Long-term oncologic outcomes of robot-assisted radical cystectomy: Prognostic indicators and complication profiles from a high-volume single-surgeon series

PURPOSE: Robot-assisted radical cystectomy (RARC) is globally accepted, but single-surgeon, high-volume data linking perioperative factors with long-term oncologic outcomes are limited. MATERIALS AND METHODS: We retrospectively reviewed 304 consecutive RARC cases performed by one surgeon between 2007 and 2024. Total intracorporeal urinary diversion (ICUD) was used in 73.0% of patients and orthotopic neobladder (ONB) reconstruction in 64.5%. Median follow-up was 51.21 months. Primary endpoints were overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). Secondary endpoints included complication profiles and pentafecta, defined as margin-negative resection, ≥16 or more lymph nodes, no Clavien-Dindo grade ≥3 or higher complication within 90 days, no recurrence within 12 months, and no ureteroenteric stricture. RESULTS: Mean operative time was 447.61 minutes, median lymph-node yield was 31.0 in the extended PLND group and 24.0 in the standard PLND group, and the positive margin rate was 1.0%. ICUD was associated with shorter hospitalization than extracorporeal diversion (13.81 days vs. 17.03 days, p=0.026) and fewer early high-grade complications. Seven-year OS, CSS, and RFS were higher in pentafecta achievers (69.3%, 94.2%, and 82.6%), and 7-year OS was also superior in patients with organ-confined (≤T2) and node-negative disease (69.0% vs. 28.6% and 67.5% vs. 19.4%). Complications occurred in 59.7% overall, with 14.9% major; infections were most common (20.7%). CONCLUSIONS: In a high-volume single-surgeon series, RARC with ICUD provided durable oncologic control, acceptable morbidity, and high pentafecta achievement. Pathologic T and N stage and pentafecta were significant prognostic indicators that may assist in refining patient selection, guiding postoperative surveillance, and informing survivorship care.