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Flammia RS, Licari LC, Bologna E, Mastroianni R, Proietti F, Tuderti G, Anceschi U, Brassetti A, Franco A, De Nunzio C, Autorino R, Leonardo C, Simone G. Comparative Outcomes of Open Radical Cystectomy vs. Robot-Assisted Approaches with Intracorporeal and Extracorporeal Urinary Diversion: A Meta-Analysis and Network Meta-Analysis of Perioperative and Quality of Life Outcomes. J Clin Med 2024; 13:2421. [PMID: 38673693 PMCID: PMC11051502 DOI: 10.3390/jcm13082421] [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: 03/05/2024] [Revised: 04/05/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
Background: To conduct a comprehensive systematic review and network meta-analysis of RCTs that compare outcomes of robot-assisted radical cystectomy (RARC) with intra- or extracorporeal urinary diversion (ICUD or ECUD) and the standard open approach (oRC). Methods: A systematic review identified RCTs including patients aged >18 years with non-metastatic bladder cancer treated with RARC (ICUD or ECUD) vs. oRC and reporting peri- and post-operative outcomes and quality of life (QoL) assessment. Standard and network metanalyses were performed. Results: Data from 1024 patients included in eight RCTs were analyzed. The standard meta-analysis found that RARC had longer OT, lower EBL, and a lower transfusion rate compared to oRC (all p < 0.001). No significant differences in terms of LOS between the ICUD vs. ECUD vs. ORC were recorded. RARC patients demonstrated better scores in fatigue, insomnia, pain, physical functioning, and role functioning-according to QoL assessment-compared to ORC at early follow-up, despite no difference at baselines. Finally, at network metanalysis, ICUD (OR = 0.74, p < 0.001) but not ECUD (OR = 0.92, p < 0.08) yielded a lower rate of high-grade 90-day complications compared to ORC despite longer OT (MD = 89.56, p = 0.0351). Conclusions: RARC represents a safe and feasible option to reduce perioperative bleeding with no definitive impact on LOS compared to ORC. Interestingly, ICUD may reduce the burden of 90-day complications to a greater extent than ECUD. Nonetheless, surgeons should be aware of the extended OT and steep learning curve of ICUD. Finally, RARC may provide some short-term benefits in terms of QoL, but more research is needed to determine its long-term effects.
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Affiliation(s)
- Rocco Simone Flammia
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00185 Rome, Italy; (R.S.F.); (L.C.L.)
- Department of Urology, “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (R.M.); (G.T.); (U.A.); (A.B.); (C.L.); (G.S.)
| | - Leslie Claire Licari
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00185 Rome, Italy; (R.S.F.); (L.C.L.)
- Department of Urology, Rush University, Chicago, IL 60612, USA; (A.F.); (R.A.)
| | - Eugenio Bologna
- Department of Maternal-Child and Urological Sciences, Sapienza University Rome, Policlinico Umberto I Hospital, 00185 Rome, Italy; (R.S.F.); (L.C.L.)
- Department of Urology, Rush University, Chicago, IL 60612, USA; (A.F.); (R.A.)
| | - Riccardo Mastroianni
- Department of Urology, “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (R.M.); (G.T.); (U.A.); (A.B.); (C.L.); (G.S.)
| | - Flavia Proietti
- Department of Urology, “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (R.M.); (G.T.); (U.A.); (A.B.); (C.L.); (G.S.)
| | - Gabriele Tuderti
- Department of Urology, “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (R.M.); (G.T.); (U.A.); (A.B.); (C.L.); (G.S.)
| | - Umberto Anceschi
- Department of Urology, “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (R.M.); (G.T.); (U.A.); (A.B.); (C.L.); (G.S.)
| | - Aldo Brassetti
- Department of Urology, “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (R.M.); (G.T.); (U.A.); (A.B.); (C.L.); (G.S.)
| | - Antonio Franco
- Department of Urology, Rush University, Chicago, IL 60612, USA; (A.F.); (R.A.)
- Department of Urology, Sant’Andrea Hospital, Sapienza University, 00185 Rome, Italy;
| | - Cosimo De Nunzio
- Department of Urology, Sant’Andrea Hospital, Sapienza University, 00185 Rome, Italy;
| | - Riccardo Autorino
- Department of Urology, Rush University, Chicago, IL 60612, USA; (A.F.); (R.A.)
| | - Costantino Leonardo
- Department of Urology, “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (R.M.); (G.T.); (U.A.); (A.B.); (C.L.); (G.S.)
| | - Giuseppe Simone
- Department of Urology, “Regina Elena” National Cancer Institute, 00144 Rome, Italy; (R.M.); (G.T.); (U.A.); (A.B.); (C.L.); (G.S.)
