1
|
Lotan P, Bercovich S, Keidar D, Malshy K, Savin Z, Haramaty R, Gal J, Modai J, Leibovici D, Mano R, Rosenzweig B, Hoffman A, Haifler M, Baniel J, Golan S. Fascial dehiscence after radical cystectomy: Is abdominal exploration mandatory? BMC Urol 2022; 22:138. [PMID: 36057602 PMCID: PMC9441031 DOI: 10.1186/s12894-022-01095-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/26/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Fascial dehiscence after radical cystectomy may have serious clinical implications. To optimize its management, we sought to describe accompanying intraabdominal findings of post-cystectomy dehiscence repair and determine whether a thorough intraabdominal exploration during its operation is mandatory. METHODS We retrospectively reviewed a multi-institutional cohort of patients who underwent open radical cystectomy between 2005 and 2020. Patients who underwent exploratory surgery due to fascial dehiscence within 30 days post-cystectomy were included in the analysis. Data collected included demographic characteristics, the clinical presentation of dehiscence, associated laboratory findings, imaging results, surgical parameters, operative findings, and clinical implications. Potential predictors of accompanying intraabdominal complications were investigated. RESULTS Of 1301 consecutive patients that underwent cystectomy, 27 (2%) had dehiscence repair during a median of 7 days post-surgery. Seven patients (26%) had accompanying intraabdominal pathologies, including urine leaks, a fecal leak, and an internal hernia in 5 (19%), 1 (4%), and 1 (4%) patients, respectively. Accompanying intraabdominal findings were associated with longer hospital stay [20 (IQR 17, 23) vs. 41 (IQR 29, 47) days, P = 0.03] and later dehiscence identification (postoperative day 7 [IQR 5, 9] vs. 10 [IQR 6, 15], P = 0.03). However, the rate of post-exploration complications was similar in both groups. A history of ischemic heart disease was the only predictor for accompanying intraabdominal pathologies (67% vs. 24%; P = 0.02). CONCLUSIONS A substantial proportion of patients undergoing post-cystectomy fascial dehiscence repair may have unrecognized accompanying surgical complications without prior clinical suspicion. While cardiovascular disease is a risk factor for accompanying findings, meticulous abdominal inspection is imperative in all patients during dehiscence repair. Identification and repair during the surgical intervention may prevent further adverse, possibly life-threatening consequences with minimal risk for iatrogenic injury.
Collapse
Affiliation(s)
- Paz Lotan
- Department of Urology,, Rabin Medical Center, 49372, Petach Tikva, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Shayel Bercovich
- Department of Urology,, Rabin Medical Center, 49372, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Keidar
- Department of Urology,, Rabin Medical Center, 49372, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kamil Malshy
- Department of Urology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ziv Savin
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Rennen Haramaty
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology, The Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Jonathan Gal
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology,, Shamir Medical Center at Assaf Harrofeh, Tzrifin, Israel
| | - Jonathan Modai
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology, Kaplan Medical Center, Rehovot, Israel
| | - Dan Leibovici
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology, Kaplan Medical Center, Rehovot, Israel
| | - Roy Mano
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Barak Rosenzweig
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology, The Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Azik Hoffman
- Department of Urology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Miki Haifler
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology, The Chaim Sheba Medical Center at Tel Hashomer, Ramat-Gan, Israel
| | - Jack Baniel
- Department of Urology,, Rabin Medical Center, 49372, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shay Golan
- Department of Urology,, Rabin Medical Center, 49372, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
2
|
Martini A, Sfakianos JP, Renström-Koskela L, Mortezavi A, Falagario UG, Egevad L, Hosseini A, Mehrazin R, Galsky MD, Steineck G, Wiklund NP. The natural history of untreated muscle-invasive bladder cancer. BJU Int 2019; 125:270-275. [PMID: 31310696 DOI: 10.1111/bju.14872] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
OBJECTIVE To describe the natural history of untreated muscle-invasive bladder cancer (MIBC) and compare the oncological outcomes of treated and untreated patients. PATIENTS AND METHODS We utilised a database encompassing all patients with newly diagnosed bladder cancer in Stockholm, Sweden between 1995 and 1996. The median follow-up for survivors was 14.4 years. Overall, 538 patients were diagnosed with bladder cancer of whom 126 had clinically localised MIBC. Patients were divided into two groups: those who received radical cystectomy or radiation therapy, and those who did not receive any form of treatment. Multivariable Cox or competing-risks regressions were adopted to predict metastasis, overall survival (OS), and cancer-specific mortality (CSM), when appropriate. Analyses were adjusted for age at diagnosis, sex, tumour stage, clinical N stage, and treatment. RESULTS In all, 64 (51%) patients did not receive any definitive local treatment. In the untreated group, the median (interquartile range) age at diagnosis was 79 (63-83) vs 69 (63-74) years in the treated group (P < 0.001). Overall, 109 patients died during follow-up. At 6 months after diagnosis, 38% of the untreated patients had developed metastatic disease and 41% had CSM. The 5-year OS rate for untreated and treated patients was 5% (95% confidence interval [CI] 1, 12%) vs 48% (95% CI 36, 60%), respectively. Patients not receiving any treatment had a 5-year cumulative incidence of CSM of 86% (95% CI 75, 94%) vs 48% (95% CI 36, 60%) for treated patients. Untreated patients had a higher risk of progression to metastatic disease (hazard ratio [HR] 2.40, 95% CI 1.28, 4.51; P = 0.006), death from any cause (HR 2.63, 95% CI 1.65, 4.19; P < 0.001) and CSM (subdistribution HR 2.02, 95% CI 1.24, 3.30; P = 0.004). CONCLUSIONS Untreated patients with MIBC are at very high risk of near-term CSM. These findings may help balance the risks vs benefits of integrating curative intent therapy particularly in older patients with MIBC.
