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Ivan SJ, Roebuck EH, Sinks AL, Robinson MM, Clark PE, Gaston KE, Matulay JT, Riggs SB. It's complicated: The relationship of non-narcotic medications and postoperative opioid use in radical cystectomy patients. Urol Oncol 2024; 42:332.e1-332.e9. [PMID: 38735799 DOI: 10.1016/j.urolonc.2024.03.007] [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: 10/24/2023] [Revised: 01/31/2024] [Accepted: 03/10/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION The effect of individual non-narcotic analgesics in cystectomy enhanced recovery after surgery (ERAS) is unknown. Additionally, many non-narcotic medications are associated with side effects pertinent to the cystectomy population. To better understand the actual use and utility of these medications, we sought to characterize the association between non-narcotic medications and milligram morphine equivalent (MME) narcotic score during the postoperative inpatient stay. METHODS We reviewed 260 consecutive ERAS cystectomy patients. The MME impact of non-narcotic compliance and cumulative dose of medication received was evaluated separately with general linear models. We also assessed relationship of non-narcotic compliance to patient reported pain score, length of stay (LOS), and time to return of bowel function (ROBF) and performed manual review of postoperative documentation to identify reasons for medication noncompliance. RESULTS Compliance with postoperative acetaminophen, gabapentin, and ketorolac was low. There was an inverse relationship between ketorolac dose and MME on postoperative day 1 (-0.026 MME/mg; P = 0.004) and postoperative day 2 (-0.33 MME/mg; P < 0.001). Compliance with ketorolac was associated with lower MME on postoperative day 1 (26.1 MME v. 33.6 MME; P = 0.023). There were no such associations identified with gabapentin or acetaminophen. Gabapentin compliance was associated with earlier ROBF (3.7 days v. 4.3 days; P = 0.006). Ketorolac compliance was associated with lower pain score on POD1 (3.25 VAS v. 4.07 VAS; P = 0.019) and POD2 (3.05 VAS v. 3.85 VAS; P = 0.040) There was no association between medication compliance and LOS. The most common reasons identified for non-compliance with gabapentin and ketorolac were renal function concerns (38% and 40% respectively), bleeding concerns with ketorolac (20%) and concerns for neurologic adverse effect with gabapentin (16%). CONCLUSION Compliance with non-narcotic medications in our ERAS cystectomy protocol was poor. There was a modest association with ketorolac and postoperative MME but no association with gabapentin or acetaminophen. Further study will clarify the role of these medications for cystectomy patients. Component specific analysis of protocolized care is valuable and may alter care pathways.
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Affiliation(s)
- Samuel J Ivan
- Department of Urology, Carolinas Medical Center, Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Emily H Roebuck
- Department of Urology, Carolinas Medical Center, Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Alexander L Sinks
- Department of Urology, Carolinas Medical Center, Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Myra M Robinson
- Department of Cancer Biostatistics, Carolinas Medical Center, Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Peter E Clark
- Department of Urology, Carolinas Medical Center, Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Kris E Gaston
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Justin T Matulay
- Department of Urology, Carolinas Medical Center, Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Stephen B Riggs
- Department of Urology, Carolinas Medical Center, Atrium Health, Levine Cancer Institute, Charlotte, NC.
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Siech C, Jannello LMI, de Angelis M, Di Bello F, Goyal JA, Tian Z, Saad F, Shariat SF, Longo N, de Cobelli O, Briganti A, Kosiba M, Mandel P, Kluth LA, Chun FKH, Karakiewicz PI. Critical care therapy use after radical cystectomy in patients with non-metastatic bladder cancer. Curr Probl Surg 2024; 61:101526. [PMID: 39098327 DOI: 10.1016/j.cpsurg.2024.101526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 08/06/2024]
Affiliation(s)
- Carolin Siech
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Goethe University Frankfurt, University Hospital, Department of Urology, Frankfurt am Main, Germany.
| | - Letizia Maria Ippolita Jannello
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy; Università degli Studi di Milano, Milan, Italy
| | - Mario de Angelis
- 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, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Di Bello
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada; Department of Neurosciences, Science of Reproduction and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Jordan A Goyal
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - 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
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, New York, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Nicola Longo
- Department of Neurosciences, Science of Reproduction and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Ottavio de Cobelli
- Department of Urology, IEO European Institute of Oncology, IRCCS, Milan, Italy; Università degli Studi di Milano, Milan, Italy; Department of Oncology and Haemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | - Alberto Briganti
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Marina Kosiba
- Goethe University Frankfurt, University Hospital, Department of Urology, Frankfurt am Main, Germany
| | - Philipp Mandel
- Goethe University Frankfurt, University Hospital, Department of Urology, Frankfurt am Main, Germany
| | - Luis A Kluth
- Goethe University Frankfurt, University Hospital, Department of Urology, Frankfurt am Main, Germany
| | - Felix K H Chun
- Goethe University Frankfurt, University Hospital, Department of Urology, 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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Pfail J, Capellan J, Passarelli R, Kaldany A, Chua K, Lichtbroun B, Srivastava A, Golombos D, Jang TL, Pitt HA, Packiam VT, Ghodoussipour S. National Surgical Quality Improvement Program audit of contemporary perioperative care for radical cystectomy. BJU Int 2024. [PMID: 39087422 DOI: 10.1111/bju.16492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
OBJECTIVE To examine the impact of increased compliance to contemporary perioperative care measures, as outlined by enhanced recover after surgery (ERAS) guidelines, among patients undergoing radical cystectomy (RC). PATIENTS AND METHODS From the National Surgical Quality Improvement Program database we captured patients undergoing RC between 2019 and 2021. We identified five perioperative care measures: regional anaesthesia block, thromboembolism prophylaxis, ≤24 h perioperative antibiotic administration, absence of bowel preparation, and early oral diet. We stratified patients by the number of measures utilised (one to five). Statistical endpoints included 30-day complications, hospital length of stay (LOS), readmissions, and optimal RC outcome. Optimal RC outcome was defined as absence of any postoperative complication, re-operation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable regressions with Bonferroni correction were performed to assess the association between use of contemporary perioperative care measures and outcomes. RESULTS Of the 3702 patients who underwent RC, 73 (2%), 417 (11%), 1010 (27%), 1454 (39%), and 748 (20%) received one, two, three, four, and five interventions, respectively. On multivariable analysis, increased perioperative care measures were associated with lower odds of any complication (odds ratio [OR] 0.66, 99% confidence interval [CI] 0.6-0.73), and shorter LOS (β -0.82, 99% CI -0.99 to -0.65). Furthermore, patients with increased compliance to contemporary care measures had increased odds of an optimal outcome (OR 1.38, 99% CI 1.26-1.51). CONCLUSIONS Among the measures we assessed, greater adherence yielded improved postoperative outcomes among patients undergoing RC. Our work supports the efficacy of ERAS protocols in reducing the morbidity associated with RC.
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Affiliation(s)
- John Pfail
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jasmin Capellan
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Rachel Passarelli
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alain Kaldany
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kevin Chua
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Benjamin Lichtbroun
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Arnav Srivastava
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - David Golombos
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Thomas L Jang
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Henry A Pitt
- Rutgers Cancer Institute, New Brunswick, NJ, USA
| | - Vignesh T Packiam
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Egen L, Wessels F, Quan A, Westhoff N, Kriegmair MC, Honeck P, Michel MS, Kowalewski KF. Maximizing efficiency and ensuring safety: Exploring the outcomes of 2 consecutive open radical cystectomies by the same team within a single surgical day. Urol Oncol 2024; 42:118.e1-118.e7. [PMID: 38246807 DOI: 10.1016/j.urolonc.2024.01.010] [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: 07/19/2023] [Revised: 12/28/2023] [Accepted: 01/07/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND The purpose of this study was to evaluate the outcomes of performing 2 consecutive open radical cystectomies (RCs) within 1 day by the same surgical team. PATIENTS AND METHODS A retrospective analysis was conducted on data from patients who underwent RC at a single tertiary care center from January 2015 to February 2023. Patient characteristics, perioperative outcomes and endpoints were analyzed. Univariable and multivariable logistic regression models were created to predict major complications. RESULTS A total of 657 patients were included in the final cohort, containing 64 paired RCs (32 RC1 and 32 RC2) and 593 single RCs. Major complications occurred in 24.7% of the entire cohort, with no significant differences between single RC vs. RC1 and RC2. Paired RCs showed significantly shorter operative time (OT; p = 0.001) and length of stay (LOS; p = 0.047) compared to single RCs. There were no significant differences in transfusion rates, 30-day readmission, 30-day mortality, or histopathological results between paired and single RCs. Multivariable analysis identified patient characteristics such as age (OR = 1.67, p = 0.03), sex (OR = 0.45, p = 0.008), BMI (OR = 1.98, p = 0.007), ASA-score (OR = 1.61, p = 0.04), and OT (OR = 1.87, p = 0.008) as independent predictors of major complications. CONCLUSION Performing 2 consecutive open RCs within 1 day by the same surgical team is a safe approach in experienced hands. This strategy optimizes the utilization of surgical resources and addresses the growing demand for urologic care while maintaining high-quality patient care. Preoperative planning should consider patient-specific factors to minimize risks associated with major complications. MICRO ABSTRACT This study evaluates the outcomes of performing 2 consecutive open radical cystectomies (RC) in a single day by the same surgical team. Data from 657 patients who underwent RC at a single tertiary medical center proved that this approach is safe, with no significant differences in major complications. Preoperative planning should consider patient-specific factors for efficient utilization of surgical resources.
