Robot-assisted radical cystectomy with intracorporeal urinary diversion – The new ‘gold standard’? Evidence from a systematic review

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Abstract
To investigate whether a totally intracorporeally radical cystectomy (RC) can be considered the new 'gold standard' in bladder cancer, as open RC (ORC) is the current 'gold standard' for surgical treatment of muscle-invasive and high-grade non-muscle-invasive bladder cancer. However, robot-assisted radical cystectomy (RARC) is becoming the preferred surgical approach in many centres as it seems to maintain the oncological control of open surgery whilst offering improved perioperative benefits. A review of the literature was conducted using the Pubmed/MEDLINE, ISI Web of Knowledge and Cochrane Databases to identify studies that included both ORC and RARC with intracorporeal and extracorporeal urinary diversion (UD) published up to July 2017. Evidence from four single-centre randomised controlled trials and now the multicentre Randomized Trial of Open versus Robotic Cystectomy (RAZOR) trial demonstrate the oncological equivalence of RARC to ORC. The only convincing evidence for the superiority of RARC is in the area of blood loss and transfusion rates. However, the UD procedure in these trials was performed extracorporeally and, to realise the full benefits of RARC, a totally intracorporeal approach is needed. Intracorporeal UDs (ICUDs) have been shown to be technically feasible by a few expert centres and have demonstrated some improved short-term perioperative outcomes compared to extracorporeal UDs. Although initial outcomes appear promising, RARC with ICUD is far from gaining 'gold standard' status. Further studies are needed to confirm that outcomes are reproducible widely. Furthermore, the benefits of a totally intracorporeal approach must be confirmed in randomised controlled trials.

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