Views on effectiveness and safety of robot-assisted radical cystectomy with intracorporeal urinary diversion

Dear Editor,

We read the article published by Shi Fu et al^[1] in International Journal of Surgery with great interest. We finished this comment and our comment is compliant with the TITAN Guidelines 2025 – governing declaration and use of AI^[2]. Shi Fu and his team have made great efforts and achieved great accomplishments. They analyzed the relevant perioperative indexes such as effectiveness, safety, and oncological outcomes of robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion. The results indicated that robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion enjoys more effectiveness and safety compared to open radical cystectomy. However, in terms of complications, they revealed a higher rate of ureteroenteric stricture among patients, who received robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion. Nevertheless, no research is without limitations, and this paper is no exception. High quality randomized controlled trials and additional samples are critical to the development of high quality sources of evidence. It is still noteworthy that the meta-analysis included 23 studies, including randomized sham-controlled trials, prospective studies and retrospective studies. Based on the results of a systematic literature review, only 4 randomized controlled trials were included. The design of retrieved randomized controlled trials should include adequate randomization, concealment of allocation sequences, intention-to-treat analysis, and blinding of outcome assessors. The specific implementation of the random sequence generation and blinding method may vary across hospital policies.

Secondly, the authors searched four English databases (including Cochrane Library, Embase, PubMed, and Web of Science) and one Chinese databases (CNKI databases), which is a good choice to search as much relevant literature as possible. However, the search terms only include: robotic surgical procedures, robot assisted surgery, robot-assisted, open, cystectomy, radical cystectomies, “cystectomy, radical,” and intracorporeal. Whether could expand the scope of retrieval though more search terms to search more retrieved randomized controlled trials because randomized controlled trials are the preferred method of studying intervention effects. In the absence of sufficient randomized controlled trials, results of meta-analysis may be highly variable, causing outcome bias, which limits generalizability to other populations.

Finally, the authors stated that when significant heterogeneity was present, they used a random effects model for analysis. In the analysis of the operative time, estimated blood loss, blood transfusion rate, and length of hospital stay, a total of seventeen, sixteen, thirteen, and seventeen studies, respectively, were included, which exhibited substantial heterogeneity. The authors conducted subgroup analyses based on region (Europe, Asia, and America), number of patients (≥100 and <100), BMI (≥28 and <28), study type (RCT, retrospective and prospective), and type of diversion (neobladder, ileal conduit, neobladder/ileal conduit, neobladder/ileal conduit/indiana pouch) to eliminate clinical heterogeneity. Furthermore, subgroup analyses were conducted in order to assess the robustness of their findings, however, there may be unmeasured variables that also affect treatment choice and outcomes. The proficiency of surgical methods used by individual surgeons, hospitals with different grades, physicians with different job titles, and magnitude of impact of medical devices can affect perioperative complications and postoperative efficacy.

Consider to the retrieval time was as of July 2023, grey literature (from July 2023 to 25 May 2025) was conducted on 25 May 2025 by us. 2 RCT and 1 prospective study met inclusion criteria^[3-5]. After reading the full texts, 1 were included. Courboin et al^[5] included 593 patients including 409 open radical cystectomy and 184 robotic-assisted radical cystectomy with intracorporeal urinary diversion comparing the safety and oncologic outcomes. In concordance with the meta-analysis by Shi Fu et al^[1], they found that compared with open radical cystectomy, robotic-assisted radical cystectomy with intracorporeal urinary diversion had less intraoperative blood loss (279 mL vs. 471 mL, P < 0.001) and shorter hospital stay (13.7 days vs. 17.2 days, P = 0.007) by using propensity-matched analysis. Meanwhile, it required longer operative time (309 min vs. 288 min, P = 0.034). However, they also found some inconsistency. There were no significant differences between the open surgery and iRARC group in positive surgical margins and intraoperative transfusion (P > 0.05). We believe their result was reliable because they applied PSM, reducing the observational study’s confounding bias and selectivity bias.

Urinary bladder cancer is the most common malignant tumor of the urinary tract, following only prostatic carcinoma in terms of urogenital malignancies^[6]. Currently, bladder cancer is increasing in incidence and mortality, and it has characteristics such as high malignancy and poor prognosis^[7]. Among the number of treatments for muscle-invasive bladder cancers, open radical cystectomy still is the gold standard. With the advent of robot-assisted radical cystectomy in 2003, it has become increasingly popular throughout the world as a minimally invasive alternative to open radical cystectomy with comparable oncologic outcomes and perioperative complication rates^[8,9]. A radical cystectomy performed with robotic assistance is an advancement in minimally invasive surgery aimed at reducing the difficulty associated with complex laparoscopic procedures.

Overall, more large-scale and prospective multicenter randomized controlled trials should be conducted to evaluate effectiveness and safety of robot-assisted radical cystectomy with intracorporeal urinary diversion.

Ethical approval

Ethical approval was not required.

Consent

Not applicable.

Sources of funding

Not applicable.

Author contributions

R.S. and L.L. contributed substantially to the conception and design of the protocol, drafted the manuscript, critically revised the manuscript for intellectual content. W.G. and X.Y. performed preliminary searches, drafted the manuscript, critically revised the manuscript for intellectual content.

Conflicts of interest disclosure

None.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.