Risk Factor Analysis in a Contemporary Cystectomy Cohort Using Standardized Reporting Methodology and Adverse Event Criteria

Role of Maximal Transurethral Resection Preceding Partial Cystectomy for Muscle-Invasive Bladder Cancer

PURPOSE

We aimed to evaluate whether maximal transurethral resection (TUR) affects the oncological outcome of partial cystectomy (PC) performed in patients with muscle-invasive bladder cancer (MIBC), although radical cystectomy (RC) and trimodal therapy (TMT) are regarded as standard treatments for MIBC.

METHODS

In this retrospective study, we evaluated the data of 98 patients who underwent PC due to MIBC between January 2006 and December 2018. Of the 98 patients, 71 underwent maximal TUR. We evaluated the recurrence-free survival (PFS), pelvic recurrence-free survival (pPFS), cancer-specific survival (CSS), and overall survival (OS) using the Kaplan-Meier method according to the maximal TUR status. Variables associated with survival were analyzed using Cox regression analyses.

RESULTS

The 5-year PFS (42.5% vs. 20.3%, p = 0.008), pPFS (50.7% vs. 24.1%, p = 0.003), and CSS (74.0% vs. 51.0%, p = 0.016) were also higher in patients who underwent maximal TUR. The multivariable Cox regression analysis showed that maximal TUR was associated with PFS (hazard ratio [HR] = 0.500, p = 0.029), pPFS (HR = 0.353, p = 0.004), and CSS (HR = 0.416, p = 0.027). However, maximal TUR did not affect the OS (HR = 0.618, p = 0.132).

CONCLUSION

PC resulted in acceptable oncological outcomes in patients with MIBC, while maximal TUR played an important role in improving the oncological outcomes. PC after maximal TUR can be suggested as a treatment option for MIBC patients who are unable to undergo RC and TMT.

Robot-assisted radical cystectomy with intracorporeal urinary diversion: an updated systematic review and meta-analysis of its differential effect on effectiveness and safety

BACKGROUND

Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion (iRARC) is increasingly being used in recent years. Whether iRARC offers advantages over open radical cystectomy (ORC) remains controversial. This study aimed to compare the difference of perioperative outcomes, oncological outcomes and complications between iRARC and ORC.

METHODS

The PubMed, Embase, Cochrane Library, Web of Science and CNKI databases were searched in July 2023 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement. Studies were identified to be eligible if they compared perioperative outcomes, oncological outcomes and complications in patients who underwent iRARC with ORC.

RESULTS

Twenty-two studies involving 7,020 patients were included. Compared to ORC, iRARC was superior for estimated blood loss [EBL WMD: -555.52; 95% CI, -681.64 to -429.39; P<0.001], blood transfusion rate [OR: 0.16; 95% CI, 0.09 to 0.28; P<0.001], length of hospital stay [LOS WMD: -2.05; 95% CI, -2.93 to -1.17; P<0.001], Clavien-Dindo grades ≥III complication rate [30d: OR: 0.57; 95% CI 0.44 to 0.75; P<0.001; 90d: OR: 0.71; 95% CI 0.60 to 0.84; P<0.001], and positive surgical margin [PSM OR: 0.65; 95% CI 0.49 to 0.85; P=0.002]. However, iRARC had a longer operative time [OT WMD: 68.54; 95%CI 47.41 to 89.67; P<0.001] and a higher rate of ureteroenteric stricture [ UES OR: 1.56; 95% CI 1.16 to 2.11; P=0.003]. Time to flatus, time to bowel, time to regular diet, readmission rate, Clavien-Dindo grades

CONCLUSION

Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion appears to be superior to open radical cystectomy in terms of effectiveness and safety. However, attention should be paid to the occurrence of ureteroenteric stricture during follow-up.

Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

Shi Fu Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
HongJin Shi Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Zhinan Fan Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China Department of Urology, Meishan People's Hospital, Meishan, China
Jinze Li Department of Urology/Institute of Urology, West China Hospital, Sichuan University, Chengdu, China
Ting Luan Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Haonan Dong Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Jincheng Wang Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Shuwen Chen Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Jinsong Zhang Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Jiansong Wang Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Mingxia Ding Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China
Haifeng Wang Department of Urology, the Second Affiliated Hospital of Kunming Medical University, Kunming, China

Collapse

Comparative study of postoperative complications after radical cystectomy during the past two decades in Japan: Radical cystectomy remains associated with significant postoperative morbidities

OBJECTIVES

During the past 2 decades, in order to improve perioperative and oncological outcomes, a minimally invasive approach, neoadjuvant chemotherapy (NAC), and an enhanced postoperative recovery program after surgery have been introduced into routine clinical practice of radical cystectomy (RC). Our aim was to examine the differences in clinical practice and postoperative complications after RC by comparing our previous and current cohorts.

MATERIALS AND METHODS

A retrospective multi-institutional study. We collected all complications within 90 days after surgery between 2011 and 2017 (current cohort), and categorized them according to a standardized methodology. Then, we compared the outcomes with those in our previous study (previous cohort, 1997-2010). A multivariate logistic regression model was utilized to determine predictors of complications in the current cohort.

RESULTS

A total of 838 patients were newly collected (current cohort), and 919 from the previous cohort were included in the subsequent analyses. In the current cohort, the rate of performing NAC was significantly higher (13% vs. 4%, respectively, P < 0.0001), and 26% (222/838) underwent laparoscopic RC (LRC, without robotic assistance: n = 210, with robotic assistance: n = 12). There was no significant difference in the overall complication [69% (580/838) vs. 68% (629/919), respectively, P = 0.7284] or major complication (Grades 3-5) [25% (211/838) vs. 22% (201/919), respectively, P = 0.1022] rates between the 2 cohorts. In both cohorts, the most frequent categories were infectious, gastrointestinal, wound-related, and genitourinary. In the current cohort, the performance status (odds ratio, OR = 2.11, P = 0.0013) and operative time (OR = 1.003, P = 0.0016) remained significant predictors of major complications. NAC was not associated with any or major complications.

CONCLUSIONS

Surgical complications related to RC still remain significant problems, despite the recent improvements in surgical techniques and perioperative care. NAC did not increase the complications.

Perioperative outcomes of intracorporeal robot-assisted radical cystectomy versus open radical cystectomy: A systematic review and meta-analysis of comparative studies

PURPOSE

To systematically review studies comparing the perioperative outcomes of intracorporeal robot-assisted radical cystectomy (iRARC) and open radical cystectomy (ORC).

METHODS

Systematic searches of PubMed, Web of Science and the Cochrane Library were performed in June 2020. Studies with data comparing iRARC and ORC were included in our review, and a pooled meta-analysis was completed.

RESULTS

In total, 8 studies (7 prospective studies, 1 retrospective study) comparing 1193 patients were included for our review and meta-analysis. Compared with ORC, iRARC demonstrated lower estimated blood loss (weighted mean difference (WMD): -449.25; 95% CI -566.47 - -332.03; p < 0.01), lower blood transfusion rates (OR: 0.31; 95% CI 0.22 - 0.46; p < 0.01), and lower postoperative complication rates with Clavien-Dindo grades III-IV (30 days: OR: 0.65; 95% CI 0.47 - 0.90; p = 0.01; 90 days: OR: 0.72; 95% CI 0.53 - 0.98; p = 0.04), but a longer operative time (WMD: 78.82; 95% CI 52.77 - 104.87; P < 0.01). Furthermore, there was no significant difference between iRARC and ORC in terms of postoperative complication rates with Clavien-Dindo grades Ⅰ-Ⅱ (30 days: OR: 0.71; 95% CI 0.36 - 1.40; p = 0.32; 90 days: OR: 0.98; 95% CI 0.74 - 1.30; p = 0.89), length of stay (WMD: -1.18; 95% CI -3.33 - -2.07; p = 0.06) and positive surgical margins (OR: 0.78; 95% CI 0.0.45 - 1.36; p = 0.38).

CONCLUSION

iRARC was associated with a significantly lower estimated blood loss and a lower blood transfusion rate and major postoperative complication rate than ORC.

