EDITORIAL COMMENT

Open radical cystectomy (ORC) is the gold standard treatment option for muscle-invasive urothelial carcinoma. However, evolution is still going on. Nowadays, there is a growing interest for laparoscopic (LRC) and robotic-assisted radical cystectomy (RARC) as well as in kidney and prostate procedures. In the European Urology Association (EAU) guidelines, LRC or RARC are still accepted as investigational options. This remarkable study presented long-term oncological results after LRC. In this multicentric study, 503 patients were included with a mean age of 68 years and median follow-up of 50 months. In previous studies with LRC, patients were younger and with lower stage of disease which was accepted as a bias in reviews. Pathological stage distribution was about 1/3 for groups except pT4 (9%). Median number of retrieved lymph nodes was 14. Although extent of lymphadenectomy in this study was not same between centers and it should be a limitation; median number of nodes was acceptable according to the EAU guidelines (<10). Bricker technique was the most urinary diversion type in this study (69%). The most interesting part in this study was elevated complications. 60 patients (12%) were re-operated within first 30 days. Minor complication rate was 36% (Clavien 1+2). Major complication rate was similar with ORC studies. Conversion rate was 3.4%. Overall positive surgical margin rate was 5.8% (29 patients) while it was a little bit high in pT2b disease (3 of 29). This result should be questioned. It might be explained by ‘learning curve’. Techniques were not standardized between centers although experienced surgeons were in the study. This was one of the limitations of this study. Global recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS9 rates at five years were 66%, 75% and 62%, respectively. These results were comparable with open series in the literature. Lack of randomization is another limitation. All patients had a body mass index of <30 and 28% of patients were in pT1 stage that these might be considered as a selection bias. Overall, this study had the largest patient number in the literature. In future, with using a standardized technique, this procedure will move one step forward. However, one should consider that success of LRC is highly dependent on surgeon’s experience and especially in learning curve, safety of oncologic control is much more important.