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Elmussareh M, Simonsen PC, Young M, Kingo PS, Jakobsen JK, Jensen JB. Correlation between organ-specific co-morbidities and complications in bladder cancer patients undergoing radical cystectomy. Scand J Urol 2019; 52:395-400. [PMID: 30624138 DOI: 10.1080/21681805.2018.1531921] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the association between patients' organ-specific co-morbidities and post-operative complications following radical cystectomy for bladder cancer. PATIENTS AND METHODS All patients who underwent radical cystectomy at Aarhus University Hospital during the period from January 2006 to February 2014 were included retrospectively. A total of 40 comorbidities and 59 complications were registered meticulously. Univariate and multivariate analyses were used to detect associations between the individual comorbidities and specific post-operative complications. RESULTS Ninety-two per cent (575/625) of patients experienced one or more complications following radical cystectomy. Clavien-Dindo grade 3-5 complications were observed in 40.8% of patients, and 6.2% had severe complications (Clavien-Dindo grade 4-5). The mortality rate was 2.2%. High BM, previous myocardial infarction and chronic obstructive pulmonary disease were noted to be associated with moderate-to-severe post-operative complications (Clavien-Dindo grade 3-5), while diabetes and lymphoproliferative disorders were significantly associated with severe complications (Clavien-Dindo grade 4-5). CONCLUSION This study demonstrates that overall complications to radical cystectomy are high (92%). The associations between specific comorbidities and complications need to be further investigated in order to evaluate whether pre-operative assessment can be more optimally used in a prevention strategy tailored to the individual patient.
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Affiliation(s)
- Muhammad Elmussareh
- a Department of Urology , Aarhus University Hospital , Aarhus , Denmark.,b Department of Urology , Mid Yorkshire Hospitals NHS Trust , Wakefield , UK
| | | | - Matthew Young
- b Department of Urology , Mid Yorkshire Hospitals NHS Trust , Wakefield , UK
| | | | | | - Jørgen Bjerggaard Jensen
- a Department of Urology , Aarhus University Hospital , Aarhus , Denmark.,c Department of Clinical Medicine , Health, Aarhus University , Aarhus , Denmark
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Jordan BJ, Lewis KC, Matulewicz RS, Kundu S. The Timing and Frequency of Infectious Complications after Radical Cystectomy: An Opportunity for Rescue Antibiotic Treatment. UROLOGY PRACTICE 2019. [DOI: 10.1016/j.urpr.2018.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Brian J. Jordan
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kevin C. Lewis
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard S. Matulewicz
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Shilajit Kundu
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Ghanaat M, Winer AG, Sjoberg DD, Poon BY, Kashan M, Tin AL, Sfakianos JP, Cha EK, Donahue TF, Dalbagni G, Herr HW, Bochner BH, Vickers AJ, Donat SM. Comparison of Postradical Cystectomy Ileus Rates Using GIA-80 Versus GIA-60 Intestinal Stapler Device. Urology 2018; 122:121-126. [PMID: 30244117 DOI: 10.1016/j.urology.2018.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/24/2018] [Accepted: 09/11/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the impact on recovery of bowel function using an 80 mm versus 60 mm gastrointestinal anastomosis (GIA) stapler following radical cystectomy and urinary diversion (RC/UD) for bladder cancer. METHODS We identified 696 patients using a prospectively maintained RC/UD database from January 2006 to November 2010. Two nonrandomized consecutive cohorts were compared. Patients between January 2006- and December 2007 (n = 180) were treated using a 60 mm GIA stapler, and 331 patients between January 2008 and December 2010 were subject to an 80 mm GIA stapler. All patients were treated on the same standardized postoperative recovery pathway. After accounting for baseline patient and perioperative characteristics, using a multivariable logistic regression model, we directly compared rates of postoperative ileus using a standardized definition. RESULTS Of 511 evaluable patients, ileus was observed in 32% (57/180) for 60 mm GIA versus 33% (110/331) for the 80 mm GIA. Preoperative renal function, age, gender, body mass index, and type of diversion were comparable between cohorts. On multivariate analysis, stapler size was not significantly associated with the development of ileus (GIA-60 vs GIA-80: OR 1.11; 95% CI 0.75, 1.66; P = .6). Positive fluid balance was associated with an increased risk (P = .019) and female sex a decreased risk (P = .008) of developing ileus compared to patients with negative fluid balance. CONCLUSION The size of the intestinal bowel anastomosis (GIA 80 mm vs 60 mm) does not independently impact the time to bowel recovery following RC/UD.
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Affiliation(s)
- Mazyar Ghanaat
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Andrew G Winer
- SUNY Downstate College of Medicine and Kings County Hospital Center, New York, NY
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bing Ying Poon
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mahyar Kashan
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; SUNY Downstate College of Medicine and Kings County Hospital Center, New York, NY
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Eugene K Cha
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Timothy F Donahue
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Guido Dalbagni
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Harry W Herr
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bernard H Bochner
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - S Machele Donat
- Urology Service at the Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Abstract
Introduction The aim of the study was to determine the most frequent early and late complications in different types of ileal urinary diversions. Patients and methods The study was conducted in a five-year period, on 106 patients who were diagnosed with invasive urinary bladder cancer and who had indication for radical cystectomy with one of the investigated types of urine derivation. They were divided into 2 groups, based on the type of ileal urinary diversions. Results The colonization of bacteria was more prominently present in the ileal conduit urinary diversion group (97%) compared to Ghoneim (25%) and Hautmann (10%) group, Ureteral stenosis was slightly less represented in the conduit group (9.1%). Wound infections were significantly more represented in the conduit (21.2%) than in the Ghoneim group (5%) Nighttime incontinence was present in 20% of patients in both groups or 4 patients in each group. Daytime incontinence in the Ghoneim group was present in 3 patients (15%) and in the Hautmann group 2 patients (10%). Late complications correlate significantly negative with the type of surgery and slightly negative with the grade, and significantly positively with the examined group and T stage, and slightly correlate positively to the N and R stages. Early complications correlate slightly negative with the type of surgery, slightly negative with the grade, and significantly positively with T stage, and slightly positively correlates with the N and R stage. Conclusion The most commonly reported complications in ileal conduit are: prolonged ileus, stoma infection, wound dehiscence and bacterial colonization, followed by peristomal skin complications and complications related only to the stoma, such as stenosis and stoma retraction, and prolaps of ileostoma and ileointestinal stenosis. The ileus rate in orthotopic derivation was significantly lower than that of the ileal conduit group, which led to the conclusion that the neomybladder position does not disturb the anatomic abdominal structure.
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Affiliation(s)
- Alden Prcic
- Bahrain Specialist Hospital, Manama, Bahrain
| | - Edin Begic
- Health Care Centre, Maglaj, Bosnia and Herzegovina
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Alvimopan usage increasing following radical cystectomy. World J Urol 2018; 37:1151-1155. [DOI: 10.1007/s00345-018-2476-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/03/2018] [Indexed: 02/05/2023] Open
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Abdi H, Elzayat E, Cagiannos I, Lavallée LT, Cnossen S, Flaman AS, Mallick R, Morash C, Breau RH. Female radical cystectomy patients have a higher risk of surgical site infections. Urol Oncol 2018; 36:400.e1-400.e5. [PMID: 30064934 DOI: 10.1016/j.urolonc.2018.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/13/2018] [Accepted: 05/21/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Surgical site infections (SSI) are common after radical cystectomy. The objectives of this study were to evaluate if female sex is associated with postoperative SSI and if experiencing an SSI was associated with subsequent adverse events. METHODS This was a historical cohort study of radical cystectomy patients from the American College of Surgeons' National Surgical Quality Improvement Program database between 2006 and 2016. The primary outcome was development of a SSI (superficial, deep, or organ/abdominal space) within 30 days of surgery. Multivariable logistic regression analyses were performed to determine the association between sex and other patient/procedural factors with SSI. Female patients with SSI were also compared to those without SSI to determine risk of subsequent adverse events. RESULTS A total of 9,275 radical cystectomy patients met the inclusion criteria. SSI occurred in 1,277(13.7%) patients, 308 (16.4%) females and 969 (13.1%) males (odds ratio = 1.27; 95% confidence interval 1.10-1.47; P = 0.009). Infections were superficial in 150 (8.0%) females versus 410 (5.5%) males (P < 0.0001), deep in 40 (2.1%) females versus 114 (1.5%) males (P = 0.07), and organ/abdominal space in 118 (6.2%) females versus 445 (6.0%) males (P = 0.66). On multivariable analysis, female sex was independently associated with SSI (odds ratio = 1.21 confidence interval 1.01-1.43 P = 0.03). Females who experience SSI had higher probability of developing other complications including wound dehiscence, septic shock, and need for reoperation (all P < 0.05). CONCLUSIONS Female sex is an independent risk factor for SSI following radical cystectomy. More detailed study of patient factors, pathogenic microbes, and treatment factors are needed to prescribe the best measures for infection prophylaxis.