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Yang H, Zhang Z, Zhao K, Zhang Y, Yin X, Zhu G, Wang Z, Li X, Li Z, Wang Q, Sui Y, Xing N, Wang K. Initial experience with 161 extraperitoneal laparoscopic radical cystectomy procedures: Comparison with transabdominal laparoscopic radical cystectomy. Int J Urol 2023; 30:155-160. [PMID: 36349911 PMCID: PMC10098523 DOI: 10.1111/iju.15076] [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: 06/03/2022] [Accepted: 09/27/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES There is substantial concern about traditional transperitoneal laparoscopic radical cystectomy (TLRC) due to multiple postoperative complications. In contrast, extraperitoneal laparoscopic radical cystectomy (ELRC) appears to cause a lower rate of morbidity. The present study aimed to compare the efficacy of ELRC and TLRC for bladder cancer (BCa). METHODS The clinical data of patients undergoing laparoscopic radical cystectomy for BCa from April 2018 to October 2021 were retrospectively analyzed, as ELRC and TLRC groups. The postoperative follow-up data of 275 patients were collected and the incidence of postoperative complications and other perioperative outcomes were compared between the two groups. RESULTS Surgery was successfully completed in all patients without conversion to open surgery. There was no significant difference in the duration of cystectomy surgery (67.32 ± 23.53 vs 72.17 ± 25.72 min, p = 0.106), intraoperative blood loss (178.06 ± 110.4 vs. 174.56 ± 127.40 ml, p = 0.413), or the number of lymph node dissection (15.1 ± 5.7 vs. 14.5 ± 5.1, p = 0.380) between the two groups. The length of stay (11.6 ± 3.8 vs 14.7 ± 5.6 d, p < 0.001), time to resume food intake after surgery (2.3 ± 0.9 vs 3.0 ± 1.3 d, p < 0.001), and the incidence of ileus (p < 0.001) in the ELRC group were significantly lower than in the TLRC group. CONCLUSIONS ELRC is a safe procedure that can reduce the incidence of postoperative complications, shorten postoperative hospital stay, reduce the duration of recovery of patients, and, therefore, should be promoted.
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Affiliation(s)
- Han Yang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zongliang Zhang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Kai Zhao
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yulian Zhang
- Department of Gynecology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinbao Yin
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guanqun Zhu
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhenlin Wang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xueyu Li
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhaofeng Li
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qinglei Wang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuanming Sui
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Nianzeng Xing
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Wang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, China
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Gabriel PÉ, Siebert M, Le Fouler A, Van Glabeke E, Trésallet C. Management of gastro-intestinal emergencies in patients with ileal conduit ureteral diversion. J Visc Surg 2022; 159:399-408. [PMID: 35690581 DOI: 10.1016/j.jviscsurg.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Radical cystectomy with urinary deviation is performed increasingly in France. Ileal conduit ureteral diversion (ICUD), described by Bricker and widely used after this type of radical resection, leads to substantial anatomic modifications that are potential danger zones during subsequent gastro-intestinal or urinary tract operations. Injury to the urinary diversion apparatus can lead to disastrous complications in these patients who are often elderly and frail. General surgeons are most often called upon to re-operate these patients, either for an ICUD-related gastro-intestinal complication, or for an unrelated abdominal emergency that arises later (bowel obstruction, infection, cancer). During such operations, certain anatomic structures are particularly exposed to injury that may be irreversible, particularly, the mesentery of the ileal conduit and the left ureter. Approaching the right lower quadrant, the dissection of the ileo-ileal anastomosis or of the left mesocolon are the procedures or maneuvers that pose the most risk. A number of simple but effective preventive measures are available and must be known, such as to operate the patient with an urologist or to insert ureteral stents before surgery. Preoperative contrast-enhanced computed tomography with late phase urinary imaging is essential to assess the anatomic modifications and anticipate the operative procedural steps. Finally, one should not hesitate to disinsert the stoma and proceed with retrograde dissection, thus facilitating the identification of the ileal conduit, the mesentery and the ureters.
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Affiliation(s)
- P-É Gabriel
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne Hospital Group, AP-HP, 93000 Bobigny, France; Paris Seine-Saint-Denis University Hospitals (Paris 13), Sorbonne Paris Nord, Paris, France
| | - M Siebert
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne Hospital Group, AP-HP, 93000 Bobigny, France; Paris Seine-Saint-Denis University Hospitals (Paris 13), Sorbonne Paris Nord, Paris, France
| | - A Le Fouler
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne Hospital Group, AP-HP, 93000 Bobigny, France; Paris Seine-Saint-Denis University Hospitals (Paris 13), Sorbonne Paris Nord, Paris, France
| | - E Van Glabeke
- Inter-hospital Urology Federation of Seine Saint-Denis, CHI André-Grégoire, 93100 Montreuil, France
| | - C Trésallet
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne Hospital Group, AP-HP, 93000 Bobigny, France; Paris Seine-Saint-Denis University Hospitals (Paris 13), Sorbonne Paris Nord, Paris, France.