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Affiliation(s)
- Luisa Egen
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany; German Cancer Research Center (DKFZ) Heidelberg, Division of Intelligent Systems and Robotics in Urology (ISRU), Heidelberg, Germany; DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany.
| | - Frederik Wessels
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany
| | - Allison Quan
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany
| | - Niklas Westhoff
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany
| | | | - Patrick Honeck
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany
| | | | - Karl-Friedrich Kowalewski
- Department of Urology, University Medical Center Mannheim, Mannheim, Germany; German Cancer Research Center (DKFZ) Heidelberg, Division of Intelligent Systems and Robotics in Urology (ISRU), Heidelberg, Germany; DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
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Zennami K, Kusaka M, Tomozawa S, Toda F, Ito K, Kawai A, Nakamura W, Muto Y, Saruta M, Motonaga T, Takahara K, Sumitomo M, Shiroki R. Impact of an enhanced recovery protocol in frail patients after intracorporeal urinary diversion. BJU Int 2024. [PMID: 38500447 DOI: 10.1111/bju.16340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
OBJECTIVE To determine whether an enhanced recovery after surgery (ERAS) protocol enhances bowel recovery and reduces postoperative ileus (POI) in both non-frail and frail patients after robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC). PATIENTS AND METHODS This retrospective cohort study included 186 patients (104 with and 82 without ERAS) who underwent iRARC between 2012 and 2023. 'Frail' patients was defined as those with a low Geriatric-8 questionnaire score (≤13). The primary outcomes were postoperative bowel recovery and the incidence of POI. Secondary outcomes included length of stay (LOS), 30- and 90-day complications, 90-day readmission rate, and POI predictors. RESULTS The ERAS group exhibited a significantly shorter LOS, early bowel recovery, a lower POI rate, fewer 90-day high-grade complications, and fewer 90-day readmissions than the non-ERAS group in the entire cohort. Non-frail patients in the ERAS group had a lower rate of POI (7.1% vs. 22.1%; P = 0.008), whereas ERAS did not reduce POI in frail patients (44.1% vs. 36.6%; P = 0.50). In the multivariate analysis, ERAS was associated with a reduced risk of POI in both the entire cohort (odds ratio [OR] 0.39, P = 0.01) and in non-frail patients (OR 0.24, P = 0.01), whereas ERAS was not likely to reduce POI (OR 1.14, P = 0.70) in frail patients. Prehabilitation was identified as a favourable predictor of POI. CONCLUSIONS The ERAS protocol did not reduce POI in frail patients after iRARC, although it enhanced bowel recovery and reduced POI in non-frail patients. Prehabilitation for frail patients might reduce POI.
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Affiliation(s)
- Kenji Zennami
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Mamoru Kusaka
- Department of Urology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Shuhei Tomozawa
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Fumi Toda
- Department of Rehabilitation Medicine I, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kazuki Ito
- Department of Rehabilitation, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Akihiro Kawai
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Wataru Nakamura
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoshinari Muto
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masanobu Saruta
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tomonari Motonaga
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kiyoshi Takahara
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Makoto Sumitomo
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Ryoichi Shiroki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
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Qin X, Li H, Long J, Feng C. A meta-analysis of the implementation of enhanced recovery after surgery pathways in anterior cervical spine surgery for degenerative cervical spine diseases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1283-1291. [PMID: 38212410 DOI: 10.1007/s00586-023-08105-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To systematically evaluate the perioperative effects of enhanced recovery after surgery (ERAS) protocol on anterior cervical spine surgery by means of meta-analysis. METHODS According to the PRISMA guidelines, the article's search on the China National Knowledge Infrastructure (CNKI), Wanfang data resource system, VIP, PubMed database and Cochrane library was conducted to identify clinical studies investigating the effects of ERAS protocols on anterior cervical spine surgery. A quantitative meta-analysis was performed for the clinical outcomes extracted from the studies that met inclusion criteria. RESULTS Of the 21 studies identified from the article search, 10 studies met inclusion criteria. The meta-analysis showed shorter length of stay (LOS) (MD = -2.16, 95% CI (-2.57, -1.75), P < 0.00001) and higher patient satisfaction for the ERAS protocols (OR = 3.13, 95% CI (1.97, 4.98), P < 0.00001). Furthermore, ERAS programs led to significant decreases in cost (MD = -0.81, 95% CI (-1.08, -0.53), P < 0.00001) and complication rates (OR = 0.15, 95% CI (0.08, 0.27), P < 0.00001), but no difference in 90-day readmission (OR = 0.63, 95% CI (0.30, 1.35), P = 0.24). CONCLUSIONS The data of this study suggest that the implementation of ERAS protocol decreases LOS, cost and complications rates and improve satisfaction for the patients undergoing anterior cervical spine surgery. To support the practice use of ERAS in anterior cervical spine surgery further, controlled trials will be indispensable.
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Affiliation(s)
- Xia Qin
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China
| | - Huaxi Li
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China
| | - Jiang Long
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China
| | - Chencheng Feng
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, 183 Xinqiao Main Street, Shapingba, Chongqing, 400037, People's Republic of China.
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Magableh HM, Ibrahim S, Pennington Z, Nathani KR, Johnson SE, Katsos K, Freedman BA, Bydon M. Transforming Outcomes of Spine Surgery-Exploring the Power of Enhanced Recovery After Surgery Protocol: A Systematic Review and Meta-Analyses of 15 198 Patients. Neurosurgery 2024:00006123-990000000-01058. [PMID: 38358272 DOI: 10.1227/neu.0000000000002865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/05/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Enhanced recovery after surgery (ERAS) protocols aim to optimize patient outcomes by reducing the surgical stress response, expediting recovery, and reducing care costs. We aimed to evaluate the impact of implementing ERAS protocols on the perioperative surgical outcomes and financial implications associated with spine surgeries. METHODS A systematic review and meta-analysis of peer-reviewed studies directly comparing outcome differences between spine surgeries performed with and without utilization of ERAS pathways was conducted along Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Of 676 unique articles identified, 59 with 15 198 aggregate patients (7748 ERAS; 7450 non-ERAS) were included. ERAS-treated patients had shorter operative times (mean difference [MD]: 10.2 mins; P < .01), shorter hospitalizations (MD: 1.41 days, P < .01), fewer perioperative complications (relative risk [RR] = 0.64, P < .01), lower postoperative opioid use (MD of morphine equivalent dose: 164.36 mg; P < .01), and more rapid mobilization/time to first out-of-bed ambulation (MD: 0.92 days; P < .01). Spine surgeries employing ERAS were also associated with lower total costs (MD: $1140.26/patient; P < .01), especially in the United States (MD: $2869.11/patient, P < .01) and lower postoperative visual analog pain scores (MD = 0.56, P < .01), without any change in odds of 30-day readmission (RR: 0.80, P = .13) or reoperation (RR: 0.88, P = .60). Subanalyses based on the region of spine showed significantly lower length of stay in both cervical and lumbar surgeries implementing ERAS. Type of procedure showed a significantly lesser time-to-initiate mobilization in fusion surgeries using ERAS protocols compared with decompression. CONCLUSION The present meta-analysis indicates that current literature supports ERAS implementation as a means of reducing care costs and safely accelerating hospital discharge for patients undergoing spine surgery.
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Affiliation(s)
- Hamzah M Magableh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Sufyan Ibrahim
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Karim Rizwan Nathani
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah E Johnson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Konstantinos Katsos
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brett A Freedman
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Sathianathen NJ, Pan HY, Furrer M, Thomas B, Dundee P, Corcoran N, Weight CJ, Konety B, Nair R, Lawrentschuk N. Comparison of Robotic vs Open Cystectomy: A Systematic Review. Bladder Cancer 2023; 9:253-269. [PMID: 38993188 PMCID: PMC11181804 DOI: 10.3233/blc-220065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/04/2023] [Indexed: 07/13/2024]
Abstract
BACKGROUND The benefits of a robot-assisted radical cystectomy (RARC) compared to an open approach is still under debate. Initial data on RARC were from trials where urinary diversion was performed by an extracorporeal approach, which does not represent a completely minimally invasive procedure. There are now updated data for RARC with intracorporeal urinary diversion that add to the evidence profile of RARC. OBJECTIVE To perform a systematic review and meta-analysis of the effectiveness of RARC compared with open radical cystectomy (ORC). MATERIALS AND METHODS Multiple databases were searched up to May 2022. We included randomised trials in which patients underwent RARC and ORC. Oncological and safety outcomes were assessed. RESULTS Seven trials of 907 participants were included. There were no differences seen in primary outcomes: disease progression [RR 0.98, 95% CI 0.78 to 1.23], major complications [RR 0.95, 95% CI 0.72 to 1.24] and quality of life [SMD 0.05, 95% CI -0.13 to 0.38]. RARC resulted in a decreased risk of perioperative blood transfusion [RR 0.57, 95% CI 0.43 to 0.76], wound complications [RR 0.34, 95% CI 0.21 to 0.55] and reduced length of hospital stay [MD -0.62 days, 95% CI -1.11 to -0.13]. However, there was an increased risk of developing a ureteric stricture [RR 4.21, 95% CI 1.07 to 16.53] in the RARC group and a prolonged operative time [MD 70.4 minutes, 95% CI 34.1 to 106.7]. The approach for urinary diversion did not impact outcomes. CONCLUSION RARC is an oncologically safe procedure compared to ORC and provides the benefits of a minimally invasive approach. There was an increased risk of developing a ureteric stricture in patients undergoing RARC that warrants further investigation. There was no difference in oncological outcomes between approaches.
