Rates and Patterns of Recurrences and Survival Outcomes after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium.

PURPOSE: There have been concerns about higher incidence of local and retroperitoneal recurrences after robot-assisted radical cystectomy compared to open radical cystectomy. We report and detail relapses following robot-assisted radical cystectomy using a multinational database. MATERIALS AND METHODS: A retrospective review of the International Robotic Cystectomy Consortium was performed. Data were reviewed for demographics, and perioperative, pathological and oncologic outcomes. Relapse rates and patterns were analyzed. Kaplan-Meier curves were used to depict relapse-free, local recurrence-free, distant metastasis-free and overall survival. Kaplan-Meier curves were further stratified by disease stage, lymph node status and margins. Multivariate stepwise Cox regression models were used to identify variables associated with relapse-free, local recurrence-free, distant metastasis-free and overall survival. RESULTS: Of 2,107 patients 521 (25%) experienced disease relapse. Mean age (SD) was 68±10 years with a median followup of 26 (IQR 11-55) months for the study cohort. Local recurrences were observed in 11% and distant metastases in 18%. Early oncologic failure (within 3 months) occurred in 4% of patients. The most common sites of local recurrence and distant metastasis were the pelvis (5%) and lungs (6%)/extrapelvic lymph nodes (5%), respectively. Abdominal wall/port site metastasis occurred in 1.2% and peritoneal carcinomatosis in 1.2%. Five-year relapse-free, local recurrence-free, distant metastasis-free and overall survival was 66%, 84%, 74% and 60%, respectively. Patients with higher disease stage, positive lymph nodes and positive soft tissue surgical margins demonstrated worse relapse-free, local recurrence-free, distant metastasis-free and overall survival (log rank p <0.01 for all comparisons). Multivariate regression models identified that node positive status and disease stage (pT3 or greater) were significantly associated with relapse-free, local recurrence-free, distant metastasis-free and overall survival (p <0.01). CONCLUSIONS: Disease stage remains the main variable associated with disease relapse and survival following radical cystectomy. Robot-assisted radical cystectomy was not associated with different patterns or higher relapse rates compared to historic open radical cystectomy data.

Prevalence and Predictors of Venous Thromboembolism After Robot-Assisted Radical Cystectomy.

OBJECTIVE: To describe incidence and variables associated with venous thromboembolism (VTE) after robot-assisted radical cystectomy (RARC). METHODS: A retrospective review of the prospectively maintained departmental database was performed. Extended thromboprophylaxis (for 4 weeks postoperatively) was implemented November 2017. Patients were divided into VTE (deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) and non-VTE groups. Baseline demographics, disease characteristics and perioperative outcomes were compared. Cochran-Armitage trend test was used to assess trends of VTE. Multivariate logistic regression was used to identify variables associated with VTE. The Kaplan-Meier method was used to depict recurrence free survival (RFS), disease specific survival (DSS), and overall survival (OS). RESULTS: Twenty nine patients (5%) developed VTE (14 developed DVT and 15 developed PE). Median time to DVT was 28 days and to PE was 23 days after RARC. The rate of VTE remained stable between 2005 and 2020 (P= .99). Patients who developed VTE had significantly higher BMI (31 vs 29, P = .04), had COPD more often (34% vs 14%, P < .01) and had longer median hospital stay (8 vs 7 days, P = .01). Multivariate analysis showed that BMI (odds ratio [OR] 1.05; 95% confidence interval [CI] 1.005-1.10; P = .03), COPD (OR 3.24; 95% CI 1.43-7.30; P < .01),and non-organ confined disease (OR 2.73; 95% CI 1.22-6.11; P = 0.01) were associated with VTE. Kaplan-Meier curves showed that patients who developed VTE exhibited similar RFS (79% vs 64%, P = .28), DSS (90% vs 76%, P = .17), and OS (54% vs 52%, P = .76) at 5 years compared to those who did not develop VTE. CONCLUSION: VTE remains a significant complication after RARC. Higher BMI, COPD, and non-organ confined disease were significantly associated with VTE.

Development and Cross-Validation of a Nomogram for Chronic Kidney Disease Following Robot-Assisted Radical Cystectomy.

Introduction: We sought to identify the factors associated with deterioration of renal functions after robot-assisted radical cystectomy, and to develop a nomogram to detect the probability of progression to chronic kidney disease (CKD). Materials and Methods: A retrospective review of our prospectively maintained database. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-Epidemiology Collaboration creatinine formula utilizing all follow-up creatinine values. CKD was defined as stage 3b (eGFR <45 mL/minute/1.73 m2) based on the National Kidney Foundation classification. Kaplan-Meier curves were used to depict CKD-free survival. A multivariate Cox regression model was used to determine predictors for CKD and to build the perioperative nomogram. Results: The data set comprised 442 patients with a median follow-up of 25 months (12-59). Thirty-seven percent developed CKD at a median of 9 months (4-18). CKD-free survival rates at 1, 3, and 5 years were 75%, 58%, and 50%, respectively. CKD was significantly associated with preoperative eGFR (hazards ratio [HR]: 0.96, 95% confidence interval [CI]: 0.95-0.97, p < 0.01), body mass index (HR: 1.03, 95% CI: 1.01-1.05, p = 0.03), Charlson Comorbidity Index ≥3 (HR: 2.20, 95% CI: 1.35-3.58, p < 0.01), diabetes (HR: 1.59, 95% CI: 1.09-2.31, p = 0.02), 90 days postoperative strictures (HR: 4.04, 95% CI: 1.76-9.30, p < 0.01), 90 days postoperative hydronephrosis (HR: 2.26, 95% CI: 1.34-3.79, p < 0.01), 90 days recurrent urinary tract infection (HR: 1.84, 95% CI: 1.08-3.14, p = 0.02), 90 days acute kidney injury (HR: 1.70, 95% CI: 1.19-2.43, p < 0.01), and node positive disease (HR: 1.94, 95% CI: 1.31-2.86, p < 0.01). A 5-year CKD-free survival nomogram was developed. Conclusion: We have developed and cross-validated a nomogram for detecting CKD-free survival. This nomogram may have a role in counseling and follow up of patients. This study was done after the approval of the IRB committee (I-79606).