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Platinum Priority – Editorial

Referring to the article published on pp. 723–726 of this issue

Upholding Rigorous Standards: Comparable Patterns and Rates of

Recurrence Between Open and Robot-assisted Radical Cystectomy

Nieroshan Rajarubendra, Monish Aron


USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

Robot-assisted radical cystectomy (RARC) has seen remark-

able growth in the last decade


. The technique is evolving

and outcomes have been evaluated in several retrospective

studies. To date, four prospective randomized trials have

been published comparing outcomes between RARC and

open radical cystectomy (ORC)


. All of the randomized

trials so far have shown at least equivalence in outcomes,

but most of the diversions in these trials have been

performed in an extracorporeal fashion. There are not too

many centers in the world that routinely perform totally

intracorporeal RARC, and hence multicenter collaboration is

critical in this arena. In this issue of

European Urology


Collins and colleagues


report on a multicenter study

from the European Robotic Urology Section (ERUS) scien-

tific working group that focuses on early recurrence

patterns following totally intracorporeal RARC.



was pooled from nine different European centers,

resulting in a cohort of 717 patients, treated by surgeons

with varying techniques and levels of experience. One needs

to keep in mind that recurrence rates and patterns can vary

depending on individual surgeon expertise and experience.

It would be interesting to see such stratification after

correcting for stage, grade


, variant histology, and adminis-

tration of neoadjuvant chemotherapy. Tabulation of insti-

tutional origin of the cases would be interesting to see

where the bulk of the operations were performed. To the

authors’ credit, they do acknowledge that the study is

retrospective and has selection bias.

Technique and experience with totally intracorporeal



has been evolving over the years. It has been shown

that increasing experience improves not only efficiency but

also outcomes

[7] .

We agree that a skillfully performed

RARC is as robust an operation as a skillfully performed ORC

in the hands of equally experienced surgeons who treat

bladder cancer routinely. It is heartening to see that the

recurrence patterns in this series are similar to those for

ORC, even when cases during the surgeons’ learning curve

are included. It is impressive to see low positive surgical

margins even during the surgeons’ learning curve, including

for T3 and T4 disease. This could potentially be attributed to

mentoring by more experienced surgeons and possibly

prior experience with robotic pelvic surgery, and ORC,

providing a smoother transition


. In addition, it

is possible that the cases in the lower-volume centers

were performed more recently, and these surgeons

benefited from established, published techniques and

experiences with intracorporeal diversion.

A previous paper published by Nguyen et al



a higher rate of recurrence in extrapelvic lymph nodes and

peritoneal carcinomatosis for RARC compared to ORC.

However, the same group published an updated report

earlier this year after accruing further cases, and indicated

that there was no difference in the patterns of recurrence

between the robotic and open groups

[10] .

They concluded

that the main factor that influenced recurrence was the

pathologic tumor characteristics and not the surgical


The present study showed that positive lymph node

status, extravesical extension, and positive surgical margins

are associated with early tumor recurrence


. Neoadjuvant

chemotherapy was utilized in only 25% of patients in this



. It would be interesting to see if such therapy can

impact recurrence patterns. There were no unusual recur-

rence patterns attributable to RARC. The incidence of

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 7 2 7 – 7 2 8

ava ilable at

journal homepage:

DOI of original article:


* Corresponding author. USC Institute of Urology, Keck School of Medicine, University of Southern California, 1441 Eastlake Ave, NOR 7416, Los Angeles,

CA 90033, USA. Tel. +1 216 5025958; Fax: +1 323 8655530.

E-mail addresses: ,

(M. Aron).

0302-2838/Published by Elsevier B.V. on behalf of European Association of Urology.