Impact of body mass index on radical cystectomy

Risk factors for mortality and morbidity related to radical cystectomy

OBJECTIVES

To evaluate the risk factors for mortality and morbidity related to radical cystectomy (RC) in a medium-sized academic centre, and to analyse the rate and trends of perioperative morbidity and mortality, as although complications related RC to are lower in modern than historic series, RC is still associated with marked risks.

PATIENTS AND METHODS

The study included 258 patients undergoing RC for bladder cancer in Turku University Hospital in 1986-2005. Basic patient characteristics and in-hospital, early (from hospital discharge to 3 months) and combined morbidity and mortality were analysed. Risk analysis included 16 risk factors for complications. Trends were analysed by comparing the two study decades (1986-1995 vs 1996-2005).

RESULTS

The total complication rate was 34%, with minor and major complications in 26%, and 11% of patients, respectively. There were no significant changes in total morbidity, but the number of myocardial infarctions and atrial fibrillations decreased significantly (P = 0.045). Operative mortality was 2.7%, with an insignificant decrease (4.2% to 0.9%, P = 0.11) over time. Salvage RC, high American Society of Anesthesiologists (ASA) score (> or = 3), extensive blood loss (>3 L), a high number of transfusions (five or more), several comorbidities (two or more), age (> or = 65 vs <65 years), and extravesical tumours were significant risk factors for major complications. An ASA score of > or = 3 and five or more transfusions were the only factors associated with mortality. A high ASA score (odds ration 3.25, 95% confidence interval 1.08-9.74) and high number of transfusions (2.74, 1.05-7.15) were independent risk factors for major complications.

CONCLUSION

Although RC is associated with acceptable morbidity, attention should be given to risk factors identified at the time of patient selection, and to meticulous haemostasis at the time of surgery. A predictable outcome comparable to that in high-volume centres is also possible in a medium-sized hospital.

Impact of body mass index on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery

BACKGROUND

Obesity is an increasingly common serious chronic health condition. We sought to determine the impact of body mass index (BMI) on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery.

METHODS

A prospective, multi-institutional, risk-adjusted cohort study of patients undergoing major intra-abdominal cancer surgery was performed from the 14 university hospitals participating in the Patient Safety in Surgery Study of the National Surgical Quality Improvement Program (NSQIP). Demographic, clinical, and intraoperative variables and 30-day morbidity and mortality were prospectively collected in standardized fashion. Analysis of variance, Bonferroni multiple comparisons of means tests, and multivariable logistic regression analysis were performed.

RESULTS

We identified 2258 patients who underwent esophagectomy (n = 29), gastrectomy (n = 223), hepatectomy (n = 554), pancreatectomy (n = 699), or low anterior resection/proctectomy (n = 753). Patients were stratified by National Institutes of Health (NIH)-defined BMI obesity class, with 573 (25.4%) patients classified as obese (BMI > 30 kg/m(2)). There were no differences in mean work relative value units, total time of operation, or length of stay amongst the BMI classes. After adjusting for other risk factors, obesity was not a risk factor for death or major complications but was a risk factor for wound complications. The risk of postoperative death was greatest in underweight patients (odds ratio [OR] 5.24; 95% confidence interval [CI] 1.7-16.2).

CONCLUSION

In patients undergoing major intra-abdominal cancer surgery, obesity is not a risk factor for postoperative mortality or major complications. Importantly, underweight patients have a fivefold increased risk of postoperative mortality, perhaps a consequence of their underlying nutritional status.

Does obesity impact the costs of partial and radical nephrectomy?

PURPOSE

We analyzed the impact of obesity on the costs of partial and radical nephrectomy.

MATERIALS AND METHODS

The charts of 237 patients who underwent open radical nephrectomy (48), laparoscopic radical nephrectomy (67), open partial nephrectomy (61) or laparoscopic partial nephrectomy (61) were retrospectively reviewed. Clinical data were collected, including age, American Society of Anesthesiologists score, body mass index, tumor size, complications and length of stay. Cost data comprised total direct costs and subcosts, including anesthesia, laboratory, operating room service, radiology, room and board, pharmacy and surgical supplies. Obese and nonobese patients were compared in each group using the Mann-Whitney U and chi-square tests for continuous and categorical variables, respectively. Univariate analysis was used to assess predictors of direct costs.

