How can we reduce morbidity after robot‐assisted radical cystectomy with intracorporeal neobladder? A report on postoperative complications by the European Association of Urology Robotic Urology Section Scientific Working Group

摘要

Robot-assisted radical cystectomy (RARC) is a technically challenging procedure associated with high overall postoperative morbidity [1, 2]. Relative to other forms of urinary diversion, neobladder reconstruction is associated with a higher complication rate [3]. As low morbidity represents one of the pivotal surgical outcomes, efforts must be focused on minimizing the morbidity rate. To achieve this goal, it is crucial to understand the most common complications associated with RARC to allow surgeons to take action to prevent their occurrence. To the best of our knowledge, only a few studies have evaluated the type of complications that may occur after RARC with intracorporeal neobladder, and the generalizability of their results is limited [1-5]. Previous studies have reported complications from small single-institution or single-surgeon series of patients who underwent RARC with either extracorporeal or intracorporeal neobladder, or did not use standardized criteria to report complications [6]. The present study aimed to characterize the type of complications occurring after RARC with intracorporeal neobladder in order to improve peri-operative management, highlight areas of need for future studies and, ultimately, reduce RARC morbidity. On behalf of the European Association of Urology (EAU) Robotic Urology Section Scientific Working Group, we created a multi-institutional database of 980 patients who underwent RARC and intracorporeal neobladder at 16 high-volume European centres between 2003 and 2022. All patients with incomplete information on postoperative outcomes were excluded. Our final population included 858 individuals. The surgical technique was previously described [7]. Postoperative outcomes were collected according to the EAU recommendations (11/14 criteria; Table S1) [6]. Complications were scored using the Clavien–Dindo classification system, grouped by type and severity (severe: Clavien–Dindo score ≥3), and divided into early (<30 days) and late (31–90 days). We compared the type of complication between patients who received and those who did not receive neoadjuvant therapy (nadjT) using Fisher's exact test. Finally, by using a multivariable logistic regression model, we evaluated if the rate of complications was associated with amount of surgical experience of each centre (coded as the total number of RARCs with intracorporeal neobladder performed in that centre before the patient operation) or operating time after accounting for potential confounders (age, body mass index [BMI], American Society of Anesthesiologists [ASA] score, sex, preoperative T stage, and nadjT). The majority of patients were male (87%), healthy (76% had an ASA score ≤2), and had muscle-invasive tumours (55%; Table S2). The median (interquartile range [IQR]) age at surgery and median (IQR) BMI were 64 years (58, 69) years and 26 (23.8, 28.4) kg/m2, respectively. Almost all patients underwent pelvic lymphadenectomy (98%). The neobladder reconstruction technique was the Studer/Wiklund in 557 patients (65%), S pouch in 16 (1.9%), Gaston in 163 (19%), vescica ileale Padovana in 102 (12%) and Hautmann in 20 (2.3%). The median (IQR) operating time was 366 (300, 440) min and the urinary diversion time was 166 min. The median (IQR) length of stay was 10 (7, 15) days (Table S3). Overall, 514 (60%) and 223 patients (26%) experienced at least one complication and at least one severe complication within 3 months, respectively. One patient died within 1 month due to a complication (sepsis), and six patients died between 2 and 3 months after surgery (two from thromboembolic events, one from sepsis and three from cancer progression). Overall, 13 (1.5%) and 28 patients (3%) required intra-operative and postoperative blood transfusion, respectively. The rate of complications was highest in the first month post-surgery (early 52% vs late 20%). UTI was the most common complication at both time points (early: 20%, late: 10%; Fig. 1, Table S4). The most co