Long-term Oncologic Outcomes Following Robot-assisted Radical Cystectomy: Results from the...

EURURO-6180; No. of Pages 8

Bladder Cancer

Long-term Oncologic Outcomes Following Robot-assisted Radical

Cystectomy: Results from the International Robotic Cystectomy

Consortium

Syed Johar Raza a, Timothy Wilson b, James O. Peabody c, Peter Wiklund d, Douglas S. Scherr e,Ali Al-Daghmin a, Shiva Dibaj a, Muhammad Shamim Khan f, Prokar Dasgupta f,Alex Mottrie g, Mani Menon c, Bertram Yuh b, Lee Richstone h, Matthias Saar i, Michael Stoeckle i,Abolfazl Hosseini d, Jihad Kaouk j, James L. Mohler a, Koon-Ho Rha k, Gregory Wilding a,Khurshid A. Guru a,*

a Roswell Park Cancer Institute, Buffalo, NY, USA; b City of Hope and Beckman Research Institute, Duarte, CA, USA; c Henry Ford Health System, Detroit, MI,

USA; d Karolinska University Hospital, Stockholm, Sweden; e Weill Cornell Medical College, New York, NY, USA; f Guy’s and St Thomas’s Hospital, London, UK;g Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium; h Arthur Smith Institute for Urology, New Hyde Park, NY, USA; i University Clinics of Saarland, Homburg,

Germany; j Cleveland Clinic Foundation, Cleveland, OH, USA; k Yonsei University Health Systems Severance Hospital, Seoul, Korea

E U R O P E A N U R O L O G Y X X X ( 2 0 1 5 ) X X X – X X X

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Article info

Article history:Accepted April 14, 2015Associate Editor:James Catto

Keywords:

Robot-assisted

Robotic

Radical cystectomy

Outcomes

Survival

Bladder cancer

Recurrence

Abstract

Background: Long-term oncologic data on patients undergoing robot-assisted radical cystec-tomy (RARC) are limited and based largely on single-institution series.Objective: Report survival outcomes of patients who underwent RARC �5 yr ago.Design, setting, and participants: Retrospective review of the prospectively populated Inter-national Robotic Cystectomy Consortium multi-institutional database identified 743 patientswith RARC performed �5 yr ago. Clinical, pathologic, and survival data at the latest follow-upwere collected. Patients with palliative RARC were excluded. Final analysis was performed on702 patients from 11 institutions in 6 countries.Intervention: RARC.Outcome measurements and statistical analysis: Outcomes of interest, recurrence-free sur-vival (RFS), cancer-specific survival (CSS), and overall survival (OS) were plotted using Kaplan-Meier survival curves. A Cox proportional hazards model was used to identify factors thatpredicted outcomes.Results and limitations: Pathologic organ-confined (OC) disease was found in 62% of patients.Soft tissue surgical margins (SMs) were positive in 8%. Median lymph node (LN) yield was 16,and 21% of patients had positive LNs. Median follow-up was 67 mo (interquartile range: 18–84mo). Five-year RFS, CSS, and OS were 67%, 75%, and 50%, respectively. Non-OC disease and SMswere associated with poorer RFS, CSS, and OS on multivariable analysis. Age predicted poorerCSS and OS. Adjuvant chemotherapy and positive SMs were predictors of RFS (hazard ratio:3.20 and 2.16; p < 0.001 and p < 0.005, respectively). Stratified survival curves demonstratedpoorer outcomes for positive SM, LN, and non-OC disease. Retrospective interrogation and lackof contemporaneous comparison groups that underwent open radical cystectomy were majorlimitations.Conclusions: The largest multi-institutional series to date reported long-term survival out-comes after RARC.Patient summary: Patients who underwent robot-assisted radical cystectomy for bladdercancer have acceptable long-term survival.

soc

. Department of Urology, Roswell Park Cancer Institute, Elm and Carlton63, USA. Tel. +1 716 845 3389; Fax: +1 716 845 3300.