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Yang H, Zhang Z, Zhao K, Zhang Y, Yin X, Zhu G, Lin C, Liu C, Wang Z, Sui Y, Li X, Li C, Wang K. Extraperitoneal Laparoscopic Radical Cystectomy With Preservation of Fertility for the Treatment of Ewing Sarcoma: The First Report of a Reliable Surgical Method. Urology 2021; 159:241-246. [PMID: 34653432 DOI: 10.1016/j.urology.2021.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/26/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To improve the complications of traditional laparoscopic radical cystectomy (LRC), a novel technique of extraperitoneal laparoscopic radical cystectomy (ELRC) with preservation of fertility was described. MATERIALS AND METHODS Selected patients with bladder cancer were treated with the ELRC technique. The seminal vesicles and the vas deferens were preserved. Patient's perioperative conditions, tumor prognosis, and follow-up data were analyzed retrospectively. RESULTS We successfully completed ELRC surgery in dozens of patients. The orthotopic ileal neobladder was placed in the extraperitoneal area, completely preserving the peritoneum. The postoperative complications caused by postoperative peritoneal loss were reduced. Moreover, the perioperative period was strictly managed with the concept of enhanced recovery after surgery (ERAS). We described the operation process in detail through a typical case of a child. All patients were free of complication at short-term follow-up, and reported satisfied sexual function with normal erections. CONCLUSION The ELRC technique has benefits in terms of decreased ileus, reoperation rates, hospital stay, ease of management of urinary leaks, and improves the patient quality of life. ELRC is also an oncologically safe approach with excellent significant functional outcomes in carefully selected transitional cell carcinoma (TCC) or non-TCC patients who expect to maintain sexual function and fertility, especially for young patients. In addition, more patient groups and longer follow-ups are needed to further understand the safety and practicality of the ELRC technology.
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Affiliation(s)
- Han Yang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Zongliang Zhang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Kai Zhao
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Yulian Zhang
- Department of Gynecology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Xinbao Yin
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Guanqun Zhu
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Chunhua Lin
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong, China
| | - Caihong Liu
- Health Bureau of Qingdao West Coast New Area, Qingdao, Shandong, China.
| | - Zhenlin Wang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Yuanming Sui
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Xueyu Li
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Chen Li
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Ke Wang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China.
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Domínguez A, Muñoz-Rodríguez J, Martos R, Parejo V, Prera Á, Tremps C, Bonfill T, Del Pino C, Augé A, Prats J. Progressive perioperative benefits of laparoscopy in combination with an ERAS (Enhanced Recovery After Surgery) protocol in radical cystectomy with ileal conduit. Actas Urol Esp 2021; 45:289-299. [PMID: 33546903 DOI: 10.1016/j.acuro.2020.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/11/2020] [Accepted: 10/30/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Although in the recent years, laparoscopy and Enhanced Recovery After Surgery (ERAS) protocols have improved postoperative recovery in radical cystectomy (RC), the clinical efficacy of their association remains unclear. Our objective is to analyze the possible benefits obtained from laparoscopic RC (LRC) and its subsequent combination with an ERAS (ERAS-LRC) protocol compared to open RC (ORC). MATERIAL AND METHODS We analyzed 187 consecutive RCs with ileal conduit performed in our center, of which 139 met the inclusion criteria: 47 ORC, 39 LRC (both with conventional protocol) and 52 ERAS-LRCs. RESULTS No significant differences were found regarding age, sex, BMI and ASA score between groups. ERAS-LRC obtained a shorter length of stay than LRC and ORC (median 8 [7-10]) vs. 13 [10-17] vs. 15 [13-19.5] days, respectively; P<.001). ERAS-LRC had a shorter stay in the ICU and less days of nasogastric tube (P<.001). Postoperative complications and readmission rates were similar among groups. Multivariate logistic regression showed that absence of complications, younger age and ERAS behaved as independent factors for shorter hospital stay, while ERAS was the only independent factor of lower readmission rate at 90 days. CONCLUSIONS Although LRC presented perioperative benefits compared to ORC, the results were better after the implementation of an ERAS protocol. ERAS protocol had stronger impact on recovery than the surgical approach of the procedure.
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Affiliation(s)
- A Domínguez
- Servicio de Urología, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona (UAB) , Sabadell, Barcelona, España.
