Editor’s ChoiceThe evolution of robotic cystectomy

A decade has passed since the publication of the first series ofrobot-assisted radical cystectomies in the BJUI by Menon et al.[1]. New technologies are fascinating, and many surgeons whoaspire to leave a mark in history take the lead in pioneering newprocedures. Others follow without waiting for any evidence tojustify the adoption of new procedures. In this race, the opinionof the most important stakeholder, the patient, gets ignored.

Although their study has many methodological flaws, Guruet al. [2] have made the effort to collect data on patients’health-related quality of life (HRQL) after robot-assistedradical cystectomy for bladder cancer. Radical cystectomy is amorbid procedure with a serious impact on patients’ HRQL,no matter how it is performed. Loosing an organ which isresponsible for the storage and evacuation of urine severaltimes a day and replacing it with alternatives of continent orincontinent diversion has a serious impact on quality of life, asis evident from this study.

Robotic cystectomy is still evolving. With more experience, afew experts have ventured to perform intracorporealreconstruction of the urinary diversion. While we await thelong-term functional outcomes of this switch over in surgicalapproach, Guru et al. report the short-term HQRL outcomesin a series of 43 patients undergoing robot-assisted radicalcystectomy and intracorporeal urinary diversion at theirinstitution. Most patients (n = 38) had ileal conduit urinarydiversion. The authors went on to compare the postoperativeoutcomes of this cohort with another group of 70 patientswho only completed the questionnaire after having undergonerobot-assisted radical cystectomy and extracorporeal urinarydiversion.

It is interesting to note that there was no significant differencein HRQL between those undergoing extracorporeal and thoseundergoing intracorporeal reconstruction. These outcomesreinforce the need to gather robust scientific evidence fromproperly conducted multi-centre, multinational randomizedtrials before the introduction of new procedures, instead ofevaluation with retrospective studies. The urological communityhas embraced new technologies and patients have benefited agreat deal from these innovative approaches; however, it isincumbent upon us to develop a culture of independent,unbiased data collection on outcomes. In this regard we mustmake the HQRL one of the most important quality indicators inassessment of the new procedures. Such an approach will enableus to justify the extra cost which society has to bear for ourinnovative trends in the management of old problems [3].

Conflict of InterestNone declared.

Muhammad Shamim Khan

Guy’s and St Thomas’s Hospital and King’s College London,London, UK

References1 Menon M, Hemal AK, Tewari A et al. Nerve-sparing robot-assisted

radical cystoprostatectomy and urinary diversion. BJU Int 2003; 92: 232–62 Poch MA, Stegemann AP, Rehman S et al. Short-term patient reported

health-related quality of life (HRQL) outcomes after robot-assisted radicalcystectomy (RARC). BJU Int 2014; 113: 260–5

3 Wang TT, Ahmed KA, Khan MS et al. Quality-of-care framework inurological cancers: where do we stand? BJU Int 2011; 109: 1436–43

A bit of LESS appears to be more

In this issue of the BJUI, Springer et al. [1] present amulti-institutional analysis of oncological outcomes and renalfunction after laparoendoscopic single-site surgery partialnephrectomy (LESS-PN).

Nephron-sparing surgery is the reference standard for smallrenal tumours, with a goal of optimising overall renal functionafter ablative surgery. Laparoscopic PN (LPN) is an everincreasingly used treatment option in the management of small

renal masses, demonstrated to render equal oncological efficacy[2] with improved convalescence compared with open PN [3].All laparoscopic urological procedures have been performedusing LESS, and it was no great surprise to receive this articlefor review. Data over a period of 5 years has been analysed; thestudy design is admittedly somewhat flawed, as patient selectioncriteria and surgical technique was not standardised. Theauthors conclude that, although challenging LESS-PN isoncologically safe, with outcomes equivalent to LPN.

BJU Int 2014; 113: 178–183© 2014 The Author

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