Reconsidering the Role of 12‐Month Recurrence in the Radical Cystectomy‐Pentafecta Metric

摘要

We read with great interest the recent study by Fukuta et al., which offers valuable insight into the prognostic significance of the radical cystectomy–pentafecta in patients receiving neoadjuvant chemotherapy followed by robot-assisted radical cystectomy [1]. Their multi-institutional analysis provides important validation of pentafecta achievement and demonstrates meaningful associations with overall, cancer-specific, and recurrence-free survival among patients treated with neoadjuvant chemotherapy. While the pentafecta has emerged as a comprehensive indicator of perioperative and oncological quality, we would like to raise a point of conceptual consideration regarding its use, specifically the inclusion of “absence of clinical recurrence in the first year” as a component of surgical quality [2]. In daily practice, early recurrence after radical cystectomy is often strongly influenced by tumor biology—such as advanced pathological stage, nodal involvement, variant histology, or occult micrometastatic disease—rather than modifiable aspects of the surgical procedure itself. As a result, patients with inherently aggressive tumor characteristics may be classified as failing to achieve the pentafecta despite undergoing technically sound surgery. This may inadvertently conflate oncologic risk with operative performance and complicate comparisons between institutions, particularly in cohorts with varying proportions of high-risk disease. The requirement for a 12-month observation period also limits the pentafecta's practicality as an early quality indicator. Surgeons and multidisciplinary teams increasingly aim to make postoperative decisions—such as the intensity of follow-up, candidacy for adjuvant therapy, or refinement of surgical techniques—within weeks of surgery rather than 1 year later. When recurrence status is embedded within the quality metric, timely evaluation becomes difficult, and the opportunity to adjust perioperative strategies may be diminished. Furthermore, the pentafecta component related to recurrence may be influenced by institutional differences in neoadjuvant chemotherapy, imaging frequency, and use of adjuvant therapy, factors that extend beyond the control of operating surgeons and may introduce additional heterogeneity. These considerations highlight the need for a complementary, perioperative-focused metric that allows earlier and more direct assessment of surgical quality. Metrics based solely on modifiable surgical factors—such as margin status, lymphadenectomy adequacy, and postoperative complications—can be evaluated within 30 days and may more accurately reflect technical performance. Recently, we have proposed simplified models aligned with this concept [3]. Such early indicators do not replace the pentafecta's oncologic rigor; rather, they provide clinicians with actionable information during the critical early postoperative period. We commend Fukuta et al. for advancing the discussion on cystectomy quality assessment and hope that further debate will help refine quality metrics that balance surgical precision with the inherent biological behavior of bladder cancer. Continued efforts toward the development of timely and equitable evaluation tools will contribute to improved surgical outcomes and more personalized postoperative care. The authors declare no conflicts of interest. This article is linked to https://doi.org/10.1111/iju.70283.