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Affiliation(s)
- Niranjan J. Sathianathen
- Department of Surgery, University of Melbourne, Parkville, VIC, Australia
- Department of Urology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Henry Y.C. Pan
- Department of Urology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Marc Furrer
- Department of Urology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Urology, University of Bern, Inselspital, Bern, Switzerland
- Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Benjamin Thomas
- Department of Surgery, University of Melbourne, Parkville, VIC, Australia
- Department of Urology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Philip Dundee
- Department of Urology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Niall Corcoran
- Department of Surgery, University of Melbourne, Parkville, VIC, Australia
- Department of Urology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Urology, Western Health, Footscray, VIC, Australia
- Victorian Comprehensive Cancer Centre, Parkville, VIC, Australia
| | | | | | - Rajesh Nair
- Department of Urology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Nathan Lawrentschuk
- Department of Surgery, University of Melbourne, Parkville, VIC, Australia
- Department of Urology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Victorian Comprehensive Cancer Centre, Parkville, VIC, Australia
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Claps F, Pavan N, Ongaro L, Tierno D, Grassi G, Trombetta C, Tulone G, Simonato A, Bartoletti R, Mertens LS, van Rhijn BWG, Mir MC, Scaggiante B. BCG-Unresponsive Non-Muscle-Invasive Bladder Cancer: Current Treatment Landscape and Novel Emerging Molecular Targets. Int J Mol Sci 2023; 24:12596. [PMID: 37628785 PMCID: PMC10454200 DOI: 10.3390/ijms241612596] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/26/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Urothelial carcinoma (UC), the sixth most common cancer in Western countries, includes upper tract urothelial carcinoma (UTUC) and bladder carcinoma (BC) as the most common cancers among UCs (90-95%). BC is the most common cancer and can be a highly heterogeneous disease, including both non-muscle-invasive (NMIBC) and muscle-invasive (MIBC) forms with different oncologic outcomes. Approximately 80% of new BC diagnoses are classified as NMIBC after the initial transurethral resection of the bladder tumor (TURBt). In this setting, intravesical instillation of Bacillus Calmette-Guerin (BCG) is the current standard treatment for intermediate- and high-risk patients. Unfortunately, recurrence occurs in 30% to 40% of patients despite adequate BCG treatment. Radical cystectomy (RC) is currently considered the standard treatment for NMIBC that does not respond to BCG. However, RC is a complex surgical procedure with a recognized high perioperative morbidity that is dependent on the patient, disease behaviors, and surgical factors and is associated with a significant impact on quality of life. Therefore, there is an unmet clinical need for alternative bladder-preserving treatments for patients who desire a bladder-sparing approach or are too frail for major surgery. In this review, we aim to present the strategies in BCG-unresponsive NMIBC, focusing on novel molecular therapeutic targets.
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Affiliation(s)
- Francesco Claps
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.C.); (L.O.); (C.T.)
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (L.S.M.); (B.W.G.v.R.)
| | - Nicola Pavan
- Department of Surgical, Oncological, and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (N.P.); (G.T.); (A.S.)
| | - Luca Ongaro
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.C.); (L.O.); (C.T.)
| | - Domenico Tierno
- Department of Life Sciences, University of Trieste, 34127 Trieste, Italy;
| | - Gabriele Grassi
- Department of Medical, Surgery and Health Sciences, Hospital of Cattinara, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Carlo Trombetta
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.C.); (L.O.); (C.T.)
| | - Gabriele Tulone
- Department of Surgical, Oncological, and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (N.P.); (G.T.); (A.S.)
| | - Alchiede Simonato
- Department of Surgical, Oncological, and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (N.P.); (G.T.); (A.S.)
| | - Riccardo Bartoletti
- Department of Translational Research and New Technologies, University of Pisa, 56126 Pisa, Italy;
| | - Laura S. Mertens
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (L.S.M.); (B.W.G.v.R.)
| | - Bas W. G. van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (L.S.M.); (B.W.G.v.R.)
| | - Maria Carmen Mir
- Department of Urology, Hospital Universitario La Ribera, 46600 Valencia, Spain;
| | - Bruna Scaggiante
- Department of Life Sciences, University of Trieste, 34127 Trieste, Italy;
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10
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Zhou Y, Li R, Liu Z, Qi W, Lv G, Zhong M, Liu X, Zhu M, Jiang Z, Chen S, Shi B, Zhu Y. The effect of the enhanced recovery after surgery program on radical cystectomy: a meta-analysis and systematic review. Front Surg 2023; 10:1101098. [PMID: 37273829 PMCID: PMC10235530 DOI: 10.3389/fsurg.2023.1101098] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 04/20/2023] [Indexed: 06/06/2023] Open
Abstract
Background Bladder cancer is the ninth most common malignant tumor worldwide. As an effective evidence-based multidisciplinary protocol, the enhanced recovery after surgery (ERAS) program is practiced in many surgical disciplines. However, the function of ERAS after radical cystectomy remains controversial. This systematic review and meta-analysis aims to research the impact of ERAS on radical cystectomy. Methods A systematic literature search on PubMed, EMBASE, SCOPUS, and the Cochrane Library databases was conducted in April 2022 to identify the studies that performed the ERAS program in radical cystectomy. Studies were selected, data extraction was performed independently by two reviewers, and quality was assessed using a random effects model to calculate the overall effect size. The odds ratio and standardized mean difference (SMD) with a 95% confidence interval (CI) served as the summary statistics for the meta-analysis. A sensitivity analysis was subsequently performed. Results A total of 25 studies with 4,083 patients were enrolled. The meta-analysis showed that the complications (OR = 0.76; 95% CI: 0.63-0.90), transfusion rate (OR = 0.59; 95% CI: 0.39-0.90), readmission rate (OR = 0.79; 95% CI: 0.64-0.96), length of stay (SMD = -0.79; 95% CI: -1.41 to -0.17), and time to first flatus (SMD = -1.16; 95% CI: -1.58 to -0.74) were significantly reduced in the ERAS group. However, no significance was found in 90-day mortality and urine leakage. Conclusion The ERAS program for radical cystectomy can effectively decrease the risk of overall complications, postoperative ileus, readmission rate, transfusion rate, length of stay, and time to first flatus in patients who underwent radical cystectomy with relative safety. Systematic Review Registration https://inplasy.com/, identifier INPLASY202250075.
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Affiliation(s)
- Yongheng Zhou
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Rongyang Li
- Department of Thoracic Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Zhifeng Liu
- Department of Urology Surgery, Taian City Central Hospital, Taian, China
| | - Wenqiang Qi
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Guangda Lv
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Minglei Zhong
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Xigao Liu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Meikai Zhu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Zhiwen Jiang
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Shouzhen Chen
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Benkang Shi
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
| | - Yaofeng Zhu
- Department of Urology, Qilu Hospital of Shandong University, Jinan, China
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11
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Maibom SL, Joensen UN, Aasvang EK, Rohrsted M, Thind PO, Bagi P, Kistorp T, Poulsen AM, Salling LN, Kehlet H, Brasso K, Røder MA. Robot-assisted laparoscopic radical cystectomy with intracorporeal ileal conduit diversion versus open radical cystectomy with ileal conduit for bladder cancer in an ERAS setup (BORARC): protocol for a single-centre, double-blinded, randomised feasibility study. Pilot Feasibility Stud 2023; 9:7. [PMID: 36639814 PMCID: PMC9838067 DOI: 10.1186/s40814-022-01229-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/16/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Radical cystectomy (RC) with urinary diversion is the recommended treatment for selected cases of non-metastatic high-risk non-muscle-invasive and muscle-invasive bladder cancer. It remains unknown whether robot-assisted laparoscopic cystectomy (RARC) offers any advantage in terms of safety compared to open cystectomy (ORC) in an Enhanced Recovery After Surgery (ERAS) setup. Blinded randomised controlled trials (RCTs) between RARC versus ORC have never been conducted in cystectomy patients. We will investigate the feasibility of conducting a double-blinded RCT comparing ORC with RARC with intra-corporal ileal conduit (iRARC) in an ERAS setup. METHODS This is a single-centre, double-blinded, randomised (1:1) clinical feasibility study for patients with non-metastatic high-risk non-muscle-invasive or muscle-invasive bladder cancer scheduled for cystectomy. All participants are recruited from Rigshospitalet, Denmark. The planned sample size is 50 participants to investigate whether blinding of the surgical technique is feasible. Participants and postoperative caring physicians and nurses are blinded using a pre-study designed abdominal dressing and blinding of the patient's electronic health record. Study endpoints are assessed 90 days postoperatively. The primary aim is to study the frequency and pattern of unplanned unblinding after surgery and the number of participants who cannot guess the surgical technique at the day of discharge. Eleven secondary endpoints are assessed: length of stay, days alive and out of hospital, in-hospital complication rate, 30-day complication rate, 90-day complication rate, readmission rate, quality of life, blood loss, pain, rate of moderate/severe post-anaesthesia care unit (PACU) complications, and delirium. Participants are managed in an ERAS setup in both arms of the trial. DISCUSSION We report on the design and objectives of a novel experimental feasibility study investigating whether blinding of the surgical technique in cystectomy patients is possible. This information is essential for the design of future blinded trials comparing ORC to RARC. There is a continued need to compare RARC and ORC in terms of both efficacy, safety, and oncological outcomes. Estimated end of study is March 2021. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03977831. Registered on the 6th of June 2019.
