Identifying risk factors for potentially avoidable complications following radical cystectomy

The effect of age and gender on bladder cancer: a critical review of the literature

While patient age and gender are important factors in the clinical decision-making for treating urothelial carcinoma of the bladder (UCB), there are no evidence-based recommendations to guide healthcare professionals. We review previous reports on the influence of age and gender on the incidence, biology, mortality and treatment of UCB. Using MEDLINE, we searched for previous reports published between January 1966 and July 2009. While men are three to four times more likely to develop UCB than women, women present with more advanced disease and have worse survival rates. The disparity among genders is proposed to be the result of a differential exposure to carcinogens (i.e. tobacco and chemicals) as well as reflecting genetic, anatomical, hormonal, societal and environmental factors. Inpatient length of stay, referral patterns for haematuria and surgical outcomes suggest that inferior quality of care for women might be an additional cause of gender inequalities. Age is the greatest single risk factor for developing UCB and dying from it once diagnosed. Elderly patients face both clinical and institutional barriers to appropriate treatment; they receive less aggressive treatment and sub-therapeutic dosing. Much evidence suggests that chronological age alone is an inadequate indicator in determining the clinical and behavioural response of older patients to UCB and its treatment. Epidemiological and mechanistic molecular studies should be encouraged to design, analyse and report gender- and age-specific associations. Improved bladder cancer awareness in the lay and medical communities, careful patient selection, treatment tailored to the needs and the physiological and physical reserve of the individual patient, and proactive postoperative care are particularly important. We must strive to develop transdisciplinary collaborative efforts to provide tailored gender- and age-specific care for patients with UCB.

Bladder cancer in the elderly

INTRODUCTION

Age is now widely accepted as the greatest single risk factor for developing bladder cancer, and bladder cancer is considered as primarily a disease of the elderly. Because of the close link between age and incidence of bladder cancer, it can be expected that this disease will become an enormous challenge with the growth of an aging population in the years ahead.

METHODS

Using MEDLINE, a search of the literature between January 1966 and July 2007 was performed to describe normative physiologic changes associated with aging, elucidate genetic and epigenetic alterations that associate aging with bladder cancer and its phenotypes; and to characterize how aging influences efficacies, risks, side effects, and potential complications of the treatments needed for the various stages of bladder cancer.

RESULTS

We discuss influence of aging on host physiology, genetic and epigenetic changes, environmental influences, and host factors in the development and treatment of bladder cancer. Treatments with intravesical bacille Calmette Guerin, radical cystectomy, and perioperative chemotherapy are less well tolerated and have poorer response in elderly patients compared with their younger counterparts. Elderly patients face both clinical and broader institutional barriers to appropriate treatment and may receive less aggressive treatment and sub-therapeutic dosing. However, when appropriately selected, elderly patients tolerate and respond well to cancer treatments.

CONCLUSIONS

The decision to undergo treatment for cancer is a tradeoff between loss of function and/or independence and extension of life, which is complicated by a host of concomitant issues such as comorbid medical conditions, functional declines and "frailty", family dynamics, and social and psychologic issues. Chronological age should not preclude definitive surgical therapy. It is imperative that healthcare practitioners and researchers from disparate disciplines collectively focus efforts towards gaining a better understanding of what the consequences of bladder cancer and its treatments are for older adults and how to appropriately meet the multifaceted medical and psychosocial needs of this growing population.

The critical limitations of volume-outcome analysis

There is a justified assumption that the patient outcome is in large part determined by the quality of the care they receive. For certain procedures outside of the field of urology, it has been demonstrated that higher surgical volume, either at the hospital or surgeon level is a proxy for higher quality of care. Multiple studies have followed this line of inquiry and attempted to show that volume may also predict outcome for certain urologic procedures. Review of the published studies shows that the association appears quite weak. However, the real weakness of this line of study is not so much in the findings, but in the universally used and critically flawed study methodology. This article demonstrates how a simple study design flaw has proved to be the Achilles heal of this entire line of research.

