laparoscopic cystectomy (RALC) and open urinarydiversion. The results show that the complication rateis 34% according to the Clavien classification, includ-ing 5 patients that had to be reoperated. The authorsconclude that RALC with urinary diversion is still atechnique with a high morbidity rate, which, in ouropinion, raises the question of whether this surgicaloption should be labeled as minimally invasive. Wecongratulate the authors for this comprehensive andnonpartisan report on issue that deserves much atten-tion because of the impact on the surgical managementof high-risk transitional cell carcinoma.

As mentioned in this paper, other clinical reports,mostly retrospectives, have been published. The resultsshow that the technique is applicable and facilitates itsexecution with laparoscopy; however, complicationrates are equivalent to open surgery. More recently, arandomized comparison of open vs robotic laparo-scopic cystectomy in 40 patients showed noninferiorityof RALC in the number of dissected nodes; however,morbidity using Clavien classification was equivalent.If clinical results are equivalent, then what could bethe contribution of robotic surgery in this indication?

1. Functional improvement on continence and erec-tile function? It is possible that dissection of theprostatic apex with use of appropriate instrumentsthat reduce the trauma of the pelvic fascia ulti-mately allow better preservation and local healing?This hypothesis will be further tested in a random-ized study (ROBOTCAP, CNIB)

2. Decrease in pelvic trauma? Laparoscopic cystectomywas shown to limit both vascular and musculartrauma, improving the recovery time. However, wellexperienced centers for this intervention showed post-operative morbidities lower than that observed in thisstudy. The question here relates to the benefit ofrobotic over laparoscopic or open surgery, which mustbe addressed in a randomized trial. Noninferiority doesnot imply superiority. Larger randomized, multicentricstudies should be done.

3. The problem of urinary diversion remains unresolved.Studies show that urinary diversion is performed exsitu, which partly explains the equality of techniquesin terms of postoperative morbidity. The “robolution”for cystectomy will be when the entire operation willbe safely performed with the help of the robot. It willthen be possible to compare techniques.

4. The socioeconomic issue remains unresolved. Theeconomic model of the Da Vinci robot was made as anopen offer to any surgeon willing to develop laparos-copy. The additional cost of these technologies isalready an economic issue for health insurances be-cause their superiority is not correctly demonstrated.It is therefore important for the international urolog-ical community to know precisely the clinical contri-bution of robotic surgery and the price payable for

each benefit. The authors of this paper clearly showed

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that the additional costs of RALC do not reduce theadditional costs of postoperative morbidity.

There are always many questions raised about theintroduction of robotics in our surgical specialty. Asother systems will be developed in the years ahead, itwould be appropriate to list the clinical and economicobjectives of these new technologies.

Marc Colombel, M.D., Ph.D.Service d’Urologie et Chirurgie de la Transplantation

Hôpital Edouard HerriotLyon Cedex 03, France

Reply

TO THE EDITOR:

We thank the authors for their comments concerning ourpaper on the morbidity of robotic-assisted laparoscopicradical cystectomy (RARC). They suggest that RARCmight not be considered minimally invasive due to thehigh rate of complications we have reported. RARC is aminimally invasive but major and complex operation andwe feel that the frequency of complications should not bethe primary determinant of whether a procedure isdeemed minimally invasive in nature or otherwise. Therate of complications in radical cystectomy by whateverapproach reflects the age and comorbidity of the patients,combined with the duration and complexity of the op-eration. As we become better at recognizing and record-ing perioperative complications using the Clavien sys-tem, complication rates have appeared to increase andsome earlier publications reporting postoperative morbid-ity rates in open surgery will become less relevant tocurrent figures as a result.

Regarding the recent randomized trial of RARC,1 al-though Clavien scores showed no difference in this smallstudy, the Nix randomized controlled trial paper doesshow in its secondary endpoints significant differences ina number of postoperative parameters in favor of roboticsurgery. These included estimated blood loss, time toflatus, time to first bowel motion, and in-house analgesiause.

The above commentary questions the benefits ofRARC at all over open surgery, but in our hands, RARChas a significantly reduced blood loss and transfusion rate,hospital stay, and complication rate when compared witheither its pure laparoscopic or open counterparts.2 It isnot just the size of the skin incision and the potential forintracorporeal reconstruction that provides the potentialpatient benefits in RARC. The learning curve appears tobe around 30 cases, as recently reported by the Interna-

tional Robotic Cystectomy Consortium.3

UROLOGY 77 (4), 2011

We fully agree that further randomized trials are vitalin this area, and such a study comparing all three currenttechniques is currently under way at our institution withthe goal of providing definitive answers to many of thesequestions.

Muhammad S. Khan, F.R.C.S. (Urol.)Benjamin Challacombe, M.S., F.R.C.S. (Urol)

Oussama Elhage, M.R.C.S.Declan Murphy, F.R.C.S. (Urol.)

Prokar Dasgupta, M.D., F.R.C.S. (Urol.), F.E.B.U.Department of Urology

Guy’s HospitalKing’s Health Partners AHSC

London, United Kingdom

UROLOGY 77 (4), 2011

Peter Rimington, F.R.C.S. (Urol.)Department of Urology

East Sussex HospitalEastbourne, United Kingdom

References1. Nix J, Smith A, Kurpad R, Nielsen ME, Wallen EM, Pruthi RS.

Prospective randomized controlled trial of robotic versus open rad-ical cystectomy for bladder cancer: perioperative and pathologicresults. Eur Urol. 2010;57:196-201.

2. Elhage O, Challacombe B, Rimington P, Khan MS, Dasgupta P. Acomparison of perioperative morbidity and oncological outcomes ofopen, laparoscopic and robotic radical cystectomy. Eur Urol. 2010;9(2):322.

3. Hayn MH, Hussain A, Mansour AM, et al. The learning curve ofrobot-assisted radical cystectomy: results from the International Robotic

Cystectomy Consortium. Eur Urol. 2010. [Epub ahead of print].

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