Intracorporeal versus extracorporeal urinary diversion after robotic-assisted radical cystectomy: evidence from a systematic review and pooled analysis of observational studies.

Introduction: We aimed to compare the perioperative, pathological and oncological outcomes of patients undergoing extracorporeal urinary diversion (EUD) and intracorporeal urinary diversion (IUD) following robot-assisted radical cystectomy (RARC).

Evidence acquisition: Multiple scientific databases were searched up to January 2020 for comparative studies comparing IUD and EUD. The data was analyzed by Review Manager 5.3.

Evidence synthesis: A total of 9 observational studies comprising 3582 patients were included in the final analysis. We observed that IUD approach were significantly associated with lower estimated blood loss (EBL) (MD: -90.50, 95% CI: -131.26 to -49.74, P<0.0001), fewer gastrointestinal complications (RR: 0.65; 95% CI: 0.45 to 0.93; P=0.02), and lower risk of uretero-ileal anastomotic stricture (RR: 0.36; 95% CI: 0.14 to 0.91; P=0.03). We did not detect significant difference in terms of length of stay (P=0.14), operative time (P=0.55), blood transfusion (P=0.10), 30-day complication (P=0.50), 90-day complication (P=0.40), 30-day readmission (P=0.12), 90-day readmission (P=0.95), positive surgical margins (P=0.42), lymph node yield (P=0.13), 30-day reoperation (P=0.11) and 90-day mortality (0.27) between IUD and EUD.

Conclusions: The approach of urinary diversion does not have a considerable impact on pathological, perioperative and oncological outcomes in patients undergoing RARC. The benefits conferred by IUD are lower EBL, lower risk of gastrointestinal complications, and uretero-ileal anastomotic stricture. Subgroup analysis of patients with ileal conduit showed similar results on perioperative and complication outcomes. Well-designed trials conducted by large volumes and experienced surgeons, and reporting complications based on standardized methodology are still warranted.