Contemporary open radical cystectomy: analysis of perioperative outcomes

Contemporary trends of in-hospital complications and mortality for radical cystectomy

What's known on the subject? and What does the study add? Radical cystectomy (RC) carries significant risks of morbidity and mortality. Little is known whether in-hospital outcomes are improving for RC. Using a contemporary population-based cohort, the present study suggests minimal improvement in postoperative complications and mortality overall or by hospital-volume category from 2001 to 2008. About 29% and 2% of patients undergoing RC will experience a postoperative complication or die during hospitalisation, respectively.

OBJECTIVE

To characterise the contemporary trends of in-hospital complications and mortality for radical cystectomy (RC) from a contemporary population-based cohort, as patients undergoing RC for bladder cancer are at significant risk for complications and mortality and the degree to which in-hospital outcomes have changed over time is unknown.

PATIENTS AND METHODS

We identified 50 625 individuals who underwent RC for bladder cancer between 2001 and 2008 from the Nationwide Inpatient Sample. Multivariable regression models were used to identify hospital and patient covariates associated with in-hospital complications and mortality and to estimate predicted probabilities of each outcome. Temporal trends of in-hospital mortality and complications were assessed by Wilcoxon rank-sum test.

RESULTS

The proportion of patients with in-hospital complications remained stable at 28.3% in 2001-2002 compared with 28.0% in 2007-2008 (P = 0.81 for trend). In-hospital mortality was also unchanged from 2.4% in 2001-2002 compared with 2.3% in 2007-2008 (P = 0.87 for trend). While high-volume hospitals were associated with lower odds of in-hospital complications (odds ratio [OR] 0.77, P = 0.01) and mortality (OR 0.60, P = 0.02) compared with low-volume hospitals, the predicted probabilities of in-hospital complications or mortality were unchanged within each volume category between 2001 and 2008.

CONCLUSIONS

In-hospital complications and mortality for RC remain unchanged from 2001 to 2008. While high-volume hospitals continue to have better outcomes, there is little evidence that postoperative mortality and morbidity are improving among low-, medium- and high-volume hospitals. Increased attention is needed to identify the modifiable aspects of postoperative care to improve in-hospital outcomes and safety for patients undergoing RC.

Selective bladder preservation with curative intent for muscle-invasive bladder cancer: a contemporary review

Radical cystectomy plus urinary diversion, the reference standard treatment for muscle-invasive bladder cancer, associates with high complication rates and compromises quality of life as a result of long-term effects on urinary, gastrointestinal and sexual function, and changes in body image. As a society ages, the number of elderly patients unfit for radical cystectomy as a result of comorbidity will increase, and thus the demand for bladder-sparing approaches for muscle-invasive bladder cancer will also inevitably increase. Trimodality bladder-sparing approaches consisting of transurethral resection, chemotherapy and radiotherapy (Σ 55-65 Gy) yield overall survival rates comparable with those of radical cystectomy series (50-70% at 5 years), while preserving the native bladder in 40-60% of muscle-invasive bladder cancer patients, contributing to an improvement in quality of life for such patients. Limitations of the trimodality therapy include (i) muscle-invasive bladder cancer recurrence in the preserved bladder, which most often arises in the original muscle-invasive bladder cancer site; (ii) potential lack of curative intervention for regional lymph nodes; and (iii) increased morbidity in the event of salvage radical cystectomy for remaining or recurrent disease as a result of high-dose pelvic irradiation. Consolidative partial cystectomy with pelvic lymph node dissection followed by induction chemoradiotherapy at lower dose (e.g. 40 Gy) is a rational strategy for overcoming such limitations by strengthening locoregional control and reducing radiation dosage. Molecular profiling of the tumor and functional imaging might play important roles in optimal patient selection for bladder preservation. Refinement of radiation techniques, intensified concurrent or adjuvant chemotherapy, and novel sensitizers, including molecular targeting agent, are also expected to improve outcomes and consequently provide more muscle-invasive bladder cancer patients with favorable quality of life.

[Robot-assisted radical cystectomy: do we actually need a robot?]

Compared to radical prostatectomy robotic surgery is far from becoming the standard of care for radical cystectomy. Concerns about perioperative and oncological safety as well as patient's benefit from this procedure may be a reason.In current publications no differences of perioperative morbidity and mortality were observed between patients undergoing open or robot-assisted radical cystectomy. Interestingly, older patients or patients with impaired health status might even profit from this technique. Though long-term data are missing, oncological results of robot-assisted radical cystectomy are encouraging. Extended lymphadenectomy is possible and positive margins are not seen more frequently. Concerning functional results (continence, potency) only little information is evaluable.In summary, operative and oncological outcomes do not seem to be impaired by robot assistance in radical cystectomy. However, whether patients or patient subgroups truly benefit from robot-assisted cystectomy needs to be elucidated in the future.