Collapse
Affiliation(s)
- Alberto Martini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lotta Renström-Koskela
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Ashkan Mortezavi
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ugo G Falagario
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lars Egevad
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Abolfazal Hosseini
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew D Galsky
- Division of Hematology and Oncology, Department of Medicine, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gunnar Steineck
- Sahlgrenska Academy Clinical Sciences, University of Göteborg, Gothenburg, Sweden
| | - N Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
3
|
Mazzone E, Preisser F, Nazzani S, Tian Z, Zaffuto E, Gallina A, Tilki D, Montorsi F, Shariat SF, Saad F, Briganti A, Karakiewicz PI. The effect of age and comorbidities on early postoperative complications after radical cystectomy: A contemporary population-based analysis. J Geriatr Oncol 2019; 10:623-631. [PMID: 31010691 DOI: 10.1016/j.jgo.2019.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 04/14/2019] [Accepted: 04/14/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Analyzing the relationship between perioperative outcomes and age in urothelial carcinoma of the bladder (UCB) patients treated with radical cystectomy (RC) in a continuous fashion may provide detailed information on the increased risk of complications in older patients, even after accounting for different comorbidity profiles. Given the limited data available in the literature, we tested these relationships within a large scale, population-based database. MATERIALS AND METHODS Within the NIS database (2003-2015), we identified patients who underwent RC for UCB. Multivariable logistic regression (MLoR) and Poisson regression (MPR) models were used after adjustment for clustering and stratification for comorbidity profiles. RESULTS Overall, 20,144 patients underwent RC with a median age of 70 years (interquartile range: 62-77). In MLoR models, continuously coded age represented an independent predictor of overall (odds ratio [OR]: 1.008, 95%-confidence interval [CI]: 1.005-1.012), cardiac (OR: 1.042, 95%-CI: 1.035-1.049), vascular (OR: 1.024, 95%-CI: 1.014-1.034), respiratory (OR: 1.016, 95%-CI 1.009-1.022), miscellaneous medical (OR: 1.013, 95%-CI: 1.009-1.017), infectious (OR: 1.012, 95%-CI 1.004-1.019), transfusions (OR: 1.011, 95%-CI 1.007-1.015) and bowel obstruction (OR: 1.009, 95%-CI 1.004-1.013) complications, and in-hospital mortality (OR: 1.057, 95%-CI 1.039-1.075). Conversely, patients age did not predict intraoperative (p = 0.7), genitourinary (p = 0.9), operative wound (p = 0.2) and miscellaneous surgical complications (p = 0.1). In MPR models, patients age predicted longer LOS (relative risk [RR]: 1.002, 95%-CI 1.001-1.003). Finally, a decreasing effect of age was observed in patients low vs high comorbidity burden for cardiac, respiratory and overall complications. CONCLUSIONS Most of early postoperative RC complications are related to patients age, but its impact varies according to comorbidity profile. Further studies are needed to validate our findings that may be then considered for individual counselling and informed consent, as well as for health expenditure planning.
Collapse
Affiliation(s)
- Elio Mazzone
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Division of Experimental Oncology, Unit of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Felix Preisser
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Martini Klinik, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastiano Nazzani
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada; Academic Department of Urology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Emanuele Zaffuto
- Division of Experimental Oncology, Unit of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Gallina
- Division of Experimental Oncology, Unit of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Derya Tilki
- Martini Klinik, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Francesco Montorsi
- Division of Experimental Oncology, Unit of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | | | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Alberto Briganti
- Division of Experimental Oncology, Unit of Urology, Urological Research Institute (URI), IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| |
Collapse
|
4
|
Laparoscopic radical cystectomy in octogenarians: analysis of a Japanese multicenter cohort. Int J Clin Oncol 2019; 24:1081-1088. [DOI: 10.1007/s10147-019-01446-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/05/2019] [Indexed: 12/31/2022]
|
5
|
