Expanding the role of robotic surgery: Non-inferiority of robot-assisted radical cystectomy in overweight patients with bladder cancer

Obesity is an increasing comorbidity in patients undergoing radical cystectomy. While robot-assisted radical cystectomy (RARC) has been widely adopted, evidence for its safety in overweight patients remains limited. We retrospectively analyzed 337 consecutive patients who underwent RARC or open radical cystectomy (ORC) at a European tertiary center (2013–2024). Outcomes were stratified by body mass index (BMI) and assessed by regression and non-inferiority analyses. In the presented cohort (135 normal-weight and 202 overweight patients) urinary-diversion patterns (continent vs. incontinent) did not differ by BMI or approach. RARC required longer operative times than ORC, but BMI itself had no independent effect. The length of stay (LOS) was shorter after RARC with BMI increasing LOS only in the ORC group. Adjusted models identified ORC as an independent predictor of prolonged stay. Non-inferiority of RARC in overweight patients was demonstrated for both length of stay (p = 0.044) and Clavien–Dindo-graded perioperative morbidity. RARC delivers robust perioperative safety in overweight patients, maintaining non-inferiority for morbidity and LOS. These findings support the use of RARC as a standard approach to radical cystectomy, including in obese populations.