AUTHOR'S REPLY.

First of all, we want to thank Prof. Mark Soloway for his comment on our article [1]. The benefit of laparoscopic radical cystectomy (LRC) with or without prostate capsule sparing (PCS) does not lie in the fact of the decrease in hospital stay when compared with open radical cystectomy (ORC) series. The true value of LRC lies in other aspects, such as decreased perioperative blood transfusion (PBT), less postoperative pain, and faster patient recovery. Nowadays, ORC is the standard treatment for localized muscle invasive bladder cancer. LRC and robot-assisted laparoscopic radical cystectomy (RRC) are feasible, but they are currently considered experimental therapies because of the limited number of cases reported, the absence of long-term oncologic and functional outcome data, and a possible selection bias [2]. Despite this fact, the numbers of series reporting perioperative outcomes and survival of LRC and RRC is increasing in the last decade. ORC is associated with a high rate of transfusion, ranging around 30% in different series [3], but there are a few studies evaluating the relationship between transfusion and survival after this procedure. These authors (JG Rivas, et al.) reported in 2014 a lower survival rate in patients who receive PBT after LRC. Also, we found a relationship between infectious postoperative complications and PBT; these findings are explained via the immunosuppression caused by blood loss and PBT. In this study, we conclude that efforts should be done to limit the use of blood products in patients surgically treated with radical cystectomy for bladder cancer [4]. Regarding pain and fast recovery, the relationship between opioid-based analgesics and postoperative ileus is well known. Guro et al. concluded that patients who underwent robot-assisted radical cystectomy achieved similar pain control but required less opiates than those who underwent open radical cystectomy [5]. The combination of minimally invasive surgery and an early recovery protocol is a feasible multidisciplinary challenge and may be useful in the recovery of patients undergoing LRC, demonstrated by a shorter hospital stay in some studies without increasing the risk of postoperative complications [6].

Long follow up for PSC was reported by Montsouris group [7] in 117 patients and outcomes are comparable with the largest published series of cystoprosatectomies. With appropriate screening, the risk of a clinically significant prostate cancer appears to be low. This technique represents a valuable additional option for bladder cancer treatment for certain selected patients, as commented in our article and as the title of Prof. Mark Soloway's comment states [1, 8].