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Impact of Patient, Surgical, and Perioperative Factors on Discharge Disposition after Radical Cystectomy. Cancers (Basel) 2022; 14:cancers14215288. [PMID: 36358707 PMCID: PMC9654179 DOI: 10.3390/cancers14215288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
Radical cystectomy (RC) is a complex procedure associated with lengthy hospital stays and high complication and readmission rates. We evaluated the impact of patient, surgical, and perioperative factors on discharge disposition following RC at a tertiary referral center. From 2012 to 2019, all bladder cancer patients undergoing RC at our institution were identified (n = 1153). Patients were classified based on discharge disposition: to home or to continued facility-based rehabilitation centers (CFRs, n = 180 (15.61%) patients). On multivariate analysis of patient factors only, age [Risk Ratio (RR): 1.07, p < 0.001)], single marital status (RR: 1.09, p < 0.001), and living alone prior to surgery (RR: 2.55, p = 0.004) were significant predictors of discharge to CFRs. Multivariate analysis of patient, surgical, and perioperative factors indicated age (RR: 1.09, p < 0.001), single marital status (RR: 3.9, p < 0.001), living alone prior to surgery (RR: 2.42, p = 0.01), and major post-operative (Clavien > 3) complications (RR: 3.44, p < 0.001) were significant independent predictors of discharge to CFRs. Of note, ERAS did not significantly impact discharge disposition. Specific patient and perioperative factors significantly impact discharge disposition. Patients who are older, living alone prior to surgery, and/or have a major post-operative complication are more likely to be discharged to CFRs after RC.
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Zhao CC, Shakir NA, Zhao LC. The emerging role of robotics in upper and lower urinary tract reconstruction. Curr Opin Urol 2021; 31:511-515. [PMID: 34155169 DOI: 10.1097/mou.0000000000000908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Developments in robotic reconstructive urology have introduced novel treatments for complex upper and lower urinary tract disease. Short-term and mid-term data demonstrates excellent outcomes and minimal morbidity, suggesting the advanced instrumentation and visualization of robotics represent a new treatment paradigm in patients that are historically difficult to treat. Here we review recent developments in the robotically assisted surgical management of urethral and ureteral strictures. RECENT FINDINGS The minimally invasive approach, enhanced precision and reach, and near-infrared fluorescence imaging capabilities of robotic platforms have proven to be valuable additions in reconstructive urology where perfusion is often compromised, or anatomy is distorted. These benefits are leveraged heavily in recent descriptions of robotic-assisted posterior urethroplasty and ureteroplasty. Short-term to mid-term follow-up data for these procedures show excellent patency rates with low morbidity and complication rates when compared with open approaches. Long-term data for these procedures are not yet available. SUMMARY The role of robotics in reconstructive urology is being actively investigated. Initial findings demonstrate excellent results with low morbidity in the treatment of upper and lower urinary tract disease. Long-term data will ultimately determine the role of robotics in the reconstructive armamentarium.
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Affiliation(s)
- Calvin C Zhao
- Department of Urology, New York University Grossman School of Medicine, New York, New York, USA
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Martin AS, Corcoran AT. Contemporary techniques and outcomes of robotic assisted radical cystectomy with intracorporeal urinary diversion. Transl Androl Urol 2021; 10:2216-2232. [PMID: 34159105 PMCID: PMC8185677 DOI: 10.21037/tau.2019.09.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The open approach to radical cystectomy continues to be accompanied by significant morbidity despite enhanced recovery protocols (ERP). Robotic assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has become an increasingly popular technique for removal of aggressive bladder cancer and subsequent urinary diversion. Randomized clinical trials comparing the robotic and open techniques address the uncertainty surrounding oncological efficacy of the RARC and show that RARC is at least comparable to open radical cystectomy (ORC) in terms of oncologic adequacy and survival. Although RARC with ICUD is a technically challenging procedure, surgeons have noted ergonomic advantages while patients experience less blood loss and quicker time to recovery and to adjuvant chemotherapy (AC), if necessary. Even with these benefits, there is a paucity of data describing outcomes of ICUD. For those surgeons who have switched to ICUD, priority remains standardization of a protocol for the reconstructive component and for a safe transition from extracorporeal urinary diversion (ECUD) to ICUD. Additionally, there is a need for evidence of reduced financial toxicity for the patient, as well as more comprehensive cost-effectiveness analyses. The literature from this review represents 10 years of accumulating data on techniques and outcomes of RARC with ICUD.