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Affiliation(s)
- Sophia Liff Maibom
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Ulla Nordström Joensen
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Eske Kvanner Aasvang
- grid.5254.60000 0001 0674 042XDepartment of Anaesthesiology, Centre for Cancer and Organ Diseases, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Malene Rohrsted
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Peter Ole Thind
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Per Bagi
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Kistorp
- grid.5254.60000 0001 0674 042XDepartment of Anaesthesiology, Centre for Cancer and Organ Diseases, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Alicia Martin Poulsen
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Lisbeth Nerstrøm Salling
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- grid.5254.60000 0001 0674 042XSection of Surgical Pathophysiology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Martin Andreas Røder
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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12
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Claps F, Mir MC, van Rhijn BWG, Mazzon G, Soria F, D'Andrea D, Marra G, Boltri M, Traunero F, Massanova M, Liguori G, Dominguez-Escrig JL, Celia A, Gontero P, Shariat SF, Trombetta C, Pavan N. Impact of the controlling nutritional status (CONUT) score on perioperative morbidity and oncological outcomes in patients with bladder cancer treated with radical cystectomy. Urol Oncol 2023; 41:49.e13-49.e22. [PMID: 36274030 DOI: 10.1016/j.urolonc.2022.09.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/04/2022] [Accepted: 09/22/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION AND OBJECTIVES To evaluate the impact of the Controlling Nutritional Status (CONUT) score on perioperative morbidity and oncological outcomes of bladder cancer (BC) patients treated with radical cystectomy (RC). MATERIALS AND METHODS We retrospectively analyzed a multi-institutional cohort of 347 patients treated with RC for clinical-localized BC between 2005 and 2019. The CONUT-score was defined as an algorithm including serum albumin, total lymphocyte count, and cholesterol. Multivariable logistic regression analyses were performed to evaluate the ability of the CONUT-score to predict any-grade complications, major complications and 30 days readmission. Multivariable Cox' regression models were performed to evaluate the prognostic effect of the CONUT-score on recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS). RESULTS A cut-off value to discriminate between low and high CONUT-score was determined by calculating the receiver operating characteristic (ROC) curve. The area under the curve was 0.72 hence high CONUT-score was defined as ≥3 points. Overall, 112 (32.3%) patients had a high CONUT. At multivariable logistic regression analyses, high CONUT was associated with any-grade complications (OR 3.58, P = 0.001), major complications (OR 2.56, P = 0.003) and 30 days readmission (OR 2.39, P = 0.01). On multivariable Cox' regression analyses, high CONUT remained associated with worse RFS (HR 2.57, P < 0.001), OS (HR 2.37, P < 0.001) and CSS (HR 3.52, P < 0.001). CONCLUSIONS Poor nutritional status measured by the CONUT-score is independently associated with a poorer postoperative course after RC and is predictive of worse RFS, OS, and CSS. This simple index could serve as a comprehensive personalized risk-stratification tool identifying patients who may benefit from an intensified regimen of supportive cares.
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Affiliation(s)
- Francesco Claps
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy; Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Fundacion Instituto Valenciano de Oncologia, Valencia, Spain.
| | - Maria Carmen Mir
- Department of Urology, Fundacion Instituto Valenciano de Oncologia, Valencia, Spain
| | - Bas W G van Rhijn
- Department of Urology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Giorgio Mazzon
- Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy
| | - Francesco Soria
- Department of Urology, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Surgical Sciences, University of Torino School of Medicine, Turin, Italy
| | - David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Giancarlo Marra
- Division of Urology, Department of Surgical Sciences, University of Torino School of Medicine, Turin, Italy
| | - Matteo Boltri
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Fabio Traunero
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Matteo Massanova
- Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy
| | - Giovanni Liguori
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Antonio Celia
- Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, University of Torino School of Medicine, Turin, Italy
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, University of Texas Southwestern Medical center, Dallas, TX; Department of Urology, Weill Cornell Medical College, New York, NY; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Carlo Trombetta
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Nicola Pavan
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
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13
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Stangl-Kremser J, Lambertini L, Di Maida F, Martinez-Fundichely A, Ferro M, Pradere B, Soria F, Albisinni S, Wu Z, Del Giudice F, Cacciamani GE, Valerio M, Briganti A, Rouprêt M, Shariat SF, Lee C, Minervini A, Moschini M, Mari A. Enhancing Recovery After Major Bladder Cancer Surgery: Comprehensive Review and Assessment of Application of the Enhanced Recovery After Surgery Guidelines. Eur Urol Focus 2022; 8:1622-1626. [PMID: 35773181 DOI: 10.1016/j.euf.2022.06.004] [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: 04/10/2022] [Revised: 06/03/2022] [Accepted: 06/10/2022] [Indexed: 01/25/2023]
Abstract
Radical cystectomy with pelvic lymphadenectomy and urinary diversion is the standard treatment for patients diagnosed with localized muscle-invasive bladder cancer. Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway comprising recommendations on different items with variable evidence that are aimed at improving outcomes. This review provides an overview of the application of specific elements of the ERAS guidelines. Forty-eight series were identified through our literature search. The studies reported a median of 16 out of the 22 ERAS steps (72.7%). The elements were applied in 79.3% of cases (interquartile range 61.1-85%) if mentioned in the studies, decreasing to 73.5% in the postoperative period. PATIENT SUMMARY: Guidelines on enhanced recovery after surgery recommend steps to follow and cover all areas of the patient's journey through the surgical process. We looked at the application of the elements for patients with bladder cancer. We found inconsistent reporting and use.
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Affiliation(s)
| | - Luca Lambertini
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Fabrizio Di Maida
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Alexander Martinez-Fundichely
- Department of Physiology and Biophysics, Weill Cornell Medicine, New York, NY 10065, USA; Institute for Computational Biomedicine, Weill Cornell Medicine, New York, NY 10021, USA; Meyer Cancer Center, Weill Cornell Medicine, New York, NY 10065, USA
| | - Matteo Ferro
- Division of Urology, European Institute of Oncology, Milan, Italy
| | | | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Simone Albisinni
- Department of Urology, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium; Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Zhenjie Wu
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Francesco Del Giudice
- Department of Maternal-Infant and Urological Sciences, Sapienza, Rome University, Policlinico Umberto I Hospital, Rome, Italy
| | - Giovanni E Cacciamani
- USC Institute of Urology and Catherine & Joseph Aresty, Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Massimo Valerio
- Department of Urology, University Hospital of Lausanne, Switzerland
| | - Alberto Briganti
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Morgan Rouprêt
- Urology, Predictive Onco-Urology, AP-HP, Urology Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, University of Vienna, Vienna, Austria; Department of Physiology and Biophysics, Weill Cornell Medicine, New York, NY 10065, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; European Association of Urology Research Foundation, Arnhem, The Netherlands
| | - Cheryl Lee
- Department of Urology, The Ohio State University, Columbus, OH, USA
| | - Andrea Minervini
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - Marco Moschini
- Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Mari
- Oncologic Minimally Invasive Urology and Andrology Unit, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy.
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14
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Fasanella D, Marchioni M, Domanico L, Franzini C, Inferrera A, Schips L, Greco F. Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081193. [PMID: 36013372 PMCID: PMC9409805 DOI: 10.3390/life12081193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022]
Abstract
Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).
