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Morizane S, Nakane K, Tanaka T, Zennami K, Muraoka K, Ebara S, Miura N, Uemura K, Sobu R, Hoshi A, Taoka R, Sugimoto M, Noma H, Sunada H, Nishiyama H, Habuchi T, Ikeda I, Saika T, Makiyama K, Shiroki R, Masumori N, Koie T, Takenaka A. Comparison of perioperative outcomes and complications between intracorporeal, extracorporeal, and hybrid ileal conduit urinary diversion during robot-assisted radical cystectomy: a comparative propensity score-matched analysis from nationwide multi-institutional study in Japan. Int J Clin Oncol 2024; 29:64-71. [PMID: 37864612 DOI: 10.1007/s10147-023-02425-8] [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: 07/26/2023] [Accepted: 10/05/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND To investigate the impact of different urinary diversion (UD) techniques on the peri- and postoperative complications of robot-assisted radical cystectomy (RARC) with ileal conduit. METHODS We retrospectively analyzed 373 patients undergoing RARC with ileal conduit at 11 institutions in Japan between April 2018 and December 2021. Propensity score weighting was performed to adjust for confounding factors such as age, sex, body mass index, performance status, American Society of Anesthesiologists score, previous abdominal surgery, neoadjuvant chemotherapy, and preoperative high T stage (≥ cT3) and high N stage (≥ cN1). Perioperative complications were then compared among three groups: extracorporeal, intracorporeal, and hybrid urinary diversion (ECUD, ICUD, and HUD, respectively). RESULTS A total of 150, 68, and 155 patients received ECUD, HUD, and ICUD, respectively. Bowel reconstruction time and UD time were significantly shorter in the ECUD group (p < 0.001), and console time was significantly longer and blood loss was significantly higher in the ICUD group (p < 0.001). For postoperative complications (Clavien-Dindo Classification grade ≥ 3), surgical site infection (p = 0.004), pelvic abscess (p = 0.013), anastomotic urine leak (p = 0.007), and pelvic organ prolapse (p = 0.011) significantly occurred in the ECUD group. For all grades, ileus was more common in the HUD group, whereas anastomotic stricture was more common in the ECUD group compared with the other groups (p < 0.05). CONCLUSIONS Severe complications did not increase after HUD and ICUD compared with ECUD; however, console time tended to be longer and blood loss was slightly higher during RARC.
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Affiliation(s)
- Shuichi Morizane
- Division of Urology, Department of Surgery, Faculty of Medicine, Tottori University, 86 Nishi-cho, Yonago, Tottori, 683-8503, Japan.
| | - Keita Nakane
- Department of Urology, Gifu University Graduate School of Medicine, Yanagido, Gifu, Japan
| | - Toshiaki Tanaka
- Department of Urology, Sapporo Medical University School of Medicine, Chuo-ku, Sapporo, Japan
| | - Kenji Zennami
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Kentaro Muraoka
- Department of Urology, School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Shin Ebara
- Department of Urology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Noriyoshi Miura
- Department of Urology, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
| | - Koichi Uemura
- Department of Urology, Yokohama Minami Kyousai Hospital, Yokohama, Japan
| | - Ryuta Sobu
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Akio Hoshi
- Department of Urology, Faculty of Medicine and Graduate School of Comprehensive Human Science, University of Tsukuba, Ibaraki, Japan
| | - Rikiya Taoka
- Department of Urology, Faculty of Medicine, Kagawa University, Takamatsu, Kagawa, Japan
| | - Mikio Sugimoto
- Department of Urology, Faculty of Medicine, Kagawa University, Takamatsu, Kagawa, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tachikawa, Tokyo, Japan
| | - Hiroshi Sunada
- Advanced Medicine, Innovation and Clinical Research Center, Tottori University Hospital, Yonago, Tottori, Japan
| | - Hiroyuki Nishiyama
- Department of Urology, Faculty of Medicine and Graduate School of Comprehensive Human Science, University of Tsukuba, Ibaraki, Japan
| | - Tomonori Habuchi
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Ichiro Ikeda
- Department of Urology, Yokohama Minami Kyousai Hospital, Yokohama, Japan
| | - Takashi Saika
- Department of Urology, Ehime University Graduate School of Medicine, Matsuyama, Ehime, Japan
| | - Kazuhide Makiyama
