Vol.:(0123456789) 1 3 Journal of Robotic Surgery https://doi.org/10.1007/s11701-020-01062-x REVIEW ARTICLE Port‑site metastasis and atypical recurrences after robotic‑assisted radical cystectomy (RARC): an updated comprehensive and systematic review of current evidences Guglielmo Mantica 1  · Salvatore Smelzo 2  · Francesca Ambrosini 1  · Stefano Tappero 1  · Stefano Parodi 1  · Andrea Pacchetti 1  · Davide De Marchi 2  · Franco Gaboardi 2  · Nazareno Suardi 1  · Carlo Terrone 1 Received: 7 November 2019 / Accepted: 3 March 2020 © Springer-Verlag London Ltd., part of Springer Nature 2020 Abstract The objective of this systematic review is to evaluate the current evidence regarding atypical metastases in patients under- going robotic-assisted radical cystectomy (RARC). A review of the current literature was conducted through the Medline and NCBI PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases in October 2019. From the literature search using the cited keys and after a careful evaluation of the full texts, we included 31 articles in the study. Fourteen studies (45.2%) reported at least an atypical recurrence during the follow-up period with a rate between 4 and 40% of all the recurrences. Overall, 105 (1.63%) of the 6720 patients who have been evaluated in the included stud- ies developed an atypical recurrence. Sixty-three (60%) of these atypical metastases were peritoneal carcinomatosis, 16 (15.2%) extrapelvic lymph nodes metastases, 11 (10.5%) port-site metastases, 10 (9.5%) retroperitoneal nodal metastases, while 5 (3.8%) patients developed more than one type of atypical recurrence. In literature, there is a low but not negligible incidence of atypical recurrences after RARC. However, publication bias and retrospective design of most studies could infuence the evidences. Further prospective randomized studies are needed to clarify the real risk of patients undergoing RARC to develop atypical metastases. Keywords Bladder cancer · Cystectomy · RARC  · Atypical recurrence · Port-site metastases Introduction Robotic surgery in urology has become a consolidated real- ity for more than a decade and is often the frst choice of surgeons and patients for the treatment of many urologi- cal diseases [1, 2]. Year after year, despite the promising but still low evidence, robotic surgery is increasingly taking over open surgery even in the treatment of muscle invasive bladder cancer. Robotic-assisted radical cystectomy (RARC) ofers a minimally invasive solution to classical open surgery and seems to guarantee similar oncological and functional results compared to open radical cystectomy [3–9]. How- ever, some doubts weigh on this fnal difusion, such as its usefulness within a cost/beneft analysis and the possible presence of atypical recurrences that some authors have hypothesized, including peritoneal carcinomatosis, extrapel- vic lymph node metastasis and port-site metastasis [10, 11]. The objective of this systematic review is to evaluate the current evidence regarding atypical metastases in patients undergoing RARC. Atypical recurrences after laparoscopic and robotic surgery: defnition, types and overview The transitional cell carcinoma (TCC) is a tumor with a high risk of local recurrence and metastasis, [12, 13] which is even more if TCC is associated with some rare histological variants [14]. If local recurrences occur at the pelvic level, the main sites of distant metastases are represented by lymph * Guglielmo Mantica guglielmo.mantica@gmail.com 1 Department of Urology, Policlinico San Martino Hospital, University of Genoa, Largo Rosanna Benzi 10, 16130 Genoa, Italy 2 Department of Urology, San Rafaele Turro Hospital, San Rafaele University, Milan, Italy