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Affiliation(s)
- Daniela Fasanella
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, SS Annunziata Hospital, 66100 Chieti, Italy
| | - Michele Marchioni
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, SS Annunziata Hospital, 66100 Chieti, Italy
| | - Luigi Domanico
- Urology Unit, Centro Salute Uomo, Via Palma il Vecchio 4a, 24122 Bergamo, Italy
| | - Claudia Franzini
- Urology Unit, Centro Salute Uomo, Via Palma il Vecchio 4a, 24122 Bergamo, Italy
| | - Antonino Inferrera
- Urology Unit, Centro Salute Uomo, Via Palma il Vecchio 4a, 24122 Bergamo, Italy
| | - Luigi Schips
- Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. d’Annunzio University of Chieti, SS Annunziata Hospital, 66100 Chieti, Italy
| | - Francesco Greco
- Urology Unit, Centro Salute Uomo, Via Palma il Vecchio 4a, 24122 Bergamo, Italy
- Correspondence: ; Tel.: +39-3317918535
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15
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Machine learning decision support model for radical cystectomy discharge planning. Urol Oncol 2022; 40:453.e9-453.e18. [PMID: 35750561 DOI: 10.1016/j.urolonc.2022.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/05/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE Timely and appropriate discharge placement for patients who have undergone radical cystectomy (RC) remains challenging. Our objective was to improve the discharge planning process by creating a machine learning model that helps to predict the need for non-home hospital discharge to a higher level of care. MATERIALS AND METHODS Patients undergoing elective radical cystectomy for bladder cancer from 2014-2019 were identified in the ACS-NSQIP database. A gradient boosted decision tree was trained on selected predischarge variables to predict discharge location, dichotomized into home and non-home. We used threshold-moving to calibrate model predictions and evaluated model performance on a testing set using receiver operating characteristic and precision recall curves. Model performance was further examined in subgroups of interest. RESULTS AND CONCLUSIONS A total of 11,881 patients met inclusion criteria with a mean age of 68.6 years. 10.6% of patients undergoing RC had non-home discharges. Our model predicting non-home discharge achieved an area under the receiver operating characteristic curve of 0.80 and an average precision of 0.33. After threshold-moving, our model had a recall of 0.757 and a precision of 0.211. Top variables by importance were septic shock occurrence, ventilator-use greater than 48 hours, organ space surgical site infection and unplanned intubation. Our model shows strong performance in identifying patients who required non-home discharge to higher levels of care, outperforming commonly used clinical indices and prior work. Modern machine learning techniques may be applied to support more timely and appropriate clinical decision making.
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16
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Ahmadi H, Daneshmand S. Association between use of ERAS protocols and complications after radical cystectomy. World J Urol 2022; 40:1311-1316. [PMID: 35568722 DOI: 10.1007/s00345-022-04023-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/21/2022] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Implementation of enhanced recovery protocols in cystectomy patients has significantly changed the perioperative course of this major operation. This paper summarizes evidence based interventions to enhance the postoperative course of radical cystectomy. METHODS A comprehensive search of PubMed and Embase databases was performed and also the results of our institutional enhanced recovery protocol were discussed. RESULTS One of the major advantages of such changes is the reduced rate of postoperative gastrointestinal (GI) complications especially postoperative ileus which could be contributed to several components of these protocols. However, Alvimopan is the only component which its use is supported by level I evidence. Although there are some evidence suggesting the decreased rate of urinary tract infection with the use of prophylactic antibiotics and wound complications by the use of negative wound pressure devices, their clear benefit is yet to be shown. Although robotic approach has proven advantages in intraoperative blood loss and postoperative blood transfusion rate, surgical team's experience and dedicated infrastructure seem to be more influential in optimized outcome than just the surgical approach. CONCLUSION current evidence suggests that such protocols have not only reached the goal of maintaining complication rate while decreasing length of hospital stay, but it might have caused a decrease in the rate of low-grade complications, especially GI complications.
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Affiliation(s)
- Hamed Ahmadi
- USC/Norris Comprehensive Cancer Center, USC Institute of Urology, 1441 Eastlake Ave, Suite 7416, Los Angeles, CA, 90089, USA.,Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Siamak Daneshmand
- USC/Norris Comprehensive Cancer Center, USC Institute of Urology, 1441 Eastlake Ave, Suite 7416, Los Angeles, CA, 90089, USA.
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17
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Shepherd ARH, Bunjo Z, Sutherland P, Fuller A. Robotic-assisted radical cystectomy with intracorporeal urinary diversion: Initial South Australian experience. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/20514158221084828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim: The aim of this study was to describe the initial experience with robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) performed by two robotic surgeons at a single, Australian centre. Methods: Retrospective analysis was conducted on 30 consecutive patients who underwent RARC with ICUD with curative intent for muscle-invasive and high-risk non-muscle-invasive bladder cancer between 2017 and 2021. Variables analysed included patient baseline characteristics, operative and peri-operative outcomes, as well as short-term pathological outcomes. Results: A total 30 patients were included; 87% were male and the median age was 71 years. Half of patients had muscle-invasive bladder cancer and 93% had ileal conduit formation (with the remaining two patients undergoing neobladder formation). The median operating time was 247 minutes. The median estimated blood loss was 450 mL and 20% of patients received a blood transfusion. A high-grade complication (Clavien III–V) was encountered in 13% of patients post-operatively. At 90 days, 30 overall complications (Clavien I–V) occurred across 67% of the patients. Conclusion: This series provides further support for the safe introduction of RARC with ICUD in Australia. Further studies with extended duration of follow-up, including oncological outcomes, are required to support widespread adoption of RARC. Level of evidence: Level 4 (case series)
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Affiliation(s)
- Andrew RH Shepherd
- Department of Urology, Royal Adelaide Hospital, Australia
- Adelaide Medical School, The University of Adelaide, Australia
| | - Zachary Bunjo
- Department of Urology, Royal Adelaide Hospital, Australia
- Adelaide Medical School, The University of Adelaide, Australia
| | | | - Andrew Fuller
- Department of Urology, Royal Adelaide Hospital, Australia
- South Terrace Urology, Australia
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18
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Bello C, Luedi MM. High time for a holistic approach to perioperative care in urological surgery. World J Urol 2022; 40:1061-1062. [PMID: 33837449 DOI: 10.1007/s00345-021-03677-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
- Corina Bello
- Department of Anesthesiology, Spitalregion Rheintal, Werdenberg, Sarganserland, Spitalstrasse 44, 9472, Grabs, Switzerland.
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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19
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Atkins CS, Tubog TD, Schaffer SK. Chewing Gum After Radical Cystectomy With Urinary Diversion for Recovery of Intestinal Function: A Systematic Review and Meta-Analysis. J Perianesth Nurs 2022; 37:467-473. [PMID: 35272926 DOI: 10.1016/j.jopan.2021.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/24/2021] [Accepted: 10/09/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE To evaluate the efficacy of chewing in the recovery of intestinal function after radical cystectomy. DESIGN Systematic review and meta-analysis. METHODS Following the PRISMA statement, PubMed, CINAHL, Google Scholar, Cochrane Review Database, EMBASE, Scopus, and grey literature were searched for evidence. FINDINGS The analysis included 2 trials with 100 patients. Compared to placebo, chewing gum resulted in faster recovery of bowel function (mean difference [MD], -16.00; 95% confidence interval [CI], -18.67 to -13.32; P < .00001). In addition, chewing gum decreased the time to flatus (MD, -14.81; 95% CI, -22.14 to -7.47; P < .0001), but did not reduced the length of stay (MD, 0.97; 95% CI, -1.23 to 3.18; P = .39) and the incidence of postoperative ileus (risk ratio, 0.67; 95% CI, 0.20-2.23; P = .51). The quality of evidence is low due to imprecision and suspected publication bias. CONCLUSIONS Chewing gum appears to be an inexpensive intervention to improve the return of bowel function in patients undergoing radical cystectomy.
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20
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Zennami K, Sumitomo M, Hasegawa K, Kozako M, Takahara K, Nukaya T, Takenaka M, Fukaya K, Ichino M, Fukami N, Sasaki H, Kusaka M, Shiroki R. Risk factors for postoperative ileus after robot-assisted radical cystectomy with intracorporeal urinary diversion. Int J Urol 2022; 29:553-558. [PMID: 35229914 DOI: 10.1111/iju.14839] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 02/14/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the risk factors for postoperative ileus in patients who underwent robot-assisted radical cystectomy with intracorporeal urinary diversion. METHODS We retrospectively analyzed 78 patients with bladder cancer who underwent robot-assisted radical cystectomy with intracorporeal urinary diversion at Fujita Health University between 2011 and 2021. Baseline characteristics and perioperative outcomes were compared between the cohorts with and without ileus. Logistic regression analysis was used to identify the risk factors for postoperative ileus. RESULTS Out of the 78 patients included in this study, 20 (25.6%) developed postoperative ileus. The ileus cohort was associated with a significantly lower Geriatric-8 score (P = 0.003) and a higher rate of previous abdominal/pelvic surgery (P = 0.04) compared with those of the nonileus cohort. Significantly longer intestinal tract reconstruction time, hospital stay, time to mobilization, fluid intake, solid intake, flatus, and stool were observed in the ileus cohort. According to the results of the logistic regression analysis, the Geriatric-8 sum (P = 0.009), time to mobilization (P = 0.03), and time to fluid intake (P = 0.004) were independent predictors of postoperative ileus. In the model predicting postoperative ileus, the area under the receiver operating characteristic curve was 0.716, and the cutoff value of the Geriatric-8 sum was 13. CONCLUSIONS Early mobilization and fluid intake and low Geriatric-8 scores were significant risk factors for postoperative ileus. Preoperative Geriatric-8 evaluation is a useful tool for predicting postoperative ileus. Comprehensive enhanced recovery after surgery, including key components, may help bowel recovery and prevent subsequent ileus.
