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Hanna P, Zabell J, Konety B, Warlick C. Perioperative complications and oncological outcomes of open versus robotic-assisted radical cystectomy: a propensity score-matched study. World J Urol 2024; 42:220. [PMID: 38587653 DOI: 10.1007/s00345-024-04907-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/24/2024] [Indexed: 04/09/2024] Open
Abstract
PURPOSE To conduct a comparative effectiveness analysis between robot-assisted radical cystectomy (RARC) and open approach (ORC). MATERIALS AND METHODS A retrospective cohort study was conducted involving all patients undergoing radical cystectomy and urinary diversion for invasive bladder cancer at our institution from 2010 to 2018. Of a total 296 patients, we matched ORC and RARC cases based on age, BMI, Charlson comorbidity index, pathological TN staging of the tumor, prior radiotherapy, and type of diversion. The perioperative complications and oncological outcomes were compared. RESULTS Eighty-nine patients were matched in the ORC and RARC groups. The median operative time was longer in RARC group (430 min) than that of ORC group (372 min) (p = 0.03); however, the median estimated blood loss (EBL) was significantly lower in RARC group (500 ml) than that of ORC (700 ml) (p < 0.0001). The median length of hospital stay (LOS) was significantly reduced in the RARC group (7 days) compared to the ORC group (8 days) (p = 0.02). There were no significant differences between both groups in 30- and 90-day postoperative complications (p = 0.3 and p = 0.2, respectively). A total of 68 deaths (38.2%) were observed, of which 36 (40.4%) were in ORC group while 32 (36%) were in RARC group (p = 0.5). The results were comparable in both groups regarding 5-year survival rate and cancer-specific survival (p = 0.3 and p = 0.1, respectively). CONCLUSION RARC showed better perioperative outcomes in the form of less EBL and shortened LOS compared to ORC group. However, both RARC and ORC provide similar postoperative oncologic control, in terms of similar positive surgical margins, cancer-specific rates, and 5-year survival rates.
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Affiliation(s)
- Peter Hanna
- Department of Urology, University of Minnesota, Minneapolis, MN, USA.
- Department of Urology, Aswan University, Aswan, Egypt.
| | - Joseph Zabell
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
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Simhal RK, Simon DP, Wang KR, Shah YB, Havranek B, Mark JR, Chandrasekar T, Shah MS, Lallas CD. Perioperative and Complication Related Outcomes for Robotic-Assisted vs Open Radical Cystectomy: A Comparative National Surgical Quality Improvement Project Analysis. J Endourol 2024; 38:331-339. [PMID: 38269428 DOI: 10.1089/end.2023.0279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Abstract
Background: Radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer, but it comes with significant perioperative risk, with half of the patients experiencing major postoperative complications. Robot-assisted radical cystectomies (RARCs) have aimed to decrease patient morbidity and been increasingly adopted in North America. Currently, both open radical cystectomies (ORCs) and RARCs are frequently performed. The aim of this study is to contribute to the existing literature using newly available data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP), representing one of the most recent, largest multi-institutional studies, while uniquely accounting for a variety of factors, including type of urinary diversion, cancer staging, and neoadjuvant chemotherapy. Methods: RC procedures performed between 2019 and 2021 were identified in NSQIP and the corresponding cystectomy-targeted database. Cases in the ORC group were planned open procedures, and cases in the RARC group were robot assisted, including unplanned conversion to open cases for intention to treat. Chi-square and t-tests were performed to compare baseline demographics and operative parameters. Multivariate analysis was performed for outcomes, including major complications, minor complications, and 30-day mortality rates, while adjusting for baseline differences significant on univariate analysis. Results: Five thousand three hundred forty-three RC cases were identified. Of these, 70% underwent planned ORC, while 30% received RARC. RARC was associated with longer operative times and shorter hospital length of stay compared with ORC. On multivariate analysis, there was no difference between the cohorts in 30-day rates of major complications, hospital readmissions, need for reoperation, or mortality. ORC was, however, associated with higher rates of minor complications, bleeding, superficial surgical site infections, and anastomotic leak. Conclusions: In the NSQIP database, ORC is associated with higher rates of 30-day minor complications, most notably bleeding, compared with RARC. However, there is no difference in regard to perioperative major morbidity or mortality rates. This study is unique in the size of the cohorts compared, timeliness of data (2019-2021), applicability to a variety of different practice settings across the country, and ability to control for factors, such as type of urinary diversion and pathological bladder cancer staging, as well as use of neoadjuvant chemotherapy. This study was approved by the Institutional Review Board (IRB) specific to Thomas Jefferson University.