Prediction of post radical nephrectomy complications based on patient comorbidity preoperatively

OBJECTIVES

Comorbidity along with tumor and patient characteristics is taken into account when deciding for the surgical treatment of renal cell carcinoma (RCC). Comorbidity has also been used as an independent predictive factor for postoperative complications of several major urological procedures including radical nephrectomy for RCC. The aim of the present study was to objectively evaluate the association between comorbidity and postoperative complications after radical nephrectomy for RCC, using standardized systems to grade both comorbidity and severity of postoperative complications.

MATERIALS AND METHODS

Clinicopathological data of 171 patients undergoing open radical nephrectomy for lesions suspected of RCC were prospectively recorded for a period of 3 years. Comorbidity was scored using the Charlson Comorbidity Index (CCI) while postoperative complications were graded according to the Clavien-Dindo system.

RESULTS

Patients were predominantly males (59.1%); their age ranged from 35 to 88 years (mean ± SD: 63.6 ± 11.9 yrs) with 50.8% of them being ≤ 65 yrs. CCI ranged from 0 to 8 with the majority (85.3%) scoring ≤ 2. The procedure was uncomplicated in 57.3% cases; 10 patients suffered major (grade III/IV) complications and 4 patients died within the 40 days postoperative period. CCI correlated with the manifestation of any postoperative complication, Clavien ≥ 1, OR (95% CI): 1.47 (1.09-1.96), p = 0.011 and the occurrence of severe complications, Clavien > 2. OR (95% CI): 1.29 (1.01-1.63), p = 0.038.

CONCLUSIONS

The present prospective study showed that considerable complications occur in patients with major comorbidities. CCI is easily calculated and should be incorporated in preoperative consultation especially in cases of elder patients with severe comorbidity and favorable tumor characteristics where less invasive interventions or even active surveillance could be applied.

Short-term morbidity and mortality following radical cystectomy: a systematic review

OBJECTIVE

To study short-term (<90 days) morbidity and mortality following radical cystectomy (RC) for bladder cancer and identify modifiable risk factors associated with these.

DESIGN

Systematic review.

METHODS

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE were searched for relevant papers on 11 June 2019 and rerun on 27 May 2020. Studies reporting complications, reoperations, length of stay and mortality within 90 days were included. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine and the quality of evidence was assessed using the Newcastle-Ottawa Scale.

RESULTS

The search retrieved 1957 articles. Sixty-six articles were included. The quality of evidence was poor to good. Most studies were retrospective, and no randomised clinical trials were identified. Of included studies a median of 6 Martin criteria for reporting complications after surgery were fulfilled. The Clavien-Dindo classification for grading complications was most frequently used. The weighted overall complication rate after RC was 34.9% (range 28.8-68.8) for in-house complications, 39.0% (range 27.3-80.0) for 30-day complications and 58.5% (range 36.1-80.5) for 90-day complications. The most common types of complications reported were gastrointestinal (29.0%) and infectious (26.4%). The weighted mortality rate was 2.4% (range 0.9-4.7) for in-house mortality, 2.1% (0.0-3.7) for 30-day mortality and 4.7% (range 0.0-7.0) for 90-day mortality. Age and comorbidity were identified as the best predictors for complications following RC.

CONCLUSION

Short-term morbidity and mortality are high following RC. Reporting of complications is heterogeneous and the quality of evidence is generally low. There is a continuous need for randomised studies to address any intervention that can reduce morbidity and mortality following RC.

PROSPERO REGISTRATION NUMBER

104937.

Perioperative outcomes and safety of robotic vs open cystectomy: a systematic review and meta-analysis of 12,640 cases

PURPOSE

Robotic radical cystectomy (RRC) has become a commonly utilised alternative to open radical cystectomy (ORC). We performed a systematic review and meta-analysis of RRC vs ORC focusing on perioperative outcomes and safety.

METHODS

Medline, EMBASE and CENTRAL were searched from January 2000 to April 2020 following the Preferred Reporting Items for Systematic Review and Meta-analysis Statement for study selection.

RESULTS

In total, 47 studies (5 randomised controlled trials, 42 non-randomised comparative studies) comprising 12,640 patients (6572 ORC, 6068 RRC) were included. There was no difference in baseline demographics between the groups apart from males were more likely to undergo ORC (OR 0.77, 95% CI 0.69-0.85). Those with muscle-invasive disease were more likely to undergo RRC (OR 1.21, 95% CI 1.09-1.34), and those with high-risk non-muscle-invasive bladder cancer were more likely to undergo ORC (OR 0.80, 95% CI 0.72-0.89). RRC had a significantly longer operating time, less blood loss and lower transfusion rate. There was no difference in lymph node yield, rate of positive surgical margins, or Clavien-Dindo Grade I-II complications between the two groups. However, the RRC group were less likely to experience Clavien-Dindo Grade III-IV (OR 1.56, 95% CI 1.30-1.89) and overall complications (OR 1.45, 95% CI 1.26-1.68) than the ORC group. The mortality rate was higher in ORC although this did not reach statistical significance (OR 1.52, 95% CI 0.99-2.35).

CONCLUSION

RRC has significantly lower blood loss, transfusion rate and is associated with fewer high grade and overall complications compared to ORC.

Bladder-sparing treatment options in localized muscle-invasive bladder cancer

Introduction: Bladder cancer is the 9th most common cancer in the world and the 4^th and 8th most common cancer diagnosed in men in the United States and United Kingdom respectively. The standard of care for the treatment of MIBC is radical cystectomy. Bladder preserving treatment approaches are emerging for select patients and should be considered strongly in patients who decline a radical cystectomy.Areas covered: In this review we look at the European and American recommended guidelines, the current standard of care, bladder-preserving options in MIBC, trimodal therapy and discuss future developments in the identification of molecular biomarkers that can predict therapeutic outcomes.Expert opinion: We strongly advocate bladder preservation for the right patient with strict criteria for enrolling patients in bladder preservation. The development of a specialized bladder cancer clinic could facilitate the selection of patients to be offered trimodal therapy. We believe that the future of bladder cancer will involve individualized care plans based upon clinical, radiological, endoscopic and molecular assessments.

Persistent, long-term risk for ureteroenteric anastomotic stricture formation: the case for long term follow-up

Background

Up to one in ten patients undergoing cystectomy with urinary diversion develop a ureteroenteric stricture (UES). Despite unrecognized ureteral obstruction contributing to infection, nephrolithiasis, and/or progression of kidney disease, the long-term natural history and risk factors associated with UES remains understudied. Herein, we report our single institutional experience with the long-term incidence, clinical presentation, and risk factors associated with UES formation following urinary diversion.

Methods

We reviewed 2,285 patients who underwent RC with urinary diversion between 1980-2008. UES was defined as radiographic evidence of ureteral obstruction at the level of the ureteroenteric anastomosis. The diagnosis of benign UES was confirmed by pathology. UES-free survival was estimated using the Kaplan-Meier method. The association between clinicopathologic features and the development of a UES were assessed using multivariable models.

Results

A total of 192 (8%) patients developed a benign UES, at a median of 7 months (IQR 4-24) following RC, with 5% occurring after 10 years. Seventy seven percent of patients exhibited signs and/or symptoms of ureteral obstruction. Patients who developed a UES had a greater body mass index (BMI) (28 vs. 27), operative time (330 vs. 301 minutes) and were more likely to experience a <30-day Clavien ≥3 complication (all P<0.05). Receipt of abdominal radiation and smoking history were not significantly associated with UES stricture risk. On multivariable analysis, only greater BMI (per 1-unit increase) (OR 1.06, 95% CI: 1.02-1.09; P=0.0009) and <30-day Clavien ≥3 complication (OR 2.85, 95% CI: 1.90-4.28; P<0.0001) were associated with the development of a UES. Development of UES was associated with renal function deterioration.

Conclusions

UES was identified in 8% of patients following RC with urinary diversion, with the majority presenting with symptoms. While the majority of these occur in the first 2 years after surgery, a patients' risk for the development of this complication persists beyond 10 years. Due to the adverse sequelae of UES, long-term functional and imaging surveillance following urinary diversion is warranted, and early reconstruction should be considered.