- Department of Urology, School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Ryoichi Shiroki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, Chuo-ku, Sapporo, Japan
| | - Takuya Koie
- Department of Urology, Gifu University Graduate School of Medicine, Yanagido, Gifu, Japan
| | - Atsushi Takenaka
- Division of Urology, Department of Surgery, Faculty of Medicine, Tottori University, 86 Nishi-cho, Yonago, Tottori, 683-8503, Japan
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Impact of Patient, Surgical, and Perioperative Factors on Discharge Disposition after Radical Cystectomy. Cancers (Basel) 2022; 14:cancers14215288. [PMID: 36358707 PMCID: PMC9654179 DOI: 10.3390/cancers14215288] [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: 09/22/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
Radical cystectomy (RC) is a complex procedure associated with lengthy hospital stays and high complication and readmission rates. We evaluated the impact of patient, surgical, and perioperative factors on discharge disposition following RC at a tertiary referral center. From 2012 to 2019, all bladder cancer patients undergoing RC at our institution were identified (n = 1153). Patients were classified based on discharge disposition: to home or to continued facility-based rehabilitation centers (CFRs, n = 180 (15.61%) patients). On multivariate analysis of patient factors only, age [Risk Ratio (RR): 1.07, p < 0.001)], single marital status (RR: 1.09, p < 0.001), and living alone prior to surgery (RR: 2.55, p = 0.004) were significant predictors of discharge to CFRs. Multivariate analysis of patient, surgical, and perioperative factors indicated age (RR: 1.09, p < 0.001), single marital status (RR: 3.9, p < 0.001), living alone prior to surgery (RR: 2.42, p = 0.01), and major post-operative (Clavien > 3) complications (RR: 3.44, p < 0.001) were significant independent predictors of discharge to CFRs. Of note, ERAS did not significantly impact discharge disposition. Specific patient and perioperative factors significantly impact discharge disposition. Patients who are older, living alone prior to surgery, and/or have a major post-operative complication are more likely to be discharged to CFRs after RC.
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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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Stangl-Kremser J, Ahmadi H, Derstine B, Wang SC, Englesbe MJ, Daignault-Newton S, Chernin AS, Montgomery JS, Palapattu GS, Lee CT. Psoas Muscle Mass can Predict Postsurgical Outcomes in Patients Who Undergo Radical Cystectomy and Urinary Diversion Reconstruction. Urology 2021; 158:142-149. [PMID: 34437899 DOI: 10.1016/j.urology.2021.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To morphometrically measure to muscle mass which may reflect physical components of frailty. Hence, we evaluated the association between L4 total psoas area (TPA) and operative outcome after radical cystectomy (RC) for bladder cancer. METHODS In a retrospective single-center study, bladder cancer patients who underwent RC and urinary diversion between 2007 and 2012 were enrolled. TPA was evaluated in the cross-sectional imaging. The psoas muscles were normalized with the height. Male patients with a psoas mass index ≤7.4 cm2/m2 and female patients with a psoas mass index ≤5.2 cm2/m2 were classified as sarcopenic. Outcome measures were 30- and 90-day readmission and complications, and survival. Multivariable logistic and Cox proportional-hazards regression models were used to determine relevant predictors. RESULTS The median age of the 441 participants and follow up time was 68 years (IQR 59-75) and 1.2 years (IQR 0.5-1.9), respectively. One hundred forty-three patients (32.4%) were sarcopenic. The 30-day readmission and the complication rates were 13.8% and 44.7%, respectively. The 90-day readmission and complication rates were 23.9% and 53.1%, respectively. The 1-year mortality rate was 11.6% (95%CI 8.7-15.4). Multivariable logistic regression analysis revealed an association between increased TPA and lower odds of 30-day complications after RC (OR 0.95, 95%CI 0.92-0.99, P = .02); similarly, an increase in TPA was of prognostic value, although not statistically significant in the multivariable model (P = .05) once adjusting for other patient factors. CONCLUSION Sarcopenia predicted early complications and showed an informative trend for overall survival after RC, and thus may inform models predicting postsurgical outcomes.