| | - J Muñoz-Rodríguez
- Servicio de Urología, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona (UAB) , Sabadell, Barcelona, España
| | - R Martos
- Servicio de Urología, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona (UAB) , Sabadell, Barcelona, España
| | - V Parejo
- Servicio de Urología, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona (UAB) , Sabadell, Barcelona, España
| | - Á Prera
- Servicio de Urología, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona (UAB) , Sabadell, Barcelona, España
| | - C Tremps
- Servicio de Anestesia, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona (UAB), Sabadell, Barcelona, España
| | - T Bonfill
- Servicio de Oncología, Hospital Universitari Parc Taulí, UAB, Sabadell, Barcelona, España
| | - C Del Pino
- Departamento de Enfermería Estomaterapeuta, Hospital Universitari Parc Taulí, UAB, Sabadell, Barcelona, España
| | - A Augé
- Servicio de Enfermería, Hospital Universitari Parc Taulí, UAB, Sabadell, Barcelona, España
| | - J Prats
- Servicio de Urología, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona (UAB) , Sabadell, Barcelona, España
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Kitamura H, Hinotsu S, Tsukamoto T, Shibata T, Mizusawa J, Kobayashi T, Miyake M, Nishiyama N, Kojima T, Nishiyama H. Effect of neoadjuvant chemotherapy on health-related quality of life in patients with muscle-invasive bladder cancer: results from JCOG0209, a randomized phase III study. Jpn J Clin Oncol 2021; 50:1464-1469. [PMID: 32699909 DOI: 10.1093/jjco/hyaa123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/05/2020] [Accepted: 07/14/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Although neoadjuvant chemotherapy provides survival benefits in muscle-invasive bladder cancer, the impact of neoadjuvant chemotherapy on health-related quality of life has not been investigated by a randomized trial. The purpose of this study is to compare health-related quality of life in patients with muscle-invasive bladder cancer who received neoadjuvant chemotherapy followed by radical cystectomy or radical cystectomy alone based on patient-reported outcome data. METHODS Patients were randomized to receive two cycles of neoadjuvant methotrexate, doxorubicin, vinblastine, and cisplatin followed by radical cystectomy or radical cystectomy alone. Health-related quality of life was measured using the Functional Assessment of Cancer Therapy-Bladder (version 4) questionnaire before the protocol treatments, after neoadjuvant chemotherapy, after radical cystectomy and 1 year after registration. RESULTS A total of 99 patients were analysed. No statistically significant differences in postoperative health-related quality of life were found between the arms. In the neoadjuvant chemotherapy arm, the scores after neoadjuvant chemotherapy were significantly lower than the baseline scores in physical well-being, functional well-being, Functional Assessment of Cancer Therapy-General total, weight loss, diarrhoea, appetite, body appearance, embarrassment by ostomy appliance and total Functional Assessment of Cancer Therapy-Bladder. However, there was no difference in scores for these domains, except for embarrassment by ostomy appliance, between the two arms after radical cystectomy and 1 year after registration. CONCLUSIONS Although health-related quality of life declined during neoadjuvant chemotherapy, no negative effect of neoadjuvant chemotherapy on health-related quality of life was apparent after radical cystectomy. These data support the view that neoadjuvant chemotherapy can be considered as a standard of care for patients with muscle-invasive bladder cancer regarding health-related quality of life.
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Affiliation(s)
- Hiroshi Kitamura
- Department of Urology, Faculty of Medicine, University of Toyama, Toyama Toyama, Japan
| | - Shiro Hinotsu
- Department of Biostatistics, Sapporo Medical University, SapporoHokkaido, Japan
| | - Taiji Tsukamoto
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo Hokkaido, Japan
| | - Taro Shibata
- Japan Clinical Oncology Group Data Center, National Cancer Center Hospital, Tokyo, Japan
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center, National Cancer Center Hospital, Tokyo, Japan
| | - Takashi Kobayashi
- Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Makito Miyake
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Naotaka Nishiyama
- Department of Urology, Faculty of Medicine, University of Toyama, Toyama Toyama, Japan
| | - Takahiro Kojima
- Department of Urology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroyuki Nishiyama
- Department of Urology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Incidence and risk factors of postoperative ileus after hysterectomy for benign indications. Int J Colorectal Dis 2020; 35:2105-2112. [PMID: 32699935 DOI: 10.1007/s00384-020-03698-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Postoperative ileus (POI) after abdominal surgery is associated with prolonged hospital stay and increased costs. The aim of this study is to investigate the incidence of, risk factors for, and outcomes associated with POI in patients undergoing hysterectomy for benign indications. METHODS A retrospective review of 1017 consecutive patients undergoing benign hysterectomy over the period 2012-2017 in a single center was performed. POI was predefined as absence of flatus and defecation for more than 2 days with the presence of one or more of the following symptoms: nausea, vomiting, and abdominal distention. The association between perioperative variables and the risk of POI was evaluated by univariate analysis. Independent risk factors were identified by multivariate logistic regression analysis. RESULTS Overall incidence of POI was 9.2%. Incidence of POI did not differ significantly among three different surgical approaches (abdominal hysterectomy, 10.6%; laparoscopic hysterectomy, 7.8%; vaginal hysterectomy, 11.3%; P = 0.279). Independent risk factors of POI identified by multivariate analysis included anesthesia technique (odds ratio [OR] 2.662, 95% interval [CI] 1.533-4.622, P = 0.001), adhesiolysis (odds ratio [OR] 1.818, 95% interval [CI] 1.533-4.622, P = 0.011), duration of operation (odds ratio [OR] 1.005, 95% interval [CI] 0.942-6.190, P = 0.029), previous cancer (odds ratio [OR] 4.789, 95% interval [CI] 1.232-18.626, P = 0.024), and dysmenorrhea (odds ratio [OR] 1.859, 95% interval [CI] 1.182-2.925, P = 0.007). CONCLUSION POI is a common complication after hysterectomy. This study identified risk factors of POI specifically for gynecologic patients. Patients exposed to these factors should be monitored closely for the development POI.
