Critical Analysis of Early Recurrence after Laparoscopic Radical Cystectomy in a Large Cohort by the ESUT

Comparison of Tumor Seeding and Recurrence Rate After Laparoscopic vs. Open Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma

Introduction: Laparoscopic surgery for Upper Urinary Tract Urothelial Cell Carcinoma (UTUC) is still debated for its possible seeding risk and thus consequent oncological recurrences, especially for atypical ones. The aim of the study is to compare recurrence and survival after Laparoscopic vs. Open Radical Nephroureterectomy (RNU) for Upper Urinary Tract Urothelial Cancer (UTUC).

Method: A retrospective evaluation of UTUC consecutive surgeries from 2008 to 2019 was conducted, including pT ≥ 2, High Grade UTUC who underwent RNU with bladder cuff excision without concomitant lymphadenectomy in three urological tertiary centers. Statistical analyses compared recurrence and cancer specific survival, based on surgical approach, while logistic multivariate analyses and Kaplan Meyer survival curve analyzed possible risk factors for recurrence and survival.

Results: One hundred seven cases of RNU, 47 (43.9%) laparoscopic and 60 (56.1%) open, were included in this report. Preoperative characteristics were comparable between groups. However, tumor stage was higher in the Open arm [T3–T4 in 44 (73.3%) vs. 20 (43.4%) in Laparoscopic]. Mean follow-up was 91.6 months in laparoscopy RNU vs. 93.5 months in open RNU. Recurrence rate (RR) was comparable between groups (p = 0.594), and so was the site, although 3 (6.3%) peritoneal recurrences were found only in laparoscopic group (p = 0.057). At multivariate logistic regression, tumor stage and surgical approach were independent predictors of recurrence (p < 0.05), while only tumor stage was predictor of cancer specific death (p = 0.029).

Conclusion: Surgical approach has no impact on recurrence site, overall survival, and RR. Still, according to our data peritoneal carcinomatosis was present only in laparoscopic arm, despite how it didn't reach statistical significance.

The effect of CO2 pressure and flow variation on carbon particles spread during pneumoperitoneum: an experimental study

BACKGROUND

A correlation between atypical recurrences and minimally-invasive surgery has been suggested in case of urothelial cancer; however, very few data are available on the role of pneumo peritoneum in terms of gas flow and intra-abdominal pressure. The objective of the study is to analyze the impact of CO2 pneumoperitoneum variation on an inert material as surrogate of neoplastic cells.

MATERIAL AND METHODS

We designed an experimental model mimicking pneumoperitoneum in three settings: sealed flow (no leakage), pulsatile flow (alternating efflux and influx) and continuous flow (AirSeal® insufflator). Each experiment was characterized by a pre-determined gas flow and pressure, trocar distance and position from the particles. Hounsfield density (HD) variation in the areas of interest was measured as index of graphite powder dispersion. A Linear regression model was employed to measure the correlation between modifiable variables and HD.

RESULTS

HD was lower in the pulsatile compared to both the sealed and continuous flows (p < 0.03). On multivariate analysis for sealed setting, flow and total gas liters delivered (i.e. gas leakage) were inversely and independently related to HD (all p <0.03). In pulsatile setting, trocar position, trocar distance and gas flow independently predicted HD (all p <0.03). In continuous setting, gas pressure was directly and independently related to HD (p = 0.004) due to decreased pneumoperitoneum stability and increased CO2 liters delivered. In case of in-flow trocar positioned laterally to the particles, low flow (1 L/min) or low pressure (8 mmHg), HD values recorded in the three settings were all overlapping (all p > 0.05).

CONCLUSIONS

Flow and pressure setting, in-flow trocar distance and contiguity from the tumor, and pneumoperitoneum stability may be all crucial component in minimally invasive surgery. In vivo, these variables should be considered as potential risk factors for tumor cells spread within the abdominal cavity.