RESULTS

Length of stay was longer in obese patients in the open partial nephrectomy group (p = 0.04). There were no differences between obese and nonobese patients in terms of complications and comorbidities. Costs were higher in obese patients in the open partial nephrectomy group ($10,187 vs $6,538, p = 0.02). There were no other differences in cost between obese and nonobese patients in the 3 other surgical groups. On univariate analysis length of stay robustly predicted the cost of each kind of operation (p <0.0001). Obesity status was almost a significant predictor of direct cost in the open partial nephrectomy group (p = 0.056).

CONCLUSIONS

Body mass index had an impact on costs only in the subset of patients who underwent open partial nephrectomy. Length of stay seems to be the main determinant of costs in renal surgery. Further studies are warranted.

Contemporary open radical cystectomy: analysis of perioperative outcomes

PURPOSE

The feasibility of laparoscopic or robotic assisted radical cystectomy has been demonstrated in several small series, but the specific advantages are uncertain and require comparisons to more recent results that incorporate refinements in open technique and perioperative management. We reviewed our contemporary radical cystectomy series to evaluate perioperative outcome measures which could be affected by surgical approach for the purpose of establishing contemporary benchmarks for future comparisons.

MATERIALS AND METHODS

The medical records of 553 consecutive patients undergoing radical cystectomy from January 2000 through June of 2005 were reviewed. Perioperative and demographic data, type of urinary diversion, hospital stay, complications and perioperative mortality were examined.

RESULTS

Median patient age was 69 years (range 22 to 94) and average American Society of Anesthesiologists classification was 2.7. Median operative time was 258 minutes (range 89 to 801). Mean operative time for ileal conduit diversion was 271 vs 312 minutes for neobladder diversion. Median blood loss was 600 ml (range 200 to 4,200). A total of 210 patients (38%) received a blood transfusion either intraoperatively or within the first 30 days of their procedure. Median length of hospital stay was 6 days (range 4 to 79). Minor and major complications occurred in 209 (38%) and 41 (7.4%) patients, respectively. Perioperative mortality was 1.7%.

CONCLUSIONS

These results demonstrate that contemporary radical cystectomy can be accomplished through an open operative approach consistently with acceptable morbidity/mortality and with a median length of stay of less than 1 week. Efforts to further reduce morbidity and improve outcomes should continue.

Robotic-Assisted Laparoscopic Radical Cystoprostatectomy

OBJECTIVES

Recent small case series have been reported for robotic-assisted laparoscopic radical cystoprostatectomy. The present literature includes 34 patients who have undergone robotic-assisted cystectomy procedures. We report our initial experience with robotic-assisted laparoscopic radical cystoprostatectomy, describing stepwise the surgical procedure and evaluating perioperative and pathologic outcomes of this novel procedure.

METHODS

Twenty men underwent robotic-assisted laparoscopic radical cystoprostatectomy and extracorporeal urinary diversion for clinically localized bladder cancer. The stepwise operative procedure is described in detail. Outcome measures evaluated included operative variables, hospital recovery, pathologic outcomes, and complication rate. Comparisons were made to these gender-matched 24 men who underwent an open procedure during this same period.

RESULTS

Mean age was 62.3 yr (range: 54-76 yr). Ten patients underwent ileal conduit diversion and 10 patients underwent an orthotopic neobladder. In all cases the urinary diversion was performed extracorporeally. Mean operating room time of all patients was 6.1h (most recent 10 cases, 5.2h). Mean surgical blood loss was 313 ml. On surgical pathology, 14 patients were < or =pT2, 4 patients pT3, and 2 patients N+. In no case was there inadvertent entry into the bladder or positive surgical margins. Mean number of lymph nodes removed was 19 (range: 6-29). Mean time to flatus was 2.1 d and bowel movement 2.8 d. Sixteen patients were discharged on postoperative day (POD) 4, three patients on POD 5, and one on POD 8. There were six postoperative complications (30%) in five patients.

CONCLUSIONS

Our initial experience with robotic-assisted laparoscopic radical cystoprostatectomy appears to be favorable with acceptable operative, pathologic, and short-term clinical outcomes. As our experience increases, we should expect to continue to refine our surgical technique and reduce operating room times. Larger experiences are required to adequately evaluate and validate this procedure as an appropriate surgical and oncologic option for the bladder cancer patient.

A comparison of the Bricker versus Wallace ureteroileal anastomosis in patients undergoing urinary diversion for bladder cancer

PURPOSE

In recent years few studies have evaluated the success and complications of the 2 most common types of ureteroenteric anastomotic techniques, the Bricker and the Wallace anastomosis. We evaluated the complications of the Bricker and Wallace techniques of ureteroenteric anastomosis in a single surgeon, single institution series.

