EURURO Vol. 71 No. 5

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peritoneal carcinomatosis and port-site recurrence was
low. There are many theories about recurrence at the port/
wound site. The most likely causal factor is the biological
aggressiveness of the primary tumor . This has been
seen in laparoscopic surgery for urothelial carcinoma and
renal cell carcinoma, for which port site recurrence was
associated with high-grade tumors. However, this alone
cannot account for this phenomenon; surgical technique
probably has an important role. Tumor violation or spillage
can result in seeding. A study in a rat model demonstrated
that traumatic manipulation of the specimen resulted in
significant contamination when compared to minimal
handling (71% vs [6_TD$DIFF]17%) . There is no convincing evidence
that the pneumoperitoneum, in and of itself, causes unusual
patterns of recurrence.
We agree that pathologic tumor factors are key predictors
of recurrence. However, we cannot neglect the fact that
some will be caused by suboptimal technique, especially as
the popularity of RARC across the world increases and many
more surgeons take on these procedures, emboldened by
their prowess in robotic prostatectomy.
In an operation with high oncologic stakes, adhering to
oncologically sound technical principles is of fundamental
importance in minimizing recurrence. There should be zero
tolerance for tumor violation and for tumor spillage from
the urethra when it is transected, even for an orthotopic
diversion. We favor clipping the urethra at the prostate apex
in men or just distal to the bladder neck in women, even
when planning an orthotopic diversion. The specimen
should be placed in an impervious bag immediately, and the
mouth of the bag tied off securely. Care should be taken
during lymph node dissection to avoid cutting into a lymph
node, as this can result in tumor contamination of the
peritoneal cavity. Nodal tissue should not be left lying in the
peritoneal cavity for later extraction; instead, individual
nodal packets should be removed in real time as they are
dissected, in an impervious reusable retrieval bag to
minimize the chances of contamination of the peritoneal
cavity. Those of us who offer RARC to our patients have a
duty to be vigilant about any potential tumor violation or
spillage. With this approach, the patient is in a steep
Trendelenburg position, and the fluids in the pelvis (blood,
lymphatic fluid, irrigation fluid, and urine) can gravitate to
the paracolic gutters and the general peritoneal cavity.
Thus, if there is any tumor violation or spillage, it is possible
to seed the peritoneal cavity or port sites. By the same
token, we would argue that if there is strong suspicion for
T4b disease (invasion of the pelvic or abdominal wall), one
should be very careful about offering RARC, as this could
lead to tumor violation during surgical excision and open up
unusual patterns of disease spread.
It should be emphasized that summarizing such a large
body of work in a brief correspondence is difficult, and the
authors are to be commended in being specific and concise
in their diligent reporting. We[2_TD$DIFF] believe that RARC and ORC
have similar outcomes in experienced hands. This study
moves the field forward and provides much-needed
ongoing governance in a new and evolving technique.
Conflicts of interest: The authors have nothing to disclose.
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