The primary management of muscle invasive bladder cancer (MIBC) is neoadjuvant chemotherapy (NAC) followed by radical cystectomy [1]. This is a highly morbid procedure with a 30-day complication rate between 20 and 60% [2]. Robot-assisted radical cystectomy (RARC) has been adopted as a minimally invasive approach, primarily with the goal of improving perioperative complications and surgical recovery [1]. Initial feasibility randomized control trials (RCTs) [3,4] did not demonstrate clear differences between open radical cystectomy (ORC) and RARC. These early RCTs compared a hybrid robotic procedure (robotic extirpative RC followed by open urinary diversion) to ORC. By comparison, the contemporary iROC phase III RCT conducted in the United Kingdom (UK) compared completely intracorporeal RARC (iRARC – robotic RC and robotic urinary diversion) to ORC. iROC met the primary endpoint, finding iRARC associated with statistically significant improvements in days alive and out of hospital, as well as lower rates of VTE and lower risk of blood transfusions [1,5]. In addition to perioperative outcomes, the ongoing utilization of RARC has been supported by noninferior cancer outcomes with regards to progression free survival [1].

Despite the increasing adoption of RARC in the United States (US), the benefits of RARC in reducing the risk of post-operative complications remains controversial. The clinical value of a 2-day difference alive and out of hospital, and a difference of 7 vs. 8 days in hospital, as demonstrated in the iROC RCT, may not necessarily apply in the US healthcare context. This is particularly true given the increasing utilization of enhanced recovery after surgery (ERAS) protocols in ORC, where documented length of stay (LOS) has been reported as a range from 3 to 15 days (median of 4 days) [6]. Given these factors, the uptake of RARC has been primarily in academic centers, and there is a paucity of real world data on complication rates, mainly owing to a lack of Current Procedural Terminology (CPT) code for RARC, which precludes analyses using administrative data [7]. To address this knowledge gap, we sought to utilize population-based data from the contemporary National Surgical Quality Improvement Program (NSQIP) cystectomy targeted database to examine the association between operative modality and 30-day postoperative complications. In addition to comprehensively assessing complications, we were also able to assess granular cystectomy-specific complications, such as postoperative ileus, which are unique to the NSQIP cystectomy targeted database.