Schulz GB, Grimm T, Buchner A, Jokisch F, Kretschmer A, Casuscelli J, Ziegelmüller B, Stief CG, Karl A. Surgical High-risk Patients With ASA ≥ 3 Undergoing Radical Cystectomy: Morbidity, Mortality, and Predictors for Major Complications in a High-volume Tertiary Center. Clin Genitourin Cancer 2018; 16:e1141-e1149. [PMID: 30174234 DOI: 10.1016/j.clgc.2018.07.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND The purpose of this study was to investigate major complications and risk factors for adverse clinical outcome in surgical high-risk (American Society of Anesthesiologists [ASA] 3-4) patients undergoing radical cystectomy (RC) in a high-volume setting. PATIENTS AND METHODS A total of 1206 patients underwent RC between 2004 and 2017 in our institution and were included. We assessed complications graded by the Clavien-Dindo-Classification system (CDC) in addition to the 90-day mortality rate and stratified results by the ASA classification. In a multivariate analysis, risk factors for high-grade complications (CDC ≥ 3) were tested. Additionally, outcome parameters were compared between 2004 to 2010 and 2010 to 2017. RESULTS Patients with ASA ≥ 3 presented with more locally advanced tumors pT ≥ 3 (52.1% vs. 42.4%; P = .002) and positive lymphatic spread N1 (27.2% vs. 23.5%; P = .001) compared with patients with ASA ≤ 2. High-grade complications were significantly (P < .001) more prevalent in patients with ASA ≥ 3 compared with patients with ASA ≤ 2: CDC3 (14.6% vs. 9.4%), CDC4 (10.2% vs. 5.4%), and CDC5 (2.5% vs. 1.0%). The 90-day mortality rate (7.6% vs. 3.2%; P = .002) and perioperative reinterventions (23.5% vs. 13.1%; P < .001) were elevated in patients with ASA ≥ 3. ASA (odds ratio [OR], 2.701, 95% confidence interval [CI], 1.089-6.703; P = .032), previous abdominal operations (OR, 1.683; 95% CI, 1.188-2.384; P = .003), and body mass index ≥ 30 (OR, 1.533; 95% CI, 1.021-2.304; P = .039) proved to function as independent predictors for major complications. CDC ≥ 3 complications (31.7% vs. 24.3%; P = .029) and 90-day mortality (10.4% vs. 5.6%; P = .018) were significantly lower in the second half of the study period. CONCLUSIONS Mortality and morbidity in surgical high-risk patients with ASA 3 to 4 undergoing RC is about twice as high compared with patients with ASA 1 to 2. ASA, previous abdominal operations, and elevated body mass index independently predict adverse clinical outcome in patients with ASA 3 to 4. Our results may help to weigh the surgical risk of RC in multimorbid patients.
Collapse
Affiliation(s)
- Gerald B Schulz
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany.
| | - Tobias Grimm
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | - Alexander Buchner
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | - Friedrich Jokisch
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | | | | | | | - Christian G Stief
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| | - Alexander Karl
- Department of Urology, Ludwig-Maximilians-University, Munich, Germany
| |
Collapse
|
6
|
Eredics K, Bretterbauer KM, Comploj E, Friedl A, Gschliesser T, Lenart S, Seklehner S, Wimpissinger F, Madersbacher S. Bladder cancer in nonagenarians: a multicentre study of 123 patients. BJU Int 2018; 122:1010-1015. [PMID: 29804311 DOI: 10.1111/bju.14419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate the oncological outcome of nonagenarians with bladder cancer, as a substantial rise in bladder cancer in the old-old age group in the upcoming decades is expected, due to demographic changes and the peak incidence around the age of 85 years. The paucity of data of nonagenarians prompted us to investigate the outcomes of such patients. PATIENTS AND METHODS A retrospective, multicentre study was designed to assess patient demographics, tumour patterns, treatment strategies and outcome in patients aged ≥90 years treated at participating centres. Patients entered either as de novo or as recurrent cancer. The study period ranged from 01.01.2006 to 31.12.2016. RESULTS A total of 123 patients with a mean (range) age of 91 (90-99) years were recruited. The American Society of Anesthesiologists Physical Status Classification (ASA-score) distribution was as follows: II, 38%; III, 50%; IV, 12%; and the male to female ratio 2.4:1. The median (range) follow-up was 8 (1-132) months. In all, 60% of patients had a de novo cancer diagnosis. Histological findings revealed: pTa 39% (n = 48), pT1 28.5% (n = 35), and ≥pT2 33% (n = 40). Overall, 67.5% patients had no recurrence, 25.2% one and 7.5% two or more. pTa tumours (n = 48) recurred in 20 patients (42%), pT1 tumours (n = 35) in 12 (34%), and ≥pT2 tumours (n = 40) in six (15%). The median overall survival (OS) was 30.0 months for patients with pTa tumours, 14.0 months for pT1 tumours, and 6.0 months for ≥pT2 tumours. The overall mortality rate of patients with pTa tumours was 40%, with pT1 tumours at 60%, and ≥pT2 tumours 75%. The ASA-score also had a strong influence on median OS after stratification by ASA-score (II, 30 months; III, 12 months; IV, 4 months). CONCLUSIONS In nonagenarians with bladder tumours, pTa/pT1/≥pT2 stages are almost evenly distributed and two-thirds of patients had no recurrence after transurethral resection of the bladder. The mean OS was 1.3 years, and 6 months for ≥pT2 tumours. Further case-series of patients in this specific age-group are required to identify the best management of this increasing proportion of patients with bladder tumours.