Feasibility and outcomes of selective tetramodal bladder-preservation therapy in elderly patients with muscle-invasive bladder cancer

OBJECTIVE

To assess the feasibility and functional/oncological outcomes of selective tetramodal bladder-preservation therapy in elderly patients with muscle-invasive bladder cancer.

METHODS

This study analyzed 154 patients with non-metastatic muscle-invasive bladder cancer who were enrolled into the protocol. After maximal transurethral resection and induction chemoradiotherapy, patients with clinical complete response were offered consolidative partial cystectomy to achieve bladder preservation; otherwise, radical cystectomy was recommended. Postoperative complications, preserved bladder function, and oncological outcomes were compared between elderly (aged ≥75 years) and younger patients (aged <75 years). Frailty and sarcopenia were further assessed as potential factors that could affect the feasibility and outcomes of the protocol.

RESULTS

A total of 44 patients (29%) were elderly, and 31 (20%) were frail (modified frailty index 2-3). Sarcopenia was observed in 68 (54%) of 126 eligible patients. Clinical complete response to induction chemoradiotherapy was achieved in 125 (81%) patients, and the bladder-preservation protocol was completed in 107 (69%) patients with consolidative partial cystectomy. Over a median follow-up period of 48 months, 5-year cancer-specific and muscle-invasive bladder cancer recurrence-free survival rates after protocol completion were 98% and 95%, respectively. There were no significant differences in complication rates related to partial cystectomy, preserved bladder function, and oncological outcomes between the elderly and younger groups. Neither frailty nor sarcopenia negatively affected these outcomes.

CONCLUSIONS

Tetramodal bladder-sparing therapy incorporating consolidative partial cystectomy is feasible and yielded favorable functional/oncological outcomes in patients with muscle-invasive bladder cancer, regardless of advanced age, frailty or sarcopenia. This protocol could be a viable treatment option for such high-risk patient populations.

Perioperative restrictive versus goal-directed fluid therapy for adults undergoing major non-cardiac surgery

BACKGROUND

Perioperative fluid management is a crucial element of perioperative care and has been studied extensively recently; however, 'the right amount' remains uncertain. One concept in perioperative fluid handling is goal-directed fluid therapy (GDFT), wherein fluid administration targets various continuously measured haemodynamic variables with the aim of optimizing oxygen delivery. Another recently raised concept is that perioperative restrictive fluid therapy (RFT) may be beneficial and at least as effective as GDFT, with lower cost and less resource utilization.

OBJECTIVES

To investigate whether RFT may be more beneficial than GDFT for adults undergoing major non-cardiac surgery.

SEARCH METHODS

We searched the following electronic databases on 11 October 2019: Cochrane Central Register of Controlled Trials, in the Cochrane Libary; MEDLINE; and Embase. Additionally, we performed a targeted search in Google Scholar and searched trial registries (World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov) for ongoing and unpublished trials. We scanned the reference lists and citations of included trials and any relevant systematic reviews identified.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing perioperative RFT versus GDFT for adults (aged ≥ 18 years) undergoing major non-cardiac surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references for eligibility, extracted data, and assessed risk of bias. We resolved discrepancies by discussion and consulted a third review author if necessary. When necessary, we contacted trial authors to request additional information. We presented pooled estimates for dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs), and for continuous outcomes as mean differences (MDs) with standard deviations (SDs). We used Review Manager 5 software to perform the meta-analyses. We used a fixed-effect model if we considered heterogeneity as not important; otherwise, we used a random-effects model. We used Poisson regression models to compare the average number of complications per person.

MAIN RESULTS

From 6396 citations, we included six studies with a total of 562 participants. Five studies were performed in participants undergoing abdominal surgery (including one study in participants undergoing cytoreductive abdominal surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)), and one study was performed in participants undergoing orthopaedic surgery. In all studies, surgeries were elective. In five studies, crystalloids were used for basal infusion and colloids for boluses, and in one study, colloid was used for both basal infusion and boluses. Five studies reported the ASA (American Society of Anesthesiologists) status of participants. Most participants were ASA II (60.4%), 22.7% were ASA I, and only 16.9% were ASA III. No study participants were ASA IV. For the GDFT group, oesophageal doppler monitoring was used in three studies, uncalibrated invasive arterial pressure analysis systems in two studies, and a non-invasive arterial pressure monitoring system in one study. In all studies, GDFT optimization was conducted only intraoperatively. Only one study was at low risk of bias in all domains. The other five studies were at unclear or high risk of bias in one to three domains. RFT may have no effect on the rate of major complications compared to GDFT, but the evidence is very uncertain (RR 1.61, 95% CI 0.78 to 3.34; 484 participants; 5 studies; very low-certainty evidence). RFT may increase the risk of all-cause mortality compared to GDFT, but the evidence on this is also very uncertain (RD 0.03, 95% CI 0.00 to 0.06; 544 participants; 6 studies; very low-certainty evidence). In a post-hoc analysis using a Peto odds ratio (OR) or a Poisson regression model, the odds of all-cause mortality were 4.81 times greater with the use of RFT compared to GDFT, but the evidence again is very uncertain (Peto OR 4.81, 95% CI 1.38 to 16.84; 544 participants; 6 studies; very low-certainty evidence). Nevertheless, sensitivity analysis shows that exclusion of a study in which the final volume of fluid received intraoperatively was higher in the RFT group than in the GDFT group revealed no differences in mortality. Based on analysis of secondary outcomes, such as length of hospital stay (464 participants; 5 studies; very low-certainty evidence), surgery-related complications (364 participants; 4 studies; very low-certainty evidence), non-surgery-related complications (74 participants; 1 study; very low-certainty evidence), renal failure (410 participants; 4 studies; very low-certainty evidence), and quality of surgical recovery (74 participants; 1 study; very low-certainty evidence), GDFT may have no effect on the risk of these outcomes compared to RFT, but the evidence is very uncertain. Included studies provided no data on administration of vasopressors or inotropes to correct haemodynamic instability nor on cost of treatment.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence, we are uncertain whether RFT is inferior to GDFT in selected populations of adults undergoing major non-cardiac surgery. The evidence is based mainly on data from studies on abdominal surgery in a low-risk population. The evidence does not address higher-risk populations or other surgery types. Larger, higher-quality RCTs including a wider spectrum of surgery types and a wider spectrum of patient groups, including high-risk populations, are needed to determine effects of the intervention.

Chemoradiation Vs Radical Cystectomy for Muscle-invasive Bladder Cancer: A Propensity Score-weighted Comparative Analysis Using the National Cancer Database

OBJECTIVE

To address the overarching question whether chemoradiation therapy (CMT) offers overall survival (OS) similar to that of radical cystectomy (RC) in muscle-invasive bladder cancer (MIBC), we performed analyses using the National Cancer Database.

MATERIALS AND METHODS

Patients diagnosed with MIBC in 2004-2014 who underwent RC or received primary CMT were identified in the National Cancer Database. Survival was estimated using the weighted Kaplan-Meier method, and propensity score-weighted Cox proportional hazards model were used to evaluate association of clinicopathologic features with outcome.

RESULTS

Of 484,367 patients with a diagnosis of bladder cancer, 35,856 underwent RC and 4050 received CMT. After applying the exclusion/inclusion criteria, data for 15,854 patients who underwent RC and 2083 who received CMT were available for analysis. Five-year OS was 40.4% in the RC group and 29.4% in the CMT group (P <.001). OS was significantly shorter in the CMT group than in the RC group in both multivariate analysis (hazards ratio [HR] 1.15, 95% CI 1.08-1.22; P <.001) and propensity score-weighted analysis (HR 1.18, 95% CI 1.07-1.30; P <.001). Interaction terms indicated better survival after RC in patients younger than 70 years (HR 1.61, 95% CI 1.34-1.93; P <.001); subgroup analyses identified a survival benefit in patients with N0/N1 disease who underwent RC (HR 1.21, 95% CI 1.09-1.33; P <.001).

CONCLUSION AND RELEVANCE

OS after 1 year of treatment was increased in RC group compared to CMT group in patient with MIBC. Further studies are required to identify optimal treatment for specific patients.

