1
|
Vangheluwe L, Legeay M, Surlemont L, Dupuis H, Defortescu G, Cornu JN, Pfister C. Clinical impact of an enhanced recovery protocol implementation for nephrectomy and radical prostatectomy. THE FRENCH JOURNAL OF UROLOGY 2024; 34:102674. [PMID: 38944244 DOI: 10.1016/j.fjurol.2024.102674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 06/19/2024] [Accepted: 06/20/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a combination of multimodal pathways to improve surgical outcomes. Recommendations for radical cystectomy have been published by the ERAS society for the cystectomy but a lack of evidence is observed for urological procedures such as nephrectomy (Ne) and radical prostatectomy (RP). The aim of our study was to evaluate the impact of enhanced recovery protocol implementation for Ne ad RP at our academic institution. METHODS We performed a retrospective, monocentric, comparative analysis, pre and post implementation of an enhanced recovery protocol for patients undergoing robotic-assisted radical prostatectomy or nephrectomy (partial or total) for cancer. The primary endpoint was the mean length of stay (LOS). Secondary endpoints included 30-days readmission, postoperative complications, 90 days survival, and oncologic outcome at 6 months. RESULTS We included 264 patients between January, 2019, and December, 2020. Statistical analysis was performed separately by type of surgery. The LOS of patients included in the ERP protocol was decreased on average by 1.3 days IC95% [-2.50; -0.08], P<0.001 for nephrectomies and by 2.2 days IC95% [-3.72; -0.62] P<0.001 for prostatectomies, compared to non-ERP patients. There were no more re-admission, death or oncologic recurrence. CONCLUSION In our experience, ERP for oncological nephrectomy and prostatectomy reduced the length of stay, without increasing postoperative complications and readmission. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Lucie Vangheluwe
- Service d'urologie, CHU de Rouen, hôpital Charles Nicolle, Rouen, France.
| | - Mathilde Legeay
- Service d'anesthésie réanimation, CHU de Rouen, hôpital Charles Nicolle, Rouen, France
| | - Louis Surlemont
- Service d'urologie, CHU de Rouen, hôpital Charles Nicolle, Rouen, France
| | - Hugo Dupuis
- Service d'urologie, CHU de Rouen, hôpital Charles Nicolle, Rouen, France
| | | | - Jean Nicolas Cornu
- Service d'urologie, CHU de Rouen, hôpital Charles Nicolle, Rouen, France
| | - Christian Pfister
- Service d'urologie, CHU de Rouen, hôpital Charles Nicolle, Rouen, France
| |
Collapse
|
2
|
Rich JM, Geduldig J, Elkun Y, Lavallee E, Mehrazin R, Attalla K, Wiklund P, Sfakianos JP. Thromboembolic Events After Robotic Radical Cystectomy: A Comparative Analysis of Extended and Limited Prophylaxis. Urology 2024:S0090-4295(24)00281-4. [PMID: 38663586 DOI: 10.1016/j.urology.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 03/07/2024] [Accepted: 03/29/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE To compare limited (only inpatient) venous thromboembolism (VTE) prophylaxis after robot-assisted radical cystectomy (RARC) to limited plus extended prophylaxis. There is little consensus on postoperative VTE prophylaxis regimens after RARC with data mostly extrapolated from other cancers. METHODS Retrospective review of all RARC patients at our center between 2014-2022, identifying two groups: patients after a prospectively implemented protocol (January 2018 to present) utilizing a prolonged 21-day postoperative course of either enoxaparin 40 mg daily or apixaban 2.5 mg twice daily after discharge, or patients prior to January 2018 receiving only limited VTE prophylaxis during their immediate postoperative inpatient stay. PRIMARY OUTCOME incidence of symptomatic VTE confirmed with imaging within 90-days postoperatively. SECONDARY OUTCOMES major hemorrhage, complications, readmission, and mortality within 30-days postoperatively. Descriptive statistics depicted baseline patient characteristics, operative information, and complications. Differences were compared between groups. Logistic regression was used to determine associations between variables and primary outcome. RESULTS Eighty-six patients received limited prophylaxis and 364 received extended prophylaxis. Twelve (2.7%) patients experienced VTE within 90-day postoperatively: (10 [2.7%] extended vs 2 [2.3%] limited, P = .9). Upon stratification into EAU "low-risk" or "high +intermediate-risk" groups, no statistically significant difference in VTE rates was seen between the extended or limited groups. When controlling for prophylaxis regimen, intracorporeal approach was found to be predictive of a lower with a lower risk of VTE (P = .019). CONCLUSION Limited and extended prophylaxis showed no significant differences in VTE rates among RARC patients. Further studies are necessary for RARC patients to improve guidelines.
Collapse
Affiliation(s)
- Jordan M Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jack Geduldig
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yuval Elkun
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Etienne Lavallee
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY.
| |
Collapse
|
3
|
van de Wiel ECJ, Mulder J, Hendriks A, Booij Liewes-Thelosen I, Zhu X, Groenewoud H, Mulders PFA, Deinum J, Langenhuijsen JF. Adrenal fast-track and enhanced recovery in retroperitoneoscopic surgery for primary aldosteronism improving patient outcome and efficiency. World J Urol 2024; 42:187. [PMID: 38517537 PMCID: PMC10959772 DOI: 10.1007/s00345-024-04911-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 02/29/2024] [Indexed: 03/24/2024] Open
Abstract
PURPOSE No data exist on perioperative strategies for enhancing recovery after posterior retroperitoneoscopic adrenalectomy (PRA). Our objective was to determine whether a multimodality adrenal fast-track and enhanced recovery (AFTER) protocol for PRA can reduce recovery time, improve patient satisfaction and maintain safety. METHODS Thirty primary aldosteronism patients were included. Fifteen patients were treated with 'standard-of-care' PRA and compared with 15 in the AFTER protocol. The AFTER protocol contains: a preoperative information video, postoperative oral analgesics, early postoperative mobilisation and enteral feeding, and blood pressure monitoring at home. The primary outcome was recovery time. Secondary outcomes were length of hospital stay, postoperative pain and analgesics requirements, patient satisfaction, perioperative complications and quality of life (QoL). RESULTS Recovery time was much shorter in both groups than anticipated and was not significantly different (median 28 days). Postoperative length of hospital stay was significantly reduced in AFTER patients (mean 32 vs 42 h, CI 95%, p = 0.004). No significant differences were seen in pain, but less analgesics were used in the AFTER group. Satisfaction improved amongst AFTER patients for time of admission and postoperative visit to the outpatient clinic. There were no significant differences in complication rates or QoL. CONCLUSION Despite no difference in recovery time between the two groups, probably due to small sample size, the AFTER protocol led to shorter hospital stays and less analgesic use after surgery, whilst maintaining and even enhancing patient satisfaction for several aspects of perioperative care. Complication rates and QoL are comparable to standard-of-care.
Collapse
Affiliation(s)
- Elle C J van de Wiel
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Janneke Mulder
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anke Hendriks
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Xiaoye Zhu
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hans Groenewoud
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter F A Mulders
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | |
Collapse
|
4
|
Rion C, Branger N, Maubon T, Rybikowski S, Pignot G, Walz J. Prehabilitation in Urology: Trial Update. Eur Urol Focus 2024; 10:8-10. [PMID: 37884402 DOI: 10.1016/j.euf.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023]
Abstract
While prehabilitation is on the verge of being a standard of care, ENHANCE is a pragmatic trial to further improve treatment of urologic cancers with an indication for surgery. The PRIMER trial and a Belgian randomized study will focus on the feasibility of at-home prehabilitation.
Collapse
Affiliation(s)
- Claire Rion
- Department of Urology, CHU de Saint Etienne, Saint Etienne, France
| | - Nicolas Branger
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
| | - Thomas Maubon
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
| | - Stanislas Rybikowski
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
| | - Geraldine Pignot
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
| | - Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France.
| |
Collapse
|
5
|
Peteinaris A, Gkeka K, Katsakiori P, Tatanis V, Anaplioti E, Faitatziadis S, Spinos T, Obaidat M, Vagionis A, Polyzonis S, Michalopoulos F, Liatsikos E, Kallidonis P. Replicating Florence Intracorporeal Neobladder Technique in Laparoscopic Radical Cystectomy: A Retrospective Study. Urology 2024; 183:106-110. [PMID: 37981058 DOI: 10.1016/j.urology.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVE To evaluate retrospectively the feasibility of Florence robotic intracorporeal neobladder technique in laparoscopic radical cystectomy. METHODS Fourteen patients with muscle-invasive bladder cancer underwent laparoscopic radical cystectomy and Florence robotic intracorporeal neobladder between September 2021 and February 2023. Patients' characteristics, pathology data, perioperative outcomes, postoperative complications, and follow-up data were collected. RESULTS All operations were successfully completed laparoscopically. The median total operative time was 343 minutes, and the median estimated blood loss was 169.5 mL. No intraoperative complications were observed. The median hospitalization time was 7days, while the median time to regular diet was 3days. Clavien Dindo Grade < III complications appeared in five patients within 30days postoperation. No other complications were noted over the 90days follow-up. Organ-confined disease was confirmed in 11 patients and locally advanced disease in three patients. At 3months follow-up, eight and four patients were daytime and night-time continent, respectively. CONCLUSION Replicating Florence robotic intracorporeal neobladder in laparoscopic radical cystectomy is safe, feasible, and repeatable, based on the encouraging perioperative, oncological, and functional outcomes of our study. However, further prospective studies on a larger scale are required to prove its long-term results.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Evangelos Liatsikos
- Department of Urology, University of Patras, Patras, Greece; Department of Urology, Medical University of Vienna, Vienna, Austria.
| | | |
Collapse
|
6
|
Gul ZG, Wu S, Raver M, Vasan R, Mihalo J, Myrga JM, Miller DT, Pere MP, Jones CA, Sharbaugh DR, Yabes JG, Jacobs BL, Davies BJ. A Multipronged Intervention to Reduce Readmissions and Readmission Intensity After Radical Cystectomy. Urology 2023; 182:155-160. [PMID: 37666330 DOI: 10.1016/j.urology.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVE To develop a multipronged, evidence-based protocol to reduce readmission risk and readmission intensity, as represented by the duration of the index readmission, after radical cystectomy. MATERIALS AND METHODS A per-protocol study was performed. The protocol included preoperative nutritional supplementation, early stent removal, and a follow-up phone call within 4-5days of discharge. The preprotocol period was from February 1, 2020 to July 31, 2021 and the postprotocol period was from December 1, 2020 to November 31, 2021. Using multivariate regression models, we compared outcomes among patients treated with radical cystectomy before and after protocol initiation. RESULTS We identified 70 preprotocol patients and 126 postprotocol patients. After adjusting for age, sex, BMI, and frailty score, there was a significant reduction in 90-day readmission intensity (7 vs 5days; P = .048) among postprotocol patients. CONCLUSION After implementation of an evidence-based protocol for patients undergoing radical 90-day readmission intensity decreased significantly. This protocol may move the needle forward on reducing readmissions, but a larger randomized trial is needed.
