Editorial Comment from Dr Schiavina et al. to Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy

Although surgical technique and postoperative care have improved over the years, radical cystectomy (RC) plus extended lymphadenectomy and urinary diversion still presents a signifi- cant morbidity rate and potential life-threatening complica- tions. 1,2 The use of standardized methodology in reporting surgical complications is essential to compare the results of each single series; the analysis of possible predictors of com- plications before surgery is important for patient selection, for the prevention of adverse events and for counseling. In this context, Roghmann et al . precisely analyzed their series with a standardized method of evaluation and confirmed that, even in a high volume center, RC is followed by compli- cations in approximately 50–60% of cases, with approximately 15–20% of severe complications and 3–4% of mortality. 3 Unfortunately, one of the most important aspects that is always missing in the surgical series reported in literature is the real experience of the surgeons and the adequacy of the hospital (i.e. the hospital volume). 4 In fact, even within the same depart- ment, there are some important differences among the sur- geons. These differences regard the selection of the patient, the operative techniques and the management of the complications: these disparities could dramatically change the outcome after RC. Furthermore, there might be important differences in the adequacy of the hospital, in terms of intensive care unit, mul- tidisciplinary management of the patients and means, which might modify the final results. In this context, it is very difficult to compare the surgical series, and in particular to honestly predict the complication rate during preoperative counseling when advocating for RC. Despite these limitations, the authors should be congratu- lated, as they precisely reported the complication rate of their series and confirmed that the Charlson Comorbidity Index, American Society of Anesthesiologists score and body mass index should be carefully taken into account before suggesting a RC to a patient. Therefore, besides its major limitations, the current manuscript represents another piece in the complex scenario evaluating the relevance of the complication rates that affect the patients submitted to RC. Recently, robotic-assisted radical cystectomy has been advo- cated in the setting of the reduction of the rate of complica- tions; 5 however, even if some kinds of complication (i.e. wound, infectious and bleeding complications) could be reduced, the whole complication rate is high, with a similar mortality rate as open RC. 6 In fact, even with the help of the most sophisticated technology, bladder cancer is an aggressive and life-threatening disease, and RC plus extended lymph-node dissection and urinary diversion is a very dangerous surgery, 1,7 with no guar- antee of success. Today, an increasing number of older patients with impaired preoperative cardiopulmonary reserve and severe comorbidity might require a RC, as it represents the sole therapeutic option for intractable hematuria in advanced tumors. 8 These are the patients more exposed to the risk of complication or death: in these patients, a “simple” ureterocutaneostomy should sometimes be considered in order to reduce the rate of major perioperative complication and mortality.