718, AUC = 0.779, Brier score = 0.191; external validation: C-index = 0.789, AUC = 0.884, Brier score = 0.137). Finally, calibration curves and DCA exhibited better predictive performance as well. Conclusions We successfully developed an explainable ML model for predicting 5-year CSM after radical cystectomy in bladder cancer patients, and it demonstrated better performance compared to existing models.

Purpose To investigate functional, oncological and complication outcomes in women undergoing robot-assisted cystectomy (RARC) with intracorporeal orthotopic neobladder. Methods From a multi-institutional database, we identified females with bladder cancer treated with RARC and intracorporeal orthotopic neobladder. We evaluated the continence rate, short-term oncological outcomes, and complication rates. Analyses were repeated and stratified by the status of preserving gynecological organs. Results The study involved 146 patients with the median age 60 years (IQR, 51–66 years). Pelvic organ-preserving procedure (POP) was performed in 77 patients (53%). Overall daytime and nighttime continence rates were 54% and 53%, respectively. For POP, the continence rate was 58% for both daytime and nighttime continence. In the non-POP cohort, the continence rate was 50% for daytime and 49% for nighttime continence. Both groups had balanced positive surgical margin rates (5,3% for POP and 4,7% for non-POP). In the whole cohort, high-grade (Clavien-Dindo ≥3) early and late complication rate was 7,5% and 7,5%, respectively. Conclusions Robot-assisted radical cystectomy with intracorporeal orthotopic neobladder in females demonstrate excellent functional and complication outcomes. Pelvic organ-preserving cystectomy enhances urinary continence rates without adversely affecting surgical margins. Orthotopic neobladder in selected women with bladder cancer, along with pelvic organ-preserving cystectomy may be used for improved functional outcomes without compromising oncological results.

Radical cystectomy is the surgical standard for invasive bladder cancer. Robot-assisted cystectomy has been proposed to provide similar oncological outcomes with lower morbidity. We aimed to compare progression-free survival in patients with bladder cancer treated with open cystectomy and robot-assisted cystectomy. The RAZOR study is a randomised, open-label, non-inferiority, phase 3 trial done in 15 medical centres in the USA. Eligible participants (aged ≥18 years) had biopsy-proven clinical stage T1–T4, N0–N1, M0 bladder cancer or refractory carcinoma in situ. Individuals who had previously had open abdominal or pelvic surgery, or who had any pre-existing health conditions that would preclude safe initiation or maintenance of pneumoperitoneum were excluded. Patients were centrally assigned (1:1) via a web-based system, with block randomisation by institution, stratified by type of urinary diversion, clinical T stage, and Eastern Cooperative Oncology Group performance status, to receive robot-assisted radical cystectomy or open radical cystectomy with extracorporeal urinary diversion. Treatment allocation was only masked from pathologists. The primary endpoint was 2-year progression-free survival, with non-inferiority established if the lower bound of the one-sided 97·5% CI for the treatment difference (robotic cystectomy minus open cystectomy) was greater than −15 percentage points. The primary analysis was done in the per-protocol population. Safety was assessed in the same population. This trial is registered with ClinicalTrials.gov, number NCT01157676. Between July 1, 2011, and Nov 18, 2014, 350 participants were randomly assigned to treatment. The intended treatment was robotic cystectomy in 176 patients and open cystectomy in 174 patients. 17 (10%) of 176 patients in the robotic cystectomy group did not have surgery and nine (5%) patients had a different surgery to that they were assigned. 21 (12%) of 174 patients in the open cystectomy group did not have surgery and one (1%) patient had robotic cystectomy instead of open cystectomy. Thus, 302 patients (150 in the robotic cystectomy group and 152 in the open cystectomy group) were included in the per-protocol analysis set. 2-year progression-free survival was 72·3% (95% CI 64·3 to 78·8) in the robotic cystectomy group and 71·6% (95% CI 63·6 to 78·2) in the open cystectomy group (difference 0·7%, 95% CI −9·6% to 10·9%; pnon-inferiority=0·001), indicating non-inferiority of robotic cystectomy. Adverse events occurred in 101 (67%) of 150 patients in the robotic cystectomy group and 105 (69%) of 152 patients in the open cystectomy group. The most common adverse events were urinary tract infection (53 [35%] in the robotic cystectomy group vs 39 [26%] in the open cystectomy group) and postoperative ileus (33 [22%] in the robotic cystectomy group vs 31 [20%] in the open cystectomy group). In patients with bladder cancer, robotic cystectomy was non-inferior to open cystectomy for 2-year progression-free survival. Increased adoption of robotic surgery in clinical practice should lead to future randomised trials to assess the true value of this surgical approach in patients with other cancer types. National Institutes of Health National Cancer Institute.

