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EDITORIAL COMMENTInterest in RARC has increased in recent years, and, as in otherareas of urology in which robotics has taken hold, enthusiasmand early adoption have been largely based on the belief thatrobotics can improve the outcomes.

In this issue of Urology, Stegemann et al report their short-term outcomes after RARC. Importantly, they used a reliableand validated health survey—CARE—to prospectively assessvarious aspects of recovery (eg, activity, cognition, gastrointes-tinal function, and pain) among 91 patients treated at theirinstitution from 2008 to 2010. Most notably, they found thatalthough certain aspects of health, such as pain and cognition,recovered relatively promptly, others lagged or did not recovercompletely. For example, activity and gastrointestinal functionwere affected to the greatest extent after cystectomy (66% and56% decline, respectively, in baseline scores just 1 week aftersurgery) and were also the slowest to recover. Although thepain and cognition domains recovered to 90% of baselinewithin 2 months of cystectomy, the activity scores did not reachthat level until the 3-month mark, and the gastrointestinalscores failed to reach the 90% threshold. As 1 of the first reportsto assess the changes in short-term outcomes after roboticcystectomy, this study provides important new informationregarding the recovery trajectory associated with robotic cys-tectomy.

Most urologic oncologists who perform a large number ofcystectomies will likely recognize the recovery patterns identi-fied by the authors, particularly with regard to the slow return

of physical activity and gastrointestinal function and the

ROLOGY 79 (6), 2012

3-month period, which often marks when patients begin to feel“normal” after cystectomy and urinary diversion. However, al-though the authors have succeeded in shedding light on howpatients recover after robotic cystectomy, this study is notwithout significant shortcomings. Perhaps most notably, nocomparison with open cystectomy was included; thus, it isunclear whether RARC actually translates into better outcomes(in this case, more timely and complete recovery from surgery).The 8-day average hospitalization reported in their series sug-gests that the morbidity associated with, and the complexity of,cystectomy and urinary diversion might not be mutable andthat recovery after open or robotic cystectomy will follow asimilar pattern. Moving forward, similar assessments amongpatients treated with open cystectomy will be important to putthe findings of this study into context. The infrequent use ofchemotherapy before cystectomy (8%) or in the adjuvant set-ting (22%), despite a large number of advanced-stage cases(46% Stage T3-T4) also highlights that although this group isat the forefront of exploring the utility of RARC, other pro-cesses of care known to be associated with better outcomescould be used more commonly. From an outside perspective, itseems inconsistent to adopt and widely use unproved or under-evaluated therapies (eg, robotic surgery) while failing to pre-scribe well-supported and effective processes of care (eg, neo-adjuvant chemotherapy). Fortunately, the expansion of roboticsto bladder cancer has engendered greater awareness of the needto more critically evaluate its use and efficacy. Consequently,several randomized controlled trials comparing robotic andopen cystectomy are currently underway. Will robotic cystec-tomy be a winner? Time, and evidence, will tell.

Scott Gilbert, M.D., M.S., F.A.C.S., Division of UrologicOncology, Department of Urology, University of Florida,Gainesville, Florida

doi:10.1016/j.urology.2011.12.063UROLOGY 79: 1279, 2012. © 2012 Elsevier Inc.

REPLYWe welcome the opportunity to publish our report in this issueof Urology and appreciate the editorial comments from Gilbert.In recent years, the volume and merit of QOL research oncystectomy and urinary diversion have increased. Validatedinstruments are now frequently used to measure QOL.1 A clearnalysis of our QOL report shows that we do not assert thatARC “translates to better outcomes” compared with open

adical cystectomy. Additional evaluation of peer-reviewedOL studies of open radical cystectomy, not RARC, has estab-

ished 2 primary conclusions. In a comprehensive literatureeview, Gerharz et al2 found that no level I evidence existed forOL reporting. In a more recent report published in 2011, Shih

nd Porter1 concluded that the vast majority of QOL studieswere retrospective and cross-sectional in nature. To the best ofour knowledge, this is the first published study to evaluateimmediate QOL in patients after RARC and 1 of the fewprospective studies comparing both preoperative and postoper-ative QOL measures.

The commentator directly refers to the infrequent use ofchemotherapy (8% neoadjuvant; 22% adjuvant) in our studypopulation. However, a recent multi-institutional report from

15 academic centers and nearly 5000 patients who underwent

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