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Affiliation(s)
- Hamidreza Abdi
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Ehab Elzayat
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Luke T Lavallée
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Sonya Cnossen
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Anathea S Flaman
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Ranjeeta Mallick
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Chris Morash
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada
| | - Rodney H Breau
- Division of Urology, The Ottawa Hospital, University of Ottawa and the Ottawa Hospital Research Institute, 501 Smyth Road, Box 222, Ottawa, ON, Canada.
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Odisho AY, Etzioni R, Gore JL. Beyond classic risk adjustment: Socioeconomic status and hospital performance in urologic oncology surgery. Cancer 2018; 124:3372-3380. [DOI: 10.1002/cncr.31587] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/24/2018] [Accepted: 05/07/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Anobel Y. Odisho
- Department of UrologyUniversity of WashingtonSeattle Washington
- Department of UrologyUniversity of California San FranciscoSan Francisco California
- Helen Diller Family Comprehensive Cancer CenterUniversity of California San FranciscoSan Francisco California
| | - Ruth Etzioni
- Fred Hutchinson Cancer Research CenterSeattle Washington
| | - John L. Gore
- Department of UrologyUniversity of WashingtonSeattle Washington
- Fred Hutchinson Cancer Research CenterSeattle Washington
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Schomburg JL, Krishna S, Cotter KJ, Soubra A, Rao A, Konety BR. Preoperative Incidence of Deep Venous Thrombosis in Patients With Bladder Cancer Undergoing Radical Cystectomy. Urology 2018; 116:120-124. [DOI: 10.1016/j.urology.2018.01.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/03/2018] [Accepted: 01/06/2018] [Indexed: 12/12/2022]
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Kulkarni JN, Agarwal H. Transperitoneal vs. extraperitoneal radical cystectomy for bladder cancer: A retrospective study. Int Braz J Urol 2018; 44:296-303. [PMID: 29219280 PMCID: PMC6050562 DOI: 10.1590/s1677-5538.ibju.2017.0441] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose Conventional transperitoneal radical cystectomy (TPRC) is the standard approach for muscle invasive bladder cancer. But, the procedure is associated with significant morbidities like urinary leak, ileus, and infection. To reduce these morbidities, the technique of extraperitoneal radical cystectomy (EPRC) was described by us in 1999. We compared these two approaches and the data accrued forms the basis of this report. Materials and Methods All patients who underwent radical cystectomy for bladder cancer by the author (JNK) with follow-up for at least 5 years were included. A total of 338 patients were studied, with 180 patients in EPRC group and 158 in TPRC group. Results There were 3 mortalities within 30 days in TPRC group and one in EPRC group. Early complication rate was 52% and 58% in EPRC and TPRC groups. Urinary leak occurred in 31 (9.2%) patients (13 in EPRC, 18 in TPRC, p=0.19). Gastrointestinal complications like ileus occurred in 9 (5%) patients in EPRC group and in 25 (15.8%) patients in TPRC group, (p<0.001). Wound dehiscence occurred in 29, and 36 patients in EPRC and TPRC groups respectively. The reoperation rate was 6.1% and 12% in EPRC and TPRC groups, (p=0.08). Intestinal obstruction were significantly less in EPRC group (1.7% vs. 7.8% in TPRC group, p=0.002). Uretero-enteric anastomosis stricture was seen in 10 patients (4 in EPRC, 6 in TPRC, p=0.39). Conclusions The EPRC is associated with decrease gastrointestinal complications, ease of management of urinary leaks, and low reoperation rates. Thus EPRC appears safe functionally and oncologically.
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Affiliation(s)
- Jagdeesh N Kulkarni
- Department of Urology, Bombay Hospital and Medical Research Centre, Mumbai, India
| | - Himanshu Agarwal
- Department of Urology, Bombay Hospital and Medical Research Centre, Mumbai, India
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Nutt M, Scaief S, Dynda D, Alanee S. Ileus and small bowel obstruction after radical cystectomy for bladder cancer: Analysis from the Nationwide Inpatient Sample. Surg Oncol 2018; 27:341-345. [PMID: 30217287 DOI: 10.1016/j.suronc.2018.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 05/08/2018] [Accepted: 05/11/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE To investigate prevalence and predictors of postoperative small bowel obstruction (SBO) and ileus in a large cohort of bladder cancer (BCa) patients treated with radical cystectomy (RC). METHODS All patients within the Nationwide Inpatient Sample who underwent RC for BCa between 2006 and 2012 were identified. First, prevalence of SBO and ileus was analyzed. Second, predictors of these bowel-related complications were identified using multivariable regression analyses. Third, the association between SBO, ileus, and length of stay was evaluated using logistic regression models adjusted for clustering. Prolonged length of stay was defined as hospital stay above mean stay of the population (>10 days). Fourth, the effect of SBO and ileus on mean inpatient cost of healthcare was examined. RESULTS Of overall 41,498 patients, 1071 (2.6%) experienced SBO, and 11,155 (26.9%) experienced ileus. Predictors of ileus included age, male gender, black race, hospital characteristics, anemia, chronic pulmonary disease, drug abuse, hypothyroidism, fluid and electrolyte disorders, and neurological disorders (all p < 0.05) Predictors of SBO included male gender, Asian/Pacific islander race, hospital characteristics, congestive heart failure, fluid and electrolyte disorders, and psychosis (all p < 0.05). . Postoperative SBO (odds ratio (OR) 19.587; 95% confidence interval (CI):15.869-24.167) and ileus (OR 5.646; 95% CI:5.336-5.974) were associated with prolonged length of stay (all p < 0.001).Median cost of hospital stay was $56.315 for patients who developed SBO, $32,472 for patients who developed ileus, and $24,600 for patients after cystectomy without ileus or SBO. CONCLUSIONS Significant prevalence of bowel-related complications in patients after RC was observed. These complications are strongly associated with prolonged length of stay and higher healthcare cost. Increasing awareness of SBO and ileus, identification of patients at risk prior to surgery, and implementation of protective strategies are strongly indicated in cystectomy patients.
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Affiliation(s)
- Max Nutt
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Steve Scaief
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Danuta Dynda
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Shaheen Alanee
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA.
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Gierth M, Zeman F, Denzinger S, Vetterlein M, Fisch M, Bastian P, Syring I, Ellinger J, Müller S, Herrmann E, Gilfrich C, May M, Pycha A, Wagenlehner F, Vallo S, Bartsch G, Haferkamp A, Grimm MO, Roigas J, Protzel C, Hakenberg O, Fritsche HM, Burger M, Aziz A, Mayr R. Influence of Body Mass Index on Clinical Outcome Parameters, Complication Rate and Survival after Radical Cystectomy: Evidence from a Prospective European Multicentre Study. Urol Int 2018; 101:16-24. [DOI: 10.1159/000488466] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/14/2018] [Indexed: 01/24/2023]
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Baldini A, Fassi Fehri H, Cerantola Y, Bayle F, Ravier E, Belot PY, Arnouil N, Colombel M, Badet L. [Do initial experience with an enhanced recovery program after surgery (ERAS) improve postoperative outcomes after cystectomy?]. Prog Urol 2018; 28:351-358. [PMID: 29706465 DOI: 10.1016/j.purol.2018.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 02/19/2018] [Accepted: 03/19/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To estimate the feasibility and the impact of an ERAS program after radical cystectomy for bladder cancer. MATERIALS AND METHODS This was a retrospective study comparing a historical pre ERAS group, including all the patients undergoing cystectomy for bladder cancer from January 2013 to December 2015 with a classic procedure, and an interventional ERAS group after introducing an enhanced recovery protocol before, during and after surgery, from February 2016. The principal outcome was the postoperative length of stay. Secondary outcomes mesures were impact on perioperative complication rate (Clavien classification≥3B), readmission rate, reanimation length of stay, ileus rate and adherence to the ERAS protocol. RESULTS There were no differences between the 2 groups as far as demographics characteristics are concerned. In total, 97 patients were included, 56 in the control group, and 41 in the ERAS group. The adherence to the protocol was about 65.8%. The ERAS group had statistically significantly shorter median length of stay (D19 versus D14; P: 0.021). The major complications rate (Clavien≥3B) were about 23.2% for the control group and 12.1% for the ERAS group (P: NS). The reinsertion of nasogastric tube were higher in the control group (39.3% vs 21.9%; P: NS) and the readmission rate was about 7.1% in the control group versus 14.6% in the ERAS group (P: NS). CONCLUSION In conclusion, introduction and application of an enhanced recovery protocol (ERAS) after cystectomy for bladder cancer allowed for better management of postoperative outcomes. It is clearly feasible in cystectomy, and improve significantly the median postoperative length of stay. Moreover, it may be effective in terms of faster return of bowel function and reduction of majors complications. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- A Baldini
- Hôpital Édouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France.
| | - H Fassi Fehri
- Hôpital Édouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France.
| | - Y Cerantola
- CHU Vaudois, 46, rue du Bugnon, 1011 Lausanne, Suisse.
| | - F Bayle
- Hôpital Édouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France.
| | - E Ravier
- Rhena clinique de Strasbourg, 15, boulevard Ohmacht, 67000 Strasbourg, France.
| | - P Y Belot
- Hôpital Édouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France.
| | - N Arnouil
- Hôpital Édouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France.
| | - M Colombel
- Hôpital Édouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France.
| | - L Badet
- Hôpital Édouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France.