Collapse
Affiliation(s)
- Zeynep G Gul
- Univserity of Washington in St. Louis, Department of Surgery, Division of Urology, St. Louis, MO.
| | - Shan Wu
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - Michael Raver
- University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - Robin Vasan
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - Jennifer Mihalo
- University of Pittsburgh, School of Medicine, Pittsburgh, PA
| | - John M Myrga
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - David T Miller
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - Maria P Pere
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | - Cameron A Jones
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | | | | | - Bruce L Jacobs
- University of Pittsburgh, Department of Urology, Pittsburgh, PA
| | | |
Collapse
|
7
|
Rich JM, Geduldig J, Cumarasamy S, Ranti D, Mehrazin R, Wiklund P, Sfakianos JP, Attalla K. Eliminating the routine use of postoperative drain placement in patients undergoing robotic-assisted radical cystectomy with intracorporeal urinary diversion. Urol Oncol 2023; 41:457.e1-457.e7. [PMID: 37863743 DOI: 10.1016/j.urolonc.2023.08.015] [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: 01/26/2023] [Revised: 07/24/2023] [Accepted: 08/19/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION Perioperative management of patients undergoing radical cystectomy and urinary diversion utilizing both open and minimally invasive techniques have routinely included the use of drains in the operative field. We herein demonstrate the safety of robotic-assisted radical cystectomy (RARC) without the routine use of postoperative drains. METHODS Patients who underwent drainless RARC with intracorporeal urinary diversion between 2017 and 2022 at our institution were reviewed. Baseline and clinical characteristics as well as perioperative and postoperative outcomes were analyzed. The primary study outcome was incidence of postoperative urinary leak or intra-abdominal infectious collections within 90 days of RARC. A univariate and multivariable logistic regression analysis was performed to determine associations between study variables and the primary outcome. RESULTS Of 381 patients, 298 (78.2%) were male and median age and BMI were 68 (63, 76) and 26.2 [23.0, 29.8], respectively. Overall 30 and 90-day complication rates were 39.6% and 50.4%, respectively. Twenty-one (5.5%) patients experienced a urine leak or intra-abdominal infectious collections. Sub-group analysis of patients who experienced the primary outcome demonstrated median postoperative day of presentation was day 19, and this group required 16 total additional procedures. On multivariable logistic regression analysis, only prior radiation therapy was associated with the development of the primary outcome of urinary leak or intra-abdominal infectious collection (odds ratio: 15.12, 95% confidence interval [1.52-156.8], p = 0.02). CONCLUSION Drainless RARC with totally intracorporeal urinary diversion achieved competitive perioperative and complications outcomes compared to prior open and robotic series. In the context of a larger enhanced recovery after surgery protocol in RARC patients, the routine use of drains may be safely omitted.
Collapse
Affiliation(s)
- Jordan M Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jack Geduldig
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shivaram Cumarasamy
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniel Ranti
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY.
| |
Collapse
|
8
|
Dal Moro F, Zattoni F, Tonet E, Morlacco A, Betto G, Novara G. Perioperative and Functional Results for Robot-assisted Radical Cystectomy with Totally Intracorporeal Neobladder in Male Patients via the Vesica Patavina (Ves.Pa.) Technique: IDEAL Stage 2a Report. EUR UROL SUPPL 2023; 57:8-15. [PMID: 37771917 PMCID: PMC10522971 DOI: 10.1016/j.euros.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 09/30/2023] Open
Abstract
Background Robot-assisted radical cystectomy (RARC) offers several advantages over open surgery, but intracorporeal neobladder construction (INC) is a challenging procedure. The vesica patavina (Ves.Pa.) refinement is a modification of the original technique that simplifies the neobladder configuration and reduces the risk of complications. Objective To present a stage 2a IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up) report on RARC with INC using the Ves.Pa. technique. Design setting and participants This was a prospective study of consecutive male patients undergoing RARC and Ves.Pa. INC performed by a single surgeon for muscle-invasive or non-muscle-invasive, bacillus Calmette-Guérin-refractory urothelial bladder cancer in a tertiary referral center. Surgical procedure RARC with INC using the refined Ves.Pa. technique. Measurements Complications were classified using the Clavien-Dindo scheme, and functional outcomes were assessed using validated questionnaires. Results and limitations A total of 20 male patients were treated. The median operative time was 382 min, and the median estimated blood loss was 350 ml. The incidence of high-grade complications was extremely low, with only one patient experiencing a grade IIIa complication. All patients had clear surgical margins. At median follow-up of 12 mo, statistically significant differences in all the functional scores measured were observed. Specifically, 6-mo parameters were all significantly worse than at baseline (all p < 0.05). No patients required intermittent catheterization. Severe urinary incontinence was experienced by approximately 25% of the patients. The median number of pad used was 0 during the day and 1 at night. The study is limited by its small sample size, single-center design, and short follow-up. Conclusions RARC with the refined Ves.Pa. technique for INC is safe, feasible, and replicable. The technique simplifies the procedure and reduces the risk of complications. The study results suggest acceptable oncological and functional outcomes over short-term follow-up. Patient summary We report our initial experience with robot-assisted removal of the bladder and construction of a new bladder using our modified technique, called Ves.Pa., in patients with bladder cancer. The technique is simple to perform. We observed a low rate of high-grade complications, and patients had surgical margins negative for cancer in all cases and fair functional outcomes at 12-month follow-up.
Collapse
Affiliation(s)
- Fabrizio Dal Moro
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Fabio Zattoni
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Elisa Tonet
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Alessandro Morlacco
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giovanni Betto
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Giacomo Novara
- Urology Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| |
Collapse
|
9
|
Rich JM, Elkun Y, Geduldig J, Lavallee E, Mehrazin R, Attalla K, Wiklund P, Sfakianos JP. Outcomes from a prospectively implemented protocol using apixaban after robot-assisted radical cystectomy. BJU Int 2023; 132:390-396. [PMID: 37186173 DOI: 10.1111/bju.16036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVES To compare the safety and efficacy of oral apixaban with that of injectable enoxaparin after robot-assisted radical cystectomy (RARC) for venous thromboembolism (VTE) thromboprophylaxis. MATERIALS AND METHODS We conducted a retrospective review of prospectively collected data for all RARC patients treated at our tertiary care centre between 2018 and 2022. The study included two groups: patients who were subject to a prospectively implemented protocol from October 2021 to the present, comprising a 21-day postoperative course of apixaban 2.5 mg twice daily after discharge, and patients treated prior to October 2021 who received enoxaparin 40 mg daily. Baseline demographics and clinical characteristics, such as VTE (defined as deep vein thrombosis and pulmonary embolism), were analysed. The primary outcome was incidence of symptomatic VTE confirmed with definitive imaging within 90 days of RARC. Secondary outcomes included major bleeding, complications, readmission, and mortality within 30 days postoperatively. Descriptive statistics included baseline patient characteristics, operative information and complications. Differences in baseline characteristics and postoperative data were compared between groups. Multivariate logistic regression was used to determine associations between variables and the primary outcome. RESULTS A total of 124 patients received apixaban and 250 patients received enoxaparin prophylaxis. Ten patients (2.7%) experienced a VTE within 90 days postoperatively (two [1.6%] apixaban group vs eight [3.2%] enoxaparin group; P = 0.5). After patient stratification into European Association of Urology risk groups, no statistically significant difference in VTE rates was seen between groups in the apixaban (2.7% high- + intermediate-risk group vs 1.1% low-risk group; P = 0.5) and enoxaparin cohorts (4.3% high- + intermediate-risk group vs 2.5% low-risk group; P = 0.5). On multivariate logistic regression, no variables were associated with the development of the primary outcome. CONCLUSION Prophylaxis with apixaban and enoxaparin showed no statistically significant differences in VTE rates among RARC patients. Apixaban appears to be safe and effective for VTE prophylaxis after RARC.
Collapse
Affiliation(s)
- Jordan M Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yuval Elkun
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jack Geduldig
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Etienne Lavallee
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Urology, Karolinska University Hospital, Solna, Sweden
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
10
|
Bai X, Chen G, Shang S, Li S, Liu H, Feng Z, Gou X. Survival prediction among pathologic T4 bladder cancer patients following cytoreductive cystectomy: A retrospective single-center study. Front Surg 2023; 10:1121357. [PMID: 37035571 PMCID: PMC10075306 DOI: 10.3389/fsurg.2023.1121357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/23/2023] [Indexed: 04/11/2023] Open
Abstract
Objectives This retrospective study aimed to describe our institutional experience with cytoreductive cystectomy (Cx) in patients with pathological T4 (pT4) bladder cancer (BCa) and to investigate the clinicopathologic factors that can predict patient survival outcomes. Methods We reviewed the baseline demographics, clinicopathologic features, perioperative complications, and follow-up data of 44 patients who underwent Cx for pT4 BCa at our institution between 2013 and 2021. The Kaplan-Meier curve and the log-rank test were used to analyze progression-free survival (PFS) and overall survival (OS). Univariate and multivariate analyses were performed using the Cox regression model. Results The median age of the patients was 68 years [95% confidence interval (CI) 49-81]. Overall, 21 patients (47.7%) were estimated to have a high age-adjusted Charlson comorbidity index (ACCI) score (>4), and nine patients (20.5%) had pT4b substage BCa. None of the patients died of complications within 30-90 days after surgery. Severe complications occurred in 16% (n = 7) of patients within 30-90 days. During a median follow-up of 51 months, disease progression was detected in 25 patients (56.8%), and 29 patients (65.9%) died of any cause. The median PFS and OS were 15.0 and 21.0 months, respectively. The Kaplan-Meier analysis indicated that patients with high ACCI scores or pT4b BCa had worse PFS (P = 0.003 and P = 0.002, respectively) and OS (P = 0.016 and P = 0.034, respectively) than those with low ACCI scores or pT4a BCa. On multivariate analysis, pT4b substage [hazard ratio (HR), 4.166; 95% CI, 1.549-11.206; P = 0.005] and ACCI score >4 (HR, 2.329; 95% CI, 1.105-4.908; P = 0.026) remained independent risk factors for PFS and OS, respectively. Conclusion Our study revealed that the pT4b substage is associated with a poor prognosis and that the ACCI score is a relevant and practical method to evaluate survival outcomes in patients with pT4 BCa after Cx.
Collapse
Affiliation(s)
- Xuesong Bai
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guo Chen
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shihai Shang
- Department of Urology, Wansheng People’s Hospital, Chongqing, China
| | - Senlin Li
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Huanrui Liu
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhenwei Feng
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin Gou
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Correspondence: Xin Gou
| |
Collapse
|
11
|
Hoeh B, Flammia RS, Hohenhorst L, Sorce G, Chierigo F, Panunzio A, Tian Z, Saad F, Gallucci M, Briganti A, Terrone C, Shariat SF, Graefen M, Tilki D, Antonelli A, Kluth LA, Becker A, Chun FKH, Karakiewicz PI. Outcomes of robotic-assisted versus open radical cystectomy in a large-scale, contemporary cohort of bladder cancer patients. J Surg Oncol 2022; 126:830-837. [PMID: 35661361 DOI: 10.1002/jso.26973] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/30/2022] [Accepted: 05/18/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES To test for differences in perioperative outcomes and total hospital costs (THC) in nonmetastatic bladder cancer patients undergoing open (ORC) versus robotic-assisted radical cystectomy (RARC). METHODS We relied on the National Inpatient Sample database (2016-2019). Statistics consisted of trend analyses, multivariable logistic, Poisson, and linear regression models. RESULTS Of 5280 patients, 1876 (36%) versus 3200 (60%) underwent RARC versus ORC. RARC increased from 32% to 41% (estimated annual percentage change [EAPC]: + 8.6%; p = 0.02). Rates of transfusion (8% vs. 16%), intraoperative (2% vs. 3%), wound (6% vs. 10%), and pulmonary (6% vs. 10%) complications were lower in RARC patients (all p < 0.05). Moreover, median length of stay (LOS) was shorter in RARC (6 vs. 7days; p < 0.001). Conversely, median THC (31,486 vs. 27,162$; p < 0.001) were higher in RARC. Multivariable logistic regression-derived odds ratios addressing transfusion (0.49), intraoperative (0.53), wound (0.68), and pulmonary (0.71) complications favored RARC (all p < 0.01). In multivariable Poisson and linear regression models, RARC was associated with shorter LOS (Rate ratio:0.86; p < 0.001), yet higher THC (Coef.:5,859$; p < 0.001). RARC in-hospital mortality was lower (1% vs. 2%; p = 0.04). CONCLUSIONS RARC complications, LOS, and mortality appear more favorable than ORC, but result in higher THC. The favorable RARC profile contributes to its increasing popularity throughout the United States.