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Wang J, Li D, Tang W, Guo J, Chen W, Yong Y, Song W, Yu G, Feng R, Yuan L, Fu G, Song J, Fan L. Pretreatment with transcutaneous electrical acupoint stimulation to prevent postoperative ileus in patients undergoing laparoscopic colon surgery: study protocol for a randomised controlled trial. BMJ Open 2020; 10:e030694. [PMID: 32819923 PMCID: PMC7440825 DOI: 10.1136/bmjopen-2019-030694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Postoperative ileus (POI), a common complication after surgery, severely affects postoperative recovery. It is unclear whether pretreatment with transcutaneous electrical acupoint stimulation (TEAS) can improve recovery from POI. This trial will evaluate the effects of pretreatment with TEAS on POI. METHODS AND ANALYSIS This will be a prospective, randomised controlled trial. American Society of Anesthesiologists (ASA) physical status classification I-III level patients, aged 18-75 years and scheduled for laparoscopic colon surgery, will be included in the study. It is planned that 146 subjects will be randomised to the TEAS and sham TEAS (STEAS) groups. The groups will undergo two sessions of TEAS/STEAS daily for 3 days before surgery, with a final TEAS/STEAS treatment 30 min before anaesthesia. The primary endpoint of the study will be time to first defaecation. Secondary endpoints will include time to first flatus, time to tolerance of oral diet, GI-2 (composite outcome of time to first defaecation and time to tolerance of oral diet), time to independent walking, length of hospital stay, postoperative pain Visual Analogue Scale score on the first 3 days after surgery, analgesic requirements, complications and plasma concentrations of interferon-β (IFN-β), IFN-γ, interleukin-6 (IL-6) and IL-1β. Multiple linear regression will be used to identify independent predictors of outcome measures. ETHICS AND DISSEMINATION This study has been approved by the Chinese Registered Clinical Trial Ethics Review Committee (No. ChiECRCT-20170084). The results of the trial will be published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER This study has been registered with the Chinese Clinical Trial Registry (No. ChiCTR-INR-17013184). TRIAL STATUS The study was in the recruitment phase at the time of manuscript submission.
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Affiliation(s)
- Jian Wang
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Dongli Li
- Anesthesiology, Wenzhou Medical University, the sixth Affiliated Hospital, Lishui, China
| | - Wei Tang
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jun Guo
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wenting Chen
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yue Yong
- Research Institute of Acupuncture Anesthesia, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wei Song
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guijie Yu
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rui Feng
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lan Yuan
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guoqiang Fu
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiangang Song
- Anesthesiology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lihua Fan
- Anesthesiology, Wenzhou Medical University, the sixth Affiliated Hospital, Lishui, China
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Özkaptan O, Çubuk A, Dinçer E, Şahan A, Kafkaslí A, Akça O. Extraperitoneal Antegrade vs Transperitoneal Open Radical Cystectomy: Single Center Experiences with 200 Cases. Bladder Cancer 2020. [DOI: 10.3233/blc-200280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND: Radical cystectomy (RC) is one of the most complex surgeries and has a high rate of morbidity. Gastrointestinal complications are the most common type of complications. To reduce these complications some modifications have been described. OBJECTIVE: To evaluate perioperative outcomes of our extraperitoneal antegrade RC technique (EARTC), where the peritoneum is opened at the end of cystectomy just before of ileal reconstruction. METHODS: Group 1 included 120 patients who were operated with a standard RC technique and Group 2 included 80 patients who were operated with the EARC technique in this study. Groups were compared according to preoperative variables including patient characteristics, perioperative parameters, pathologic data, and postoperative overall and gastrointestinal complications. RESULTS: There were no significant differences between the two groups in terms of preoperative characteristics and mean operative time. The group 1 has longer time for the exposure of abdominal cavity to the atmosphere (p < 0.01). Hospitalization time was significantly lower in Group 2 (p < 0.01). Concerning the rate of 90-day overall perioperative complication, no statistically significant difference was determined between the groups. Gastrointestinal complication was significantly higher in Group 1 (p:0.048). The average number of removed lymph nodes was similar between the groups (p:0.85). The time for recovery of bowel function, the time for passage of stool and the rate of postoperative ileus were significantly lower in Group 2 (p < 0.01, p < 0.01 and p < 0.043) respectively). CONCLUSIONS: EARC provides advantages over the standard technique in terms of gastrointestinal symptoms and poses no disadvantage when the oncological outcome and operative difficulty were considered.