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Affiliation(s)
- Rishabh K Simhal
- Department of Urology, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Daniel P Simon
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Urology, Intermountain Health Care, Salt Lake City, Utah, USA
| | - Kerith R Wang
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yash B Shah
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brandon Havranek
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James R Mark
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Mihir S Shah
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Costas D Lallas
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Mastroianni R, Iannuzzi A, Ragusa A, Tuderti G, Ferriero M, Anceschi U, Bove AM, Brassetti A, Misuraca L, D’Annunzio S, Guaglianone S, Papalia R, Simone G. Health Related Quality of Life in Patients with Bladder Cancer Receiving a Radical Cystectomy. Cancers (Basel) 2023; 15:5830. [PMID: 38136375 PMCID: PMC10741964 DOI: 10.3390/cancers15245830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Radical Cystectomy (RC) and Urinary Diversion (UD) is a complex surgery associated with a significant impact on health-related quality of life (HRQoL). However, HRQoL assessment is too often overlooked, with survival and complications being the most commonly investigated outcomes. This study aimed to identify the most impaired HRQoL features in patients receiving RC, compared to a healthy population (HP) control, as well as patients' recovery after surgery, differentiating between patients receiving ORC and RARC. Patients with Bca, who were candidates for RC with curative intent, were enrolled in the "BCa cohort". HRQoL outcomes were collected with an EORTC QLQ-C30 questionnaire. These were collected at baseline, and then at 6-, 12- and 24 mo after surgery in the BCa cohorts, and at baseline in the HP cohort. A 1:1 propensity score matched (PSM)-analysis, adjusted for age, Charlson Comorbidity Index (CCI) and smoking history, was performed. Between January 2018 and February 2023, a total of 418 patients were enrolled in the study, 116 and 302 in the BCa and HP cohorts, respectively. After applying the 1:1 propensity scored match (PSM) analysis, two homogeneous cohorts were selected, including 85 patients in each group. Baseline HRQoL assessment showed a significant impairment in terms of emotional and cognitive functioning, appetite loss and financial difficulties for the BCa cohort. Among secondary outcomes, we investigated patients' recovery after RC and UD, comparing HRQoL outcome questionnaires between the HP and BCa cohorts at 6-, 12- and 24 mo after surgery, and a subgroup analysis was performed differentiating between patients receiving ORC and RARC with totally intracorporeal UD. Interestingly, ORC compared to RARC provided a major impact on HRQoL recovery across the early, mid and long term. In particular, the ORC cohort experienced a major impairment in terms of symptoms scales items such as fatigue, nausea and vomiting, pain and appetite loss. Consequently, comparing ORC and RARC vs. HP reported a major HRQoL impairment in the ORC cohort, possibly defining a benefit of RARC in early, mid- and long-term recovery. To conclude, this study confirmed the undeniable impact of RC on HRQoL. Interestingly, we highlighted the benefit of RARC in early, mid- and long-term recovery, expressed as less impairment of symptoms scales.
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Affiliation(s)
- Riccardo Mastroianni
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
| | - Andrea Iannuzzi
- Department of Urology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (A.I.); (A.R.); (R.P.)
| | - Alberto Ragusa
- Department of Urology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (A.I.); (A.R.); (R.P.)
| | - Gabriele Tuderti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
| | - Mariaconsiglia Ferriero
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
| | - Umberto Anceschi
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
| | - Alfredo Maria Bove
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
| | - Aldo Brassetti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
| | - Leonardo Misuraca
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
| | - Simone D’Annunzio
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
| | - Salvatore Guaglianone
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
| | - Rocco Papalia
- Department of Urology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy; (A.I.); (A.R.); (R.P.)
| | - Giuseppe Simone
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (G.T.); (M.F.); (U.A.); (A.M.B.); (A.B.); (L.M.); (S.D.); (S.G.); (G.S.)
