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EDITORIAL COMMENT This is an impressive and important series from a high volume center dealing with early complications occurring within 30 days and late complications occurring within 90 days after radical cystectomy. These data are helpful for decision making, especially for patients for whom major surgery is critical or when, in anticipation of high postoperative morbidity leading to readmission, prophylactic treatment may be advisable. Radical cystectomy is still the best and preferred option for the treatment of locally advanced bladder cancer.1 However, this is only if patients survive and comorbidities of the treatment are acceptable. We have to consider that like in many other series some of those 6.9% of patients dying of the surgical intervention might have had favorable disease and would have survived by applying bladder conserving noninvasive or minimally invasive strategies. Of the comorbidities ileus is one of the most frequently noted reasons for early readmission to hospitals. It seems that laparoscopic or robotic assisted laparoscopic cystectomy reduces bowel related side effects due to a more delicate handling of gastrointestinal segments and, therefore, may be able to decrease bowel problems in the future.2
Pyelonephritis, urinary tract infection and fever account for 25% and 20% of early and late complications, respectively, leading to readmission in this series. The rate of pyelonephritis was more commonly seen in patients with orthotopic neobladder compared to ileal conduit. Therefore, we have to rethink the postoperative regimen with regard to type and length of postoperative antimicrobial and maybe antifungal treatment. The gender related difference in the readmission rate is surprising. It is difficult to find a clue for this significant difference. In a recent study a gender and race related difference was seen with regard to early tumor progression in favor of men but it is improbable that this in any way affected 90-day morbidity.3 Bowel related problems, pyelonephritis, and other inflammatory and infectious complications are important for the decision of whether to perform cystectomy and for the possible application of prophylactic treatment. However, patient gender alone should not be of any consequence with regard to the indication for cystectomy or the type of urinary diversion until we know the cause. Arnulf Stenzl Department of Urology Eberhard-Karls University Tübingen, Germany
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