Screening logs from a pilot randomized controlled trial of radical cystectomy versus chemoradiation therapy for muscle-invasive bladder cancer

INTRODUCTION AND OBJECTIVES

There is growing interest in a bladder preservation approach using chemoradiation therapy with transurethral resection of bladder tumor (TURBT), i.e., combined modality treatment (CMT), for muscle-invasive bladder cancer (MIBC). We have initiated a pilot study to determine feasibility of conducting a larger-scale clinical trial comparing CMT to radical cystectomy (RC) in patients with MIBC. Here we present the screening logs from the recruitment phase of this trial.

METHODS

Patients who were diagnosed to have MIBC after TURBT between April 2016 and August 2017 and considered to be candidates for surgery were enrolled in this prospective, single center, randomized controlled pilot feasibility trial and scheduled to undergo RC (with neoadjuvant chemotherapy if appropriate) or CMT.

RESULTS

Of 62 patients screened during the recruitment phase, only 5 were found to be suitable candidates for either treatment modality hence eligible for randomization. The reasons for exclusion were as follows: multifocal disease (n = 24, 40%), variant histology (n = 15, 25%), previous pelvic radiation (n = 6, 10%), severe lower urinary tract symptoms (n = 5, 8.3%), unwillingness to be enrolled (n = 8, 13.3%), and receipt of neoadjuvant chemotherapy (n = 2, 3.3%). One of the 5 eligible patients was randomized to CMT but was subsequently switched to RC because of a high tumor burden, 1 was randomized to RC, 2 were randomized to CMT but subsequently underwent TURBT and were considered ineligible because of extensive bladder disease, and 1 elected to undergo RC.

CONCLUSIONS

We identified many patients with MIBC over a period of 16 months. However, the number of patients eligible to receive chemotherapy and in whom cystectomy and radiation therapy were both valid options was not as high as previously reported in retrospective CMT series. Many patients were excluded after TURBT. Our preliminary data indicate that only a very small subset of patients with MIBC are ideal candidates for CMT. Further research is required to identify patients who are suitable for CMT.

Decrease in skeletal muscle index 1 year after radical cystectomy as a prognostic indicator in patients with urothelial bladder cancer

PURPOSE

The present study aimed to determine whether sarcopenia after radical cystectomy (RC) could predict overall survival (OS) in patients with urothelial bladder cancer (UBC).

MATERIALS AND METHODS

The lumbar skeletal muscle index (SMI) of 80 patients was measured before and 1 year after RC. The prognostic signifi cance of sarcopenia and SMI decrease after RC were evaluated using Kaplan-Meier analysis and a multivariable Cox regression model.

RESULTS

Of 80 patients, 26 (32.5%) experienced sarcopenia before RC, whereas 40 (50.0%) experienced sarcopenia after RC. The median SMI change was -2.2 cm2/m2. Patients with sarcopenia after RC had a higher pathological T stage and tumor grade than patients without sarcopenia. Furthermore, the overall mortality rate was signifi - cantly higher in patients with sarcopenia than in those without sarcopenia 1 year after RC. The median follow-up time was 46.2 months, during which 22 patients died. Kaplan-Meier estimates showed a signifi cant difference in OS rates based on sarcopenia (P=0.012) and SMI decrease (P=0.025). Multivariable Cox regression analysis showed that SMI decrease (≥2.2 cm2/m2) was an independent predictor of OS (hazard ratio: 2.68, confi dence interval: 1.007-7.719, P = 0.048).

CONCLUSIONS

The decrease in SMI after surgery might be a negative prognostic factor for OS in patients who underwent RC to treat UBC.

Rapamycin Prevents Surgery-Induced Immune Dysfunction in Patients with Bladder Cancer

The mechanistic target of rapamycin (mTOR) integrates environmental inputs to regulate cellular growth and metabolism in tumors. However, mTOR also regulates T-cell differentiation and activation, rendering applications of mTOR inhibitors toward treating cancer complex. Preclinical data support distinct biphasic effects of rapamycin, with higher doses directly suppressing tumor cell growth and lower doses enhancing T-cell immunity. To address the translational relevance of these findings, the effects of the mTOR complex 1 (mTORC1) inhibitor, rapamycin, on tumor and T cells were monitored in patients undergoing cystectomy for bladder cancer. MB49 syngeneic murine bladder cancer models were tested to gain mechanistic insights. Surgery-induced T-cell exhaustion in humans and mice and was associated with increased pulmonary metastasis and decreased PD-L1 antibody efficacy in mouse bladder cancer. At 3 mg orally daily, rapamycin concentrations were 2-fold higher in bladder tissues than in blood. Rapamycin significantly inhibited tumor mTORC1, shown by decreased rpS6 phosphorylation in treated versus control patients (P = 0.008). Rapamycin reduced surgery-induced T-cell exhaustion in patients, evidenced by a significant decrease in the prevalence of dysfunctional programmed death-1 (PD-1)-expressing T cells. Grade 3 to 4 adverse event rates were similar between groups, but rapamycin-treated patients had a higher rate of wound complications versus controls. In conclusion, surgery promoted bladder cancer metastasis and decreased the efficacy of postoperative bladder cancer immunotherapy. Low-dose (3 mg daily) oral rapamycin has favorable pharmacodynamic and immune modulating activity in surgical patients and has the potential to decrease surgery-induced immune dysfunction.

Comparative Effectiveness in Perioperative Outcomes of Robotic versus Open Radical Cystectomy: Results from a Multicenter Contemporary Retrospective Cohort Study

BACKGROUND

The comparative effectiveness of robotic-assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) in terms of perioperative outcomes is still a matter of debate affecting payors, physicians, and patients.

OBJECTIVE

To evaluate comparative perioperative and longer-term morbidity of RARC versus ORC in a multicenter contemporary retrospective cohort of patients.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective multicenter study included patients with bladder cancer treated with radical cystectomy at 10 academic centers between 2000 and 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Intraoperative outcomes including blood loss and operative time as well as postoperative outcomes including time to discharge, complication, readmission, reoperation, and mortality rates at 30 and 90 d were assessed. Multiple imputation and inverse probability of treatment weighting (IPTW) were used. IPTW-multivariable-adjusted regression and logistic analyses were performed to evaluate the associations of RARC versus ORC with perioperative outcomes at 30 and 90 d.

RESULTS AND LIMITATIONS

Overall, 1887 patients (1197 RARC and 690 ORC) were included in the study. After IPTW-adjusted analysis, no differences between the groups in terms of preoperative characteristics were observed. RARC was associated with lower blood loss (p<0.001), shorter length of stay (p<0.001), and longer operative time (p=0.007). On IPTW-adjusted multivariable logistic regression analyses, no differences in terms of 30- and 90-d complications, reoperation, and mortality rates were observed. RARC was independently associated with a higher readmission rate at both 30 and 90 d. Limitations are mainly related to the retrospective nature of the study.

CONCLUSIONS

While RARC was associated with less blood loss and shorter hospital stay, it also led to longer operation times and more readmissions. There were no differences in 30- and 90-d complications. Because there are no apparent differences in safety between ORC and RARC in expert centers, differences in oncologic and cost-effectiveness outcomes are likely to drive decision making regarding RARC utilization.

PATIENT SUMMARY

In this study we investigated the differences between RARC and ORC in terms of perioperative outcomes. We found no difference in early and late complications. We concluded that, to date, differences in oncologic and cost-effectiveness outcomes should drive decision making regarding RARC utilization.

Frailty as a predictor of complications after radical cystectomy: A prospective study of various preoperative assessments

PURPOSE

Frailty has been correlated with worse postoperative outcomes. Prospective studies examining frailty and bladder cancer are lacking. We aimed to determine whether a prospective frailty assessment or traditional risk indices can identify patients undergoing radical cystectomy (RC) at risk for complications.

MATERIALS AND METHODS

Patients ≥65 years undergoing RC were preoperatively assessed using Fried Frailty Criteria (FFC; grip strength, gait speed, exhaustion, physical activity, shrinking), Charlson Comorbidity Index, American Society of Anesthesiologists score, Katz Index of Independence in Activities of Daily Living, Karnofsky Performance Scale, Eastern Cooperative Oncology Group performance status, and Center for Epidemiological Studies Depression scale. Thirty-day and 90-day postoperative complications were recorded. Univariate and multivariate analyses were performed.