Candidate quality of care indicators for localized bladder cancer

The surgical management of clinically localized bladder cancer is challenging, and the quality of care delivered to patients with bladder cancer is a subject of increasing interest. Multiple large studies have examined the association between surgical volume and outcomes after radical cystectomy. These studies generally find lower mortality and complication rates at high-volume centers, though interpretation of the data must be tempered by limitations of the datasets driving the studies. Benefits of regionalization of care also must be weighed against other measures proven to predict outcomes; a delay in time to cystectomy beyond 3 months, for example, is strongly associated with increased mortality. Other candidate process measures supported by existing literature include adequacy of lymphadenectomy as measured by nodal yield and availability or offering of orthotopic diversion when appropriate. Assessment and reporting of bladder cancer outcomes should be risk adjusted based on oncologic risk factors and patient comorbid illness. Perioperative morbidity and mortality, cause-specific survival, and overall survival are all key measures. Assessment of health-related quality of life after bladder cancer treatment should also be standardized for reporting. Multiple survey instruments have been developed in recent years, but none has yet been well validated or widely adopted. In particular, capturing variation in quality of life outcomes between patients undergoing bladder-sparing protocols vs. continent diversion vs. incontinent diversion is an important but difficult goal that has not yet been met. The urologic oncology community should take a strong lead in achieving consensus regarding the definition, assessment, and reporting of quality of care data for bladder cancer.

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.

Risk factors for mortality and morbidity related to radical cystectomy

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology

BACKGROUND

Reporting methodology is highly variable and nonstandardized, yet surgical outcomes are utilized in clinical trial design and evaluation of healthcare provider performance.

OBJECTIVE

We sought to define the type, incidence, and severity of early postoperative morbidities following radical cystectomy (RC) using a standardized reporting methodology.

DESIGN, SETTING, AND PARTICIPANTS

Between 1995 and 2005, 1142 consecutive RCs were entered into a prospective complication database and retrospectively reviewed for accuracy. All patients underwent RC/urinary diversion by high-volume fellowship-trained urologic oncologists.

MEASUREMENTS

All complications within 90 d of surgery were analyzed and graded according to the Memorial Sloan-Kettering Cancer Center complication grading system. Complications were defined and stratified into 11 specific categories. Univariate and multivariate regression models were used to define predictors of complications.

RESULTS AND LIMITATIONS

Sixty-four percent (735/1142) of patients experienced a complication within 90 d of surgery. Among patients experiencing a complication, 67% experienced a complication during the operative hospital admission and 58% following discharge. Overall, the highest grade of complication was grade 0 in 36% (n=407), grade 1-2 in 51% (n=582), and grade 3-5 in 13% (n=153). Gastrointestinal complications were most common (29%), followed by infectious complications (25%) and wound-related complications (15%). The 30-d mortality rate was 1.5%.

CONCLUSIONS

Surgical morbidity following RC is significant and, when strict reporting guidelines are incorporated, higher than previously published. Accurate reporting of postoperative complications after RC is essential for counseling patients, combined modality treatment planning, clinical trial design, and assessment of surgical success.

Potential impact of postoperative early complications on the timing of adjuvant chemotherapy in patients undergoing radical cystectomy: a high-volume tertiary cancer center experience

BACKGROUND

Perioperative cisplatin combination chemotherapy is associated with a survival benefit in patients with invasive bladder cancer (BCa). However, in a recent report from the National Cancer Database (NCDB), only 11.6% of stage III BCa patients received perioperative chemotherapy, the majority in the adjuvant setting.

OBJECTIVE

We explore the impact of postoperative complications on the timing of adjuvant chemotherapy.

DESIGN, SETTING, AND PARTICIPANTS

An independent review board approved the review of 1142 consecutive radical cystectomies (RC), and data from these cases were entered into a prospective complication database (1995-2005) which was utilized and retrospectively reviewed for accuracy at a single, academic, tertiary cancer center.

INTERVENTIONS

All patients underwent RC/urinary diversion by high-volume, fellowship-trained, urologic oncologists.

MEASUREMENTS

All complications within 90 d of surgery were defined and graded using a five-grade modification of the original Clavien system utilized at Memorial Sloan-Kettering Cancer Center and stratified into 11 categories. Grade 2-5 complications typically prohibit starting adjuvant chemotherapy. Univariate and multivariable logistic regression were used to evaluate variables associated with complications.

RESULTS AND LIMITATIONS

Overall, 64% (735 of 1142 patients) experienced one or more complications, of which 83% (611 of 735) were grade 2-5. Furthermore, 57% of grade 2-5 complications (347 of 611) occurred between discharge and 90 d, 38% (233 of 611) within 6 wk, and 19% (114 of 611) between 6 wk and 12 wk, the general time frame for adjuvant chemotherapy. Overall, 26% (298 of 1142 patients) required readmission. Surgical morbidity at a high-volume tertiary cancer center may not reflect the case mix or surgical experience seen in the community setting.

