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© Translational Andrology and Urology. All rights reserved. Bladder cancer is the 9 most common cancer in the world and 4 most common cancer diagnosed in men in the United States (1). The age-standardized incidence rate (per 100,000 person/years) is 9.0 for men and 2.2 for women (2). Approximately 30% of patients diagnosed with nonmuscle invasive bladder cancer (NMIBC) progress to muscle invasive bladder cancer (MIBC), while a further 25% present upfront as MIBC (1). The treatment options are based upon stage at diagnosis. The current standard of care for the treatment of MIBC is radical cystectomy (3-5). Bladder sparing approaches are an alternative for patients with MIBC who are too comorbid to undergo a radical cystectomy or who refuse a radical. The guidelines regarding MIBC from the urological societies [European Association of Urology (EAU), American Urological Association (AUA), American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), Society of Urologic Oncology (SUO) and National Comprehensive Cancer Network (NCCN)] recommend radical cystectomy and pelvic lymph node dissection as the gold standard treatment for patients with MIBC. There is also evidence supporting the use of cisplatin-based neoadjuvant chemotherapy (3-5). A significant proportion of MIBC patients still develop metastatic disease despite stage appropriate treatment with radical cystectomy and neo-adjuvant chemotherapy (3). The 5-year overall survival with MIBC is only 50% despite treatment (6). Untreated patients do very poorly with symptomatic local progression, development of metastases and mortality. Fewer than 15% survive longer than 2 years if untreated (1). In the article entitled ‘Long-term Oncological Outcomes from an Early Phase Randomised Controlled Threearm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL)’ published in European Urology in January 2020, the bladder group from Guy’s and St Thomas’ Hospital in London report the oncological outcomes of a randomized control trial (RCT) of radical cystectomy operative technique (7). The CORAL trial was a three arm RCT comparing open, laparoscopic and robotic radical cystectomy. With over 5 years of follow-up, 60 patients were randomized with primary end points of recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS). The authors concluded robotic and laparoscopic radical cystectomy achieved equivalent oncological outcomes to the gold standard of open radical cystectomy. The 5-year RFS was 60%, 58%, and 71%; 5-year CSS was 64%, 68%, and 69%; and 5-year OS was 55%, 65%, and 61% for open, robotic, and laparoscopic radical cystectomy, respectively. There was no significant survival differences noted based on surgical modality. The durability of open radical cystectomy is well known from numerous large retrospective studies. The goals in the management of MIBC include oncological and functional outcomes as well as quality of life. Any move to a minimally invasive approach needs to at the very least match that of open cystectomy. The 5 and 10-year OS rates associated with open radical cystectomy have been reported around 60–66% and 43%, respectively (8,9), which are comparable to the 5-year OS results of the CORAL trial. Furthermore, similar to the findings of the CORAL Trial, an open series by Madersbacher et al., revealed a high rate of undiagnosed nodal metastases (24%) which were associated with poor Editorial Commentary

Radical cystectomy—what is the optimal surgical approach?