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Affiliation(s)
- Ardenne S Martin
- Department of Urology, NYU Winthrop Hospital, Garden City, NY, USA
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Otaola-Arca H, Coelho R, Patel VR, Orvieto M. Totally intracorporeal robot-assisted urinary diversion for bladder cancer (Part 1). Review and detailed characterization of ileal conduit and modified Indiana pouch. Asian J Urol 2021; 8:50-62. [PMID: 33569272 PMCID: PMC7859455 DOI: 10.1016/j.ajur.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/28/2020] [Accepted: 07/09/2020] [Indexed: 12/01/2022] Open
Abstract
Objective To review the most used robot-assisted cutaneous urinary diversion (CUD) after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives, including new consistent images Methods A non-systematic review of the literature with the keywords “bladder cancer”, “cutaneous urinary diversion”, and “radical cystectomy” was performed. Results Twenty-four studies of intracorporeal ileal conduit (ICIC) and two of intracorporeal Indiana pouch (ICIP) were included in the analysis. Regarding ICIC, the patients’ age ranged from 60 to 76 years. The operative time to perform a urinary diversion ranged from 60 to 133 min. The total estimated blood loss ranged from 200 to 1 117 mL. The rate of positive surgical margins ranged from 0% to 14.3%. Early minor and major complication rates ranged from 0% to 71.4% and from 0% to 53.4%, respectively. Late minor and major complication rates ranged from 0% to 66% and from 0% to 32%, respectively. Totally ICIP data are limited to one case report and one clinical series. Conclusion The most frequent type of CUD is ICIC. Randomized studies comparing the performance of the different types of CUD, the performance in an intra- or extracorporeal manner, or the performance of a CUD versus orthotopic ileal neobladder are lacking in the literature. To this day, there are not enough quality data to determine the supremacy of one technique. This manuscript represents a compendium of the most used CUD with detailed descriptions of the technical aspects, operative and perioperative outcomes, and new consistent images for each technique.
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Affiliation(s)
- Hugo Otaola-Arca
- Department of Urology, Clínica Alemana, Santiago, Chile.,School of Medicine, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Rafael Coelho
- Universidade de São Paulo Instituto do Câncer do Estado de São Paulo, Brazil
| | - Vipul R Patel
- Department of Urology, AdventHealth Global Robotics Institute, Celebration, United States
| | - Marcelo Orvieto
- Department of Urology, Clínica Alemana, Santiago, Chile.,School of Medicine, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
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Brodie A, Kijvikai K, Decaestecker K, Vasdev N. Review of the evidence for robotic-assisted robotic cystectomy and intra-corporeal urinary diversion in bladder cancer. Transl Androl Urol 2020; 9:2946-2955. [PMID: 33457267 PMCID: PMC7807361 DOI: 10.21037/tau.2019.12.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Radical cystectomy, pelvic lymph node dissection and urinary diversion is the gold-standard treatment for muscle-invasive bladder cancer. The surgery is both complex and highly morbid. Robotic cystectomy is now in its 16th year with established techniques and sufficient research maturity to enable comparison with its open counterpart. The present review focuses on the current evidence for robotic cystectomy and assesses various metrics including oncological, perioperative, functional, surgeon-specific and cost outcomes. The review also encapsulates the current evidence for intra-corporeal urinary diversion and its current status in the cystectomy arena.
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Affiliation(s)
- Andrew Brodie
- Hertfordshire and Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK
| | - Kittinut Kijvikai
- Division of Urology, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Nikhil Vasdev
- Hertfordshire and Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Stevenage, UK.,School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
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A right colon pouch with a novel efferent channel concept: long-term results of the Turin pouch. World J Urol 2020; 39:1935-1940. [PMID: 32897395 DOI: 10.1007/s00345-020-03412-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To report stoma stenosis rates and efferent channel (EC) complications at long term follow-up for Turin pouch (TP). METHODS This is a retrospective analysis of the prospectively maintained database of patients who underwent TP between March 2006 and May 2018. The TP is a U-shaped right colon pouch. The EC was conceived by the tubularization of 5 cm of the colon wall with the use of a stapler and sutured to the skin (EC-cutaneostomy). The ureters are sutured separately to the last 10 cm of ileum before the ileocecal valve. In literature, catheterization problems have been described on average in 20.3% of patients and stoma stenosis in 19.5% of the patients with flap valve systems. RESULTS Thirty-eight consecutive patients underwent a TP procedure. The median age was 55 years (IQR: 52-60). Median operative time was 201 min (IQR: 170-210), median reconstructive time was 61 min (IQR: 55-65) and the blood loss was 244 ml (IQR: 150-300) and 4 patients (10.5%) needed blood transfusions. The median follow-up was 52 months (IQR: 37-92). Complete 24h continence was achieved in 34 (89%) patients. Seven (18.4%) patients reported difficulties in EC catheterization and 4 (10.5%) patients had stoma stenosis. This study is limited by the relatively small number of patients. CONCLUSION In relation to similar systems, the TP seems to offer comparatively good functional results but EC and stoma complications were lower than other pouch variants in literature.