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Affiliation(s)
- Orkunt Özkaptan
- Department of Urology, Kartal Lutfi Kirdar Training and Research Hospital, Kartal, Istanbul, Turkey
| | - Alkan Çubuk
- Department of Urology, Kartal Lutfi Kirdar Training and Research Hospital, Kartal, Istanbul, Turkey
| | - Erdinç Dinçer
- Department of Urology, Kartal Lutfi Kirdar Training and Research Hospital, Kartal, Istanbul, Turkey
| | - Ahmet Şahan
- Department of Urology, Kartal Lutfi Kirdar Training and Research Hospital, Kartal, Istanbul, Turkey
| | - Alper Kafkaslí
- Department of Urology, Kartal Lutfi Kirdar Training and Research Hospital, Kartal, Istanbul, Turkey
| | - Oktay Akça
- Department of Urology, Kartal Lutfi Kirdar Training and Research Hospital, Kartal, Istanbul, Turkey
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The Efficacy of Chewing Gum in Postoperative Ileus Management After Robot Assisted Laparoscopic Radical Prostatectomy: A Prospective Randomized Study. JOURNAL OF CONTEMPORARY MEDICINE 2020. [DOI: 10.16899/jcm.656495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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11
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Burden S, Billson HA, Lal S, Owen KA, Muneer A. Perioperative nutrition for the treatment of bladder cancer by radical cystectomy. Cochrane Database Syst Rev 2019; 5:CD010127. [PMID: 31107970 PMCID: PMC6527181 DOI: 10.1002/14651858.cd010127.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Radical cystectomy (RC) is the primary surgical treatment for muscle-invasive urothelial carcinoma of the bladder. This major operation is typically associated with an extended hospital stay, a prolonged recovery period and potentially major complications. Nutritional interventions are beneficial in some people with other types of cancer and may be of value in this setting too. OBJECTIVES To assess the effects of perioperative nutrition in people undergoing radical cystectomy for the treatment of bladder cancer. SEARCH METHODS We performed a comprehensive search using multiple databases (Evidence Based Medicine Reviews, MEDLINE, Embase, AMED, CINAHL), trials registries, other sources of grey literature, and conference proceedings published up to 22 February 2019, with no restrictions on the language or status of publication. SELECTION CRITERIA We included parallel-group randomised controlled trials (RCTs) of adults undergoing RC for bladder cancer. The intervention was any perioperative nutrition support. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias and the quality of evidence using GRADE. Primary outcomes were postoperative complications at 90 days and length of hospital stay. The secondary outcome was mortality up to 90 days after surgery. When 90-day outcome data were not available, we reported 30-day data. MAIN RESULTS The search identified eight trials including 500 participants. Six trials were conducted in the USA and two in Europe.1. Parenteral nutrition (PN) versus oral nutrition: based on one study with 157 participants, PN may increase postoperative complications within 30 days (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.07 to 1.82; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance and selective reporting bias) and serious imprecision. This corresponds to 198 more complications per 1000 participants (95% CI 35 more to 405 more). Length of hospital stay may be similar (mean difference (MD) 0.5 days higher, CI not reported; low-quality evidence).2. Immuno-enhancing nutrition versus standard nutrition: based on one study including 29 participants, immuno-enhancing nutrition may reduce 90-day postoperative complications (RR 0.31, 95% CI 0.08 to 1.23; low-quality evidence). These findings correspond to 322 fewer complications per 1000 participants (95% CI 429 fewer to 107 more). Length of hospital stay may be similar (MD 0.20 days, 95% CI 1.69 lower to 2.09 higher; low-quality evidence). We downgraded the quality of evidence of both outcomes for very serious imprecision.3. Preoperative oral nutritional support versus normal diet: based on one study including 28 participants, we are very uncertain if preoperative oral supplements reduces postoperative complications. We downgraded quality for serious study limitations (unclear risk of selection, performance, attrition and selective reporting bias) and very serious imprecision. The study did not report on length of hospital stay.4. Early postoperative feeding versus standard postoperative management: based on one study with 102 participants, early postoperative feeding may increase postoperative complications (very low-quality evidence) but we are very uncertain of this finding. We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and very serious imprecision. Length of hospital stay may be similar (MD 0.95 days less, CI not reported; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and serious imprecision.5. Amino acid with dextrose versus dextrose: based on two studies with 104 participants, we are very uncertain whether amino acids reduce postoperative complications (very low-quality evidence). We are also very uncertain whether length of hospital stay is similar (very low-quality evidence). We downgraded the quality of evidence for both outcomes for serious study limitations (unclear and high risk of selection bias; unclear risk of performance, detection and selective reporting bias), serious indirectness related to the patient population and very serious imprecision.6. Branch chain amino acids versus dextrose only: based on one study including 19 participants, we are very uncertain whether complication rates are similar (very low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance, detection, attrition and selective reporting bias), serious indirectness related to the patient population and very serious imprecision. The study did not report on length of hospital stay.7. Perioperative oral nutritional supplements versus oral multivitamin and mineral supplement: based on one study with 61 participants, oral supplements compared to a multivitamin and mineral supplement may slightly decrease postoperative complications (low-quality evidence). These findings correspond to 135 fewer occurrences per 1000 participants (95% CI 256 fewer to 65 more). Length of hospital stay may be similar (low-quality evidence). We downgraded the quality of evidence of both outcomes for study limitations and imprecision. AUTHORS' CONCLUSIONS Based on few, small and dated studies, with serious methodological limitations, we found limited evidence for a benefit of perioperative nutrition interventions. We rated the quality of evidence as low or very low, which underscores the urgent need for high-quality research studies to better inform nutritional support interventions for people undergoing surgery for bladder cancer.