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Affiliation(s)
- Judith Stangl-Kremser
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Michigan Medicine, Ann Arbor, MI
| | - Hamed Ahmadi
- Department of Urology, University of Southern California, Los Angeles, CA
| | | | | | | | - Stephanie Daignault-Newton
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Department of Biostatistics, Michigan Medicine, Ann Arbor, MI
| | - Anna S Chernin
- Department of Biostatistics, Michigan Medicine, Ann Arbor, MI
| | | | - Ganesh S Palapattu
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Michigan Medicine, Ann Arbor, MI
| | - Cheryl T Lee
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Department of Urology, The Ohio State University, Columbus, OH.
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Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
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Chandrapal J, Simmons K, Purves JT, Wiener JS, Routh JC. Association between race and in-hospital outcomes in children with spina bifida following inpatient urologic surgery. J Pediatr Rehabil Med 2021; 14:597-604. [PMID: 34864697 PMCID: PMC9941957 DOI: 10.3233/prm-200699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Post-operative complication rates may vary among racial and/or ethnic groups and have not been previously described in individuals with spina bifida (SB) undergoing urologic surgery. The aim of this study was to compare in-hospital complication frequencies of individuals with SB following urologic surgery by race/ethnicity. METHODS The Nationwide Inpatient Sample was used to identify pediatric patients with SB who underwent inpatient urologic procedures. A pediatric cohort (<18 years old) with SB that underwent urologic surgery were assessed. All analyses report weighted descriptive statistics, outcomes, and race/ethnicity was the primary predictor variable. The primary outcome of interest was post-operative complications which were defined using NSQIP ICD-9 code definitions. Secondary analysis included length of stay (LOS), and encounter cost was estimated using the cost-to-charge ratio files provided by the Healthcare Cost and Utilization Project. RESULTS The unadjusted model showed no differences in complications, LOS, and cost. In the adjusted model there were no differences in complications, LOS, and cost between Black and White encounters. However, Hispanic ethnicity was associated with a 20%(95%CI: 4-40%) increase in LOS and 18%(95%CI: 2-35%, p = 0.02) increase in cost compared to White encounters. CONCLUSION There was no evidence of variation for in-hospital complication rates among racial/ethnic groups undergoing urologic surgery. Hispanic ethnicity was associated with higher costs and longer LOS in pediatric SB encounters.
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Affiliation(s)
- Jason Chandrapal
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Kirsten Simmons
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - J Todd Purves
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University School of Medicine, Durham, NC, USA
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Comparing open-radical cystectomy and robot-assisted radical cystectomy: current status and analysis of the evidence. Curr Opin Urol 2020; 30:400-406. [PMID: 32235281 DOI: 10.1097/mou.0000000000000755] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Radical cystectomy is the definitive surgical treatment for aggressive bladder cancer. The robotic platform offers a new approach to radical cystectomy, but the benefits are unclear. This review examines the latest evidence, with a particular focus on developments in the last two years. RECENT FINDINGS Prospective evaluations of open (ORC) and robot-assisted radical cystectomy (RARC) are emerging. The radical cystectomy in patients with bladder cancer trial reported in 2018 and demonstrated oncological noninferiority for both approaches and marginal shorter length of stays with RARC using an extracorporeal reconstruction. The trial confirmed prospective randomized comparisons are possible, and replicates observations from two earlier, smaller randomised controlled trials with longer follow-up. Although there has been significant traction to the intracorporeal approach to RARC, randomized trial evidence is awaited to show any benefit over ORC. SUMMARY New evidence alludes to the noninferiority of the robotic platform in radical cystectomy in comparison to open surgery. There is minimal evidence of a clinically meaningful benefit. Until this is addressed, ORC remains the gold standard for the definitive surgical management of bladder cancer.
