Refers to article:
The Role of Laparoscopic and Robotic Cystectomy in the Management of Muscle-Invasive Bladder Cancer With Special Emphasis on Cancer Control and Complications
Accepted 3 May 2011
October 2011 (Vol. 60, Issue 4, pages 767 - 775)
We read with great interest the paper by Challacombe et al. concerning minimally invasive radical cystectomy (MIRC)—an impressive review of the literature on this challenging subject . Radical cystectomy (RC) is the preferred treatment for muscle-invasive bladder cancer, but even if both laparoscopic RC (LRC) and robot-assisted RC (RRC) are feasible procedures, these approaches continue to be recommended as optional alternatives . Performing MIRC depends on careful case selection to operate on patients with organ-confined disease, and “the presence of locally advanced disease is a strong contraindication to the MIRC”; however, as emphasized by the authors, some institutes have completely abandoned open RC and offer only LRC or RRC, even in cases of locally advanced bladder cancer .
Because the authors have made these preliminary remarks and assert that an expert surgeon is not supposed to have positive surgical margins (PSMs) in organ-confined tumors, they would be expected to stratify the postoperative data on oncologic outcomes by pathologic stage, so that readers can better evaluate the impact of PSMs reported in these series. For a similar reason, namely, the extreme scarcity of PSMs in highly experienced centers , we feel that the presence of PSM is not such a valuable indicator of oncologic outcome, even if its role as an independent predictor of metastatic progression is well known . In our opinion, a stratification of patients by pathologic stage and by nodal involvement could be more useful for readers and could also complete lymph nodes yield reporting .
We appreciate that Challacombe et al.  discussed concerns regarding peritoneal seeding as an effect of pneumoperitoneum, but despite their encouraging conclusion, we would like to recall our personal experience, specifically, the case of a patient presenting with bilateral inguinal lymph node involvement as first presentation of recurrence of transitional cell carcinoma 7 mo after LRC . When we reported this case, we evaluated the possible role of tissue dissection and retrograde or impaired lymphatic venous flow caused by pneumoperitoneum in the genesis of this unusual presentation of recurrence. For this reason, we still consider LRC an experimental technique, and we would like to wait for the growth of the population of patients treated with LRC and a longer follow-up before considering this approach to be completely safe oncologically.
A further important consideration of the paper is that the evaluation of complications following MIRC is extremely difficult due to the absence of standardization in quality reporting of surgical complications , but it is well accepted that the postoperative morbidity after RC is strongly related to the urinary diversion (UD) used . We believe that stratification of the complications for UD would be of substantial importance in clarifying this point.
Conflicts of interest
The author has nothing to disclose.
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© 2011 European Association of Urology, Published by Elsevier B.V.