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Affiliation(s)
- Sorrel Burden
- The University of Manchester, and Manchester Academic Health Science
CentreSchool of Health SciencesManchesterUKM13 9PL
| | - Hazel A Billson
- Manchester Royal InfirmaryDietetic Department, Platt 2 RehabilitationOxford RoadManchesterUKM13 9WL
| | - Simon Lal
- Salford Royal Foundation TrustIntestinal Failure UnitSalfordUKM6 8HD
| | - Kellie A Owen
- Manchester Royal InfirmaryDietetic Department, Platt 2 RehabilitationOxford RoadManchesterUKM13 9WL
| | - Asif Muneer
- University College London HospitalDepartment of Urology and NIHR Biomedical Research CentreLondonUK
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Declercq P, Van der Aa F, De Pourcq L, Spriet I. Impact of an oral nutrition protocol in patients treated with elective radical cystectomy: a long term follow-up. Int J Clin Pharm 2019; 41:408-413. [PMID: 30864080 DOI: 10.1007/s11096-019-00800-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 02/19/2019] [Indexed: 11/28/2022]
Abstract
Background After radical cystectomy, delayed return of bowel function is relatively common. Although studies investigating on the best modality for delivering nutritional support to this patient group are limited, parenteral nutrition was standard of care in those patients at the urological ward of the University Hospitals Leuven. In 2015, we published the findings from our study conducted in patients undergoing elective regular radical cystectomy at the urological ward of the University Hospitals Leuven comparing the length of hospital stay in patients with early postoperative parenteral nutrition (n = 48) versus an immediate oral nutrition protocol (n = 46). It was demonstrated that the implementation of an oral nutrition protocol was associated with a significant reduced length of hospital stay (median [IQR] of 18 [15-22] to 14 [13-18] days (p < 0.001)). The sample size was however too small to investigate the impact of the oral nutrition protocol on the incidence of catheter-related bloodstream infection, a common parenteral nutrition related complication. Objective To investigate the long term impact of an oral nutrition protocol on the incidence of catheter-related bloodstream infection, duration of catheterization and the length of hospital stay. Method Retrospectively, before (parenteral nutrition group) and after the implementation of the oral nutrition protocol (since March 10th 2010), two cohorts of 549 patients who underwent an elective regular radical cystectomy were included. The incidence of a catheter-related bloodstream infection and the length of stay were compared. A central venous catheter was present in every patient, which is standard of care. Results Catheter-related bloodstream infection was reduced from 22 (4%) to 10 (1.8%) (p = 0.031). The median duration of catheterization was 10 [7-13] days for the parenteral nutrition versus 7 [7-7] days for the oral nutrition group (p < 0.001). The median length of stay between both groups, 20 [17-25] before versus 17 [14-21] days after the implementation of the oral nutrition protocol, also differed significantly (p < 0.001). Implementing the oral nutrition protocol resulted in a parenteral nutrition associated cost saving of €470 per patient. Conclusion This large follow-up study showed that the oral nutrition protocol is associated with a reduction in catheter-related bloodstream infection. Besides, postponing parenteral nutrition in favour of oral nutrition enhances recovery.
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Affiliation(s)
- Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Louvain, Belgium. .,Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Herestraat 49, 3000, Louvain, Belgium.