MATERIALS AND METHODS

From 2001 to 2005 a total of 186 patients underwent ileal conduit or ileal neobladder after cystectomy for bladder cancer. All patients were followed for a minimum of 12 months after surgery with complete clinical information. In all cases the ureters were anastomosed to a segment of ileum in a separate (Bricker) or conjoined (Wallace) fashion.

RESULTS

Of the 186 patients 94 underwent a Bricker (51%), 90 underwent a Wallace (48%) and 2 patients underwent both procedures (Wallace on duplicated system on 1 side, Bricker on contralateral side). Ureteral stricture developed in 5 of 186 (2.6%) patients and the overall stricture rate for all ureters was 7 of 371 (1.9%). In patients undergoing Bricker anastomosis the total stricture rate for all ureters was 3.7% (7 of 187). With the Wallace anastomosis the total stricture rate for all ureters was 0% (0 of 184). This difference in stricture rate in the Bricker vs Wallace subgroups was significant (p = 0.015). There was no difference in age, gender, creatinine, prior radiation, complications or mode of diversion between the groups. Body mass index was higher in the Bricker vs the Wallace group (29.0 vs 25.9 kg/m(2)). Of the 5 patients with strictures 1 underwent successful open repair, 1 had successful interventional radiological repair and 3 were treated with chronic ureteral stents (1 after failed open repair and 2 after failed radiological repair).

CONCLUSIONS

Both the Bricker and the Wallace anastomoses provide acceptably low stricture rates in a single surgeon case series. Indeed, the Wallace anastomosis had no strictures in this series. The Bricker group had a higher body mass index which was likely due to the often disparate ureteral lengths in obese patients after retrosigmoidal tunneling, which would have affected the choice of technique.

Radical cystectomy and lymphadenectomy for invasive bladder cancer: towards the evolution of an optimal surgical standard

The surgical management of invasive bladder cancer has undergone a significant evolution in technique since its initial introduction. Changes in the extent of surgery have largely reflected a better understanding of the natural history of bladder cancer and the recognized pathways of progression. Incorporation of contemporary surgical techniques that target the perivesical soft tissues, regional lymph nodes, and adjacent organs appear to enhance oncologic outcomes. A growing body of evidence indicates that the quality of radical cystectomy (RC) directly affects patient outcome. Recently, quality of life and functional considerations have led to surgical modifications such as nerve-, prostate-, vaginal wall-, and urethra-sparing approaches. While some modifications in appropriate candidates appear not to decrease cancer control, further studies will be needed to establish their role and safety. This ongoing evolution in the technique of RC and pelvic lymph node dissection (PLND) may help define a new surgical standard that provides optimal benefit in patients with invasive bladder cancer.

Does Body Mass Index Affect Outcome After Reconstruction of Orthotopic Neobladder?

OBJECTIVES

To evaluate the impact of body mass index (BMI) on outcome after orthotopic neobladder (NB) reconstruction.

METHODS

We performed a retrospective analysis of patients who underwent radical cystectomy and NB from 1992 to 2004. The patients were categorized according to BMI into group 1, BMI less than 25 kg/m2; group 2, BMI 25 to 29.9 kg/m2; and group 3, BMI greater than 30 kg/m2. The relationships among the BMI categories, the predominant complications (eg, urinary tract infection [UTI]; pyelonephritis; ureteral, bladder neck, and urethral stricture), other complications, and continence were analyzed.

RESULTS

Of the 343 patients who underwent radical cystectomy, 116 had an NB. The patient characteristics among the BMI groups were similar. Group 1 had fewer complications compared with the other groups (P <0.012). The principal complications observed were UTI, stricture, and pyelonephritis. The incidence of UTI, pyelonephritis, and wound infection were less in group 1 than in the other groups, with statistically significant differences (P = 0.001, P = 0.04, and P = 0.04, respectively). At the last follow-up visit, only 10% of the patients required clean intermittent catheterization to empty the NB, and no statistically significant differences were found in the continence status and voiding pattern among the groups.

CONCLUSIONS

An increased incidence of UTI, pyelonephritis, and wound infection was found in patients with increased BMI. However, they were transient and not life threatening. The continence and voiding patterns were relatively similar. Hence, an NB can be offered to patients with an increased BMI, and they should be formally counseled.

Standards for Surgical Complication Reporting in Urologic Oncology: Time for a Change

OBJECTIVES

No standards for reporting surgical morbidity exist in the urologic oncology literature, yet surgical outcomes are used to assess the success of surgical techniques and surgeon competency. This study analyzes the quality of complication reporting in the urologic literature.

