EURURO Vol. 71 No. 5

725 844

urethelial cancer. Four of the five patients with peritoneal
carcinomatosis presented with multiple metastases, and
80% had postoperative upstaging of disease from organ-
confined to non–organ-confined disease on the pathologic
specimen report; only one of these patients (20%) received
neoadjuvant chemotherapy. These findings indicate that
peritoneal carcinomatosis due to tumour seeding is related
to tumour biology rather than the pneumoperitoneum or
other effects of an RARC approach.
It is important to replicate the oncologic principles of
open surgery during RARC. Indications and contraindica-
tions for totally intracorporeal RARC, along with the
preoperative work-up, patient preparation, and a standar-
dised RARC surgical technique with extended PLND
template, have previously been described Accepted
early indicators of oncologic efficacy include PSM rates and
lymph node yields . Our multi-institutional database
shows respectable PSM rates of 4.8% and median extended
PLND yields of 18, consistent with open series . On
multivariable analysis the risk of recurrence was associated
with positive compared to negative lymph nodes (N1 vs N0:
hazard ratio [HR] 3.6, p < 0.0001; N2 vs N0: HR 5.6,
p < 0.0001) and with pathologic non–organ-confined com-
pared to organ-confined disease (HR 3.8, p < 0.0001), and
was negatively associated with pT0 compared to organ-
confined disease (HR 0.3, p < 0.001). On univariable
analysis, PSMs (HR 4.49, p < 0.0001), selection for ileal
conduit urinary diversion versus neobladder (HR 1.88,
p < 0.001), and female gender (HR 1.63, p < 0.01) were all
associated with a higher risk of recurrence. Neobladder
patients are generally younger with less advanced disease
, and female gender has been identified in ORC as an
independent adverse prognostic factor for both recurrence
and progression of bladder cancer . These findings are
consistent with findings in large ORC series, giving a further
indication that early recurrences following RARC are
primarily related to tumour biology . Limitations of this
study include the retrospective review, patient selection
bias, and inclusion of learning curves. Despite the inclusion
of learning curves, 32.6% of RARC patients had pT3/4 disease
and 18.0% had positive lymph nodes.
No unusual recurrence patterns after RARC were
identified in this multi-institutional study. Early recurrence
rates and sites of recurrence appear similar to those for ORC
series. Indicators of oncologic efficacy, namely PSM rates
and PLND yields, are comparable to ORC series. Positive
lymph nodes, non–organ-confined disease, and PSMs were
associated with early recurrences, indicating that early
recurrences following RARC are primarily related to tumour
biology and not the modality of surgical treatment.
Histopathologic stage pT0 was a positive prognostic factor
for favourable oncologic outcomes.
Author contributions : Justin W. Collins had full access to all the data in the
study and takes responsibility for the integrity of the data and the accuracy
of the data analysis.
Study concept and design: Collins, Hosseini, Adding, Wiklund.
Acquisition of data: Collins, Hosseini, Adding, Koupparis, Rowe, Perry,
Issa, Schumacher, Wijburg, Canda, Balbay, Decaestecker, Schwentner,
Stenzl, Edeling, Pokupic´, D’Hondt, Mottrie, Wiklund.
Analysis and interpretation of data: Nyberg, Collins, Adding, Wiklund.
Drafting of the manuscript: Collins, Hosseini, Adding, Wiklund.
Critical revision of the manuscript for important intellectual content:
Hosseini, Adding, Koupparis, Rowe, Perry, Issa, Schumacher, Wijburg,
Canda, Balbay, Decaestecker, Schwentner, Stenzl, Edeling, Pokupic´,
D’Hondt, Mottrie, Wiklund.
Statistical analysis: Nyberg, Collins, Adding, Wiklund.
Obtaining funding: None.
Administrative, technical, or material support: Nyberg, Collins, Adding,
Wiklund.
Supervision: Wiklund.
Other: None.
Financial disclosures: Justin W. Collins certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at
.
References
[1]
.
[2]
.
Table 2 – Kaplan-Meier estimates of frequency of recurrence by site
Estimated recurrence rate (%)
3 mo 12 mo 24 mo
Any recurrence 4.1 19.8 25.4
Local recurrence 1.8 8.2 10.7
Cystectomy bed 0.7 2.8 3.4
Distal ureteric 0.1 0.3 0.5
Urethral 0.0 0.1 0.5
Pelvic lymph nodes 1.0 5.3 7.2
Distant recurrences 3.0 13.9 17.8
Lung 1.1 4.6 6.2
Liver 0.8 4.1 5.5
Bone 1.0 5.2 6.4
Brain 0.1 0.6 1.0
Adrenal 0.0 0.3 0.7
Bowel 0.0 0.3 0.3
Pancreas 0.0 0.1 0.1
Extrapelvic lymph nodes 1.4 4.9 6.6
Peritoneal carcinomatosis 0.3 0.7 0.7
Port site 0.0 0.3 0.3
Skin 0.0 0.1 0.1
Muscle 0.0 0.2 0.2
Secondary urothelial cancer
Upper urinary tract 0.0 0.3 0.3
Multiple recurrences 2.0 8.0 11.0
E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 7 2 3 – 7 2 6 725