Prevention and Management of Complications Following Radical Cystectomy for Bladder Cancer

Trimodal therapy vs radical cystectomy in patients with muscle-invasive bladder cancer: a systematic review and meta-analysis of comparative studies

OBJECTIVE

To perform a systematic review and meta-analysis of trials comparing trimodal therapy (TMT) and radical cystectomy (RC), evaluating differences in terms of oncological outcomes, quality of life, and costs.

MATERIALS AND METHODS

In July 2023, a literature search of multiple databases was conducted to identify studies analysing patients with cT2-4 N any M0 muscle-invasive bladder cancer (MIBC; Patients) receiving TMT (Intervention) compared to RC (Comparison), to evaluate survival outcomes, recurrence rates, costs, and quality of life (Outcomes). The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS) and metastasis-free survival (MFS). Hazard ratios (HRs) were used to analyse survival outcomes according to different treatment modalities and odds ratios were used to evaluate the likelihood of receiving each type of treatment according to T stage.

RESULTS

No significant difference in terms of OS was observed between RC and TMT (HR 1.07, 95% confidence interval [CI] 0.81-1.4; P = 0.6), even when analysing radiation therapy regimens ≥60 Gy (HR 1.02, 95% CI 0.69-1.52; P = 0.9). No significant difference was observed in CSS (HR 1.12, 95% CI 0.79-1.57, P = 0.5) or MFS (HR 0.88, 95% CI 0.66-1.16; P = 0.3). The mean cost of TMT was significantly higher than that of RC ($289 142 vs $148 757; P < 0.001), with greater effectiveness in terms of cost per quality-adjusted life-year. TMT ensured significantly higher general quality-of-life scores.

CONCLUSION

Trimodal therapy appeared to yield comparable oncological outcomes to RC concerning OS, CSS and MFS, while providing superior patient quality of life and cost effectiveness.

Effectiveness of Prolonged Antibiotic Prophylaxis in Radical Cystectomy: Preliminary Analysis of the MACS Randomized Clinical Trial

BACKGROUND

Standard 24-hour antibiotic prophylaxis is widely employed to minimize the risk of infection complications within 30 days following radical cystectomy. However, a considerable variety of protocols and drug combinations don't prevent a high complication rate, ranging from 37 to 67%. This paper presents the interim analysis of the MACS clinical trial, comparing antibiotic prophylaxis regimens by duration.

OBJECTIVE

To evaluate the rate of infection complications within 30 days following radical cystectomy by comparing standard 24-hour antibiotic prophylaxis (Group A) with a prolonged 120-hour regimen (Group B).

METHODS

Patients were randomized in a 1 : 1 ratio. The primary endpoint was the evaluation of the frequency of infection complications. The secondary endpoints were the rate of re-administrating antibiotics and the dynamics of the inflammation biomarker.

RESULTS

A total of 78 patients (85.0% of the sample size) were enrolled (Group A: 40 and Group B: 38). The baseline and perioperative features were balanced between groups. The overall complication rate was higher in Group A (65.0% vs. 41.1%, p = 0.043). The infection complication rate was 2.7 times higher in the standard antibiotic prophylaxis group: 37.5% compared to 18.4% cases in Group B (p = 0.041), and upper urinary tract infection was more frequent in Group A (22.5% vs. 2.6%). The prolonged antibiotic prophylaxis reduced the overall frequency of infection complications compared with standard 24-hour prophylaxis (RR = 0.12; 95% CI 0.02-0.88; p = 0.037).

CONCLUSIONS

In this interim analysis, the administration of prolonged antibiotic prophylaxis over 120 hours appears to be safe and feasible, demonstrating a reduction in the total number of complications, particularly infection complications.

Prolonged 120-h meropenem antibiotic prophylaxis in radical cystectomy compared to 24h standard antibiotic prophylaxis: Final analysis of the randomized clinical trial

Background

Standard 24-h antibiotic prophylaxis (AP) is widely employed to minimize the risk of infection complications (ICs) within 30 days following a radical cystectomy (RC). However, a considerable variety of prophylaxis protocols do not prevent a high ICs rate after surgery (37-67%). Therefore, antibiotic's type and its duration are still controversial for AP.(.

Objective

To compare standard 24-h AP with a prolonged 120-h regimen in a multicenter randomized clinical trial.

Methods

Patients were randomized in a 1:1 ratio to standard 24-h AP regimen (Group A) versus the prolonged meropenem AP 120-h (Group B). The primary endpoint was an event rate defined as the frequency of ICs within 30 days. The secondary endpoint were biomarker's analysis and antibiotic re-administration rate (ArAR).

Results

A total of 92 patients were enrolled. The Clavien-Dindo complications rate did not differ between the groups (p = 0.065), however the overall complication rate was higher in Group A (63.0% vs. 34.8%, p = 0.007). The infection complication rate was 2.75 times higher in the standard antibiotic prophylaxis group: 47.8% compared to 17.4% cases in Group B (p = 0.002). The new prolonged antibiotic regimen decreased the risk of ICs (OR 0.23; 95% CI 0.08-.598; p = 0.003).The event-free survival for ICs of clinical interest in group A was 7.00 days and in group B was 9.00 days (HR = 0.447; 0.191-1.050, p = 0.065). The ArAR was higher in Group A -47.8%, while in Group B it was only in 17.4% of the cases. The incidence of bacteriuria before RC was the same between groups (p = 0.666), however, after stent removal the risk of a positive culture was lower in group B (RR = 0.64; 95% CI 0.37-1.08; p = 0.05).

Conclusions

The administration AP over 120-h appears to be safe and feasible, demonstrating a reduction in the total number of complications and ArAR. Trial registration in Clinical Trials: NCT05392634.Trial registration in Clinical Trials: NCT05392634.

A modified ureteroileal anastomosis can reduce ureteroileal anastomotic stricture after ileal conduit

PURPOSE

Ileal conduit is commonly employed as a urinary diversion procedure for patients with bladder cancer after radical cystectomy. Studies have reported that ureteroileal anastomotic stricture remains a serious complication following ileal conduit diversion. The aim of this study was to introduce a novel modified technique for ureteroileal anastomosis and evaluate postoperative complications, with a specific focus on the incidence of ureteroileal anastomotic stricture.

METHODS

A prospective single-center, single-surgeon cohort study was conducted on 29 consecutive patients who underwent laparoscopic radical cystectomy with ileal conduit urinary diversion between February 2017 and April 2021. A descriptive statistical analysis was performed where intraoperative variables and postoperative complications were assessed.

RESULTS

All 29 operations were successful with an average operation time of 372.9 ± 94.3 min. The mean follow-up time was 39.62 ± 15.93 months. No cases of UIAS occurred. Three patients (10.3%) had febrile urinary tract infection, three patients (10.3%) had a transient small bowel obstruction, one patient (3.4%) had ileal anastomotic fistula, one patient (3.4%) had ileal conduit leakage, and one patient (3.4%) died 2 months after surgery due to multiple respiratory diseases. One patient (3.4%) had a mild left ureteral obstruction and CT indicated the obstruction site was in front of the iliac vessels where the left ureter had transposed to the right.

CONCLUSION

The modified ureteroileal anastomosis can reduce the incidence of UIAS.

Beyond surgery: bladder preservation and the role of systemic treatment in localised muscle-invasive bladder cancer

Over the last two to three decades the non-surgical curative management of bladder cancer has significantly progressed. Increasing evidence supports the use of bladder preservation as an alternative to radical cystectomy (RC) for localised muscle-invasive bladder cancer (MIBC). Radiosensitisation with chemotherapy or hypoxia modification improves the efficacy of radiotherapy. Systemic treatments play an important role in the management of localised MIBC with the benefit of neoadjuvant chemotherapy prior to radical treatment well established. The use of immune checkpoint inhibitors (ICIs) in the radical treatment of bladder cancer, their safe combination with radical radiotherapy regimens and whether the addition of ICIs improve rates of cure are outstanding questions beginning to be answered by ongoing clinical trials. In this narrative review, we discuss the current evidence for bladder preservation and the role of systemic treatments for localised MIBC.

Enhancing recurrence risk prediction for bladder cancer using multi-sequence MRI radiomics

OBJECTIVE

We aimed to develop a radiomics-clinical nomogram using multi-sequence MRI to predict recurrence-free survival (RFS) in bladder cancer (BCa) patients and assess its superiority over clinical models.

METHODS

A retrospective cohort of 229 BCa patients with preoperative multi-sequence MRI was divided into a training set (n = 160) and a validation set (n = 69). Radiomics features were extracted from T2-weighted images, diffusion-weighted imaging, apparent diffusion coefficient, and dynamic contrast-enhanced images. Effective features were identified using the least absolute shrinkage and selection operator (LASSO) method. Clinical risk factors were determined via univariate and multivariate Cox analysis, leading to the creation of a radiomics-clinical nomogram. Kaplan-Meier analysis and log-rank tests assessed the relationship between radiomics features and RFS. We calculated the net reclassification improvement (NRI) to evaluate the added value of the radiomics signature and used decision curve analysis (DCA) to assess the nomogram's clinical validity.