Perioperative morbidity of radical cystectomy: A review

A systematic review of the literature on perioperative morbidity (POM) was done using Medline software with a combination of keywords like mortality, morbidity, and complications. In addition, we review the analysis of our hospital data of 261 Radical cystectomies (RCs) performed in an 11-year period and our latest clinical pathway for RC. Age range in our series was 50 to 81 years with 240 males and 21 females. RCs were performed by intraperitoneal method in 172 patients and by our extraperitoneal (EP) method in 89 patients. Urinary diversion was ileal conduit in 159 patients and neobladder in 102 patients. Blood loss ranged between 500 and 1500 ccs. Postoperative mortality occurred in eight patients (3%). Among the other early post-op complications, major urinary leak was seen in nine and minor in 11, requiring PCN in five patients and reoperation in four patients. Bowel leak or obstruction was seen in six and four patients, respectively, requiring reoperation in six patients. EP RC in our series showed some benefit in reduction of POM. The mortality of RC has declined but the POM still ranges from 11 to 68%, as reported in 23 series (1999-2008) comprising of 14 076 patients. Various risk factors leading to POM and some corrective measures are discussed in detail. However, most of these series are retrospective and lack standard complication reporting, which limits the comparison of outcomes. Various modifications in open surgical technique and laparoscopic and Robotic approaches are aimed at reduction in mortality and POM of RC.

Perioperative complications of radical cystectomy after induction chemoradiotherapy in bladder-sparing protocol against muscle-invasive bladder cancer: a single institutional retrospective comparative study with primary radical cystectomy

OBJECTIVE

To compare rates of early morbidity after radical cystectomy in patients treated with or without induction chemoradiotherapy (CRT) using a standardized reporting methodology.

METHODS

All 193 consecutive patients undergoing radical cystectomy for bladder cancer between 1989 and 2010 were retrospectively reviewed. Induction chemoradiotherapy consists of radiation at 40 Gy to the small pelvis and two cycles of concurrent cisplatin at 20 mg/day for 5 days. Deaths within 90 days after radical cystectomy and complications arising within 30 days were recorded and graded according to the Clavien-Dindo classification. Grades 1-2 were considered minor; Grades 3-5 were considered major.

RESULTS

Eighty-seven patients underwent radical cystectomy following chemoradiotherapy (chemoradiotherapy group) while the remaining 106 primarily underwent radical cystectomy (no chemoradiotherapy group). No Grade 4-5 complication was observed. Overall, 118 patients (61%) experienced 36 major and 122 minor complications. There was no significant difference in the incidence of overall complications between the chemoradiotherapy and no chemoradiotherapy groups (67 vs. 57%). Overall urinary anastomosis-related complications and major gastrointestinal complications, most of which were Grade 3 ileus, were more frequent in the chemoradiotherapy group than the no chemoradiotherapy group (11 vs. 2%, P = 0.007; and 14 vs. 4%, P = 0.02; respectively). Multivariate analysis identified induction chemoradiotherapy as an independent risk factor for overall urinary anastomosis-related complications (relative risk 6.0, P = 0.01) but not for major gastrointestinal complications.

CONCLUSIONS

Induction chemoradiotherapy at 40 Gy in bladder-sparing protocols against MIBC is unlikely to increase the rate of severe complications of radical cystectomy.

Predicting the probability of 90-day survival of elderly patients with bladder cancer treated with radical cystectomy

PURPOSE

Despite the increased morbidity and mortality of radical cystectomy in elderly individuals with bladder cancer numerous studies show that surgery can provide a survival benefit. We sought to better identify patients at substantial risk for postoperative mortality.

MATERIALS AND METHODS

We evaluated 220 consecutive patients 75 years old or older treated with radical cystectomy for bladder cancer at a single institution from 2000 to 2008. The analytical cohort comprised 169 patients with complete preoperative data available. A Cox proportional hazards model was used to determine the value of precystectomy clinical information to predict 90-day survival after radical cystectomy. Results were used to create a nomogram predicting the probability of 90-day survival after radical cystectomy. The model was then subjected to 200 bootstrap resamples for internal validation.

RESULTS

Of the 220 patients 28 (12.7%) died within 90 days of surgery. Older age (HR 2.30, 95% CI 1.22-4.32) and lower preoperative albumin (HR 2.50, 95% CI 1.40-4.45) were significant predictors of 90-day mortality. We developed a nomogram based on patient age, clinical stage, Charlson comorbidity index and albumin to predict the likelihood of 90-day mortality with 75% accuracy. Internal validation showed a bootstrap adjusted concordance index of 71%.

CONCLUSIONS

We developed a nomogram that provides individualized risk estimations to predict the probability of 90-day mortality, potentially enhancing preoperative counseling and providing clinicians with an added tool to individualize treatment decisions in this challenging patient population. These data suggest that albumin is a strong predictor of postoperative mortality and show the importance of assessing this variable before surgery.

