Propensity matching study of robot-assisted intracorporeal versus extracorporeal orthotopic neobladder reconstruction
Objective To compare the surgical efficacy and perioperative complications of total intracorporeal neobladder(ICNB)and extracorporeal neobladder(ECNB)reconstruction during robot-assisted radical cystectomy.Methods We retrospectively reviewed our single-institutional,prospectively collected database for consecutive patients who underwent RARC with an ileum neobladder from January 2017 to June 2022.A total of 265 patients were collected,158 in ICNB group and 107 in ECNB group.The two groups were matched 1∶1 according to gender,age,BMI,ASA score,NAC,history of abdominal surgery and tumor characteristics using propensity score matching(PSM)method.After PSM,operating time,estimated blood loss and perioperative complications were compared between ICNB and ECNB group.A total of 186 patients were paired(93 patients in each group).There were 91 males and 2 females in ICNB group.The median age of ICNB group was 64(55,68)years;median BMI was 23.54(22.39,25.39)kg/m2;There were 91 cases with Clinical stage ≤T2 stage and 15 cases with ASA score ≥3;25 cases received neoadjuvant chemotherapy.There were 91 males and 2 females in ECNB group.The median age of ECNB group was 63(52,67)years;median BMI was 23.31(20.76,24.80)kg/m2;There were 90 cases with Clinical stage ≤T2 stage and 8 cases with ASA score ≥3;12 cases received neoadjuvant chemotherapy.In the ECNB group,after completing the radical cystectomy and pelvic lymph node dissection with robot assistance,the traditional lower abdominal incision was used to pull the intestinal tube outside the body to complete the preparation of the new bladder and then restore it to the pelvic cavity for anastomosing,while in the ICNB group,the reconstruction of the new bladder in situ was always completed in the body cavity with robot assistance.The operative time,intraoperative blood loss and perioperative complications were compared between the two groups.Results The median operative time in ICNB and ECNB groups was 302(261,350)min and 337(285,397)min,respectively(P=0.003);median intraoperative blood loss was 300(225,500)ml and 500(300,650)ml,respectively(P＜0.01);perioperative blood transfusion rates were 4.3％(4/93)and 14.0％(13/93),respectively(P=0.022);all the differences between the 2 groups were statistically significant.90-d overall complications rate was significant lower in ICNB group(38.7％vs.61.3％,P=0.002).There was no difference in 90-d major complications(8.6％vs.16.1％,P=0.119).On multivariate logistic regression analysis,operating time(OR=1.004,95％CI 1.000-1.007,P=0.040),surgical approach(ICNB/ECNB)(OR=2.248,95％CI 1.220-4.141,P=0.009)and age(OR=1.036,95％CI 1.002-1.072,P=0.037)were associated with 90-day overall complications.Operating time(OR=1.036,95％CI 1.002-1.072,P=0.037),neoadjuvant chemotherapy(OR=0.198,95％CI 0.059-0.663,P=0.009)and ASA score(OR=0.167,95％CI 0.044-0.634,P=0.009)were associated with 90-day high-grade complications.Conclusion Intracorporeal neobladder during robot-assisted radical cystectomy is safe and feasible.Compared with ECNB,ICNB significantly improved perioperative outcomes such as shorter operating time,fewer estimated blood loss and perioperative complications.
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