The Impact of Previous Prostate Surgery on Surgical Outcomes for Patients Treated with Robot-assisted Radical Cystectomy for Bladder Cancer

Background: The feasibility and safety of robot-assisted radical cystectomy (RARC) may be undermined by unfavorable preoperative surgical characteristics such as previous prostate surgery (PPS). Objective: To compare perioperative outcomes for patients undergoing RARC with versus without a history of PPS. Design, setting, and participants: The study included 220 consecutive patients treated with RARC and pelvic lymph node dissection for bladder cancer at a single European tertiary centre. Of these, 43 had previously undergone PPS, defined as transurethral resection of the prostate/holmium laser enucleation of the prostate (n = 21) or robot-assisted radical prostatectomy (n = 22). Surgical procedure: RARC in patients with a history of PPS. Measurements: Data on postoperative complications were collected according to the quality criteria for accurate and comprehensive reporting of surgical outcomes recommended by the European Association of Urology guidelines. Multivariable logistic, linear, and Poisson regression analyses were performed to test the effect of PPS on surgical outcomes. Results and limitations: Overall, 43 patients (20%) were treated with RARC after PPS. Operative time (OT) was longer in the PPS group (360 vs 330 min; p < 0.001). Patients with PPS experienced higher rates of intraoperative complications (19% vs 6.8%) and higher rates of 30-d (67% vs 39%), and Clavien-Dindo >3 (33% vs 16%) postoperative complications (all p < 0.05). Moreover, the positive surgical margin (PSM) rate after RARC was higher in the PPS group (14% vs 4%; p = 0.03). On multivariable analyses, PPS at RARC independently predicted higher risk of intraoperative (odds ratio [OR] 2.10, 95% confidence interval [CI] 1.04–6.21; p = 0.01) and 30-d complications (OR 2.26, 95% CI 1.05–5.22; p = 0.02), as well as longer OT (relative risk [RR] 1.03, 95% CI 1.00–1.05; p = 0.02) and length of stay (RR 1.13, 95% CI 1.02–1.26; p = 0.02). Lack of randomization represents the main limitation. Conclusions: RARC in patients with a history of PPS is feasible, but it is associated with a higher risk of complications and longer OT and length of stay. Moreover, higher PSM rates have been reported for these patients. Thus, measures aimed at improving surgical outcomes appear to be warranted. Patient summary: We investigated the effect of previous prostate surgery (PPS) on surgical outcomes after robot-assisted removal of the bladder. We found that patients with PPS have a higher risk of complications and longer hospitalization after bladder removal. These patients deserve closer evaluation before this type of bladder operation. Robot-assisted radical cystectomy for bladder cancer in patients with a history of previous prostate surgery is feasible, even if it is associated with worse perioperative outcomes. Thus, measures aimed at improving surgical outcomes in this patient population appear to be warranted.