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Page 8 of 12 Miller et al. Mini-invasive Surg 2021;5:24 https://dx.doi.org/10.20517/2574-1225.2021.25

Multiple studies have since demonstrated that recurrence patterns do not differ by surgical approach. The
RAZOR trial found no significant difference between ORC and RARC in recurrence patterns and showed
low overall local recurrence rates (2% vs. 4%). Rare atypical recurrences were also observed in the ORC arm
[7]
and did not differ between approaches . A large non-randomized single center comparative study from
Mayo Clinic in Arizona showed similar rates of local, distant and rare atypical recurrences . An
[16]
institutional report of ~180 cases, 90 of which were robotic with intracorporeal diversion, showed a low rate
of atypical recurrences with no difference between surgical approaches . An IRCC study of 2107 pts
[21]
showed slightly higher local recurrence (11%, citing a greater percentage of extravesical disease and variant
histology in their cohort) with atypical recurrence patterns similar to ORC series and those of the RAZOR
trial [7,25] . A separate IRCC analysis found that tumor factors rather than those related to surgical approach
were predictive of early recurrence after cystectomy and also showed that surgeons in their cohort reported
a very low rate of divergence from oncologic principles . Lastly, a large multi-institutional robotic
[28]
cystectomy and totally intracorporeal urinary diversion cohort from the EAU Robotic Urology Section
Scientific Working Group found that early recurrence rates and patterns appeared comparable to open
series .
[29]
If oncologic principles are followed, these aggregate data suggest that atypical recurrence is exceedingly rare
and are more likely reflective of tumor biology than surgical approach.

SURVIVAL OUTCOMES
The primary measure of treatment efficacy in radical cystectomy is survival, including recurrence-free,
cancer-specific and overall survival . Though reported here for reference, we would discourage direct
[1]
comparison across studies as there is significant heterogeneity with respect to cancer variables (e.g., receipt
of neoadjuvant chemotherapy, disease stage, and tumor histopathology), patient demographic and clinical
characteristics, surgeon and institutional factors including intra-operative practices and post-operative
follow up protocols, adjuvant therapies and length of follow up. This heterogeneity is reflected by a 2015
systematic review of mostly retrospective studies which demonstrated a wide range of 5-year survival
estimates of DFS, CSS and OS between 53%-74%, 66%-80% and 39%-66%, respectively .
[35]

Several contemporary comparative studies do offer additional limited insight, though we are only aware of 3
RCTs that report survival outcomes. RAZOR is the largest RCT reporting survival outcomes at
approximately 150 patients in each arm and reports 3 year outcomes . RARC was similar compared with
[7]
ORC in RFS (68% vs. 65%, P = 0.6) and OS (74% vs. 69%, P = 0.3). Bochner et al. found that a median
[9]
follow up of 4.9 years, no differences were observed in recurrence [hazard ratio (HR) = 1.27; 95%CI: 0.69-
2.36; P = 0.4], cancer-specific survival (P = 0.4), or overall survival (P = 0.8). However, the authors cautioned
that their study was not powered to assess survival outcomes. A meta-analysis with pooled data from these
two studies found that RARC and ORC may result in similar time to recurrence (HR = 1.1; 95%CI: 0.8-1.4),
[37]
but the evidence of certainty was low . More recently, the CORAL study reported 5-year RFS, CSS, OS as
well and found no differences in surgical approaches comparing open vs. robotic vs. laparoscopic
approaches . However, their study was limited by low sample size as only 20 patients were included in each
[8]
arm and included high-risk non-muscle invasive bladder cancer.

Though lacking the rigor of a controlled trial, long-term oncologic outcomes from several robotic cohorts
have recently become available. Faraj et al. reported their 10 year survival outcomes in a single institution
[16]
retrospective comparative study and found that RFS and OS were similar between ORC and RARC
approaches (63% vs. 70%, P = 0.14 and 46% vs. 40%, P = 0.47 respectively). The cohorts were similar in
cancer characteristics, patient demographics and clinical factors as well as intra operative practices.