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Ercolino A, Droghetti M, Schiavina R, Bianchi L, Chessa F, Mineo Bianchi F, Barbaresi U, Angiolini A, Casablanca C, Mottaran A, Molinaroli E, Pultrone C, Dababneh H, Bertaccini A, Brunocilla E. Postoperative outcomes of Fast-Track-enhanced recovery protocol in open radical cystectomy: comparison with standard management in a high-volume center and Trifecta proposal. Minerva Urol Nephrol 2020; 73:763-772. [PMID: 33200895 DOI: 10.23736/s2724-6051.20.03843-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND We aimed at comparing perioperative outcomes in patients submitted to radical cystectomy followed by Fast Track (FT) protocol or standard management, and propose a definition of Trifecta, to improve standardized quality assessment for RC. METHODS We considered 191 patients submitted to RC between January 2017 and January 2019. Patients followed FT or standard management according to surgeon's preference. Preoperative and intraoperative characteristics, alongside with postoperative outcomes were compared between the two groups. Trifecta was defined as follows: in-hospital stay (HS) ≤ 10 days, time to defecation (TtD) below the overall mean and no major (≥ Clavien-Dindo grade III) complications. Finally, Trifecta achievement rates were assessed in both groups. RESULTS Seventy-five patients (39%) followed the FT protocol and 116 (61%) standard management. The two groups were homogeneous for preoperative, intraoperative and pathological characteristics. Patients in the FT group had shorter TtD (5 vs. 6 days P=0.006), HS (12 vs. 14 days P=0.008) and lower readmission rate (8% vs. 19% P=0.04). Early complication rates and grades were similar, while less late complications were found in FT group (6.7% vs. 21.6% P=0.006). Trifecta achievement rate was higher for FT group (31% vs. 8% P<0.001). Single-item failure percentages for HS, TtD and major grade complications were respectively 90%, 60% and 19%, with no difference between the two groups. CONCLUSIONS FT protocol can safely consent faster bowel recovery and earlier discharge after RC, plus reducing readmission rates. Using a Trifecta incorporating essential perioperative outcomes, could improve standardized quality assessment for RC.
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Affiliation(s)
- Amelio Ercolino
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Droghetti
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Riccardo Schiavina
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
| | - Lorenzo Bianchi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy - .,University of Bologna, Bologna, Italy
| | - Francesco Chessa
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
| | | | - Umberto Barbaresi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Angiolini
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carlo Casablanca
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Angelo Mottaran
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Enrico Molinaroli
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristian Pultrone
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Hussam Dababneh
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Bertaccini
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
| | - Eugenio Brunocilla
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,University of Bologna, Bologna, Italy
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Zhang D, Sun K, Wang T, Wu G, Wang J, Cui Y, Wu J. Systematic Review and Meta-Analysis of the Efficacy and Safety of Enhanced Recovery After Surgery vs. Conventional Recovery After Surgery on Perioperative Outcomes of Radical Cystectomy. Front Oncol 2020; 10:541390. [PMID: 33072572 PMCID: PMC7538712 DOI: 10.3389/fonc.2020.541390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/13/2020] [Indexed: 12/31/2022] Open
Abstract
Background and objective: Radical cystectomy has been characterized as the most difficult operation in urology because of the complex surgical procedures and postoperative complications. Enhanced recovery after surgery (ERAS), which reduces the incidence of perioperative complications, has been widely used in clinical surgery. Herein, we performed a meta-analysis to evaluate the efficacy and safety of ERAS vs. conventional recovery after surgery (CRAS) on perioperative outcomes of radical cystectomy. Methods: We performed a systematic search of randomized controlled trials (RCTs) in the following databases: Medline, Embase, and the Cochrane Controlled Trials Register, based on the PICOS strategy. The reference lists of the retrieved studies were further surveyed for relevant publications. Results: Our search yielded seven RCTs containing 813 patients. The ERAS group was found to have better performance in the following parameters: length of hospital stay [mean difference (MD) = -1.12, 95% confidence interval (CI): -1.80 to -0.45, P = 0.001], time to first flatus (MD = -0.70, 95% CI: -0.98 to 0.41, P < 0.00001), and time to regular diet (MD = -0.12, 95% CI: -1.76 to -0.28, P = 0.007). However, there were no significant differences between the two groups in major complications [odds ratio (OR) = 0.91, 95% CI: 0.63 to 1.34, P = 0.64], readmission (OR = 1.15, 95% CI: 0.65 to 2.01, P = 0.63), ileus (OR = 0.75, 95% CI: 0.44 to 1.28, P = 0.29), wound infection (OR = 0.56, 95% CI: 0.31 to 1.01, P = 0.05), mortality (OR = 0.69, 95% CI: 0.24 to 1.99, P = 0.49), or time to first bowel movement (MD = -0.55, 95% CI: -1.62 to 0.53, P = 0.32). Conclusion: ERAS reduced the length of hospital stay, time to first flatus, and time to regular diet after cystectomy. Compared to CRAS protocols, ERAS protocols do not increase the risk of adverse events.