The Influence of Lymph Node Count on Oncological Outcome of Radical Cystectomy in Chemotherapy Pre-Treated and Chemotherapy-Naïve Patients with Muscle Invasive Bladder Cancer

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) remains the mainstay of treatment for muscle-invasive bladder cancer (MIBC). The extent of PLND and number of removed lymph nodes (LNs) have been associated with improved staging and survival outcomes in several series of RC patients. Neoadjuvant chemotherapy (NAC) has become standard of care for cisplatin-eligible patients qualified to RC, yet few studies on PLND stratified cases according to the receipt of NAC. We aimed to address this issue and reevaluate the prognostic value of PLND nodal yields in series of patients who underwent RC on the verge of the NAC era. This single-center, retrospective, clinical follow-up study enrolled 439 consecutive patients, out of whom 83 received NAC. We analyzed survival outcome of RC according to the number of removed nodes between NAC and non-NAC subgroups. We found PLND thresholds of 10 and 15 LNs prognostically meaningful in our study cohort, and this association was particularly pronounced in the non-NAC subgroup. Higher numbers of LNs provided a 25% reduction in risk of all-cause mortality and correspondingly correlated with up to a 14% increase in 3-year overall survival. The receipt of NAC diminished the benefit of adequate PLND, as the number of retrieved LNs was not associated with survival in the NAC-RC cohort. Given the limitations of our study, additional research is needed to verify these findings.

Randomized Controlled Trial of Laparoscopic versus Open Radical Cystectomy in a Laparoscopic Naïve Center

Background

Laparoscopic radical cystectomy is a challenging surgical procedure; however, it has been largely abandoned in favor of the more intuitive robotic-assisted cystectomy. Due to the prohibitive cost of robotic surgery, the adoption of laparoscopic cystectomy is of relevance in low-resource institutes. Methodology. This is a randomized controlled trial comparing laparoscopic radical cystectomy (LRC) to open radical cystectomy (ORC) at a single institute. Each group included thirty patients. The trial was designed to compare both approaches regarding operative time, blood loss, transfusion requirements, length of hospital stay, time to oral intake, requirement of opioid analgesia, and complications.

Results

LRC was associated with less hospital stay (9.8 vs. 13.8 days, P=0.001), less time to oral solid intake (6 vs. 8.6 days, P=0.031), and lower opioid requirements (23.3% vs. 53.3%, P=0.033). There was a trend towards lower blood loss and transfusion requirements, but this did not reach statistical significance. Overall complication rates were comparable.

Conclusion

Laparoscopic radical cystectomy was associated with comparable postoperative outcomes when compared to ORC in the first laparoscopic cystectomy experience in our center. Benefitting from the assistance of an experienced laparoscopic surgeon is recommended to shorten the learning curve.

Laparoscopic versus open radical cystectomy in 607 patients with bladder cancer: Comparative survival analysis

OBJECTIVES

To compare perioperative and oncologic survival outcomes between laparoscopic radical cystectomy and open radical cystectomy.

METHODS

A total of 607 patients underwent open radical cystectomy (n = 412) or laparoscopic radical cystectomy (n = 195) at a single academic institution from January 2006 to April 2017. Their medical records were retrospectively analyzed. One-to-one propensity score matching was carried out to reduce selection bias. Estimated blood loss and complications were compared. Overall survival, cancer-specific survival and progression-free survival estimates for all patients and patients with locally advanced bladder cancer were analyzed using the Kaplan-Meier method.

RESULTS

Either before or after matching, the laparoscopic radical cystectomy group had less estimated blood loss (P < 0.001 and P < 0.001) and fewer complications (P < 0.001 and P = 0.008). There was no difference in the overall survival (P = 0.216 and P = 0.961) and progression-free survival (P = 0.826 and P = 0.462) for all the patients having either laparoscopic radical cystectomy or open radical cystectomy. However, the 5-year progression-free survival of open radical cystectomy was higher than that of laparoscopic radical cystectomy (P = 0.019 and P = 0.021) for patients with locally advanced bladder cancer.

CONCLUSIONS

Laparoscopic radical cystectomy is superior to open radical cystectomy in terms of perioperative outcomes, and similar to open radical cystectomy in terms of oncologic outcomes for patients with early stage bladder cancer. However, for patients with locally advanced bladder cancer, laparoscopic radical cystectomy seems to be associated with shorter progression-free survival than open radical cystectomy.

Isolated non-ascitic peritoneal carcinomatosis after robotic radical prostatectomy for prostate cancer: A case report

Oncologic recurrence can occur after Robot-Assisted Radical Prostatectomy. Prostate cancer metastasizes often in bones, however the peritoneum is infrequently targeted. Even more, peritoneal dissemination without any other organ involved especially the bones is very rare, only few cases are reported. Through the available literature we discuss about the presumed seeding theory leading to this atypical location for prostatic metastases. Here we report a case of isolated non-ascitic prostatic peritoneal metastases most probably due to iatrogenic spillage during surgery.

