Beyond Pooled Estimates: A Stratified Systematic Review with Quantitative Comparisons of Surgical Approaches and Diversion Strategies After Radical Cystectomy.

backgroundRadical cystectomy (RC) remains associated with substantial perioperative morbidity despite advances in minimally invasive surgery and reconstructive techniques. Comparisons between intracorporeal reconstruction, robotic-assisted approaches, and urinary diversion strategies are frequently confounded by clinical heterogeneity and patient selection. This study aimed to perform a stratified surgical systematic review evaluating perioperative outcomes across distinct reconstructive pathways following RC.

methodsA PRISMA-guided systematic review identified comparative studies evaluating intracorporeal versus extracorporeal/open orthotopic neobladder reconstruction, robotic-assisted versus open radical cystectomy in frail patients undergoing ureterocutaneostomy, and ileal conduit versus orthotopic urinary diversion. Analyses were performed within predefined clinical modules to preserve surgical context. Outcomes were expressed as odds ratios (ORs) with 95% confidence intervals (CIs), complemented by rare-event sensitivity analyses and exploratory absolute risk metrics, including number needed to treat or harm (NNT/NNH). Continuous outcomes such as estimated blood loss and length of hospital stay were assessed descriptively.

resultsThree comparative observational cohorts met inclusion criteria. Intracorporeal neobladder reconstruction and robotic-assisted cystectomy demonstrated consistent reductions in transfusion rates and favourable trends in perioperative morbidity. In frail patient populations, robotic surgery showed reduced intraoperative burden without increased readmission or mortality. Ileal conduit diversion was associated with increased wound-related complications and infectious outcomes; however, these findings likely reflect baseline differences in patient frailty and selection. Rare-event sensitivity analyses confirmed directional consistency of treatment effects despite wide confidence intervals. Integration of absolute risk differences and NNT/NNH metrics provided clinically interpretable context for stratified outcomes.

conclusionsMinimally invasive and intracorporeal strategies following radical cystectomy may reduce perioperative burden, whereas diversion type primarily influences complication patterns rather than overall morbidity. A stratified analytical framework integrating relative and absolute effect measures may offer a more clinically meaningful approach to evaluating reconstructive strategies in heterogeneous surgical populations.