RESULTS

Radiomics features significantly correlated with RFS (log-rank p < 0.001) and were independent of clinical factors (p < 0.001). The combined model, incorporating radiomics features and clinical data, demonstrated the best prognostic value, with C-index values of 0.853 in the training set and 0.832 in the validation set. Compared to the clinical model, the radiomics-clinical nomogram exhibited superior calibration and classification (NRI: 0.6768, 95% CI: 0.5549-0.7987, p < 0.001).

CONCLUSION

The radiomics-clinical nomogram, based on multi-sequence MRI, effectively assesses the BCa recurrence risk. It outperforms both the radiomics model and the clinical model in predicting BCa recurrence risk.

CRITICAL RELEVANCE STATEMENT

The radiomics-clinical nomogram, utilizing multi-sequence MRI, holds promise for predicting bladder cancer recurrence, enhancing individualized clinical treatment, and performing tumor surveillance.

KEY POINTS

• Radiomics plays a vital role in predicting bladder cancer recurrence. • Precise prediction of tumor recurrence risk is crucial for clinical management. • MRI-based radiomics models excel in predicting bladder cancer recurrence.

Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Length of Hospital Stay in Radical Cystectomy: A Prospective Randomized Controlled Study

Enhanced recovery after surgery (ERAS) protocols challenge the conventional and rigid methods of surgery and anesthesia and bring about novel changes that are quite drastic. The core principle of the protocol is to minimize the metabolic disturbance caused by surgical injury, facilitate the restoration of functions in a brief period, and promote the resumption of normal activity at the earliest. To compare the outcomes of ERAS and standard protocol for patients who have undergone radical cystectomy (RC) with ileal conduit urinary diversion. This prospective randomized controlled study was performed between 2015 and 2023. The 77 patients were divided into two groups ERAS (n=39) and Standard (n=38) by sequential randomization. These two groups are divided according to protocols of bowel preparation, anesthesia, and postoperative nutrition. The clinical and demographic characteristics of the patients, and the American Society of Anesthesiologists (ASA) and Eastern Cooperative Oncology Group (ECOG) scores were recorded. Perioperative findings, the degree of complications according to the Clavien-Dindo classification, and the total cost of treatment were recorded and analyzed. Length of hospital stay (18.82±9.25 day vs 27.34±15.05 day), and cost of treatment (2168,2±933$ 2879±1806$) were higher in the standard group. The rate of nausea and vomiting and the use of antiemetics were higher in the ERAS group compared to the standard group. In patients undergoing RC, the ERAS protocol was found to shorten the duration of hospitalization and reduce the total cost of hospital stay.

The feasibility of an exercise intervention after robotic-assisted radical cystectomy for urinary bladder cancer, prior to the CanMoRe trial

BACKGROUND

Complications after radical cystectomy for urinary bladder cancer are common. Physical activity after surgery is thought to reduce complications. However, patients with urinary bladder cancer have low levels of physical activity, and interventions supporting physical exercise are needed. This study aimed to evaluate the feasibility of a physical exercise intervention in primary health care. One of the aims of the larger clinical trial will be to reduce complications.

METHODS

Patients with urinary bladder cancer and who were scheduled for a robotic-assisted radical cystectomy were recruited from Karolinska University Hospital, between February and May 2019. The patients had to be mobile, understand Swedish, and live in Stockholm. The exercise programme was conducted at one primary health care setting over 12 weeks. The exercise programme included supervised aerobic and strengthening exercises, which were performed twice a week, as well as daily walks. Feasibility was measured with process feasibility, including eligibility criteria, adherence, and acceptability, and scientific feasibility, including the ability of outcomes to indicate change, safety, and progression in the exercise programme.

RESULTS

Ten patients with a median age of 70 years (min 53-max 86) were included. Adherence to all parts of the intervention was not feasible because of patients' postoperative complications, resulting in dropouts. For the patients who took part in the exercise programme, adherence and acceptability for the exercise period were feasible, but the 6-min walk test was not feasible at discharge from the hospital. Physiotherapists in the primary health care setting perceived the process as feasible. Moreover, the ability of outcomes to indicate change and progression in the exercise programme was feasible, meanwhile no adverse events were registered.

CONCLUSIONS

The exercise intervention was feasible for the patients that took part in the exercise programme, with respect to safety and progression through the exercise programme. Furthermore, this study suggests that some improvements needed to be implemented in the process, prior to the upcoming randomised controlled trial.

Implementation of the enhanced recovery after surgery protocol for radical cystectomy patients: A single centre experience

PURPOSE

The enhanced recovery after surgery (ERAS) protocol for radical cystectomy aims to facilitate postoperative recovery and hasten a return to normal daily activities. This study aims to report on the perioperative outcomes of implementation of an ERAS protocol at a single Australian institution.

MATERIALS AND METHODS

We identified 73 patients with pT1-T4 bladder cancer who underwent open radical cystectomy at Western Health, Victoria between June 2016 and August 2021. A retrospective analysis of a prospectively maintained database was performed. Perioperative outcomes included length of hospital stay, nasogastric tube requirement and duration of postoperative ileus.

RESULTS

The median age was 74 years (interquartile range [IQR] 66-78) for the ERAS group and 70 years (IQR 65-78) for the pre-ERAS group patients. All patients in each group underwent ileal conduit formation. The median length of hospital stay was 7.0 days (IQR 7.0-9.3) for the ERAS group and 12.0 days (IQR 8.0-16.0) for the pre-ERAS group (p=0.003). Within the ERAS group, 25.0% had a postoperative ileus, and 25.0% had a nasogastric tube inserted, compared with 64.9% (p=0.001) and 45.9% (p=0.063) respectively within pre-ERAS group. The median bowel function recovery time, defined as duration from surgery to first bowel action, was 5.0 days (IQR 4.0-7.0) in the ERAS group and 7.5 days (IQR 5.0-8.5) in the pre-ERAS group (p=0.016).

CONCLUSIONS

Implementation of an ERAS protocol is associated with a reduction in hospital length of stay, postoperative ileus and bowel function recovery time.

Sequential intravesical gemcitabine/docetaxel provides a durable remission in recurrent high-risk NMIBC following BCG therapy

PURPOSE

Bacillus Calmette-Guerin (BCG) is the standard of care for high-risk nonmuscle invasive bladder cancer (NMIBC), but half of patients develop disease recurrence. Intravesical regimens for BCG unresponsive NMIBC are limited. We report the safety, efficacy, and differential response of sequential gemcitabine/docetaxel (gem/doce) depending on BCG failure classification.

METHODS

Multi-institutional retrospective analysis of patients treated with induction intravesical gem/doce (≥5/6 instillations) for recurrent high-risk NMIBC after BCG therapy from May 2018 to December 2021. Maintenance therapy was provided to those without high-grade (HG) recurrence on surveillance cystoscopy. Kaplan-Meier curves and Cox regression analyses were utilized to assess survival and risk factors for disease recurrence.

RESULTS

Our cohort included 102 patients with BCG-unresponsive NMIBC. Median age was 72 years and median follow-up was 18 months. Six-, 12-, and 24-month high-grade recurrence-free survival was 78%, 65%, and 49%, respectively. Twenty patients underwent radical cystectomy (median 15.5 months from induction). Six patients progressed to muscle invasive disease. Fifty-seven percent of patients experienced mild/moderate adverse effects (AE), but only 6.9% experienced a delay in treatment schedule. Most common AE were urinary frequency/urgency (41%) and dysuria (21%). Patients with BCG refractory disease were more likely to develop HG recurrence when compared to patients with BCG relapsing disease (HR 2.14; 95% CI 1.02-4.49).

CONCLUSIONS

In patients with recurrence after BCG therapy, sequential intravesical gem/doce is an effective and well-tolerated alternative to early cystectomy. Patients with BCG relapsing disease are more likely to respond to additional intravesical gem/doce. Further investigation with a prospective trial is imperative.

Advancing Clinical Trial Design for Non-Muscle Invasive Bladder Cancer

BACKGROUND

Despite recent drug development for non-muscle invasive bladder cancer (NMIBC), few therapies have been approved by the US Food and Drug Administration (FDA), and there remains an unmet clinical need. Bacillus Calmette-Guerin (BCG) supply issues underscore the importance of developing safe and effective drugs for NMIBC.

OBJECTIVE

On November 18-19, 2021, the FDA held a public virtual workshop to discuss NMIBC research needs and potential trial designs for future development of effective therapies.

METHODS

Representatives from various disciplines including urologists, oncologists, pathologists, statisticians, basic and translational scientists, and the patient advocacy community participated. The workshop format included invited lectures, panel discussions, and opportunity for audience discussion and comment.