Collapse
Affiliation(s)
- Klaus Eredics
- Department of Urology, Kaiser-Franz-Josef-Spital, Vienna, Austria
| | | | - Evi Comploj
- Department of Urology, Hospital of Bolzano/Bozen, Bozen, Italy.,Department of Research, College of Health Care Professions Claudiana, Bozen, Italy
| | - Alexander Friedl
- Department of Urology, Barmherzige Schwestern Krankenhaus, Vienna, Austria
| | - Tanja Gschliesser
- Department of Urology, Krankenhaus Wiener Neustadt, Wiener Neustadt, Austria
| | - Sebastian Lenart
- Department of Urology, Krankenhaus der Barmherzigen Brüder, Vienna, Austria.,Department of Urology, Paracelsus Medical University, Salzburg, Austria
| | - Stephan Seklehner
- Department of Urology, Landesklinikum Baden-Mödling, Baden, Austria.,Department of Urology, Paracelsus Medical University, Salzburg, Austria
| | | | - Stephan Madersbacher
- Department of Urology, Kaiser-Franz-Josef-Spital, Vienna, Austria.,Department of Urology, Sigmund Freud Private University, Vienna, Austria
| |
Collapse
|
7
|
Risks and benefits of pelvic lymphadenectomy in octogenarians undergoing radical cystectomy due to urothelial carcinoma of the bladder. Int Urol Nephrol 2017; 49:2137-2142. [PMID: 28900840 DOI: 10.1007/s11255-017-1699-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES According to current guidelines, radical cystectomy (RC) should be combined with an extended pelvic lymphadenectomy (PLND) as therapeutic and staging instrument. Objective of this study was to analyze the influence of PLND on survival rates and complication rates in a selected group of elderly patients with a minimum age of 80 years. MATERIALS AND METHODS In this single-center retrospective analysis, we evaluated 102 patients who underwent RC due to UCB from 2004 to 2015 at our institution. In 74 patients (73%), RC was combined with PLND; in 28 cases (27%), RC was performed without PLND. Impact of PLND on cancer specific survival (CSS), overall survival (OS) and progression-free survival (PFS) was analyzed using log-rank test and COX regression model. RESULTS In univariate analysis of the data, we were not able to show a significant impact of PLND on CSS (p = 0.606), OS (p = 0.979) or PFS (p = 0.883). Also in multivariate analysis of the data, we were not able to identify PLND as an independent prognostic parameter on survival rates of patients undergoing RC, neither for CSS (p = 0.912) nor OS (p = 0.618) or PFS (p = 0.900). CONCLUSIONS Our small and single-center study was not able to demonstrate a significant independent influence of PLND on CSS, OS and PFS in octogenarians undergoing RC due to UCB. There is no doubt that RC should usually be combined with PLND, but the results of this small data set with a selected patient cohort indicate that RC without PLND might be an option in selected cases of elderly patients.
Collapse
|
8
|
Stensland KD, Galsky MD. Current approaches to the management of bladder cancer in older patients. Am Soc Clin Oncol Educ Book 2015:e250-6. [PMID: 24857110 DOI: 10.14694/edbook_am.2014.34.e250] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Bladder cancer is largely a disease of older adults, with nearly half of diagnoses occurring in those older than age 75. This has led to a disconnect between the efficacy and effectiveness of various treatment strategies. For example, surgical removal of the bladder is a potentially curative approach to muscle-invasive disease, although the large single-center and multicenter series that have established the efficacy of this approach include only a small proportion of older patients. Similarly, clinical trials that have established optimal chemotherapeutic regimens for use in the perioperative and metastatic settings comprise largely younger patients. Extrapolating the available evidence to the population of older patients with bladder cancer requires careful assessment of an individual patient's functional status and comorbidities to estimate the likelihood of treatment-related harms. This should be coupled with an understanding of an individual patient's goals of therapy, independence, estimated longevity, and social support to facilitate a shared medical decision regarding treatment. The use of validated approaches to geriatric assessment may refine risk stratification in older adults, although practical challenges have prevented uniform adoption in routine clinical practice.
Collapse
Affiliation(s)
- Kristian D Stensland
- From the Department of Medicine, Division of Hematology/Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Urology, Ichan School of Medicine at Mount Sinai, New York, NY
| | - Matthew D Galsky
- From the Department of Medicine, Division of Hematology/Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Urology, Ichan School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
9
|
Cresswell J, Mariappan P, Thomas SA, Khan MS, Johnson MI, Fowler S. Radical cystectomy: Analysis of trends in UK practice 2004–2012, from the British Association of Urological Surgeons’ (BAUS) Section of Oncology Dataset. JOURNAL OF CLINICAL UROLOGY 2015. [DOI: 10.1177/2051415815595325] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To analyse the British Association of Urological Surgeons’ (BAUS) radical cystectomy (RC) dataset, to examine the trends in patient selection, use of neoadjuvant chemotherapy (NAC) and operative technique. Methods: Data for RC were entered into a database voluntarily, by operating surgeons. A comparison was made to the Hospital Episode Statistics (HES) data, to estimate the proportion of cases captured by the dataset. Results: From 2004 to 2012, data was collected on 5321 patients undergoing RC. This constituted 37.1% of all HES RC cases during the corresponding time period. Notable trends were: An increasing use of NAC, the introduction of minimally-invasive surgery (23.5% in 2012), a dramatic reduction in blood transfusion rates and the increasing yields from lymph node dissection. The ileal conduit urinary diversion predominated as the urinary diversion of choice (80% of cases). Conclusions: This analysis of a large multi-centre dataset provides insight into RC practice in the UK, over 8 years. The major weaknesses of the study were that only one-third of cases were recorded and that outcome data was very limited. Mandatory publication of outcome data from 2016 should increase the recording of cases and provide material for a more complete analysis.