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Zainfeld D, Shah A, Daneshmand S. Enhanced Recovery After Surgery Pathways: Role and Outcomes in the Management of Muscle Invasive Bladder Cancer. Urol Clin North Am 2018; 45:229-239. [PMID: 29650138 DOI: 10.1016/j.ucl.2017.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Radical cystectomy remains the gold standard therapy for the treatment of muscle-invasive urothelial carcinoma, yet is accompanied by significant rates of perioperative complications and readmission. Enhanced recovery protocols aim to apply evidence-based principles of care to ameliorate the morbidity of this procedure by enabling better tolerance of and recovery from radical cystectomy. Multiple patient series have demonstrated the capacity for enhanced-recovery-after-surgery (ERAS) principles to improve outcomes among patients undergoing radical cystectomy through decreased incidence of gastrointestinal complications and decreased length of hospitalization without increased readmissions or overall morbidity. Opportunities remain for adoption of established ERAS principles.
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Affiliation(s)
- Daniel Zainfeld
- Department of Urology, USC Keck/Norris Comprehensive Cancer Center, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90089, USA
| | - Ankeet Shah
- Department of Urology, USC Keck/Norris Comprehensive Cancer Center, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90089, USA
| | - Siamak Daneshmand
- Department of Urology, USC Keck/Norris Comprehensive Cancer Center, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA 90089, USA.
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Vukovic N, Dinic L. Enhanced Recovery After Surgery Protocols in Major Urologic Surgery. Front Med (Lausanne) 2018; 5:93. [PMID: 29686989 PMCID: PMC5900414 DOI: 10.3389/fmed.2018.00093] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/23/2018] [Indexed: 01/31/2023] Open
Abstract
The purpose of the review The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery. Recent findings ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function. Summary Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.
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Affiliation(s)
- Natalija Vukovic
- Anesthesiology and Reanimation Center, Clinical Center Nis, Nis, Serbia
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Abstract
AIM To scrutinize the rapid development of robotic versus traditional laparoscopic technique in pelvic urologic surgery. INTRODUCTION In the last few decades, advances in research and development have led to tremendous progress in medical diagnostics and treatment of disease. Minimally invasive surgery has moved from experimental to becoming the dominant form of surgical management across the surgical specialties. Laparoscopy is nowadays used widely in abdominal surgery, from simple diagnostic laparoscopy to complex colorectal and gynecologic cancer procedures. METHODS A literature search of electronic databases (PubMed, Medscape, Embase) using the key words: "pelvic laparoscopy, urologic oncology, robotic surgery, minimally invasive access" was performed for all relevant articles in the English language. Data were extrapolated from the abstracts alone to avoid subjective bias in drawing conclusions. RESULTS Telemedicine and telesurgery, the diagnostic and operative process is conducted from a distance. The surgeon uses computer-assisted surgery away from the bedside via a robotic system and performs the surgical task at hand. In pelvic urological cancer surgery the use of robotic technique expands to female and reconstructive procedures as well. The leap forward is so massive, that traditional laparoscopic surgery is starting to be considered less, with a growing number of organizations being now more interested in developing a robotic service. Minimally invasive surgical techniques aim to improve surgical outcome in conjunction with delivery of high-quality patient care. Quality studies demonstrating superiority and cost effectiveness are lacking, however. CONCLUSIONS Although tremendous accomplishments took place over a few years, there is still a lot of ground to be covered in standardizing the learning process and evaluating the outcome from the application of new technologies in the field of robotic pelvic surgery.
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Groeben C, Koch R, Baunacke M, Schmid M, Borkowetz A, Wirth MP, Huber J. Urinary Diversion After Radical Cystectomy for Bladder Cancer: Comparing Trends in the US and Germany from 2006 to 2014. Ann Surg Oncol 2018; 25:3502-3509. [DOI: 10.1245/s10434-018-6381-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Indexed: 11/18/2022]
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Schomburg J, Krishna S, Soubra A, Cotter K, Fan Y, Brown G, Konety B. Extended outpatient chemoprophylaxis reduces venous thromboembolism after radical cystectomy. Urol Oncol 2018; 36:77.e9-77.e13. [DOI: 10.1016/j.urolonc.2017.09.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/04/2017] [Accepted: 09/29/2017] [Indexed: 11/30/2022]
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Li R, Metcalfe M, Kukreja J, Navai N. Role of Radical Cystectomy in Non-Organ Confined Bladder Cancer: A Systematic Review. Bladder Cancer 2018; 4:31-40. [PMID: 29430505 PMCID: PMC5798530 DOI: 10.3233/blc-170130] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: Currently, a diagnosis of non-organ confined bladder cancer (NOCBCa) confers a grave prognosis. The mainstay of treatment consists of systemic chemotherapy. However, it must be recognized that NOCBCa is a heterogeneous disease state with important clinical distinctions. While surgical extirpation has traditionally been regarded as overly aggressive for all NOCBCa patients, its utility as part of a multimodal treatment strategy in various clinical scenarios has not been thoroughly investigated. Objective: To perform a review of the literature regarding the role of radical cystectomy and pelvic lymph node dissection (RC-LND) in the setting of NOCBCa. Methods: Medline, and Pubmed electronic database were queried for English language articles from January 1990 to Nov 2016 on RC-LND for cT4, lymph node positive, and metastatic urothelial cancer. NOCBCa was separated into four distinct clinical scenarios: 1. Locally advanced/unresectable disease (cT4bN0M0); 2. Occult pelvic nodal disease (pN+) (cTxN0M0 and pTxN1-3Mx); 3. Clinical node positive disease (cN+) (cTxN1-3M0); and 4. Distant metastatic disease (TxNxM1). Evidence for the role of RC-LND in each of these clinical scenarios was summarized. Results: cT4b may be more effectively treated by presurgical chemotherapy (PSC) than other forms of NOCBCa. Although clinical response predicted improved survival, surgical factors, such as surgical margin status may also play a role in determining outcomes. In well selected patients, 5-year CSS may reach 60% after consolidative RC-LND. Survival in patients found to have pathologic nodal metastases without PSC was dictated not only by the histologically verified metastatic nodal disease burden, but also by the meticulousness of the lymph node dissection. In these patients, adjuvant chemotherapy may improve survival. On the other hand, in patients undergoing RC-LND after PSC, pathologic complete response (pCR) was the strongest predictor of improved CSS. The results of population based studies have suggested a therapeutic role by consolidative RC-LND in both patients with cN+ and metastatic BCa (mBCa). For the cN+ population, 5-year OS was 31% in patients undergoing RC-LND after PSC vs. 14% in those receiving chemotherapy alone. Similarly, consolidative intensive local therapy improved OS by approximately 5 months in patients with mBCa. Metastasectomy has also been shown to be effective in small retrospective series and may especially be useful in patients with solitary pulmonary lesions. Conclusions: Extirpative treatment of the primary tumor may be an important step in the management of de novo NOCBCa. The current retrospective and population based studies have demonstrated improved survival outcomes in patients with NOCBCa following RC-LND, especially in those with favorable response to PSC. With the advent of minimally invasive surgery and the enhanced post-surgical recovery protocols, RC-LND has not only been demonstrated to be feasible, but also tolerable in the setting of advanced BCa. Well designed, prospective trials are needed to definitively assess the value of surgical extirpation for NOCBCa patients.
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Affiliation(s)
- Roger Li
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Metcalfe
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Janet Kukreja
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neema Navai
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lin W, Lin JH, Chiu KH, Ho DR, Huang YC, Huang KT, Chen CS. Performing laparoscopic radical cystectomy is feasible for the elderly with marginal cardiopulmonary function. UROLOGICAL SCIENCE 2018. [DOI: 10.4103/uros.uros_9_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
Urinary diversion (UD) with an intestinal segment has significant risks of short- and long-term complications. With modern reporting criteria, understanding of the true prevalence and spectrum of these complications has improved. Methods to minimize early postoperative complications include enhanced recovery pathways, restricted intraoperative fluid protocols, and referral to high-volume centers. With long-term follow-up after UD, the risk of complications steadily rises. Late surgical complications include ureterointestinal anastomotic strictures, urolithiasis, and stomal issues. Patients with UDs require close surveillance to monitor for anatomic, infectious, and metabolic complications and surgeons who perform UD should be aware of the risk and timing of postoperative complications.