# 2015 European As

* Corresponding authorStreets, Buffalo, NY 142
E-mail address: khurshid.gu
Please cite this article in press as: Raza SJ, et al. Long-term OncolResults from the International Robotic Cystectomy Consortium. Eu

http://dx.doi.org/10.1016/j.eururo.2015.04.0210302-2838/# 2015 European Association of Urology. Published by Elsevier

iation of Urology. Published by Elsevier B.V. All rights reserved.

[email protected] (K.A. Guru).

ogic Outcomes Following Robot-assisted Radical Cystectomy:r Urol (2015), http://dx.doi.org/10.1016/j.eururo.2015.04.021

B.V. All rights reserved.

http://dx.doi.org/10.1016/j.eururo.2015.04.021

mailto:[email protected]



Table 1 – Patient characteristics and operative and pathologicfindings

Characteristic Result

Patient characteristics

Age, yr, median (IQR) 69 (61–76)

Gender, male, n (%) 569 (82)

BMI, median (IQR) 26.6 (24–30)

ASA score >2, n (%) 273 (47)

Neoadjuvant chemotherapy, yes, n (%) 94 (15)

Operative data

Overall operative time, median (IQR) 438 (360–515)

Estimated blood loss, median (IQR) 400 (250–600)

Pathologic data

Positive soft tissue margins, yes, n (%) 55 (8)

LN yield, median (IQR) 16 (10–24)

Positive LNs, yes, n (%) 137 (21)

pT stage, n (%)*

pT0 116 (17)

pIS 78 (11)

pT1 80 (12)

pT2 148 (22)

pT3 197 (29)

pT4 60 (9)

pN stage, n (%)

N0 484 (75)

N1 54 (8)

N2–3 83 (13)

Nx 27 (4)

Adjuvant chemotherapy, yes, n (%) 134 (24)

Histology, n (%)

Transitional cell 349 (68)

Squamous cell 133 (26)

Adenocarcinoma 21 (4)

Small cell 7 (1)

Sarcomatoid 4 (1)

Extent of LN dissection, n (%)

Standard 30 (4)

Extended 507 (72)

Unknown 138 (20)

None 27 (4)

ASA = American Society of Anesthesiology; BMI = body mass index;

IQR = interquartile range; LN = lymph node.* Percentages may not add up to a total of 100, due to rounding off or due to

missing values.

E U R O P E A N U R O L O G Y X X X ( 2 0 1 5 ) X X X – X X X2


1. Introduction

Recent technological advancements in minimally invasive

surgery have increased the diversity of options for surgical

management of oncologic diseases. Robot-assisted radical

cystectomy (RARC) has been compared with open radical

cystectomy (ORC) in randomized and prospective studies

and appears to reduce operative blood loss and complica-

tions while providing similar early oncologic outcomes [1–

4]. However, ORC and pelvic lymph node dissection (PLND)

remain the gold standard for muscle-invasive or recurrent

noninvasive bladder cancer, since open operation provides

>60% 10-yr recurrence-free survival (RFS) [5,6].

RARC has been criticized for limited reports of long-term

oncologic outcomes [7]. Published series report outcomes

from individual institutions with smaller numbers of

patients, representative of selected patient cohorts [8–

10]. The International Robotic Cystectomy Consortium

(IRCC) has a prospectively populated quality-assurance

database that contains >2000 RARC patients. The IRCC has

reported on learning curve, margin status, lymph node (LN)

yield, and complications [11–14]. The IRCC database was

queried to report the long-term oncologic outcomes for a

large series of patients who underwent RARC.

2. Patients and methods

The study is a retrospective review of the prospectively populated and

maintained, institutional review board–approved (I97906) database.

The IRCC database comprises 2187 patients from 37 institutions in

17 countries who were treated with RARC for clinically localized bladder

cancer from 2003 to date. Overall, 743 patients underwent RARC �5 yr

earlier. Patients with missing pathologic information or palliative RARC

were excluded at the time of analysis.