Collapse
Affiliation(s)
- Benedikt Hoeh
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.,Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Rocco S Flammia
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy
| | - Lukas Hohenhorst
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriele Sorce
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Chierigo
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Andrea Panunzio
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.,Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Zhe Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Fred Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| | - Michele Gallucci
- Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy
| | - Alberto Briganti
- Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Terrone
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.,Department of Urology, Weill Cornell Medical College, New York, New York, USA.,Department of Urology, University of Texas Southwestern, Dallas, Texas, USA.,Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.,Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Markus Graefen
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Department of Urology, Koc University Hospital, Istanbul, Turkey
| | - Alessandro Antonelli
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Luis A Kluth
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Andreas Becker
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Felix K H Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada
| |
Collapse
|
12
|
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).
Collapse
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
| |
Collapse
|
13
|
Fuchs HF, Collins JW, Babic B, DuCoin C, Meireles OR, Grimminger PP, Read M, Abbas A, Sallum R, Müller-Stich BP, Perez D, Biebl M, Egberts JH, van Hillegersberg R, Bruns CJ. Robotic-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer training curriculum-a worldwide Delphi consensus study. Dis Esophagus 2022; 35:6348318. [PMID: 34382061 DOI: 10.1093/dote/doab055] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/29/2021] [Accepted: 07/23/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Structured training protocols can safely improve skills prior initiating complex surgical procedures such as robotic-assisted minimally invasive esophagectomy (RAMIE). As no consensus on a training curriculum for RAMIE has been established so far it is our aim to define a protocol for RAMIE with the Delphi consensus methodology. METHODS Fourteen worldwide RAMIE experts were defined and were enrolled in this Delphi consensus project. An expert panel was created and three Delphi rounds were performed starting December 2019. Items required for RAMIE included, but were not limited to, virtual reality simulation, wet-lab training, proctoring, and continued monitoring and education. After rating performed by the experts, consensus was defined when a Cronbach alpha of ≥0.80 was reached. If ≥80% of the committee reached a consensus an item was seen as fundamental. RESULTS All Delphi rounds were completed by 12-14 (86-100%) participants. After three rounds analyzing our 49-item questionnaire, 40 items reached consensus for a training curriculum of RAMIE. CONCLUSION The core principles for RAMIE training were defined. This curriculum may lead to a wider adoption of RAMIE and a reduction in time to reach proficiency.
Collapse
Affiliation(s)
- Hans F Fuchs
- Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany
| | | | - Benjamin Babic
- Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany
| | | | | | | | | | | | | | | | - Daniel Perez
- Department of Surgery, University of Hamburg, Hamburg, Germany
| | | | | | | | - Christiane J Bruns
- Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany
| |
Collapse
|
14
|
W AC, GJ N, T M, A A, A T, AL W, A R, S UL, J U, D M, R I, MJA P, K P. The impact of socio-economic deprivation on recovery following robotic assisted radical cystectomy. Urologia 2022; 90:136-140. [PMID: 35673803 DOI: 10.1177/03915603221100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Despite enhanced recovery programmes, length of stay is variable following robotic assisted radical cystectomy (RARC). The aim of this study was to assess the impact socioeconomic deprivation on recovery following RARC. Methods: The prospectively maintained RARC databases at two tertiary referral hospitals were reviewed from 2015 to 2017. Demographic, histological, and outcome data including length of stay (LOS), operation time and blood loss were recorded. The Index of Multiple Deprivation, was chosen as a deprivation index as this is used by the UK government to direct funding and resources to regions, towns and postal codes by assessing a number of indicators. Results: During the study period, 340 consecutive patients underwent RARC. Deprivation deciles were significantly higher in site 1 patients (7.9 in site 1 vs 6.6 in site 2, p < 0.001) implying that these patients are more likely to have higher incomes, levels of education and improved living environments. The mean operating time was longer in the site 1 cohort (397 vs 366 min, p > 0.001) with a reduced mean blood loss volume (252 and 484 mL, p < 0.001). There was a significant difference in mean LOS (6.2 days in site 1 vs 10.6 days in site 2, p < 0.001). On multivariable analysis, a higher deprivation decile did not predict LOS (OR = 1, 95% CI = 0.9–1.1, p = 0.407). Sex and operation site were however significantly associated with LOS (p = 0.006 and <0.001). Conclusion: Recovery following RARC was independent of socioeconomic status when comparing two hospitals with diverse catchment areas in the UK.
Collapse
Affiliation(s)
- Abou Chedid W
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Nason GJ
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Mahesan T
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Ashton A
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Tay A
- Department of Urology, St George’s Hospital, London, UK
| | - Walsh AL
- Department of Urology, St George’s Hospital, London, UK
| | - Roodhouse A
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Uribe-Lewis S
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Uribe J
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Moschonas D
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Issa R
- Department of Urology, St George’s Hospital, London, UK
| | - Perry MJA
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - Patil K
- Department of Urology, Royal Surrey NHS Foundation Trust, Guildford, UK
| |
Collapse
|
15
|
Wijburg CJ, Hannink G, Michels CT, Weijerman PC, Issa R, Tay A, Decaestecker K, Wiklund P, Hosseini A, Sridhar A, Kelly J, d'Hondt F, Mottrie A, Klaver S, Edeling S, Dell'Oglio P, Montorsi F, Rovers MM, Witjes JA. Learning Curve Analysis for Intracorporeal Robot-assisted Radical Cystectomy: Results from the EAU Robotic Urology Section Scientific Working Group. EUR UROL SUPPL 2022; 39:55-61. [PMID: 35528784 PMCID: PMC9068730 DOI: 10.1016/j.euros.2022.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2022] [Indexed: 11/29/2022] Open
Abstract
Background The utilisation of robot-assisted radical cystectomy with intracorporeal reconstruction (iRARC) has increased in recent years. Little is known about the length of the learning curve (LC) for this procedure. Objective To study the length of the LC for iRARC in terms of 90-d major complications (MC90; Clavien-Dindo grade ≥3), 90-d overall complications (OC90, Clavien-Dindo grades 1–5), operating time (OT), estimated blood loss (EBL), and length of hospital stay (LOS). Design, setting, and participants This was a retrospective analysis of all consecutive iRARC cases from nine European high-volume hospitals with ≥100 cases. All patients had bladder cancer for which iRARC was performed, with an ileal conduit or neobladder as the urinary diversion. Outcome measurements and statistical analysis Outcome parameters used as a proxy for LC length were the number of consecutive cases needed to reach a plateau level in two-piece mixed-effects models for MC90, OC90, OT, EBL, and LOS. Results and limitations A total of 2186 patients undergoing iRARC between 2003 and 2018were included. The plateau levels for MC90 and OC90 were reached after 137 cases (95% confidence interval [CI] 80–193) and 97 cases (95% CI 41–154), respectively. The mean MC90 rate at the plateau was 14% (95% CI 7–21%). The plateau level was reached after 75 cases (95% CI 65–86) for OT, 88 cases (95% CI 70–106) for EBL, and 198 cases (95% CI 130–266) for LOS. A major limitation of the study is the difference in the balance of urinary diversion types between centres. Conclusions This multicentre retrospective analysis for the iRARC LC among nine European centres showed that 137 consecutive cases were needed to reach a stable MC90 rate. Patient summary We carried out a multicentre analysis of the surgical learning curve for robot-assisted removal of the bladder and bladder reconstruction in patients with bladder cancer. We found that 137 consecutive cases were needed to reach a stable rate of serious complications.
Collapse
|
16
|
Del Giudice F, Chung BI, Moschini M, Mari A, D'Andrea D, Soria F, Krajewski W, Gallioli A, DE Berardinis E, Maggi M. Comment on: 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 2022; 74:119-121. [PMID: 35272453 DOI: 10.23736/s2724-6051.22.04872-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Francesco Del Giudice
- Department of Maternal-Infant and Urological Sciences, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy - .,Stanford University School of Medicine, Department of Urology, Stanford, CA, USA -
| | - Benjamin I Chung
- Stanford University School of Medicine, Department of Urology, Stanford, CA, USA
| | - Marco Moschini
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andrea Mari
- Unit of Oncologic Minimally Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy
| | - David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Wojciech Krajewski
- Department of Urology and Oncological Urology, Wrocław Medical University, Wrocław, Poland
| | - Andrea Gallioli
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - Ettore DE Berardinis
- Department of Maternal-Infant and Urological Sciences, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Martina Maggi
- Department of Maternal-Infant and Urological Sciences, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | | |
Collapse
|
17
|
From Fast-track to Enhanced Recovery after Surgery (ERAS) in Radical Cystectomy Pathways –a Nursing Perspective. Asia Pac J Oncol Nurs 2022; 9:100048. [PMID: 35647225 PMCID: PMC9136268 DOI: 10.1016/j.apjon.2022.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/24/2022] [Indexed: 01/02/2023] Open
Abstract
Objective The purpose of this narrative review is to summarize existing knowledge and evidence about the establishment of enhanced recovery after surgery (ERAS) pathways with emphasize on radical cystectomy (RC), and the emerging and prominent role of nursing within the ERAS pathway. The current status of implementation and adherence to ERAS protocol in RC is discussed and the impact on primary outcomes according to ERAS is summarized. Methods The review was conducted based on a focused search in PubMed and CINAHL. Results The goal of a modern RC enhanced recovery protocols (ERPs) anno 2022 is to have a positive impact on patient care from diagnosis throughout recovery with focus on the quality, rather than speed, of recovery. This may be more in alignment with the patient's needs and preferences. Conclusions Nursing has been in the forefront since the establishment of ERAS, and the nurse-coordinator must be skilled in evidence-based medicine and have excellent communicative competencies to support the patient journey. Implementation of ERAS have reduced hospitalization by improved minimal surgery, optimized anesthetic regimes without increasing readmission rates. It is not known which items can reduce post-operative complications. In the future, nurses should seek a more prominent and leading role during the implementation process and take responsibility for continued education of the staff. Likewise, future nursing interventions will focus on early identification of modifiable risk factors, and a deeper exploration of the patients personally needs and preferences to upcoming surgery could optimize adherence throughout the pathway, which may add to positive outcomes.
Collapse
|
18
|
Djordjevic D, Dragicevic S, Vukovic M. Mini-laparotomy radical cystectomy with limited bowel externalization during ileal conduit urinary diversion reduces the rate of postoperative complications: a match-paired, single centered analysis. Acta Chir Belg 2022:1-7. [PMID: 35019802 DOI: 10.1080/00015458.2022.2025724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To assess the feasibility and functional outcomes of mini-laparotomy radical cystectomy (RC) in association with limited bowel externalization during ileal conduit urinary diversion. METHODS Between January 2018 and March 2020, 53 patients underwent RC plus pelvic lymph node dissection (PLND) for invasive carcinoma of the urinary bladder. This group of patients was intentionally treated utilizing the mini-laparotomy approach, with the addition of limited bowel externalization during conduit preparation and match-paired with 46 examinees from a historical series of patients who underwent conventional open RC plus PLND and ileal conduit diversion. Clinicopathological features and perioperative outcomes were examined from medical records, while postoperative pain was evaluated through the Visual Analog Scale for Pain (VAS). Mean pain scores were evaluated on postoperative days (POD) 1-3. RESULTS There was no difference in specific intraoperative complications between groups, with a median (range) incision length of 8 (5-10) cm within the first group and 16.3 (12-22.6) cm within the second group. The first group had less postoperative pain compared with patients in the second group, with mean pain scores significantly lower across POD 1-3, 3.8 (IQR: 0-6) versus 6.7 (IQR: 3.8-8.1) and 2.5 (IQR: 1-3.7) versus 4.6 (IQR: 3-6), respectively (p = .012 and .002). CONCLUSIONS By using this technique, we were able to significantly reduce patients' postoperative pain, time to bowel restitution, and hospital stay, which are major issues in minimizing short-term postoperative complications of conventional open surgery.
