Complications after robot-assisted radical cystectomy with urinary diversion: New approach same old foe

Roughly, 25% of patients who have radical cystectomy will experience a major complication event within the first 3 months to a year from this procedure and there is a 2% mortality rate that increases to about 5% by the eighth decade of life. Mortality rates are affected by how frequently a radical cystectomy with urinary diversion is performed at a given hospital and by whom. Morbidity events are most often related to the urinary reconstruction, such as urinary tract infections (UTIs), pyelonephritis, urinary leaks, strictures of the ureter, and chronic renal failure. Long-term studies have not demonstrated a plateau effect, and consequently delayed complications remain possible for the diverted patient. A positive surgical margin may also be considered a complication, as subsequent radiation and/or chemotherapy does not appear to salvage these cases. Case series from a handful of expert centers (i.e., level 4 evidence) have only demonstrated comparable complication rates (20–30%) for robot-assisted radical cystectomy (RARC) compared to open approaches. Therefore, despite its minimally invasive potential, we must limit our expectations and biases that robotics will reduce the high rates from the gold standard open surgery. The lack of overwhelming patient-driven self-selection toward robotics (unlike for prostate cancer) may allow the environment for a properly conduced randomized clinical trial to demonstrate a difference in effectiveness – either with duration of recovery, and/or the impact of complications.