*Robot-Assisted Radical Cystectomy with Intra-Corporeal Neo-Bladder DOI: http://dx.doi.org/10.5772/intechopen.98973*

meta-analysis also reported a longer surgical time in comparison to ORC [33]. A prolonged operative time could be associated to peri-operative complications, such as, deep vein thrombosis, wound infection and increase anesthetic risk [32].

#### **7.3 Urinary diversion**

In a retrospectively study of 2,125 patients, Hussein et al. reported the outcomes of 1,094 patients who underwent RARC with intra-corporeal urinary diversion (ICUD) [38]. ICUD was associated with a shorter surgical time (357 VS 400 minutes, *p*<0.001), less surgical blood loss (300 VS 350 mL, *p*<0.001) and fewer blood transfusions (5% VS 13%, *p*<0.001) than extra-corporeal urinary diversion (ECUD) but high-grade complications were more frequent (57% VS 43%) 30 days after surgery. The incidence of high-grade complications decreased significantly trough time, from 25% in 2005 to 6% in 2015 (p<0.001) and remained stable [38]. The ICUD is very complex robotic procedure but the decision to perform a type of urinary diversion (neo-bladder o cutaneous pouch) should not be based on the surgical approach [18].

The modified Y-neo-bladder intra-corporeal technique performed in the Clinique Saint-Augustin, described by Asimakopoulos and two of the authors of this chapter, is an almost spherical urinary reservoir without the need to transpose either ureter [19]. This will allow the neobladder to remain aligned in a natural fashion and enables a tension-free ureter-neo-bladder anastomosis (buttonhole anastomosis). The reported data obtained via voiding charts indicated low 12-month voiding frequency with no pathological post-void residual volume, good mean maximal functional bladder capacity and no need for clean intermittent catheterization [19].

#### **7.4 Complications**

Previously, multiple articles and reviews have stated a lower rate of perioperative complications related RARC [37]. The RCT elaborated by Bochner et al. described a rate of peri-operative complications grade 2–5 (Clavien-Dindo) of 62% for RARC and 66% for ORC [39]. In accordance with those findings, a recent RCT meta-analysis found similar peri-operative complication rate for RARC and ORC within 30 days [33]. Sathianathen et al. and Khan et al. meta-analysis, reported no difference in the 90-day incidence of major complications (Clavien Dindo III-V) between both approaches (RR 1.06, CI 95% 0.75–1.49) [32, 37].

One key benefit of the robotic surgery is lower surgical blood loss (mean difference of 300 mL), it is possible to suggest that RARC may reduce the rate of transfusion [32–34, 36]. In contrast, multiple articles have reported no difference in the rate of blood transfusion and others up to 77% reduction in the odds for blood transfusion [24, 26]. Wang et al. reported an estimated median blood loss of 400 (100–1200) mL for RARC and 750 (250–2500) mL for ORC (p=0–002), 0.5 (0–3) and 2 (0–7) units of blood for transfusion respectively (p=0.007) [36].

Sathianathen meta-analysis included two studies that reported the blood transfusion rate as a result, the peri-operative blood transfusion necessity was lower for RARC (42% risk reduction) [32]. As previously mentioned, an odds reduction of blood transfusion might be one of the benefits of the robotic approach because of the clinical impact, risks and adverse effects of blood transfusions should not be foreseen (hemolysis, anaphylaxis).

#### **7.5 Length of hospital stay**

n the article of Wang and his group, the median length of hospital stay days for RARC was 5 (4–18) days and 8 (5–28) days for ORC (p=0.007) [36]. The length of

#### *Robot-Assisted Radical Cystectomy with Intra-Corporeal Neo-Bladder DOI: http://dx.doi.org/10.5772/intechopen.98973*

stay <5 days for the RARC group was 40/139 (29%) and 27/146 (18%) for ORC group (p=0.0407) [29]. The length of stay had no statistical difference in the analysis of Tang and his group (weighted mean difference: −0.60, 95% CI: −1.61–0.40, p=.24) [33]. Sathianathen et al. also reported a minimal marginal and no statistical difference in length of stay for the RARC group (RR −0.63, CI 95% −1.21−−0.05) [32].