Older patients suffer from adverse histopathological features after radical cystectomy

OBJECTIVES

Radical cystectomy (RC) remains a complex procedure in older patients. Perioperative morbidity can be significant and it can represent a limitation for its indication in this population. The aim of the present study was to evaluate the outcomes of RC in elderly patients from a large single-center cohort.

METHODS

A total of 447 patients who underwent RC between 1996 and 2009 at our institution were considered. Patients were stratified by age (≤70 vs >70 years). Logistic regression analyses were carried out comparing both groups regarding clinical, perioperative and histopathological findings, as well as complications according to the modified Clavien system and survival.

RESULTS

Data of 390 patients were available for the analysis. Of these, 265 (67.9%) versus 125 (32.1%) patients were <70 versus ≥70 years-of-age. The median age was 61 and 75 years, respectively. In the elderly, ASA score (P < 0.001), delay between transurethral resection of the bladder (TURBT) and RC (P = 0.004), and number of perioperative blood transfusions (P = 0.002) were significantly higher. Additionally, a clear trend towards higher stages (pT3-4) was observed (P = 0.04). However, complications, and overall and cancer-specific mortality were not increased in older patients. Finally, age was identified as a significant risk factor for upstaging (P = 0.04). Upstaging between TURBT and final histopathology in patients <70 versus ≥70 years occurred in 45% versus 58%, respectively (P = 0.03).

CONCLUSIONS

RC is equally feasible in older patients without increasing morbidity or mortality. On the contrary, older patients have a higher risk of significant upstaging and advanced stages at final histopathology. These findings suggest that RC should neither be delayed in nor withheld from elderly patients.

The role of laparoscopic and robotic cystectomy in the management of muscle-invasive bladder cancer with special emphasis on cancer control and complications

CONTEXT

Minimally invasive radical cystectomy (MIRC) techniques for the treatment of muscle-invasive bladder cancer (BCa) are being increasingly applied. MIRC offers the potential benefits of a minimally invasive approach in terms of reduced blood loss and analgesic requirements whilst striving to provide similar oncologic efficacy to open radical cystectomy (ORC). Whether quicker recovery, shorter hospital stay, and a reduction in complications are routinely achieved with MIRC remains to be proved in prospective comparisons.

OBJECTIVE

To explore both laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RRC), focusing specifically on the oncologic parameters and comorbidity of the procedures. Reported complications from major centres are identified and categorised via the Clavien system. Positive margins rates, local recurrence, and both cancer-specific survival (CSS) and overall survival rates are assessed.

EVIDENCE ACQUISITION

A comprehensive electronic literature search was conducted in November 2010 using the Medline database to identify publications relating to laparoscopic, robotic, or minimally invasive radical cystectomy.

EVIDENCE SYNTHESIS

There are encouraging short- to medium-term results for both LRC and RRC in terms of postoperative morbidity and oncologic outcomes. It seems possible in experienced hands to perform a satisfactory minimally invasive lymphadenectomy regarding lymph node counts and levels of dissection. Positive soft-tissue margins are similar to large open series for T2/T3 disease but inferior for bulky T4 disease. Local recurrence rates and CSS rates seem equivalent to ORC at up to 3 yr of follow-up; however, mature outcome data still need to be presented before definitive comparisons can be made.

CONCLUSIONS

Robotic and laparoscopic cystectomy has a growing role in the management of muscle-invasive BCa. Long-term oncologic results are awaited, and there are concerns over the ability of MIRC to treat bulky and locally advanced disease, making careful patient selection vital. Forthcoming randomised trials in this area will more fully address these issues.

[Robot-assisted radical cystectomy. Pilot study for the prospective evaluation of perioperative parameters compared to open radical cystectomy]

BACKGROUND

For robot-assisted radical cystectomy prospective assembly and evaluation of peri- and postoperative parameters within a national database is planned. This pilot study evaluated which parameters should be assessed and which problems might occur for assembly and interpretation of data.

PATIENTS AND METHODS

Of 84 patients with radical cystectomy, 14 underwent RARC. Evaluable patients were compared to patients with open radical cystectomy (ORC) regarding perioperative parameters. In addition, a literature review on published single-center RARC series and comparative investigations (RARC vs ORC) was performed. Published data were compared to results of our own series.

RESULTS

RARC patients received less packed red blood cells [RARC: 0 (0-2), ORC 2 (0-12), p=0.009] and hospitalization was shorter [RARC: 14 (8-18) days, ORC: 18 (11-97) days, p=0.015]. Comorbidities as assessed by the Charlson Comorbidity Index were less common in RARC patients [RARC: 4 (3-8), ORC: 6 (3-11), p=0.11]. No major differences between our own and published results were observed. The rate of continent urinary diversions in the Düsseldorf RARC cohort was, apart from one study, larger. Problems in the assembly and interpretation of operation time, blood loss, transfusion rate, and postoperative recovery were observed.

CONCLUSIONS

Even in this small cohort results of published studies were confirmed. Potential problems in data assembly were identified. Appropriate solutions will be implemented in the national database.