CONCLUSION

This series demonstrates that 30% of patients (347 of 1142) undergoing RC may not have been able to receive adjuvant chemotherapy due to postoperative complications. This information should be taken into consideration when planning multimodal therapy and further supports the use of perioperative chemotherapy in the neoadjuvant setting.

Impact of stapling devices on radical cystectomy: comparative study between low- and high-volume surgeons

OBJECTIVES

To compare effectiveness in terms of blood loss and operative time of stapling devices among surgeons with different levels of surgical volume.

METHODS

We evaluated a group of 29 male patients with invasive bladder cancer who underwent radical cystectomy by two groups of surgeons. The first group included two high-volume surgeons, and the second group two low-volume surgeons. All cystectomies were performed using the multifire autosuture articulated vascular Endo-GIA. We compared patients with a series of 28 patients who had undergone radical cystectomy during the same period using standard technique by the same surgeons. Blood loss was defined as the difference between the hemoglobin at the beginning and at the end of cystectomy.

RESULTS

In the group of high-volume surgeons, the mean operative time was 81.4 +/- 17 minutes and 79.3 +/- 20 minutes for the classical and stapler arm, respectively (P = 0.551). In the low-volume surgeons group, the mean operative time was 114.3 +/- 22 minutes and 92.4 +/- 12 minutes for the two methods (P = 0.003). The mean intraoperative blood loss in the experienced surgeons was 2.3 +/- 0.82 g/dL and 1.49 +/- 0.66 g/dL for the classical and stapler arm, respectively (P = 0.008). In the group of low-volume surgeons, the difference in hemoglobin was 3.02 +/- 0.84 g/dL and 1.91 +/- 0.6 g/dL for the two methods (P = 0.02).

CONCLUSIONS

Stapling devices seem to make cystectomy safer and faster in surgeons with different surgical volumes. The group of low-volume surgeons benefited more.

Contemporary open radical cystectomy: analysis of perioperative outcomes

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of Procedure Volume With Radical Cystectomy Outcomes in a Nationwide Database

PURPOSE

Studies of national databases yield important information about expected outcomes after radical cystectomy and factors that influence patient morbidity and mortality. We examined the hospital characteristics associated with outcomes after radical cystectomy in a cohort study using results from a single, high volume academic institution as well as a nationwide data set of academic institutions.

MATERIALS AND METHODS

We obtained data from the University HealthSystem Consortium Clinical Database on 6,728 patients nationwide who underwent radical cystectomy for bladder cancer between 2002 and 2005 as well as on 421 who underwent cystectomy at our institution during this period. Outcomes were compared by hospital characteristics (geographic location, total hospital discharges and procedure volume). The outcome measures analyzed were length of hospital stay, the complication rate and in hospital mortality.

RESULTS

The overall complication rate at our institution was 32.07% with an in hospital mortality rate of 0.95% and an average length of stay of 7.05 days. The overall complication rate in the University HealthSystem Consortium data set was 37.16% with an in hospital mortality rate of 1.47% and an average length of stay of 10.98 days. Institutions with higher cystectomy volumes had significantly better outcomes than institutions with lower procedure volumes. The mortality rate at institutions with greater than 50 cystectomies per year was 0.54% compared to 2.70% at institutions with 10 or fewer per year (p <0.0005). Outcomes varied only minimally with total hospital discharges or geographic region.

CONCLUSIONS

Even among academic medical centers hospitals with a higher volume of cystectomies in 2002 to 2005 were associated with improved outcomes, including decreased mortality, shorter length of stay and lower rehospitalization rates. These data may provide a framework for self-assessment and help establish criteria for performance evaluation.

Multimodal perioperative plan for radical cystectomy and intestinal urinary diversion. I. Effect on recovery of intestinal function and occurrence of complications

OBJECTIVES

To discuss a multimodal perioperative plan aimed at reducing postoperative ileus and complications associated with radical cystectomy and urinary reconstruction.

METHODS

The protocol consisted of preoperative, intraoperative, and postoperative measures. The clinical parameters assessed were the time to the return of bowel movements, the presence and duration of postoperative ileus, the presence and duration of an intolerance to oral feeding, the interval to re-institution of a regular diet, and complications. The biochemical parameters (serum total protein and albumin levels and lymphocyte counts) were also assessed. A sample of 40 patients treated before the implementation of this protocol was included for comparison.