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Panunzio A, Gozzo A, Mazzucato G, Ornaghi PI, Filippo GD, Soldano A, De Maria N, Cianflone F, Orlando R, Boldini M, Pettenuzzo G, Montanaro F, Artibani W, Porcaro AB, Pagliarulo V, Cerruto MA, Antonelli A, Tafuri A. Impairment in Activities of Daily Living Assessed by the Barthel Index Predicts Adverse Oncological Outcomes After Radical Cystectomy for Bladder Cancer. Clin Genitourin Cancer 2023; 21:e495-e501.e2. [PMID: 37365053 DOI: 10.1016/j.clgc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/30/2023] [Accepted: 06/04/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION We tested the association between functional impairment in activities of daily living (ADL) assessed through the Barthel Index (BI), and oncological outcomes following radical cystectomy (RC) for bladder cancer (BCa). PATIENTS AND METHODS We retrospectively analyzed data of 262 clinically nonmetastatic BCa patients, who underwent RC between 2015 and 2022, with available follow-up. According to preoperative BI, patients were divided in 2 groups: BI ≤90 (moderate/severe/total dependency in ADL) versus BI 95 to 100 (slight dependency/independency in ADL). Kaplan-Meier plots compared disease recurrence (DR)-, cancer-specific mortality (CSM)-, and overall mortality (OM)-free survival according to established categories. Multivariable Cox regression models tested the BI as an independent predictor of oncological outcomes. RESULTS According to the BI, the patient cohort was distributed as follows: 19% (n = 50) BI ≤90 versus 81% (n = 212) BI 95-100. Compared to patients with BI 95 to 100, patients with BI ≤90 were less likely to receive intravesical immuno- or chemotherapy (18% vs. 34%, p = .028), and more frequently underwent less complex urinary diversion as ureterocutaneostomy (36% vs. 9%, p < .001), or harbored muscle-invasive BCa at final pathology (72% vs. 56%, p = .043). In multivariable Cox regression models adjusted for age, ASA physical status score, pathological T and N stage, and surgical margins status, BI ≤90 independently predicted higher DR (HR [hazard ratio]:2.00, 95%CI [confidence interval]:1.21-3.30, p = .007), CSM (HR:2.70, 95%CI:1.48-4.90, p = .001), and OM (HR:2.09, 95%CI:1.28-3.43, p = .003). CONCLUSION Preoperative impairment in ADL was associated with adverse oncological outcomes following RC for BCa. The integration of the BI into clinical practice may improve the risk assessment of BCa patients candidates to RC.
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Affiliation(s)
- Andrea Panunzio
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Department of Urology, "Vito Fazzi" Hospital, Lecce, Italy
| | - Alessandra Gozzo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Giovanni Mazzucato
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Paola Irene Ornaghi
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Giacomo Di Filippo
- Department of General and Hepatobiliary Surgery, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Antonio Soldano
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Nicola De Maria
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Francesco Cianflone
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Rossella Orlando
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Michele Boldini
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Greta Pettenuzzo
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Francesca Montanaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Walter Artibani
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Antonio Benito Porcaro
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | | | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Alessandro Tafuri
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy; Department of Urology, "Vito Fazzi" Hospital, Lecce, Italy.
