Commentary on Laparoscopic radical cystectomy for muscle-invasive bladder cancer: pathological and oncological outcomes: Stephenson AJ, Gill IS, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH

Open radical cystectomy (ORC) has been the mainstay of treatment for invasive bladder cancer for decades and remains the standard by which new treatments are judged. Despite improvements in technique and perioperative care, the development of effective perioperative chemotherapy, continent urinary diversion, and extending the limits of pelvic lymphadenectomy, an estimated 35%–50% of patients will die from progressive cancer. Likewise, the impact of RC on the patient in terms of treatment-related morbidity and health-related quality of life is substantial. Laparoscopic RC (LRC) offers patients the potential of decreased morbidity and quicker convalescence, while maintaining oncological efficacy by recapitulating the open technique. We and others have investigated this procedure in selected patients with invasive bladder cancer, with slow and measured progress. We favor an open-assisted approach, performing the urinary diversion through a small midline incision. Preliminary comparative data suggest that open-assisted LRC is associated with reduced blood loss and transfusion requirements and it might improve convalescence. These results are achieved while being comparable with ORC for postoperative complications, positive soft-tissue margin rates, and lymph node counts. This procedure is difficult to learn, and ideally it should be restricted to patients with clinically organ-confined cancers, and carried out by surgeons with extensive experience in pelvic laparoscopic procedures. Randomized trials are necessary to determine if the results achieved with LRC are equivalent to those of ORC.