METHODS

Reports identified by a MEDLINE search reporting surgical outcomes after radical prostatectomy, radical cystectomy, retroperitoneal node dissection, and radical/partial nephrectomy were analyzed using 10 established criteria for surgical complication reporting. Open (n = 73) and minimally invasive (n = 36) surgical series of 50 patients or more published from January 1995 to December 2005 were reviewed.

RESULTS

A total of 109 studies reporting the outcomes for 146,961 patients, including 95 retrospective (87%), 11 prospective (10%), 1 randomized (1%), and 2 population-based (2%) studies were analyzed. Of the 10 critical reporting elements, 2% met 9 to 10, 21% met 7 to 8, 43% met 5 to 6, 30% met 3 to 4, and 4% met 1 to 2 criteria. The most commonly underreported criteria were complication definitions in 79%, complication severity/grade in 67%, outpatient data in 63%, comorbidities in 59%, and the duration of the reporting period in 56%. Additionally, 47% of minimally invasive surgical series met fewer than 5 of the 10 reporting criteria compared with 28% of open series. Of the 36 studies reporting complication severity, a numeric grading system was used in 7 (19%), with 29 (81%) of 36 using a "major versus minor" categorization but using 26 different definitions of what constituted "major."

CONCLUSIONS

The disparity in the quality of surgical complication reporting in urologic oncology makes it impossible to compare the morbidity of surgical techniques and outcomes. Standard guidelines need to be established.

A rationale for developing benchmarks for the treatment of muscle-invasive bladder cancer

Benchmarks are established standards of operation developed by a given group or industry generally designed to improve outcomes. The health care industry is increasingly required to develop such standards and document adherence to meet demands of regulatory bodies. Although established practice patterns exist for the treatment of invasive bladder cancer, there is significant treatment variation. This article provides a rationale for the development of benchmarks in the treatment of invasive bladder cancer. Such benchmarks may permit advances in treatment application and potentially improve patient outcomes.

The impact of tobacco use and body mass index on the length of stay in hospital and the risk of post-operative complications among patients undergoing total hip replacement

We carried out a retrospective cohort study of 3309 patients undergoing primary total hip replacement to examine the impact of tobacco use and body mass index on the length of stay in hospital and the risk of short term post-operative complications. Heavy tobacco use was associated with an increased risk of systemic post-operative complications (p = 0.004). Previous and current smokers had a 43% and 56% increased risk of systemic complications, respectively, when compared with non-smokers. In heavy smokers, the risk increased by 121%. A high body mass index was significantly associated with an increased mean length of stay in hospital of between 4.7% and 7%. The risk of systemic complications was increased by 58% in the obese. Smoking and body mass index were not significantly related to the development of local complications. Greater efforts should be taken to reduce the impact of preventable life style factors, such as smoking and high body mass index, on the post-operative course of total hip replacement.

Greater body mass index is associated with better pathologic features and improved outcome among patients treated surgically for clear cell renal cell carcinoma

OBJECTIVES

Obesity increases the risk of developing renal cell carcinoma (RCC); however, it remains unclear whether obesity is associated with RCC aggressiveness and survival. We used data from a large cohort of patients treated surgically for clear cell RCC to evaluate the association of obesity with the pathologic features of tumor aggressiveness and cancer-specific outcomes.

METHODS

From 1988 to 2002, 970 patients underwent nephrectomy at Mayo Clinic Rochester for clear cell RCC and had body mass index (BMI) data available. To evaluate the association of BMI at surgery with the tumor pathologic features, we used the chi-square and Fisher's exact tests. We then analyzed the association of BMI with cancer-specific survival using Kaplan-Meier curves and Cox regression models.

RESULTS

Overweight (BMI 25 to less than 30 kg/m2) and obese (BMI 30 kg/m2 or more) patients were more likely to present with less-aggressive tumors compared with normal-weight patients (BMI less than 25 kg/m2). The 5-year cancer-specific survival rate was 62.3%, 76.9%, and 81.7% for the normal, overweight, and obese patients, respectively. The overweight (hazard ratio 0.64, 95% confidence interval 0.49 to 0.84) and obese (hazard ratio 0.48, 95% confidence interval 0.36 to 0.66) patients were at a reduced risk of RCC death compared with patients with a BMI in the normal range. The inverse association of BMI with survival was attenuated after adjustment for well-known pathologic predictors of tumor aggressiveness.

CONCLUSIONS

BMI offers little additional prognostic information beyond the accepted prognostic features; however, the association of an increased BMI with a less-aggressive disease profile at presentation warrants further exploration.