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Affiliation(s)
- Dongxu Zhang
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Kai Sun
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Tianqi Wang
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Gang Wu
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Jipeng Wang
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Yuanshan Cui
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China.,Department of Urology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jitao Wu
- Department of Urology, Yantai Yuhuangding Hospital, Qingdao University, Yantai, China
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Feng D, Liu S, Lu Y, Wei W, Han P. Clinical efficacy and safety of enhanced recovery after surgery for patients treated with radical cystectomy and ileal urinary diversion: a systematic review and meta-analysis of randomized controlled trials. Transl Androl Urol 2020; 9:1743-1753. [PMID: 32944535 PMCID: PMC7475686 DOI: 10.21037/tau-19-941] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to evaluate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes in patients undergoing radical cystectomy (RC) and ileal urinary diversion (IUD). We performed a literature search of PubMed, Web of Science, EMBASE, the Cochrane Library and three main Chinese databases (WANFANG, CNKI and VIP) in December 2019 without language restrictions. Two reviewers independently selected studies, evaluated methodological quality and extracted data using Cochrane Collaboration’s tools. Efficacy was assessed by the time to first flatus, first bowel movement, and hospitalization time. Safety was assessed by 30-day readmission and complications after surgery. Our searches identified 6 studies, including 628 patients. A total of 323 (51%) patients took ERAS. We observed that ERAS reduced the time to first flatus [standard mean difference (SMD): −1.65, 95% CI: −2.63 to −0.68, P=0.0009], first bowel movement (SMD: −1.14, 95% CI: −1.78 to −0.50, P=0.0005), and hospitalization time (MD: −4.09, 95% CI: −6.34 to −1.85, P=0.0004). We did not detect significant difference in terms of 30-day readmission [relative risk (RR): 1.33, 95% CI: 0.61–2.88, P=0.48] and postoperative complications (RR: 0.91, 95% CI: 0.65–1.26, P=0.56) between ERAS and conventional recovery after surgery (CRAS). Our findings indicated that ERAS protocols throughout the perioperative period of RC with IUD might reduce hospitalization expenses and contribute to higher turnover ward, more efficient utilization of medical resources and lower risk of nosocomial infection as a result of shorter length of stay. Besides, early rehabilitation of gastrointestinal function might not only facilitate wound healing and early mobilization, thereby reducing the incidence of basic complications such as cardiopulmonary disease, but also improve patients’ psychological trauma and stress response, increase self-confidence and motivation in treatments, and then lead to unexpected benefits. Further large volume, multicenter randomized controlled studies are warranted before making the final clinical guidelines.
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Affiliation(s)
- Dechao Feng
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Shengzhuo Liu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Yiping Lu
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Wuran Wei
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Han
- Department of Urology, Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
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Zhang X, Yang J, Chen X, Du L, Li K, Zhou Y. Enhanced recovery after surgery on multiple clinical outcomes: Umbrella review of systematic reviews and meta-analyses. Medicine (Baltimore) 2020; 99:e20983. [PMID: 32702839 PMCID: PMC7373593 DOI: 10.1097/md.0000000000020983] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [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
BACKGROUND Previously, many meta-analyses have reported the impact of enhanced recovery after surgery (ERAS) programs on many surgical specialties. OBJECTIVES To systematically assess the effects of ERAS pathways on multiple clinical outcomes in surgery. DESIGN An umbrella review of meta-analyses. DATE SOURCES PubMed, Embase, Web of Science and the Cochrane Library. RESULTS The umbrella review identified 23 meta-analyses of interventional study and observational study. Consistent and robust evidence shown that the ERAS programs can significantly reduce the length of hospital stay (MD: -2.349 days; 95%CI: -2.740 to -1.958) and costs (MD: -$639.064; 95%CI:: -933.850 to -344.278) in all the surgery patients included in the review compared with traditional perioperative care. The ERAS programs would not increase mortality in all surgeries and can even reduce 30-days mortality rate (OR: 0.40; 95%CI: 0.23 to 0.67) in orthopedic surgery. Meanwhile, it also would not increase morbidity except laparoscopic gastric cancer surgery (RR: 1.49; 95%CI: 1.04 to 2.13). Moreover, readmission rate was increased in open gastric cancer surgery (RR: 1.92; 95%CI: 1.00 to 3.67). CONCLUSION The ERAS programs are considered to be safe and efficient in surgery patients. However, precaution is necessary for gastric cancer surgery.
