Demonstrating the non-inferiority of robotic radical cystectomy for cT3-cT4 urothelial carcinoma in the era of neoadjuvant chemotherapy: a propensity score-matched analysis.

We evaluated whether robot-assisted radical cystectomy (RARC) is non-inferior to open radical cystectomy (ORC) in patients with cT3-cT4 urothelial carcinoma receiving cisplatin-based neoadjuvant chemotherapy (NAC). We retrospectively analyzed 204 patients (ORC = 123, RARC = 81) across 11 centers. A 1:1 propensity score matching based on age, sex, T stage, and nodal status minimized the selection bias. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were compared using Kaplan-Meier analyses and log-rank tests. Cox regression identified independent prognostic factors. Before PSM, the RARC group included younger patients and had fewer individuals with cT4 tumors. Following PSM, 81 patients remained in each arm with balanced characteristics. RARC and ORC showed similar RFS (log-rank p = 0.90) and CSS (p = 0.16), whereas OS slightly favored RARC (p = 0.049). In a multivariable analysis, the surgical approach did not independently predict oncologic outcomes; instead, advanced pathologic stage (≥ pT2), lymphovascular invasion, and nodal involvement (≥ N1) were significant risk factors. The operative time was longer, but blood loss was lower in RARC, with no significant difference in positive margins or major complications. RARC demonstrated non-inferior oncologic outcomes compared to ORC in patients with cT3-cT4 urothelial carcinoma treated with NAC. These findings support the feasibility of a minimally invasive approach without compromising efficacy in advanced bladder cancer.