RESULTS

One hundred and twenty three patients were assessed with median age of 74 years. Fifty-nine patients (48.0%) had ≥1 complication within 30 days and 72 (58.5%) within 90 days. Center for Epidemiological Studies Depression scale (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.17, P = 0.027) and shrinking (OR 3.79, 95% CI 1.64-9.26, P = 0.0024) were significant for any 30-day complication, while physical activity was protective (OR 0.84, 95% CI 0.69-1.00, P = 0.072) for any 90-day complication. Being intermediately frail or frail was associated with high-grade 30-day (OR 4.87, 95% CI 1.39-22.77, P = 0.022) and 90-day complications (OR 3.01, 95% CI 1.05-9.37, P = 0.045), along with Eastern Cooperative Oncology Group score ≥3 (OR 45.00, 95% CI 6.92-437.69, P = 0.0010 and OR 17.85, 95% CI 3.21-143.26, P = 0.0079, respectively).

CONCLUSIONS

Fried Frailty Criteria were predictive of high-grade complications, while individual components were predictive of having any complication. Elderly patients should be routinely assessed prior to RC to guide postoperative care.

Thromboembolism in Patients with Bladder Cancer: Incidence, Risk Factors and Prevention

Patients with bladder cancer are at high risk of developing both venous and arterial thromboembolic events. Factors that contribute to this phenomenon include the hypercoagulable state induced by the malignancy itself, medical comorbidities that are common in this predominantly elderly patient population as well as treatments such as prolonged pelvic surgery and cisplatin-based chemotherapy. While formal guidelines address prevention of venous thromboembolism in patients undergoing radical cystectomy, consensus regarding the role of pharmacologic prophylaxis in patients with bladder cancer being treated with chemotherapy, either with neoadjuvant or adjuvant intent in conjunction with radical cystectomy, as part of bladder preservation protocols or for metastatic disease, has proved elusive. The present narrative review was undertaken to define the incidence of and identify risk factors for thromboembolism among patients with bladder cancer, as well as to assess the efficacy of pharmacologic prophylaxis in reducing the risk of thromboembolism in this patient population.

Effects of Nonsteroidal Anti-Inflammatory Drugs as Patient Controlled Analgesia on Early Bowel Function Recovery after Radical Cystectomy

This study aimed to evaluate the effects of ketorolac, a commonly used non-steroidal anti-inflammatory drug (NSAID) as patient controlled intravenous infusion analgesia (PCIA) for the patients underwent radical cystectomy (RC) due to bladder cancer regarding post-operational indices of recovery. Total seventy patients who underwent radical cystectomy for the treatment of bladder cancer were included in the study. 35 patients received ketorolac as PCIA (NSAIDS group) and 35 patients had morphine infusion as PCIA (morphine group). Pain intensity, bowel function recovery and length of hospital stay were evaluated. Early postoperative complications were analyzed according to surgical types (robot RC vs. open RC). Demographics were similar between two groups. NSAIDS group showed a significant reduction in postoperative vomiting (p = 0.001), time to flatus (p = 0.028), time to first bowel movement (p = 0.001) and time to first clear liquid diet (p = 0.002) compared with morphine group. No statistically significant differences were observed between two groups regarding length of hospitalization, and postoperative complications. For 48 hours after RC, pain relief was slightly better in morphine group (p < 0.001). Both open RC and robot RC cases showed significantly better bowel function recovery with NSAIDS groups. Ketorolac as PCIA is relatively effective in pain management with better gastrointestinal recovery after RC.

Complications within 90 days after radical cystectomy for bladder cancer: results of a multicenter prospective study in Japan

PURPOSE

We prospectively evaluated the 90-day postoperative mortality and morbidity of open radical cystectomy by using a standardized reporting methodology. Additionally, we assessed the preoperative characteristics to determine risk factors for major complications.

METHODS

This multicenter prospective study included 185 consecutive patients undergoing open radical cystectomy from October 2010 through March 2014. Postoperative complications within 90 days were recorded and graded according to the modified Clavien-Dindo classification.

RESULTS

Totally, 328 postoperative complications were observed in 149 patients (80.5%). Of these events, 73 (22.2%) were high grade (≥ Grade III), and developed in 46 patients (24.9%). Three patients (1.6%) died postoperatively. Urinary tract infection, wound complications, and paralytic ileus were common complications that occurred in 55 (29.7%), 42 (22.7%) and 41 (22.2%) patients, respectively. Ureteroenteric stricture was diagnosed in 13 of the 151 patients (8.6%) undergoing intestinal urinary diversion. Emergency room visits were required for 13 patients (7.0%) and readmission after discharge was needed for 36 (19.5%). A body mass index ≥ 25 kg/m², smoking history and Charlson Comorbidity Index ≥ 2 were independent risk factors for high-grade complications, and their odds ratios (95% confidence intervals) were 2.357 (1.123-4.948), 2.843 (1.225-6.596) and 3.025 (1.390-6.596), respectively.

CONCLUSIONS

Open radical cystectomy is associated with a high incidence of postoperative complications. Most, however, are of low grade. Our results suggest that obesity, a smoking history, and increasing comorbidity are risk factors for major complications.

Preoperative nutritional factors and outcomes after radical cystectomy: A narrative review

Only a few nutritional factors have been identified to predict the risk of developing complications after radical cystectomy (RC). This narrative review delineates the current known effects of preoperative nutritional status factors in this context. The report highlights the heterogeneity between study methods and results. We determined that low albuminemia values increase mortality risk and overall complications. In addition, obesity tends to increase the risk of developing venous thromboembolism and adverse events. Additional prospective studies, using standardized methods to both define and report complications, should be conducted to strengthen the connections between preoperative nutritional status factors and post-RC complications. Furthermore, intervention studies testing the impact of strategies to improve nutritional status on the risk of complications after RC are also needed.

National Surgical Quality Improvement Program surgical risk calculator poorly predicts complications in patients undergoing radical cystectomy with urinary diversion

PURPOSE

To evaluate the accuracy of the American College of Surgeons National Surgical Quality Improvement Programs (ACS-NSQIP) surgical risk calculator in patients undergoing radical cystectomy (RC) with urinary diversion.

MATERIALS AND METHODS

Preoperative characteristics of patients who underwent RC with ileal conduit or orthotropic neobladder (ONB) between 2007 and 2016 were entered into the proprietary online ACS-NSQIP calculator to generate 30-day predicted risk profiles. Predicted and observed outcomes were compared by measuring Brier score (BS) and area under the receiver operating characteristic curve (AUC).

RESULTS

Of 954 patients undergoing RC, 609 (64%) received ileal conduit and 345 (36%) received ONB. The calculator underestimated most risks by 10%-81%. The BSs exceeded the acceptable threshold of 0.01 and AUC were less than 0.8 for all outcomes in the overall cohort. The mean (standard deviation) predicted vs. observed length of stay was 9 (1.5) vs. 10.6 (7.4) days (Pearson's r = 0.09). Among patients who received ONB, adequate BS (<0.01) was observed for pneumonia, cardiac complications, and death. The receiver operating characteristic curve analysis revealed moderate accuracy of calculator for cardiac complications (AUC = 0.69) and discharge to rehab center (AUC = 0.75) among patients who underwent RC with ONB.

CONCLUSIONS

The universal ACS-NSQIP calculator poorly predicts most postoperative complications among patients undergoing RC with urinary diversion. A procedure-specific risk calculator is required to better counsel patients in the preoperative setting and generate realistic quality measures.

Safety and Effectiveness of Robot-Assisted Versus Open Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the safety and effectiveness of robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC) in bladder cancer.

METHODS

A literature search for the systematic review was conducted using international databases as well as domestic databases up to April 2015. Outcomes of interest included baseline characteristics, complication rates, perioperative, and oncologic outcomes.

