RARC using the da Vinci Surgical System™ (Intuitive Surgical, Sunny vale, CA, USA) was first reported in 2003 by Menon et al. [2]. Owing to the high flexibility and sophisticated operability of the instruments, this system is effective in radical cystectomy, which requires high surgical skill. In Japan, RARC has spread rapidly since it was covered by health insurance in April 2018.
There are several reports of RARC in older patients[3, 4]. Phillips et al. reported perioperative outcomes in 22 cases of RARC in older patients aged 80 years or older [3]. With a 90-day complication rate of 34.8% and no cases of Clavien–Dindo grade 5 complications, the authors concluded that RARC should be strongly considered in patients aged 80 years or older who are candidates for cystectomy. De Groote et al. reported on the perioperative outcomes and prognoses of 22 older patients aged 80 years or older among 155 patients who underwent RARC [4]. The older and younger patients did not differ in the rates for perioperative complications, mortality, or 3-year recurrence-free survival. Therefore, the authors concluded that skilled operators can safely perform RARC in older patients. Elsayed et al. reported on the perioperative and oncological outcomes of 81 older adult patients aged 80 years or older among 522 patients who underwent RARC [5]. Despite higher Charlson Comorbidity Index and ASA-PS scores in the older patients compared with younger patients, there was no significant difference in terms of blood loss, overall and major complications, readmissions, or perioperative mortality. Older patients exhibited comparable 5-year recurrence-free survival and cancer-specific survival compared with younger patients. The authors concluded that RARC did not increase perioperative risks or compromise oncological outcomes in older patients and should be considered a treatment option in this population.
The choice of urinary diversion following radical cystectomy in older patients is controversial. Ileal conduit is usually avoided in older and more frail patients because of its longer operative time and hospital stay and higher blood loss, transfusion rates, necessity of intensive care, and incidence of perioperative complications (including gastrointestinal complications), compared with CUS [6]. Conversely, ICUD following RARC has the advantages of less bleeding, shorter hospital stay, and faster postoperative recovery, compared with conventional procedures [1]. However, there are few reports of ICIC in older patients, and thus the safety of ICIC in older patients has not been clarified.
Compared with CUS, ICIC involves many more complicated surgical procedures and consequently a longer operation time. In the current study, ICIC was associated with a significantly prolonged operation time and increased EBL compared with CUS. However, the transfusion rate did not differ significantly from that of the CUS group. Mastroianni et al. reported the results of the randomized controlled trial comparing 58 cases of open radical cystectomy (ORC) and 58 cases of RARC with ICUD [7]. Both EBL (401 [243–511] vs. 467 [330–625] ml, p = 0.020) and the transfusion rate (22% vs. 41%, p = 0.046) were significantly lower in the RARC group vs. the ORC group, respectively. In the current study, the EBL in the ICIC group was 392 [194–537] ml, with a transfusion rate of 36%. Compared with the results of the study by Mastroianni et al., the transfusion rate in our study was higher despite similar blood loss in both studies. In the study by Mastroianni et al., the age of the patients who underwent RARC was 64 [53–70] years, which is much younger compared with the patients in our study, and younger patients may have a higher tolerance to hemorrhage. In addition, there were no significant differences in the length of hospital stay or the incidence of perioperative complications in the current study, suggesting that the effect of prolonging the operation time was tolerable. Conversely, there were no significant differences between the two groups in the overall, cancer-specific, or recurrence-free survival rates. Based on these results, we believe that ICIC is comparable to CUS in terms of oncological prognoses and perioperative outcomes, and that ICIC can be performed safely even in older patients.
No reports have evaluated the health-related quality of life (HRQoL) of patients between ICIC and CUS, although several reports have evaluated the HRQoL of patients who underwent radical cystectomy [8, 9]. Mastroianni et al. reported a comparison of patient-reported HRQoL scores between ORC and RARC with ICUD [8]. Overall, both groups reported significant worsening of body image and physical and sexual functions at the 1-year follow-up compared with baseline. Comparing the two groups, patients who underwent ORC were more likely to experience a decline in role functioning and report higher scores on the symptoms scale, while those who underwent RARC with ICUD were more likely to report significant increases in urinary symptoms and related problems. Arman et al. reported a comparison of postoperative HRQoL after ileal conduit and CUS after ORC in 70 patients [9]. The authors concluded that the HRQoL after ileal conduit was significantly superior to that after bilateral but not unilateral CUS. The authors also reported a stent-free rate of 73.9% and 32.0% for bilateral and unilateral CUS, respectively [9]. In the current study, the stoma was created by the Toyoda method in the CUS group [10]. Nevertheless, the stent-free rate was significantly lower in the CUS group compared with the ICIC group. In CUS cases that do not become stent-free, the burden on patients and their families forced to undergo regular stent replacement cannot be underestimated. Improving the stent-free rate is an urgent need from the perspective of UTIs. Murai et al. reported the effects of indwelling stents on urinary bacterial flora and UTI in 24 patients who underwent ureterostomy [11]. Patients with indwelling stents had higher incidences of UTI and recurrent UTI compared with patients who were stent-free. In addition, patients with UTIs often have stent obstruction, which increases intrapelvic pressure and causes UTI. Murai et al. concluded that indwelling stents after CUS are strong risk factors for pyelonephritis and the development of antibiotic-resistant bacteria. In the current study, the incidence of UTI tended to be higher in the CUS group compared with the ICIC group within 30–90 days after surgery. Thus, the low incidence of UTI is also a significant aspect of ICIC. Based on the above, the lower stent-free rate and high UTI rate in the CUS group may lead to decreased postoperative HRQoL of patients. However, we did not compare HRQoL between the ICIC and CUS groups in this study. A future research topic is to conduct an objective evaluation of HRQoL using questionnaires. Considering the higher stent-free rate and lower UTI rate (also in the older patients), ileal conduit is preferable to CUS. However, there are patients who cannot undergo ileal conduit for reasons such as their general condition and comorbidities. In such cases, further efforts are required to improve the stent-free rate. For example, several reports have evaluated tubeless CUS during open surgery [12,13,14,15]. However, we did not find any reports on CUS in robot-assisted surgery. Whether the tubeless surgical technique used during open surgery can be applied to robot-assisted surgery is a topic for future studies.
The present study had some limitations. First, this was a retrospective study with a small sample size. Second, although the patient backgrounds were matched as much as possible by propensity score matching, it was not possible to match the patients’ ages, and patient selection bias was unavoidable. Third, we did not objectively evaluate the patients’ HRQoL between the ICIC and CUS groups. Finally, the assessment of the general condition of older patients was inadequate. ECOG-PS and ASA-PS are simple evaluation tools for comprehensively evaluating a patient’s general condition. However, in older patients, factors such as decreased physical reserve, decreased cognitive function, and comorbidities may make it difficult to assess the general condition using these assessment tools alone. In the future, it may be more practical to use screening tools such as the G8 and the Flemish version of the Triage Risk Screening Tool to evaluate the general condition of older patients [16].