A Comparison of Open versus Robotic Assisted Radical Cystectomy: A 10 year surgical site infection analysis
Soum D. Lokeshwar, MD, MBA1, Ankur U. Choksi, MD1, Kevan L. Ip, BS2, Syed N. Rahman, MD1, Juan F. Javier-DesLoges, MD, MS3, Thomas V. Martin, MD1, David G. Hesse, MD1.
1Yale University, New Haven, CT, USA, 2Thomas Jefferson University, Philadelphia, CT, USA, 3University of California San Diego, San Diego, CA, USA.
Introduction: Radical cystectomy is associated with a high peri-operative complication rate. Specifically, surgical site infection (SSI) is a significant cause of morbidity in patients. The purpose of this study was to investigate the difference in SSI between open versus robotic-assisted radical cystectomy. Materials and Methods:We retrospectively analyzed peri-operative characteristics and surgical site infections as defined by the National Surgical Quality Improvement Program, for patients undergoing a radical cystectomy from 2007 to 2017. Patients were stratified by surgical approach (robotic vs. open) and differences in cohorts were assessed using Students t-test for continuous variables and Pearson chi-square analysis for categorical variables. Univariate and multivariate logistic regressions were performed to identify predictors of surgical site infection. P-values were two sided and considered statistically significant if <0.05. Results:We identified 237 patients who underwent radical cystectomy, of which 163 were open and 74 were robotic. The two cohorts were similar with regards to age, gender, BMI, Charlson Comorbidity Index (CCI), history of diabetes, type of diversion, operative time, blood loss and length of stay (Table 1). On univariate analysis, surgical approach (OR 0.46, 95% CI: 0.22 - 0.99, p = 0.047), blood loss (OR 1.06, 95% CI: 1.00 - 1.12, p = 0.03), and length of stay (OR 1.06, 95% CI: 1.01 - 1.11, p = 0.01). On multivariate analysis, surgical approach predicts surgical site infection (OR: 0.34, 95% CI: 0.12 - 0.91, p = 0.031) when controlling for age, gender, BMI, history of diabetes, CCI, operative duration, length of stay and type of urinary diversion however did not predict surgical site infection (OR: 0.46, 95% CI: 0.20 - 1.05, p = 0.066) when adjusting for blood loss. Conclusion: Patients who underwent robotic cystectomy had significantly lower surgical site infections, less blood loss, and length of stay compared to those who underwent open cystectomy, however surgical site infection was not significant after adjusting for blood loss. Randomized controlled trials are needed to validate these results
Table 1: Baseline characteristics of patients undergoing a robotic vs. open radical cystectomy
| All Patients | Open Approach | Robotic Approach | p-value | |
| Number | 237 | 163 | 74 | |
| Age (years) | 68.9 ± 10.0 | 67.6 ± 9.5 | 71.2 ± 10.6 | 0.820 |
| Male Gender (%) | 188 (79.3%) | 126 (77.3%) | 62 (83.8%) | 0.253 |
| History of Diabetes (%) | 59 (24.9%) | 43 (26.4%) | 16 (21.6%) | 0.432 |
| Body Mass Index (kg/m2) | 28.0 ± 5.1 | 28.0 ± 5.1 | 28.2 ± 5.3 | 0.981 |
| Urinary Diversion | 0.510 | |||
| Incontinent | 167 (70.5%) | 117 (71.8%) | 50 (67.6%) | |
| Continent | 70 (29.5%) | 46 (28.2%) | 24 (32.4%) | |
| Charlson Comorbidity Index | 5.7 ± 2.1 | 5.3 ± 1.7 | 6.4 ± 2.6 | 0.721 |
| Operative Time (mins) | 420.9 ± 145.8 | 365.6 ± 123.9 | 542.8 ± 113.0 | 0.375 |
| Estimated Blood Loss (mL) | 748.8 ± 509.0 | 855.0 ± 526.6 | 514.9 ± 376.6 | 0.680 |
| Length of Stay (days) | 9.8 ± 6.0 | 9.4 ± 5.5 | 10.7 ± 7.0 | 0.891 |
| Blood Transfusion (units) | 0.6 ± 1.3 | 0.7 ± 1.4 | 0.2 ± 0.7 | 0.815 |
| Surgical Site Infections | 51 (21.5%) | 41 (25.2%) | 10 (13.5%) | 0.043 |
Table 2: Univariate logistic regression on predictors of post-operative surgical site infection in patients undergoing radical cystectomy
| Odds Ratio | 95% Confidence Interval | p-value | |
| Surgical Approach | |||
| Open | 1.00 | ||
| Robotic | 0.46 | 0.22 - 0.99 | 0.047 |
| Age | 0.98 | 0.95 - 1.01 | 0.185 |
| Gender | 0.323 | ||
| Male | 1.00 | ||
| Female | 1.51 | 0.66 - 3.49 | |
| Body Mass Index | 1.05 | 0.99 - 1.11 | 0.088 |
| Charlson Comorbidity Index | 0.89 | 0.76 - 1.04 | 0.132 |
| History of Diabetes Mellitus | 1.04 | 0.51 - 2.12 | 0.912 |
| Operative Time (mins) | 0.99 | 0.99 - 1.00 | 0.619 |
| Estimated Blood Loss (100 mL) | 1.06 | 1.00 - 1.12 | 0.030 |
| Length of Stay (days) | 1.06 | 1.01 - 1.11 | 0.010 |
| Urinary Diversion | 0.746 | ||
| Incontinent | 1.00 | ||
| Continent | 1.12 | 0.57 - 2.19 | |
| Blood Transfusion (units) | 1.11 | 0.89 - 1.39 | 0.369 |
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