Mild hypothermia protects obese rats from fulminant hepatic necrosis induced by ischemia-reperfusion

BACKGROUND

Obese Zucker rats demonstrate increased susceptibility to hepatic ischemia-reperfusion injury. This study evaluates the effect of mild systemic hypothermia on ischemia-induced acute fulminant necrosis during warm ischemia and reperfusion, and investigates blood metabolic profiles under normothermic and mildly hypothermic conditions.

METHODS

The left and median hepatic lobes of male, obese, Zucker rats were exposed to 75 minutes of ischemia under either normothermic (36.9 +/- 0.3 degrees C) or mildly hypothermic (33.3 +/- 0.1 degrees C) conditions followed by 8 hours of reperfusion. Animals were killed and tissue and blood were harvested for analysis of histology, liver enzymes, and metabolic 1H-NMR spectroscopy.

RESULTS

Liver enzyme activities were significantly higher in the normothermic group when compared with mildly hypothermic animals. Histologic analysis showed greater than 75% necrosis in the normothermic group, whereas in the mildly hypothermic group necrosis was less than 25%. Blood from normothermic animals contained greater concentrations of lactate (190%, P = .001) and lower concentrations of glucose (60%, P = .01) than hypothermic animals; hepatic osmolyte betaine was also increased in blood from the normothermic group (220%, P = .0002). In addition, normothermic rats had increased concentrations of circulating fatty acids, triglycerides, glutamate, succinate, and acetate when compared with the hypothermic.

CONCLUSION

Mild hypothermia decreased hepatic necrosis in obese rats. NMR blood profiles indicate that hypothermia protects hepatic metabolism.

Obesity adversely affects health related quality of life before and after radical retropubic prostatectomy

PURPOSE

Obesity adversely affects surgical procedures and outcomes. We used a validated health related quality of life measure to examine the effects of obesity on disease specific health related quality of life before and following radical retropubic prostatectomy.

MATERIALS AND METHODS

From June 2000 to April 2003, 575 consecutive patients with prostate cancer were approached to participate in a prospective, health related quality of life study. Health related quality of life was assessed before surgery, and 1, 4, 12, 24 and 36 months postoperatively. Repeated measures mixed models were constructed to determine the independent effects of body mass index on health related quality of life.

RESULTS

Of 472 consenting subjects 376 (80%) completed a baseline and at least 1 followup survey. Higher body mass index was associated with worse preoperative hormonal/vitality function (p = 0.0009) and bother (p = 0.02), and delayed recovery of bowel function (p = 0.01) and bother (p = 0.01) health related quality of life. There were no measurable differences postoperatively in hormonal/vitality, urinary or sexual health related quality of life associated with higher body mass index. Increased body mass index was associated with prostate specific antigen recurrence (p = 0.05) and adjuvant treatment (p = 0.02). Adjuvant treatment was independently associated with worse bowel function (p = 0.01) and bother (p = 0.01) health related quality of life in obese patients. At 24 months bowel health related quality of life in obese patients no longer significantly differed from that in nonobese patients.

CONCLUSIONS

Obesity is associated with worse preoperative hormonal/vitality health related quality of life, slower recovery of bowel function and bother health related quality of life after radical retropubic prostatectomy, and prostate specific antigen recurrence. Impaired health related quality of life recovery in obese patients is influenced by disease recurrence and resultant adjuvant therapies. Despite these findings obese patients should not be dissuaded from considering prostatectomy as definitive treatment for localized prostate cancer.

Lift-assisted offset lithotomy: positioning for transurethral operations in morbidly obese

The incidence of morbid obesity is rapidly increasing in the United States. This presents a unique challenge in the diagnosis, management, and surgical treatment of urologic disease. The use of the lithotomy position for transurethral procedures is often not possible because of the body habitus and equipment-specific weight limitations. During positioning, it becomes imperative to maintain the safety of both the patient and the operating room personnel. We present a new, bariatric lift-assisted positioning technique used in the management of a 311-kg morbidly obese man with high-grade, superficial, papillary urothelial carcinoma.

Care of the Obese PatientWith an Ostomy

Obesity has become the number one health problem in the United States. The patients who is obese and undergoing a surgical procedure that results in the formation of fecal or urinary diversion requires advanced skills of a multidisciplinary healthcare team. Patients who are obese carry a high risk of wound and cardiopulmonary complications and often present a serious challenge in terms of stoma creation and management. The purpose of this article is to examine the risk factors that face the patient who is obese and undergoing stoma surgery, the challenges of stoma creation, and the resultant stoma management problems.