Atypical oncologic failure after laparoscopic and robot-assisted radical cystectomy at a single institution

BACKGROUND

The incidence of atypical oncologic failure in patients with bladder cancer, including peritoneal carcinomatosis, and recurrences at the port site and soft tissue after laparoscopic and robot-assisted radical cystectomy are not well characterized.

METHODS

We retrospectively reviewed the records of 52, 51, and 12 patients who underwent open, laparoscopic, and robot-assisted radical cystectomy, respectively, for bladder cancer from 2007 to 2018 at our institution. We identified techniques associated with atypical oncologic failure.

RESULTS

The median follow-up period was 29 months. Among the 115 patients, 29 (25%) experienced oncological recurrences, and 7 (6%), 12 (10%), and 23 (20%) had atypical, local, and distant recurrences, respectively. The laparoscopic and robot-assisted radical cystectomy groups had significantly higher incidences of total atypical oncologic failure than the open radical cystectomy group (p = 0.013), including six, one, and two patients with peritoneal carcinomatosis, port site carcinomatosis, and soft tissue involvement, respectively. All 7 patients with atypical oncologic failure died of cancer; the median time from surgery to death was 9.3 months. All these patients were cT ≧ 3 and had grade 3 disease. In three patients (43%), the pathological tissue contained variants other than urothelial carcinoma. Five (71%) were among the initial twenty patients. Four patients (57%) had histories of intraoperative urine spillage or bladder perforation during transurethral resection.

CONCLUSIONS

Patients with cT ≧ 3 stage, with pathological variants other than urothelial carcinoma, and those undergoing procedures that lead to extravesical dissemination should avoid laparoscopic radical cystectomy when the procedures are first introduced.

Port-site metastasis and atypical recurrences after robotic-assisted radical cystectomy (RARC): an updated comprehensive and systematic review of current evidences

The objective of this systematic review is to evaluate the current evidence regarding atypical metastases in patients undergoing robotic-assisted radical cystectomy (RARC). A review of the current literature was conducted through the Medline and NCBI PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar databases in October 2019. From the literature search using the cited keys and after a careful evaluation of the full texts, we included 31 articles in the study. Fourteen studies (45.2%) reported at least an atypical recurrence during the follow-up period with a rate between 4 and 40% of all the recurrences. Overall, 105 (1.63%) of the 6720 patients who have been evaluated in the included studies developed an atypical recurrence. Sixty-three (60%) of these atypical metastases were peritoneal carcinomatosis, 16 (15.2%) extrapelvic lymph nodes metastases, 11 (10.5%) port-site metastases, 10 (9.5%) retroperitoneal nodal metastases, while 5 (3.8%) patients developed more than one type of atypical recurrence. In literature, there is a low but not negligible incidence of atypical recurrences after RARC. However, publication bias and retrospective design of most studies could influence the evidences. Further prospective randomized studies are needed to clarify the real risk of patients undergoing RARC to develop atypical metastases.

Evaluation of laparoscopic approach in radical cystectomy from implementation to consolidation: Internal validation

INTRODUCTION AND OBJECTIVES

The AEU Guidelines of 2017 consider laparoscopic and robot-assisted approaches as investigational procedures. The surgical learning curve is defined as the minimum number of cases that a surgeon has to perform in order to reproduce a technique considered as standard. The aim of this study is to analyze, within our department, the implementation of a laparoscopic radical cystectomy (LRC) program compared with a well consolidated and standardized open radical cystectomy (ORC) program.

MATERIAL AND METHODS

Retrospective cohort analysis of two cystectomy groups: LRC (n=196) (20062016) vs. ORC (n=96) (2003-2005). Comparison of the evolution over time of the following parameters: operative time, blood transfusion rates, resection margins, postoperative complications, hospital stay and recurrence. Three time periods have been defined for LRC: implementation (2006-09) (LRC-I), development (2010-14) (LRC-D) and consolidation (2015-16) (LRC-C); comparing each of them with the control group (ORC). The chi-square test was used for the comparison of the qualitative variables and the Anova test for the numerical ones.