Collapse
Affiliation(s)
- J Cresswell
- Department of Urology, James Cook University Hospital, Middlesbrough, UK
| | - P Mariappan
- Department of Urology, Western General Hospital, Edinburgh, Scotland, UK
| | - SA Thomas
- Department of Urology, Royal Derby Hospital, UK
| | - MS Khan
- Department of Urology, Guy’s Hospital, London, UK
| | - MI Johnson
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - S Fowler
- British Association of Urological Surgeons, London, UK
| | | |
Collapse
|
10
|
Meyer CP, Rios Diaz AJ, Dalela D, Hanske J, Pucheril D, Schmid M, Trinh VQ, Sammon JD, Menon M, Chun FKH, Noldus J, Fisch M, Trinh QD. Wound dehiscence in a sample of 1 776 cystectomies: identification of predictors and implications for outcomes. BJU Int 2015; 117:E95-E101. [PMID: 26118393 DOI: 10.1111/bju.13213] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy (RC). PATIENTS AND METHODS In all, 1 776 patient records with Current Procedural Terminology (CPT) codes for radical cystectomy (RC) were extracted from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) between 2005 and 2012. Stratification was made based on the occurrence of postoperative wound dehiscence, defined as loss of integrity of fascial closure. Descriptive and logistic regression models were used to identify predictors of postoperative wound dehiscence. The implications of wound dehiscence on peri- and postoperative outcomes such as complications, mortality, prolonged length of stay (>11 days), and prolonged operative time (>411 min), were assessed. RESULTS Of 1 776 patients analysed, 57 (3.2%) had a documented wound dehiscence. In multivariable analyses, chronic obstructive pulmonary disease (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.0-4.0; P = 0.03) and high body mass index (OR 2.3, 95% CI 1.3-4.4; P = 0.008) were significant predictors of wound dehiscence. While female gender had significantly lower proportions of wound dehiscence, multivariable analyses did not confirm this (OR 0.4, 95% CI 0.4-1.4; P = 0.75). CONCLUSIONS Our study is the first to identify predictors of wound dehiscence after RC in a large, contemporary multi-institutional cohort. Identifying patients at risk of postoperative wound complications may guide the use of preventative measures at the time of surgery.
Collapse
Affiliation(s)
- Christian P Meyer
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arturo J Rios Diaz
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepansh Dalela
- Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Julian Hanske
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - Daniel Pucheril
- Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Marianne Schmid
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vincent Q Trinh
- Department of Pathology and Cellular Biology, Université de Montréal, Montreal, QC, Canada
| | - Jesse D Sammon
- Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Mani Menon
- Vattikuti Urology Institute Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Felix K H Chun
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Noldus
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - Margit Fisch
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Quoc-Dien Trinh
- Center for Surgery and Public Health and Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
11
|
Zakaria AS, Santos F, Tanguay S, Kassouf W, Aprikian AG. Radical cystectomy in patients over 80 years old in Quebec: A population-based study of outcomes. J Surg Oncol 2015; 111:917-22. [PMID: 25663440 DOI: 10.1002/jso.23887] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/27/2014] [Accepted: 12/29/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To document radical cystectomy (RC) outcomes in patients over 80 years old across Quebec during the years 2000-2009 and to examine potentially related factors. METHODS Within Quebec health insurance medical services database, we identified patients over 80 years who underwent RC. The outcomes analyzed were post-operative complications, mortality rates at 30, 60 and 90 days and overall survival. RESULTS A total of 275 patients over 80 years old had RC performed in 38 hospitals across Quebec. Among them, 33% had major post-operative complications with 16% having more than one complication. Mortality rates at 30, 60 and 90 days were 5.8%, 9.8% and 13% respectively. 44.3% of RCs were performed in seven academic hospitals with mortality rates of 2.5%, 6.5% and 9% respectively. Community hospitals had mortality of 8.5%, 12.4% and 16.3% respectively (P < 0.001). The cohort 5-year overall survival rate was 27%. The presence of post-operative complications and the number of complications negatively affected overall survival (P < 0.001) CONCLUSION: Patients over 80 years of age have high post-RC mortality rates, especially at 90 days. In addition, it appears that they have lower post-operative mortality if their RCs were performed in academic centers. Mortality rates and complications can be used when obtaining informed consent.