Primary outcome measures included RFS, cancer-specific survival

(CSS), and overall survival (OS). OS was defined as time from date of

cystectomy to death due to any cause. CSS was defined as the time to

death due to bladder cancer, whereas RFS was defined as time from date

of cystectomy to local and or metastatic recurrence, based on histologic

or radiologic evidence. Patients who were still alive without experienc-

ing the event of interest at their last follow-up date were considered

censored in analyses. Univariable and multivariable analyses were

performed to determine the influence of perioperative factors on the

primary outcome. Considered predictors included age, gender, patho-

logic tumor stage, pelvic LN (PLN) status, soft tissue surgical margins

(SMs), adjuvant chemotherapy, and histology. Tumor grade and

pathologic stage were determined using, respectively, the 2002 Ameri-

can Joint Committee on Cancer TNM staging system and the 2004 World

Health Organization/International Society of Urologic Pathologists

classification of papillary urothelial neoplasms [15]. Positive SM

(PSM) included radial bladder soft tissue margins. Pathologic specimens

were not reviewed at a central pathology facility.

Patients were followed using clinical, radiologic, and pathologic

evaluation, at the treating physician’s discretion. Follow-up data were

entered prospectively in the centralized database, using preset

parameters. Any missing information from any institution was acquired

to generate the most recent and thorough data set possible for this

analysis.

Descriptive analyses consisted of frequencies and relative frequen-

cies for all categorical variables. Numeric variables were summarized

using median and interquartile range (IQR). The estimated distributions

of RSF, CSS, and OS were obtained using the product limit–based


Kaplan-Meier method. The comparison of time-to-event distributions

for groups defined by categorical predictors was done using the log-rank

test. The univariable statistical assessment of numeric predictors was

done using the Cox proportional hazards model. Furthermore, the Cox

proportional hazards model was used in examining the multivariable

associations among RFS, CSS, and OS and considered predictors. Because

the predictive nature of each variable in the presence of the other

considered predictors was of interest, all variables were included in the

multivariable model regardless of univariable results. A nominal

significance level of 0.05 was used throughout, and all analyses were

conducted using SAS version 9.3 (SAS Institute, Cary, NC, USA).

3. Results

Overall, 702 patients were included in the analysis. The

median age was 69 yr (IQR: 61–76 yr), and 569 patients

(82%) were male. Median operative time was 438 min (IQR:

360–515 min). Most of the patients (62%) had pathologic

organ-confined (OC) disease. SMs were positive in 8%.

Median PLN yield was 16 (IQR: 10–24 nodes), and 21% of

PLNs were positive (Table 1).



Table 2 – Recurrence, survival, and follow-up data

Variable Result

Follow-up, mo, median (IQR) 67 (18–84)

Local recurrence, yes, n (%)* 79 (11)

Metastatic recurrence, yes, n (%)* 154 (22)

Time to recurrence, mo, median (IQR) 24 (8–60)

Survival status, alive, n (%) 383 (55)

Time to cancer-specific death, mo, median (IQR) 14 (8–28)

Time to non–cancer-specific death, mo, median (IQR) 10 (4–33)

Time to death, mo, median (IQR) 15 (7–33)

5-yr survival, %

Recurrence-free 67

Cancer-specific 75

Overall 50

IQR = interquartile range.* Includes combined local and metastatic recurrences.

E U R O P E A N U R O L O G Y X X X ( 2 0 1 5 ) X X X – X X X 3


Median follow-up was 67 mo (IQR: 18–84 mo) from the

date of RARC until the time of analysis (Table 2). The overall

recurrence rate was 29%, which included an 11% local

recurrence rate. The median time to cancer-specific and

non–cancer-specific death was 14 and 10 mo, respectively.

RFS, CSS, and OS were 67%, 75%, and 50%, respectively

(Table 2; Fig. 1).

Non–organ-confined (NOC) disease and positive PLNs

predicted RFS, CSS, and OS on multivariate analysis

(Table 3). PSM was associated with RFS only, on multivari-

able analysis. Age affected CSS and OS, whereas adjuvant

chemotherapy was associated with RFS only. The log-rank

test demonstrated better RFS, CSS, and OS for patients with

OC, PLN-negative, and SM-negative disease (Figs. 2 and 3).

4. Discussion

RARC is used increasingly for muscle-invasive and high-

grade recurrent bladder cancer because of consistent

applicability and acceptable perioperative morbidity

[2]. Despite a paucity of long-term oncologic outcomes,

retrospective reports of short- and intermediate-term

outcomes appear to show that RARC provides results

similar to ORC; however, selection bias has been considered

limiting [8–10]. The IRCC database was used to evaluate

whether 5-yr oncologic outcomes for RARC appeared

similar to those reported by many for ORC.