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Affiliation(s)
- Kenji Zennami
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Makoto Sumitomo
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kyu Hasegawa
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masaki Kozako
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kiyoshi Takahara
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takuhisa Nukaya
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masashi Takenaka
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kosuke Fukaya
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Manabu Ichino
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Naohiko Fukami
- Department of Urology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Hitomi Sasaki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Mamoru Kusaka
- Department of Urology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Ryoichi Shiroki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
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21
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Alam SM, Michel C, Robertson H, Camargo JT, Linares B, Holzbeierlein J, Hamilton-Reeves JM. Optimizing Nutritional Status in Patients Undergoing Radical Cystectomy: A Systematic Scoping Review. Bladder Cancer 2021; 7:449-461. [PMID: 34993293 PMCID: PMC8730471 DOI: 10.3233/blc-200428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 06/20/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Nutrition is a modifiable risk factor for patients undergoing multimodal oncologic interventions and plays a major supportive role in the setting of bladder cancer. For patients undergoing radical cystectomy (RC), malnutrition is associated with increased postoperative complications and mortality. OBJECTIVES The purpose of this scoping review is to characterize the role of nutritional interventions for patients undergoing RC for bladder cancer. METHODS A multi-database systematic scoping review based on the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR) guidelines was performed. Search terms were developed a priori to identify clinical trials that focused on nutritional interventions for patients with bladder cancer undergoing RC. Eligible articles were original research articles or abstracts from clinical trials evaluating nutritional interventions in adult patients undergoing RC. Articles were excluded if they did not focus on a nutritional intervention, if patients did not carry a diagnosis of bladder cancer, or if RC was not performed. Articles were reviewed independently by the authors, and inclusion/exclusion were based on consensus agreement. RESULTS A total of 83 articles were identified, of which 17 were included in the final analysis. A total of 49 articles were excluded during abstract screening. An additional 17 articles were excluded based on the review of full-text articles. Results of the scoping review suggest that data on the use of nutritional screening, assessment, and intervention for patients undergoing RC are scarce. Although parenteral nutrition (PN) appears to be associated with greater complications after RC, early introduction of food postoperatively or feeding enterally offers benefit and immunonutrition supplements with a focus on a high protein diet has the potential to better optimize surgical outcomes. CONCLUSIONS Although the prevalence and consequences of malnutrition among patients undergoing RC are well-established, there are limited data evaluating the use of nutritional screening, assessment, and interventions for this population. The pursuit of future clinical trials in this space is critical.
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Affiliation(s)
- Syed M. Alam
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Carrie Michel
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Hilary Robertson
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Juliana T. Camargo
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, KS, USA
| | - Brenda Linares
- Department of Research and Learning, Dykes Library, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Jill M. Hamilton-Reeves
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, KS, USA
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22
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Maibom SL, Røder MA, Aasvang EK, Rohrsted M, Thind PO, Bagi P, Kistorp T, Poulsen AM, Salling LN, Kehlet H, Brasso K, Joensen UN. Open vs robot-assisted radical cystectomy (BORARC): a double-blinded, randomised feasibility study. BJU Int 2021; 130:102-113. [PMID: 34657367 DOI: 10.1111/bju.15619] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine surgical outcomes and feasibility of blinding patients and care providers to the surgical technique of radical cystectomy (RC). PATIENTS AND METHODS Single-centre, parallel-group, double-blinded, randomised feasibility study of open RC (ORC) vs robot-assisted RC with intracorporeal urinary diversion (iRARC) in an 'Enhanced Recovery After Surgery' setup. A total of 50 patients aged ≥18 years with bladder cancer planned for RC with an ileal conduit were included. Patients with previous major abdominal/pelvic surgery, pelvic radiation or anaesthesiological contraindications were excluded. Primary outcomes were proportion of unblinded patients and success of blinding using Bang's Blinding Index. Secondary outcomes included length of stay (LOS), complication rates, blood loss, pain, and opioid consumption. RESULTS A total of 26% of the patients were unblinded before discharge. We demonstrated that patients and doctors remained blinded for the allocated treatment, but nurses did not. Blood loss was greater in the ORC group as was operative time in the iRARC group. We found no difference in complication rate, LOS, or use of analgesics. CONCLUSIONS The present study demonstrates that blinding of surgical technique in RC is possible. The results of secondary outcomes are consistent with the findings of previous unblinded randomised controlled trials. Our study highlights that it is possible to perform a blinded phase III study to explore the optimal surgical technique in RC.
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Affiliation(s)
- Sophia L Maibom
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Martin A Røder
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Eske K Aasvang
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Malene Rohrsted
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peter O Thind
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Per Bagi
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Thomas Kistorp
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Alicia M Poulsen
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lisbeth N Salling
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Section for Surgical Pathophysiology, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ulla N Joensen
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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23
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[Early cystectomy-patient selection and technique]. Urologe A 2021; 60:1424-1431. [PMID: 34652475 DOI: 10.1007/s00120-021-01682-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
Early radical cystectomy (RC) is a therapeutic option for non-muscle invasive bladder cancer (NMIBC). The 15-year overall survival after early RC in NMIBC patients is about 70%. Nevertheless, RC is associated with significant morbidity and mortality and therefore requires careful patient selection. The aim of the following review is to assess the selection process for early RC in NMIBC. Especially, the new European Association of Urology (EAU) risk calculator identifying NMIBC patients with very high risk for disease progression is described in detail. Furthermore, the technical aspects of the procedure are evaluated. A review of the current literature (PubMed) and national and international guideline recommendations was also conducted.
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24
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Clinical indications for necessary and discretionary hospital readmissions after radical cystectomy. Urol Oncol 2021; 40:164.e1-164.e7. [PMID: 34629281 DOI: 10.1016/j.urolonc.2021.09.001] [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: 05/30/2021] [Revised: 08/29/2021] [Accepted: 09/07/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND To assess predictors, indicators and medical necessity of readmissions after neoadjuvant chemotherapy and radical cystectomy in order to identify opportunities for reducing readmission rates. METHODS Records for patients treated with cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy between 2007 and 2017 were reviewed for 90-day complications and readmission. Readmissions were classified as necessary vs. discretionary based on independent clinician review. The association between postoperative complications and necessary or discretionary readmission were examined with adjusted regression models. RESULTS Among a total of 250 patients, 76 patients (30.4%) were readmitted within 90 days of surgery (19 discretionary and 57 necessary). Age, insurance coverage, and comorbidity were similar between readmitted and non-readmitted patients. Readmission was more likely after neobladder than ileal conduit (39% vs. 23%, P = 0.02). Major (grade ≥ 3) complications within 90-day of surgery including index admission and post-discharge period were significantly more common among re-admitted patients compared to patients who were not readmitted (40% in necessary, 21% in discretionary, 3% in none, P < 0.001). Median length of stay on readmission was twice as long in necessary cases compared to discretionary cases (5 vs. 2.5 days, P < 0.001). Gastrointestinal and infectious complications were associated with discretionary readmission in adjusted analyses, while infectious, renal/genitourinary and thromboembolic complications were associated with necessary readmission. CONCLUSIONS Twenty-five percent of readmissions were categorized as discretionary and were driven primarily by low-grade gastrointestinal complications, marginal oral intake and failure to thrive, suggesting that better coordinated post-discharge supportive care could help avoid a substantial proportion of readmissions.
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25
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Martin L, Gillis C, Ljungqvist O. Preoperative nutrition care in Enhanced Recovery After Surgery programs: are we missing an opportunity? Curr Opin Clin Nutr Metab Care 2021; 24:453-463. [PMID: 34155154 DOI: 10.1097/mco.0000000000000779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW A key component of Enhanced Recovery After Surgery (ERAS) is the integration of nutrition care elements into the surgical pathway, recognizing that preoperative nutrition status affects outcomes of surgery and must be optimized for recovery. We reviewed the preoperative nutrition care recommendations included in ERAS Society guidelines for adults undergoing major surgery and their implementation. RECENT FINDINGS All ERAS Society guidelines reviewed recommend preoperative patient education to describe the procedures and expectations of surgery; however, only one guideline specifies inclusion of routine nutrition education before surgery. All guidelines included a recommendation for at least one of the following nutrition care elements: nutrition risk screening, nutrition assessment, and nutrition intervention. However, the impact of preoperative nutrition care could not be evaluated because it was rarely reported in recent literature for most surgical disciplines. A small number of studies reported on the preoperative nutrition care elements within their ERAS programs and found a positive impact of ERAS implementation on nutrition care practices, including increased rates of nutrition risk screening. SUMMARY There is an opportunity to improve the reporting of preoperative nutrition care elements within ERAS programs, which will enhance our understanding of how nutrition care elements influence patient outcomes and experiences.
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Affiliation(s)
- Lisa Martin
- Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Chelsia Gillis
- Department of Anesthesia, McGill University Health Center, Québec, Canada
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
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26
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Current application of the enhanced recovery after surgery protocol for patients undergoing radical cystectomy: lessons learned from European excellence centers. World J Urol 2021; 40:1317-1323. [PMID: 34076754 DOI: 10.1007/s00345-021-03746-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE There is no consensus on which items of Enhanced Recovery After Surgery (ERAS) should and should not be implemented in radical cystectomy (RC). The aim of this study is to report current practices across European high-volume RC centers involved in ERAS. METHODS Based on the recommendations of the ERAS society, we developed a survey with 17 questions that were validated by the Young Academic Urologists-urothelial group. The survey was distributed to European expert centers that implement ERAS for RC. Only one answer per-center was allowed to keep a representative overview of the different centers. RESULTS 70 surgeons fulfilled the eligibility criteria. Of note, 28.6% of surgeons do not work with a referent anesthesiologist and 25% have not yet assessed the implementation of ERAS in their center. Avoiding bowel preparation, thromboprophylaxis, and removal of the nasogastric tube were widely implemented (> 90%application). On the other hand, preoperative carbohydrate loading, opioid-sparing anesthesia, and audits were less likely to be applied. Common barriers to ERAS implementation were difficulty in changing habits (55%), followed by a lack of communication across surgeons and anesthesiologist (33%). Responders found that performing a regular audit (14%), opioid-sparing anesthesia (14%) and early mobilization (13%) were the most difficult items to implement. CONCLUSION In this survey, we identified the ERAS items most and less commonly applied. Collaboration with anesthesiologists as well as regular audits remain a challenge for ERAS implementation. These results support the need to uniform ERAS for RC patients and develop strategies to help departments implement ERAS.