PurposeThere is no consensus on which items of Enhanced Recovery After Surgery (ERAS) should and should not be implemented in radical cystectomy (RC). The aim of this study is to report current practices across European high-volume RC centers involved in ERAS.MethodsBased on the recommendations of the ERAS society, we developed a survey with 17 questions that were validated by the Young Academic Urologists–urothelial group. The survey was distributed to European expert centers that implement ERAS for RC. Only one answer per-center was allowed to keep a representative overview of the different centers.Results70 surgeons fulfilled the eligibility criteria. Of note, 28.6% of surgeons do not work with a referent anesthesiologist and 25% have not yet assessed the implementation of ERAS in their center. Avoiding bowel preparation, thromboprophylaxis, and removal of the nasogastric tube were widely implemented (> 90%application). On the other hand, preoperative carbohydrate loading, opioid-sparing anesthesia, and audits were less likely to be applied. Common barriers to ERAS implementation were difficulty in changing habits (55%), followed by a lack of communication across surgeons and anesthesiologist (33%). Responders found that performing a regular audit (14%), opioid-sparing anesthesia (14%) and early mobilization (13%) were the most difficult items to implement.ConclusionIn this survey, we identified the ERAS items most and less commonly applied. Collaboration with anesthesiologists as well as regular audits remain a challenge for ERAS implementation. These results support the need to uniform ERAS for RC patients and develop strategies to help departments implement ERAS.

Purpose We aimed to evaluate perioperative complications of radical cystectomy (RC) by using standardized methodology. Additionally, we identified independent risk factors associated with perioperative complications. Materials and methods We retrospectively analyzed 30-day and 90-day perioperative complications of 211 consecutive RC patients. The intraoperative and postoperative complications were defined according to Clavien-Dindo classification (CDC) and reported based on the ICARUS criteria, Martin, and EAU quality criteria. Age-adjusted Charlson comorbidity index (ACCI), systemic inflammatory response index (SIRI), body mass index (BMI) ≥ 25 kg/m 2 , and neoadjuvant chemotherapy (NAC) were also evaluated. Multivariable regression models according to severe ( CDC ≥ IIIb grade) complications were tested. Results Overall, 88.6% (187/211) patients experienced at least one intraoperative complication. Bleeding during cystectomy was the most common complication observed (81.5% [172/211]). Severe intraoperative complications (EAUiaiC grade > 2) were recorded in 8 patients. Overall, 521 postoperative complications were recorded. Overall, 69.6% of the patients experienced complications. Thirty-nine patients suffered from most severe ( CDC ≥ IIIb grade) complications. ACCI ( OR : 1.492 [1.144–1.947], p = 0.003), SIRI ( OR : 1.279 [1.029–1.575], p = 0.031), BMI ( OR : 3.62 [1.58–8.29], p = 0.002), and NAC ( OR : 0.342 [0.133–0.880], p = 0.025) were significant independent predictive factors for 90-day most severe complications ( CDC ≥ IIIb grade). Conclusions RC complications were reported within a standardized manner, concordant with the ICARUS and Martin criteria and EAU guideline recommendations. Complication reporting seems to be improved with the use of standard methodology. Our results showed that ACCI, SIRI, and BMI ≥ 25 kg/m 2 and the absence of NAC were significant predictive factors for most severe complications.

Purpose Even though there isn't enough clinical evidence to demonstrate that robot-assisted radical cystectomy (RARC) is preferable to open radical cystectomy (ORC), RARC has become a widely used alternative. We performed the present study of RARC vs ORC with a focus on oncologic, pathological, perioperative, and complication-related outcomes and health-related quality of life (QOL). Methods We conducted a literature review up to August 2022. The search included PubMed, EMBASE and Cochrane controlled trials register databases. We classified the studies according to version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). The data was assessed by Review Manager 5.4.0. Results 8 RCTs comparing 1024 patients were analyzed in our study. RARC was related to lower estimated blood loss (weighted mean difference (WMD): -328.2; 95% CI -463.49—-192.92; p  < 0.00001), lower blood transfusion rates (OR: 0.45; 95% CI 0.32 – 0.65; p  < 0.0001) but longer operation time (WMD: 84.21; 95% CI 46.20 -121.72; p  < 0.0001). And we found no significant difference in terms of positive surgical margins ( P  = 0.97), lymph node yield ( P  = 0.30) and length of stay ( P  = 0.99). Moreover, no significant difference was found between the two groups in terms of survival outcomes, pathological outcomes, postoperative complication outcomes and health-related QOL. Conclusion Based on the present evidence, we demonstrated that RARC and ORC have similar cancer control results. RARC is related to less blood loss and lower transfusion rate. We found no difference in postoperative complications and health-related QOL between robotic and open approaches. RARC procedures could be used as an alternate treatment for bladder cancer patients. Additional RCTs with long-term follow-up are needed to validate this observation.

