LAUSR

Experts’ summary: Will open radical cystectomy (ORC) always remain the gold standard for bladder cancer? Robot-assisted radical cystectomy (RARC) is one of the few minimally invasive surgical techniques for which randomized controlled trials have shown equivalence to ORC. The study by Ko and colleagues using data from the National Cancer Data Base demonstrates that RARC has slowly been adopted, with a 10% increase over a decade and a corresponding decline in ORC [1]. When does noninferiority become superiority? The most interesting observation was a low open conversion rate (4.3%) and its continued downward trend. Conversions were independent of or were not impacted by clinical tumor stage or annual RC volumes. Only the year of RARC impacted the conversion rate. This captures the maturation of the modern surgeon's skill (visual cues take over from tactile feedback). The RARC procedures converted to ORC were associated with poorer surgical margins (lack of tactile feedback), lower lymph node yield (despite no difference in node dissections), longer hospital stay, and a higher rate of 30-d readmission, but they were not different from ORCs that were planned a priori. Notably, multivariate analysis revealed that ORC was associated with a greater incidence of positive surgical margins. The increasing rates of RARC and decreasing rates of conversion indicate overall adoption of RARC.