RESULTS

When compared to ORC, LRC presented longer operative times in LRC-I and LRC-D periods. We observed a trend toward shorter operative time than ORC in the consolidation period (LRC-C). LRC also presented lower intraoperative transfusion rates in all periods and lower postoperative rates in CRL-D and CRL-C. Overall complications in LRC-D and LRC-C were lower in LRC, having fewer major complications (Clavien≥3) in the 3 periods. A decrease in mortality and hospital stay after the LRC-I phase was also observed. These results were consolidated during the two last periods of the study. We have not observed significant differences between ORC and LRC when comparing surgical margins and recurrence rates, neither in the total series, nor in the comparison between the different periods. These results endorse the oncologic safety of LRC from the beginning of the implementation process.

CONCLUSIONS

When compared to ORC, LRC improves perioperative transfusion rates, complications and hospital stay from its implementation period, maintaining oncological safety. On the contrary, longer operative times during implementation and development were observed. However, in our series, we observed a trend toward shorter operative times than ORC approach in the consolidation period. We have validated the laparoscopic approach for radical cystectomy in our service.

Oncological outcomes and recurrence patterns after laparoscopic radical cystectomy for bladder cancer: A Japanese multicenter cohort

OBJECTIVE

To investigate oncological outcomes and recurrence patterns after laparoscopic radical cystectomy for bladder cancer in a Japanese multicenter cohort, and to explore the risk factors associated with recurrences due to tumor dissemination.

METHOD

Laparoscopic radical cystectomies carried out at 10 institutions were included in this retrospective study. Multivariate analyses were carried out to identify the clinical parameters associated with overall recurrences together with specific recurrence types. Kaplan-Meier curves were created to elucidate time to recurrence and survival.

RESULTS

A total of 411 patients were included after the final analysis. Postoperative pathology was T2 or higher in 196 patients (48%), and lymph node metastasis was present in 46 patients (11%). The median follow-up period was 23 months, and the 2-year recurrence-free and cancer-specific survival rates were 71.0% and 84.7%, respectively. The recurrence sites involved distant metastasis in 75 patients (18%), local recurrence in 52 patients (13%) and urinary tract recurrence in eight patients (2%). When local recurrence at the cystectomy bed (28 patients; 7%) and abdominal recurrence including peritoneal carcinomatosis or port site recurrence (17 patients; 4%), which might be caused by tumor dissemination, were combined into a single group, prolonged surgical time was a significant risk factor, in addition to high pathological stage (T3-4 and/or positive lymph nodes), positive surgical margins, and variant histology by both univariate and multivariate analyses.

CONCLUSIONS

Our study findings suggest that recurrences after laparoscopic radical cystectomy might be caused by tumor dissemination, and attention should be paid to avoid prolonged surgical time in laparoscopic radical cystectomy.

Post-surgical complications in patients with bladder cancer treated with cystectomy: Differences between open and laparoscopic approach

INTRODUCTION

Minimally invasive surgery regarding cystectomy has not had the same development as other urological surgeries. This could be due to the lack of published studies defining the advantages of this approach versus open surgery.

OBJECTIVES

The main objective of this study is to establish the role of minimally invasive surgery, laparoscopic radical cystectomy, versus open surgery by analyzing their perioperative complications.

MATERIAL AND METHOD

Retrospective cohort analysis of perioperative complications of 2homogeneous series of cystectomies: laparoscopic (n = 196) versus open (n = 197). Identification of independent predictors of perioperative complications by multivariate analysis.

RESULTS

In the comparative analysis between laparoscopic cystectomies and open cystectomies we observed a lower rate of perioperative blood transfusion (P < 0.0001), a lower rate of global postoperative complications (P < 0.0001) and a lower rate of serious complications (Clavien > 3; P < 0.001) in the LRC group. There was also a lower mortality rate in the laparoscopic series compared to open ones (P < 0.0001). Surgical approach and surgical time (P < 0.001) were identified as independent predictors of complications.

CONCLUSIONS

We have identified the laparoscopic approach as a complication shield for radical cystectomy. The open approach almost triples the risk of complications.

Influence of laparoscopic access in cancer-specific mortality of patients with pTa-2pN0R0 bladder cancer treated with radical cistectomy

INTRODUCTION AND OBJECTIVE

Minimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality.

