A multi‑criteria decision analysis comparing robot‑assisted, laparoscopic, and open radical cystectomy using large-scale Japanese nationwide databases.

This study aims to provide an integrated, probability-based comparison of robot-assisted radical cystectomy (RARC), laparoscopic radical cystectomy (LRC), and open radical cystectomy (ORC) in Japan by jointly evaluating clinical and economic outcomes using multi-criteria decision analysis (MCDA). Clinical and economic outcomes were extracted from large nationwide studies based on the National Clinical Database and the Diagnosis Procedure Combination database in Japan, including estimated blood loss, grade ≥ 3 complications, lymph node count, in-hospital fee, length of stay, and transfusion rates. Outcome uncertainty was propagated using parametric bootstrap resampling with 50,000 iterations, and criterion-specific values were normalized to a common 0-1 scale within each iteration. Six prespecified weighting scenarios (balanced, safety-focused, perioperative-focused, oncology-focused, cost-focused, and efficiency-focused) produced overall scores, rank probabilities, and pairwise net advantages. Sensitivity analyses were conducted to assess the robustness of the results. Across all weighting scenarios, both minimally invasive approaches outperformed ORC, with RARC consistently achieving the highest expected MCDA scores and rank probabilities. The advantage of RARC over LRC remained evident across scenarios, including cost-focused analyses, but was attenuated under safety-focused weighting. Sensitivity analyses did not materially alter the overall ranking patterns. Using MCDA to integrate heterogeneous clinical and economic outcomes from Japanese nationwide data, RARC most frequently emerged as the preferred surgical approach over LRC and ORC. This transparent and reproducible framework supports informed clinical decision-making and policy discussions regarding the role of RARC in Japan.