RESULTS

A total of 71 patients, mean age 74 years and American Society of Anesthesiologists status 2 and 3, consecutively underwent radical surgery for bladder cancer and were evaluable for results and complications. Urinary diversion was a heterotopic neobladder in 27 patients (38%), orthotopic in 23 (32.3%), and an ileal conduit in 21 (29.5%). Bowel movements returned after a median of 2 days (range 1 to 6), intolerance to oral feeding was observed in 17 (23.9%) of 71 patients, and the median time to re-institution of a regular diet was 4 days (range 3 to 9). The complication rate was 26.7%, and the mortality rate was 4.2%. No effects were observed on postoperative protein depletion. In the historical group, the median time to diet resumption was 8 days (range 7 to 12).

CONCLUSIONS

A short time to the resumption of normal intestinal function and a low incidence of postoperative ileus after cystectomy was observed. However, the incidence of postoperative protein depletion was unaffected. Additional studies should address this subject.

Getting under the hood of the volume-outcome relationship for radical cystectomy

PURPOSE

Hospital and surgeon volumes independently explain variations in outcomes for a host of surgical procedures. However, the mediators of the volume effect remain unclear. We assessed whether differences among hospitals could explain some or all of the volume effect on short-term outcomes after cystectomy for bladder cancer.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample a 20% sampling of hospital discharges in the United States and the American Hospital Association file we applied International Classification of Diseased, 9th revision, clinical modification procedure codes to identify 1,847 patients who underwent cystectomy for bladder cancer in 2003. Multivariable mixed models were fit to quantify the differences in measures of hospital structure (capacity, staffing and health services) by hospital volume. Separate models were fit to determine the impact of accounting for these differences on the volume-outcome relationship.

RESULTS

There were substantial differences in hospital structure according to radical cystectomy volume, including those characterizing capacity, staffing levels and the breadth of available health services. For example, 40.7% of low and 87.8% of high volume hospitals for radical cystectomy offered open heart surgery (OR 10.4, 95% CI 1.3-85.3). After adjusting for case mix patients treated at low volume centers were 3.2 times (95% CI 0.8-13.4) more likely to die postoperatively. Accounting for differences in hospital structure attenuated the volume effect by 59% (OR 1.9, 95% CI 0.4-8.6).

CONCLUSIONS

Measurable differences in the availability and breadth of consultative, diagnostic and ancillary services may at least partially explain the association between procedure volume and short-term cystectomy outcomes.

Morbidity and mortality after liver resection: results of the patient safety in surgery study

BACKGROUND

Liver resection is performed with increasing frequency. Nearly all of the published information on operative mortality and morbidity rates associated with liver resection is derived from studies that rely on retrospective data collection from single centers. The goal of this study is to use audited multiinstitutional data from the private sector of the Patient Safety in Surgery Study to characterize complications after liver resection and to identify variables that are associated with 30-day morbidity and mortality.

STUDY DESIGN

Prospectively collected data on liver resection patients from 14 hospitals were collected using National Surgical Quality Improvement Program's methodology. Rates of occurrence of 21 defined postoperative complications were measured. Bivariate analyses and stepwise logistic regression were used to identify factors associated with 30-day morbidity and mortality.

RESULTS

At least one complication occurred in 22.6% of patients within 30 days. Stepwise logistic regression identified several preoperative factors associated with morbidity, including serum albumin, SGOT > 40, previous cardiac operation, operative work relative value unit, and history of severe COPD. Mortality within 30 days was observed in 2.6% of patients. Factors associated with mortality were found to be male gender, American Society of Anesthesiologists class 3 or higher, presence of ascites, dyspnea, and severe COPD. Only 0.7% of patients without any complications died, compared with 9.0% of patients with at least 1 complication (p < 0.0001).

CONCLUSIONS

Prospective, standardized, audited, multiinstitutional data were analyzed to identify several preoperative and intraoperative factors associated with morbidity and mortality after liver resection. These factors should be considered during patient selection and perioperative management.

Volume, process of care, and operative mortality for cystectomy for bladder cancer

OBJECTIVES

High-volume hospitals have lower mortality rates for a wide range of surgical procedures, including cystectomy for bladder cancer. However, the processes of care that mediate this effect are unknown. We sought to identify the processes that underlie the volume-outcome relationship for cystectomy.