[Robotic-assisted laparoscopic radical cystectomy: evaluation of functional and oncological results]

PURPOSE

radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. We report our experience with 84 consecutive cases of robotic assisted laparoscopic radical cystectomy with regard to perioperative results, pathological outcomes and surgical complications.

MATERIALS AND METHODS

a total of 84 consecutive patients (70 male and 14 female) underwent robotic radical cystectomy and urinary diversion at our institution from January 2007 to August 2010 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes and complication rate.

RESULTS

mean age of this cohort was 65.5 years (range 28 to 82). Of the patients 62 underwent ileal conduit diversion, 22 received a neobladder. Mean operating room time for all patients was 261min. (range: 243-618min.) and mean surgical blood loss was 298ml (range: 50-2000ml). 29% of the cases were pT1 or less disease, 38% were pT2, 26% and 7% were pT3 and T4 disease respectively, 15% were node positive. Mean number of lymph nodes removed was 15 (range 1 to 33). In 2 cases (2.4%) there was a positive surgical margin. Mean days to flatus were 2.12, bowel movement 2.87 and discharge home 17.7 (range: 10-33). There were 45 postoperative complications with 11.9% having a major complication (Clavien grade 3 or higher). At a mean followup of 16.7 months 10 patients (11%) had disease recurrence and 2 died of disease.

CONCLUSIONS

our experience with robotic radical cystectomy for the treatment of bladder cancer suggests that in proper hands this procedure provides acceptable surgical and pathological outcomes.

Robotic surgery in urologic oncology: gathering the evidence

In less than a decade, the widespread application of robotic technology to the field of urologic oncology has permanently altered the way urologists approach malignancy. The short-term benefits of minimally invasive surgery using robotic assistance (i.e., decreased blood loss, improved convalescence and ergonomic appeal), as well as a broad marketing campaign, have helped the technology gain traction in the field of urology. Although the long-term benefits of its use in urologic surgery are less clear and the costs of robotic surgery are consistently greater than those of other approaches, the numbers of prostate, kidney and bladder cancer cases continue to rise. Identifying transferable surgical processes of care that matter most for each of the robotic cases in urologic oncology (e.g., prostatectomy, cystectomy and partial nephrectomy) is a next step toward broadly improving the quality of urologic cancer care. To this end, urologic professional societies and their surgeons should aim to identify underwriters for and participate in large clinical registries and surgical quality collaboratives.

Effect of preoperative nutritional deficiency on mortality after radical cystectomy for bladder cancer

PURPOSE

Poor preoperative nutritional status is a risk factor for adverse outcomes after major surgery. We evaluated the effect of preoperative nutritional deficiency on perioperative mortality and overall survival in patients undergoing radical cystectomy for bladder cancer.

MATERIALS AND METHODS

A total of 538 patients underwent radical cystectomy for urothelial carcinoma between January 2000 and June 2008, and had nutritional parameters documented. Patients with preoperative albumin less than 3.5 gm/dl, body mass index less than 18.5 kg/m(2) or preoperative weight loss greater than 5% of body weight were considered to have nutritional deficiency. Primary outcomes were 90-day mortality and overall survival. Survival was estimated using Kaplan-Meier analysis and compared using the log rank test. Cox proportional hazards models were used for multivariate survival analysis.

RESULTS

Of 538 patients 103 (19%) met the criteria for nutritional deficiency. The 90-day mortality rate was 7.3% overall (39 deaths), with 16.5% in patients with nutritional deficiency and 5.1% in the others (p < 0.01). Nutritional deficiency was a strong predictor of death within 90 days on multivariate analysis (HR 2.91; 95% CI 1.36, 6.23; p < 0.01). Overall survival at 3 years was 44.5% (33.5, 54.9) for nutritionally deficient patients and 67.6% (62.4, 72.2) for those who were nutritionally normal (p < 0.01). On multivariate analysis nutritional deficiency cases had a significantly higher risk of all cause mortality (HR 1.82; 95% CI 1.25, 2.65; p < 0.01).

CONCLUSIONS

Nutritional deficiency, as measured by preoperative weight loss, body mass index and serum albumin, is a strong predictor of 90-day mortality and poor overall survival. Prospective studies are needed to demonstrate the best indices of preoperative nutritional status and whether nutritional intervention can alter the poor prognosis for patients treated with radical cystectomy who have nutritional deficiencies.