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27
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MacGregor CA, Neerhof M, Sperling MJ, Alspach D, Plunkett BA, Choi A, Blumenthal R. Post-Cesarean Opioid Use after Implementation of Enhanced Recovery after Surgery Protocol. Am J Perinatol 2021; 38:637-642. [PMID: 33264809 DOI: 10.1055/s-0040-1721075] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study aimed to evaluate whether implementation of an enhanced recovery after surgery (ERAS) protocol is associated with lower maternal opioid use after cesarean delivery (CD). STUDY DESIGN We performed a pre- and postimplementation (PRE and POST, respectively) study of an ERAS protocol for cesarean deliveries. ERAS is a multimodal, multidisciplinary perioperative approach. The four pillars of our protocol include education, pain management, nutrition, and early ambulation. Patients were counseled by their outpatient providers and given an educational booklet. Pain management included gabapentin and acetaminophen immediately prior to spinal anesthesia. Postoperatively patients received scheduled acetaminophen and ibuprofen. Oxycodone was initiated as needed 24 hours after spinal analgesia. Preoperative diet consisted of clear carbohydrate drink consumed 2 hours prior to scheduled operative time with advancement as tolerated immediately postoperation. Women with a body mass index (BMI) <40 kg/m2 and scheduled CD were eligible for ERAS. PRE patients were randomly selected from repeat cesarean deliveries (RCDs) at a single site from October 2017 to September 2018, BMI <40 kg/m2, without trial of labor. The POST cohort included women who participated in ERAS from October 2018 to June 2019. PRE and POST demographic and clinical characteristics were compared. Primary outcome was total postoperative morphine milligram equivalents (MMEs). Secondary outcomes included length of stay (LOS) and maximum postoperative day 2 (POD2) pain score. RESULTS All women in PRE (n = 70) had RCD compared with 66.2% (49/74) in POST. Median total postoperative MMEs were 140.0 (interquartile range [IQR]: 87.5-182.5) in PRE compared with 0.0 (IQR: 0.0-72.5) in POST (p < 0.001). Median LOS in PRE was 4.02 days (IQR: 3.26-4.27) compared with 2.37 days (IQR: 2.21-3.26) in POST (p < 0.001). Mean maximum POD2 pain score was 5.28 (standard deviation [SD] = 1.86) in PRE compared with 4.67 (SD = 1.63) in POST (p = 0.04). CONCLUSION ERAS protocol was associated with decreased postoperative opioid use, shorter LOS, and decreased pain after CD. KEY POINTS · ERAS protocol was associated with decreased postoperative opioid use after CD.. · ERAS protocol was associated with shorter length of stay after CD.. · ERAS protocol was associated with decreased postoperative pain after CD..
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Affiliation(s)
- Caitlin A MacGregor
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois.,Department of Obstetrics and Gynecology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Mark Neerhof
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois
| | - Mary J Sperling
- Care Transformation, NorthShore University HealthSystem, Evanston, Illinois
| | - David Alspach
- Department of Anesthesiology, NorthShore University HealthSystem, Evanston, Illinois
| | - Beth A Plunkett
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois
| | - Alexandria Choi
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois
| | - Rebecca Blumenthal
- Department of Anesthesiology, NorthShore University HealthSystem, Evanston, Illinois
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28
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Maibom SL, Røder MA, Poulsen AM, Thind PO, Salling ML, Salling LN, Kehlet H, Brasso K, Joensen UN. Morbidity and Days Alive and Out of Hospital Within 90 Days Following Radical Cystectomy for Bladder Cancer. EUR UROL SUPPL 2021; 28:1-8. [PMID: 34337519 PMCID: PMC8317890 DOI: 10.1016/j.euros.2021.03.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 11/26/2022] Open
Abstract
Background Morbidity after radical cystectomy (RC) is usually quantified in terms of rates of complications, mortality, reoperations, and readmissions, and length of stay (LOS). The overall burden following RC within the first 90 d following RC may be better described using days alive and out of hospital (DAOH), which is a validated, patient-centred proxy for both morbidity and mortality. Objective To report short-term morbidity, LOS, and DAOH within 90 d after RC and risk factors associated with these parameters. Design setting and participants The study included 729 patients undergoing RC for bladder cancer at a single academic centre from 2009 to 2019. Data were retrieved from national electronic medical charts. Outcome measurements and statistical analysis Multivariate analysis was used to investigate variables associated with a major complication, LOS >7 d, and DAOH <80 d. Results and limitations The 90-d complication rate was 80%, including major complications in 37% of cases. Median LOS was 7 d (interquartile range (IQR) 6-9) and median DAOH was 80 d (IQR 71-83) days. Body mass index and the Charlson comorbidity index (CCI) predicted major complications. CCI predicted LOS >7 d and DAOH <80 d. Conclusions RC was associated with significant short-term morbidity and DAOH was a good marker for cumulative morbidity after RC. We propose that DAOH should be a standard supplement for reporting surgical outcomes following RC for bladder cancer, which may facilitate better comparison of outcomes across treating institutions. Patient summary We studied complications after surgical removal of the bladder for bladder cancer. We assessed a novel patient-centred tool that more accurately describes the total burden of complications after surgery than traditional models. We found that patients with a high body mass index and coexisting chronic diseases had a higher risk of a complicated surgical course.
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Affiliation(s)
- Sophia L Maibom
- Department of Urology, Rigshospitalet University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Martin A Røder
- Department of Urology, Rigshospitalet University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Alicia M Poulsen
- Department of Urology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Peter O Thind
- Department of Urology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Marie L Salling
- Department of Urology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Lisbeth N Salling
- Department of Urology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Section of Surgical Pathophysiology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- Department of Urology, Rigshospitalet University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulla N Joensen
- Department of Urology, Rigshospitalet University Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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29
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Maibom SL, Joensen UN, Poulsen AM, Kehlet H, Brasso K, Røder MA. Short-term morbidity and mortality following radical cystectomy: a systematic review. BMJ Open 2021; 11:e043266. [PMID: 33853799 PMCID: PMC8054090 DOI: 10.1136/bmjopen-2020-043266] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To study short-term (<90 days) morbidity and mortality following radical cystectomy (RC) for bladder cancer and identify modifiable risk factors associated with these. DESIGN Systematic review. METHODS The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE were searched for relevant papers on 11 June 2019 and rerun on 27 May 2020. Studies reporting complications, reoperations, length of stay and mortality within 90 days were included. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine and the quality of evidence was assessed using the Newcastle-Ottawa Scale. RESULTS The search retrieved 1957 articles. Sixty-six articles were included. The quality of evidence was poor to good. Most studies were retrospective, and no randomised clinical trials were identified. Of included studies a median of 6 Martin criteria for reporting complications after surgery were fulfilled. The Clavien-Dindo classification for grading complications was most frequently used. The weighted overall complication rate after RC was 34.9% (range 28.8-68.8) for in-house complications, 39.0% (range 27.3-80.0) for 30-day complications and 58.5% (range 36.1-80.5) for 90-day complications. The most common types of complications reported were gastrointestinal (29.0%) and infectious (26.4%). The weighted mortality rate was 2.4% (range 0.9-4.7) for in-house mortality, 2.1% (0.0-3.7) for 30-day mortality and 4.7% (range 0.0-7.0) for 90-day mortality. Age and comorbidity were identified as the best predictors for complications following RC. CONCLUSION Short-term morbidity and mortality are high following RC. Reporting of complications is heterogeneous and the quality of evidence is generally low. There is a continuous need for randomised studies to address any intervention that can reduce morbidity and mortality following RC. PROSPERO REGISTRATION NUMBER 104937.
