# Intracorporeal Versus Extracorporeal Urinary Diversion Following Robotic-Assisted Radical Cystectomy for Bladder Cancer in Patients ≥ 65 Years of Age: A Systematic Review and Meta-Analysis

## TL;DR

This study compares two urinary diversion methods in elderly bladder cancer patients and finds that one method reduces blood loss and transfusion rates.

## Contribution

The study provides the first meta-analysis comparing intracorporeal and extracorporeal urinary diversion in patients aged 65 and older undergoing robotic cystectomy.

## Key findings

- Intracorporeal urinary diversion significantly reduces estimated blood loss and transfusion rates in elderly patients.
- It also lowers gastrointestinal complication rates compared to extracorporeal diversion.
- No significant differences were found in operative duration, hospitalization length, or complication rates.

## Abstract

There is scarce information regarding intracorporeal (ICUD) and extracorporeal urinary diversion (ECUD) for the treatment of bladder cancer in patients aged 65 and older. This review aims to investigate this literature gap.

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria, this systematic review and meta-analysis was prospectively registered with PROSPERO (registration number CRD42024620211).

We searched PubMed, Scopus, and the Cochrane Library up to April 28, 2024, for any relevant literature comparing ICUD to ECUD in patients aged ≥65 years. We pooled the data using either weighted mean differences or odds ratios with random effects models. Heterogeneity was assessed with the Higgins I2 statistic, and the study quality was examined with the Newcastle-Ottawa scale. For results with moderate to high heterogeneity, we conducted a sensitivity analysis by excluding one study at a time. Nine studies with 4,340 patients in total, 1,967 in ICUD and 2,373 in ECUD, were included in the meta-analysis. The results showed that the ICUD significantly reduced the estimated blood loss (weighted mean differences (WMD): -64.34 mL, 95% CI: -113.26, -15.42; I² = 92%, p-heterogeneity < 0.00001, p-overall = 0.010), blood transfusion rates (OR: 0.29, 95% CI: 0.11, 0.76; I² = 86%, p-heterogeneity < 0.0001, p-overall = 0.01), and overall gastrointestinal complications (OR: 0.65, 95% CI: 0.46, 0.92; I² = 0%, p-heterogeneity = 0.70, p-overall = 0.02), when compared to ECUD, in patients 65 and over. However, we observed no significant differences, with regards to the operative duration (WMD: 3.48, 95% CI: -28.42, 35.38; I² = 98%, p-heterogeneity < 0.00001, p-overall = 0.83), length of hospitalization (WMD: 0.53, 95% CI: -0.15, 1.21; I² = 85%, p-heterogeneity < 0.00001, p-overall = 0.13), 30-day complication rates (OR: 1.22, 95% CI: 0.83, 1.78; I² = 77%, p-heterogeneity = 0.0005, p-overall = 0.30), 90-day complication rates (OR: 0.92, 95% CI: 0.61, 1.39; I² = 61%, p-heterogeneity = 0.04, p-overall = 0.68), or 30-day readmission rates (OR: 0.86, 95% CI: 0.62, 1.20; I² = 35%, p-heterogeneity = 0.20, p-overall = 0.38). The sensitivity analysis showed that several studies increased the heterogeneity, especially for results like the expected volume of blood loss and the transfusion rate. Overall, elderly patients undergoing robot-assisted radical cystectomy (RARC) may benefit from ICUD with regard to reduced blood loss, lower rates of blood transfusion, and decreased rate of gastrointestinal complications. However, more robust studies are required in order to reach firm findings.