The effect of age on bladder cancer incidence, prognosis and therapy

Age is now widely accepted as the single greatest risk factor for developing urothelial carcinoma of the bladder (UCB). The aim of this article is to assess the incidence, prognosis and therapy of UCB in the elderly. Using MEDLINE, we performed a search of the literature between January 1966 and July 2009. The link between aging and cancer is more complex than the simple passage of time; certain genes may be activated while others may be suppressed with advancing age. Treatments for nonmuscle-invasive UCB are generally well-tolerated by the elderly. However, several studies have demonstrated a lower response rate to intravesical immunotherapy in the elderly. While elderly patients have a higher rate of perioperative complication and mortality after radical cystectomy, the difference is too small and insufficient to avoid radical cystectomy in these patients. Similarly, in certain selected cases, centers of excellence report similar complication rates in elderly patients, regardless of the type of urinary diversion. The optimal application of perioperative chemotherapy is dependent on the degree of compromise of the organ systems through comorbid conditions and physiologic deterioration. Restrictive case selection and proactive postoperative rehabilitation are important for elderly patients to obtain good results. Age alone does not preclude optimal treatment for patients with aggressive UCB. Radical surgery, urinary diversion and systemic chemotherapy are feasible, safe and efficacious in the treatment of adequately selected elderly UCB patients. It is imperative that healthcare practitioners and researchers from disparate disciplines collectively focus their efforts to appropriately meet the multifaceted medical and psychosocial needs of the elderly.

Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series

PURPOSE

Radical cystectomy remains associated with significant morbidity. Most series report outcomes with relatively short-term followup that may underestimate the true magnitude of the procedure and many report length of hospital stay but ignore readmission rates. We analyzed the predictors of early (30 days or less), late (31 to 90 days) and cumulative 90-day hospital readmissions, as well as morbidity and mortality rates.

MATERIALS AND METHODS

We reviewed our prospectively collected database of 753 patients who underwent radical cystectomy for urothelial cancer between January 2001 and December 2007. We examined the relationship between clinical variables and readmission rates during the early, late and 90-day postoperative period, and reviewed mortality and perioperative morbidity rates.

RESULTS

There were 200 (26.6%) patients readmitted in the first 90 days following radical cystectomy. Of these patients 148 (19.7%) were readmitted early, 81 (10.8%) were readmitted late, and 29 (3.9%) had an early and late readmission. Logistical regression revealed gender (OR 1.50, 95% CI 1.00-2.27, p = 0.05), age adjusted Charlson comorbidity index (OR 1.19, 95% CI 1.06-1.34, p = 0.003) and any postoperative complications before discharge home (OR 1.84, 95% CI 1.19-2.83, p = 0.006) as independent predictors of 90-day readmission. The 30 and 90-day mortality rates were 2.1% (16) and 6.9% (52), respectively.

CONCLUSIONS

Readmission rates after radical cystectomy are significant, approaching 27% within the first 90 days. Gender and age adjusted Charlson comorbidity index were independent predictors providing preoperative information identifying patients more likely to require readmission or possibly to benefit from a longer initial hospital stay.

Evidence-based clinical practice guidelines for bladder cancer (summary - JUA 2009 Edition)

In Japan, until now, the treatment of bladder cancer has been based on guidelines from overseas. The problem with this practice is that the options recommended in overseas guidelines are not necessarily suitable for Japanese clinical practice. A relatively large number of clinical trials have been conducted in Japan in the field of bladder cancer, and the Japanese Urological Association (JUA) considered it appropriate to formulate their own guidelines. These Guidelines present an overview of bladder cancer at each clinical stage, followed by clinical questions that address problems frequently faced in everyday clinical practice. In this English translation of a shortened version of the original Guidelines, we have abridged each overview, summarized each clinical question and its answer, and only included the references we considered of particular importance.

The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium

BACKGROUND

Robot-assisted radical cystectomy (RARC) has evolved as a minimally invasive alternative to open radical cystectomy for patients with invasive bladder cancer.

OBJECTIVE

We sought to define the learning curve for RARC by evaluating results from a multicenter, contemporary, consecutive series of patients who underwent this procedure.

DESIGN, SETTING, AND PARTICIPANTS

Utilizing the International Robotic Cystectomy Consortium database, a prospectively maintained and institutional review board-approved database, we identified 496 patients who underwent RARC by 21 surgeons at 14 institutions from 2003 to 2009.

MEASUREMENTS

Cut-off points for operative time, lymph node yield (LNY), estimated blood loss (EBL), and margin positivity were identified. Using specifically designed statistical mixed models, we were able to inversely predict the number of patients required for an institution to reach the predetermined cut-off points.

RESULTS AND LIMITATIONS

Mean operative time was 386 min, mean EBL was 408 ml, and mean LNY was 18. Overall, 34 of 482 patients (7%) had a positive surgical margin (PSM). Using statistical models, it was estimated that 21 patients were required for operative time to reach 6.5h and 8, 20, and 30 patients were required to reach an LNY of 12, 16, and 20, respectively. For all patients, PSM rates of <5% were achieved after 30 patients. For patients with pathologic stage higher than T2, PSM rates of <15% were achieved after 24 patients.

CONCLUSIONS

RARC is a challenging procedure but is a technique that is reproducible throughout multiple centers. This report helps to define the learning curve for RARC and demonstrates an acceptable level of proficiency by the 30th case for proxy measures of RARC quality.