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Young MJ, Elmussareh M, Weston P, Dooldeniya M. Radical cystectomy in the elderly - Is this a safe treatment option? Arab J Urol 2017; 15:360-365. [PMID: 29234541 PMCID: PMC5717452 DOI: 10.1016/j.aju.2017.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/30/2017] [Accepted: 09/11/2017] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To determine if significant differences exist in the perioperative outcomes of patients aged >75 years treated with radical cystectomy (RC) compared to younger patients, as RC is frequently not offered to 'elderly' patients with bladder cancer because of supposed increased risks of complications. PATIENTS AND METHODS We retrospectively analysed prospectively collected data of all patients that underwent RC in our centre from May 2013 to June 2015. In all, 81 consecutive RCs were identified and included in our study. Patients were divided into two age groups: Group A, aged <75 years (51 patients) and Group B, aged ≥75 years (30). Co-morbidities and perioperative outcomes were compared between the groups. Fisher's exact test was used for statistical analysis. RESULTS In 68 patients RC was performed laparoscopically and the remaining 13 patients underwent open RC. The mean (range) age was 70.7 (36-85) years. There were 37 patients with muscle-invasive disease and 42 had non-muscle-invasive disease. The median hospital stay was not significantly different between the two age groups (10 vs 11 days). There was no significant difference in the preoperative Charlson co-morbidity index. The 30-day mortality rate was 4% for those aged <75 years and 6.6% for those aged ≥75 years, with overall perioperative complication rates of 57% vs 66%, respectively. Most complications were minor (Clavien-Dindo Grade I-II) and there was no statistically significant difference between the two cohorts. There was also no statistically significant difference in blood transfusion rates. CONCLUSION RC in patients aged ≥75 years has similar perioperative morbidity when compared with younger patients and can be offered in selected elderly patients. Thus, age should not be an absolute contraindication for RC.
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Affiliation(s)
- Matthew J Young
- Department of Urology, Pinderfields General Hospital, Mid-Yorkshire Hospitals Trust, Wakefield, West Yorkshire, UK
| | - Muhammad Elmussareh
- Department of Urology, Pinderfields General Hospital, Mid-Yorkshire Hospitals Trust, Wakefield, West Yorkshire, UK
| | - Philip Weston
- Department of Urology, Pinderfields General Hospital, Mid-Yorkshire Hospitals Trust, Wakefield, West Yorkshire, UK
| | - Mohantha Dooldeniya
- Department of Urology, Pinderfields General Hospital, Mid-Yorkshire Hospitals Trust, Wakefield, West Yorkshire, UK
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Abstract
BACKGROUND Enhanced recovery pathways, also known as fast-track protocols, have been adopted since the early 2000s by various surgical specialties with the goal of improving patient outcomes and reducing the cost burden of major surgery on the health care system. OBJECTIVE To review the scientific literature on the origin of enhanced recovery pathways, track the contemporary utilization of such practices for patients undergoing radical cystectomy, and analyze the available data regarding their effect on morbidity, mortality, and treatment cost. METHODS A literature search of multiple electronic databases was undertaken. Manuscripts including patients undergoing radical cystectomy were chosen based on predefined criteria with an emphasis on randomized controlled trials and cohort studies. Strength of evidence for each study that met inclusion criteria was assessed based on the risk of bias, consistency, directness, and precision. RESULTS Database searches resulted in 1,236 potentially relevant articles. A total of 485 articles were selected for full-text dual review and 106 studies in 52 publications met the inclusion criteria. CONCLUSION The utilization of enhanced recovery pathways with the goal of improving overall patient morbidity and mortality is well supported in the literature, however standardization of implementation and adherence across institutions is lacking, and their direct efficacy on reducing preventable treatment related expenditures is unconfirmed.
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Affiliation(s)
- Ian Maloney
- Department of Urology, The University of Oklahoma Health Sciences Center and The Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Daniel C. Parker
- Department of Urology, The University of Oklahoma Health Sciences Center and The Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Michael S. Cookson
- Department of Urology, The University of Oklahoma Health Sciences Center and The Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Sanjay Patel
- Department of Urology, The University of Oklahoma Health Sciences Center and The Stephenson Cancer Center, Oklahoma City, OK, USA
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Vetterlein MW, Gild P, Kluth LA, Seisen T, Gierth M, Fritsche HM, Burger M, Protzel C, Hakenberg OW, von Landenberg N, Roghmann F, Noldus J, Nuhn P, Pycha A, Rink M, Chun FKH, May M, Fisch M, Aziz A. Peri-operative allogeneic blood transfusion does not adversely affect oncological outcomes after radical cystectomy for urinary bladder cancer: a propensity score-weighted European multicentre study. BJU Int 2017; 121:101-110. [DOI: 10.1111/bju.14012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Malte W. Vetterlein
- Department of Urology; University Medical Centre Hamburg-Eppendorf; Hamburg Germany
| | - Philipp Gild
- Department of Urology; University Medical Centre Hamburg-Eppendorf; Hamburg Germany
| | - Luis A. Kluth
- Department of Urology; University Medical Centre Hamburg-Eppendorf; Hamburg Germany
| | - Thomas Seisen
- Department of Urology; Pitié-Salpêtrière Hospital; Pierre and Marie Curie University; Paris France
| | - Michael Gierth
- Department of Urology; Caritas St. Josef Medical Centre; University of Regensburg; Regensburg Germany
| | - Hans-Martin Fritsche
- Department of Urology; Caritas St. Josef Medical Centre; University of Regensburg; Regensburg Germany
| | - Maximilian Burger
- Department of Urology; Caritas St. Josef Medical Centre; University of Regensburg; Regensburg Germany
| | - Chris Protzel
- Department of Urology; University Medical Centre Rostock; Rostock Germany
| | | | | | - Florian Roghmann
- Department of Urology; Marien Hospital Herne; Ruhr-University Bochum; Herne Germany
| | - Joachim Noldus
- Department of Urology; Marien Hospital Herne; Ruhr-University Bochum; Herne Germany
| | - Philipp Nuhn
- Department of Urology; Mannheim Medical Centre; University of Heidelberg; Mannheim Germany
| | - Armin Pycha
- Department of Urology; Central Hospital of Bolzano; Bolzano Italy
- Centre for Urology and Nephrology; Faculty of Medicine; Sigmund Freud University Vienna, Vienna Austria
| | - Michael Rink
- Department of Urology; University Medical Centre Hamburg-Eppendorf; Hamburg Germany
| | - Felix K.-H. Chun
- Department of Urology; University Medical Centre Hamburg-Eppendorf; Hamburg Germany
| | - Matthias May
- Department of Urology; St. Elisabeth Medical Centre; Straubing Germany
| | - Margit Fisch
- Department of Urology; University Medical Centre Hamburg-Eppendorf; Hamburg Germany
| | - Atiqullah Aziz
- Department of Urology; University Medical Centre Rostock; Rostock Germany
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Palazzetti A, Sanchez-Salas R, Capogrosso P, Barret E, Cathala N, Mombet A, Prapotnich D, Galiano M, Rozet F, Cathelineau X. Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy. Actas Urol Esp 2017; 41:416-425. [PMID: 27908634 DOI: 10.1016/j.acuro.2016.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 11/30/2022]
Abstract
Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.
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Affiliation(s)
- A Palazzetti
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - R Sanchez-Salas
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia.
| | - P Capogrosso
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - E Barret
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - N Cathala
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - A Mombet
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - D Prapotnich
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - M Galiano
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - F Rozet
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - X Cathelineau
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
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75
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Lin JH, Chiu KH, Ho DR, Huang YC, Huang KT, Chen CS, Lin WY. Laparoscopic radical cystectomy is feasible for the elderly with marginal cardiopulmonary function. UROLOGICAL SCIENCE 2017. [DOI: 10.1016/j.urols.2017.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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76
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Contreras-García R, García-Perdomo H, García-Ángel A. Mortalidad perioperatoria en pacientes sometidos a cistectomía radical en un hospital universitario. Rev Urol 2017. [DOI: 10.1016/j.uroco.2016.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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77
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Urinary Diversion for Severe Urinary Adverse Events of Prostate Radiation: Results from a Multi-Institutional Study. J Urol 2017; 197:744-750. [DOI: 10.1016/j.juro.2016.10.091] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2016] [Indexed: 11/19/2022]
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78
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Arafat W, Darwish A, Naoum GE, Sameh W, Husseiny GE, Abd-El-Gawad F, Samir M. Comparison between standard and reduced volume radiotherapy in bladder preservation trimodality protocol for muscle-invasive bladder cancer patients. Ecancermedicalscience 2016; 10:682. [PMID: 27899955 PMCID: PMC5102689 DOI: 10.3332/ecancer.2016.682] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Indexed: 01/23/2023] Open
Abstract
Aim Our aim is to compare the toxicity, pelvic nodal relapse, and overall survival of whole bladder irradiation only to the standard technique of whole pelvis irradiation followed by bladder boost in patients with muscle-invasive bladder carcinoma undergoing bladder preservation protocol. Material and method A total of 60 patients with transitional cell carcinoma, stage T2-3, N0, M0 bladder cancer were subjected to maximal transurethral resection bladder tumour (TURB). Then, the patients were randomised into two groups: group I (30 patients) to receive whole pelvis radiotherapy 44 Gy followed by 20 Gy bladder boost. While group II (30 patients) were randomised to receive whole bladder radiotherapy alone for a total dose of 64 Gy. In both groups, concomitant cisplatin and paclitaxel were given weekly throughout the whole course of radiotherapy where conventional 2 Gy/fraction were used. Additionally, four cycles of adjuvant cisplatin and paclitaxel were given after the end of the chemoradiotherapy induction course. Results The first assessment after the induction chemoradiotherapy showed that complete response was achieved in 73.3% of patients in group I and 76.7% of the patients in group II. After a median follow-up of 2 years, regional relapse occurred in 7.1% of patients in group I and 10.3% in group II. (p = 1). Distant metastases were detected in 17.9% of patient in group I and 13.8% in group II (p = 0.73). The 2-year disease-free survival was 60% in group I and 63.3% in group II (p = 0.79). The whole 2-year overall survival was 75% in group I and 79.3% in group II (p = 0.689). Radiation gastrointestinal (GI) acute toxicity was higher in group I than in group II (p = 0.001), while late GI radiation toxicity was comparable in both groups. Conclusion Treating the bladder only, without elective pelvic nodal irradiation, did not compromise pelvic control rate, but significantly decreased the acute radiation toxicity.