Fig. 1 – Kaplan-Meier recurrence-free, c


The IRCC data demonstrated that 38% patients had NOC

disease, 21% had positive PLNs, and 8% had PSM. At median

follow-up of 67 mo, 11% of patients had developed local

recurrence. The 5-yr CSS was 75%, with median time to

cancer-specific death of 14 mo. Oncologic outcomes of RARC

have been reported but with smaller numbers of patients in

selected cohorts [16]. Recently, a few studies have reported

intermediate- to long-term oncologic outcomes of RARC.

Raza et al [8] reported long-term oncologic outcomes of

99 consecutive RARC patients from a single institution. The

OS was 42% at median follow-up of 73 mo, and 52% patients

had NOC disease. The study reported 8% with PSM, with 5-yr

RFS and CSS of 53% and 68%, respectively. Yuh et al [9]

reported intermediate-term outcomes for 162 RARC

patients over a median follow-up of 52 mo. The study

included a higher number of patients with OC disease (67%)

and lower PSMs and positive PLNs (4.3% and 22%,

respectively). The 5-yr OS, RFS, and CSS were 54%, 74%,

and 80%, respectively. Xylinas et al [10] reported outcomes

for 175 RARC patients over a relatively shorter follow-up of

37 mo. They reported 65% of patients with OC disease, and

5% had PSM. The 5-yr RFS and CSS were 63% and 66%,

respectively. Long-term data from a multicenter European

database of 503 patients undergoing laparoscopic radical

cystectomy (RC) was reported by Albisinni et al [17]. Five-

year RFS, CSS, and OS rates were 66%, 75%, and 62%,

respectively. This study reported poorer outcomes associ-

ated with advanced stage, margin status, and LN involve-

ment; however, the study did not relate preoperative

variables with survival outcomes. The better OS may have

been related to selection of a younger and healthier cohort

(median age: 68 yr; American Society of Anesthesiologists

score <2 in 71% of patients).

Long-term oncologic efficacy of ORC has been well

reported [5,6,18]. Table 4 summarizes and compares the

IRCC results with the key ORC and RARC series results. Stein

et al reported outcomes of 1054 patients in a large single-

institution series and found 68% and 60% 5-yr RFS and OS,

respectively [5]. Non-OC disease and LN metastases were

37% and 23%, respectively. Ghoneim et al reported RFS of

56% at 5 yr in patients with transitional cell carcinoma

[6]. Shariat et al [19] reported outcomes of 888 consecutive

patents with transitional cell carcinoma after ORC in a

ancer-specific, and overall survival.



Table 3 – Univariable and Multi variable analysis of factors associated with recurrence-free, cancer-specific, and overall survival

Variable Univariable Multivariable

Hazard ratio Confidence interval p value Hazard ratio Confidence interval p value

Proportional hazard model for recurrence-free survival

Age 1.01 (1.00–1.02) 0.2 1.00 (0.98–1.02) 0.8

Gender (male vs female) 0.83 (0.58–1.17) 0.29 0.74 (0.50–1.11) 0.1

pT stage (>2 vs � 2) 3.74 (2.77–5.05) <0.001 2.12 (1.43–3.13) 0.0002

LN (positive vs negative) 1.13 (1.10–1.17) <0.001 1.08 (1.02–1.13) 0.003

Margins (positive vs negative) 2.96 (1.93–4.56) <0.001 2.16 (1.27–3.68) 0.005

Adjuvant chemotherapy (yes vs no) 4.59 (3.37–6.25) <0.001 3.20 (2.20–4.66) <0.001