RESULTS

In a pre-workshop survey, 92% of urologists surveyed considered the development of alternatives to BCG as a high drug development priority for BCG-naïve high-risk patients. Key topics discussed included definitions of disease states; trial design for BCG-naïve NMIBC, BCG-unresponsive carcinoma in situ, and BCG-unresponsive papillary carcinoma; strengths and limitations of single-arm trial designs; assessing patient-reported outcomes; and considerations for assessing avoidance of cystectomy as an efficacy measure.

CONCLUSIONS

The workshop discussed several important opportunities for trial design refinement in NMIBC. FDA encourages sponsors to meet with the appropriate review division to discuss trial design proposals for NMIBC early in drug development.

Successful wound closure using fibrin glue for intractable neobladder-urethral anastomosis leakage after radical cystectomy and neobladder reconstruction

Introduction

Complications of cystectomy and neobladder reconstruction such as anastomotic leakage have been reported. It is a common complication; however, most cases improve conservatively. The use of fibrin glue for fistulas has been reported, but no reports have shown its effectiveness for urinary tract anastomotic leakage. We experienced a case of intractable neobladder-urethral anastomosis leakage after radical cystectomy and neobladder reconstruction, which was effectively managed using fibrin glue.

Case presentation

A 70-year-old man underwent radical cystectomy and ileal neobladder reconstruction for invasive bladder cancer with urothelial carcinoma. After surgery, the urethral catheter fell off and the anastomotic leakage did not improve by adjusting the position of the urethral catheter and percutaneous nephrostomy. We closed the intractable neobladder-urethral anastomotic leakage by injecting fibrin glue and the leakage completely disappeared.

Conclusion

Injecting fibrin glue into anastomotic site can be effective in severe neobladder-urethral anastomosis leakage.

Robot-assisted radical cystectomy vs open radical cystectomy in patients with bladder cancer: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Even though there isn't enough clinical evidence to demonstrate that robot-assisted radical cystectomy (RARC) is preferable to open radical cystectomy (ORC), RARC has become a widely used alternative. We performed the present study of RARC vs ORC with a focus on oncologic, pathological, perioperative, and complication-related outcomes and health-related quality of life (QOL).

METHODS

We conducted a literature review up to August 2022. The search included PubMed, EMBASE and Cochrane controlled trials register databases. We classified the studies according to version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). The data was assessed by Review Manager 5.4.0.

RESULTS

8 RCTs comparing 1024 patients were analyzed in our study. RARC was related to lower estimated blood loss (weighted mean difference (WMD): -328.2; 95% CI -463.49--192.92; p < 0.00001), lower blood transfusion rates (OR: 0.45; 95% CI 0.32 - 0.65; p < 0.0001) but longer operation time (WMD: 84.21; 95% CI 46.20 -121.72; p < 0.0001). And we found no significant difference in terms of positive surgical margins (P = 0.97), lymph node yield (P = 0.30) and length of stay (P = 0.99). Moreover, no significant difference was found between the two groups in terms of survival outcomes, pathological outcomes, postoperative complication outcomes and health-related QOL.

CONCLUSION

Based on the present evidence, we demonstrated that RARC and ORC have similar cancer control results. RARC is related to less blood loss and lower transfusion rate. We found no difference in postoperative complications and health-related QOL between robotic and open approaches. RARC procedures could be used as an alternate treatment for bladder cancer patients. Additional RCTs with long-term follow-up are needed to validate this observation.

Comparative study on the clinical effect of preparing neobladder with different lengths of ileum

OBJECTIVE

To investigate the relationship between orthotopic U-shaped ileal neobladder volume and bladder function. To investigate the correlation between the volume of the radical cystectomy and the U-shaped ileal neobladder in situ and the function of the bladder.

METHODS

The clinical data of patients undergoing in orthotopic U-shaped neobladder in our hospital were retrospectively analyzed. They were divided into two groups according to the length of the retained ileum. Group 1: The length of the ileum was 25-35cm (including 35cm), and the second group: the length of the ileum was 35-45cm. The basic information, cushion usage, urodynamic examination and complications of the two groups were obtained.

RESULTS

A total of 88 patients were included in the study, including 33 in the first group and 55 in the second group. There was no statistical difference in general data, lymph node collection, lymph node positive rate, positive margin rate, postoperative pathological stage, pathological grade, pathological type, intraoperative blood loss, blood transfusion, postoperative hospital stay, and complications between the two groups of patients. significance. Although the usage of urine pads in group 1 was more than that in group 2 in the short term after operation (P<0.05), it started from the third year after operation. Patients in group 1 used less cushion than group 2 (P<0.05). Urodynamic examination was performed on the patients, and the bladder function of group 1 maintained satisfactory time longer than that of group 2. The total number of deaths in the two groups was 12 and 23, respectively. The 5-year overall survival (OS) rate of group 1 was 53.60%, and the 5-year overall survival rate of group 2 was 52.9%.

CONCLUSIONS

A new bladder formed by cutting the ileum with a length of 25-35 cm (including 35cm) has a longer time to maintain good bladder function than cutting the ileum with a length of 35-45 cm to produce a new bladder.

Is it necessary to perform a retrosigmoid transposition of the left ureter in Bricker Ileal Conduit surgery?

BACKGROUND

The need for the left ureter to pass through the subsigmoid during ileal conduit diversion surgery has not been investigated in any studies. A modified technique is simply used in the ileal conduit with the left ureter straight over the sigmoid colon due to the possible damage and lack of scientifically validated advantages of this procedure. Our study aimed to investigate the feasibility of the suggested surgical technique, as well as to evaluate perioperative outcomes and postoperative complications with a focus on the prevalence of small bowel obstruction (SBO) and ureteroileal anastomotic stricture (UAS).

METHODS

A prospective single-center cohort of 84 consecutive patients undergoing laparoscopic radical cystectomy (LRC) and ileal conduit urinary diversion was conducted between January 2018 and April 2020. The incidence of SBO and UAS, perioperative outcomes, and postoperative complications were compared between a trial group of 30 patients receiving the modified procedure and a control group of 54 patients receiving the conventional Bricker ileal conduit.

RESULTS

The two groups were comparable concerning patient characteristics and clinicopathologic features. No differences were observed in terms of the operation time, perioperative outcomes, and short-term (< 90 days) postoperative complications between the two groups. There were no occurrences of UAS in the modified group, while there were two cases (3.70%) in the patients who received Bricker's ureteroileal anastomosis (p = 0.535).

CONCLUSION

In the present study, a simple and feasible modified technique of ileal conduit is proposed. Compared with traditional techniques, our method has several advantages, including the ability to avoid compression of the left ureter from the mesentery without establishing a retrosigmoid tunnel, a low rate of UAS, and the ability to perform a secondary operation at long-term follow-up.

The effect of retroperitonealization of ureteroileal anastomosis on perioperative complications of radical cystectomy with ileal conduit urinary diversion

BACKGROUND

Radical cystectomy (RC) has been considered the standard management of muscle-invasive bladder cancer. Despite the improvements in surgical techniques and perioperative care, RC is still associated with high perioperative morbidity and mortality.

OBJECTIVE

This study aims to evaluate the effect of retroperitonealization of ureteroileal anastomosis on perioperative complications of RC with ileal conduit urinary diversion.

PATIENTS AND METHODS

This is a retrospective cohort study. We reviewed medical charts of 876 patients who underwent RC between 2016 and 2021. Based on the inclusion and exclusion criteria, 748 patients entered the study. According to retroperitonealization of the ureteroileal anastomosis, patients were categorized into two groups (group I without retroperitonealization of the ureteroileal anastomosis and group II with retroperitonealization of the ureteroileal anastomosis). Patients' characteristics and occurrences of any complications and high-grade complications were compared between these groups.

RESULTS

In comparing the complication categories between the two groups, fewer patients in group II suffered from gastrointestinal, urinary, and cardiac events (p values were 0.018, 0.021, and 0.013, respectively). Moreover, fewer patients in group II experienced any complications and high-grade complications (p values were < 0.001 and < 0.001, respectively). The length of hospital stay was also significantly shorter in group II (p < 0.001).

CONCLUSIONS

RC is associated with comparatively high perioperative morbidity and mortality. In the present study, 61% of the patients experienced at least one complication postoperatively. Retroperitonealization of the ureterointestinal anastomosis may decrease perioperative adverse events of RC with ileal conduit urinary diversion.

Non-continent urinary diversion (ileal conduit) as salvage therapy in patients with refractory lower urinary tract dysfunctions due to multiple sclerosis: results of a national cohort from the French Association of Urology (AFU) Neurourology Committee and the French-speaking Neurourology Study Group (GENULF)

OBJECTIVE

To describe the outcomes of ileal conduit as a salvage therapy for refractory lower urinary tract dysfunctions (LUTDs) due to multiple sclerosis (MS) in a national neurourology referral center network.

METHODS

A retrospective multicenter French study was carried out to identify MS patients who underwent non-continent urinary diversion for refractory LUTDs from January 2010 to December 2015. Multiple sclerosis status, urological history, surgical indication and technique, postoperative complications, renal anatomy and function at last follow-up as well as number of rehospitalizations for urinary tract infections (UTI) were collected. Preoperative and postoperative urinary-related quality of life (urQoL) through the Qualiveen^TM short-form questionnaire (QSF^TM) and patient global impression of improvement (PGI-I) were collected and analyzed.