METHODS

Within the Surveillance, Epidemiology, and End Results (SEER)-Medicare data set, we used International Classification of Diseases (ICD)-9 procedure codes to identify 4465 patients who underwent cystectomy for bladder cancer between 1992 and 1999. The preoperative and perioperative processes of care were abstracted from the inpatient, outpatient, and physician files using the procedure and diagnosis codes available through 2002. Logistic models were used to assess the relationship between the process and hospital volume, adjusting for differences in patient characteristics.

RESULTS

Substantial variation was found in the use of specific processes of care across the hospital volume strata. High-volume hospitals had greater rates of preoperative cardiac testing (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.24 to 1.98), intraoperative arterial monitoring (OR 3.73, 95% CI 3.11 to 4.46), and the use of a continent diversion (OR 4.01, 95% CI 3.03 to 5.30), among many others. Patients treated at low-volume hospitals were 48% more likely to die in the postoperative period (4.9% versus 3.5%, adjusted OR 1.48, 95% CI 1.03 to 2.13). Differences in the use of processes of care explained 23% of this volume-mortality effect.

CONCLUSIONS

High-volume and low-volume hospitals differ with regard to many processes of care before, during, and after radical cystectomy. Although these practices have partly explained the volume-outcome relationships for cystectomy, the primary mechanisms underlying this effect remain unclear.

Intraoperative cell salvage during radical cystectomy does not affect long-term survival

OBJECTIVES

To evaluate the risk of long-term recurrence for patients who received cell-salvaged blood during radical cystectomy (RC).

METHODS

We retrospectively analyzed an RC database and compared those who did and did not receive cell-salvaged blood according to baseline parameters, pathologic outcomes, and recurrence.

RESULTS

A total of 378 patients underwent RC between 1992 and 2005 by one surgeon. Of these, 65 (17.2%) received cell-salvaged blood and 313 (82.8%) did not. The two groups had similar baseline characteristics. There were no differences between the two groups when compared by pathologic stage. The median follow-up for patients who did and did not receive cell-salvaged blood was 19.1 and 20.7 months, respectively (P = 0.464). The 3-year disease-specific survival rate for the two groups was 72.2% and 73.0%, respectively (P = 0.90).

CONCLUSIONS

Intraoperative cell salvage is a safe blood management strategy for patients undergoing RC. There is no increased risk of metastatic disease or death for those who receive cell-salvaged blood. Concerns about spreading tumors cells by IOCS during RC would seem unwarranted. However, only a prospective, multicenter, randomized trial would provide the most valid assessment of the safety of IOCS.

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

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

Evaluation of findings during re-exploration for obstructive ileus after radical cystectomy and ileal-loop urinary diversion: insight into potential technical improvements

OBJECTIVE

To retrospectively evaluate the findings during re-exploration for obstructive ileus after radical cystectomy (RC) and ileal conduit diversion.

PATIENTS AND METHODS

During a 12-year period, 434 patients who had RC and ileal conduit diversion were retrospectively evaluated for the diagnosis of early (</=30 days after RC) or late abdominal re-exploration. The operative reports of patients requiring a second abdominal procedure were reviewed, evaluating in particular the reason for small bowel obstruction (SBO). In addition, the type of entero-enteric anastomosis and the retroperitonealization of the uretero-enteric anastomosis were compared between patients who required abdominal re-exploration for SBO and those who did not.

RESULTS

Abdominal re-exploration for SBO was necessary for 14 (3.2%) and 32 (7.3%) patients in the early and late postoperative period, respectively. The most common reasons for SBO were anastomotic malfunction (1.4%) and malignant recurrence (2.8%). Adhesions were the second most common cause leading to ileus in both periods (1.1% and 2.3%, respectively). When there was no retroperitonealization of the uretero-enteric anastomosis, SBO occurred more often both early and late (P = 0.06). Early anastomotic malfunction leading to SBO was more common (but not statistically significant, P = 0.06) when the entero-enteric anastomosis was hand-sutured end-to-end.

CONCLUSIONS

Anastomotic malfunction, bowel adhesions and internal hernias are responsible for SBO early after surgery. The above reasons, in addition to malignant recurrence, are the most common reasons for SBO in the late postoperative period.

Complications in laparoscopic radical cystectomy. The South American experience with 59 cases

OBJECTIVE

In this study, we have gathered the second largest series yet published on laparoscopic radical cystectomy in order to evaluate the incidence and cause of intra and postoperative complication, conversion to open surgery, and patient mortality.