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Affiliation(s)
- Xingxia Zhang
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Xinrong Chen
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Liang Du
- Chinese Evidence-Based Medicine/Cochrane Center, Chengdu, China
| | - Ka Li
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Yong Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
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Zhao Y, Zhang S, Liu B, Li J, Hong H. Clinical efficacy of enhanced recovery after surgery (ERAS) program in patients undergoing radical prostatectomy: a systematic review and meta-analysis. World J Surg Oncol 2020; 18:131. [PMID: 32552894 PMCID: PMC7301489 DOI: 10.1186/s12957-020-01897-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/28/2020] [Indexed: 12/14/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) protocol has been identified to be beneficial in the amount of operations such as gastrointestinal surgery. However, the efficacy and safety in robot-assisted laparoscopic prostatectomy/laparoscopic radical prostatectomy (RALP/LRP) still remain controversial. Method We searched randomized controlled trials and retrospective cohort studies comparing ERAS versus conventional care for prostate cancer patients who have undergone RALP/LRP. ERAS-related data were extracted, and quality of included studies was assessed using the Newcastle-Ottawa quality assessment scale and the Jadad scale. Result As a result, seven trials containing 784 prostate cancer patients were included. ERAS was observed to be significantly associated with shorter length of hospital stay (SMD − 2.55, 95%CI − 3.32 to − 1.78, P < 0.05), shorter time to flatus (SMD − 1.55, 95%CI − 2.26 to − 0.84, P < 0.05), shorter time to ambulate (SMD − 6.50, 95%CI − 10.91 to − 2.09, P < 0.05), shorter time to defecate (SMD − 2.80, 95%CI − 4.56 to − 1.04, P < 0.05), and shorter time to remove drainage tube (SMD − 2.72, 95%CI − 5.31 to − 0.12, P < 0.05). Otherwise, no significant difference was reported in other measurements. Conclusions In conclusion, ERAS can reduce length of hospital stay, time to flatus, time to defecate, time to ambulate, and time to remove drainage tube in prostate cancer patients who have undergone RALP/LRP compared with conventional care.
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Affiliation(s)
- Yurong Zhao
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Shaobo Zhang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Bianjiang Liu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jie Li
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Hanxia Hong
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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Kim S, Kokorovic A, Sharma V, Boorjian S, Rendon RA, Bell D, Mason R. Factors predicting early mortality after radical cystectomy for urothelial carcinoma in a contemporary cohort of patients. Can Urol Assoc J 2020; 14:E636-E642. [PMID: 32569561 DOI: 10.5489/cuaj.6400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We aimed to identify preoperatively available patient variables associated with increased mortality within 30 and 90 days of radical cystectomy (RC) for localized urothelial carcinoma (UC), and to evaluate temporal trends in early mortality rates. METHODS We reviewed the National Cancer Database to identify patients who underwent RC for UC between 2006 and 2013. Preoperatively available patient-specific demographics and mortality rates at 30 and 90 days postoperatively were analyzed. Univariable and multivariable logistic regression analyses were performed to examine factors associated with 30- and 90-day mortality. RESULTS We identified 37 366 patients who underwent RC between 2006 and 2013. Overall mortality rates remained stable over time. From 2006-2013, 936 patients (2.5%) and 2554 patients (6.8%) died of any cause within 30 and 90 days post-RC, respectively. On multivariable analysis, increased age, higher clinical T and N stage, increased Charlson-Deyo comorbidity classification, African-American race, lower hospital volume, non-academic centers, lower patient income, and absence of insurance were each significantly associated with increased early mortality after RC (p<0.05). The protective effect of higher hospital volume was similar regardless of patient's age, clinical stage, or comorbidity status. CONCLUSIONS Our study identified patient-specific variables that are significantly associated with increased early mortality after RC. These findings can be used in counselling to identify ideal candidates for RC to decrease patient harm. Furthermore, early mortality rates after RC have remained stable over time, indicating that ongoing quality improvement is essential to improve outcomes.