RESULTS

Twenty-four articles were finally selected for inclusion in the meta-analysis. Complication rates of RARC were similar to those of ORC, except for 90-day overall complication rate, wound dehiscence, abscess, pneumonia, respiratory failure, and sepsis, which was lower after RARC. RARC was also associated with a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield, whereas ORC was associated with a shorter operation time and lower rate of stricture. Considering oncologic outcomes, there were no differences between RARC and ORC.

CONCLUSIONS

RARC seems to be associated with equivalent complication rates, a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield. Randomized controlled trials with a large sample size and comparative studies with long-term follow-up data are warranted to assess our findings and the oncologic effectiveness of RARC.

Impact of neoadjuvant chemotherapy on complications of minimally invasive radical cystectomy

BACKGROUND

Neoadjuvant chemotherapy (NC) before minimally invasive radical cystectomy (MIRC) is considered a standard of care in muscle-invasive bladder cancer or recurrent high-risk non-muscle-invasive bladder cancer.

OBJECTIVE

To evaluate the impact of NC on morbidity and mortality after MIRC.

DESIGN, SETTING, AND PARTICIPANTS

We prospectively evaluated 135 patients who underwent MIRC (laparoscopic: n=100; robotic: n=35) between 2007 and 2013 with ≥90 days of follow-up (median age: 66 year). Complications were analyzed and graded according to the Clavien Dindo classification system.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Logistic regression models were used to evaluate the impact of NC on postoperative complications. Kaplan-Meier methods with the log-rank test were used for cancer-specific survival probabilities and differences between the 2groups (MIRC with and without NC).

RESULTS AND LIMITATIONS

Sixty-two of 135 patients received NC. A total of 118 patients (87.4%) developed 179 complications, chiefly infectious (48.0%) or gastrointestinal (21.2%), ≤90 days after surgery; 3 patients died <90 days after cystectomy (none had NC). NC had no impact on the incidence of postoperative complications but was associated with fewer positive nodes (P=.004) compared with patients without NC. The median duration of follow-up was 17.2 months. Overall survival rates were 83% and 79% at 2 year in patients with NC and without NC, respectively.

CONCLUSIONS

NC does not affect postoperative morbidity or postoperative mortality. Longer follow-up is needed to evaluate the impact of NC on oncologic outcomes.

PATIENT SUMMARY

Perioperative complications of radical cystectomy were compared for patients with bladder cancer who had NC versus no NC. We did not find any significant differences in terms of early or late complications, length of stay, or reintervention. The oncologic outcomes regarding NC were encouraging.

Phase 1b Trial to Evaluate Tissue Response to a Second Dose of Intravesical Recombinant Adenoviral Interferon α2b Formulated in Syn3 for Failures of Bacillus Calmette-Guerin (BCG) Therapy in Nonmuscle Invasive Bladder Cancer

BACKGROUND

A phase 1b trial was conducted to evaluate the duration of interferon-alpha (IFNα) production after intravesical administration of recombinant adenovirus-mediated interferon α2b (Ad-IFN) formulated with the excipient Syn3. The primary aim was to determine whether a second instillation 3 days after initial treatment produced prolonged urinary IFN production.

METHODS

The study enrolled seven patients who experienced recurrent non-muscle invasive bladder cancer after bacillus Calmette-Guerin therapy. Each treatment consisted of intravesical instillation of SCH721015 (Syn3) and Ad-IFN at a concentration of 3 × 10¹¹ particles/mL to a total volume of 75 mL given on days 1 and 4. The patients were followed for 12 weeks, during which the magnitude and duration of gene transfer were determined by urine INFα levels. Drug efficacy was determined by cystoscopy and biopsy, and patients who had no recurrence at 12 weeks were eligible for a second course of treatment.

RESULTS

Seven patients were treated with an initial course (instillation on days 1 and 4). Two of the patients had a complete response at 12 weeks and received a second course of treatment. One patient remained without evidence of recurrence after a second course (total 24 weeks). One patient experienced a non-treatment-associated adverse event. Despite a transient rise in IFNα levels, sustained production was not demonstrated.

CONCLUSION

Previously, Ad-IFNα intravesical therapy has shown promising drug efficacy. A prior phase 1 trial with a single instillation compared similarly with the current study, suggesting that a second instillation is not necessary to achieve sufficient urinary IFNα levels.

A Multi-Center International Study Assessing the Impact of Differences in Baseline Characteristics and Perioperative Care Following Radical Cystectomy

Background: To identify potential avenues for quality improvement, we compared the variations in clinical practice and their association with perioperative morbidity and mortality following radical cystectomy (RC) for bladder cancer in the United States (US) and Japan.

Methods: We reviewed our retrospectively collected database of 2240 patients who underwent RC for bladder cancer at the University of Michigan (n = 1427) and in 21 Japanese institutions (n = 813) between 1997 and 2014. We performed a systematic comparison of clinical and perioperative factors and assessed predictors of perioperative morbidity and mortality. Death within 90 days of surgery was the primary outcome.

Results: There were apparent differences between the two study populations. Notably, US patients had a significantly greater BMI and higher ASA score. In Japanese institutions, median postoperative hospital stay was significantly higher (40 days vs. 7 days, p <  0.001) and 90-day readmission rates were significantly lower (0.6% vs. 26.8% , p <  0.001). There was a total of 1372/2240 (61.2%) patients with complications within 90 days and 66/2240 (2.9%) patient deaths. Significant predictors of 90-day mortality were older age (OR 1.04, CI 1.01–1.07), higher body mass index (OR 1.07, CI 1.02–1.12), node-positive disease (OR 3.14, CI 1.78–5.47), increased blood loss (OR 1.02, CI 1.01–1.03), and major (Clavien-grade 3 or greater) complication (OR 3.29, CI 1.88–5.71).

Conclusion: Despite major differences in baseline characteristics and care of cystectomy patients between the two study populations, peri-operative mortality rates proved to be comparable. This data supports an exploration of non-traditional factors that may influence mortality after cystectomy.

Patient Psoas Muscle Mass as a Predictor of Complications and Survival After Radical Cystectomy

As a treatment for high-risk bladder cancer, radical cystectomy (RC) remains a highly morbid operation with complication rates of 40-60% and mortality rates as high as 9% in the first 90 days after surgery (Aziz et al., Eur Urol 66(1):156-163, 2014; Shabsigh et al., Eur Urol 55(1):164-174, 2009). Many patients suffer from a failure-to-thrive syndrome associated with anorexia, weight loss, dehydration, and immobility. In elderly patients, failure-to-thrive may result in loss of independence and a cascade of events that increases the risk of perioperative morbidity and mortality, ultimately resulting in impaired survival. Psoas muscle mass has been used to predict morbidity and mortality after major surgical procedures in vulnerable populations with substantial comorbidities. Increasingly, psoas muscle mass is also being used to predict outcomes after RC. If patients with a high risk of impaired survival are identified preoperatively, prehabilitative interventions can be integrated into their preparation for surgical treatment (Porserud et al., Clin Rehab 28(5):451-459, 2014; Friedman et al., Nutr Clin Pract: Off Publ Am Soc Parenter Enter Nutr 30(2):175-179, 2015). This chapter discusses the role of psoas muscle mass as a predictor of negative surgical outcomes after cystectomy.

Acute Kidney Injury After Radical Cystectomy for Bladder Cancer is Associated with Chronic Kidney Disease and Mortality

PURPOSE

The aim of this study was to investigate the prevalence of acute kidney injury (AKI) after radical cystectomy, and evaluate its impact on chronic kidney disease (CKD) and mortality.

METHODS

The medical records of 866 patients who underwent radical cystectomy for bladder cancer were reviewed. AKI was assessed within 7 days after surgery according to the Acute Kidney Injury Network criteria. The prevalence of AKI after surgery was examined, and the significance of AKI for CKD and mortality was analyzed.