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Tappero S, Chierigo F, Parodi S, Bandini M, Moschini M, Cucchiara V, Chessa F, Di Maida F, Mari A, Manfredi M, Mantica G, Cerruto MA, Fiori C, Schiavina R, Briganti A, Suardi N, Brunocilla E, Antonelli A, Porpiglia F, Minervini A, Montorsi F, Terrone C. Radical cystectomy in bladder cancer patients previously treated for prostate cancer: Insights from a large European multicentric series. Surg Oncol 2023; 50:101973. [PMID: 37454433 DOI: 10.1016/j.suronc.2023.101973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/25/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Previous radical prostatectomy (RP) for prostate cancer (PCa) might impair feasibility of radical cystectomy (RC) for bladder cancer (BCa). The current study addressed morbidity, operative time (OT), and length of stay (LOS) of RC, within the largest available series of patients with history of previous RP. MATERIALS AND METHODS All patients previously submitted to RP for PCa and subsequently submitted to RC for BCa, at six high-volume European institutions between 2010 and 2019, were identified. Presence of either PCa or BCa metastases, RT as primary treatment for PCa, and palliative RC represented exclusion criteria. The quality criteria for accurate and comprehensive reporting of intra- and post-operative surgical outcomes, recommended by the European Association of Urology guidelines, were fulfilled. Multivariable logistic and Poisson regression analyses were performed. RESULTS Overall, 140 RC patients with history of RP were identified. After RP, 69 (49%) patients received radiotherapy (RT) for PCa, either in adjuvant (n = 50, 36%) or salvage setting (n = 19, 13%). Median age-adjusted Charlson comorbidity index was 6 (IQR 5, 7). Median OT, estimated blood loss and LOS were, respectively, 300 min, 500 ml, and 16 days. Intra-operative transfusions rate was 47% (n = 65). One intra-operative complication occurred (EAUiaiC grade 2, perforation of the rectum managed with immediate repair). Eighty-two (59%) patients experienced a total of 107 post-operative complications during the hospital stay, and seven (5%) patients required hospital readmission. In multivariable regression analyses, RT for PCa was associated with higher risk of post-operative complications (odds ratio 1.82, p = 0.039), longer OT (incidence rate ratio 1.09, p < 0.001), and longer LOS (incidence rate ratio 1.24, p < 0.001). CONCLUSIONS RC in patients with history of RP is feasible, albeit burdened by remarkable morbidity, even in centers of excellence. RT after RP for PCa portends worse surgical outcomes.
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Affiliation(s)
- Stefano Tappero
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; Ospedale Policlinico San Martino, Genova, Italy.
| | - Francesco Chierigo
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; Ospedale Policlinico San Martino, Genova, Italy
| | - Stefano Parodi
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; Ospedale Policlinico San Martino, Genova, Italy
| | - Marco Bandini
- Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Moschini
- Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vito Cucchiara
- Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Chessa
- Department of Urology, University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Fabrizio Di Maida
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Andrea Mari
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Matteo Manfredi
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Guglielmo Mantica
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; Ospedale Policlinico San Martino, Genova, Italy
| | - Maria Angela Cerruto
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
| | - Cristian Fiori
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Riccardo Schiavina
- Department of Urology, University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Alberto Briganti
- Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nazareno Suardi
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; Ospedale Policlinico San Martino, Genova, Italy; Department of Urology, Spedali Civili of Brescia, Brescia, Italy
| | - Eugenio Brunocilla
- Department of Urology, University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
| | - Francesco Porpiglia
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Andrea Minervini
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Francesco Montorsi
- Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Terrone
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy; Ospedale Policlinico San Martino, Genova, Italy
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Hoeh B, Wenzel M, Eckart O, Fleisgarten F, Garcia CC, Köllermann J, Würnschimmel C, Larcher A, Karakiewicz P, Kluth LA, Chun FKH, Mandel P, Becker A. Comparison of peri- and intraoperative outcomes of open vs robotic-assisted partial nephrectomy for renal cell carcinoma: a propensity-matched analysis. World J Surg Oncol 2023; 21:189. [PMID: 37349748 DOI: 10.1186/s12957-023-03061-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 06/03/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Partial nephrectomy (PN) is the gold standard surgical treatment for resectable renal cell carcinoma (RCC) tumors. However, the decision whether a robotic (RAPN) or open PN (OPN) approach is chosen is often based on the surgeon's individual experience and preference. To overcome the inherent selection bias when comparing peri- and postoperative outcomes of RAPN vs. OPN, a strict statistical methodology is needed. MATERIALS AND METHODS We relied on an institutional tertiary-care database to identify RCC patients treated with RAPN and OPN between January 2003 and January 2021. Study endpoints were estimated blood loss (EBL), length of stay (LOS), rate of intraoperative and postoperative complications, and trifecta. In the first step of analyses, descriptive statistics and multivariable regression models (MVA) were applied. In the second step of analyses, to validate initial findings, MVA were applied after 2:1 propensity-score matching (PSM). RESULTS Of 615 RCC patients, 481 (78%) underwent OPN vs 134 (22%) RAPN. RAPN patients were younger and presented with a smaller tumor diameter and lower RENAL-Score sum, respectively. Median EBL was comparable, whereas LOS was shorter in RAPN vs. OPN. Both intraoperative (27 vs 6%) and Clavien-Dindo > 2 complications (11 vs 3%) were higher in OPN (both < 0.05), whereas achievement of trifecta was higher in RAPN (65 vs 54%; p = 0.028). In MVA, RAPN was a significant predictor for shorter LOS, lower rates of intraoperative and postoperative complications as well as higher trifecta rates. After 2:1 PSM with subsequent MVA, RAPN remained a statistical and clinical predictor for lower rates of intraoperative and postoperative complications and higher rates of trifecta achievement but not LOS. CONCLUSIONS Differences in baseline and outcome characteristics exist between RAPN vs. OPN, probably due to selection bias. However, after applying two sets of statistical analyses, RAPN seems to be associated with more favorable outcomes regarding complications and trifecta rates.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany.