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Affiliation(s)
- Sandra Kim
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Andrea Kokorovic
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | | | | | - Ricardo A Rendon
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - David Bell
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Ross Mason
- Department of Urology, Dalhousie University, Halifax, NS, Canada
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Wessels F, Lenhart M, Kowalewski KF, Braun V, Terboven T, Roghmann F, Michel MS, Honeck P, Kriegmair MC. Early recovery after surgery for radical cystectomy: comprehensive assessment and meta-analysis of existing protocols. World J Urol 2020; 38:3139-3153. [PMID: 32124020 PMCID: PMC7716903 DOI: 10.1007/s00345-020-03133-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/09/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose Different enhanced recovery after surgery (ERAS) protocols (EP) for radical cystectomy (RC) have been published. Protocols highly differ in number of included items and specific measures. Materials and methods A systematic review and meta-analysis on EPs in RC were performed using the databases MedLine, Cochrane Library, Web of science, and Google Scholar. The specific ERAS measures of the protocols were extracted, analyzed, and compared. Pooling of available outcome data was performed for length of stay, complications, readmission rate, and time to defecation. Results The search yielded a total of 860 studies of which 25 studies were included in qualitative and 22 in quantitative analysis. Oral bowel preparation (BP) was omitted in 24/25 (96%) EPs, optimized fluid management was administered in 22/25 (88%) EPs and early mobilization (postoperative day 1) in 21/25 (84%). Gum chewing (n = 12, 46%), metoclopramide (n = 11, 44%), and alvimopan (n = 6, 24%) were the most common measures to prevent postoperative ileus. Our meta-analysis revealed a significant benefit in favor of EPs for the outcome parameters length of stay [mean difference (MD) − 3.46 d, 95% confidence interval (CI) − 4.94 to − 1.98, p < 0.01], complications [Odds ratio (OR) = 0.76, 95% CI 0.61–0.94, p = 0.01] and time to defecation (MD − 1.37 d, 95% CI − 2.06 to − 0.69, p < 0.01). Readmission rate did not show a significant difference (OR = 0.73, 95% CI 0.52–1.03, p = 0.07). Conclusion Current EPs focus on omitting oral BP, early mobilization, and optimized fluid management while they differ in methods preventing postoperative ileus. Our meta-analysis revealed a benefit in introducing these protocols into clinical practice.
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Affiliation(s)
- F Wessels
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - M Lenhart
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - K F Kowalewski
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - V Braun
- Library for the Medical Faculty, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68165, Mannheim, Germany
| | - T Terboven
- Department of Anesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68165, Mannheim, Germany
| | - F Roghmann
- Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany
| | - M S Michel
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - P Honeck
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M C Kriegmair
- Department of Urology, University Medical Centre Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Naito Y, Kanazawa H, Okada Y, Nagayama J, Syo N, Yamamoto A, Kojima I, Terashima Y, Nagai T. [ADOPTION OF ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL FOR THE MANAGEMENT OF PATIENTS UNDERGOING RADICAL CYSTECTOMY IN JAPAN]. Nihon Hinyokika Gakkai Zasshi 2020; 111:9-15. [PMID: 33473094 DOI: 10.5980/jpnjurol.111.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
(Objectives) The Enhanced Recovery After Surgery (ERAS) protocols are standardized and multimodal perioperative care pathways designed to improve surgical outcomes by minimizing stress response and inflammation following surgery. First adopted in colorectal surgery, ERAS is now being employed in various other types of surgeries, most recently in patients undergoing radical cystectomy (RC). Implementation of ERAS protocols resulted in reductions in perioperative complication rates and length of hospital stay (LOS). However, information on the adoption of ERAS in patients undergoing RC in Japan is limited. The objective of this study was to evaluate the safety and efficacy of ERAS implemented in the Toyohashi Municipal Hospital in 2017 for the management of patients with RC. (Patients and methods) This was a retrospective study of 103 