RESULTS

Overall, 10 centers identified 211 patients with a mean age of 54±11 and mean preoperative EDSS (expanded disability status scale) score of 7.3±0.9. The main indication for diversion was MS progression leading to impossible intermittent self-catheterization (55%). Cystectomy was performed either by open (34.6%), laparoscopic (39.3%) or robotic (21.8%) approach (unknown: 4.2%) with cystectomy in all cases. Early complications were reported in 42% of the patients, mainly Clavien I or II grades. There was no difference in GFR (glomerular filtration rate) after surgery. After diversion, patients had fewer hospitalizations for UTI and better urQoL on QSF™ confirmed by evaluation of PGI-I.

CONCLUSION

This study, reporting the largest series of ileal conduit in selected MS patients with end-stage LUTDs, showed significant improvement in symptomatic UTI and quality of life with a low high-grade complication rate.

A Novel Nomogram and Risk Classification System Predicting the Cancer-Specific Survival of Muscle-Invasive Bladder Cancer Patients after Partial Cystectomy

Purpose

To establish a prognostic model that estimates cancer-specific survival (CSS) probability for muscle-invasive bladder cancer patients undergoing partial cystectomy. Patients and Methods. 866 patients from the Surveillance, Epidemiology, and End Results (SEER) database (2004–2015) were enrolled in our study. These patients were randomly divided into the development cohort (n = 608) and validation cohort (n = 258) at a ratio of 7 : 3. A Cox regression was performed to select the predictors associated with CSS. The Kaplan–Meier method was used to analyze the survival outcome between different risk groups. The calibration curves, receiver operating characteristic (ROC) curves, and the concordance index (C-index) were utilized to evaluate the performance of the model.

Results

The nomogram incorporated age, histology, T stage, N stage, M stage, regional nodes examined, and tumour size. The C-index of the model was 0.733 (0.696–0.77) in the development cohort, while this value was 0.707 (0.705–0.709) in the validation cohort. The AUC of the nomogram was 0.802 for 1-year, 0.769 for 3-year, and 0.799 for 5-year, respectively, in the development cohort, and was 0.731 for 1-year, 0.748 for 3-year, and 0.752 for 5-year, respectively, in the validation cohort. The calibration curves for 1-year, 3-year, and 5-year CSS showed great concordance. Significant differences were observed between high, medium, and low risk groups (P < 0.001).

Conclusions

We have constructed a highly discriminative and precise nomogram and a corresponding risk classification system to predict the cancer-specific survival for muscle-invasive bladder cancer patients undergoing partial cystectomy. The model can assist in the decision on choice of treatment, patient counselling, and follow-up scheduling.

Risk factors for postoperative ileus after robot-assisted radical cystectomy with intracorporeal urinary diversion

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.

ERAS vs. Traditional Protocol in Patients Who Had Radical Cystectomy with Ileal Conduit: A Retrospective Comparative Analysis of 182 Cases

Objective

To examine the effects of ERAS protocol application on hospital stay, postoperative antibiotic use, and gastrointestinal recovery time in radical cystectomy patients with ileal conduit.

Materials and Methods

This retrospective study included 182 patients (112 traditional vs. 72 ERAS) who underwent radical cystectomy (RC) with ileal conduit between November 2017 and December 2020. Patients were compared in terms of time to start enteral feeding (SEF), length of hospital stay (LOS), time to first stool, duration of postoperative intravenous antibiotic use, postoperative ileus rate, and serum albumin levels.

Results

The traditional and ERAS groups contained 112 and 72 patients, respectively. LOS (14.79 ± 6.44 vs. 10.44 ± 4.64 days, p=0.003), first stool time (4.43 ± 2.39 vs. 2.89 ± 1.81 days, p=0.011), and duration of postoperative intravenous antibiotic use (8.79 ± 5.17 vs. 4.61 ± 4.90, p=0.004) were to be found significantly shorter in the ERAS group.

Conclusion

According to the results of this study, the ERAS protocol shortened the length of hospital stay, duration of antibiotic use, and time of first stool in patients who underwent RC with ileal conduit.

Definition of a Structured Training Curriculum for Robot-assisted Radical Cystectomy with Intracorporeal Ileal Conduit in Male Patients: A Delphi Consensus Study Led by the ERUS Educational Board

Robot-assisted radical cystectomy (RARC) continues to expand, and several surgeons start training for this complex procedure. This calls for the development of a structured training program, with the aim to improve patient safety during RARC learning curve. A modified Delphi consensus process was started to develop the curriculum structure. An online survey based on the available evidence was delivered to a panel of 28 experts in the field of RARC, selected according to surgical and research experience, and expertise in running training courses. Consensus was defined as ≥80% agreement between the responders. Overall, 96.4% experts completed the survey. The structure of the RARC curriculum was defined as follows: (1) theoretical training; (2) preclinical simulation-based training: 5-d simulation-based activity, using models with increasing complexity (ie, virtual reality, and dry- and wet-laboratory exercises), and nontechnical skills training session; (3) clinical training: modular console activity of at least 6 mo at the host center (a RARC case was divided into 11 steps and steps of similar complexity were grouped into five modules); and (4) final evaluation: blind review of a video-recorded RARC case. This structured training pathway will guide a starting surgeon from the first steps of RARC toward independent completion of a full procedure. Clinical implementation is urgently needed. PATIENT SUMMARY: Robot-assisted radical cystectomy (RARC) is a complex procedure. The first structured training program for RARC was developed with the goal of aiding surgeons to overcome the learning curve of this procedure, improving patients' safety at the same time.

Is it possible to reduce the complications and mortality of patients undergoing radical cystectomy? Effectiveness of pre-operative parameters. A prospective study

OBJECTIVE

To evaluate the relationship between serum albumin, hematocrit (HTC), age-dependent Charlson comorbidity index, body mass index (BMI), and deleted operation time in predicting mortality and complications associated with radical cystectomy.

MATERIALS AND METHODS

All patients planned for radical cystectomy owing to bladder cancer were investigated prospectively between 2015 and 2016 in our clinic. A total of 55 cases were included in the study. Patients' characteristics, preoperative serum albumin values, hematocrit level, age-dependent Charlson comorbidity index (CCI), body mass index and deleted operation time, drainage catheter time, gas-stool expulsion time were recorded. The patients were followed up for 90 days.

RESULTS

Age of cases, Charlson comorbidity index scores, and HCT were not different in patients with or without complications (overall) or severe complications nor in patients who died or survived after the procedure. The albumin value of the cases with observed mortality and complications was significantly lower than that of the cases with no mortality and complications. In multivariate and univariate analysis, low albumin level was established to be meaningful in predicting mortality and serious complications. The cut-off point for albumin, according to mortality, was found to be 4.1. Mortality within 90 days was 16.3% (n = 9).

CONCLUSIONS

We have evaluated albumin as a marker that could indicate both mortality and the presence of severe complications after radical cystectomy and urinary diversion.

Long-Term Renal Function Following Radical Cystectomy for Bladder Cancer

OBJECTIVE

To evaluate long-term renal function following radical cystectomy (RC) for bladder cancer and identify risk factors associated with postoperative decline in renal function.

METHODS

The study included patients who underwent RC at a single centre in Denmark between 2009 and 2019. Data was collected through national electronic medical records. Renal function was evaluated by estimated glomerular filtration rate (eGFR) using pre- and postoperative creatinine measurements. Cumulative incidence and Cox Proportional Hazards models were used to describe the loss of renal function and its association with clinicopathological variables, as well as its effect on mortality.

RESULTS

After exclusions, 670 patients were eligible for analyses. Median follow-up time was 6.2 years (interquartile range 4.0 -8.4). The proportion of patients with renal insufficiency (eGFR<45 mL/min) increased from 8.9% before RC to 19% 5 years after surgery. A total of 610 patients with preoperative eGFR≥45 were included in survival analyses. The absolute risk of renal function decline to CKD stage G3b or worse (eGFR<45 mL/min) was 17% (95% CI 14 -20) at 5 years postoperatively. Loss of renal function was not significantly associated with higher all-cause mortality. In multivariate analysis lower preoperative eGFR, diabetes mellitus, prior pelvic radiation therapy, continent urinary diversion types, and postoperative ureteral stricture were all independently associated with renal function decline.

CONCLUSION

The long-term renal function decreases considerably for a large number of RC patients. Recognizing preoperative risk factors could identify patients who benefit from enhanced renal surveillance or early intervention for modifiable factors to minimize renal insufficiency following RC.

Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder

Background: We evaluated the feasibility and safety of stentless uretero-intestinal anastomosis (UIA) during radical cystectomy (RC) with an ileal orthotopic neobladder. Methods: We retrospectively reviewed 403 patients who underwent RC for bladder cancer between August 2014 and December 2018. The primary objective was to study the effect of stentless UIA on uretero-intestinal anastomosis stricture (UIAS), and the secondary objective was to evaluate the association between stentless UIA and other complications, including paralytic ileus, febrile urinary tract infection (UTI), and urine leakage. Kaplan–Meier survival analysis was used to estimate UIAS-free survival, and Cox proportional hazard models were applied to identify factors associated with the risk of UIAS. Results: Among 403 patients with 790 renal units, UIAS was identified in 39 (9.7%) patients and 53 (6.7%) renal units. Forty-four (83.0%) patients with UIAS were diagnosed within 6 months. The 1- and 2-year overall UIAS-free rates were 93.9% and 92.7%, respectively. Paralytic ileus was identified in 105 (26.1%) patients and resolved with supportive treatment. Febrile UTI occurred in 57 patients (14.1%). However, there was no leak of the UIA. Conclusions: Stentless UIA during RC with an ileal orthotopic neobladder is a feasible and safe surgical option. Further prospective randomized trials are required to determine the clinical usefulness of stentless UIA during RC.

Development of nomograms related to inflammatory biomarkers to estimate the prognosis of bladder cancer after radical cystectomy

Background

Bladder cancer is one of the most common carcinomas and it brings about huge social economic burden. There is not a reliable way to predict the prognosis of bladder patients. We develop the nomogram to predict the prognosis of bladder cancer patients.

Methods

A total of 127 bladder cancer patients after radical cystectomy were studied retrospectively. Their clinicopathological data were collected for statistical analysis.

Results

The level of albumin/globulin ratio (AGR), C-reactive protein/albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) associated with pathological and hematological parameters like T stage and hemoglobin. Furthermore, the AGR was associated with overall survival (OS) and CAR, NLR, and PLR were associated with both OS and progression-free survival (PFS) (P<0.05). The multivariate analysis revealed that tobacco smoking, tumor T stage, M stage, NLR, CAR, and AGR were all independent predictors for OS of patients and tobacco smoking, tumor T stage, NLR, CAR, and AGR were independent predictors for PFS of patients. In addition, AGR, CAR, and NLR, as well as, the clinicopathological parameters in the development of nomograms with a C index of 0.901 (95% CI: 0.505-1.269) for OS, and 0.807 (95% CI: 0.755-0.858) for PFS. The nomograms were able to provide a prognosis of the OS with the area under the curve (AUC) =0.86. Further, tests assessed the PFS with the AUC =0.84.

Conclusions

This study demonstrates that the nomograms of the inflammatory biomarkers were able to predict prognosis of bladder cancer patients after radical cystectomy.

Clinical indications for necessary and discretionary hospital readmissions after radical cystectomy

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.

Enhanced Recovery after Surgery for Radical Cystectomy Decreases Postoperative Complications at Different Times

INTRODUCTION

This study aimed to assess whether enhanced recovery after surgery (ERAS) improves, at different time points, postoperative complications in patients undergoing radical cystectomy.

METHODS

We performed a retrospective monocentric study using prospectively maintained databases including all patients treated by radical cystectomy between January 2015 and July 2019. An ERAS protocol was applied in all patients from February 2018. We analyzed and compared between non-ERAS and ERAS groups early and 90-day postoperative complications and 90-day readmission. ERAS was analyzed to know its implication in fast recovery improvement over time.

RESULTS

A total of 150 patients underwent radical cystectomy, 74 without ERAS and 76 with ERAS protocol. ERAS decreased significantly early (p = 0.039) and 90-day (0.012) postoperative complications. In multivariate analysis, ERAS was an independent factor associated with less early (OR: 0.48, 95% CI: 0.25-0.96; p = 0.37) and 90-day (OR: 0.31, 95% CI: 0.14-0.68; p = 0.004) postoperative complications. There was no significant difference between groups for 90-day readmission (p = 0.349). Mean length of stay did not differ significantly between ERAS and non-ERAS groups (12.7 ± 6.2 and 13.1 ± 5.7 days, respectively; p = 0.743).

DISCUSSION/CONCLUSION

Our study shows that ERAS has an early positive impact that lasts over time on postoperative complications. ERAS implementation has decreased early and 90-day postoperative complications without increasing 90-day readmission. In our cohort, length of stay was not improved with ERAS protocol.

Surgical management of urinary diversion and stomas in adults: multidisciplinary Italian panel guidelines

BACKGROUND

Urinary stomas represent a worldwide medical and social problem. Data from literature about stoma management are extensive, but inhomogeneous. No guidelines exist about this topic. So, clear and comprehensive clinical guidelines based on evidence-based data and best practice are needed. This article aims to elaborate guidelines for practice management of urinary stomas in adults.

METHODS

Experts guided review of the literature was performed in PubMed, National Guideline Clearing-house and other databases (updated March 31, 2018). The research included guidelines, systematic reviews, meta-analysis, randomized clinical trials, cohort studies and case reports. Five main topics were identified: "stoma preparation", "stoma creation", "stoma complications", "stoma care" and "stoma reversal". The systematic review was performed for each topic and studies were evaluated according to the GRADE system, AGREE II tool. Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low level of scientific evidence statements a consensus conference composed by expert members of the major Italian scientific societies in the field of stoma management and care was performed.

RESULTS

After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines with definitive recommendations was elaborated and prepared for publication. This manuscript is focused on statements about surgical management of urinary stomas. These guidelines include recommendations for adult patients only, articles published in English or Italian and with complete text available.

CONCLUSIONS

These guidelines represent the first Italian guidelines about urinary stoma multidisciplinary management with the aim to assist urologists and stoma specialized nurses during the urinary stoma management and care.

Significance of urinary liver-type fatty acid-binding protein in patients with normal renal function after undergoing intestinal urinary diversion: a preliminary study

BACKGROUND

Liver-type fatty acid-binding protein (L-FABP) in urine is one of the early diagnostic biomarkers for acute and chronic kidney injuries. Although this protein is also identified in the intestine, there is no verified reference value for patients with intestinal urinary diversion (UD). The aim of the present study was to measure L-FABP values in such patients and compare them with the results for patients without UD.

METHODS

Spot urine specimens were collected from 41 patients with UD and 50 subjects without UD with estimated glomerular filtration rates of over 60 ml/min/1.73 m², and the L-FABP values were measured. The normal upper cutoff value in healthy subjects without UD is considered to be 7.24 μg/g Cr. First, the median values of the two groups were compared. Next, the subjects with negative proteinuria and without comorbidities associated with renal function were further selected and the median values of the groups were compared.

RESULTS

The mean age was significantly higher in the UD group. The types of UD were ileal conduit (38 patients) and ileal neobladder (three patients). The median L-FABP value in the UD group was significantly higher than that in the non-diversion group (89.1 μg/g Cr vs. 2.0 μg/g Cr, p < 0.0001). After adjustment for their backgrounds, the median value remained higher in the UD group.

CONCLUSIONS

L-FABP values in subjects with UD are higher than in those without UD. By this result, to develop a reference value in patients with intestinal UD population, further studies are required.

Urinary tract infection as the main cause of admission in cystectomized patients

INTRODUCTION AND OBJECTIVES

Radical cystectomy with urinary diversion associated with extended pelvic lymphadenectomy continues to be the treatment of choice in muscle invasive bladder cancer. Sixty-four percent of patients submitted to this procedure present postoperative complications, with urinary infection being responsible in 20-40% of cases. The aim of this project is to assess the rate of urinary infection as a cause of re-admission after cystectomy, and to identify protective and predisposing factors for urinary infection in our environment. Finally, we will evaluate the outcomes after the establishment of a prophylactic antibiotic protocol after removal of ureteral catheters.

MATERIAL AND METHODS

Retrospective descriptive study of cystectomized patients in the Urology Service of the Hospital Clínico Universitario of Zaragoza, from January 2012 to December 2018. A urinary tract infection (UTI) prevention protocol after catheter removal is established for all patients since October 2017.

RESULTS

UTI is responsible for 54.7% of readmissions, with 55.1% of these being due to UTI after removal of ureteral catheters. Of the patients who received with prophylaxis, 9.5% presented UTIs after withdrawal, compared to 10.6% in the group of patients without prophylaxis. The patient who is re-admitted for UTI after withdrawal has a mean catheter time of 24.3±7.2 days, compared to 24.5±7.4 days for patients in the group without UTI (P=.847).

CONCLUSIONS

The type of urinary diversion performed is not related to the rate of urinary infection. The regression model does not identify antibiotic prophylaxis, nor catheter time, as independent factors of UTI after catheter removal.

Drain fluid creatinine-to-serum creatinine ratio as an initial test to detect urine leakage following cystectomy: A retrospective study

Introduction:

Urine leak following radical cystectomy is a known complication. Among the various methods to diagnose this, assessment of drain fluid creatinine is a relatively easy procedure. We aimed to ascertain the validity of the drain fluid creatinine-to-serum creatinine ratio (DCSCR) as an initial indicator of urinary leak in patients undergoing radical cystectomy.