MATERIALS AND METHODS

From 1997 to 2005, 59 laparoscopic radical cystectomies were performed for the management of bladder cancer at 3 institutions in South America. Twenty nine patients received continent urinary diversion, including 25 orthotopic ileal neobladders and 4 Indiana pouches. Only one case of continent urinary diversion was performed completely intracorporeally.

RESULTS

Mean operative time was 337 minutes (150-600). Estimated intraoperative blood loss was 488 mL (50-1500) and 12 patients (20%) required blood transfusion. All 7 (12%) intraoperative complications were vascular in nature, that is, 1 epigastric vessel injury, 2 injuries to the iliac vessels (1 artery and 1 vein), and 4 bleedings that occurred during the bladder pedicles control. Eighteen (30%) postoperative complications (not counting mortalities) occurred, including 3 urinary tract infections, 1 pneumonia, 1 wound infection, 5 ileus, 2 persistent chylous drainage, 3 urinary fistulas, and 3 (5%) postoperative complications that required surgical intervention (2 hernias - one in the port site and one in the extraction incision, and 1 bowel obstruction). One case (1.7%) was electively converted to open surgery due to a larger tumor that precluded proper posterior dissection. Two mortalities (3.3%) occurred in this series, one early mortality due to uncontrolled upper gastrointestinal bleeding and one late mortality following massive pulmonary embolism.

CONCLUSIONS

Laparoscopic radical cystectomy is a safe operation with morbidity and mortality rates comparable to the open surgery.

Defining Optimal Therapy for Muscle Invasive Bladder Cancer

PURPOSE

We defined an optimal curative strategy for muscle invasive bladder cancer and to determine how best to deliver curative therapy.

MATERIALS AND METHODS

We reviewed published reports from 1985 to 2006 dealing with the treatment of muscle invasive (stage T2-T4a) bladder cancer. We analyzed all cohort, phase II and randomized phase III studies providing level 1 to 3 evidence impacting survival.

RESULTS

Cisplatin based chemotherapy combined with high quality radical cystectomy and complete pelvic lymph node dissection improves survival over that of cystectomy alone. Surgery quality is an important predictor of survival even in patients receiving chemotherapy. Neoadjuvant chemotherapy is favored over adjuvant chemotherapy because it is better tolerated and more patients are able to receive effective therapy before rather than after surgery.

CONCLUSIONS

Neoadjuvant chemotherapy followed by radical cystectomy and complete pelvic lymph node dissection is the optimal curative strategy in most patients presenting with muscle invasive bladder cancer.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Influence of Post-Cystectomy Complications on Cost and Subsequent Outcome

PURPOSE

Of commonly performed urological cancer procedures radical cystectomy is associated with the highest morbidity and mortality. The impact of each individual type of complication or a combination of them on various outcome measures, such as mortality, charges and length of stay, is unclear. We quantified the impact of specific post-cystectomy complications and combinations thereof in terms of mortality, charges and length of stay.

MATERIALS AND METHODS

All 6,577 patients undergoing radical cystectomy for bladder cancer were identified from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (1998 to 2002). The prevalence of different International Classification of Diseases, 9th Revision, Clinical Modification coded complications following cystectomy were determined. Outcome variables of interest were in-hospital mortality, total charges and length of stay. The association between types of complications and measured outcomes were examined using univariate and multivariate regression models. The cumulative impact of multiple complications and various combinations of complications on outcomes was also examined.

RESULTS

The overall complication rate was 28.4% in 1,869 cases and the mortality rate was 2.6%. Median total charges was 41,905 dollars and median length of stay was 9 days. Overall 20.7% of patients had 1, 6.1% had 2, 1.2% had 3 and 0.42% had greater than 3 complications. At least 1 complication almost doubled the odds of mortality and increased median total charges and length of stay by 15,000 dollars and 4 days, respectively. We defined expected levels of increase in the various outcome measures with increasing numbers of complications. The combination of postoperative infection and respiratory complication had the greatest impact on mortality, while the combination of wound and urinary tract infection had the greatest impact on length of stay and total charges.

CONCLUSIONS

Although most patients undergoing cystectomy are older and have multiple comorbidities, the postoperative complications with the most significant impact were those directly related to surgery (primary complications). Secondary complications (cardiac, respiratory, vascular, etc) appear to have less of an impact on most common outcome measures. Hence, the greatest gains can be achieved by limiting primary complications. These data could be used to develop benchmarks of expected levels of primary and secondary complications after cystectomy.