patients who underwent RC and urinary diversion from January 2012 to March 2019. Of the 103 patients, 71 underwent surgery prior to the introduction of the ERAS were allocated to the 'traditional' group, while 32 were exposed to the ERAS protocol were allocated to the 'ERAS' group. In this study, ERAS included no bowel preparation, preoperative carbohydrate loading, preoperative fluid reduction, preoperative fasting, reduced drainage use, no nasogastric intubation, and early postoperative drinking and eating. A comparative analysis was performed to evaluate LOS and postoperative complication rate (Clavien classification ≥2) after RC between the 'traditional' and 'ERAS' groups. (Results) Patient characteristics and intraoperative variables such as median age, sex, body mass index, clinical and pathological cancer stage, amount of bleeding, need for transfusion, and technique of urinary diversion did not differ between groups. However, duration of surgery was significantly shorter in the ERAS group than in the traditional group (402 min vs. 470 min; P = 0.03). Further, rate of complication was significantly lower (43.8% vs. 67.6%; P=0.03) and LOS after RC was significantly shorter (21 days vs. 28 days; P<0.001) in the ERAS group compared to the traditional group. Moreover, ERAS was an independent factor affecting shorter LOS after RC (OR, 5.22; 95% CI, 1.52-17.90; P = 0.009) in multivariate analyses. (Conclusions) It is possible that the ERAS protocol adopted in this study reduced the LOS and postoperative complication rate after RC at this site in Japan.
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Affiliation(s)
- Yushi Naito
- Department of Urology, Toyohashi Municipal Hospital
| | | | - Yurika Okada
- Department of Urology, Toyohashi Municipal Hospital
| | - Jun Nagayama
- Department of Urology, Toyohashi Municipal Hospital
| | - Norie Syo
- Department of Urology, Toyohashi Municipal Hospital
| | | | - Ippei Kojima
- Department of Urology, Toyohashi Municipal Hospital
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Jiang J, Ji HY, Xie WM, Ran LS, Chen YS, Zhang CT, Quan XQ. Could platelet-to-lymphocyte ratio be a predictor for contrast-induced nephropathy in patients with acute coronary syndrome?: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e16801. [PMID: 31393410 PMCID: PMC6708824 DOI: 10.1097/md.0000000000016801] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Contrast-induced nephropathy (CIN) is acute renal failure observed after administration of iodinated contrast media during angiographic or other medical procedures. In recent years, many studies have focused on biomarkers that recognize CIN and/or predict its development in advance. One of the many biomarkers studied is the platelet-to-lymphocyte ratio (PLR). We performed a systematic review and meta-analysis to evaluate the correlation between PLR level and CIN. METHODS Relevant studies were searched in PUBMED, EMBASE, and Web of Science until September 15, 2018. Case-control studies reporting admission PLR levels in CIN and non-CIN group in patients with acute coronary syndrome (ACS) were included. The pooled weighted mean difference (WMD) and 95% confidence intervals (95%CI) were calculated to assess the association between PLR level and CIN using a random-effect model. RESULTS Six relevant studies involving a total of 10452 ACS patients (9720 non-CIN controls and 732 CIN patients) met our inclusion criteria. A meta-analysis of 6 case-control studies showed that PLR levels were significantly higher in CIN group than those in non-CIN group (WMD = 33.343, 95%CI = 18.863 to 47.823, P < .001, I = 88.0%). CONCLUSION For patients with ACS after contrast administration, our meta-analysis shows that on-admission PLR levels in CIN group are significantly higher than those of non-CIN group. However, large and matched cohort studies are needed to validate these findings and assess whether there is a real connection or just an association.
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Affiliation(s)
- Jie Jiang
- Department of Geriatrics
- Second Clinical School, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong-Yan Ji
- Department of Geriatrics
- Second Clinical School, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei-Ming Xie
- Department of Geriatrics
- Second Clinical School, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu-Sen Ran
- Department of Geriatrics
- Second Clinical School, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu-Si Chen
- Department of Geriatrics
- Second Clinical School, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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