Long-term Outcomes of Cystectomy and Crossfolded Ileal Reservoir Combined with an Afferent Tubular Segment for Heterotopic Continent Urinary Diversion: A Longitudinal Single-centre Study

Urinary diversions for benign and oncologic indications: what did we learn about short term complications in the last 24 months?

PURPOSE OF THE REVIEW

Urinary diversion (UD) with or without cystectomy is a procedure with high short term complication rates. In this review, we summarize the most relevant findings of the last 2 years.

RECENT FINDINGS

The use of a prophylactic mesh decreases the risk of parastomal hernia after ileal conduit (IC) surgery without adding mesh-related complications according to a recent randomized multicentre trial. Robot-assisted surgery is increasingly applied for UD and is evolving from extra- to intra-corporeal reconstruction in both continent and incontinent diversions, but there is still a need for appropriately designed studies assessing both short- and long-term complications. Promising techniques to decrease ureterointestinal stricture rates have been reported from small series, such as retrosigmoid placement of the proximal IC to avoid transpositioning of the left ureter, or in robot-assisted surgery the use of indocyanine green with near-infrared light to improve visualisation of distal ureteral viability.

SUMMARY

Most recent reports derive from observational data. Appropriate randomized studies are warranted for the evaluation of new techniques to be implemented in a surgical area that still is associated with high complication rates.

Routine Preoperative Bone Scintigraphy Has Limited Impact on the Management of Patients with Invasive Bladder Cancer

BACKGROUND

According to current guidelines, bone scintigraphy is not routinely indicated in patients with invasive bladder cancer prior to radical cystectomy unless specific symptoms are present. These guidelines, however, are based on sparse data of low quality.

OBJECTIVE

To assess the clinical impact of routine staging bone scintigraphy on further patient management.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective, single-center study of 1287 consecutive patients, who were scheduled to undergo radical cystectomy due to invasive bladder cancer between January 2000 and December 2017, was conducted. All patients were prospectively followed up according to our institutional protocol.

INTERVENTION

Bone scintigraphy as staging imaging prior to radical cystectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was the change in intended patient management. Secondary endpoints were the need for additional imaging, the diagnostic performance of baseline bone scintigraphy, and the association between clinical and radiological findings on bone metastases and survival. Logistic and Cox regression models were used for univariate and multivariate analyses.

RESULTS AND LIMITATIONS

Of 1287 patients scheduled for radical cystectomy, 1148 (89%) underwent bone scintigraphy as staging imaging. Overall, baseline bone scintigraphy led to a change in the intended management in 19/1148 (1.7%) patients. Additional imaging was performed in 44/1148 (4%) patients. Although positive bone scintigraphy findings were associated with the occurrence/development of bone metastases, the diagnostic performance of baseline bone scintigraphy was generally poor (positive predictive value, negative predictive value, sensitivity, and specificity were 56%, 89%, 27%, and 96%, respectively). Higher clinical tumor stage and the nonperformance of cystectomy had negative impacts on cancer-specific survival and overall survival, while positive bone scintigraphy was associated with worse cancer-specific survival. This study was limited by its retrospective nature and the lack of follow-up bone scintigraphy in all patients.

CONCLUSIONS

These results demonstrate the limited value of bone scintigraphy in the staging of invasive bladder cancer and do not support its routine use.

PATIENT SUMMARY

In this study, we looked at the clinical impact of bone scintigraphy on the diagnostics of patients with invasive bladder cancer. We found that routine staging bone scintigraphy had limited impact on further patient management. We conclude that bone scintigraphy should not be part of routine staging in patients with invasive bladder cancer.