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Affiliation(s)
- Waleed Arafat
- Oncology Department, Faculty of Medicine, Alexandria University, Egypt; Alexandria Comprehensive Cancer Centre, Alexandria, Egypt; University of Alabama at Birmingham, 1720 2nd Ave S, Birmingham, AL 35233, USA
| | - Azza Darwish
- Oncology Department, Faculty of Medicine, Alexandria University, Egypt
| | - George E Naoum
- Alexandria Comprehensive Cancer Centre, Alexandria, Egypt
| | - Wael Sameh
- Urology Department, Faculty of Medicine, Alexandria University, Egypt
| | - Gamal El Husseiny
- Oncology Department, Faculty of Medicine, Alexandria University, Egypt
| | | | - Mostafa Samir
- Alexandria Comprehensive Cancer Centre, Alexandria, Egypt
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79
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Christopher Doiron R, Jaeger M, Booth CM, Wei X, Robert Siemens D. Is there a measurable association of epidural use at cystectomy and postoperative outcomes? A population-based study. Can Urol Assoc J 2016; 10:321-327. [PMID: 27800053 DOI: 10.5489/cuaj.3856] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Thoracic epidural analgesia (TEA) is commonly used to manage postoperative pain and facilitate early mobilization after major intra-abdominal surgery. Evidence also suggests that regional anesthesia/analgesia may be associated with improved survival after cancer surgery. Here, we describe factors associated with TEA at the time of radical cystectomy (RC) for bladder cancer and its association with both short- and long-term outcomes in routine clinical practice. METHODS All patients undergoing RC in the province of Ontario between 2004 and 2008 were identified using the Ontario Cancer Registry (OCR). Modified Poisson regression was used to describe factors associated with epidural use, while a Cox proportional hazards model describes associations between survival and TEA use. RESULTS Over the five-year study period, 1628 patients were identified as receiving RC, 54% (n=887) of whom received TEA. Greater anesthesiologist volume (lowest volume providers relative risk [RR] 0.85, 95% confidence interval [CI] 0.75-0.96) and male sex (female sex RR 0.89, 95% CI 0.79-0.99) were independently associated with greater use of TEA. TEA use was not associated with improved short-term outcomes. In multivariable analysis, TEA was not associated with cancer-specific survival (hazard ratio [HR] 1.02, 95% CI 0.87-1.19; p=0.804) or overall survival (HR 0.91, 95% CI 0.80-1.03; p=0.136). CONCLUSIONS In routine clinical practice, 54% of RC patients received TEA and its use was associated with anesthesiologist provider volume. After controlling for patient, disease and provider variables, we were unable to demonstrate any effect on either short- or long-term outcomes at the time of RC.
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Affiliation(s)
| | | | - Christopher M Booth
- Department of Oncology;; Public Health Sciences;; Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute; Queen's University, Kingston, ON, Canada
| | - Xuejiao Wei
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute; Queen's University, Kingston, ON, Canada
| | - D Robert Siemens
- Department of Urology;; Department of Oncology;; Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute; Queen's University, Kingston, ON, Canada
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80
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90-Day complication rate in patients undergoing radical cystectomy with enhanced recovery protocol: a prospective cohort study. World J Urol 2016; 35:907-911. [PMID: 27734131 DOI: 10.1007/s00345-016-1950-z] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 10/04/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To report 90-day complication rates following radical cystectomy (RC) with enhanced recovery after surgery (ERAS) protocol. METHODS All consecutive patients who underwent open RC with ERAS protocol from 2012 to 2014 were included. The protocol includes no bowel preparation or NGT, early feeding, predominantly non-narcotic pain management and μ-opioid antagonists. Non-consenting and lost to follow-up patients were excluded. All patients were closely followed up, and 90-day complication (Clavien-Dindo grading), readmission and emergency room (ER) visits were prospectively recorded. RESULTS One hundred and sixty-nine cases with a median age of 71 years were included in the study. 90-Day major and minor complication rates were 24.3 and 53.9 %, respectively. The most common complications were infectious and gastrointestinal. The 90-day ER visit rate was 37.9 %, whereas the readmission rate was 29.6 %. The most common cause of hospital readmission and ER visits was infections. CONCLUSION Radical cystectomy and urinary diversion with enhanced recovery protocol is a morbid surgery. The most common complication, cause of ER visit and readmission is yet infections. Further studies on methods to decrease these rates are underway.
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81
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Packiam VT, Agrawal VA, Pariser JJ, Cohen AJ, Nottingham CU, Pearce SM, Smith ND, Steinberg GD. Redefining the implications of nasogastric tube placement following radical cystectomy in the alvimopan era. World J Urol 2016; 35:625-631. [PMID: 27476163 DOI: 10.1007/s00345-016-1910-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/26/2016] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Alvimopan has decreased ileus and need for nasogastric tube (NGT) after radical cystectomy (RC). However, the natural history of ileus versus intestinal obstruction in patients receiving alvimopan is not well defined. We sought to examine the implications of NGT placement before and after the introduction of alvimopan for RC patients. METHODS Retrospective review identified 278 and 293 consecutive patients who underwent RC before and after instituting alvimopan between June 2009 and May 2014. Baseline characteristics and postoperative outcomes were compared by alvimopan status. Multivariate logistic regression was performed to assess the impact of alvimopan on rates of NGT placement and reoperation for bowel complications. RESULTS The cohorts had similar age, stage, approach, and BMI. Patients receiving alvimopan had decreased ileus (16 vs 32 %, p < 0.01) but similar rates of reoperation for bowel complications (2.8 vs 2.7 %). On multivariate analysis, alvimopan was associated with lower risk of NGT placement (OR 0.30, p < 0.01). For patients requiring NGT placement, there was an increased rate of reoperation among patients receiving alvimopan compared with those who did not (28 vs 11 %, p = 0.03). Patients receiving alvimopan who needed NGT had significantly increased median length of stay (22 vs 7 days), need for TPN (66 vs 5.3 %), and readmission for ileus (10.3 vs 2.3 %) compared with those who did not require NGT. CONCLUSIONS Alvimopan significantly reduced the incidence of ileus and NGT placement following RC. NGT placement was associated with an increased need for reoperation for bowel complications in the setting of alvimopan.
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Affiliation(s)
| | | | | | - Andrew J Cohen
- Section of Urology, University of Chicago, Chicago, IL, USA
| | | | - Shane M Pearce
- Section of Urology, University of Chicago, Chicago, IL, USA
| | - Norm D Smith
- Section of Urology, University of Chicago, Chicago, IL, USA
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82
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Sui W, Onyeji IC, Matulay JT, James MB, Theofanides MC, Wenske S, DeCastro GJ. Perioperative blood transfusion in radical cystectomy: Analysis of the National Surgical Quality Improvement Program database. Int J Urol 2016; 23:745-50. [PMID: 27399354 DOI: 10.1111/iju.13152] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/31/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine whether perioperative blood transfusion is associated with worse 30-day postoperative outcomes in radical cystectomy patients. METHODS Utilizing the National Surgical Quality Improvement Program database, we identified 2934 patients diagnosed with bladder cancer (International Classification of Diseases Ninth Revision codes 188-188.9) who underwent radical cystectomy (Current Procedure Terminology codes 51570, 51575, 51580, 51585, 51590, 51595, 51596) between 2005 and 2013. Patients were stratified by transfusion status and assessed based on four composite postoperative outcomes: morbidity, surgical site infection, mortality and readmission. Multivariate regression models were used to determine significant independent predictors of the composite outcomes. RESULTS Overall, 40.1% of patients received a transfusion, and there were significant differences in baseline variables such as age, sex, body mass index, smoking history and comorbidities. Transfusion was associated with increased morbidity, surgical site infection, readmission, operative time and length of stay on unadjusted analyses. On multivariate regression, transfusion was associated with increased morbidity (OR 1.361, 95% CI 1.131-1.638) and surgical site infection (OR 1.371, 95% CI 1.070-1.757). CONCLUSIONS Perioperative blood transfusion is associated with increased risk of postoperative infection and morbidity. Previous work in this area has focused on negative long-term oncological outcomes, but this is the first study to examine short-term postoperative outcomes. Future research should focus on the immunosuppressive mechanism of perioperative blood transfusion and on restrictive transfusion guidelines for oncology patients.
