We very much agree with the idea of adding alvimopan as a standard component of the perioperative regimen for patients undergoing radical cystectomy as proposed by the editorial commentary. Unlike prior studies which reported the use of alvimopan at high-volume centers, our study identified benefits of thisdrug across a wide range of practices, most of which were relatively lower volume (IQR 5-25 cases/year). We believe that it is among these lower volume centers where alvimopan is likely to be most attractive because the reduced surgical volume may make it more difficult to optimize the perioperative experience for radical cystectomy such as the multidisciplinary efforts of enhanced recovery after surgery and prehabilitation protocols. Therefore, while there is no single approach to reduce surgical morbidity, we believe that alvimopan is an effective adjunct to any strategy improving the care of patients undergoing radical cystectomy.
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