Evaluating Surgical Approaches in Advanced Age: A Propensity Matched Analysis of Postoperative Morbidity and Short-Term Outcomes Following Open Versus Robotic Radical Cystectomy (ASPECT Study)

Introduction: The optimal surgical approach for elderly bladder cancer patients remains controversial. We compared perioperative morbidity and short-term outcomes in patients aged ≥75 years undergoing open radical cystectomy (ORC) versus robotic-assisted radical cystectomy (RARC). Methods: A retrospective, multicenter cohort study was performed including 179 patients aged ≥75 years, of whom 101 underwent RARC between 2021 and 2025, and 78 underwent ORC between 2016 and 2020. After 1:1 propensity score matching, 138 patients were analyzed to assess perioperative complications and oncological outcomes, adjusting for age, body mass index (BMI), pathological stage, comorbidities, prior chemotherapy, and type of urinary diversion. Perioperative complications and oncological outcomes were subsequently compared between the two groups. Results: Following propensity score matching, RARC was associated with longer operative time (332 vs. 247 min; p< 0.001) but resulted in significantly lower blood loss (310 vs. 743 mL; p< 0.001), reduced transfusion rates, shorter length of hospital stay (p< 0.001), and fewer overall intraoperative complications (8.7% vs. 18.8%; p=0.04). Patients undergoing RARC also experienced lower rates of any complications (43.4% vs. 62.3%; p=0.02), major complications (Clavien–Dindo III–V: 11.6% vs. 27.5%; p=0.03), and postoperative mortality (1.4% vs. 2.9%; p< 0.001) compared with ORC. In multivariate analysis, surgical approach independently predicted major complications, with RARC conferring a significantly lower risk (OR 0.75; 95% CI 0.51–0.88; p=0.04). Analysis of the learning curve showed a significant reduction in major complications over time for RARC (OR 0.68; 95% CI 0.53–0.93; p=0.01) but not for ORC. Conclusion: RARC offers superior perioperative outcomes, including reduced blood loss, shorter hospitalization, and lower rates of major complications, without compromising oncological control. These data support RARC as a safe and effective option for elderly patients undergoing radical cystectomy.