Histology (TCC vs variant) 0.79 (0.55–1.13) 0.2 0.55 (0.37–0.80) 0.002

Proportional hazard model for cancer-specific survival

Age 1.01 (1.00–1.03) 0.09 1.02 (1.00–1.04) 0.03


pT stage (>2 vs � 2) 4.87 (3.34–7.09) <0.001 4.78 (2.91 – 7.86) <0.001

LN (positive vs negative) 1.12 (1.08–1.15) <0.001 1.11 (1.05–1.17) <0.001


Adjuvant chemotherapy (yes vs no) 2.75 (1.90–4.00) <0.001 1.23 (0.77–1.95) 0.4


Proportional hazard model for overall survival

Age 1.02 (1.01–1.03) 0.002 1.02 (1.01–1.04) 0.002


pT stage (>2 vs � 2) 3.40 (2.70–4.27) <0.001 3.60 (2.60–4.98) <0.001

LN (positive vs negative) 1.10 (1.07–1.13) <0.001 1.07 (1.02–1.12) 0.003


Adjuvant chemotherapy (yes vs no) 2.31 (1.78–2.98) <0.001 1.12 (0.80–1.55) 0.5


LN = lymph node; TCC = transitional cell carcinoma.



multi-institutional series. Overall, 43% of patients had NOC

disease and 20% had positive PLNs, with 5-yr RFS and CSS of

58% and 66%, respectively.

The negative impact of tumor stage on oncologic outcome

has been demonstrated by several studies [20,21]. Stein et al

Fig. 2 – Kaplan-Meier (a) recurrence-free and (b) cancer-specific survival estimmargins.


reported 5-yr RFS and OS of 68% and 66%, respectively.

However, substratified analysis of patients with pT3b and

pT4 were associated with 47% and 37% 5-yr RFS, respectively

[5]. In addition to surgical approach, OS and RFS differences

between series could be confounded by many factors like age,

ates, stratified according to pT stage, pN stage, and soft tissue surgical



Fig. 3 – Kaplan-Meier overall survival estimates, stratified according to pT stage, pN stage, and soft tissue surgical margins.



preoperative surgical risks, and thoroughness of the follow-

up protocol seen with current advances in imaging.

A significant body of evidence suggests that an extended

PLND (ePLND) may improve staging, better identify patients

for adjuvant chemotherapy, control micrometastasis, and

improve survival. Abol-Enein et al [21] reported the

beneficial effect of ePLND on survival. The ePLND group,

with a median of 49 LNs removed, had 66% 5-yr CSS

compared with the standard PLND group. The difference in

survival was noted even for patients with LN-positive disease

(node positive in 24%). In the present study, 21% patients had

LN metastasis and a median nodal yield of 16 LNs. Negative

impact of LN metastasis on survival has been well

documented [22]. Shariat et al [19] found that patients with

LN-negative disease had 7-yr RFS and CSS of 66% and 72%,

respectively. Similarly, RFS is negatively affected by LN

metastasis, with 5-yr RFS of only 27% versus 62% for patients

with and without LN metastasis, respectively [6].

Meticulous tumor resection with negative SM is a key

predictor of oncologic outcomes in bladder cancer [23]. The

standards reported by collaborative groups remain the

main criteria for adequate cancer control following

ORC [24]. The IRCC reported outcomes based on these

Table 4 – Comparison of long-term oncologic outcomes among histori

Study Number Duration Follow-up, mo,mean (range)

OCdisease, %

Ghoneim

et al, 2008 [6]

2720/O 1970–2000 66 (0–410) 74

Stein et al, 2001 [5] 1054/O 1971–1997 120 (1–336) 63^

Hautmann

et al, 2012 [18]

1100/O 1986–2009 38 (0–282) 67

Shariat

et al, 2006 [19]

888/O 1984–2003 39* (0.4–183) 57

Xylinas

et al, 2013 [10]

175/R 2004–2011 37 (21–53) 65

Yuh

et al, 2014 [9]

162/R 2004–2010 52* (NR) 67

Raza

et al, 2014 [8]

99/R 2005–2009 40* (12.7–70.8) 49

Current study 702/R 2003–2009 67* (18–84) 62

CSS = cancer-specific survival; NR = not reported; O = open radical cystectomy; OC

assisted radical cystectomy; RFS = recurrence-free survival; TCC = transitional cel* Median.^ Includes pT3a as organ confined.