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Affiliation(s)
- Wilson Sui
- Herbert Irving Cancer Center, New York-Presbyterian Hospital/Columbia University Medical Center and Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ifeanyi C Onyeji
- Herbert Irving Cancer Center, New York-Presbyterian Hospital/Columbia University Medical Center and Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Justin T Matulay
- Herbert Irving Cancer Center, New York-Presbyterian Hospital/Columbia University Medical Center and Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Maxwell B James
- Herbert Irving Cancer Center, New York-Presbyterian Hospital/Columbia University Medical Center and Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Marissa C Theofanides
- Herbert Irving Cancer Center, New York-Presbyterian Hospital/Columbia University Medical Center and Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Sven Wenske
- Herbert Irving Cancer Center, New York-Presbyterian Hospital/Columbia University Medical Center and Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Guarionex J DeCastro
- Herbert Irving Cancer Center, New York-Presbyterian Hospital/Columbia University Medical Center and Columbia University College of Physicians and Surgeons, New York, New York, USA
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83
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Chemoradiation for organ preservation in the treatment of muscle-invasive bladder cancer. Urol Oncol 2016; 34:271-8. [DOI: 10.1016/j.urolonc.2016.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 03/08/2016] [Accepted: 03/14/2016] [Indexed: 02/04/2023]
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84
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Djaladat H, Daneshmand S. Gastrointestinal Complications in Patients Who Undergo Radical Cystectomy with Enhanced Recovery Protocol. Curr Urol Rep 2016. [PMID: 27125653 DOI: 10.1007/s11934.016-0607-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Gastrointestinal (GI) complications are among the most common complications following radical cystectomy and urinary diversion. The most common is postoperative ileus, although its precise pathophysiology is not completely understood. Enhanced recovery after surgery (ERAS) protocols include evidence-based steps to optimize postoperative recovery and shorten hospital stay, mainly through expedited GI function recovery. They include avoiding bowel preparation and postoperative nasogastric tube, early feeding, non-narcotic pain management, and the use of cholinergic and mu-receptor opioid antagonists. We reviewed the literature in regard to GI complications using enhanced recovery protocols and share our institutional experience with over 300 patients.
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Affiliation(s)
- Hooman Djaladat
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, 90089, Los Angeles, CA, USA
| | - Siamak Daneshmand
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, 90089, Los Angeles, CA, USA.
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85
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Gastrointestinal Complications in Patients Who Undergo Radical Cystectomy with Enhanced Recovery Protocol. Curr Urol Rep 2016; 17:50. [DOI: 10.1007/s11934-016-0607-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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86
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Hugar LA, Turner RM, Gusenoff JA, Correa AF, Jacobs BL, Davies BJ. Panniculectomy and Cystectomy: An Approach to the Morbidly Obese Patient. Case Rep Urol 2016; 2016:6980843. [PMID: 27195168 PMCID: PMC4852348 DOI: 10.1155/2016/6980843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/04/2016] [Indexed: 11/17/2022] Open
Abstract
The obese patient undergoing radical cystectomy faces a unique set of challenges. We present the case of a 68-year-old gentleman who presented to our institution with Bacillus Calmette-Guerin refractory disease, a body mass index of 38.5, and a large pannus. The present paper describes our technique for performing radical cystectomy with ileal conduit urinary diversion and concomitant panniculectomy. We discuss the impact of obesity on patients undergoing radical cystectomy and how this may be mitigated by panniculectomy.
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Affiliation(s)
- Lee A. Hugar
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA 15213, USA
| | - Robert M. Turner
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA 15213, USA
| | - Jeffrey A. Gusenoff
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, 3380 Boulevard of the Allies, Suite 158, Pittsburgh, PA 15213, USA
| | - Andres F. Correa
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA 15213, USA
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA 15213, USA
| | - Benjamin J. Davies
- Department of Urology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 700, Pittsburgh, PA 15213, USA
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87
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Moschini M, Simone G, Stenzl A, Gill IS, Catto J. Critical Review of Outcomes from Radical Cystectomy: Can Complications from Radical Cystectomy Be Reduced by Surgical Volume and Robotic Surgery? Eur Urol Focus 2016; 2:19-29. [PMID: 28723446 DOI: 10.1016/j.euf.2016.03.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 12/12/2022]
Abstract
CONTEXT Radical cystectomy (RC) is a highly complex procedure with multiple risks for perioperative complications. OBJECTIVE We reviewed the literature to report perioperative outcomes and the incidence of complications in contemporary RC series. We focused on the potential impact of surgical approach and surgeon volume on these outcomes. EVIDENCE ACQUISITION A systematic literature search was performed in December 2015 using the Medline, Embase, and Web of Science databases for articles published in English between 2005 and 2015. The search strategy included the terms complications, cystectomy, robotic assisted radical cystectomy, and surgical volume, alone or in combination. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. EVIDENCE SYNTHESIS Our searches retrieved 49 papers. Open RC (ORC) and robot-assisted RC (RARC) are morbid procedures with consistent risk of perioperative complications (mean weighted incidence: 48.7%; range: 27.0-72.5%). Higher hospital and surgeon volumes were associated with reduced risks of perioperative complications. Prior robotic expertise in radical prostatectomy showed a beneficial protective risk on development of complications after RARC. Surgical volume appears to be a good predictor of safety in ORC and RARC. RARC is associated with reduced estimated blood loss and lower perioperative transfusion rates compared with ORC. Further evidence is needed to support the reproducibility of intracorporeal diversion during RARC, beyond large tertiary referral centers. Several strategies have been demonstrated to be effective for reducing the risk of incurring perioperative complications and should be pursued by physicians. CONCLUSIONS Despite improvements in quality of care, RC remains a challenging procedure with high morbidity, regardless of surgical approach. RARC is a safe procedure with potential advantages in terms of reduced blood loss and transfusion rates. Surgical volume appears to be related to the improvement of perioperative outcomes and complications. PATIENT SUMMARY Radical cystectomy is a challenging and morbid procedure. The robotic approach has gained popularity and proved to be safe and effective in tertiary referral centers, although further studies are needed to confirm its wide reproducibility. Centers with higher surgical volume have lower incidence of perioperative complications.
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Affiliation(s)
- Marco Moschini
- Unit of Urology/Division of Oncology, IRCCS Ospedale San Raffaele, URI Milan, Milan, Italy.