Collapse
Affiliation(s)
- Ahmed S Zakaria
- Department of Surgery, Division of Urology, McGill University, Montreal, Quebec, Canada
| | | | | | | | | |
Collapse
|
12
|
Santos F, Zakaria AS, Kassouf W, Tanguay S, Aprikian A. High hospital and surgeon volume and its impact on overall survival after radical cystectomy among patients with bladder cancer in Quebec. World J Urol 2014; 33:1323-30. [DOI: 10.1007/s00345-014-1457-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/22/2014] [Indexed: 12/01/2022] Open
|
13
|
Schiffmann J, Gandaglia G, Larcher A, Sun M, Tian Z, Shariat SF, McCormack M, Valiquette L, Montorsi F, Graefen M, Saad F, Karakiewicz PI. Contemporary 90-day mortality rates after radical cystectomy in the elderly. Eur J Surg Oncol 2014; 40:1738-45. [PMID: 25454826 DOI: 10.1016/j.ejso.2014.10.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 09/28/2014] [Accepted: 10/06/2014] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Existing radical cystectomy (RC) perioperative mortality estimates may underestimate the contemporary rates due to more advanced age, more baseline comorbidities and potentially broader inclusion criteria for RC, relative to past criteria. METHODS Within the most recent Surveillance, Epidemiology, and End Results (SEER)-Medicare database we identified clinically non-metastatic, muscle-invasive (T2-T4a) urothelial carcinoma of the urinary bladder (UCUB) patients, who underwent RC between 1991 and 2009. Mortality at 30- and 90-day after RC was quantified. Multivariable logistic regression analyses tested predictors of 90-day mortality. RESULTS Within 5207 assessable RC patients 30- and 90-day mortality rates were 5.2 and 10.6%, respectively. According to age 65-69, 70-79 and ≥ 80 years, 90-day mortality rates were 6.4, 10.1 and 14.8% (p < 0.001). Additionally, 90-day mortality rates increased with increasing Charlson Comorbidity Index (CCI, 0, 1, 2 and ≥ 3): 6.3, 10.3, 12.6 and 15.9% (p < 0.001). 90-day mortality rate in unmarried patients was 13.0 vs. 9.3% in married individuals (p < 0.001). In multivariable logistic regression analyses, advanced age, higher CCI, low socioeconomic status, unmarried status and non organ-confined stage were independent predictors of 90-day mortality (all p < 0.05). CONCLUSIONS The contemporary SEER-Medicare derived 90-day mortality rates are substantially higher than previously reported estimates from centers of excellence, and even exceed previous SEER reports. More advanced age, higher CCI score, and other patient characteristics that distinguish the current population from others account for these differences.
Collapse
Affiliation(s)
- J Schiffmann
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - G Gandaglia
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
| | - A Larcher
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
| | - M Sun
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
| | - Z Tian
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada
| | - S F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - M McCormack
- Department of Urology, University of Montreal Health Center, Montreal, Canada
| | - L Valiquette
- Department of Urology, University of Montreal Health Center, Montreal, Canada
| | - F Montorsi
- Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy
| | - M Graefen
- Martini-Clinic Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - F Saad
- Department of Urology, University of Montreal Health Center, Montreal, Canada
| | - P I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Canada; Department of Urology, University of Montreal Health Center, Montreal, Canada
| |
Collapse
|
14
|
Jerlström T, Gårdmark T, Carringer M, Holmäng S, Liedberg F, Hosseini A, Malmström PU, Ljungberg B, Hagberg O, Jahnson S. Urinary bladder cancer treated with radical cystectomy: Perioperative parameters and early complications prospectively registered in a national population-based database. Scand J Urol 2014; 48:334-40. [DOI: 10.3109/21681805.2014.909883] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
15
|
Pycha A, Comploj E. The dilemma of cystectomy in old-old and oldest-old patients. Expert Rev Anticancer Ther 2014; 11:1863-70. [DOI: 10.1586/era.11.188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
16
|
[Radical cystectomy and ileal neobladder reconstruction in elderly female patients over 70 years old: morbidity, functional and oncological long-term results]. Urologe A 2012; 51:1419-23. [PMID: 23053038 DOI: 10.1007/s00120-012-3019-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND As life expectancy is increasing the incidence and therefore the number of elderly female patients with bladder cancer is also increasing. The aim of this study was to assess long-term clinical, functional and oncological outcome in elderly women (≥70 years) who were treated by radical cystectomy and ileal neobladder reconstruction for invasive bladder cancer. MATERIAL AND METHODS A total of 121 women with clinically organ-confined invasive urothelial carcinoma underwent radical cystecomy with an orthotopic ileal neobladder in Ulm between 1995 and 2010. The clinical course, functional, pathological, and oncological outcome of these women were analyzed retrospectively and compared between patients ≥70 (n=24) and <70 years of age (n=97). All complications which occurred during the first 90 days after surgery were analyzed in detail, defined and classified according to the modified Clavien system. RESULTS The overall 90 day complication rates were 66.7 % and 62.5 % for patients ≥70 and <70 years, respectively. Of these 54.2% and 44.8% were minor complications and 12.5 % and 17.7 % were major complications, respectively. Infections were the most frequent cause of complications with 36.7 %. Univariate analyses revealed that neither age nor comorbidity (ASA score) were significant predictors of perioperative complications. The daytime continence rates were comparable in both age groups (71% versus 82%, p=0.64); however, younger patients showed significantly higher night time urinary continence rates (43% versus 89%, p=0.013). Neither univariable nor multivariable analyses indicated that age ≥70 years had a significant impact on tumor-specific survival. CONCLUSIONS Chronological age per se does not seem to be a contraindication for the creation of an orthotopic ileal neobladder; however, the risk of postoperative incontinence seems to increase with age.
