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In 2013, more than 70,000 new cases of bladder cancer will be diagnosed and about 15,000 deaths from the malignancy will occur.1

In men, bladder cancer is the fourth most common malignancy and the most common genitourinary cancer apart from prostate cancer.1 

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Of all the newly diagnosed bladder cancer patients, 25%-30% of them will have muscle-invasive disease that ideally will require major surgery in the form of a radical cystectomy, bilateral pelvic lymphadenectomy, and creation of a urinary diversion as an integral part of their curative therapy.2 

Although an invasive extirpative and reconstructive surgery, radical cystectomy is an effective therapy to treat bladder cancer, but it is associated with significant postoperative morbidity and mortality.

A high-risk population

As with many cancers, bladder cancer is a disease of aging.1,3 Also, bladder cancer, similar to lung cancer, is strongly associated with cigarette smoking. 

Thus, the combination of age and its attendant comorbidities as well as a smoking history and its associated negative health effects on a given patient’s cardiovascular and pulmonary physiology creates an inherently high-risk surgical population undergoing major non-cardiac surgery. 

As such, recent attention has been paid not only to standardizing but also fully compiling the true perioperative risk associated with radical cystectomy and urinary diversion. In a seminal paper from Memorial Sloan-Kettering Cancer Center, the authors from this high-volume referral center reported their perioperative results of 1,142 patients undergoing radical cystectomy.  

In this series, 64% of patients experienced a postoperative complication within 90 days of surgery,4 according to a standardized complication reporting system (Clavien-Dindo classification5). Although the majority of these complications were considered minor, a still not insignificant 13% of all patients experienced a major complication, indicating the need for another procedure, unplanned ICU admission, or death.4 

Other studies using either institutional,6,7population-based,8 or administrative datasets9 have confirmed a similar perioperative complication rate. Furthermore, a recent study from the Mayo Clinic detailed just over a 60% incidence of long-term complications related to a patient’s urinary diversion, indicating the potential chronic morbidity associated with this surgery.10

Robotic vs. open radical cystectomy

Finally, it is worth noting that despite the perception that robotic surgery in general is better tolerated with fewer complications than traditional open surgery for bladder cancer, recently published data from a large robotic consortium appears to contradict this assumption.

In this series of 939 patients from multiple centers, the median hospital stay was eight days, and 448 (48%) patients experienced a complication.11 Furthermore, there was a 20% 90-day readmission rate and a 30- and 90-day post-operative mortality rates of 1.3% and 4.2%, respectively.11

The perioperative morbidity and mortality rates reported in this robotic study are very similar to the reported rates in patients undergoing open radical cystectomy. Importantly, as this study highlights, many patients will incur a complication after the traditional 30-day postoperative time point, and the risk of 90-day mortality after radical cystectomy is strongly associated with increasing age.

For example, in one population-based study, patients younger than 70 years and aged 70-79 years experienced a 2.0% and 5.4% rate of 90-day perioperative mortality after radical cystectomy.12 Furthermore, for octogenarians, the risk of perioperative mortality after radical cystectomy ranged from 9.2%-20% in both population-based and institutional studies.12,13