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
- Young Academics in Urology (YAU) Working Group Robotic Surgery, Arnhem, The Netherlands
| | - Olivia Eckart
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Felicia Fleisgarten
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Cristina Cano Garcia
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Jens Köllermann
- Dr. Senckenberg Institute of Pathology, University Hospital Frankfurt, Frankfurt Am. Main, Germany
| | - Christoph Würnschimmel
- Young Academics in Urology (YAU) Working Group Robotic Surgery, Arnhem, The Netherlands
- Luzerner Kantonsspital, Lucerne Hospital, Lucerne, Switzerland
| | - Alessandro Larcher
- Young Academics in Urology (YAU) Working Group Robotic Surgery, Arnhem, The Netherlands
- Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pierre Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Andreas Becker
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
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Dell'Oglio P, Tappero S, Panunzio A, Antonelli A, Salvador D, Xylinas E, Alvarez-Maestro M, Hurle R, Salas RS, Colomer A, Simone G, Hendricksen K, Peroni A, Lonati C, Olivero A, Rouprêt M, Roumiguié M, Soria F, Umari P, D'Andrea D, Terrone C, Galfano A, Moschini M, Trapani ED. Age represents the main driver of surgical decision making in patients candidate to radical cystectomy. J Surg Oncol 2023. [PMID: 37126407 DOI: 10.1002/jso.27255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/10/2023] [Accepted: 03/13/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Age might influence the choice of surgical approach, type of urinary diversion (UD) and lymph node dissection (LND) in patients candidate to radical cystectomy (RC) for urothelial bladder cancer (UBC). Similarly, age may enhance surgical morbidity and worsen perioperative outcomes. We tested the impact of age (octogenarian vs. younger patients) on surgical decision making and peri- and postoperative outcomes of RC. METHODS Non-metastatic muscle-invasive UBC patients treated with RC at 18 high-volume European institutions between 2006 and 2021 were identified and stratified according to age (≥80 vs. <80 years). Intraoperative Complications Assessment and Reporting with Universal Standards and European Association of Urology guidelines recommendations were accomplished in collection and reporting of, respectively, intraoperative and postoperative complications. Multivariable logistic regression models (MVA) tested the impact of age on outcomes of interest. Sensitivity analyses after 1:3 propensity score matching were performed. RESULTS Of 1955 overall patients, 251 (13%) were ≥80-year-old. Minimally invasive RC was performed in 18% and 40% of octogenarian and younger patients, respectively (p < 0.001). UD without bowel manipulation (ureterocutaneostomy, UCS) was performed in 31% and 7% of octogenarian and younger patients (p < 0.001). LND was delivered to 81% and 93% of octogenarian and younger patients (p < 0.001). At MVA, age ≥80 years independently predicted open approach (odds ratio [OR]: 1.55), UCS (OR: 3.70), and omission of LND (OR: 0.41; all p ≤ 0.02). Compared to their younger counterparts, octogenarian patients experienced higher rates of intraoperative (8% vs. 4%, p = 0.04) but not of postoperative complications (64% vs. 61%, p = 0.07). At MVA, age ≥80 years was not an independent predictor of length of stay, intraoperative or postoperative transfusions and complications, and readmissions (all p values >0.1). These results were replicated in sensitivity analyses. CONCLUSIONS Age ≥80 years does not independently portend worse surgical outcomes for RC. However, octogenarians are unreasonably more likely to receive open approach and UCS diversion, and less likely to undergo LND.
