Editorial Comment on: Rates and Predictors of Conversion to Open Surgery During Minimally Invasive Radical Cystectomy by Ko et al.

With the advancement of laparoscopic and robotic technology, a greater number of uro-oncologic procedures are being performed in a minimally invasive manner. However, since the introduction of minimally invasive radical cystectomy (MIRC), urologists have argued the merits of open radical cystectomy vs MIRC. Often, this is heavily influenced by individual bias, which is frequently driven by a surgeon experience. ^1,2 The initial technique describing nerve-sparing robot-assisted laparoscopic cystectomy and urinary diversion was performed in 2003 in 17 patients. ²

In this article, authors sought to compare ORC with MIRC with respect to oncologic and perioperative outcomes in a retrospective manner by examining the National Cancer Database from 2010 to 2013. The authors found that patients undergoing MIRC exhibited fewer positive surgical margins and a higher lymph node yield with a shorter length of stay and fewer readmission rates than the corresponding ORC cohort. Furthermore, the authors further investigated a specific subset of patients (N = 245) who were converted to ORC and found that patients undergoing conversion were similar to ORC patients with respect to hospital stay and 30-day readmission rates and exhibited poorer perioperative and oncologic outcomes when compared with MIRC patients. The authors concluded that MIRC had superior short-term outcomes than ORC, and patients undergoing conversion to ORC had similarly worse outcomes as ORC compared with MIRC patients.

Comparisons of laparoscopic and robot-assisted MIRC with ORC with respect to perioperative oncologic outcomes and complications, as well as medium-term oncologic and functional outcomes have previously been described, favoring less blood loss, need for transfusion, and lower Clavien >3 complications in the robotic cohort. ^3,4 Single-surgeon experience may reflect particular skills or abilities with open surgery that might not translate fully to MIRC or vice versa.

However, the presented data set is more generalizable to other surgeons in other hospitals. Based on our own substantial experience with MIRC, our perspective has changed as robotic assistance allows ability to observe better tissue planes, better dissection, hemostasis, and allows better lymph nodes dissection, which may not necessarily translate into better long-term oncologic outcomes. ⁵

The authors should be commended for conducting a study with significant power using a nationally available database to highlight the comparisons between ORC and MIRC and patients converted to ORC. However, several limitations exist with this study. First, the etiology or root cause of conversion for n = 245 patients is unknown. The authors attempt to explain that patient-specific factors such as tumor stage do not significantly impact conversion but cannot offer a reason of why conversion occurred. Single-center or multicenter review of individual data may better answer these questions. Moreover, an inherent limitation of the database is the combination of both the laparoscopic and robotic platforms into MIRC. Given the technical challenges of pure laparoscopic cystectomy and the increasing dissemination of robotic technology, the decrease in conversion rates may be attributed to the rise in robotically performed procedures as opposed to pure laparoscopy. Unfortunately, the database may not be able to tease out these differences.

Surgeon experience and expertise matter in ORC and MIRC. The focus for the future should be how to best select patients who will benefit from MIRC without compromising oncologic outcomes.