Variable Recurrence Patterns After Cystectomy in Bladder Cancer: Can the Robot Be Blamed?

Radical cystectomy (RC) with extended pelvic lymph node dissection is the gold standard treatment for muscleinvasive bladder cancer (MIBC), yet large series have shown recurrence rates exceeding 40% during extended follow-up [1]. Recurrence of disease often occurs early, with average presentation 10–15 mo after RC and >80% occurring within the first 2 yr after RC [2]. Survival after local (LR) or distant recurrence (DR) remains poor despite local or systemic salvage therapy. Factors consistently acknowledged to be associated with recurrence are advanced pathologic stage, margin positivity, and lymph node involvement. Use of robot-assisted RC (RARC) has increased without definitive evidence of equivalency to open RC (ORC) from a cancer control standpoint. With RARC outcomes exceeding 5 yr now becoming available, further analysis of oncologic outcome is necessary. Effects of RARC such as insufflation, pneumoperitoneum, quality of resection, lymph node dissection, methods for lymph node extraction, and their effect on oncologic efficacy remain unproven. In this issue of European Urology, Nguyen et al [3] examine a singlesurgeon cohort of 383 patients who underwent ORC (n = 120) or RARC (n = 263) and specifically evaluate the recurrence of disease. LR rates and locations were similar between the two groups (18% RARC vs 23% ORC), and although DR rates were also similar (29% RARC vs 36% ORC), the patterns of recurrence differed. The authors noted a higher incidence of extrapelvic lymph node recurrence and peritoneal carcinomatosis after RARC. Of important note, no port-site metastases occurred in the RARC group. The authors should be commended for their meticulous data collection for this large contemporary RC cohort. Their detailed assessment of the incidence and location of disease recurrence provides insight into whether ORC or RARC affects recurrence patterns. Another arguable strength is the single-surgeon experience, which may reduce variability in surgical technique (such as node dissection template) and skill. Several aspects of this retrospective analysis need to be contemplated. Selection of patients for different treatments is a nuance of surgical medicine that can limit comparative analyses. In this study as well as in our experience, patients treated with ORC had worse pathologic disease status. In addition, neoadjuvant, adjuvant, and downsizing chemotherapy were grouped into a single category, and some recurrences were not confirmed histologically. While opinions differ on the boundaries of lymph node dissection (standard vs extended vs superextended [4]), the specific locations of extrapelvic (n = 14) lymph node involvement are relevant in this study, as the proximal limit of dissection was the common iliac nodes. At the City of Hope National Cancer Center we routinely perform dissection above the aortic bifurcation, as our experience shows that 10% of patients with positive lymph nodes have nodes positive at or above this level. With reported median follow-up for RARC not quite 2 yr, this still represents more of an analysis of ‘‘earlier’’ recurrence. The rates of recurrence reported may also be misleading, as the denominator will inherently be lower in the RARC group given that the calculation accounts for patients with follow-up of 2 yr, of which there were fewer in the robotic group. As the authors recognize, even assuming that recurrence patterns do differ, we cannot presume to attribute this to the technique alone. There is debate regarding the optimal monitoring regimens after cystectomy, as detection of recurrent disease