We thank the authors for their kind appreciation and keen observations. We performed a randomized controlled trial assessing enhanced recovery after surgery (ERAS) protocol for patients undergoing radical cystectomy in the Indian setting.[1] Our study population included patients undergoing both ileal conduit (51 patients) and neobladder formation (3 patients). As the authors suggest, the patients undergoing neobladder formation are logically expected to have a longer operative time and delayed bowel recovery compared to patients undergoing ileal conduit. However, the aim of the current study was not to compare the outcome of patients undergoing ileal conduit versus neobladder formation. Because only three patients underwent neobladder formation at our center during our study period, a subgroup analysis was not done. In addition, stratified randomization of the patients would have been required in that case. However, a prospective study may be planned to evaluate that aspect.
One patient in our study had cT4b disease on exploration and underwent bilateral ureterostomy formation. We do agree with the authors that neoadjuvant chemotherapy followed by cystectomy is the ideal option in locally advanced cases. However, in real-life scenario, it is not always feasible to give neoadjuvant chemotherapy in every case. In this case, the disease looked resectable on preoperative clinical examination and cross-sectional imaging. However, intraoperatively, the patient was found to have an unresectable disease. Because the patient was planned for chemotherapy afterward, bilateral ureterostomy was done to preserve both the functioning kidneys so as to preserve maximum renal function.
We routinely perform open radical cystectomy at our center. We agree that the use of minimally invasive technique with intracorporeal conduit formation is another component of the ERAS protocol and can further help to reduce the morbidity of the procedure, as supported by recent single-institution studies.[2,3] However, further multi-institutional research with larger sample size is required for a definitive answer.
Footnotes
Financial support and sponsorship: Nil.
Conflicts of Interest: There are no conflicts of interest.
REFERENCES
- 1.Bansal D, Nayak B, Singh P, Nayyar R, Ramachandran R, Kumar R, et al. Randomized controlled trial to compare outcomes with and without the enhanced recovery after surgery protocol in patients undergoing radical cystectomy. Indian J Urol. 2020;36:95. doi: 10.4103/iju.IJU_11_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Tamhankar AS, Ahluwalia P, Patil SR, Nambiath S, Gautam G. Implementation of ERAS protocol in robot-assisted radical cystectomy with intracorporeal ileal conduit urinary diversion: An outcome analysis beyond the learning curve. Indian J Urol. 2020;36:37–43. doi: 10.4103/iju.IJU_207_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Khan MS, Omar K, Ahmed K, Gan C, van Hemelrijck M, Nair R, et al. Long-term oncological outcomes from an early phase randomised controlled three-arm trial of open, robotic, and laparoscopic radical cystectomy (CORAL) Eur Urol. 2020;77:110–8. doi: 10.1016/j.eururo.2019.10.027. [DOI] [PubMed] [Google Scholar]