| | - Giuseppe Simone
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Arnulf Stenzl
- Department of Urology, University Hospital Tübingen, Tübingen, Germany
| | - Inderbir S Gill
- University of Southern California Institute of Urology, Keck School of Medicine, Catherine and Joseph Aresty Department of Urology, Los Angeles, CA, USA
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
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88
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Kassouf W, Aprikian A, Black P, Kulkarni G, Izawa J, Eapen L, Fairey A, So A, North S, Rendon R, Sridhar SS, Alam T, Brimo F, Blais N, Booth C, Chin J, Chung P, Drachenberg D, Fradet Y, Jewett M, Moore R, Morash C, Shayegan B, Gotto G, Fleshner N, Saad F, Siemens DR. Recommendations for the improvement of bladder cancer quality of care in Canada: A consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015. Can Urol Assoc J 2016; 10:E46-80. [PMID: 26977213 DOI: 10.5489/cuaj.3583] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This initiative was undertaken in response to concerns regarding the variation in management and in outcomes of patients with bladder cancer throughout centres and geographical areas in Canada. Population-based data have also revealed that real-life survival is lower than expected based on data from clinical trials and/or academic centres. To address these perceived shortcomings and attempt to streamline and unify treatment approaches to bladder cancer in Canada, a multidisciplinary panel of expert clinicians was convened last fall for a two-day working group consensus meeting. The panelists included urologic oncologists, medical oncologists, radiation oncologists, patient representatives, a genitourinary pathologist, and an enterostomal therapy nurse. The following recommendations and summaries of supporting evidence represent the results of the presentations, debates, and discussions. Methodology
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Affiliation(s)
- Wassim Kassouf
- Department of urology, McGill University Health Centre, Montreal, QC, Canada
| | - Armen Aprikian
- Department of urology, McGill University Health Centre, Montreal, QC, Canada
| | - Peter Black
- Department of urology, University of British Columbia, Vancouver, BC, Canada
| | - Girish Kulkarni
- Department of surgery (urology) and surgical oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jonathan Izawa
- Division of urology, Western University, London, ON, Canada
| | - Libni Eapen
- Division of radiation oncology, University of Ottawa, Ottawa, ON, Canada
| | - Adrian Fairey
- Division of urology, University of Alberta, Edmonton, AB, Canada
| | - Alan So
- Department of urology, University of British Columbia, Vancouver, BC, Canada
| | - Scott North
- Medical oncology, University of Alberta, Edmonton, AB, Canada
| | - Ricardo Rendon
- Division of urology, Dalhousie University, Halifax, NS, Canada
| | - Srikala S Sridhar
- Medical oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | - Tarik Alam
- School of nursing, Dawson College, Montreal, QC, Canada
| | - Fadi Brimo
- Pathology, McGill University Health Centre, Montreal, QC, Canada
| | - Normand Blais
- Division of medical oncology, University of Montreal, Montreal, QC, Canada
| | - Chris Booth
- Departments of oncology, Queen's University, Kingston, ON, Canada
| | - Joseph Chin
- Division of urology, Western University, London, ON, Canada
| | - Peter Chung
- Radiation oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | | | - Yves Fradet
- Division of urology, Laval University, Quebec City, QC, Canada
| | - Michael Jewett
- Department of surgery (urology) and surgical oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ron Moore
- Division of urology, University of Alberta, Edmonton, AB, Canada
| | - Chris Morash
- Urology, University of Ottawa, Ottawa, ON, Canada
| | - Bobby Shayegan
- Division of urology, McMaster University, Hamilton, ON, Canada
| | - Geoffrey Gotto
- Division of urology, University of Calgary, Calgary, AB, Canada
| | - Neil Fleshner
- Department of surgery (urology) and surgical oncology, Princess Margaret Cancer Centre and the University Health Network, University of Toronto, Toronto, ON, Canada
| | - Fred Saad
- Urology, University of Montreal, Montreal, QC, Canada
| | - D Robert Siemens
- Departments of oncology, Queen's University, Kingston, ON, Canada;; Urology, Queen's University, Kingston, ON, Canada
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89
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Mani J, Vallo S, Brandt MP, Gust KM, Bartsch C, Daechert J, Tsaur I, Bartsch G, Haferkamp A. What should be the patient's preference regarding the choice of hospital in the case of radical cystectomy? Evaluation of early complications after open radical cystectomy in a medium and high volume setting in one hospital. Patient Prefer Adherence 2016; 10:2181-2187. [PMID: 27822019 PMCID: PMC5094608 DOI: 10.2147/ppa.s103217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE This study compares early complications after cystectomy and urinary diversion (UD) stratified by the surgical focus and case load of two different department chairpersons in a single institution in two time periods. Creating clear data about complications that can affect the quality of life is an important tool for patients to decide whether and where to perform this extensive surgery. HYPOTHESIS A team of surgeons with a clear focus on pelvic surgery leads to lower complication rates in radical cystectomy. MATERIALS AND METHODS Radical cystectomy was performed in two separate time periods under the patronage of two different chairmen in the same university hospital. The patient data were analyzed retrospectively and the complications 30 days after surgery were assessed using the Clavien-Dindo classification. RESULTS Statistical analysis showed a significant difference in the severity of complications between the two time periods, A and B, in total (P<0.001). When placing patients into subgroups, significantly more complications in period A were also seen concerning sex (male, P<0.001; female, P=0.003), age (<70 years, P<0.001; >70 years, P≤50.001) tumor grade (low grade, P<0.001; high grade, P≤0.001), and UD (ileal conduit, P<0.001; neobladder, P<0.001). In a multivariable analysis, age (P=0.031) and type of UD (P=0.028) were determined as independent predictors for complications in period A. When joining the two periods together, the type of UD (P=0.0417), age (P=0.041), and the time periods (A/B) (P<0.001) show a significant association with the presence of complications. CONCLUSION This study compares for the first time surgical complications in two time periods with different case load and surgical focus in one department. Categorization shows that patients should prefer radical cystectomy in centers of excellence or a high-volume hospital in order to keep complications at the lowest possible level and thus have the highest benefit for oncologic outcome and quality of life.
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Affiliation(s)
- Jens Mani
- Department of Urology, Goethe University Hospital, Frankfurt am Main
- Correspondence: Jens Mani, Department of Urology, Goethe-University, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany, Tel +49 69 6301 7107, Fax +49 69 6301 7108, Email
| | - Stefan Vallo
- Department of Urology, Goethe University Hospital, Frankfurt am Main
| | | | - Kilian M Gust
- Department of Urology, Goethe University Hospital, Frankfurt am Main
| | - Claudia Bartsch
- Department of Urology, Goethe University Hospital, Frankfurt am Main
| | - Johannes Daechert
- Department of Urology, Goethe University Hospital, Frankfurt am Main
| | - Igor Tsaur
- Department of Urology, Goethe University Hospital, Frankfurt am Main
| | - Georg Bartsch
- Department of Urology, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Axel Haferkamp
- Department of Urology, Goethe University Hospital, Frankfurt am Main
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90
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Effect of Intraoperative Red Blood Cell Transfusion on Postoperative Complications After Open Radical Cystectomy: Old Versus Fresh Stored Blood. Clin Genitourin Cancer 2015; 13:581-7. [PMID: 26165733 DOI: 10.1016/j.clgc.2015.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 11/22/2022]
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91
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Ortega-Lucea S, Martínez-Ubieto J, Júdez-Legaristi D, Muñoz-Rodriguez L, Gil-Bona J, Pascual-Bellosta A. The results of implementing a fast-track protocol in radical cystectomy in a tertiary hospital. Actas Urol Esp 2015; 39:620-7. [PMID: 26142895 DOI: 10.1016/j.acuro.2015.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/24/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Radical cystectomy (RC) is the urological procedure associated with the highest rates of morbidity, mortality and hospital stay. The implementation of fast-track programs seeks to speed postsurgical recovery. Its application to radical cystectomy has yielded positive results. OBJECTIVES To assess the results of the fast-track protocol in RC at our hospital, in terms of morbidity, mortality and hospital stay, comparing these results with those of patients who underwent RC following the classic protocol. To thereby ascertain whether the implementation of the fast-track protocol represents a reduced number and severity of complications and shorter hospital stays. MATERIAL AND METHODS Ambispective cohort study of patients who underwent RC between January 2010 and October 2012 by either protocol (classic and fast-track). We analyzed the patient characteristics, intraoperative variables, postoperative complications (according to the Clavien classification), hospital stay and recovery stay. RESULTS Ninety-nine patients were included, 51 following the classic protocol and 48 following the fast-track protocol. The groups were homogeneous. The hospital stay and recovery stay were longer in the classic group than in the fast-track group (29 and 2 days, respectively, vs. 17 and 1 day). There was less intraoperative bleeding in the fast track group (600mL) than in the traditional group (1,000mL). Of the 99 patients, 31 (60.8%) of the classic group presented a postoperative complication, while the fast-track group had 14 (29.2%), most of which were minor (Clavien degrees 1 and 2). In the multivariate analysis, the type of protocol and the number of comorbidities were significant. CONCLUSIONS The implementation of the fast-track protocol in RC was associated with a significant reduction in intraoperative and postoperative complications and hospital stay.
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92
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Contemporary radical cystectomy outcomes in patients with invasive bladder cancer: a population-based study. BJU Int 2015; 116 Suppl 3:18-25. [DOI: 10.1111/bju.13152] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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93
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Knight BA, Potretzke AM, Larson JA, Bhayani SB. Comparing Expert Reported Outcomes to National Surgical Quality Improvement Program Risk Calculator-Predicted Outcomes: Do Reporting Standards Differ? J Endourol 2015; 29:1091-9. [DOI: 10.1089/end.2015.0178] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- B. Alexander Knight
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Aaron M. Potretzke
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey A. Larson
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sam B. Bhayani
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, Missouri
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94
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Use of urostomy bags in the management of perioperative urine leakage after radical cystectomy. Cancer Nurs 2015; 37:170-4. [PMID: 23357883 DOI: 10.1097/ncc.0b013e318277db29] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Urine leakage is a common complication in patients with bladder cancer after radical cystectomy and neobladder reconstruction. OBJECTIVE The aim of this study was to evaluate the clinical value of the use of urostomy bags in the management of urine leakage in patients with bladder cancer after radical cystectomy. METHODS Urine leakage during the perioperative period was retrospectively analyzed in 483 patients with bladder cancer who underwent radical cystectomy from 2004 to 2010. Before 2008, all patients with urine leakages were treated by routine dressing changes (group A). After 2008, the leakages were managed with urostomy bags (group B). The perioperative quality of life (EQ-5D) and cost for urine leakage for both groups were compared in this controlled study. RESULTS The average cost in management of preoperative urine leakage was significantly higher in group A than in group B as well as the patients with extravasations of urine or lymphoceles. Patients in group B had an overall better perioperative life quality compared with group A. In particular, the score for pain/discomfort was significantly higher in group A than in group B. CONCLUSIONS The management of perioperative urine leakage with urostomy bags avoided constant body wetness and significantly increased the quality of life and reduced the special costs of urine leakage in patients with bladder cancer after cystectomy. IMPLICATIONS FOR PRACTICE Early use of urostomy bag is a good choice for perioperative urine leakage in patients with bladder cancer after radical cystectomy and neobladder reconstruction.
