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Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy and 90-Day Morbidity and Mortality Among Patients With Bladder Cancer—Reply
In Reply Drs Sivarajan and Akhter raise several interesting points about our iROC trial. First, we agree that NAC for invasive bladder cancer is standard of care in suitable patients, and we encourage this treatment within our practice. Within iROC, 107 participants (34%) received NAC. The denominator for this percentage included NAC-ineligible participants with either nonurothelial tumors (n = 21) or inadequate kidney function, defined as glomerular filtration rate of 50 mmol/L or lower (n = 25). Tumor heterogeneity was also common (71 participants had mixed histological subtypes for which the role of NAC is uncertain); we did not capture definitive pre–radical cystectomy clinical stage in all participants (of note, the stage data in Table 1 in the article are post–radical cystectomy data and include down-staging among responders to chemotherapy). Thus, at least 39% (107/271) of suitable participants received NAC, but this is an underestimate because the denominator includes participants with non–muscle-invasive cancers or mixed histological subtypes. Use of NAC is common in the UK (eg, 48% in a national data set), and 3 to 4 cycles of gemcitabine-cisplatin is the most frequently used regimen. Adjuvant chemotherapy was not captured in the iROC trial, but its use in node-negative patients is uncommon in the UK. We did observe responses to NAC in the final histological outcomes. Of the 107 participants who received NAC, post–radical cystectomy histology revealed that 24% had pT0 tumors (ie, complete response) and 12% had a partial response, down-staging to pTis-pT1. We agree that the benefits from robotic surgery (vs open surgery) might be greater in participants who are less fit (including those with lower performance status and high number of comorbidities), who have higher body mass index, or who experience fatigue after NAC.
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