RESULTS

Of 866 patients, 269 (31.1 %) developed AKI in the first week after surgery. Of these, 231 (85.9 %) were at stage 1, 32 (11.9 %) at stage 2, and 6 (2.2 %) at stage 3. Of 722 patients with a preoperative Modification of Diet in Renal Disease estimated glomerular filtration rate (eGFR) of >60 ml/min/1.73 m(2), CKD developed in 23.0 % (118/513) of patients in the non-AKI group and 32.5 % (68/209) of patients in the AKI group. Independent factors predicting new-onset CKD were a preoperative eGFR (p < 0.001), age (p = 0.011), urinary tract complication (p < 0.001) and AKI (p = 0.015). In all, 297 patients died (191 in the non-AKI group and 106 in the AKI group). AKI also correlated significantly with overall survival (p = 0.001).

CONCLUSIONS

AKI is not only commonly encountered after radical cystectomy but is also associated with higher CKD rates and mortality. There is a critical need for strategies to increase the identification of patients at risk of postoperative AKI, and to improve the management of patients, with an aim toward preventing AKI and improving the treatment of AKI once it occurs.

Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy

CONTEXT

Although open radical cystectomy (ORC) is still the standard approach, laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) have gained popularity.

OBJECTIVE

To report a systematic literature review and cumulative analysis of perioperative outcomes and complications of RARC in comparison with ORC and LRC.

EVIDENCE ACQUISITION

Medline, Scopus, and Web of Science databases were searched using a free-text protocol including the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy. RARC case series and studies comparing RARC with either ORC or LRC were collected. Cumulative analysis was conducted.

EVIDENCE SYNTHESIS

The searches retrieved 105 papers. According to the different diversion type, overall mean operative time ranged from 360 to 420 min. Similarly, mean blood loss ranged from 260 to 480 ml. Mean in-hospital stay was about 9 d for all diversion types, with consistently high readmission rates. In series reporting on RARC with either extracorporeal or intracorporeal conduit diversion, overall 90-d complication rates were 59% (high-grade complication: 15%). In series reporting RARC with intracorporeal continent diversion, the overall 30-d complication rate was 45.7% (high-grade complication: 28%). Reported mortality rates were ≤3% for all diversion types. Comparing RARC and ORC, cumulative analyses demonstrated shorter operative time for ORC, whereas blood loss and in-hospital stay were better with RARC (all p values <0.003). Moreover, 90-d complication rates of any-grade and 90-d grade 3 complication rates were lower for RARC (all p values <0.04), whereas high-grade complication and mortality rates were similar.

CONCLUSIONS

RARC can be performed safely with acceptable perioperative outcome, although complications are common. Cumulative analyses demonstrated that operative time was shorter with ORC, whereas RARC may provide some advantages in terms of blood loss and transfusion rates and, more limitedly, for postoperative complication rates over ORC and LRC.

PATIENT SUMMARY

Although open radical cystectomy (RC) is still regarded as a standard treatment for muscle-invasive bladder cancer, laparoscopic and robot-assisted RC are becoming more popular. Robotic RC can be safely performed with acceptably low risk of blood loss, transfusion, and intraoperative complications; however, as for open RC, the risk of postoperative complications is high, including a substantial risk of major complication and reoperation.

Use of intravesical valrubicin in clinical practice for treatment of nonmuscle-invasive bladder cancer, including carcinoma in situ of the bladder

OBJECTIVES

The objective was to conduct a US multicenter, retrospective medical record study examining the effectiveness, safety, and patterns of use of valrubicin for treatment of nonmuscle-invasive bladder cancer (NMIBC) by clinicians since the 2009 reintroduction of valrubicin.

METHODS

Patients ≥ 18 years with NMIBC who received had one or more instillations of valrubicin (October 2009- September 2011) were eligible. The primary endpoint was event-free survival (EFS). Safety and tolerability were also assessed.

RESULTS

The medical records of 113 patients met the inclusion criteria; 100 patients (88.5%) completed valrubicin treatment. The median age was 75 years (range 42-95 years). The median NMIBC duration was 31 months since diagnosis: 51.3% (58/113) had carcinoma in situ (CIS) alone, and 31.9% (36/113) had unspecified NMIBC. Most patients, 94.7% (107/113), had more than three valrubicin instillations and 70.8% (80/113) completed a full course. The EFS rate (95% confidence interval) was 51.6% (40.9-61.3%), 30.4% (20.4-41.1%), and 16.4% (7.9-27.5%) at 3, 6, and 12 months, respectively. Median time to an event was 3.5 (2.5-4.0) months after the first valrubicin instillation. Local adverse reactions (LARs) were experienced by 49.6% (56/113) of patients; most LARs were mild (93.6%). The most frequent LARs were hematuria, pollakiuria, micturition urgency, bladder spasm, and dysuria. In total, 4.4% (5/113) of patients discontinued valrubicin because of adverse events or LARs.

CONCLUSIONS

Data from the present retrospective study are consistent with previous prospective clinical trials that demonstrated valrubicin effectiveness and tolerability for select patients with CIS, before considering cystectomy. Additional prospective studies are warranted to evaluate valrubicin safety and efficacy in the broader patient population with NMIBC.

Robot-assisted radical cystectomy with intracorporeal neobladder diversion: The Karolinska experience

Introduction:

The aim of this report is to describe our surgical technique of totally intracorporeal robotic assisted radical cystectomy (RARC) with neobladder formation.

Materials and Methods:

Between December 2003 and March 2013, a total of 147 patients (118 male, 29 female) underwent totally intracorporeal RARC for urinary bladder cancer. We also performed a systematic search of Medline, Embase and PubMed databases using the terms RARC, robotic cystectomy, robot-assisted, totally intracorporeal RARC, intracorporeal neobladder, intracorporeal urinary diversion, oncological outcomes, functional outcomes, and complication rates.

Results:

The mean age of our patients was 64 years (range 37-87). On surgical pathology 47% had pT1 or less disease, 27% had pT2, 16% had pT3 and 10% had pT4. The mean number of lymph nodes removed was 21 (range 0-60). 24% of patients had lymph node positive dAQ1isease. Positive surgical margins occurred in 6 cases (4%). Mean follow-up was 31 months (range 4-115 months). Two patients (1.4%) died within 90 days of their operation. Using Kaplan-Meier analysis, overall survival and cancer specific survival at 60 months was 68% and 69.6%, respectively. 80 patients (54%) received a continent diversion with totally intracorporeal neobladder formation. In the neobladder subgroup median total operating time was 420 minutes (range 265-760). Daytime continence and satisfactory sexual function or potency at 12 months ranged between 70-90% in both men and women.

Conclusions:

Our experience with totally intracorporeal RARC demonstrates acceptable oncological and functional outcomes that suggest this is a viable alternative to open radical cystectomy.

Is postoperative epidural analgesia better than patient-controlled analgesia for radical cystectomy?

Background:

The purpose of this study was to evaluate postoperative epidural analgesia (EPA) and intravenous patient-controlled analgesia (PCA) in terms of morbidity and mortality in patients undergoing radical cystectomy for bladder cancer.

Methods:

A retrospective study on patients undergoing radical cystectomy for clinical Tis-4N0M0 urothelial carcinoma of the bladder was performed. Patients were separated into two groups: primary EPA or PCA for postoperative analgesia. The surgical complication severity was determined according to the Clavien system. Mann-Whitney U tests, χ2 with Yates’ correction, or Fisher’s exact test were used. Predictive risk factors were explored using univariable and multivariable Cox regression models.

Results:

Of the 274 patients studied, 209 (76%) received EPA and 65 (24%) had PCA. Baseline balance was observed. Similar complication rates were observed between the EPA (36%) and PCA (34%) ( p=0.382). Patients greater than 70 years of age had more complications (35% vs 21%, p=0.002). PCA patients had higher rates of high-grade complications compared with EPA patients [40% vs 20% ( p=0.0007)]. Only age at time of surgery ( p=0.032) was associated with complications. Patients with pulmonary disease had a higher risk of complications ( p=0.001). EPA or PCA were not predictors for overall survival.

Conclusions:

There does not appear to be a significant difference in terms of morbidity or mortality between EPA and PCA following radical cystectomy (RC). Rare, catastrophic complications specific to EPA may occur. Standardized reporting of surgical complications is essential to compare studies and appropriately counsel patients.

Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial

BACKGROUND

Radical cystectomy (RC) for bladder cancer is frequently associated with delayed gastrointestinal (GI) recovery that prolongs hospital length of stay (LOS).