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Anceschi U, Brassetti A, Tuderti G, Ferriero MC, Costantini M, Bove AM, Calabrò F, Carlini P, Vari S, Mastroianni R, Gallucci M, Simone G. Impact of Clinical Response to Neoadjuvant Chemotherapy in the Era of Robot Assisted Radical Cystectomy: Results of a Single-Center Experience. J Clin Med 2020; 9:E2736. [PMID: 32847113 PMCID: PMC7564756 DOI: 10.3390/jcm9092736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/07/2020] [Accepted: 08/19/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Response to neoadjuvant chemotherapy (NACT) has been proven to be an established prognostic factor after open radical cystectomy (ORC). We evaluated the impact of NACT on survival outcomes of a single-institution robotic radical cystectomy (RARC) series. METHODS From January 2012 to June 2020, 79 patients were identified. Baseline, demographic, perioperative, and pathologic data were described. Kaplan-Meier with the log-rank test was used to compare overall survival (OS) differences between complete, partial, and no-NACT responders, respectively. Univariable and multivariable regression analyses were performed to identify predictors of OS. RESULTS Complete, partial, and absent response to NACT were recorded in 43 (54.4%), 21 (19%), and 15 (26.6%) patients, respectively. A complete response to NACT displayed a trend toward significant higher OS (p = 0.03). In univariable analysis, significant predictors of lower OS were hypertension (HR 3.37; CI 95% 1.31-8.62; p = 0.01); advanced nodal involvement (HR 2.41; CI 95% 0.53-10.9; p < 0.001); and incomplete response to NACT (HR 0.41; CI 95% 0.18-0.95; p = 0.039). In multivariable analysis, the only independent predictor of worse OS was advanced pathologic N stages (HR 10.1; CI: 95% CI 2.3-44.3; p = 0.002). CONCLUSIONS Complete response to NACT is associated with increased OS probability, but significant nodal residual disease remains the only independent predictor of OS after RARC.
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Affiliation(s)
- Umberto Anceschi
- Department of Urology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (G.T.); (M.C.F.); (M.C.); (A.M.B.); (G.S.)
| | - Aldo Brassetti
- Department of Urology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (G.T.); (M.C.F.); (M.C.); (A.M.B.); (G.S.)
| | - Gabriele Tuderti
- Department of Urology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (G.T.); (M.C.F.); (M.C.); (A.M.B.); (G.S.)
| | - Maria Consiglia Ferriero
- Department of Urology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (G.T.); (M.C.F.); (M.C.); (A.M.B.); (G.S.)
| | - Manuela Costantini
- Department of Urology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (G.T.); (M.C.F.); (M.C.); (A.M.B.); (G.S.)
| | - Alfredo Maria Bove
- Department of Urology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (G.T.); (M.C.F.); (M.C.); (A.M.B.); (G.S.)
| | - Fabio Calabrò
- Department of Oncology, San Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy;
| | - Paolo Carlini
- Department of Oncology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (P.C.); (S.V.)
| | - Sabrina Vari
- Department of Oncology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (P.C.); (S.V.)
| | - Riccardo Mastroianni
- Department of Urology, La Sapienza—University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.M.); (M.G.)
| | - Michele Gallucci
- Department of Urology, La Sapienza—University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (R.M.); (M.G.)
| | - Giuseppe Simone
- Department of Urology, Regina Elena National Cancer Institute, Via Elio Chianesi 53, 00144 Rome, Italy; (A.B.); (G.T.); (M.C.F.); (M.C.); (A.M.B.); (G.S.)