recommendations, with PSMs of 8% and LN yield of

16. Urologic oncologists are more likely to perform a PLND

in comparison to general urologists while performing RC

(62% vs 23%) [25]. In our series, 72% had an ePLND. Based on

previous study, a majority of IRCC members do not perform

PLND above the inferior mesenteric artery and presacral

regions [13]. PSM rates should be <15% for locally advanced

tumors and <20% for salvage RC. IRCC results compare

favorably with a multi-institutional study for 4410 patients

by Novara et al [23], who reported PSM rates of 4.1% for OC

disease and 12% for NOC disease (7.7% and 24% for pT3 and

pT4, respectively). In IRCC data, PSM did not independently

predict CSS and OS. On the contrary, Dotan et al [26]

demonstrated PSM as an independent predictor of local

disease relapse, distant metastasis, and CSS. In IRCC data,

5-yr RFS for NOC and PLN-negative disease and for

SM-negative patients was approximately 80% and 70%,

respectively (Fig. 2). Similar benefit was noted for CSS and

OS (Figs. 2 and 3). These findings reiterate that pathologic

factors drive outcomes for both RARC and ORC.

SWOG emphasizes the need for good surgical technique

and the benefits of favorable pathology for better outcomes

[25]. In this study of muscle-invasive disease only, 9% had

cal open and robot-assisted radical cystectomy series

Non-TCC,%

PLNyield

pN+,%

Neoadjuvantchemotherapy, %

RFS,%

CSS,%

OS,%

64 NR 20 NR 56 NR NR

0 NR 23 5 68 NR 66

0 18 18 Excluded 70 71 58

0 20 23 5 58 66 NR

4 19 17 23 63 66 NR

0 28 22 23 74 80 54

NR 21 30 6 53 68 42

32 16 21 15 67 75 50

= organ confined; OS = overall survival; PLN = pelvic lymph node; R = robot-

l carcinoma.



Table 5 – Site of recurrence and related pathologic findings

Recurrence site * n (%) Mean time to recurrence. d �pT2, % SM, % LN positive, %

Local 38 (19) 356 85 12 26

Pelvis 23 421 86 14 33

Vagina 4 634 100 0 0

Rectum 2 364 50 0 0

Perineum 5 140 80 0 0

Incision/port site 1 88 100 100 100

Multiple local recurrences 1 230 100 0 0

Other+ 2 153 100 0 50

Distant 121 (63) 458 78 9 46

LNs 27 537 68 8 56

Lung 27 534 73 0 31

Liver 11 506 64 18 36

Bone 23 323 83 4 48

Peritoneum 7 178 100 0 60

Multiple distant recurrences 15 390 85 23 54

Other^ 11 492 100 18 45

GU tract 17 (8) 593 53 0 21

Renal pelvis/ureter 6 736 60 0 0

Urethra 7 490 29 0 29

Anastomotic site 4 434 100 0 50

Combined (local and distant) 18 (10) 422 83 11 44

GU = genitourinary; LN = lymph node; SM = soft tissue surgical margins.* Total recurrences in 200, information on site of recurrence unavailable for 6 patients. In case of overlap, site of first recurrence is reported.** Other: Pubis and penis.^ Other: Cause not mentioned in database for 9, adrenal for 1, mesentery for 1.



no PLND, 37% had node sampling, and 54% had a standard

bilateral PLND. Only 26% had >15 nodes removed. The

recurrence risks reported for patients with disease higher

than pT3, with PSM, and with PLND were 32%, 68%, and 29%,

respectively. A group at the University of Bern found that

only 4% of LNs were situated above the aorta and vena cava

as high as the inferior mesenteric artery [27]. These findings

were based on the use of single photon emission computed

tomography. The authors postulated that only 1 in 100 cys-

tectomy patients may benefit from a superextended LN

dissection up to the inferior mesenteric artery.

