Bladder cancer (BC) remains a leading cause of death, accounting for almost 4% of cancer-related deaths.¹ Worldwide, BC had an incidence of 5.6 per 100,000 and a mortality rate of 1.9 per 100,000 in 2020, with predictions of a 73% increase in incidence and an 87% increase in mortality by 2040.² Radical cystectomy is the gold standard treatment for nonmetastatic muscle-invasive bladder cancer and high-risk nonmuscle-invasive bladder cancer; therefore, multidisciplinary assessment is essential for improving survival outcomes and quality of life (QoL).³ Although open radical cystectomy (ORC) has traditionally been favored, the improvement of robotic-assisted laparoscopic techniques over the years has led to a substantial rise in the use of robotic-assisted radical cystectomy (RARC), whether intracorporeal urinary diversion (iUD) or extracorporeal urinary diversion (eUD).⁴

Prime Time for Robotic-Assisted Radical Cystectomy

Recently, several systematic reviews (SRs) and meta-analyses (MAs) supporting RARC vs ORC have been published in the last years, promoting an increasing use of this approach in many high-volume centers.⁵ Firstly, Sathianathen et al conducted an SR of 5 studies, which reported decreased rates of blood transfusion and shorter length of stay (LOS) with RARC, although operative time was longer with no significant difference in health-related QoL.⁶ As modifications to the technique are described and learning curves shortened, SRs and MAs now provide robust and reliable evidence. For instance, Cella et al demonstrated that both ORC and RARC yield similar outcomes in terms of oncological results and complication rates; moreover, health-related QoL at 3 and 6 months is comparable between the 2 approaches.⁷

Fontanet and colleagues performed an SR and MA, showing that RARC is associated with longer operative times but lower transfusion rates, with no significant difference in oncological outcomes, major complication rates, LOS, bowel recovery, or health-related QoL. However, a limitation of their study was the relatively small number of patients in the RARC group in randomized trials.⁸ Mastroianni and colleagues also compared the achievement of trifecta and pentafecta outcomes between ORC and RARC with iUD, finding no difference in oncological and surgical outcomes, global health status, or QoL.⁹ Also, Sasaki et al evaluated the feasibility of lymph node dissection between these groups, reporting a significantly higher lymph node yield in the RARC group compared to ORC, with no difference in oncological outcomes.¹⁰

RARC With iUD vs eUD

RARC with eUD was first described by Dr Menon back in 2003.¹¹ Since then, surgeons have aimed to improve RARC techniques and reduce iUD operative time, as eUD diminishes the benefits of minimally invasive surgery. The RAZOR trial compared RARC with eUD vs ORC, reporting that RARC with eUD resulted in shorter LOS and longer operative times, with noninferiority in terms of oncological outcomes at 2 years and similar complication rates.¹² In the iROC randomized controlled trial, Catto and colleagues analyzed 90-day complications and mortality in iUD RARC vs ORC, finding that iUD RARC patients had a lower median number of days out of the hospital within 90 days after surgery (82 days, interquartile range 76-84) compared to ORC (80 days, interquartile range 72-83), with lower complication rates and higher QoL at 5 and 12 weeks, with similar outcomes beyond 12 weeks.¹³ Also, Mastroianni et al analyzed 3-year outcomes of RARC with iUD vs ORC, reporting a 50% reduction in transfusion rates and similar complication rates and oncological outcomes, although operative time remained longer for RARC with iUD.¹⁴

When comparing RARC with iUD vs RARC with eUD and ORC, Murthy and colleagues found no difference in complication rates at 90 days, and long-term oncological outcomes were not compromised among the different techniques.¹⁵ In an SR comparing uretero-enteric stricture (UES) rates among the 3 procedures, McNicholas et al found lower UES rates in ORC compared to robotic approaches, although the evidence did not include any randomized controlled trials.¹⁶ Tuderti and colleagues followed up on 192 patients who underwent iUD with Padua ileal bladder, reporting a trifecta rate of 64.1% and 1-year day-continence rate of 78.6%, with 5-year oncological outcomes comparable to other series.¹⁷ In a retrospective analysis, Rich et al compared intracorporeal ileal conduit vs neobladder urinary diversion, finding higher pT stages and increased nodal involvement in ileal conduit patients, but similar complication rates and oncological outcomes between the 2 groups.¹⁸ In a study performed by Presicce and colleagues, with a median follow-up of 33 ± 22 months, long-term complications in iUD with neobladder were UES in 15%, stone formation in 8%, bowel occlusion in 1%, and metabolic acidosis in 1%.¹⁹

Are We Ready for RARC in Latin America?

In Latin America, there are an estimated 33,840 new cases and 13,100 deaths annually, with higher mortality in low-income countries, highlighting the urgent need to improve global health care and reduce social disparities to address these numbers.^20,21

As higher-quality evidence grows and more surgeons adopt robotic approaches, trending toward RARC approach has increased. However, it is essential to recognize that for radical cystectomy, costs and accessibility in marginalized communities make RARC difficult to implement. Consequently, ORC remains the gold standard in many settings, with major complications similar to those reported in the literature. In Brazil, Moschovas et al evaluated 37 patients who underwent RARC with 25 iUDs with ileal conduit and 9 neobladders; the complication rate was 32%, with a major complication rate of 17%.²² In Mexico, Castillejos-Molina and colleagues reported a major complication rate of 39% in a series of 61 patients undergoing ORC at a referral center.²³ Similarly, Acosta-Garduño et al reported a 31% major complication rate in 33 patients who underwent ORC.²⁴ Also, Mayorga et al evaluated 18 patients with a complication rate of 46%.²⁵

It is well established that radical cystectomy, regardless of the surgical approach, induces significant catabolism in patients. Sarcopenia is strongly linked to prognosis and postoperative complications and probably impacts the survival of patients with muscle-invasive bladder cancer.²⁶ However, enhanced recovery after surgery programs are available to rehabilitate patients even before cystectomy. Despite the benefits of RARC, its widespread adoption in Latin America is not yet feasible. Instead, efforts should be focused on enhancing access to high-quality health care, reducing social and economic disparities, and gradually introducing robotic techniques where possible. In the meantime, ORC will likely remain the predominant approach in the region, ensuring that patients continue to receive effective treatment within the available resources. Future strategies should consider both the advancement of surgical techniques and the equitable distribution of health care resources to improve outcomes for BC patients across Latin America.

Since 2002, the AUA Residents and Fellows Committee has represented the voice of trainee members. The Committee’s mission is to address the educational and professional needs of urology residents and fellows and promote engagement with the AUA. The Committee welcomes your input and feedback! To contact us, or inquire about ways to be involved, please email rescommittee@AUAnet.org.