Collapse
|
17
|
Karl A, Schneevoigt B, Weninger E, Grimm T, Stief C. Feasibility of radical cystectomy in exclusive spinal and/or epidural anaesthesia. World J Urol 2012; 31:1279-84. [PMID: 22832588 DOI: 10.1007/s00345-012-0912-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 07/12/2012] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Muscle invasive bladder cancer can be found predominantly in elderly people with a high likelihood of suffering from concomitant diseases; especially in these patients, the risks associated with general anaesthesia during radical cystectomy can be the limiting factor of performing an otherwise indicated radical operation. To overcome this limitation, we analysed the feasibility of performing radical cystectomy in exclusive spinal and/or epidural anaesthesia. METHODS Between March and June 2010, nine patients underwent radical cystectomy in exclusive spinal and/or epidural anaesthesia. These patients were either not willing or unfit to undergo radical cystectomy in general anaesthesia. A continent urinary diversion (ileum neobladder) and an ileum-conduit were performed in five patients and four patients, respectively. The feasibility of radical cystectomy in regional anaesthesia was tested using a variety of parameters. RESULTS All nine procedures could be performed under strict regional anaesthesia. Mean operation time was 206 min (range 146-265 min), mean intraoperative blood loss was 622 ml (range 200-1,500 ml), mean postoperative time at intermediate care was 1 day (range 0-3 days) and mean length of hospital stay was 21.8 days (range 17-26 days). Analgesics of the WHO class I, II and III were applied for 5.7, 1.2 and 2.8 days mean, respectively. CONCLUSION Performance of radical cystectomy in exclusive spinal and/or epidural anaesthesia is feasible and can be considered particularly in those patients who would be otherwise unfit to undergo radical cystectomy in general anaesthesia. This new operative and anaesthesiological concept could also play an important role in new fast track regimens.
Collapse
Affiliation(s)
- A Karl
- Department of Urology, Ludwig-Maximilians-University, LMU, Marchionistr. 15, 81377, Munich, Germany,
| | | | | | | | | |
Collapse
|
18
|
Guillotreau J, Miocinovic R, Gamé X, Forest S, Malavaud B, Kaouk J, Rischmann P, Haber GP. Outcomes of laparoscopic and robotic radical cystectomy in the elderly patients. Urology 2012; 79:585-90. [PMID: 22386404 DOI: 10.1016/j.urology.2011.11.042] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 11/23/2011] [Accepted: 11/29/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the perioperative outcomes of laparoscopic/robotic radical cystectomy (LRRC) for urothelial cancer of bladder (UCB) between elderly (≥ 70 years) and younger (<70 years) patients. MATERIALS AND METHODS A retrospective review of 146 patients who underwent LRRC between 2003 and 2010 at 2 academic institutions (Cleveland, Ohio, United States and Toulouse, France) was performed. Of these, 74 patients were classified as elderly (≥ 70 years) and 72 patients were considered younger (<70 years). Perioperative outcomes, final pathology results, overall survival (OS), and cancer specific survival (CSS) were compared between the 2 groups. RESULTS Both groups had similar clinical stage at diagnosis, American Society of Anesthesiologists score, body mass index, and gender distribution. Ileal conduit-type diversion was favored in the older vs younger group, 84% vs 36%, respectively. Overall conversion rate to open procedures was 4% in both groups. Perioperative complication rate was not significantly different between the younger and older patients. Positive margin rate was 5% in both groups. The 5-year OS for older and younger patients was 75% and 87%, respectively (P = .03), and the 5-year CSS for the 2 groups was 51% and 54%, respectively (P = .7). CONCLUSION Laparoscopic/robotic radical cystectomy in the elderly does not have worse perioperative complications or pathologic outcomes compared with younger patients and therefore can be offered as treatment option in select older patients.
Collapse
Affiliation(s)
- Julien Guillotreau
- Service d'Urologie, Transplantation Rénale et Andrologie, CHU, Toulouse, France
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Rink M, Chun F, Chromecki T, Fajkovic H, Dahlem R, Fisch M, Shariat S. Das fortgeschrittene Urothelkarzinom der Harnblase beim älteren Patienten. Urologe A 2012; 51:820-8. [DOI: 10.1007/s00120-011-2769-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
20
|
Gravante G, Elmussareh M. Enhanced recovery for non-colorectal surgery. World J Gastroenterol 2012; 18:205-11. [PMID: 22294823 PMCID: PMC3261537 DOI: 10.3748/wjg.v18.i3.205] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 06/15/2011] [Accepted: 06/22/2011] [Indexed: 02/06/2023] Open
Abstract
In recent years the advent of programs for enhanced recovery after major surgery (ERAS) has led to modifications of long-standing and well-established perioperative treatments. These programs are used to target factors that have been shown to delay postoperative recovery (pain, gut dysfunction, immobility) and combine a series of interventions to reduce perioperative stress and organ dysfunction. With due differences, the programs of enhanced recovery are generally based on the preoperative amelioration of the patient’s clinical conditions with whom they present for the operation, on the intraoperative and postoperative avoidance of medications that could slow the resumption of physiological activities, and on the promotion of positive habits in the early postoperative period. Most of the studies were conducted on elective patients undergoing colorectal procedures (either laparotomic or laparoscopic surgery). Results showed that ERAS protocols significantly improved the lung function and reduced the time to resumption of oral diet, mobilization and passage of stool, hospital stay and return to normal activities. ERAS’ acceptance is spreading quickly among major centers, as well as district hospitals. With this in mind, is there also a role for ERAS in non-colorectal operations?