Ureteroileal anastomosis with intraluminal visualization: technique and outcomes

OBJECTIVES

Although the ileal conduit is the most well-established urinary diversion, the optimal technique for ureteroileal anastomosis remains controversial. Here, we present a technique for anastomosis of the ureters from within the lumen of the ileal conduit, under direct visualization. We examine the rate of ureteral stricture using this method, and review the literature regarding ureteroenteric anastomotic complications with various techniques.

METHODS

An intraluminal technique for ureteroenteric anastomsosis was performed by opening the conduit on the antimesenteric border to allow direct visualization of the ureteroileal anastomosis. Using our prospectively collected database, we investigated the prevalence of anastomotic stricture in patients undergoing urinary diversion using this method for anastomosis.

RESULTS

One-hundred eighteen patients underwent ileal conduit diversion with ureteroileal anastomoses performed as described. Median postoperative follow-up was 15 months. Ureteral strictures were identified in 5/118 patients (4.2%). Of the patients with strictures, one was successfully treated with endoscopic balloon dilatation, three were managed with chronic ureteral stents, and one was managed with a chronic percutaneous nephrostomy. Review of the recent literature reveals stricture rates up to 10% with current techniques.

CONCLUSIONS

We conclude from these results that during ileal conduit creation, intraluminal anastomosis of the ureters to the ileal segment under direct vision represents a viable alternative to other techniques, with complication rates that compare favorably with other reported series.

Urinary diversion and morbidity after radical cystectomy for bladder cancer

BACKGROUND

The rate of continent urinary diversion after radical cystectomy for bladder cancer varies by patient and provider characteristics. Demonstration of equivalent complication rates, independent of diversion type, may decrease provider reluctance to perform continent reconstructions. The authors sought to determine whether continent reconstructions confer increased complication rates after radical cystectomy.

METHODS

From the Nationwide Inpatient Sample, the authors used International Classification of Disease (ICD-9) codes to identify subjects who underwent radical cystectomy for bladder cancer during 2001-2005. They determined acute postoperative medical and surgical complications from ICD-9 codes and compared complication rates by reconstruction type using the nearest neighbor propensity score matching method and multivariate logistic regression models.

RESULTS

Adjusting for case-mix differences between reconstructive groups, continent diversions conferred a lower risk of medical, surgical, and disposition-related complications that was statistically significant for bowel (3.1% lower risk; 95% confidence interval [95% CI], -6.8% to -0.1%), urinary (1.2% lower risk; 95% CI, -2.3%, to -0.4%), and other surgical complications (3.0% lower risk; 95% CI, -6.2% to -0.4%), and discharge other than home (8.2% lower risk; 95% CI, -12.1% to -4.6%) compared with ileal conduit subjects. Older age and certain comorbid conditions, including congestive heart failure and preoperative weight loss, were associated with significantly increased odds of postoperative medical and surgical complications in all subjects.

CONCLUSIONS

Mode of urinary diversion after radical cystectomy for bladder cancer is not associated with increased risk of immediate postoperative complications. These results may encourage broader consideration of continent urinary diversion without concern for increased complication rates.

Radical cystectomy in the elderly patient: a contemporary comparison of perioperative complications in a single institution series

PURPOSE

To report on our recent experience with peri- and postoperative morbidity of radical cystectomy in patients 75 years and older compared to younger patients.

PATIENTS AND METHODS

Medical records of 326 consecutive patients undergoing radical cystectomy from May 2004 through April 2008 were reviewed.

RESULTS

Eighty-five of 326 patients (26%) were > or =75 years (75-95) old. ASA score was equal 3 or greater in 51% of patients > or =75 years and 32% of patients <75 years. Ileal conduit was performed in 83% of patients > or =75, 16% received an ileal neobladder compared to 46 and 51%, respectively, in patients <75. A total of 33 patients (39%) in the older patient group received blood transfusions intraoperatively compared to 76 patients (32%) in the younger age group. In 6 patients > or =75 years (7.1%) and 17 patients <75 (7.1%) open surgical revision was necessary, perioperative complication rate was 22 and 21%, respectively. The most common complications were wound dehiscence (5.9 vs. 7.5%), infections (4.7 vs. 4.6%), and pulmonary embolism (3.5 vs. 2.1%). Perioperative mortality was 1.2% (1 patient) in the elderly versus 0.4% (1 patient) in the younger age group.

CONCLUSION

Our data show that radical cystectomy can be offered to the elderly patient with acceptable morbidity. Because of higher comorbidity rate in the elderly, therapeutic decision for radical cystectomy in elderly patients should be made carefully and individually. Nevertheless our results demonstrate that age itself is not a main criterion which has to be considered strongly in decision making for radical cystectomy.

Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results

BACKGROUND

In recent years, surgeons have begun to report case series of minimally invasive approaches to radical cystectomy, including robotic-assisted techniques demonstrating the surgical feasibility of this procedure with the potential of lower blood loss and more rapid return of bowel function and hospital discharge. Despite these experiences and observations, at this point high levels of clinical evidence with regard to the benefits of robotic cystectomy are absent, and the current experiences represent case series with limited comparisons to historical controls at best.