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Affiliation(s)
- Sophia Liff Maibom
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Ulla Nordström Joensen
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Alicia Martin Poulsen
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
- Section for Surgical Pathophysiology, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Andreas Røder
- Department of Urology, Urological Research Unit, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
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España-Navarro R, Rabadán-Márquez P, Pérez-Argüelles D, Sánchez-Martínez N, Hernández-Alcaraz D, García-Galisteo E. Implementation of ERAS (Enhanced Recovery After Surgery) protocols for radical cystectomy patients: The pathway to standardization. A systematic review. Actas Urol Esp 2021; 45:103-115. [PMID: 32709429 DOI: 10.1016/j.acuro.2020.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/07/2020] [Indexed: 01/24/2023]
Abstract
CONTEXT The development of ERAS (Enhanced Recovery After Surgery) protocols in patients undergoing major surgery has brought perioperative benefits in several disciplines. Its main application in urology is focused on patients undergoing radical cystectomy. OBJECTIVE Systematic review of the available literature on ERAS protocols applied to patients undergoing radical cystectomy in terms of perioperative outcomes as well in the analysis of their implementation. EVIDENCE ACQUISITION A bibliographic search was conducted in the electronic databases PubMed, Embase, Cochrane and Scopus, using the terms «Cystectomy», «Enhanced Recovery After Surgery» and «Fast-Track». Randomized and non-randomized studies that compared the implementation of an ERAS protocol versus a traditional protocol in patients undergoing radical cystectomy were selected. EVIDENCE SYNTHESIS 869 articles were identified; 25 were selected for final analysis: 22 non-randomized and 3 randomized studies. No differences were observed in terms of demographic characteristics between studies. Statistically significant differences were identified in favor of the ERAS protocol: length of hospital stay, major complication rate, time to first ambulation and return of bowel function. In the analysis of protocols, a high variability was detected in the number of items and in the implementation method. CONCLUSIONS The multidisciplinary nature and the number of items of the ERAS protocols imply a high heterogeneity in their implementation. Further randomized studies, standardized reporting and analyzing results, as well as a systematic analysis of subsequent adherence are required to increase comparability between groups.
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Roghmann F, Breyer J, Kriegmair M, Wezel F, Burger M, Noldus J, Bolenz C. [Quality assessment of radical cystectomy-opportunities, risks, challenges]. Urologe A 2021; 60:151-161. [PMID: 33481063 DOI: 10.1007/s00120-020-01439-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 12/17/2022]
Abstract
Radical cystectomy (RC) is the standard treatment for nonmetastatic muscle-invasive urothelial carcinoma of the urinary bladder. It is associated with relevant morbidity and mortality. After RC, the 5‑year overall survival rate is approximately 60%. In the context of the present work, quality parameters of RC divided into oncological/functional criteria and freedom from complications are identified and summarized. A PubMed search was performed. In addition to early criteria such as negative surgical margins, performance of pelvic lymphadenectomy, creation of a continent urinary diversion or preservation of sexual function, long-term criteria were identified such as the absence of higher-grade postoperative complications, recurrence-free survival and the preservation of health-related quality of life. The early criteria are suitable for individualized therapy planning, whereas the long-term criteria can be used for quality monitoring.
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Affiliation(s)
- F Roghmann
- Klinik für Urologie und Neuro-Urologie, Universitätsklinikum der Ruhr-Universität Bochum, Marien Hospital, 44625, Herne, Deutschland.
| | - J Breyer
- Klinik für Urologie der Universität Regensburg, Caritas-Krankenhaus St. Josef, Regensburg, Deutschland
| | - M Kriegmair
- Klinik für Urologie, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - F Wezel
- Klinik für Urologie und Kinderurologie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - M Burger
- Klinik für Urologie der Universität Regensburg, Caritas-Krankenhaus St. Josef, Regensburg, Deutschland
| | - J Noldus
- Klinik für Urologie und Neuro-Urologie, Universitätsklinikum der Ruhr-Universität Bochum, Marien Hospital, 44625, Herne, Deutschland
| | - C Bolenz
- Klinik für Urologie und Kinderurologie, Universitätsklinikum Ulm, Ulm, Deutschland
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Korolkiewicz P, Ali S, Szmuda T, Słoniewski P. A commentary on coffee consumption for recovery of intestinal function after laparoscopic gynecological surgery: A randomized controlled trial (Int J Surg 2020; 82:130-5). Int J Surg 2020; 85:29. [PMID: 33276166 DOI: 10.1016/j.ijsu.2020.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Pawel Korolkiewicz
- Scientific Circle of Neurology and Neurosurgery, Medical University of Gdansk, Poland, Dębinki 7, Gdansk, 80-952, Poland.
| | - Shan Ali
- Scientific Circle of Neurology and Neurosurgery, Medical University of Gdansk, Poland, Dębinki 7, Gdansk, 80-952, Poland
| | - Tomasz Szmuda
- Neurosurgery Department, Medical University of Gdansk, Poland, Dębinki 7, Gdansk, 80-952, Poland
| | - Paweł Słoniewski
- Neurosurgery Department, Medical University of Gdansk, Poland, Dębinki 7, Gdansk, 80-952, Poland
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Pennington Z, Cottrill E, Lubelski D, Ehresman J, Theodore N, Sciubba DM. Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery. J Neurosurg Spine 2020; 34:325-347. [PMID: 33157522 DOI: 10.3171/2020.6.spine20795] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate. METHODS Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care. RESULTS Of 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference -1.22 days [95% CI -1.98 to -0.47]) and lumbar spine ERAS protocols (-1.53 days [95% CI -2.89 to -0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use. CONCLUSIONS Present data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.
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Essential elements of anaesthesia practice in ERAS programs. World J Urol 2020; 40:1299-1309. [PMID: 32839862 DOI: 10.1007/s00345-020-03410-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Enhanced recovery pathways vary amongst institutions but include key components for anesthesiologists, such as haemodynamic optimization, use of short-acting drugs (and monitoring), postoperative nausea and vomiting (PONV) prophylaxis, protective ventilation, and opioid-sparing multimodal analgesia. METHODS After critical appraisal of the literature, studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies. For each item of the perioperative treatment pathway, available English literature was examined and reviewed. RESULTS Patients should be permitted to drink clear fluids up to 2 h before anaesthesia and surgery. Oral carbohydrate loading should be used routinely. All patients may have an individualized plan for fluid and haemodynamic management that matches the monitoring needs with patient and surgical risk. Minimizing the side effects of anaesthetics and analgesics using short-acting drugs with careful perioperative monitoring should be encouraged. Protective ventilation with alveolar recruitment maneuvers is required. Preventive use of a combination with 2-3 antiemetics in addition to propofol-based total intravenous anaesthesia (TIVA) is most likely to reduce PONV. While the ideal analgesia regimen remains to be determined, it is clear that a multimodal opioid-sparing analgesic strategy has significant benefits. CONCLUSION Careful evaluation of single patient and planning of the anesthetic care are mandatory to join the ERAS philosophy. Optimal fluid management, use of short-acting drugs, prevention of PONV, protective ventilation, and multimodal analgesia are the cornerstones of the anaesthesia management within ERAS protocols.
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Gungorduk K, Paskal EK, Demirayak G, Köseoğlu SB, Akbaba E, Ozdemir IA. Coffee consumption for recovery of intestinal function after laparoscopic gynecological surgery: A randomized controlled trial. Int J Surg 2020; 82:130-135. [PMID: 32853783 DOI: 10.1016/j.ijsu.2020.08.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/15/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
BACKROUND To investigate the effect of postoperative coffee consumption on bowel motility after laparoscopic gynecological surgery. MATERIALS AND METHODS In this randomized controlled trial, patients were allocated postoperatively to 3 cups of either coffee or warm water at 6, 12, or 18 h after the operation. Total hysterectomy and bilateral salpingectomy were performed on all patients. In addition, a salpingo-oophorectomy and systematic pelvic with/without para-aortic lymphadenectomy were performed according to clinical indications. The primary endpoint was time to the first passage of flatus after surgery. RESULTS A total of 96 patients were enrolled; 49 patients were assigned to the coffee group, and 47 were enrolled in the control group (warm water). The median time to flatus (19 [13-35] vs. 25 [15-42] h; hazard ratio [HR] 1.9, 95% confidence interval [CI], 1.2-2.9; P = 0.0009), median time to defecation (30 [22-54] vs. 38 [26-65] h, HR 2.4, 95% CI, 1.5-3.8; P < 0.0001), and mean time to tolerate food (2 [2-5] vs. 3 [2-8] days, HR 1.5, 95% CI, 1.02-2.3; P = 0.002) were decreased significantly in patients who consumed coffee compared with the control subjects. Postoperative ileus was observed in seven patients (14.9%) in the control group and one patient (2.0%) in the coffee group (P = 0.02). No adverse events were attributed to coffee consumption. CONCLUSION Postoperative coffee intake after laparoscopic gynecological surgery hastened the recovery of gastrointestinal function by reducing the time to the first passage of flatus, time to the first defecation, and time to tolerate a solid diet. This simple, cheap, and well-tolerated treatment merits routine use alongside other existing enhanced recovery pathways in the postoperative setting.
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Affiliation(s)
- Kemal Gungorduk
- Department of Gynecology and Oncology, Muğla Sitki Koçman University Education and Research Hospital, Muğla, Turkey.
| | - Ezgi Karakas Paskal
- Department of Gynecology and Oncology, Muğla Sitki Koçman University Education and Research Hospital, Muğla, Turkey
| | - Gökhan Demirayak
- Department of Gynecology and Oncology, Bakirkoy Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Sezen Bozkurt Köseoğlu
- Department of Gynecology and Oncology, Muğla Sitki Koçman University Education and Research Hospital, Muğla, Turkey
| | - Eren Akbaba
- Department of Gynecology and Oncology, Muğla Sitki Koçman University Education and Research Hospital, Muğla, Turkey
| | - Isa Aykut Ozdemir
- Department of Gynecology and Oncology, Bakirkoy Sadi Konuk Research and Training Hospital, Istanbul, Turkey
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