Collapse
Affiliation(s)
| | | | - Marko Vukovic
- Urology Clinic, Euromedic General Hospital, Belgrade, Serbia
- Urology Clinic, Clinical Centre of Montenegro, Podgorica, Montenegro
| |
Collapse
|
19
|
Lee G, Patel HV, Srivastava A, Ghodoussipour S. Updates on enhanced recovery after surgery for radical cystectomy. Ther Adv Urol 2022; 14:17562872221109022. [PMID: 35844831 PMCID: PMC9280843 DOI: 10.1177/17562872221109022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022] Open
Abstract
Enhanced Recovery after Surgery (ERAS) is a multimodal pathway that provides evidence-based guidance for improving perioperative care and outcomes in patients undergoing surgery. In 2013, the ERAS society released its original guidelines for radical cystectomy (RC) for bladder cancer (BC), adopting much of its supporting data from colorectal literature. In the last decade, growing interest in ERAS has increased RC-specific ERAS research, including prospective randomized controlled trials (RCTs). Collective data suggest ERAS contributes to improved complication rates, decreased hospital length-of-stay, and/or time to bowel recovery. Various institutions have adopted modified versions of the ERAS pathway, yet there remains a lack of consensus on the efficacy of specific ERAS items and standardization of the protocol. In this review, we summarize updated evidence and practice patterns of ERAS pathways for RC since the introduction of the original 2013 guidelines. Novel target interventions, including use of immunonutrition, prehabilitation, alvimopan, and methods of local analgesia are reviewed. Finally, we discuss barriers to implementing and future steps in advancing the ERAS movement.
Collapse
Affiliation(s)
- Grace Lee
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Hiren V Patel
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Arnav Srivastava
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, 195 Little Albany Street, Room 4561, New Brunswick, NJ 08903, USA
| |
Collapse
|
20
|
Influence of steep Trendelenburg position on postoperative complications: a systematic review and meta-analysis. J Robot Surg 2021; 16:1233-1247. [PMID: 34972981 PMCID: PMC9606098 DOI: 10.1007/s11701-021-01361-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022]
Abstract
Intraoperative physiologic changes related to the steep Trendelenburg position have been investigated with the widespread adoption of robot-assisted pelvic surgery (RAPS). However, the impact of the steep Trendelenburg position on postoperative complications remains unclear. We conducted a meta-analysis to compare RAPS to laparoscopic/open pelvic surgery with regards to the rates of venous thromboembolism (VTE), cardiac, and cerebrovascular complications. Meta-regression was performed to evaluate the influence of confounding risk factors. Ten randomized controlled trials (RCTs) and 47 non-randomized controlled studies (NRSs), with a total of 380,125 patients, were included. Although RAPS was associated with a decreased risk of VTE and cardiac complications compared to laparoscopic/open pelvic surgery in NRSs [risk ratio (RR), 0.59; 95% CI 0.51–0.72, p < 0.001 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively], these differences were not confirmed in RCTs (RR 0.92; 95% CI 0.52–1.62, p = 0.77 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively). In subgroup analyses of laparoscopic surgery, there was no significant difference in the risk of VTE and cardiac complications in both RCTs and NRSs. In the meta-regression, none of the risk factors were found to be associated with heterogeneity. Furthermore, no significant difference was observed in cerebrovascular complications between RAPS and laparoscopic/open pelvic surgery. Our meta-analysis suggests that the steep Trendelenburg position does not seem to affect postoperative complications and, therefore, can be considered safe with regard to the risk of VTE, cardiac, and cerebrovascular complications. However, proper individualized preventive measures should still be implemented during all surgeries including RAPS to warrant patient safety.
Collapse
|
21
|
Opportunities and Problems of the Consensus Conferences in the Care Robotics. Healthcare (Basel) 2021; 9:healthcare9121624. [PMID: 34946350 PMCID: PMC8701370 DOI: 10.3390/healthcare9121624] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/17/2021] [Accepted: 11/20/2021] [Indexed: 02/02/2023] Open
Abstract
Care robots represent an opportunity for the health domain. The use of these devices has important implications. They can be used in surgical operating rooms in important and delicate clinical interventions, in motion, in training-and-simulation, and cognitive and rehabilitation processes. They are involved in continuous processes of evolution in technology and clinical practice. Therefore, the introduction into routine clinical practice is difficult because this needs the stability and the standardization of processes. The agreement tools, in this case, are of primary importance for the clinical acceptance and introduction. The opinion focuses on the Consensus Conference tool and: (a) highlights its potential in the field; (b) explores the state of use; (c) detects the peculiarities and problems (d) expresses ideas on how improve its diffusion.
Collapse
|
22
|
Tan WS, Leow JJ, Marchese M, Sridhar A, Hellawell G, Mossanen M, Teoh JYC, Fowler S, Colquhoun AJ, Cresswell J, Catto JWF, Trinh QD, Kelly JD. Defining Factors Associated with High-quality Surgery Following Radical Cystectomy: Analysis of the British Association of Urological Surgeons Cystectomy Audit. EUR UROL SUPPL 2021; 33:1-10. [PMID: 34723215 PMCID: PMC8546928 DOI: 10.1016/j.euros.2021.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 11/28/2022] Open
Abstract
Background Radical cystectomy (RC) is associated with high morbidity. Objective To evaluate healthcare and surgical factors associated with high-quality RC surgery. Design setting and participants Patients within the prospective British Association of Urological Surgeons (BAUS) registry between 2014 and 2017 were included in this study. Outcome measurements and statistical analysis High-quality surgery was defined using pathological (absence of positive surgical margins and a minimum of a level I lymph node dissection template with a minimum yield of ten or more lymph nodes), recovery (length of stay ≤10 d), and technical (intraoperative blood loss <500 ml for open and <300 ml for minimally invasive RC) variables. A multilevel hierarchical mixed-effect logistic regression model was utilised to determine the factors associated with the receipt of high-quality surgery and index admission mortality. Results and limitations A total of 4654 patients with a median age of 70.0 yr underwent RC by 152 surgeons at 78 UK hospitals. The median surgeon and hospital operating volumes were 23.0 and 47.0 cases, respectively. A total of 914 patients (19.6%) received high-quality surgery. The minimum annual surgeon volume and hospital volume of ≥20 RCs/surgeon/yr and ≥68 RCs/hospital/yr, respectively, were the thresholds determined to achieve better rates of high-quality RC. The mixed-effect logistic regression model found that recent surgery (odds ratio [OR]: 1.22, 95% confidence interval [CI]: 1.11-1.34, p < 0.001), laparoscopic/robotic RC (OR: 1.85, 95% CI: 1.45-2.37, p < 0.001), and higher annual surgeon operating volume (23.1-33.0 cases [OR: 1.54, 95% CI: 1.16-2.05, p = 0.003]; ≥33.1 cases [OR: 1.64, 95% CI: 1.18-2.29, p = 0.003]) were independently associated with high-quality surgery. High-quality surgery was an independent predictor of lower index admission mortality (OR: 0.38, 95% CI: 0.16-0.87, p = 0.021). Conclusions We report that annual surgeon operating volume and use of minimally invasive RC were predictors of high-quality surgery. Patients receiving high-quality surgery were independently associated with lower index admission mortality. Our results support the role of centralisation of complex oncology and implementation of a quality assurance programme to improve the delivery of care. Patient summary In this registry study of patients treated with surgical excision of the urinary bladder for bladder cancer, we report that patients treated by a surgeon with a higher annual operative volume and a minimally invasive approach were associated with the receipt of high-quality surgery. Patients treated with high-quality surgery were more likely to be discharged alive following surgery.
Collapse
Affiliation(s)
- Wei Shen Tan
- Division of Surgery & Interventional Science, University College London, London, UK.,Department of Urology, Royal Free London NHS Foundation Trust, London, UK
| | - Jeffrey J Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Maya Marchese
- Center for Surgery and Public Health, Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ashwin Sridhar
- Division of Surgery & Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Giles Hellawell
- Department of Urology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Matthew Mossanen
- Lank Center for Genitourinary Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jeremy Y C Teoh
- The S H Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Sarah Fowler
- British Association of Urological Surgeons, London, UK
| | - Alexandra J Colquhoun
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jo Cresswell
- Department of Urology, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Quoc-Dien Trinh
- Lank Center for Genitourinary Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - John D Kelly
- Division of Surgery & Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | | |
Collapse
|
23
|
Zillioux J, Werneburg GT, Goldman HB. Same-day discharge across FPMRS surgical cases is safe and feasible: A 10-year single-surgeon experience. Neurourol Urodyn 2021; 40:1754-1760. [PMID: 34224599 DOI: 10.1002/nau.24739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/27/2021] [Accepted: 06/10/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Enhanced recovery after surgery protocols and increased attention to value-based care have led to the reconsideration of routine postoperative admission in female pelvic medicine and reconstructive surgery (FPMRS) cases. We aimed to assess trends in same-day discharge (SDD) and associated readmissions and emergency room visits in a single-surgeon 10-year experience. METHODS The electronic medical record was queried for 30-day outcomes (readmission and emergency department visits with associated indications) for all cases performed between June 2010 and August 2020 by a single FPMRS surgeon. Non-FPMRS specialty cases were excluded. Patient characteristics and 30-day outcomes were compared based on SDD status for the overall cohort as well as the subset of cases traditionally involving an overnight stay (i.e., robotic transabdominal, apical prolapse repair). RESULTS 1793 surgeries were identified and analyzed, including 357 apical prolapse repairs, 370 slings, 392 neuromodulation and 114 complex mesh excisions. The majority (79.1%) had SDD. For admitted patients, mean length of stay was 1.5 (1.3) days. Among cases traditionally involving overnight stay, rates of SDD were significantly higher in 2020 than 2010 (84% vs. 32%, p < 0.001), and increased over time. Overall rates of 30-day readmission and ED visits were low (1.9% and 2.6%, respectively) and did not differ based on SDD status (p = 0.76). Readmissions occurred at mean 11.6 (7.0) days, most commonly for urinary tract infection (13/34). CONCLUSIONS SDD is not associated with increased 30-day readmission or ED visits across a wide breadth of FPMRS cases. SDD is safe and feasible in the majority of FPMRS cases.
Collapse
Affiliation(s)
- Jacqueline Zillioux
- Department of Urology, Glickman Urological and Kidney Institute, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Glenn T Werneburg
- Department of Urology, Glickman Urological and Kidney Institute, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Howard B Goldman
- Department of Urology, Glickman Urological and Kidney Institute, Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
24
|
The robotic approach improves the outcomes of ERAS protocol after radical cystectomy: A prospective case-control analysis. Urol Oncol 2021; 39:833.e1-833.e8. [PMID: 34092478 DOI: 10.1016/j.urolonc.2021.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/01/2021] [Accepted: 04/09/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Minimally-invasive approach is one of the mainstays of Enhanced Recovery After Surgery (ERAS) pathways. Robot-assisted radical cystectomy (RARC) introduction has reduced the surgical burden on patient's recovery. Accordingly, ERAS protocol benefits may be more striking in RARC patients. We evaluated the impact of surgical approach on perioperative outcomes, Fast Track (FT) recovery steps and Trifecta success rates in patients undergoing RC followed by FT protocol. MATERIALS AND METHODS We considered 147 patients who underwent RC, with open (Open radical cystectomy [ORC]; 47.6%) or robotic (RARC; 52.4%) approach at 2 tertiary centers. Urinary diversions were ileal conduit or orthotopic neobladder. All patients underwent FT protocol. We analyzed perioperative surgical and functional outcomes and Trifecta success rates (namely, defecation <5 days, in-hospital stay <10 days and no major complications). Uni and multivariable logistic regression explored the predictors for Trifecta success and the impact of surgical approach on recovery steps. RESULTS Patients undergoing RARC had higher FT adherence (95% vs. 61%) compared to ORCs (P < 0.01). Trifecta success rates were higher for RARC (79.2% vs 28.6%; P < 0.001). At multivariable analyses, RARC was an independent predictor for Trifecta success (OR 9.1), early mobilization (OR 5.9) and FT adherence (OR 3.33; all P < 0.001). Surgical technique was not associated with major complications or readmission within 90 days (all P > 0.05). CONCLUSION RARC has more favorable perioperative outcomes compared to ORC, with higher Trifecta success rates. Accordingly, robotic approach should be ideally included in every center where ERAS protocol is applied to RC for maximizing patient's recovery.
