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Miller et al. Mini-invasive Surg 2021;5:24 https://dx.doi.org/10.20517/2574-1225.2021.25 Page 9 of 12

Retrospective non-comparative results from the IRCC on patients with long-term follow up show RFS, CSS
[27]
and OS at 10 years were 59%, 65% and 35%, consistent with historical ORC and MIS cohorts . Not
surprisingly, in multivariable models, they found that survival was associated with age, positive margins,
tumor/nodal stage, and adjuvant treatments. Similar results are described in a multicenter study among
RARC patients with totally intracorporeal urinary diversion . A single institutional comparative study also
[26]
showed similar survival in a totally intracorporeal urinary diversion robotic cohort when compared with
ORC .
[18]

Matured, long-term survival data from randomized controlled studies, including RAZOR, are further
anticipated. Early and intermediate survival outcomes between RARC and ORC appear to be similar. Since
no consistent difference in PSM rates or recurrence patterns have been found in the literature, we expect
long-term survival differences to be driven largely by factors related to disease aggressiveness including
stage and need for adjuvant therapies, rather than surgical approach.

FUTURE PERSPECTIVES
[3]
Nearly 20 years after the robotic approach to radical cystectomy was described . RARC remains an effective
and minimally invasive option for patients undergoing cystectomy that can achieve oncologic outcomes
that are comparable to the gold standard open approach. Evidence-based consensus and best practices on
RARC are available .
[34]

There are no absolute contraindications to the robotic approach, but an early learning curve is recognized
and several challenging case scenarios (e.g., large bulky tumors, history of pelvic radiation) should be
preferentially managed by experienced robotic surgeons. RARC can be safely utilized in the octogenarian ,
[48]
and oncologic outcomes are excellent in sex-sparing techniques in the female patient as well as male
[49]
[50]
patient . Excellent pathologic outcomes have been described for aggressive histopathological variants
which are known to present with higher tumor stage . The usage of the robotic approach to cystectomy
[51]
will continue to increase as urologic surgeons become more experienced and comfortable with the platform
and education becomes more commonplace in residency training programs .
[4]
Though the current evidence is well-supported, it is limited by the lack of large, randomized controlled
trials. We eagerly anticipate more mature, high-quality data comparing oncologic outcomes of open and
robotic cystectomy. Robot-assisted radical cystectomy with intracorporeal urinary diversion vs. open radical
cystectomy (iROC) is a multicenter prospective RCT in England randomizing 320 patients to iRARC or
ORC. Accrual finished in February 2020, and oncologic outcomes of interest include atypical recurrence
patterns, survival, as well as outcomes related to surgeon fatigue, cost-effectiveness and patient quality of
life .
[52]

CONCLUSION
Surgical quality indicators, including lymph node yield and positive surgical margin rate, are comparable
between ORC and RARC. Despite an early case series of atypical recurrence patterns, contemporary
comparative studies, including the largest randomized controlled trial, as well as a multi-institutional
retrospective robotic cohort of > 2000 consecutive patients, show this is a rare occurrence and not associated
with surgical approach. Survival outcomes appear to be similar as well, including long term survival from
several comparative and non-comparative reports. Ultimately, surgeon comfort with the selected approach
and adherence to oncologic principles is more important than the approach itself.