Methods:

We retrospectively identified consecutive patients with documentation of drain fluid creatinine in the postoperative period following cystectomy and urinary diversion at our institution between January 2009 and December 2018. All continent diversions and any patient with a DCSCR >1.5:1 underwent contrast study postoperatively. A diagnosis of urine leak was made following confirmatory imaging. Receiver operative characteristic curves were created, and Youden's index was used to determine the strength and clinical utility of DCSCR as a diagnostic test.

Results:

Two hundred forty-four of the 340 patients included in the study underwent cystectomy with conduit and 81 underwent neobladder creation. Sixteen out of 340 (4.7%) patients had radiologically confirmed urinary leak. DCSCR was elevated in all ureteric anastomotic leaks and in 1 out of the 7 neobladder-urethral anastomotic (NUA) leaks. The sensitivity and specificity of DCSCR to predict all urinary leaks were 68.8% and 80.9% at 1.12 (area under the curve [AUC] = 0.838), whereas at a value of 1.18 (AUC = 0.876) and with the exclusion of NUA leaks, the sensitivity was 77.8% and specificity was 87.6%.

Conclusions:

DCSCR is a good preliminary test for identifying patients who need prompt confirmatory testing for localizing urinary leaks. A drain creatinine level just 18% higher than the serum creatinine level can signify a urine leak. This is different from general assumptions of a higher DCSCR.

Morbidity, mortality, and quality assessment following open radical cystectomy in elderly patients with bladder cancer

BACKGROUND

Open radical cystectomy (ORC) with pelvic lymph-node dissection (PLND) for bladder cancer (BCa) and urinary diversion is a morbid procedure, and advanced age has been associated with a higher incidence of Clavien-Dindo ≥ 3 complications.

AIM

To investigate the association between chronological age, survival outcomes, incidence of perioperative complications, and quality parameters in patients undergoing ORC.

METHODS

We reviewed 413 patients who underwent ORC and PLND at a single academic centre between December 2009 and June 2018 for cT2-T4N0M0 BCa. Complete clinical, demographic, and pathological data were collected in the preoperative, preoperative, and postoperative setting. Patients were categorized as ≥ 75 years or < 75 years and statistical analysis was performed accordingly. Besides descriptive statistics, Kaplan-Meier log-rank test was used. Cox regression univariate and multivariate analyses were used to assess any potential predictor of OS and CSS.

RESULTS

There were 285 (69%) patients < 75 years and 128 (31%) patients ≥ 75 years old. There was no significant difference between the two age groups neither in terms of distribution of pathological stage nor in terms of overall incidence of postoperative complications. Chronological age was not significantly associated with survival outcomes on multivariate analysis. Finally, the comorbidity index was the only significant risk factor for the incidence of any complications (OR = 0.83, p = 0.002) at multivariate binary logistic regression.

CONCLUSION

Open radical cystectomy (ORC) is a feasible and safe procedure in patients with high-risk non-metastatic bladder cancer. Uro-oncologists should consider evaluating elderly patients for surgery according to a thorough geriatric assessment despite chronological age.

Retrosigmoid ileal conduit without transposition of the left ureter after open radical cystectomy for bladder cancer

OBJECTIVES

To assess perioperative outcomes, complications, and rate of uretero-ileal anastomotic stricture (UAS) in patients undergoing retrosigmoid ileal conduit after radical cystectomy (RC).

PATIENTS AND METHODS

Clinical records of consecutive patients receiving retrosigmoid ileal conduit after open RC for bladder cancer between March 2016 and June 2020 at two academic centres were prospectively collected. Two expert surgeons performed all cases. Operating room (OR) time, estimated blood loss (EBL), transfusion rate, and 90-day postoperative complications classified according to the Clavien-Dindo system, were assessed. In particular, rate of UAS, defined as upper urinary tract dilatation requiring endourological or surgical management, was evaluated.

RESULTS

A total of 97 patients were analysed. The median (interquartile range [IQR]) OR time was 245 (215-290) min, median (IQR) EBL was 350 (300-500) mL, and blood transfusions were given to 15 (15.5%) cases. There were no intraoperative complications. There were 90-day postoperative complications in 33 patients (34%), being major (Grade III-V) in 19 (19.6%). Two patients died from early postoperative complications. At a median (IQR) follow-up of 25 (14-40) months, there was only one case (1%) of UAS, involving the right ureter and requiring an open uretero-ileal re-implantation.

CONCLUSION

The retrosigmoid ileal conduit is a safe and valid option for non-continent urinary diversion after RC, ensuring a very low risk of UAS at an intermediate-term follow-up.

Lung protective ventilation strategy to reduce postoperative pulmonary complications (PPCs) in patients undergoing robot-assisted laparoscopic radical cystectomy for bladder cancer: A randomized double blinded clinical trial

STUDY OBJECTIVE

To evaluate the effects of ventilation with low tidal volume and positive end-expiratory pressure (PEEP) on postoperative pulmonary complications in patients undergoing robot-assisted laparoscopic radical cystectomy (RARC) for bladder cancer.

DESIGN

A prospective randomized double-blinded study.

SETTING

A single center trial in a comprehensive tertiary hospital from January 2017 to January 2019.

PATIENTS

A total of 258 patients undergoing RARC for bladder cancer.

INTERVENTIONS

Patients were randomly assigned to receive either lung-protective ventilation (LPV group) [tidal volume 6 ml/ kg predicated body weight (PBW) + PEEP 7 cmH₂O] or nonprotective ventilation (control group) (tidal volume 9 ml/ kg PBW without PEEP) during anesthesia.

MEASUREMENTS

The primary outcome was the occurrence of postoperative pulmonary complications (PPCs) during the first 90 days after surgery. The secondary outcomes were extubation time, oxygenation index (OI) after extubation and at postoperative day 1 in blood gas.

MAIN RESULTS

The incidence of PPCs at postoperative day1, 2 and 3 were lower in LPV group [26.8% vs. 47.2%, odds ratio (OR) 0.41, 95% confidence interval (CI), 0.24-0.69, P = 0.0007, 21.3% vs. 43.3%, OR 0.36, 95% CI, 0.20-0.61, P = 0.0002, 14.2% vs. 27.5%, OR0.43, 95%CI, 0.23-0.82, P = 0.0087, respectively], while no differences were observed at day 7 and 28 (3.9% vs. 9.4%, P = 0.0788, 0% vs. 1.6%, P = 0.4980, respectively). No PPCs were observed at postoperative day 90 in both groups. Furthermore, immediately after extubating and at postoperative day 1, OI was significantly higher in LPV group compared with control group [390(337-467) vs. 343(303-420), P = 0.0005, 406.7(73.0) vs. 425.5(74.7), P = 0.0440, respectively]. Patients in LPV group had a significant shorter extubation time after operation compared with control group [38(33-54) vs. 35(25-46), P = 0.0012].

CONCLUSION

LPV combining low tidal volume and PEEP during anesthesia for RARC may decrease the incidence of postoperative pulmonary complications.

Effect of neoadjuvant chemotherapy on health-related quality of life in patients with muscle-invasive bladder cancer: results from JCOG0209, a randomized phase III study

BACKGROUND

Although neoadjuvant chemotherapy provides survival benefits in muscle-invasive bladder cancer, the impact of neoadjuvant chemotherapy on health-related quality of life has not been investigated by a randomized trial. The purpose of this study is to compare health-related quality of life in patients with muscle-invasive bladder cancer who received neoadjuvant chemotherapy followed by radical cystectomy or radical cystectomy alone based on patient-reported outcome data.

METHODS

Patients were randomized to receive two cycles of neoadjuvant methotrexate, doxorubicin, vinblastine, and cisplatin followed by radical cystectomy or radical cystectomy alone. Health-related quality of life was measured using the Functional Assessment of Cancer Therapy-Bladder (version 4) questionnaire before the protocol treatments, after neoadjuvant chemotherapy, after radical cystectomy and 1 year after registration.

RESULTS

A total of 99 patients were analysed. No statistically significant differences in postoperative health-related quality of life were found between the arms. In the neoadjuvant chemotherapy arm, the scores after neoadjuvant chemotherapy were significantly lower than the baseline scores in physical well-being, functional well-being, Functional Assessment of Cancer Therapy-General total, weight loss, diarrhoea, appetite, body appearance, embarrassment by ostomy appliance and total Functional Assessment of Cancer Therapy-Bladder. However, there was no difference in scores for these domains, except for embarrassment by ostomy appliance, between the two arms after radical cystectomy and 1 year after registration.

CONCLUSIONS

Although health-related quality of life declined during neoadjuvant chemotherapy, no negative effect of neoadjuvant chemotherapy on health-related quality of life was apparent after radical cystectomy. These data support the view that neoadjuvant chemotherapy can be considered as a standard of care for patients with muscle-invasive bladder cancer regarding health-related quality of life.

