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Surgical Site Infection in Robot-assisted Radical Cystectomy vs. Open Radical Cystectomy
Katelyn K. Johnson, MD, Kevan Ip, BA, Sara Rubino, BA, Cynthia Leung, MD, Cayce B. Nawaf, MD, Thomas V. Martin, MD, David G. Hesse, MD.
Yale University, New Haven, CT.

BACKGROUND: Radical cystectomy has a high incidence of complications due to the complex nature of the procedure. Little is known about the comparative risk of surgical site infection associated with robot-assisted radical cystectomy (RARC) vs. open radical cystectomy (ORC). Patients at our institution were analyzed to assess risk of developing SSI based on surgical approach.
METHODS: All patients undergoing radical cystectomy with pelvic lymph node dissection for urothelial carcinoma of the bladder at a single institution from 2007-2017 were retrospectively reviewed. Data included age, sex, body mass index (BMI), Charlson Age-Adjusted Comorbidity Index (CCI), history of diabetes, surgical approach (RARC or ORC), urinary diversion type, length of operation, estimated blood loss (EBL), surgical site infection (SSI), and length of hospital stay (LOS). SSIs were defined using criteria outlined by the National Surgical Quality Improvement Program (NSQIP) that occurred at any point postoperatively. There were no exclusion criteria in terms of clinical or pathologic stage. Simple and multiple logistic regression models were fitted to the data to assess the role of perioperative factors on risk of surgical site infection. Independent variables that are correlated were excluded during variable selection in multiple regression analysis in order to satisfy the assumption of non-multicollinearity. Differences between the RARC and ORC patient cohorts were analyzed using Student's t-test or Wilcoxon rank sum test for continuous variables, and Pearson's Chi-squared test for categorical variables. Statistically significant differences were defined as p<0.05.
RESULTS: We identified a total of 232 patients (73 robotic, 159 open) who underwent radical cystectomy. SSI was significantly lower in RARC vs. ORC (14% vs. 29%, p=0.01). RARC patients had lower EBL than ORC patients (mean: 500 vs. 850 mL, p<0.0001), higher CCI (mean: 6.2 vs. 5.3, p<0.05), and longer operative times (mean: 550 vs. 360 minutes, p<0.0001). There was no significant difference in BMI (p=0.93), diabetes (p= 0.58), urinary diversion type (continent vs. non-continent, p=0.71), or LOS (p=0.34) between surgical approaches. On simple univariate logistic regression, surgical approach (RARC vs. ORC, OR=0.40, 95% CI: 0.19-0.84, p=0.016), EBL (OR=1.0008, 95% CI: 1.0002-1.0014, p=0.007), BMI (OR=1.06, 95% CI: 1.002-1.125, p=0.043), and LOS (OR=1.05, 95% CI: 1.006-1.102, p=0.026) were found to have significant correlation with risk of SSI. Diabetes, CCI, operative time, and urinary diversion method had no significant correlation with risk of SSI. Multivariate logistic regression including surgical approach (OR=0.34, p=0.008), LOS (OR=1.06, p= 0.017), and BMI (OR=1.07, p=0.035) show that these variables have a significant relationship with SSI risk.
CONCLUSIONS: Patients who underwent RARC had a significantly lower SSI rate compared to those who underwent ORC. RARC patients experienced significantly lower EBL. Logistic regression analysis shows a strong relationship between surgical approach and SSI risk, suggesting a 60% reduction in SSI risk associated with RARC, as well as a strong relationship between EBL and SSI risk. Reduced risk of SSI in RARC may be mediated by lower EBL in RARC vs. ORC.


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