Collapse
|
25
|
Potential for optimizing the perioperative care in robotic prostatectomy patients by adoption of enhanced recovery after surgery principles. J Robot Surg 2021; 16:415-419. [PMID: 34053017 DOI: 10.1007/s11701-021-01260-1] [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: 04/08/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
Several benefits have been reported after applying the principles of enhanced recovery after surgery (ERAS) into the perioperative care of patients undergoing robot-assisted radical prostatectomy (RARP). Nevertheless, there are still barriers. We aimed to identify the key areas by systematically surveying urology departments in Germany and Austria. A 27-question survey on the adoption of ERAS principles for the perioperative care of RARP patients was designed, in compliance with the guidelines on good practice in conducting and reporting of survey research. After positive testing for face and content validity, the survey was distributed via postal mail to 82 departments performing RARP. In total, 39 departments responded to our survey (response rate 48%). The ERAS adoption rates ranged from 21 to 97%, with nine ERAS principles being widely adopted (72-92% of the departments). The lowest adoption rates and, subsequently, the largest potential for optimization were detected for the preoperative nutrition counselling (21%), preoperative pelvic floor physiotherapy (54%), postoperative early initiation of nutrition (44%) and postoperative patient audit for further quality improvement (36%). High-volume centers performed more frequently a perioperative nutrition counselling (8/27; 30%) than low-volume centers (0/12; 0%; p = 0.036). The implementation of the ERAS principles into the perioperative care algorithm were medium-to-high, yet not optimal. Our real-world data assessment revealed four key areas showing low adoption rates (nutrition counselling, preoperative pelvic floor physiotherapy, early initiation of nutrition and patient audit), implying a great potential for further optimization.
Collapse
|
26
|
Martin AS, Corcoran AT. Contemporary techniques and outcomes of robotic assisted radical cystectomy with intracorporeal urinary diversion. Transl Androl Urol 2021; 10:2216-2232. [PMID: 34159105 PMCID: PMC8185677 DOI: 10.21037/tau.2019.09.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The open approach to radical cystectomy continues to be accompanied by significant morbidity despite enhanced recovery protocols (ERP). Robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has become an increasingly popular technique for removal of aggressive bladder cancer and subsequent urinary diversion. Randomized clinical trials comparing the robotic and open techniques address the uncertainty surrounding oncological efficacy of the RARC and show that RARC is at least comparable to open radical cystectomy (ORC) in terms of oncologic adequacy and survival. Although RARC with ICUD is a technically challenging procedure, surgeons have noted ergonomic advantages while patients experience less blood loss and quicker time to recovery and to adjuvant chemotherapy (AC), if necessary. Even with these benefits, there is a paucity of data describing outcomes of ICUD. For those surgeons who have switched to ICUD, priority remains standardization of a protocol for the reconstructive component and for a safe transition from extracorporeal urinary diversion (ECUD) to ICUD. Additionally, there is a need for evidence of reduced financial toxicity for the patient, as well as more comprehensive cost-effectiveness analyses. The literature from this review represents 10 years of accumulating data on techniques and outcomes of RARC with ICUD.
Collapse
Affiliation(s)
- Ardenne S Martin
- Department of Urology, NYU Winthrop Hospital, Garden City, NY, USA
| | | |
Collapse
|
27
|
Wei H, Gao J, Wang M, Wasilijiang W, Ai P, Zhou X, Cui L, Song L, Wu A, Xing N, Niu Y. Impact of preoperative body mass index on perioperative outcomes is optimized by enhanced recovery protocols in laparoscopic radical cystectomy with intracorporeal urinary diversion. Transl Androl Urol 2021; 10:2008-2018. [PMID: 34159081 PMCID: PMC8185665 DOI: 10.21037/tau-21-171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background We aimed to examine whether body mass index (BMI) had an impact on clinical outcomes of laparoscopic radical cystectomy with intracorporeal urinary diversion. Furthermore, we analyzed the optimization of enhanced recovery protocols (ERPs) on the impact of BMI on clinical outcomes. Methods By searching our database, data of 83 consecutive patients were retrospectively collected, including 37 patients with a BMI <24 kg/m2 (group A) and 46 patients with a BMI ≥24 kg/m2 (group B). The baseline and peri-operative variables of the two groups were compared. Subgroup analysis was conducted for ERPs (11 patients in group A1, 18 patients in group B1) and conventional recovery protocols (CRPs; 26 patients in group A2, 28 patients in group B2). The primary outcomes were 30-day overall complication rate and ΔALBmin (reduction proportion of minimum albumin). The secondary outcomes were operative time and length of stay. Results The baseline variables were similar between the two groups (P>0.05). The 30-day overall complication rate, operative time, and length of stay were similar between the two groups (P>0.05). But post-operative nausea and vomiting (PONV) was higher in group A than in group B (32.4% vs. 8.7%, P=0.014). Group A was associated with lower serum albumin level pre-operatively and on post-operative days 1–3. ΔALBmin was higher in group A than in group B (33.08%±9.88% vs. 27.92%±8.52%, P<0.05). In the subgroup analysis, the CRPs group presented similar results, with group A2 showing higher PONV rate, lower albumin level pre- and post-operatively, and higher level of reduction proportion (P<0.05). For the ERPs group, the PONV rate, pre-operative albumin level, and reduction proportion were similar between group A1 and B1 (P>0.05). Multivariable analysis showed that PONV and CRPs were independently associated with ΔALBmin ≥34% (P<0.05). Conclusions BMI had no impact on the 30-day overall complication rate, operative time, and length of stay of patients who underwent laparoscopic radical cystectomy with intracorporeal urinary diversion. BMI <24 kg/m2 was associated with higher PONV rate and more albumin loss, both of which could be optimized by ERPs.
Collapse
Affiliation(s)
- Houyi Wei
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jiandong Gao
- Department of Anaesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Mingshuai Wang
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Wahafu Wasilijiang
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pan Ai
- Department of Anaesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiaoguang Zhou
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Liyan Cui
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Liming Song
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Anshi Wu
- Department of Anaesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Nianzeng Xing
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinong Niu
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
28
|
Abstract
The cornerstone for diagnosis and treatment of bladder and upper tract urothelial carcinoma involves surgery. Transurethral resection of bladder tumors forms the basis of further management. Radical cystectomy for invasive bladder carcinoma provides good oncologic outcomes. However, it can be a morbid procedure, and advances such as minimally invasive surgery and early recovery after surgery need to be incorporated into routine practice. Diagnostic ureteroscopy for upper tract carcinoma is needed in cases of doubt after cytology and imaging studies. Low-risk cancers can be managed with conservative endoscopic surgery without compromising oncological outcomes; however, high-risk disease necessitates radical nephroureterectomy.
Collapse
|
29
|
Rodrigues Pessoa R, Mueller AC, Boxley P, Flaig TW, Piper C, Konety B, Yu JB, Gershman B, Kukreja J, Kim SP. Systematic review and meta-analysis of radiation therapy for high-risk non-muscle invasive bladder cancer. Urol Oncol 2021; 39:786.e1-786.e8. [PMID: 33846085 DOI: 10.1016/j.urolonc.2021.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/28/2021] [Accepted: 03/14/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Radiation therapy (XRT) has been investigated as a possible treatment for high-risk non-muscle invasive bladder cancer (NMIBC) with the goal of bladder preservation, especially with the ongoing Bacillus Calmette-Guerin (BCG) shortage. Yet, little is known about the clinical efficacy and the quality of evidence supporting XRT for NMIBC. Herein, we performed a systematic review and meta-analysis to evaluate XRT in the treatment of patients with high-risk NMIBC. METHODS Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Web of Science were searched for high-risk NMIBC (high grade T1, T1/Ta with associated risk features: carcinoma in-situ (CIS), multifocality, > 5cm in diameter, and/or multiple recurrences) treated with primary XRT. Outcomes evaluated were recurrence-free survival (RFS), cancer-specific-survival (CSS), overall survival (OS), and salvage cystectomy and progression to metastatic disease rates. A meta-analysis was performed to assess outcomes for XRT in NMIBC. RESULTS Overall,13 studies including 746 patients met the search criteria. The 5-year rates of RFS, CSS and OS were 54% (95% CI = 38% - 70%), 86% (95% CI = 80% - 92%), and 72% (95% CI = 64% - 79%). Notably, 13% of patients proceeded to salvage radical cystectomy and 9% developed metastatic disease. All studies were of poor quality, comprising single institution and retrospective studies with only one clinical trial. CONCLUSION XRT for high-risk NMIBC provides some degree of oncologic control, although distant progression was noted. In the setting of the low-quality evidence, a prospective clinical trial is needed to clearly define the risks and benefits of this approach.
Collapse
Affiliation(s)
| | - Adam C Mueller
- University of Colorado, Department of Radiation Oncology, Aurora, CO
| | - Peter Boxley
- University of Colorado, Division of Urology, Aurora, CO
| | - Thomas W Flaig
- University of Colorado, Division of Medical Oncology, Aurora, CO
| | - Christi Piper
- University of Colorado, Strauss Health Sciences Library, Aurora, CO
| | | | - James B Yu
- Yale University, Department of Radiation Oncology, New Haven, CT; Yale University, Cancer Outcomes and Public Policy Effectiveness Research, (COPPER) Center, New Haven, CT
| | - Boris Gershman
- Beth Israel Deaconess Medical Center, Division of Urologic Surgery, Boston, MA
| | - Janet Kukreja
- University of Colorado, Division of Urology, Aurora, CO
| | - Simon P Kim
- University of Colorado, Division of Urology, Aurora, CO; Yale University, Cancer Outcomes and Public Policy Effectiveness Research, (COPPER) Center, New Haven, CT.
| |
Collapse
|
30
|
Piazza P, Rosiello G, Chacon VT, Puliatti S, Amato M, Farinha R, Schiavina R, Brunocilla E, Berquin C, Develtere D, Sinatti C, Van Puyvelde H, De Groote R, Schatteman P, De Naeyer G, D'Hondt F, Mottrie A. Robot-assisted Cystectomy with Intracorporeal Urinary Diversion After Pelvic Irradiation for Prostate Cancer: Technique and Results from a Single High-volume Center. Eur Urol 2021; 80:489-496. [PMID: 33838960 DOI: 10.1016/j.eururo.2021.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Radiation therapy (RT) for prostate cancer (PCa) treatment is burdened by high rates of late urinary adverse events (UAEs). The feasibility of robot-assisted cystectomy (RAC) with intracorporeal urinary diversion (ICUD) for treatment of high-grade UAEs has never been assessed. OBJECTIVE To report perioperative outcomes, early (≤90 d) and late (>90 d) complications among patients undergoing RAC for UAEs after RT. DESIGN, SETTING, AND PARTICIPANTS We retrospectively evaluated 32 patients undergoing RAC with ICUD for UAEs in a single tertiary centre. SURGICAL PROCEDURE Surgery was performed using a da Vinci Xi system with adaptation for the primary treatment. MEASUREMENTS Perioperative outcomes included estimated blood loss (EBL), operative time (OT), intraoperative complications, and length of stay (LOS). Data for early and late postoperative complications were collected using the quality criteria recommended by the European Association of Urology. Univariate logistic regressions were performed to test the effect of baseline and perioperative characteristics on early postoperative complications. RESULTS AND LIMITATIONS The median age-adjusted Charlson comorbidity index (ACCI) was 6 (IQR 5-7). The indication for RAC was hemorrhagic radiation cystitis in 29 cases (91%), contracted bladder in two cases (6.2%), and urinary fistula in one case (3.1%). The median EBL, OT, and LOS were 250 ml, 330 min, and 10 d, respectively. A total of 31 (97%) patients received an ileal conduit. The 90-d rate of Clavien-Dindo grade ≥IIIa complications was 28%. The late complication rate was 46% and the perioperative mortality rate was 0%. On univariate analyses, ACCI was the only parameter correlated with the risk of early complications (odds ratio 1.75, 95% confidence interval 1.05-2.9; p = 0.03). The median follow-up was 30 mo (IQR 15-40). The lack of comparison with open cystectomy represents the main limitation. CONCLUSIONS RAC for UAEs in patients with a history of pelvic irradiation is a feasible option in high-volume centers. The use of new technologies can help to overcome some of the technical difficulties and reduce the risk of perioperative and late complications. PATIENT SUMMARY We report our experience with robot-assisted surgery for removal of the bladder in the management of urinary problems after radiation therapy for prostate cancer. When performed by highly experienced surgeons, this is a feasible procedure with outcomes and early and late complication rates that are acceptable.