Impact of Perioperative Multidisciplinary Rehabilitation Pathway on Early Outcomes after Robot-assisted Radical Cystectomy: A Matched Analysis

OBJECTIVE

To investigate the effect of incorporating physical rehabilitation, nutrition and psychosocial care as part of the "NEEW" (Nutrition, Exercise, patient Education and Wellness) on perioperative outcomes after robot-assisted radical cystectomy.

METHODS

Patients were divided into 2 groups: pathway group (NEEW in addition to enhanced recovery after surgery), vs prepathway group, before NEEW initiation (enhanced recovery after surgery only). Propensity score matching was performed (ratio 1:2 ratio). Perioperative outcomes were analyzed and compared. Multivariate analyses were modeled to assess for association between NEEW pathway and postoperative outcomes.

RESULTS

One hundred and niney-two were included in the study: 64 patients (33%) in the pathway group vs 128 patients (67%) in the prepathway group. Pathway group had shorter median inpatient stay (5 vs 6 days, P <.01), faster bowel recovery (3 vs 4 days, P <.01), and better pain scores, and demonstrated fewer 30-day high grade complications (5% vs 16%, P = .02). On multivariate analysis, the NEEW pathway was associated with shorter hospital stay (1.75 days shorter), faster bowel recovery (1 day faster), longer functional mobility time (4 minutes longer) and less pain scores (average 1 point less).

CONCLUSION

Standardized perioperative pathway with weekly multidisciplinary team meeting was associated with improved short-term perioperative outcomes after robot-assisted radical cystectomy.

A high monocyte-to-lymphocyte ratio predicts poor prognosis in patients with radical cystectomy for bladder cancer

BACKGROUND

At present, it is well known that many hemogram parameters were related to the prognosis of a variety of cancers. Among them, monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have attracted more and more attention. The purpose of this study was to investigate the prognostic value of MLR, NLR, PLR, especially MLR, in patients with bladder cancer (BC) treated with radical cystectomy (RC).

METHODS

Between January 2009 and October 2018, 203 BC patients who underwent RC participated in the survey, and various clinical and hematological parameters were recorded. The optimal cutoff of MLR, NLR and PLR were determined by X-tile software, and Cox regression analysis was performed to investigated the effect of MLR, NLR and PLR on the overall survival (OS) and disease-free survival (DFS).

RESULTS

The optimal cutoff values of MLR, NLR and PLR were 0.54, 4.10 and 164.63, respectively. Patients with high MLR (>0.54) predicted shorter OS [hazard ratio (HR): 2.30; 95% confidence interval (CI): 1.36-3.89; P=0.002] and DFS (HR: 2.13; 95% CI: 1.21-3.75; P=0.009) compared with patients with low MLR (≤0.54). Multivariate Cox regression analysis showed that only MLR was an independent risk factor for OS and DFS in MLR, NLR and PLR. In addition, receiver operating characteristic (ROC) analysis showed that at most time points, the area under the curve (AUC) of MLR was greater than that of NLR and PLR used to predict OS and DFS.

CONCLUSIONS

Our results show that MLR can be independently used as a poor prognostic factor for OS and DFS in BC patients with RC. The prognosis of BC patients after RC can be predicted by measuring the level of MLR.

The CanMoRe trial - evaluating the effects of an exercise intervention after robotic-assisted radical cystectomy for urinary bladder cancer: the study protocol of a randomised controlled trial

Background

Patients who have undergone radical cystectomy for urinary bladder cancer are not sufficiently physically active and therefore may suffer complications leading to readmissions. A physical rehabilitation programme early postoperatively might prevent or at least alleviate these potential complications and improve physical function. The main aim of the CanMoRe trial is to evaluate the impact of a standardised and individually adapted exercise intervention in primary health care to improve physical function (primary outcome) and habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications in patients undergoing robotic-assisted radical cystectomy for urinary bladder cancer.

Methods

In total, 120 patients will be included and assigned to either intervention or control arm of the study. All patients will receive preoperative information on the importance of early mobilisation and during the hospital stay they will follow a standard protocol for enhanced mobilisation. The intervention group will be given a referral to a physiotherapist in primary health care close to their home. Within the third week after discharge, the intervention group will begin 12 weeks of biweekly exercise. The exercise programme includes aerobic and strengthening exercises. The control group will receive oral and written information about a home-based exercise programme.

Physical function will serve as the primary outcome and will be measured using the Six-minute walk test. Secondary outcomes are gait speed, handgrip strength, leg strength, habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications. The measurements will be conducted at discharge (i.e. baseline), post-intervention and 1 year after surgery. To evaluate the effects of the intervention mixed or linear regression models according to the intention to treat procedure will be used.

Discussion

This proposed randomised controlled trial has the potential to provide new knowledge within rehabilitation after radical cystectomy for urinary bladder cancer. The programme should be easy to apply to other patient groups undergoing abdominal surgery for cancer and has the potential to change the health care chain for these patients.

Trial registration

ClinicalTrials.gov. Clinical trial registration number NCT03998579. First posted June 26, 2019.

The Use of a Polytetrafluoroethylene Membrane-Covered Stent in the Management of Urine Extravasation After Radical Cystectomy and Ileal Conduit Formation

Radical cystectomy for urothelial carcinoma is a challenging operation that is associated with significant morbidity and mortality rates. In the literature, the complication rates have been described up to 68%. We describe a unique method of managing a ureteroileal anastomotic leak in a patient with limited ureteral length. The use of polytetrafluoroethylene-covered ureteral stents has been described in the management of ureteral strictures, but this is the first time they have been used in the treatment of a urinary leak after radical cystectomy.

Defining postoperative ileus and associated risk factors in patients undergoing radical cystectomy with an Enhanced Recovery After Surgery (ERAS) program

INTRODUCTION

Postoperative ileus (POI) is a common complication of radical cystectomy (RC), occurring in 1.6-23.5% of cases. It is defined heterogeneously in the literature. POI increases hospital length of stay and postoperative morbidity. Factors such as age, epidural use, length of procedure, and blood loss may impact POI. In this study, we aimed to evaluate risk factors that contribute to POI in a cohort of patients managed with a comprehensive Enhanced Recovery After Surgery (ERAS) protocol.

METHODS

A retrospective review of consecutive patients who underwent RC from March 2015 to December 2016 at Vancouver General Hospital was performed. POI was defined a priori as insertion of nasogastric tube for nausea or vomiting, or failure to advance to a solid diet by the seventh postoperative day. To illustrate heterogeneity in previous studies, we also evaluated POI using other previously reported definitions in the RC literature. The influence of potential risk factors for POI, including patient comorbidities, American Society of Anesthesiologists score, gender, age, prior abdominal surgery or radiation, length of operation, diversion type, extent of lymph node dissection, removal date of analgesic catheter, blood loss, and fluid administration volume was analyzed.

RESULTS

Thirty-six (27%) of 136 patients developed POI. Using other previously reported definitions for POI, the incidence ranged from <1-51%. Node-positive status and age at surgery were associated with POI on univariate analysis but not multivariable analysis.

CONCLUSIONS

A large range of POI incidence was observed using previously published definitions of POI. We advocate for a standardized definition of POI when evaluating RC outcomes. POI occurs frequently even with a comprehensive ERAS protocol, suggesting that additional measures are needed to reduce the rate of POI.

Development and Cross-Validation of a Nomogram for Chronic Kidney Disease Following Robot-Assisted Radical Cystectomy

Introduction: We sought to identify the factors associated with deterioration of renal functions after robot-assisted radical cystectomy, and to develop a nomogram to detect the probability of progression to chronic kidney disease (CKD). Materials and Methods: A retrospective review of our prospectively maintained database. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-Epidemiology Collaboration creatinine formula utilizing all follow-up creatinine values. CKD was defined as stage 3b (eGFR <45 mL/minute/1.73 m²) based on the National Kidney Foundation classification. Kaplan-Meier curves were used to depict CKD-free survival. A multivariate Cox regression model was used to determine predictors for CKD and to build the perioperative nomogram. Results: The data set comprised 442 patients with a median follow-up of 25 months (12-59). Thirty-seven percent developed CKD at a median of 9 months (4-18). CKD-free survival rates at 1, 3, and 5 years were 75%, 58%, and 50%, respectively. CKD was significantly associated with preoperative eGFR (hazards ratio [HR]: 0.96, 95% confidence interval [CI]: 0.95-0.97, p < 0.01), body mass index (HR: 1.03, 95% CI: 1.01-1.05, p = 0.03), Charlson Comorbidity Index ≥3 (HR: 2.20, 95% CI: 1.35-3.58, p < 0.01), diabetes (HR: 1.59, 95% CI: 1.09-2.31, p = 0.02), 90 days postoperative strictures (HR: 4.04, 95% CI: 1.76-9.30, p < 0.01), 90 days postoperative hydronephrosis (HR: 2.26, 95% CI: 1.34-3.79, p < 0.01), 90 days recurrent urinary tract infection (HR: 1.84, 95% CI: 1.08-3.14, p = 0.02), 90 days acute kidney injury (HR: 1.70, 95% CI: 1.19-2.43, p < 0.01), and node positive disease (HR: 1.94, 95% CI: 1.31-2.86, p < 0.01). A 5-year CKD-free survival nomogram was developed. Conclusion: We have developed and cross-validated a nomogram for detecting CKD-free survival. This nomogram may have a role in counseling and follow up of patients. This study was done after the approval of the IRB committee (I-79606).