OBJECTIVE

We report our results on a prospective randomized trial of open versus robotic-assisted laparoscopic radical cystectomy with regard to perioperative outcomes, complications, and short-term narcotic usage.

DESIGN, SETTING, AND PARTICIPANTS

A prospective randomized single-center noninferiority study comparing open versus robotic approaches to cystectomy in patients who are candidates for radical cystectomy for urothelial carcinoma of the bladder. Of the 41 patients who underwent surgery, 21 were randomized to the robotic approach and 20 to the open technique.

INTERVENTION

Radical cystectomy, bilateral pelvic lymphadenectomy, and urinary diversion by either an open approach or by a robotic-assisted laparoscopic technique.

MEASUREMENTS

The primary end point was lymph node (LN) yield with a noninferiority margin of four LNs. Secondary end points included demographic characteristics, perioperative outcomes, pathologic results, and short-term narcotic use.

RESULTS AND LIMITATIONS

On univariate analysis, no significant differences were found between the two groups with regard to age, sex, body mass index, American Society of Anesthesiologists classification, anticoagulation regimen of aspirin, clinical stage, or diversion type. Significant differences were noted in operating room time, estimated blood loss, time to flatus, time to bowel movement, and use of inpatient morphine sulfate equivalents. There was no significant difference in regard to overall complication rate or hospital stay. On surgical pathology, in the robotic group 14 patients had pT2 disease or higher; 3 patients had pT3/T4 disease; and 4 patients had node-positive disease. In the open group, eight patients had pT2 disease or higher; five patients had pT3/T4 disease; and seven patients had node-positive disease. The mean number of LNs removed was 19 in the robotic group versus18 in the open group. Potential study limitations include the limited clinical and oncologic follow-up and the relatively small and single-institution nature of the study.

CONCLUSIONS

We present the results of a prospective randomized controlled noninferiority study with a primary end point of LN yield, demonstrating the robotic approach to be noninferior to the open approach. The robotic approach also compares favorably with the open approach in several perioperative parameters.

Urinary diversion trends at a high volume, single American tertiary care center

PURPOSE

We analyzed patient characteristics and practice patterns at our institution with time, and identified current patterns and factors contributing to the choice of urinary diversion.

MATERIALS AND METHODS

We reviewed the records of 553 consecutive radical cystectomy and urinary diversions performed from January 2000 to July 2005. Multivariate analysis was done to determine significant differences in diversion choice.

RESULTS

We analyzed the records of 539 patients, including 338 with an ileal conduit and 201 with a neobladder. Patients with a neobladder were younger (mean age 62 vs 71 years) and had fewer comorbidities (American Society of Anesthesiologists class greater than 2 in 31% vs 69%) than those with an ileal conduit. Mean age and the percent of American Society of Anesthesiologists class 3 or 4 cases increased during the study. Neobladder represented 47% of urinary diversions in 2000 and 21% in 2005. On multivariate analysis age (p <0.001), gender (p = 0.004), surgery year (p = 0.002), American Society of Anesthesiologists class greater than 2 (p = 0.004), organ confined disease (p = 0.01) and surgeon (p <0.001) independently predicted diversion choice. Patients were dichotomized into young (younger than 65 years) and old (65 years old or older) groups. Overall 59% of younger and 26% of older patients received a neobladder (p <0.001).

CONCLUSIONS

There was a significant trend toward the more liberal use of ileal conduit urinary diversion. Patients with female gender, advanced age, significant medical comorbidity or locally advanced disease were less likely to undergo neobladder urinary diversion. This trend is partly explained by surgeon preference combined with an aging, more comorbid patient population. Neobladder continues to be the most commonly performed urinary diversion in patients younger than 65 years.

Complications following radical cystectomy for bladder cancer in the elderly

CONTEXT

The incidence of bladder cancer increases with advancing age. Considering the increasing life expectancy and the increasing proportion of elderly people in the general population, radical cystectomy will be considered for a growing number of elderly patients who suffer from muscle-invasive or recurrent bladder cancer.

OBJECTIVE

This article reviews contemporary complication and mortality rates after radical cystectomy in elderly patients and the relationship between age and short-term outcome after this procedure.

EVIDENCE ACQUISITION

A literature review was performed using the PubMed database with combinations of the following keywords cystectomy, elderly, complications, and comorbidity. English-language articles published in the year 2000 or later were reviewed. Papers were included in this review if the authors investigated any relationship between age and complication rates with radical cystectomy for bladder cancer or if they reported complication rates stratified by age groups.

EVIDENCE SYNTHESIS

Perioperative morbidity and mortality are increased and continence rates after orthotopic urinary diversion are impaired in elderly patients undergoing radical cystectomy. Complications are frequent in this population, particularly when an extended postoperative period (90 d instead of 30 d) is considered.