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW To review the epidemiology, diagnosis, and management of all stages of bladder cancer with an emphasis on studies published within the last year. RECENT FINDINGS Smoking continues to be the most important risk factor for the development of bladder cancer, and this risk has increased over time. Although a number of urinary markers for bladder cancer are now approved by the Food and Drug Administration, there is not enough evidence that any marker can replace surveillance cystoscopy. Management of high-risk patients with nonmuscle-invasive cancer remains a challenge, with continued controversy over which patients may safely be treated with bladder-sparing regimens. Efforts toward developing agents for bacillus Calmette-Guerin-refractory superficial bladder cancer continue, however, none to date have shown high rates of long-term success. In patients undergoing cystectomy, reports using more standardized measures of complications have demonstrated high rates of postoperative morbidity and mortality, particularly in elderly individuals. Robot-assisted radical cystectomy is being more widely studied as a potential approach to decrease operative blood loss and shorten recovery. Although more expensive, increasing evidence suggests that it is well tolerated, does not increase the risk of positive surgical margins, and can achieve similar lymph node counts as open cystectomy in experienced hands and with careful patient selection. Despite level I evidence supporting the use of neoadjuvant chemotherapy, there remains disagreement regarding its use vs. selective adjuvant therapy, given the modest benefits seen with current regimens. SUMMARY Progress continues in bladder cancer diagnosis and management, and we anticipate that future work will further advance the care of patients with this disease.
Collapse
|
22
|
Liedberg F, Holmberg E, Holmäng S, Ljungberg B, Malmström PU, Månsson W, Nunez L, Wessman C, Wijkström H, Jahnson S. Long-term follow-up after radical cystectomy with emphasis on complications and reoperations: A Swedish population-based survey. ACTA ACUST UNITED AC 2011; 46:14-8. [DOI: 10.3109/00365599.2011.609835] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Erik Holmberg
- Department of Urology,
Sahlgrenska University Hospital Göteborg, Sweden
| | - Sten Holmäng
- Department of Surgical and Perioperative Sciences,
Urology and Andrology, Umeå, Sweden
| | - Börje Ljungberg
- Department of Urology,
Akademiska University Hospital, Uppsala, Sweden
| | | | - Wiking Månsson
- Department of Urology,
Karolinska University Hospital, Stockholm, Sweden
| | - Leyla Nunez
- Oncologic Centre Sahlgrenska University Hospital, Göteborg, Sweden
| | - Catrin Wessman
- Oncologic Centre Sahlgrenska University Hospital, Göteborg, Sweden
| | - Hans Wijkström
- Oncologic Centre Sahlgrenska University Hospital, Göteborg, Sweden
| | - Staffan Jahnson
- Department of Urology,
Linköping University Hospital, Linköping, Sweden
| |
Collapse
|
23
|
Rink M, Dahlem R, Kluth L, Minner S, Ahyai SA, Eichelberg C, Fisch M, Chun FK. Older patients suffer from adverse histopathological features after radical cystectomy. Int J Urol 2011; 18:576-84. [PMID: 21699582 DOI: 10.1111/j.1442-2042.2011.02794.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Michael Rink
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
24
|
May M, Fritsche HM, Gilfrich C, Brookman-May S, Burger M, Otto W, Bolenz C, Trojan L, Herrmann E, Michel M, Wülfing C, Tiemann A, Müller S, Ellinger J, Buchner A, Stief C, Tilki D, Wieland W, Höfner T, Hohenfellner M, Haferkamp A, Roigas J, Müller O, Bretschneider-Ehrenberg P, Zacharias M, Gunia S, Bastian P. Einfluss des Alters auf das karzinomspezifische Überleben nach radikaler Zystektomie. Urologe A 2011; 50:821-9. [DOI: 10.1007/s00120-011-2507-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
25
|
Shalhoub PJ, Quek ML. Management of bladder cancer in the elderly: clinical decision-making and guideline recommendations. ACTA ACUST UNITED AC 2010. [DOI: 10.2217/ahe.10.51] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Evaluation of: Bolenz C, Ho R, Nuss GR et al.: Management of elderly patients with urothelial carcinoma of the bladder: guideline concordance and predictors of overall survival. BJU Int. (2010) (Epub ahead of print). Treatment recommendations for all stages of bladder cancer have been proposed in the form of clinical guidelines from the European Association of Urology and the American Urological Association. However, the therapeutic considerations, especially when dealing with elderly patients with limited functional status and associated comorbidities, may be much more complex. This retrospective study reviewed the records of 206 patients aged over 75 years with bladder cancer and compared their subsequent treatment with established European Association of Urology and American Urological Association guidelines to see if their actual treatment was concordant or discordant with the published recommendations. Overall guideline concordance was relatively high (88.8%) at this tertiary referral institution. While treatment of muscle-invasive bladder cancer in the elderly can be performed in accordance with accepted guidelines, the margin of error is greatly reduced and proper patient selection and attention to detail is critical to ensure a favorable outcome. Further research is needed to more objectively distinguish patients who may benefit from aggressive cancer therapy from those with serious competing risks who would probably die from other causes.
Collapse
Affiliation(s)
- Philip J Shalhoub
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | | |
Collapse
|