Study shows value of radical cystectomy–pentafecta for measuring quality of RARC surgery

A study published in Urologic Oncology demonstrated the value of radical cystectomy (RC)–pentafecta as a tool to objectively measure the quality of surgical outcomes and experience in patients with high-risk bladder cancer receiving robot-assisted RC.1

The RC-Pentafecta consists of absence of early major complications, absence of urinary diversion at 12 months or less, absence of soft tissue in the margins, 16 or more lymph nodes at final pathology, and an absence of clinical recurrence at 12 months. The 5-year OS rate was 71.8% in the RC-Pentafecta group and 59.6% for those who did not experience it (P <.001). The cancer specific mortality-free survival (CSS) rate was 84% in the RC-Pentafecta group and 71% in the non–RC-Pentafecta group (P <.001).

A total of 366 patients were enrolled in the study, 191 of whom achieved the RC-Pentafecta and 175 did not. who that did achieve the RC-Pentafecta had a lower rate or prostatic surgery at 7% compared with 26% of those who did not achieve it (P = .03). At the time of surgery, there were not statistical differences between age, body mass index, American Society of Anesthesiologist score, Charlson Comborbidity index, neoadjuvant chemotherapy, and diabetes mellitus (P ≥.05).

Those who achieved RC-Pentafecta had less blood loss at 300 ml vs 350 ml in those who did not achieve RC-Pentafecta (P = .007), as well as shorter hospital stays (11 vs 13 days; P <.001), lower perioperative mortality (0% vs 3.4%; P <.001), and at 90-days had lower rates of complications at 41% vs 51% (P <.001).

Additionally, 131 patients achieved a pathological T3 , and 50 patients had pN-positive disease in the overall population. Those who achieved RC-Pentafecta had lower rates of pT3 disease at 33% vs 40% for those who did not achieve RC-Pentafecta (P = .04), as well as having lower surgical margin rates (1.5% vs 14.1%; P <.001). Twelve months after RC, 29 patients had disease recurrence, including 5 patients with local recurrence, 2 with upper urinary tract recurrence, and 22 with distant recurrence.

The median follow-up was 29 months, during which those in the RC-Pentafecta group had a 26% overall mortality rate vs 48% for those who did not achieve RC-Pentafecta, and the CSS being 13% vs 30%, respectively. Adjuvant chemotherapy (7.8% vs 8%; P = .08) and salvage chemotherapy (12% vs 17%; P = .03) administration was similar between those who achieved RC-Pentafecta and those who did not.

Significant predictors of overall mortality were found in the Cox’s proportional hazard regression model, including RC-Pentafecta achievement (HR, 0.53; P = .03), pN-positive (HR, 2.19; P = .003), pT of 3 or more (HR, 1.74; P = .04), orthotopic neo-bladder (HR, 0.48; P = .001), and current smoking status (HR, 2.23; P = .007) were all significant predictors.

A sensitivity analysis of Cox’s proportional hazard regression model found those undergoing robot-assisted RC with ileal conduit, achieving RC-Pentafecta (HR, 0.42; P = .005), positive surgical margins (HR, 2.30; P = .005), pN-positive (HR, 2.36; P = .003), pT of 3 or more (HR, 1.32; P = .02), and current smoking status (HR, 2.23; P = .007) were predictors of overall mortality.


1. Piazza P, Bravi CA, Puliatti S, et al. Assessing pentafecta achievement after robot-assisted radical cystectomy and its association with surgical experience: results from a high-volume institution. Urol Oncol. Published Online January 27, 2022. doi:10.1016/j.urolonc.2022.01.001