CONCLUSIONS

Although age alone does not preclude radical cystectomy for muscle-invasive or recurrent bladder cancer or for certain types of urinary diversion, careful surveillance is required, even after the first 30 d after surgery. Excellent perioperative management may contribute to the prevention of morbidity and mortality of radical cystectomy, supplementary to the skills of the surgeon, and is probably a reason for the better perioperative results obtained in high-volume centers.

Does the presence of significant risk factors affect perioperative outcomes after robot-assisted radical cystectomy?

OBJECTIVE

To evaluate the effect of preoperative risk factors on perioperative outcomes up to 3 months after robot-assisted radical cystectomy (RARC), as RC continues to be associated with a high rate of morbidity and mortality.

PATIENTS AND METHODS

From 2005 to 2007, 66 consecutive patients had RARC at Roswell Park Cancer Institute. Patient demographics, preoperative risk factors and complications up to 3 months after RARC were reviewed from a prospective quality-assurance database. Patients were stratified into high- and low risk groups based on age, previous abdominal surgery, chronic obstructive pulmonary disease (COPD), body mass index (BMI), Revised Cardiac Risk Index (RCRI) and American Society of Anesthesiologists (ASA) score.

RESULTS

Age, previous abdominal surgery, COPD, BMI, RCRI score and ASA score did not significantly influence complications during or up to 3 months following RARC (P > 0.05). Advanced age was associated with a higher RCRI score (P = 0.014) and an increased likelihood of admission to the Intensive Care Unit (P = 0.007). A higher ASA score was associated with an increased overall hospital stay (P = 0.039). Previous abdominal surgery was associated with more frequent unscheduled postoperative clinic visits (P = 0.014). Operative duration did not significantly influence complication rates (P > 0.05). Fifteen of 62 patients (24%) had a major complication, while 15 (24%) had minor complications within 3 months of surgery. The reoperation rate was 11% and the overall mortality rate was 1.6%.

CONCLUSIONS

RARC appears to be well tolerated, independent of comorbid risk factors such as age, BMI, RCRI and ASA score.

Bladder cryoablation in a porcine model: evaluation of three surgical approaches and cryolesion predictability

PURPOSE

To determine the feasibility of bladder cryoablation (BC) applied laparoscopically, percutaneously, and transurethrally in a porcine survival study. The expected and observed area of cell death after BC was also examined.

MATERIALS AND METHODS

Nine pigs were divided equally into the three treatment groups. Cryoablation was performed with two freeze-thaw cycles after the bladder had been insufflated with CO2. Each animal was observed for 7 days after the procedure for treatment-related complications. After cystectomy, each specimen was examined pathologically to determine the degree and dimension of cell death achieved.

RESULTS

BC applied via the laparoscopic and percutaneous approach is feasible and safe. No BC-related complications occurred in these two groups. A complication resulting from BC developed in all three animals that were treated cystoscopically, including two intraperitoneal bladder perforations at the time of BC necessitating immediate sacrifice, and one enterovesical fistula discovered at cystectomy. Transmural necrosis was demonstrated in seven of seven animal specimens that survived to the end of the protocol. The observed diameter of tissue necrosis was highly predictable based on the reported cryoprobe isotherms given by the manufacturer.

CONCLUSION

All locations within the bladder can be successfully and predictably treated with cryoablation. Of the three approaches, laparoscopically administered BC appears to be the most safe and consistent method. Transurethral BC was not safe with the equipment available without laparoscopic assistance to prevent bowel complications.

Surgical apgar outcome score: perioperative risk assessment for radical cystectomy

PURPOSE

Currently objective perioperative risk assessment metrics are lacking for radical cystectomy. Using a simple 10-point scale similar to neonatal Apgar assessment we evaluated whether a surgical outcome score calculated immediately after radical cystectomy would predict major complications and mortality.

MATERIALS AND METHODS

We identified 155 consecutive radical cystectomies performed between 2005 and 2007 at our institution. Data were collected on 45 preoperative and intraoperative variables. We used a framework established by the National Surgical Quality Improvement Program to evaluate major complications within 30 days of surgery. We used a 10-point scoring system that had been previously validated in general and vascular surgery populations, comprising estimated blood loss, lowest heart rate and lowest mean arterial pressure.

RESULTS

A total of 40 (26%) patients undergoing radical cystectomy experienced a major complication within 30 days of the operation. There was a progressive decrease in complications with increasing surgical Apgar score, in that patients with a low vs a high Apgar score were more likely to experience complications (OR 6.9, 95% CI 1.9-24.2). Coronary artery disease, American Society of Anesthesiologists class, intraoperative blood transfusion, volume of intravenous fluid administered and female gender were also associated with major complications (p <0.05).

CONCLUSIONS

In patients undergoing radical cystectomy the surgical Apgar score predicts major postoperative complications and death. This simple and objective postoperative metric may be used to dictate the intensity of care. Prospective studies are needed to determine whether treatment decisions based on this scoring system improve radical cystectomy outcomes.