Evolution of survival outcomes in robot-assisted radical cystectomy over 20 years of experience in a high-volume tertiary robotic center.

BACKGROUND

Radical cystectomy (RC) is the gold standard for muscle-invasive and recurrent high-risk non-muscle-invasive bladder cancer (BCa). Over time, robot-assisted radical cystectomy (RARC) has gained adoption. Despite technological advancements, survival differences may persist between patients treated in earlier versus recent years. This study examines temporal variations in overall survival (OS) among patients undergoing robotic-assisted radical cystectomy (RARC) at a high-volume tertiary robotic center, comparing a historical cohort (2003-2016) with a contemporary one (2017-2024).

METHODS

Data from patients undergoing RARC at AZORG Hospital (Aalst, Belgium) between July 2003 and March 2024 were analyzed. Three experienced surgeons performed all procedures. Baseline characteristics were compared, Kaplan-Meier plots illustrated OS, and Cox regression models evaluated overall mortality (OM). An 18-month landmark analysis minimized immortal time bias.

RESULTS

Overall, 358 BCa patients underwent RARC (53% historical vs. 47% contemporary). The 3-year OS was 85% for the historical cohort vs. 93% for the contemporary cohort (P=0.001). Multivariable Cox regression showed that treatment in the contemporary cohort was an independent predictor of lower OM (hazard ratio [HR]: 0.52, 95% CI: 0.34-0.83; P=0.006), with further reduction after the 18-month landmark analysis (HR: 0.42, 95% CI: 0.19-0.92; P=0.03). Higher pathological T stage (pT3-4) was associated with increased OM before (HR: 3.9, 95% CI: 2.19-6.95; P<0.001) and after landmark analysis (HR: 2.25, 95% CI: 1.08-4.68; P=0.03). Grade 3-4 Clavien-Dindo complications predicted higher OM before (HR: 2.02, 95% CI: 1.27-3.22; P=0.003), but not after landmark analysis (HR: 2.04; 95% CI: 0.99-4.18; P=0.052).

CONCLUSIONS

Patients treated between 2017-2024 had significantly lower OM, with a 50% reduction in mortality risk compared to 2003-2016. Advancements in surgical techniques and perioperative care likely contributed to improved OS. However, pathological T stage remained a strong predictor of OM, highlighting the need for enhanced early detection and disease management despite technological progress.