Collapse
Affiliation(s)
- Pietro Piazza
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium.
| | - Giuseppe Rosiello
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium; Department of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Victor Tames Chacon
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium; Department of Urology, Bellvitge University Hospital, Barcelona, Spain
| | - Stefano Puliatti
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium; Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Amato
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium; Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
| | - Rui Farinha
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| | - Riccardo Schiavina
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Eugenio Brunocilla
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Camille Berquin
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| | - Dries Develtere
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| | - Celine Sinatti
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| | - Hannah Van Puyvelde
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| | - Ruben De Groote
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| | - Peter Schatteman
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| | - Geert De Naeyer
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| | - Frederiek D'Hondt
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| | - Alexandre Mottrie
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium; ORSI Academy, Melle, Belgium
| |
Collapse
|
31
|
Wei H, Wang M, Wasilijiang W, Wang W, Guan X, Zhou X, Song L, Xing N, Niu Y. Modified ileal conduit intracorporeally accomplished following laparoscopic radical cystectomy with enhanced recovery protocols: experience with 48 cases. Transl Androl Urol 2021; 10:1596-1606. [PMID: 33968648 PMCID: PMC8100832 DOI: 10.21037/tau-20-1515] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background This study introduces the results of laparoscopic radical cystectomy with modified intracorporeal ileal conduit (mICIC), which was accompanied by enhanced recovery after surgery (ERAS) protocols. Methods From March 2014 to June 2020, 48 patients underwent mICIC. Patients were divided into ERAS (n=17) and non-ERAS groups (n=31). Baseline and perioperative variables were analyzed. The primary outcome was 90-day complications. Secondary outcomes were operative time, length of stay, two-year overall survival, cancer-specific survival, and disease-free survival. Results Forty-eight patients underwent intracorporeal ileal conduit with no transition to open surgery. Twenty-five patients (52.1%) experienced at least one complication, including 22 minor cases (45.8%) and three major cases (6.2%). The median operative time, urinary diversion time, estimated blood loss, and length of stay were 320 min, 135 min, 200 mL, and 10.5 days, respectively. The median time to flatus and normal diet were two days and three days, respectively. A comparison between ERAS and non-ERAS groups indicated that ERAS implementation was associated with less complications (29.4% vs. 64.5%, P=0.018), faster time to flatus (2 vs. 3 days, P=0.016) and liquid diet (2 vs. 4 days, P<0.001). The results of hydronephrosis and compromised renal function showed no difference between the preoperative period and six months after surgery. The mean follow-up time was 25.4 months, and the two-year overall survival, cancer-specific survival, and disease-free survival rates were 61.3%, 73.2%, and 58.4%, respectively. Conclusions The complication rate and operative time of the mICIC were acceptable. Clinical outcomes can be optimized with ERAS pathway.
Collapse
Affiliation(s)
- Houyi Wei
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Mingshuai Wang
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wahafu Wasilijiang
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Wang
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xing Guan
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaoguang Zhou
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Liming Song
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Nianzeng Xing
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinong Niu
- Institute of Urology, Capital Medical University, Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
32
|
Otaola-Arca H, Coelho R, Patel VR, Orvieto M. Totally intracorporeal robot-assisted urinary diversion for bladder cancer (Part 1). Review and detailed characterization of ileal conduit and modified Indiana pouch. Asian J Urol 2021; 8:50-62. [PMID: 33569272 PMCID: PMC7859455 DOI: 10.1016/j.ajur.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/28/2020] [Accepted: 07/09/2020] [Indexed: 12/01/2022] Open
Abstract
Objective To review the most used robot-assisted cutaneous urinary diversion (CUD) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new consistent images Methods A non-systematic review of the literature with the keywords “bladder cancer”, “cutaneous urinary diversion”, and “radical cystectomy” was performed. Results Twenty-four studies of intracorporeal ileal conduit (ICIC) and two of intracorporeal Indiana pouch (ICIP) were included in the analysis. Regarding ICIC, the patients’ age ranged from 60 to 76 years. The operative time to perform a urinary diversion ranged from 60 to 133 min. The total estimated blood loss ranged from 200 to 1 117 mL. The rate of positive surgical margins ranged from 0% to 14.3%. Early minor and major complication rates ranged from 0% to 71.4% and from 0% to 53.4%, respectively. Late minor and major complication rates ranged from 0% to 66% and from 0% to 32%, respectively. Totally ICIP data are limited to one case report and one clinical series. Conclusion The most frequent type of CUD is ICIC. Randomized studies comparing the performance of the different types of CUD, the performance in an intra- or extracorporeal manner, or the performance of a CUD versus orthotopic ileal neobladder are lacking in the literature. To this day, there are not enough quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used CUD with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images for each technique.
Collapse
Affiliation(s)
- Hugo Otaola-Arca
- Department of Urology, Clínica Alemana, Santiago, Chile.,School of Medicine, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Rafael Coelho
- Universidade de São Paulo Instituto do Câncer do Estado de São Paulo, Brazil
| | - Vipul R Patel
- Department of Urology, AdventHealth Global Robotics Institute, Celebration, United States
| | - Marcelo Orvieto
- Department of Urology, Clínica Alemana, Santiago, Chile.,School of Medicine, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| |
Collapse
|
33
|
|
34
|
Schubach K, Diocera M, Lauridsen SV. Bladder Cancer Nursing Updates (EAUN BC SIG and ANZUP BC SIG): Global Updates and Future Joint Directions. Semin Oncol Nurs 2021; 37:151115. [PMID: 33485733 DOI: 10.1016/j.soncn.2020.151115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Kath Schubach
- ANZUNS President Wyndham Urology Group Melbourne, Australia
| | - Marc Diocera
- Genitourinary Nurse Consultant, Peter MacCallum Cancer Cenrre, Melbourne, Australia.
| | - Susanne Vahr Lauridsen
- Department of Urology, Copenhagen University Hospital, Denmark and WHO-CC, Clinical Health Promotion Centre, The Parker Institute Bispebjerg & Frederiksberg University Hospital, Copenhagen, Denmark
| |
Collapse
|
35
|
Schulz GB, Volz Y, Jokisch F, Casuscelli J, Eismann L, Pfitzinger P, Stief CG, Schlenker B. [Enhanced Recovery After Surgery (ERAS®) after radical cystectomy-current data]. Urologe A 2021; 60:162-168. [PMID: 33439288 DOI: 10.1007/s00120-020-01435-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Radical cystectomy is associated with considerable morbidity and mortality. Based on the solid evidence in colorectal surgery, fast-track/ERAS® (Enhanced Recovery After Surgery) protocols have been developed to improve the perioperative management of patients undergoing radical cystectomy. OBJECTIVES To review the literature and guidelines and evaluate the evidence regarding the different components of ERAS® protocols. MATERIALS AND METHODS Systemic literature search and evaluation of relevant guidelines. RESULTS The majority of ERAS® recommendations for radical cystectomy are based on extrapolations of abdominal surgery studies. Four randomized, controlled trials and one ERAS® guideline were published for radical cystectomy. ERAS® seems to shorten length of stay without increasing the complication rate. Key elements are no bowel preparation, no nasogastric tube, optimized fluid substitution, multimodal pain management, early mobilization, and oral diet. CONCLUSIONS Implementation of ERAS® requires multidisciplinary collaboration. Individualization of an ERAS® program, identification of the most important components and adaption to the specific needs of radical cystectomy patients are future goals.
Collapse
Affiliation(s)
- G B Schulz
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland.
| | - Y Volz
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - F Jokisch
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - J Casuscelli
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - L Eismann
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - P Pfitzinger
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - C G Stief
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - B Schlenker
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| |
Collapse
|
36
|
Radical Cystectomy. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
37
|
Teoh JC, Yee CH, Chiu PF, Chan VS, Chan ET, Ng CF, Chan EY. Key steps in performing robotic-assisted radical cystectomy with intracorporeal urinary diversion and the evidence that we have so far. UROLOGICAL SCIENCE 2021. [DOI: 10.4103/uros.uros_108_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
38
|
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.
Collapse
|
39
|
Coombs C, Hislop D, Taneva SK, Barnard S. The strategic impacts of Intelligent Automation for knowledge and service work: An interdisciplinary review. JOURNAL OF STRATEGIC INFORMATION SYSTEMS 2020. [DOI: 10.1016/j.jsis.2020.101600] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
40
|
Aminoltejari K, Black PC. Radical cystectomy: a review of techniques, developments and controversies. Transl Androl Urol 2020; 9:3073-3081. [PMID: 33457280 PMCID: PMC7807330 DOI: 10.21037/tau.2020.03.23] [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: 12/17/2022] Open
Abstract
Radical cystectomy (RC) with urinary diversion is considered the standard treatment for muscle invasive bladder cancer (MIBC). As one of the most challenging surgical techniques performed by urologists, RC was described many decades ago, and yet patient morbidity rates have remained stagnant over the years. This review outlines the most recent indications and techniques for RC and analyses the current landscape of complications after cystectomy. There is significant room for improvement with respect to both oncologic and functional outcomes after RC. Future efforts will need to focus on unifying reporting methodology, optimal patient selection criteria, enhanced surgical techniques and peri-operative care pathways, and technological advances to improve patient outcomes.
Collapse
Affiliation(s)
- Khatereh Aminoltejari
- Department of Urologic Sciences, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- Department of Urologic Sciences, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
41
|
Sung LH, Yuk HD. Enhanced recovery after surgery of patients undergoing radical cystectomy for bladder cancer. Transl Androl Urol 2020; 9:2986-2996. [PMID: 33457271 PMCID: PMC7807364 DOI: 10.21037/tau.2020.03.44] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Radical cystectomy (RC) is the standard treatment for patients diagnosed with muscle invasive bladder cancer, but is associated with significant morbidity and long hospital stays. Enhanced recovery after surgery (ERAS) is based on a variety of interventions during the peri-treatment stage. It is designed to improve morbidity, enhance recovery, and reduce hospital stays after RC. The study provides an overview of the key elements of the ERAS protocol recommended for patients undergoing RC and directions for further research. We have analyzed the rationale for 15 key elements related to the ERAS protocol: preoperative patient counseling and education, preoperative medical optimization and nutrition, mechanical bowel preparation, preoperative fasting and carbohydrate loading, pre-anesthetic medication, thromboembolic prophylaxis, minimally invasive surgical approach, resection-site drainage, preventing intraoperative hypothermia, perioperative fluid management, perioperative analgesia, urinary drainage, prevention of postoperative ileus, nausea and vomiting, early oral feeding, and early mobilization. Several studies have shown that ERAS improves the recovery of RC patients. Evidence suggests that ERAS facilitates the recovery of RC patients. However, additional randomized controlled studies or large prospective studies are needed to demonstrate the effectiveness of ERAS in RC patients.