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Affiliation(s)
- Paolo Dell'Oglio
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Urology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - Stefano Tappero
- Department of Urology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Andrea Panunzio
- Department of Urology, Azienda Ospedaliera Universitaria Integrata, University of Verona, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, Azienda Ospedaliera Universitaria Integrata, University of Verona, Verona, Italy
| | - Daniel Salvador
- Department of Urology, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Evanguelos Xylinas
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Department of Urology Cochin Hospital, APHP, Paris Descartes University, Paris, France
| | | | - Rodolfo Hurle
- Department of Urology, Istituto Clinico Humanitas Istituto di Ricovero e Cura a Carattere Scientifico-Clinical and Research Hospital, Milan, Italy
| | | | - Anna Colomer
- Department of Urology, Institut Mutualiste Montsouris, Paris, France
| | - Giuseppe Simone
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Angelo Peroni
- Department of Urology, ASST Spedali Civili, Brescia, Italy
| | - Chiara Lonati
- Department of Urology, ASST Spedali Civili, Brescia, Italy
| | - Alberto Olivero
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Morgan Rouprêt
- Department of Urology, Pierre and Marie Curie Medical School, Pitié-Salpêtrière Academic Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Sorbonne, Paris, France
| | - Mathieu Roumiguié
- Department of Urology, Institut Universitaire du Cancer, Oncopole, Toulouse, France
| | - Francesco Soria
- Department of Surgical Sciences, Division of Urology, Torino School of Medicine, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Paolo Umari
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Carlo Terrone
- Department of Urology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Antonio Galfano
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Moschini
- University Vita-Salute San Raffaele, Milan, Italy
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ettore Di Trapani
- Division of Urology, IEO-European Institute of Oncology, IRCCS, Milan, Italy
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Hoeh B, Flammia RS, Hohenhorst L, Sorce G, Chierigo F, Panunzio A, Tian Z, Saad F, Gallucci M, Briganti A, Terrone C, Shariat SF, Graefen M, Tilki D, Antonelli A, Kluth LA, Becker A, Chun FKH, Karakiewicz PI. Regional differences in total hospital costs for radical cystectomy in the United States. Surg Oncol 2023; 48:101924. [PMID: 36948042 DOI: 10.1016/j.suronc.2023.101924] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 02/22/2023] [Accepted: 03/05/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVES To test for regional differences in total hospital costs (THC) across the United States in bladder cancer patients treated with open radical cystectomy (ORC) or robotic-assisted radical cystectomy (RARC). MATERIALS We relied on the National Inpatient Sample (NIS) database (2016-2019) and stratified RC patients according to census region (Midwest, Northeast, South, West). Primary statistical analyses consisted of THC-trend analyses and multivariable log-link linear regression models, after adjustment for hospital clustering (Generalized Estimating Equation function) and discharge disposition weighting. Finally, sensitivity analysis, relying on most favorable patient cohort, was performed. RESULTS Of 5280 eligible patients, 1441 (27%), 1031 (20%), 1854 (35%) and 954 (18%) underwent RC in the Midwest, Northeast, South and West, respectively. Median THC was 28,915$ and differed significantly between regions (Midwest: 28,105$; Northeast: 28,886$; South: 26,096$; West: 38,809$; p < 0.001). After stratification between ORC and RARC, highest THC was invariably recorded in the West: ORC 36,137$ vs 23,941-28,850$ and RARC 43,119$ vs 28,425-29,952$ (both p < 0.05). In multivariable log-link linear regression models, surgery in the West was independently associated with higher THC: ORC (Exponent beta [Exp[β]]: 1.39; 95%-CI: 1.32-1.47; p < 0.001) and RARC (Exp[β]: 1.46; 95%-CI: 1.38-1.55; p < 0.001). Results remained unchanged when analyses were refitted in most favorable patient subgroup. CONCLUSIONS Important regional differences in ORC and RARC THC distinguish the West from other United States regions. The THC discrepancy clearly requires closer examination to identify underlying processes that contribute to inflated costs in the West.
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Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany; Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.
| | - Rocco Simone Flammia
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy
| | - Lukas Hohenhorst
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriele Sorce
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Chierigo
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Andrea Panunzio
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Michele Gallucci
- Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy
| | - Alberto Briganti
- Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Terrone
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Italy
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Andreas Becker
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
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