Comparing performance of Morbidity and Mortality Conference and National Surgical Quality Improvement Program for detection of complications after urologic surgery

OBJECTIVES

The detection of postoperative complications is a necessary quality-of-care endeavor. Despite its historical role, the Morbidity and Mortality (M&M) Conference depends on voluntary reporting and may be an insufficient mechanism for comprehensive complication surveillance. In response to this concern, we compared the concordance between complications voluntarily reported at the M&M Conference and those identified prospectively by the National Surgical Quality Improvement Program (NSQIP).

METHODS

For a single calendar year (2004), we compiled a comprehensive list of complications that were either identified and voluntarily entered into our department's electronic M&M Conference database and/or identified prospectively (from an explicit sample of cases) by a trained research associate-based NSQIP protocol. For analytic purposes, we treated NSQIP as the reference standard for the detection of complications. We then determined the sensitivity of the M&M Conference for the identification of complications at a patient and event level. Logistic regression modeling was used to evaluate for an association between complication category (ie, organ system affected) and detection by the M&M Conference.

RESULTS

The NSQIP detected 347 complications in 176 patients. Using this reference standard, the patient-level and event-level sensitivity of the M&M Conference was 25% (44 of 176) and 14% (47 of 347), respectively. The sensitivity of the M&M Conference varied by NSQIP complication category (P = 0.08). Circulatory events were 11 times more likely to be reported at the M&M Conference than urinary complications (odds ratio 11.3, 95% confidence interval 2.4 to 53.7).

CONCLUSIONS

Compared with the NSQIP, the M&M Conference has a low (but variable) sensitivity for the detection of postoperative complications. Therefore, despite its limitations, the NSQIP may provide a better foundation for urologic quality improvement endeavors.

Risk factors for surgical infections

BACKGROUND

Many risk factors for postoperative infections have been identified that can be used individually or in combination as scoring indices.

METHODS

Infection risk scores can be applied in clinical practice to identify high-risk surgical patients, to indicate the need to implement risk-reduction strategies, and to stratify risk for comparison of outcome among different patient series.

RESULTS

In the hierarchy of patient-related risk factors, serum albumin concentration and advanced age rank at the top of the list. Among the treatment-related factors, the quality of the surgical technique is a most important determinant, although most surgical site infections are attributable to patient-related risk factors rather than to flawed surgical care. Scoring systems can identify the patients at highest risk, thus prompting the implementation of therapy to improve modifiable conditions, but most clinicians outside the academic and research setting do not use them. Risk assessment also can be performed by expert clinical judgment. Discussion with the patient and informed consent are essential.

CONCLUSIONS

Carefully collected scores of patient risk factors may be valuable to document the relations between the risk and the outcome of surgery. Ideally, each institution should select a validated scoring system to audit postoperative infectious morbidity and surgical performance in the various specialties.

Risk factors for prostatic inflammation extent and infection in benign prostatic hyperplasia

AIM

To investigate the risk factors for prostatic inflammation extent and infection in patients with benign prostatic hyperplasia (BPH) so as to manage prostatic inflammation more efficiently.

METHODS

Sixty patients with BPH undergoing TURP between September 2005 and December 2005 in West China Hospital of Sichuan University were studied. Prostate fluid (PF) was collected for the measurement of secretory IgA (SIgA) and complement 3 (C3). Prostate tissue were collected for testing bacterial 16S rDNA by real-time PCR, examining SIgA in the tissue and examining the inflammation. The possible clinical and immune risk factors for prostatic inflammation or infection were analyzed by using the logistic regression method.

RESULTS

Abnormal white blood cell count in urinalysis, prostatic infection and a high concentration of C3 in PF are the risk factors for prostatic inflammation extent (P = 0.025, 0.034 and 0.035, respectively and odds ratio [OR] = 18.269, 8.284 and 1.508, respectively). Risk factors for prostatic infection include the C3 concentration and the concentration of SIgA in PF (P = 0.003 and 0.013, respectively, and OR=1.645 and 0.993, respectively).

CONCLUSION

The present study suggests that prostatic inflammation is associated with urinary tract infection, prostatic infection and the activated complement and that prostatic infection is associated with the activated complement and downregulated mucosal immunity in prostates of the patients with BPH. It is also suggested that individual immune regulation should be considered in the treatment of prostatic inflammation and infection of patients with BPH.