Re: Critical Analysis of Early Recurrence after Laparoscopic Radical Cystectomy in a Large Cohort by the ESUT

The authors critically analyze a large cohort by the European Association of Urology Section of Uro-Technology and assess early recurrences after laparoscopic radical cystectomy and evaluation of risk factors, including the impact of pneumoperitoneum. They focus their analysis on patients with favorable pathology (pT2 N0 R0 disease), finding that 27 of 311 patients (8.7%) experienced recurrences during the following 24 months. Surgical negligence was observed in only 1 patient, which was associated with the endo bag rupturing during transvaginal extraction with subsequent vulvar and peritoneal tumor metastasis after 4 months. Among the 27 patients with recurrence a shorter recurrence-free survival was significantly predictive of cancer specific death (HR 0.86, 95% CI 0.78e0.94, p ¼ 0.001) as well as carcinoma in situ on pathological examination (HR 3.68, 95% CI 1.07e12.7, p ¼ 0.039). While analyzing causes of early recurrence, the authors suggest that the continuous insufflation-desufflation and leakage of gas around the portsdwith consequent aspiration of tumor cells via a chimney effectdmay promote tumor seeding (TS).