MATERIAL AND METHOD

A retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n=191) and laparoscopic radical cystectomy (LRC) (n=74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival.

RESULTS

90.9% were males with a median age of 65years and a median follow-up period of 65.5 (IQR27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P=.0001), a longer time between TUR and cystectomy (P=.04), a lower rate of intraoperative transfusion (P=.0001), a lower pT stage (P=.002) and a lower incidence of infection associated with surgical wounds (P=.04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P=.007). Open approach to cystectomy multiplied the risk of mortality by 3.27.

CONCLUSIONS

In our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.

Prospective study comparing laparoscopic and open radical cystectomy: Surgical and oncological results

INTRODUCTION

Laparoscopic radical cystectomy with lymphadenectomy and urinary diversion is an increasingly widespread operation. Studies are needed to support the oncological effectiveness and safety of this minimally invasive approach.

PATIENTS AND METHODS

A nonrandomised, comparative prospective study between open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) was conducted in a university hospital. The main objective was to compare cancer-specific survival. The secondary objective was to compare the surgical results and complications according to the Clavien-Dindo scale.

RESULTS

We treated 156 patients with high-grade invasive bladder cancer with either ORC (n=70) or LRC (n=86). The mean follow-up was 33.5±23.8 (range 12-96) months. The mean age was 66.9+9.4 years, and the male to female ratio was 19:1. Both groups were equivalent in age, stage, positive lymph nodes, in situ carcinoma, preoperative obstructive uropathy, adjuvant chemotherapy and type of urinary diversion. There were no differences between the groups in terms of cancer-specific survival (log-rank; P=.71). The histopathology stage was the only independent variable that predicted the prognosis. The hospital stay (P=.01) and operative transfusion rates (P=.002) were less for LRC. The duration of the surgery was greater for LRC (P<.001). There were no differences in the total complications rate (p=.62) or major complications (P=.69). The risk of evisceration (P=.02), surgical wound infection (P=.005) and pneumonia (P=.017) was greater for ORC. The risk of rectal lesion (P=.017) and urethrorectal fistulae (P=.065) was greater for LRC.

CONCLUSION

LRC is an equivalent treatment to ORC in terms of oncological efficacy and is advantageous in terms of transfusion rates and hospital stays but not in terms of operating room time and overall safety. Studies are needed to better define the specific safety profile for each approach.

[LAPAROSCOPIC RADICAL CYSTECTOMY AT HIROSHIMA CITY ASA HOSPITAL]

(Objective) To evaluate the utility of laparoscopic radical cystectomy (LRC), we retrospectively compared the background factors and perioperative parameters of LRC with those of open radical cystectomy (ORC). (Patients and methods) The study cohort consisted of 116 consecutive patients who underwent radical cystectomy by LRC (n=59) or ORC (n=57). The background factors and perioperative parameters were compared between LRC and ORC. (Results) The patients consisted of 103 men and 13 women with a median age of 69 years and median BMI of 23.0. Their clinical stage was as follows, ≤T1: 19 cases, T2: 69 cases, T3: 25 cases and T4: 3 cases, respectively.While the patients' age at the time of LRC was significantly higher than that of ORC (71.3 yrs vs. 66.2 yrs, P<0.001) and the ASA physical status of LRC was significantly higher than that of ORC (P=0.028), the other background factors were not different between the two groups.Although there was no difference in the total operating time between LRC and ORC, the estimated blood loss for LRC was significantly less than that for ORC (372.3 ml vs. 2,134.5 ml, P<0.001) and the duration of the postoperative hospital stay for LRC was significantly shorter than that for ORC (23.5 days vs. 36.9 days, P<0.001).There were no significant differences in the pathological findings, of the postoperative recurrence-free rate or cancer-specific survival rate between the LRC and ORC groups. In multivariate analysis, only pN+was an independent predictive factor of postoperative recurrence. (Conclusion) This study showed that LRC is less invasive and can lead to similar oncological outcomes compared with ORC.

Early Oncologic Failure after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

PURPOSE

We sought to investigate the prevalence and variables associated with early oncologic failure.

MATERIALS AND METHODS

We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot-assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot-assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan-Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival.

RESULTS

A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38-5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00-6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21-3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001).

CONCLUSIONS

The incidence of early oncologic failure following robot-assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot-assisted radical cystectomy.