The IRCC data showed a higher percentage of distant

metastasis than local recurrences (63% vs 19%), whereas

only seven patients (3.5%) were found to have peritoneal

carcinomatosis (Table 5). Nguyen et al reported their

recurrence experience for RARC and ORC [28]. Extra PLN

metastases (23% vs 15%) and peritoneal carcinomatosis

were more frequent in RARC than in ORC (21% vs 8%),

Table 6 – Number of procedures per year from participating Internati

Year Instituti

A B C D E F

2002 0 0 0 0 0 2

2003 0 0 0 0 0 1

2004 0 0 8 0 3 3

2005 0 2 12 0 5 3

2006 0 16 16 0 4 5

2007 4 1 12 1 11 15

2008 7 2 21 8 16 9

2009 12 11 12 10 19 3

Total 23 32 81 19 58 41

* Alphabetical arrangement, not arranged based on volume, author, or institution


respectively, and were attributed to possible cancer biology

(eight of nine RARC patients with peritoneal carcinomatosis

had disease higher than pT3). Our study included patients

from this group, but these patients may not have been

included in the current analysis, as our last date of

cystectomy was in 2009. The IRCC previously reported its

findings of early oncologic failure and found that 0.4% of

1586 patients had rapid local and port-site metastases

[29]. All of these patients had disease higher than pT2, and

two patients had positive PLNs.

Honma et al [30] found higher T stage (higher than T3–4)

and positive PLNs to be predictors of recurrence while

analyzing recurrence and distant metastasis; however,

concomitant squamous cell carcinoma was the only inde-

pendent predictor of local recurrence. Squamous cell

carcinoma was seen in 26% of our patients, but multivariable

analysis did not predict variant histology as a predictor for

recurrence.

onal Robotic Cystectomy Consortium institutions in the study

on* Total

G H I J K L

0 0 0 0 0 0 2

1 3 0 0 0 0 5

6 1 0 0 1 0 22

1 11 3 0 0 0 37

5 8 32 0 23 0 109

2 13 33 12 35 6 145

8 12 51 13 39 8 194

17 3 39 28 27 7 188

40 51 158 53 125 21 702

authorship.





The present IRCC report is the largest multi-institutional,

multinational series of RARC and reports long-term

oncologic outcomes. The IRCC reports suffer from limita-

tions inherent to retrospective analysis. The IRCC database

is standardized and populates multiple surgeons with

variable experience, institutional operative volume, patient

selection, and reporting bias (Table 6). The majority of

surgeons participating in the IRCC are experienced robotic

surgeons, so IRCC results should not be applied to all

urologic surgeons. Oncologic outcomes from the largest

series of RARC add to the current body of evidence, which

suggests similarity between RARC and ORC.

5. Conclusions

The largest multi-institutional cohort of RARC presents

long-term oncologic outcomes that appear similar to

historical ORC data, which support the need for randomized

trials comparing RARC and ORC.

Author contributions: Khurshid A. Guru had full access to all the data in

the study and takes responsibility for the integrity of the data and the

accuracy of the data analysis.

Study concept and design: Guru, Wilson, Wiklund, Menon, Peabody.

Acquisition of data: Raza, Saar, Stoeckle, Mottrie, Dasgupta, Scherr, Yuh,

Richstone, Kaouk, Hosseini, Rha, Khan.

Analysis and interpretation of data: Raza, Wilding, Guru.

Drafting of the manuscript: Raza, Al-Daghmin, Guru, Mohler.

Critical revision of the manuscript for important intellectual content:

Menon, Wilson, Wiklund, Peabody, Yuh.

Statistical analysis: Dibaj, Wilding.

Obtaining funding: Guru.

Administrative, technical, or material support: Raza.

Supervision: Guru.

Other (specify): None.

Financial disclosures: Khurshid A. Guru certifies that all conflicts of

interest, including specific financial interests and relationships and

affiliations relevant to the subject matter or materials discussed in the

manuscript (eg, employment/affiliation, grants or funding, consultan-

cies, honoraria, stock ownership or options, expert testimony, royalties,

or patents filed, received, or pending), are the following: None.

Funding/Support and role of the sponsor: Funding support was received

from the Vattikuti Foundation Collective Quality Initiative and the

Roswell Park Alliance Foundation. P.D. acknowledges support from the

Medical Research Council Centre for Transplantation, National Institute

for Health Research Biomedical Research Centre, King’s College London-

Vattikuti Institute of Robotic Surgery, Guy’s Hospital, King’s Health

Partners, the Guy’s and St. Thomas’ Charity, and European Union 7th

Framework Programme (EU-FP7), Sponsors were involved in the

collection of the data.

Acknowledgments: The authors acknowledge Lindsay A. Amico for

administrative support.

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