OBJECTIVE

To assess the efficacy of alvimopan to accelerate GI recovery after RC.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a randomized double-blind placebo-controlled trial in patients undergoing RC and receiving postoperative intravenous patient-controlled opioid analgesics.

INTERVENTION

Oral alvimopan 12 mg (maximum: 15 inpatient doses) versus placebo.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The two-component primary end point was time to upper (first tolerance of solid food) and lower (first bowel movement) GI recovery (GI-2). Time to discharge order written, postoperative LOS, postoperative ileus (POI)-related morbidity, opioid consumption, and adverse events (AEs) were evaluated. An independent adjudication of cardiovascular AEs was performed.

RESULTS AND LIMITATIONS

Patients were randomized to alvimopan (n=143) or placebo (n=137); 277 patients were included in the modified intention-to-treat population. The alvimopan cohort experienced quicker GI-2 recovery (5.5 vs 6.8 d; hazard ratio: 1.8; p<0.0001), shorter mean LOS (7.4 vs 10.1 d; p=0.0051), and fewer episodes of POI-related morbidity (8.4% vs 29.1%; p<0.001). The incidence of opioid consumption and AEs or serious AEs (SAEs) was comparable except for POI, which was lower in the alvimopan group (AEs: 7% vs 26%; SAEs: 5% vs 20%, respectively). Cardiovascular AEs occurred in 8.4% (alvimopan) and 15.3% (placebo) of patients (p=0.09). Generalizability may be limited due to the exclusion of epidural analgesia and the inclusion of mostly high-volume centers utilizing open laparotomy.

CONCLUSIONS

Alvimopan is a useful addition to a standardized care pathway in patients undergoing RC by accelerating GI recovery and shortening LOS, with a safety profile similar to placebo.

PATIENT SUMMARY

This study examined the effects of alvimopan on bowel recovery in patients undergoing radical cystectomy for bladder cancer. Patients receiving alvimopan experienced quicker bowel recovery and had a shorter hospital stay compared with those who received placebo, with comparable safety.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT00708201.

The effect of neoadjuvant chemotherapy on perioperative outcomes in patients who have bladder cancer treated with radical cystectomy: a population-based study

BACKGROUND

Although therapeutic guidelines recommend the use of neoadjuvant chemotherapy before radical cystectomy (RC) in patients who have muscle-invasive bladder cancer (MIBC), this approach remains largely underused. One of the main reasons for this phenomenon might reside in concerns regarding the risk of morbidity and mortality associated with neoadjuvant chemotherapy.

OBJECTIVE

To compare perioperative outcomes between patients receiving neoadjuvant chemotherapy and those treated with RC alone.

DESIGN, SETTING, AND PARTICIPANTS

Relying on the Surveillance Epidemiology and End Results-Medicare-linked database, 3760 patients diagnosed with MIBC between 2000 and 2009 were evaluated.

INTERVENTION

RC alone or RC plus neoadjuvant chemotherapy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Complications occurred within 30 and 90 d after surgery. Heterologous blood transfusions (HBTs), length of stay (LoS), readmission, and perioperative mortality were compared. To decrease the effect of unmeasured confounders associated with treatment selection, propensity score-matched analyses were performed.

RESULTS AND LIMITATIONS

Overall, 416 (11.1%) of patients received neoadjuvant chemotherapy. Following propensity score matching, 416 (20%) and 1664 (80%) patients treated with RC plus neoadjuvant chemotherapy and RC alone remained, respectively. The 30-d complication, readmission, and mortality rates were 66.0%, 32.2%, and 5.3%, respectively. The 90-d complication, readmission, and mortality rates were 72.5%, 46.6%, and 8.2%, respectively. When patients were stratified according to neoadjuvant chemotherapy status, no significant differences were observed in the rates of complications, HBT, prolonged LoS, readmission, and mortality between the two groups (all p ≥ 0.1). These results were confirmed in multivariate analyses, where the use of neoadjuvant chemotherapy was not associated with higher risk of 30- and 90-d complications, HBT, prolonged LoS, readmission, and mortality (all p ≥ 0.1). Our study is limited by its retrospective nature.

CONCLUSIONS

The use of neoadjuvant chemotherapy is not associated with higher perioperative morbidity or mortality. These results should encourage wider use of neoadjuvant chemotherapy when clinically indicated.

PATIENT SUMMARY

Chemotherapy before radical cystectomy in patients with muscle-invasive bladder cancer does not increase the risk of complications or death. The use of chemotherapy should be strongly encouraged, as recommended by clinical guidelines, given its benefits.

The economics of bladder cancer: costs and considerations of caring for this disease

CONTEXT

Due to high recurrence rates, intensive surveillance strategies, and expensive treatment costs, the management of bladder cancer contributes significantly to medical costs.

OBJECTIVE

To provide a concise evaluation of contemporary cost-related challenges in the care of patients with bladder cancer. An emphasis is placed on the initial diagnosis of bladder cancer and therapy considerations for both non-muscle-invasive bladder cancer (NMIBC) and more advanced disease.

EVIDENCE ACQUISITION

A systematic review of the literature was performed using Medline (1966 to February 2011). Medical Subject Headings (MeSH) terms for search criteria included "bladder cancer, neoplasms" OR "carcinoma, transitional cell" AND all cost-related MeSH search terms. Studies evaluating the costs associated with of various diagnostic or treatment approaches were reviewed.

EVIDENCE SYNTHESIS

Routine use of perioperative chemotherapy following complete transurethral resection of bladder tumor has been estimated to provide a cost savings. Routine office-based fulguration of small low-grade recurrences could decrease costs. Another potential important target for decreasing variation and cost lies in risk-modified surveillance strategies after initial bladder tumor removal to reduce the cost associated with frequent cystoscopic and radiographic procedures. Optimizing postoperative care after radical cystectomy has the potential to decrease length of stay and perioperative morbidity with substantial decreases in perioperative care expenses. The gemcitabine-cisplatin regimen has been estimated to result in a modest increase in cost effectiveness over methotrexate, vinblastine, doxorubicin, and cisplatin. Additional costs of therapies need to be balanced with effectiveness, and there are significant gaps in knowledge regarding optimal surveillance and treatment of both early and advanced bladder cancer.

CONCLUSIONS

Regardless of disease severity, improvements in the efficiency of bladder cancer care to limit unnecessary interventions and optimize effective cancer treatment can reduce overall health care costs. Two scenarios where economic and comparative-effectiveness research is limited but would be most beneficial are (1) the management of NMIBC patients where excessive costs are due to vigilant surveillance strategies and (2) in patients with metastatic disease due to the enormous cost associated with late-stage and end-of-life care.

Lower skeletal muscle index and early complications in patients undergoing radical cystectomy for bladder cancer

BACKGROUND

Radical cystectomy (RC) is the standard treatment for patients with muscle-invasive bladder cancer (BC), and it is also a valid option for selected patients with high-risk non-muscle-invasive BC. The purpose of this study was to evaluate the effect on the lower skeletal muscle index (SMI) of short-term postoperative complications of radical cystectomy (RC) in patients with bladder cancer (BC).

METHODS

A total of 247 patients who received RC for BC and 204 age-matched healthy population-based controls were retrospectively assessed. SMI was measured by preoperative computed tomography scans at the L4 to L5 level. Early complications were graded by Clavien-Dindo classification; severity of grade III or greater was identified as a severe complication. Logistic regression was utilized to determine the relationships between covariables and severe complications.

RESULTS

A total of 125 (50.61%)/19 (7.69%) patients exhibited overall/severe complications during the early postoperative period. SMI was strongly associated with gender (P <0.01), but not age and body mass index (BMI), among patients with BC. Compared with the matched control group, BC patients exhibited lower SMI. The difference was statistically significant in the subgroup of male patients (P = 0.03). In the multivariate analysis, SMI was an independent predictor of developing severe complications. Each 1 cm²/m² increase in SMI was associated with a decrease in the odds of morbidity by 4.8%.

CONCLUSIONS

A lower SMI is frequently observed in bladder cancer patients undergoing RC and is shown to be strongly associated with early complications following surgery.