Background This study describes the construction of an anti-reflux neobladder using an ileum valve-pouch (IVP) and compares its efficacy with that of the modified Studer-pouch (MSP). Methods This study included a total of 127 patients who underwent radical cystectomy + neobladder construction (IVP: n  = 66; MSP = 61) between January 2015 and June 2023 at two major medical centers in our city. Potential bias was reduced by 1:1 propensity score matching (PSM) to compare oncology, complications, and renal function protection between the two groups. The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. Survival was assessed using Kaplan–Meier analysis. Results The median follow-up time was 44.5 and 35.5 months in the IVP and MSP groups, respectively. After propensity scoring, 84 patients (42 in each group) were included in the analysis.There was no significant statistical difference in the operation time( p  = 0.128) and the time of urinary diversion ( p  = 0.354) between the two groups.Kaplan–Meier curves showed no significant differences in cancer-specific survival (CSS) ( p  = 0.181) and overall survival (OS) ( p  = 0.611) between the two groups. In addition, the total complications and renal function were not statistically different between the two groups ( p  > 0.05). The incidence of patients who needed to be re-hospitalized due to urinary tract infection was lower in the VIP group than in the MSP group ( p  = 0.039). At 12 months postoperatively, lower rates of decreased eGFR and renal function damage were observed in the IVP group compared to the MSP group ( p  = 0.031 and < 0.001), which were significantly related to the type of neobladder ( p  = 0.004) and preoperative eGFR values ( p  < 0.001). Conclusion The preliminary results of VIP technique are safe and effective. It does not increase the time of anti-reflux construction. The incidence of complications similar in the two groups. However, the protection of renal function at 12 months after surgery seemed to be superior to MSP.The independent factors affecting renal function damage are neobladder type and preoperative eGFR.

Objective To evaluate and compare the long-term oncologic outcomes and perioperative performance of extraperitoneal laparoscopic radical cystectomy (ELRC) versus transperitoneal laparoscopic radical cystectomy (TLRC) in patients with bladder cancer (BC). Patients and methods This retrospective single-center cohort study included 298 BC patients who underwent ELRC ( n  = 202) or TLRC ( n  = 96) between January 2020 and January 2025. Primary endpoints included overall survival (OS), cancer-specific survival (CSS), progression-free survival (PFS), and recurrence-free survival (RFS). Secondary endpoints were operative time, estimated blood loss, gastrointestinal recovery, and perioperative complications. Kaplan–Meier survival analysis, Cox regression, and subgroup analysis were used to evaluate outcomes and risk factors. Results The mean follow-up was 25.6 months for ELRC and 30.7 months for TLRC. There were no significant differences in projected OS (HR = 0.89, P  = 0.562), CSS (HR = 0.87, P  = 0.492), PFS (HR = 1.09, P  = 0.693), or RFS (HR = 1.16, P  = 0.453) between the two groups. ELRC was associated with significantly shorter operative time, less blood loss, faster gastrointestinal recovery, and lower incidence of ileus and infections (all P  < 0.05). Multivariable analysis identified pathological T stage and ASA score as independent predictors of OS. Subgroup analysis showed no significant impact of urinary diversion type or tumor stage on survival outcomes between the two approaches. Conclusion LRC may be a feasible alternative to TLRC, with potential advantages in perioperative recovery and reduced postoperative complications, while demonstrating comparable oncologic outcomes. Prospective multicenter studies with longer-term follow-up are warranted to confirm these findings.

One of the most complex surgeries including radical cystectomy (RC) has a high rate of morbidity. The standard approach for the muscle-invasive bladder is conventional transperitoneal radical cystectomy. However, the procedure is associated with significant morbidities like ileus, urinary leak, bleeding, and infection. The aim of this study is to compare the transperitoneal RC approach with the extraperitoneal RC approach in the treatment of bladder cancer patients. The outcomes of this study are Operative time, Estimated Blood Loss, Hospital Stay, Post-Operative Ileus, Infection, and Major Complication (Clavien-Dindo Grade 3-5). PubMed, Cochrane Library, and Science Direct were systematically searched for different publications related to the meta-analysis. Keywords used for searching were Radical Cystectomy AND Extraperitoneal AND Transperitoneal up until 31st August 2022. The studies were screened for our eligibility criteria. Demographic parameters, perioperative variables, and postoperative complications were recorded and analyzed. The Newcastle-Ottawa Scale was used to evaluate the risk of bias in each study. The Review Manager (RevMan) software version 5.4.1 was used for statistical analysis. Eight studies (3 laparoscopic and 5 open methods) involving 1207 subjects (588 patients using the extraperitoneal approach and 619 using the transperitoneal approach) were included. The incidence of postoperative ileus is significantly lower after the extraperitoneal approach compared to the transperitoneal approach (p < 0.00001). The two techniques did not differ in operative time, estimated blood loss, duration of hospital stay, total infection, and major complication events. This meta-analysis shows that extraperitoneal radical cystectomy benefits in terms of reduced postoperative ileus.