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95
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Tzortzis V, Dimitropoulos K, Karatzas A, Zachos I, Stamoulis K, Melekos M, Gravas S. Feasibility and safety of radical cystectomy under combined spinal and epidural anesthesia in octogenarian patients with ASA score ≥3: A case series. Can Urol Assoc J 2015; 9:E500-4. [PMID: 26279724 DOI: 10.5489/cuaj.2063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION This study evaluated the feasibility and safety of open radical cystectomy (RC) under combined regional anesthesia (CRA) in high-risk octogenarian patients. METHODS We retrospectively evaluated the medical records of high-risk, octogenarian bladder cancer patients submitted to open RC with CRA. Demographic and clinical data, intraoperative parameters and perioperative and postoperative complications were recorded using the Clavien-Dindo classification. RESULTS In total, 14 male and 4 female patients, with a median age of 82.5 years were enrolled. Ureterocutaneostomy was performed in 15 patients and Bricker ileal conduit in the remaining 3. Operative time ranged from 97 to 184 minutes. Five patients were transfused and no major intraoperative complications occurred. Postoperative complications 30 days later included ileus (Grade II) in 3 patients, surgical trauma infection in 1 patient (Grade II), respiratory infection in 2 patients (Grade III), and hydronephrosis with concurrent urinary tract infection in 3 patients (Grade III). No deaths occurred. CONCLUSIONS Our study showed that octogenarian, high-risk bladder cancer patients with indications for RC can safely undergo the surgical procedure under CRA, without apparent increase in major complications.
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Affiliation(s)
- Vassilios Tzortzis
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Konstantinos Dimitropoulos
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Anastasios Karatzas
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Ioannis Zachos
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Konstantinos Stamoulis
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Michael Melekos
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Stavros Gravas
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
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96
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Potretzke AM, Wong KS, Shi F, Christensen W, Downs TM, Abel EJ. Highest risk of symptomatic venous thromboembolic events after radical cystectomy occurs in patients with obesity or nonurothelial cancers. Urol Ann 2015; 7:355-60. [PMID: 26229325 PMCID: PMC4518374 DOI: 10.4103/0974-7796.152050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 06/24/2014] [Indexed: 11/04/2022] Open
Abstract
CONTEXT Venous thromboembolism (VTE) is a common cause of postoperative morbidity and mortality in cystectomy patients. AIMS The aim of this study is to identify variables associated with risk of developing deep venous thrombosis (DVT) or pulmonary embolism (PE) within 90 days after radical cystectomy (RC). SETTING AND DESIGN Retrospective chart review of patients undergoing RC from 2004 to 2011 at the University of Wisconsin. SUBJECTS AND METHODS Clinical variables collected for all RC patients. All patients received mechanical prophylaxis, and routine heparin prophylaxis began in 2010. STATISTICAL ANALYSIS USED Univariate and multivariate analyses were used to evaluate VTE association with known risk factors. RESULTS A total of 241 patients were identified with median age of 67.1 (interquartile range: 57.8-74.3) years. Body mass index (BMI) was ≥30 in 36.8% of patients. Median blood loss was 950 (600-1500) mL and 157/241 (65.2%) patients received a blood transfusion. CONCLUSIONS Patients with BMI ≥30 or nonurothelial cancer are at highest risk for postoperative VTE and should be considered for extended heparin prophylaxis.
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Affiliation(s)
- Aaron M Potretzke
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Kelvin S Wong
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Fangfang Shi
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - William Christensen
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Tracy M Downs
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - E Jason Abel
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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97
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Meyer CP, Rios Diaz AJ, Dalela D, Hanske J, Pucheril D, Schmid M, Trinh VQ, Sammon JD, Menon M, Chun FKH, Noldus J, Fisch M, Trinh QD. Wound dehiscence in a sample of 1 776 cystectomies: identification of predictors and implications for outcomes. BJU Int 2015; 117:E95-E101. [PMID: 26118393 DOI: 10.1111/bju.13213] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy (RC). PATIENTS AND METHODS In all, 1 776 patient records with Current Procedural Terminology (CPT) codes for radical cystectomy (RC) were extracted from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) between 2005 and 2012. Stratification was made based on the occurrence of postoperative wound dehiscence, defined as loss of integrity of fascial closure. Descriptive and logistic regression models were used to identify predictors of postoperative wound dehiscence. The implications of wound dehiscence on peri- and postoperative outcomes such as complications, mortality, prolonged length of stay (>11 days), and prolonged operative time (>411 min), were assessed. RESULTS Of 1 776 patients analysed, 57 (3.2%) had a documented wound dehiscence. In multivariable analyses, chronic obstructive pulmonary disease (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.0-4.0; P = 0.03) and high body mass index (OR 2.3, 95% CI 1.3-4.4; P = 0.008) were significant predictors of wound dehiscence. While female gender had significantly lower proportions of wound dehiscence, multivariable analyses did not confirm this (OR 0.4, 95% CI 0.4-1.4; P = 0.75). CONCLUSIONS Our study is the first to identify predictors of wound dehiscence after RC in a large, contemporary multi-institutional cohort. Identifying patients at risk of postoperative wound complications may guide the use of preventative measures at the time of surgery.
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Affiliation(s)
- Christian P Meyer
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arturo J Rios Diaz
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepansh Dalela
- Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Julian Hanske
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - Daniel Pucheril
- Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Marianne Schmid
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vincent Q Trinh
- Department of Pathology and Cellular Biology, Université de Montréal, Montreal, QC, Canada
| | - Jesse D Sammon
- Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Mani Menon
- Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Felix K H Chun
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Noldus
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Quoc-Dien Trinh
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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98
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Calidad de vida y supervivencia global en pacientes de alto riesgo tras cistectomía radical con una derivación urinaria simple. Cir Esp 2015; 93:368-74. [DOI: 10.1016/j.ciresp.2013.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 03/21/2013] [Accepted: 03/25/2013] [Indexed: 11/23/2022]
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99
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Morphological and functional analysis of a cohort of patients undergoing orthotopic ileal neobladder. Urologia 2015; 82:164-7. [PMID: 25953333 DOI: 10.5301/uro.5000119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2015] [Indexed: 11/20/2022]
Abstract
INTRODUCTION This study was conducted between January 2001 and December 2013 to evaluate patient's outcomes after radical cystectomy and orthotopic ileal neobladder from a morphological and functional point of view at a median follow-up of 2 years. MATERIALS AND METHODS A total of 48 eligible patents were included. We first report our technical modifications to Studer's neobladder. Sequently, after a medium follow-up of two years, we assessed morphology of the reservoir and voiding functionality of this patients cohort, submitting them to specific questionnaires and to uroflowmetry. RESULTS Early and late postoperative data are available for 36 patients. From the morphological follow-up, 2 years after surgery, six patients had hydroureteronephrosis for vescico-ureteral reflux in four cases (11% of total) and uretero-neobladder anastomosis stenosis in the other two (5.6% of total). Neobladder shape always remained spherical, with a relative right lateralization in eight cases (22.2%). Regarding the nine patients subjected to uroflowmetry, seven (77.7%) highlighted the lack of postvoid residual urine, with a maximum urinary flow rate within the normal range in six of them. DISCUSSION Improvements in surgical technique may help to reduce complications rate. From uroflowmetry analysis, we can observe that the mean filling pressure following surgery was relatively stable and urinary flow rate was mostly satisfactory. In patients without postvoid residual urine, all referred absence of daily incontinence and good quality of life. CONCLUSION From this morpho-functional evaluation, our orthotopic Studer-modified ileal neobladder seems an ideal solution for urinary diversion, presenting functional features similar to native bladder and assuming a well-defined morphology, not changing in time.
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100
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Aziz A, Gierth M, Rink M, Schmid M, Chun FK, Dahlem R, Roghmann F, Palisaar RJ, Noldus J, Ellinger J, Müller SC, Pycha A, Martini T, Bolenz C, Moritz R, Herrmann E, Keck B, Wullich B, Mayr R, Fritsche HM, Burger M, Bastian PJ, Seitz C, Brookman-May S, Xylinas E, Shariat SF, Fisch M, May M. Optimizing outcome reporting after radical cystectomy for organ-confined urothelial carcinoma of the bladder using oncological trifecta and pentafecta. World J Urol 2015; 33:1945-50. [DOI: 10.1007/s00345-015-1572-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022] Open
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