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Murthy PB, Bryk DJ, Lee BH, Haber GP. Robotic radical cystectomy with intracorporeal urinary diversion: beyond the initial experience. Transl Androl Urol 2020; 9:942-948. [PMID: 32420210 PMCID: PMC7214984 DOI: 10.21037/tau.2019.11.36] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/05/2019] [Indexed: 12/11/2022] Open
Abstract
Robotic assisted radical cystectomy (RARC) has gained popularity within minimally-invasive urologic surgery, and has been shown to be a safe procedure with similar oncologic outcomes when compared to the conventional open standard. While initial RARC feasibility and outcomes studies were performed with extracorporeal urinary diversion, intracorporeal urinary diversion (ICUD) is becoming increasingly utilized. Reported benefits of an intracorporeal approach include decreased blood loss and a lower incidence of ureteral strictures. While ICUD is technically challenging, many have overcome the learning curve associated with this procedure via a mentorship model and a dedicated operative team. Techniques vary between institutions, and ileal conduit, continent cutaneous and orthotopic continent (neobladder) diversions have all been performed. Herein, we describe the learning curve, technical points, and unique complications associated with ICUD.
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Affiliation(s)
- Prithvi B Murthy
- Department of Urology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Darren J Bryk
- Department of Urology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Byron H Lee
- Department of Urology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Georges-Pascal Haber
- Department of Urology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
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Contemporary techniques and outcomes of robotic cystectomy and intracorporeal urinary diversions. Curr Opin Urol 2019; 28:115-122. [PMID: 29256905 DOI: 10.1097/mou.0000000000000472] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is being increasingly performed worldwide. This review summarizes recent technical developments and outcome data for RARC with ICUD. RECENT FINDINGS With the recent description of intracorporeal continent cutaneous diversion, all classes of urinary diversion can presently be performed totally intracorporeally. The summary of our seven cases of intracorporeal continent cutaneous diversion in this article brings the number of reported cases in the literature to 17. Additional recent advancements in ICUD focus on novel technical descriptions and outcome data. Several intracorporeal orthotopic ileal neobladder techniques have been described with intermediate perioperative outcomes. There is some rationale for reduced overall, wound, gastrointestinal and genitourinary complications with ICUD. SUMMARY RARC with intracorporeal diversion is a feasible option for patients with bladder cancer. Prospective and randomized outcome data are needed to better characterize the benefit of ICUD in patients following radical cystectomy.
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Lobo N, Thurairaja R, Nair R, Dasgupta P, Khan MS. Robot-assisted radical cystectomy with intracorporeal urinary diversion - The new 'gold standard'? Evidence from a systematic review. Arab J Urol 2018; 16:307-313. [PMID: 30140466 PMCID: PMC6104669 DOI: 10.1016/j.aju.2018.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/30/2018] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To investigate whether a totally intracorporeally radical cystectomy (RC) can be considered the new 'gold standard' in bladder cancer, as open RC (ORC) is the current 'gold standard' for surgical treatment of muscle-invasive and high-grade non-muscle-invasive bladder cancer. However, robot-assisted radical cystectomy (RARC) is becoming the preferred surgical approach in many centres as it seems to maintain the oncological control of open surgery whilst offering improved perioperative benefits. MATERIALS AND METHODS A review of the literature was conducted using the Pubmed/MEDLINE, ISI Web of Knowledge and Cochrane Databases to identify studies that included both ORC and RARC with intracorporeal and extracorporeal urinary diversion (UD) published up to July 2017. RESULTS Evidence from four single-centre randomised controlled trials and now the multicentre Randomized Trial of Open versus Robotic Cystectomy (RAZOR) trial demonstrate the oncological equivalence of RARC to ORC. The only convincing evidence for the superiority of RARC is in the area of blood loss and transfusion rates. However, the UD procedure in these trials was performed extracorporeally and, to realise the full benefits of RARC, a totally intracorporeal approach is needed. Intracorporeal UDs (ICUDs) have been shown to be technically feasible by a few expert centres and have demonstrated some improved short-term perioperative outcomes compared to extracorporeal UDs. CONCLUSIONS Although initial outcomes appear promising, RARC with ICUD is far from gaining 'gold standard' status. Further studies are needed to confirm that outcomes are reproducible widely. Furthermore, the benefits of a totally intracorporeal approach must be confirmed in randomised controlled trials.
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Affiliation(s)
- Niyati Lobo
- Department of Urology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Rajesh Nair
- Department of Urology, Guy’s Hospital, London, UK
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Smith JA. This Month in Adult Urology. J Urol 2017. [DOI: 10.1016/j.juro.2017.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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