Collapse
Affiliation(s)
- Luck Hee Sung
- Department of Urology, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Hyeong Dong Yuk
- Department of Urology, Seoul National University Hospital, Seoul, Korea
| |
Collapse
|
42
|
Mortezavi A, Crippa A, Edeling S, Pokupic S, Dell'Oglio P, Montorsi F, D'Hondt F, Mottrie A, Decaestecker K, Wijburg CJ, Collins J, Kelly JD, Tan WS, Sridhar A, John H, Canda AE, Schwentner C, Rönmark EP, Wiklund P, Hosseini A. Morbidity and mortality after robot-assisted radical cystectomy with intracorporeal urinary diversion in octogenarians: results from the European Association of Urology Robotic Urology Section Scientific Working Group. BJU Int 2020; 127:585-595. [PMID: 33058469 PMCID: PMC8246851 DOI: 10.1111/bju.15274] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objectives To evaluate the postoperative complication and mortality rate following laparoscopic radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in octogenarians. Patients and Methods We conducted a retrospective analysis comparing postoperative complication and mortality rates depending on age in a consecutive series of 1890 patients who underwent RARC with ICUD for bladder cancer between 2004 and 2018 in 10 European centres. Outcomes of patients aged <80 years and those aged ≥80 years were compared with regard to postoperative complications (Clavien–Dindo grading) and mortality rate. Cancer‐specific mortality (CSM) and other‐cause mortality (OCM) after surgery were calculated using the non‐parametric Aalen‐Johansen estimator. Results A total of 1726 patients aged <80 years and 164 aged ≥80 years were included in the analysis. The 30‐ and 90‐day rate for high‐grade (Clavien–Dindo grades III–V) complications were 15% and 21% for patients aged <80 years compared to 11% and 13% for patients aged ≥80 years (P = 0.2 and P = 0.03), respectively. In a multivariable logistic regression analysis adjusting for pre‐ and postoperative variables, age ≥80 years was not an independent predictor of high‐grade complications (odds ratio 0.6, 95% confidence interval 0.3–1.1; P = 0.12). The non‐cancer‐related 90‐day mortality was 2.3% for patients aged ≥80 years and 1.8% for those aged <80 years, respectively (P = 0.7). The estimated 12‐month CSM and OCM rates for those aged <80 years were 8% and 3%, and for those aged ≥80 years, 15% and 8%, respectively (P = 0.009 and P < 0.001). Conclusions The minimally invasive approach to RARC with ICUD for bladder cancer in well‐selected elderly patients (aged ≥80 years) achieved a tolerable high‐grade complication rate; the 90‐day postoperative mortality rate was driven by cancer progression and the non‐cancer‐related rate was equivalent to that of patients aged <80 years. However, an increased OCM rate in this elderly group after the first year should be taken into account. These results will support clinicians and patients when balancing cancer‐related vs treatment‐related risks and benefits.
Collapse
Affiliation(s)
- Ashkan Mortezavi
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.,Department of Urology, University Hospital Zurich, Zurich, Switzerland.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Alessio Crippa
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sebastian Edeling
- Department of Urology, Vinzenzkrankenhaus Hannover, Hannover, Germany
| | - Sasa Pokupic
- Department of Urology, Vinzenzkrankenhaus Hannover, Hannover, Germany
| | - Paolo Dell'Oglio
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.,ORSI Academy, Melle, Belgium
| | - Francesco Montorsi
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Alexandre Mottrie
- Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.,ORSI Academy, Melle, Belgium
| | | | - Carl J Wijburg
- Department of Urology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Justin Collins
- Department of Urology, University College London Hospital, London, UK
| | - John D Kelly
- Department of Urology, University College London Hospital, London, UK
| | - Wei Shen Tan
- Department of Urology, University College London Hospital, London, UK
| | - Ashwin Sridhar
- Department of Urology, University College London Hospital, London, UK
| | - Hubert John
- Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | | | | | - Erik Peder Rönmark
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.,Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abolfazl Hosseini
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
43
|
Jensen BT, Lauridsen SV, Jensen JB. Optimal Delivery of Follow-Up Care After Radical Cystectomy for Bladder Cancer. Res Rep Urol 2020; 12:471-486. [PMID: 33117747 PMCID: PMC7569073 DOI: 10.2147/rru.s270240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/24/2020] [Indexed: 01/10/2023] Open
Abstract
Purpose of Review To identify components representing optimal delivery of follow-up care after radical cystectomy because of bladder cancer and report the current level of evidence. Methods We conducted a systematic literature search of the following databases: Cochrane, MEDLINE, Embase, CINAHL, Web of Science, Physiotherapy Evidence Database and ClinicalTrials.gov. The search results were managed in Covidence Reference Manager and abstracts were screened by title. Articles relevant to the subject of interest were included and the results are reported narratively. Results Several studies have evaluated the positive impact of enhanced recovery after surgery (ERAS) on length of stay, albeit not on the further impact on 90-day postoperative complication rate, functional recovery, or mortality. Minimally invasive surgery may result in a slighter shorter length of stay compared to open surgery. Physical training combined with nutritional intervention can improve functional recovery up to one year after surgery. Nutritional supplements can preserve muscle and bone mass, and potentially improve recovery. Patient education in stoma care and prevention of infection can significantly improve self-efficacy and avoid symptoms of infection postoperatively. Moreover, specific devices like applications (apps) can support these efforts. Continued smoking increases the risk of developing postoperative complications while no evidence was found on the impact of continued alcohol drinking. Currently, there is no evidence on psychological well-being, sexual health, or shared decision making interventions with an impact on rehabilitation after radical cystectomy. Conclusion Data are scarce but indicate that peri- and postoperative multi-professional interventions can reduce prevalence of sarcopenia, and improve functional recovery, physical capacity, nutritional status, and self-efficacy in stoma care (level 1 evidence). Continued smoking increases the risk of complications, but the effects of a smoking and alcohol intervention remain unclear (level 3 evidence). The results of this review provide guidance for future directions in research and further attempts to develop and test an evidence-based program for follow-up care after radical cystectomy.
Collapse
Affiliation(s)
| | - Susanne Vahr Lauridsen
- Department of Urology, Copenhagen University Hospital, Denmark and WHO-CC, Clinical Health Promotion Centre, The Parker Institute Bispebjerg & Frederiksberg University Hospital, Copenhagen, Denmark
| | - Jørgen Bjerggaard Jensen
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
44
|
Posada Calderon L, Al Hussein Al Awamlh B, Shoag J, Patel N, Nicolas JD, Scherr DS. The role of surgical experience in patient selection, surgical quality, and outcomes in robot-assisted radical cystectomy. Urol Oncol 2020; 39:6-12. [PMID: 33127299 DOI: 10.1016/j.urolonc.2020.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Robot-assisted radical cystectomy (RARC) remains one of the most complex urological procedures. Due to regionalization of bladder cancer care, there is likely an imbalance in experience among urologists performing RARC. We sought to describe changes in patient selection, surgical quality surrogates and rates of complications in relation to surgical experience. METHODS We retrospectively reviewed 409 consecutive patients with bladder cancer who underwent RARC between 2006 and 2017 by a single surgeon. The cohort was divided into 4 quartiles (Q1-Q4) according to surgical experience, based on the chronologic order at which RARC was performed. Baseline, perioperative and pathologic characteristics of patients were compared among the 4 groups. 30-day and 90-day complications were assessed using the Clavien-Dindo system. The association between surgical experience (quartile) and complications was assessed using multivariable logistic regression analyses. RESULTS Median age (interquartile range [IQR] from 70-73 years), body mass index (IQR from 25 to 27 kg/m2) and preoperative glomerular filtration rate (IQR from 59 to 65 ml/min) were similar among all quartiles (all P > 0.05). Patients in Q4 had higher rates of previous abdominopelvic surgery (46.1% vs. 30.4%, P = 0.031) and American Society of Anesthesiologists score of 3 to 4 (72.3% vs. 47.1%, P = 0.003) compared to patients in Q1. Patients who underwent RARC in Q4 compared to Q1, had less estimated blood loss (250 ml vs. 350 ml, P < 0.001), shorter operative time (346 vs. 360 minutes, P < 0.001), and higher lymph node yield (22 vs. 17 nodes, P < 0.001). The 30-day and 90-day complication rates were 53% and 62%, respectively. Thirty-day complication rates were similar among all 4 quartiles (P > 0.05), but higher among patients in Q4 compared to Q1 within 90 days (74% vs. 54%, P = 0.01). On multivariable analysis, patients in Q4 were more likely to experience any 90-day complication (OR 2.03, 95%Cl 1.11-3.70) compared to Q1. CONCLUSION Our results show that with surgical experience, more complex cases can be performed while continuing to improve surgical quality. Nonetheless, there appears to be a trade-off between the increase in complexity of cases performed with experience and accepting higher rates of complications.
Collapse
Affiliation(s)
- Lina Posada Calderon
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY
| | | | - Jonathan Shoag
- University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH, USA; Department of Urology, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Neal Patel
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY
| | - Joseph D Nicolas
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY
| | - Douglas S Scherr
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY.
| |
Collapse
|
45
|
A perioperative management to reduce rate of urinary tract infection for patient underwent radical cystectomy with ileal conduit diversion. Int Urol Nephrol 2020; 53:401-407. [PMID: 33068208 DOI: 10.1007/s11255-020-02653-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/14/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Although radical cystectomy, as the standard surgical treatment for muscle-invasive bladder cancer patients, prolongs survival remarkably, there are postoperative complications associated with urinary diversion. This study aimed to explore the antibiotic prophylaxis, according to culture of single J stent and urine from patients underwent urinary diversion (ileal conduit), its capacity to reduce the rate of urinary tract infection (UTI). METHODS A total of 179 patients at Renji Hospital were reviewed in the study between Jan 2016 and June 2019. All patients included in this study were underwent radical cystectomy and ileal conduit. In Jan 2018, we enacted a quality initiative of urologic department to create a modified management. Following this initiative, antibiotic prophylaxis began to be used according to postoperative urine culture and stub of J-stent culture, which were obtained in 3rd days and 7th days after surgery, respectively. All consecutive patients treated with this process were compared with a conventional group. The clinicopathologic features of the two groups were compared using the t test and Chi square test. Multivariable logistic regression analysis was performed to determine the odds of developing 30-day UTI in two groups. RESULTS 112 and 67 patients underwent the modified and conventional postoperative management, respectively. Two groups were comparable with regard to all demographic, clinical variables. The most common organism in urine culture and stub of J-stent culture was Candida albicans (38.46% and 31.7%). The rate of UTI was significantly lower in the modified group than in the conventional group (4.5% vs 13.4%, P = 0.031). In multivariable analyses, the conventional management was significantly more likely to develop UTI (OR = 4.992, 95% confidence interval [CI] 1.432-17.398 P = 0.012) than modified management. CONCLUSION This procedure is associated with a significant decrease in UTI after surgery. During perioperative period, urine/single J stent culture with drug sensitivity test is necessary.