Cost of cystectomy-related complications in patients with bladder cancer in the United States

Aims: To describe healthcare utilization and cost associated with the short-term and long-term complications of cystectomy among commercially insured bladder cancer patients in the United States.Materials and methods: This retrospective, observational cohort study evaluated adults with bladder cancer receiving a transurethral resection of bladder tumor followed by a partial or radical cystectomy procedure using U.S. administrative claims from the 2005-2015 IBM MarketScan Commercial and Medicare Supplemental databases. Bladder cancer patients were classified into two cohorts: partial cystectomy or radical cystectomy. Cystectomy complications were identified during the cystectomy admission, short-term period, and long-term period. Complication-related utilization and cost outcomes were reported in aggregate during the cystectomy admission and per patient per month (PPPM) during the short-term and long-term follow-up periods.Results: Of 5136 patients who received a cystectomy, 488 (9.5%) received partial cystectomy and 4648 (90.5%) received radical cystectomy. The mean (SD) costs of complications during the cystectomy admission were $11,728 ($43,380) for radical cystectomy and $4657 ($25,668) for partial cystectomy. In the short-term period, PPPM complication-related healthcare costs were $638 [$3793] for partial cystectomy and $2681 [$14,705] for radical cystectomy. In the long-term period, PPPM complication-related healthcare costs were $544 [$2580] for partial cystectomy and $1619 [$7874] for radical cystectomy.Conclusions: Cystectomy-related complications, especially with radical cystectomy, present a substantial financial burden to patients and payers immediately after surgery as well as in the long term. Targeted interventions which improve clinical outcomes but reduce substantial costs associated with cystectomy for bladder cancer are needed.

Preoperative Risk Factors Predicting Postoperative Complications in Radical Cystectomy for Bladder Cancer

BACKGROUND AND OBJECTIVE: While radical cystectomy (RC) is the gold-standard treatment for patients with muscle-invasive bladder cancer, it is associated with a significant rate of complications. We aim to develop a prediction model to assess the risk of complications in the postoperative period using routinely collected data in the course of preoperative evaluation in patients undergoing RC for bladder cancer. METHODS: We retrospectively reviewed 508 patients who underwent RC for bladder cancer from January 2008 to October 2016. Potential preoperative risk predictors were collected. Postoperative complications were graded using the Clavien-Dindo scale. Prediction models were developed using variables with the highest predictive value for postoperative complications. The accuracy of themodels was assessed using the area under the receiver operating characteristic curve (AUROC) and cross-validation. RESULTS: Variables achieved the highest prediction accuracy for major postoperative complications in the 31 to 90-day postoperative period. In this period, 14 variables were predictive of major postoperative complications. The three most predictive individual variables were BMI, neoadjuvant chemotherapy, and creatinine with AUROC/odds ratios of 0.643/1.09, 0.609/2.43, and 0.597/1.22, respectively. This postoperative period also had the best performing prediction model for major complications, which utilized four variables to achieve an AUROC of 0.727. CONCLUSION: Routinely collected preoperative variables may be useful for determining patient risk for short-term postoperative complications after RC. Prediction models can help identify patients who may benefit from patient education, counseling and development of risk reduction strategies. Interactions between individual variables should be evaluated to further improve accuracy of the prediction models.

Modified wallace anastomotic technique reduces ureteroenteric stricture rates after ileal conduit urinary diversion

PURPOSE

To compare perioperative outcomes, complications and anastomotic stricture rate in a contemporary series of patients who underwent open radical cystectomy (RC) with modified Wallace anastomotic technique versus traditional ileal conduit.

MATERIALS AND METHODS

Study enrolled 180 patients, of whom 140 were randomized and underwent RC; seventy were randomized to group I and the seventy to the group II. For the primary objective, we hypothesized that the rate of ureteroenteric strictures would be at least 20 % lower in the second group. Secondary end points included rate of anastomotic leak, surgical time, deterioration of the upper tract, intraoperative blood loss and patient-reported quality of life (HRQOL). The modified Wallace 1 technique involved eversion of the ureteral plate and bowel mucosa edges, which were anastomosed together in running fashion, while the outher anastomotic wall was augmented with sero-serosal interrupted sutures.

RESULTS

The mean (SD) follow-up time was 26.1 (5.7) months in group I and 25.2 (4.8) months in group II, during which, anastomotic stricture was observed in 8 patients (12%) from the first and 2 patients (3%) from the second group (p < 0.05). The anastomotic leakage rate was significantly higher in first group (17% vs. 8.5%, p < 0.05), while patient-reported HRQOL outcomes were similar between groups after the 12 month follow-up period.

CONCLUSIONS

By using a modified Wallace technique, we were able to significantly lower anastomotic stricture and anastomotic leakage rates, which are major issues in minimizing both short- and long-term postoperative complications.

Salvage Hyperthermic Gemcitabine and Docetaxel Combination Chemotherapy After BCG Failure in Non-Muscle Invasive Bladder Cancer Patients

BACKGROUND: Bacillus Calmette-Guerin (BCG) is the recommended therapy for high and intermediate risk non-muscle invasive bladder cancer (NMIBC), but treatment failure is common. While a radical cystectomy is recommended after BCG failure, some patients desire bladder preservation and others are poor surgical candidates. Salvage chemotherapy treatments may be offered to this subgroup of patients. OBJECTIVE: To assess if combination, hyperthermic Gemcitabine and Docetaxel chemotherapy (GEM/DOCE) is a safe and effective salvage option for treating NMIBC. METHODS: Sixty patients who received our GEM/DOCE protocol between 2007–2017 were identified (51 BCG failures, 9 BCG naïve). This study measured overall treatment success, defined as no recurrence, progression, cystectomy, nor death due to bladder cancer. Kaplan-Meier curves were used to ascertain probability of treatment success. The log-rank test was used to identify factors associated with treatment success. RESULTS: Sixty patients received treatment with a median follow-up of 14.9 months. All patients completed the induction course with no significant adverse effects. Overall treatment success was 83% at first surveillance, 69% at 1 year, and 55% at 2 years in the entire cohort, and 90% at first surveillance, 74% at 1 year, and 56% at 2 years in the BCG-failure patients. All-cause and bladder-cancer-specific survival were both 97.9% at 1 year, 85.9% and 94.6% respectively at 2 years. Three patients underwent cystectomy at a median of 10.2 months, two of these were secondary to recurrences. Three patients had progression of their disease. CONCLUSIONS: Hyperthermic GEM/DOCE seems to be a well-tolerated salvage regimen that demonstrates a reasonable efficacy and warrants further investigation.

Postoperative cognitive dysfunction after robot-assisted radical cystectomy (RARC) with cerebral oxygen monitoring an observational prospective cohort pilot study

Background

The incidence and risk factors of postoperative cognitive dysfunction (POCD) during robot-assisted radical cystectomy (RARC) in extreme Trendelenburg positioning and pneumoperitoneum are still controversial. The aim of this prospective observational study was to find the incidence rate as well as possible risk factors of POCD in RARC with cerebral oxygen monitoring.

Methods

Patients who underwent RARC and open abdominal surgery in horizontal positioning were included. Preoperative and postoperative arterial blood gas (ABG), S-100β, C-reactive protein (CRP), and cognitive dysfunction scales were tested. Also, we used Z score to analyze and comprehensively evaluate POCD. Measurements of heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), end-tidal CO₂ (etCO₂), and cerebral oxygen were immediately obtained after different time points during the surgery.

Results

Here, 24 and 23 patients were included in the RARC group and in the control group, respectively. The incidence of POCD didn’t have significant difference in RARC group (45.8%), in contrast to the control group (26.1%). The laboratory tests of s100β and CRP between two groups didn’t contain significant difference as well. As duration of Trendelenburg and pneumoperitoneum prolonged, the cerebral oxygen saturation in the RARC group increased, which didn’t cause excessive perfusion nevertheless (rSO₂<75%). We compared laboratory tests, age, education status, blood loss, and fluid input between POCD and non-POCD patients. A significant difference was found in the serum concentrations of CRP (72.59 ± 42.09 vs. 48.50 ± 26.53, P = 0.025) and age (69.20 ± 7.033 vs. 65.34 ± 5.228, P = 0.041).

Conclusion

RARC in extreme Trendelenburg positioning and pneumoperitoneum did not significantly increase the incidence of POCD and didn’t cause excessive perfusion. The inflammation marker CRP and age might be independent risk factors of POCD.

Trial registration

Clinicaltrials.gov with registration number NCT03372135. Registered 1 November 2017 (retrospectively registered).