Robot-assisted versus open radical cystectomy with extracorporeal urinary diversion for bladder cancer: a GRADE-assessed systematic review and meta-analysis of randomized controlled trials with subgroup analyses by orthotopic neobladder utilisation.

backgroundRobot-assisted radical cystectomy (RARC) has become a minimally invasive alternative to open radical cystectomy (ORC) for muscle-invasive bladder cancer, with potential advantages in perioperative outcomes and recovery times. However, their comparative effectiveness remains debatable, particularly when extracorporeal urinary diversion is employed in both approaches. This systematic review and meta-analysis integrated evidence from randomized controlled trial data comparing RARC with ORC using extracorporeal reconstruction, with novel subgroup analyses by neobladder utilization and GRADE certainty assessment.

methodsWe systematically searched MEDLINE, Embase, CENTRAL, Web of Science, and Scopus from inception to November 2025 for randomized controlled trials comparing robot-assisted radical cystectomy (RARC) with open radical cystectomy (ORC) with extracorporeal urinary diversion in adults with bladder cancer. The primary outcomes included 90-day overall complications, major complications, operative time, blood loss, length of hospital stay, and positive surgical margins. Secondary outcomes included lymph node yield, venous thromboembolic events, postoperative ileus, and health-related quality of life (HRQoL). Random-effects meta-analyses were used to calculate risk ratios and mean differences with 95% confidence intervals. Subgroup analyses were stratified by neobladder utilization (≥ 20% vs. <20%), and the GRADE methodology was used to assess the certainty of the evidence.

resultsFive randomized trials (541 patients: 271 RARC and 270 ORC) met the inclusion criteria. RARC and ORC demonstrated equivalent 90-day overall complications (RR 0.95, 95% CI 0.83–1.07; moderate certainty) and major complications (RR 1.03, 95% CI 0.74–1.44; low certainty) with negligible heterogeneity. RARC significantly reduced intraoperative blood loss (MD − 230.47 mL, 95% CI − 382.46 to − 78.47; low certainty) and improved postoperative physical functioning (MD 0.40, 95% CI 0.22–0.58; high certainty), but required a longer operative time (MD + 65.30 min, 95% CI 33.53–97.07; low certainty). The positive surgical margin rates were similar (RR 1.09, 95% CI 0.54–2.21; low-certainty). Subgroup analyses revealed no effect modification by neobladder utilization on complications or other outcomes.

conclusionsRARC with extracorporeal urinary diversion offers comparable perioperative safety to ORC, with significantly reduced blood loss and improved early physical functioning, offset by longer operative times. Oncological margin control was equivalent across the approaches. RARC represents an evidence-based alternative for selected patients prioritizing functional recovery; however, long-term oncological data are required.