Collapse
|
46
|
Fong Y, Buell JF, Collins J, Martinie J, Bruns C, Tsung A, Clavien PA, Nachmany I, Edwin B, Pratschke J, Solomonov E, Koenigsrainer A, Giulianotti PC. Applying the Delphi process for development of a hepatopancreaticobiliary robotic surgery training curriculum. Surg Endosc 2020; 34:4233-4244. [PMID: 32767146 DOI: 10.1007/s00464-020-07836-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/21/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Robotic hepatopancreaticobiliary (HPB) procedures are performed worldwide and establishing processes for safe adoption of this technology is essential for patient benefit. We report results of the Delphi process to define and optimize robotic training procedures for HPB surgeons. METHODS In 2019, a robotic HPB surgery panel with an interest in surgical training from the Americas and Europe was created and met. An e-consensus-finding exercise using the Delphi process was applied and consensus was defined as 80% agreement on each question. Iterations of anonymous voting continued over three rounds. RESULTS Members agreed on several points: there was need for a standardized robotic training curriculum for HPB surgery that considers experience of surgeons and based on a robotic hepatectomy includes a common approach for "basic robotic skills" training (e-learning module, including hardware description, patient selection, port placement, docking, troubleshooting, fundamentals of robotic surgery, team training and efficiency, and emergencies) and an "advanced technical skills curriculum" (e-learning, including patient selection information, cognitive skills, and recommended operative equipment lists). A modular approach to index procedures should be used with video demonstrations, port placement for index procedure, troubleshooting, and emergency scenario management information. Inexperienced surgeons should undergo training in basic robotic skills and console proficiency, transitioning to full procedure training of e-learning (video demonstration, simulation training, case observation, and final evaluation). Experienced surgeons should undergo basic training when using a new system (e-learning, dry lab, and operating room (OR) team training, virtual reality modules, and wet lab; case observations were unnecessary for basic training) and should complete the advanced index procedural robotic curriculum with assessment by wet lab, case observation, and OR team training. CONCLUSIONS Optimization and standardization of training and education of HPB surgeons in robotic procedures was agreed upon. Results are being incorporated into future curriculum for education in robotic surgery.
Collapse
Affiliation(s)
- Yuman Fong
- Department of Surgery, City of Hope Medical Center, 1500 East Duarte Road, Duarte, CA, 91011, USA.
| | - Joseph F Buell
- Department of Surgery, Mission Healthcare, HCA Healthcare, North Carolina Division, MAHEC University of North Carolina, Asheville, NC, USA
| | - Justin Collins
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - John Martinie
- Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Christiane Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Allan Tsung
- Department of Surgical Oncology, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, University Hospital of Zurich, Zurich, Switzerland
| | - Ido Nachmany
- Department of "Surgery B". Tel Aviv Sourasky Medical Center, Tel Aviv & The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Evgeny Solomonov
- Department of General and Hepato-Pancreatico-Biliary and Transplant Surgery, Ziv Medical Centre, Zefat (Safed), Israel
| | - Alfred Koenigsrainer
- Department of General, Visceral, Cancer and Surgery, University of Tuebingen, Tuebingen, Germany
| | | |
Collapse
|
47
|
Nason GJ, Kim JK, HeeTan G, Ajib K, Nam RK. Single-night stay for open radical prostatectomy. Can Urol Assoc J 2020; 15:E130-E134. [PMID: 32807288 DOI: 10.5489/cuaj.6600] [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 The aim of this study was to assess the effect of an enhanced care pathway on length of stay (LOS) for open radical prostatectomy (RP) given that robotic-assisted laparoscopic prostatectomy (RALP) is not available to all patients in Canada. METHODS A retrospective review was conducted of all RPs performed. An enhanced care pathway was established for RPs in 2011. Patients were compared in the period before (2005-2010) and after (2011-2019) the introduction of the pathway. RESULTS During the study period, 581 RPs were performed by a single surgeon with a median followup of 66.9 months (range 3-176). A total of 211 (36.3%) RPs were performed from 2005-2010, while 370 (63.9%) were performed from 2011-2019. The median age at RP was 65 years (range 44-81). Following the introduction of an enhanced care pathway, there were significant decreases in intraoperative blood loss (350 ml vs. 200 ml; p=0.0001) and the use of surgical drains (90% vs. 9.5%; p=0.0001). The median LOS over the whole study period was one day (range 1-7), which significantly decreased with the enhanced care pathway (3 vs. 1 day; p=0.0001). Since introducing the enhanced care pathway in 2011, 344 (93%) patients were discharged day 1 following surgery. There were no differences in post-discharge presentations to the emergency department (5.7% vs. 9%; p=0.15) or 30-day readmission rates (3.8% vs. 3.8%; p=1.00). CONCLUSIONS A single-night stay for open RP is safe and achievable for most patients. A dedicated, multifaceted pathway is required to attain targets for a safe and timely discharge.
Collapse
Affiliation(s)
- Gregory J Nason
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON, Canada
| | - Justin K Kim
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON, Canada
| | - Guan HeeTan
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON, Canada
| | - Khaled Ajib
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON, Canada
| | - Robert K Nam
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto ON, Canada
| |
Collapse
|
48
|
Tan YG, Allen JC, Tay KJ, Huang HH, Lee LS. Benefits of robotic cystectomy compared with open cystectomy in an Enhanced Recovery After Surgery program: A propensity-matched analysis. Int J Urol 2020; 27:783-788. [PMID: 32632988 DOI: 10.1111/iju.14300] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 05/28/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To compare the perioperative and oncological outcomes between robot-assisted radical cystectomy with intracorporeal urinary diversion versus open cystectomy for bladder cancer in a contemporary Enhanced Recovery After Surgery cohort. METHODS All consecutive patients who underwent radical cystectomy and managed under an Enhanced Recovery After Surgery protocol, from December 2013 to October 2018, were reviewed. Propensity score adjustment was carried out to reduce biases attributable to covariate imbalances. RESULTS There were 19 robot-assisted radical cystectomy with intracorporeal urinary diversion and 21 open cystectomy patients. The robot-assisted radical cystectomy with intracorporeal urinary diversion cohort was associated with lower estimated blood loss (397 vs 787 mL, P = 0.05), with a trend toward shorter duration of ileus and postoperative opioid administration. These benefits were apparent, despite a longer operative time (581 vs 446 mins, P = 0.03), a higher proportion of orthotopic bladder reconstruction (26.3 vs 9.5%, P = 0.08), a more prevalent use of neoadjuvant chemotherapy and a higher number of salvage cystectomies for the robot-assisted radical cystectomy with intracorporeal urinary diversion group. Comparable perioperative complications and length of hospital stay were observed. The pathological and intermediate oncological outcomes were similar in both groups (locally advanced disease: 52.6 vs 47.6%, P = 0.85; lymph node yield: 29 vs 34, P = 0.23). The mean recurrence-free survival and overall survival in the robot-assisted radical cystectomy with intracorporeal urinary diversion group was 37.5 and 43.0 months, respectively, compared with 21.4 (P = 0.09) and 35.5 (P = 0.14) months, respectively, in open cystectomy. CONCLUSION Robot-assisted radical cystectomy with intracorporeal urinary diversion has perioperative benefits of lower estimated blood loss, with a trend toward faster bowel recovery and a shorter duration of opioid analgesia when compared with open cystectomy. Robot-assisted radical cystectomy with intracorporeal urinary diversion also achieves similar intermediate-term oncological and survival outcomes.
Collapse
Affiliation(s)
- Yu Guang Tan
- Department of Urology, Sengkang General Hospital, Singapore.,Department of Urology, Singapore General Hospital, Singapore
| | - John Carson Allen
- Center for Quantitative Medicine/Office of Research, Duke-NUS Medical School, Singapore
| | - Kae Jack Tay
- Department of Urology, Singapore General Hospital, Singapore
| | - Hong Hong Huang
- Department of Urology, Singapore General Hospital, Singapore
| | - Lui Shiong Lee
- Department of Urology, Sengkang General Hospital, Singapore.,Department of Urology, Singapore General Hospital, Singapore
| |
Collapse
|
49
|
Ploussard G, Almeras C, Beauval JB, Gautier JR, Garnault V, Frémont N, Dallemagne S, Loison G, Salin A, Tollon C. A combination of enhanced recovery after surgery and prehabilitation pathways improves perioperative outcomes and costs for robotic radical prostatectomy. Cancer 2020; 126:4148-4155. [PMID: 32639601 DOI: 10.1002/cncr.33061] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/25/2020] [Accepted: 03/25/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND An enhanced recovery after surgery (ERAS) pathway has shown benefit in oncologic surgery. However, literature is scarce regarding the impact of this pathway, alone or combined with prehabilitation (PreHab) programs, on outcomes after robot-assisted radical prostatectomy (RARP). METHODS Included in this study were 507 consecutive patients undergoing RARP from 2014 to 2019. The primary endpoint was duration of hospital stay. Secondary outcomes included intraoperative blood loss, operative duration, readmission rate, and overall costs. Univariate and multivariate comparisons were performed according to the ERAS and PreHab program status. RESULTS ERAS patients had shorter hospital stays (P < .001), reduced operative times (P < .001), and decreased blood loss (P < .001) in comparison with non-ERAS patients. Shorter hospital stays were not associated with an increased readmission rate (7.9% [stable over time]; P = .757). Patients from an ERAS-/PreHab- group had a longer hospital stay (4.7 days) than those from an ERAS+/PreHab- group (3.5 days) and those from an ERAS+/PreHab+ group (1.6 days; P < .001). In a multivariate analysis, operative time and perioperative pathway (odds ratio for ERAS, 0.144; P < .001; odds ratio for ERAS and PreHab, 0.025; P < .001) were independently predictive for a prolonged length of stay (P < .001). Costs significantly decreased when ERAS and PreHab pathways were combined. CONCLUSIONS The implementation of ERAS and PreHab programs significantly changes the postoperative course of patients and may synergistically optimize RARP outcomes. The combination of these pathways improves patient recovery and is associated with reduced lengths of stay, blood loss, operative times, and costs without an increase in the postdischarge readmission rate.
Collapse
Affiliation(s)
| | - Christophe Almeras
- Department of Urology, La Croix du Sud Hospital, Quint-Fonsegrives, France
| | | | | | - Valérie Garnault
- Department of Public Health, La Croix du Sud Hospital, Quint-Fonsegrives, France
| | | | | | - Guillaume Loison
- Department of Urology, La Croix du Sud Hospital, Quint-Fonsegrives, France
| | - Ambroise Salin
- Department of Urology, La Croix du Sud Hospital, Quint-Fonsegrives, France
| | - Christophe Tollon
- Department of Urology, La Croix du Sud Hospital, Quint-Fonsegrives, France
| |
Collapse
|
50
|
Moschovas MC, Seetharam Bhat KR, Jenson C, Patel VR, Ogaya-Pinies G. Robtic-assisted radical cystectomy: Literature review. Asian J Urol 2020; 8:14-19. [PMID: 33569268 PMCID: PMC7859419 DOI: 10.1016/j.ajur.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/25/2020] [Accepted: 04/22/2020] [Indexed: 11/24/2022] Open
Abstract
Radical cystectomy (RC) with pelvic lymph node dissection (PLND) is the standard treatment for localized muscle-invasive bladder cancer (MIBC) and non-muscle-invasive bladder cancer (NMIBC) with recurrence or high risk of progression. Also, the robotic approach to this type of surgery is well established in the literature. Our objective is to summarize in this manuscript the most relevant articles related to the robotic-assisted radical cystectomy for prostate cancer. We performed a literature review of articles describing the robotic approach to RC in patients with bladder cancer. Also, we described the procedure since the patient selection until the bladder removal. The reconstructive techniques were not included in this review. Twenty-five articles were used to divide our manuscript into key points such as preoperative patient selection and protocols, surgical technique, pathology report, oncological outcomes, complication rates, and quality of life after the procedure. Robotic-assisted radical cystectomy is feasible and safe with satisfactory oncological outcomes. The robotic approach is related to lower blood loss and fewer transfusion rates. However, when compared to open surgery, the use of this technology increases the operative time.
Collapse
Affiliation(s)
- Marcio Covas Moschovas
- Department of Urology, AdventHealth Global Robotics Institute, Celebration, FL, United States
| | | | - Cathy Jenson
- Department of Urology, AdventHealth Global Robotics Institute, Celebration, FL, United States
| | - Vipul R Patel
- Department of Urology, AdventHealth Global Robotics Institute, Celebration, FL, United States
| | - Gabriel Ogaya-Pinies
- Department of Urology, Hospital Rey Juan Carlos, Madrid, Spain.,Lyx Instituto de Urologia, Madrid, Spain
| |
Collapse
|