| | - Frank Van der Aa
- Department of Urology, University Hospitals Leuven, Louvain, Belgium.,Department Development and Regeneration, Faculty of Medicine, KU Leuven, Louvain, Belgium
| | - Lutgart De Pourcq
- Pharmacy Department, University Hospitals Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Herestraat 49, 3000, Louvain, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Louvain, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Herestraat 49, 3000, Louvain, Belgium
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Cao Q, Li P, Yang X, Qian J, Wang Z, Lu Q, Gu M. Laparoscopic radical cystectomy with pelvic re-peritonealization: the technique and initial clinical outcomes. BMC Urol 2018; 18:113. [PMID: 30541538 PMCID: PMC6291951 DOI: 10.1186/s12894-018-0424-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 11/16/2018] [Indexed: 11/20/2022] Open
Abstract
Background Delayed bowel function recovery and postoperative ileus are relatively serious complications of laparoscopic radical cystectomy (LRC). Our study aimed to determine whether performing pelvic re-peritonealization reduces the incidence of these complications. Methods Clinical data of 78 patients who had undergone LRC with pelvic re-peritonealization from August 2015 to December 2017 were retrospectively collected and compared with those of 92 patients who had undergone LRC alone between January 2013 and July 2015 in our institution. Differences in duration of surgery, estimated blood loss, time to recovery of bowel function, the complications of intestinal and blood vessel injury, and incidence of postoperative ileus between the two groups were analyzed. Results Baseline characteristics such as age, sex and BMI were balanced between the two groups. There were no significant differences in duration of surgery (P = 0.072), estimated blood loss (P = 0.717), or incidence of intestinal obstruction (P = 0.225) between the two groups. Interestingly, patients who had undergone pelvic re-peritonealization recovered bowel function more rapidly than those had not (2.79 d vs. 3.72 d, P = 0.001). Additionally, hospitalization stay was significantly shorter for patients with re-peritonealization than for those without (5.46 d vs. 6.68 d, P = 0.029). Conclusions Compared with LRC alone, LRC with pelvic re-peritonealization as described in the present study had comparable perioperative complications, but was associated with more rapid gastrointestinal recovery and shorter hospitalization stay.
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Affiliation(s)
- Qiang Cao
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Pengchao Li
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xiao Yang
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jian Qian
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Zengjun Wang
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Qiang Lu
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - Min Gu
- Department of Urology, the First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
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Park JS, Kim J, Jang WS, Heo JE, Elghiaty A, Rha KH, Choi YD, Ham WS. Management of postoperative ileus after robot-assisted laparoscopic prostatectomy. Medicine (Baltimore) 2018; 97:e13036. [PMID: 30383668 PMCID: PMC6221667 DOI: 10.1097/md.0000000000013036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
To compare different postoperative management methods on the recovery of bowel function after robot-assisted laparoscopic prostatectomy (RALP).This is a prospective study of 716 patients who underwent RALP at Severance Hospital in Seoul, South Korea, between March 2017 and February 2018. Instructions for the different postoperative management methods (mobilization, abdominal massage, hot pack therapy, and gum chewing) were presented to patients, who subsequently reported when these activities were performed as well as the time to first flatus on a designated form.There were no significant differences in age, height, weight, body mass index, body surface area, prevalence of hypertension and diabetes mellitus, and in American Society of Anesthesiologists (ASA) scores with respect to early bowel recovery. Prolonged times of surgery and anesthesia significantly caused delays in bowel recovery. The total number and time of mobilization, total time of hot pack therapy, and number of gum chewing were significantly and positively associated with bowel recovery. A Kaplan-Meier analysis showed that all of the postoperative management methods were positively associated with the mean time to first flatus.Methods of postoperative management (mobilization, abdominal massage, hot pack therapy, and gum chewing) have positive effect on bowel motility after RALP. Furthermore, reductions in the times of surgery and anesthesia could significantly decrease prolonged delays in bowel recovery.
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Affiliation(s)
- Jee Soo Park
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongchan Kim
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Sik Jang
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Eun Heo
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ahmed Elghiaty
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Urology, Tanta University College of Medicine, Tanta, Egypt
| | - Koon Ho Rha
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Deuk Choi
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Sik Ham
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Wayan Y, Ayu PD, Gde OAA, Wayan N, Widyadharma IPE. Pathological Profile, Early Complications, Functional and Oncological Outcome after Radical Cystectomy - Ileal Conduit for Bladder Cancer Patients in Sanglah General Hospital between January 2013 and December 2016. Open Access Maced J Med Sci 2018; 6:1647-1651. [PMID: 30337981 PMCID: PMC6182542 DOI: 10.3889/oamjms.2018.384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/08/2018] [Accepted: 09/09/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND: Radical cystectomy is the standard treatment for nonmetastatic bladder cancer (muscle-invasive and selective superficial bladder cancer). There are many types of urinary diversion after this procedure; the ileal conduit is the most and simplest one. AIM: To asses clinical, pathological profile, early complication, functional and oncological outcome after radical cystectomy and ileal conduit for muscle-invasive bladder cancer patients. METHOD: Between January 2013 and December 2016, there were 68 patients diagnosed with bladder cancer. From those patients, 24 (35.29%) patients had been performed radical cystectomy with ileal conduit type for urinary diversion (100%). Patients demographic, clinical and pathological profile, early postoperative complication, functional and oncological outcome were collected from the medical record. RESULT: Among the 24 patients who underwent radical cystectomy, 20 patients were male (83.3%) with the mean age was 57.3 y.o (33–77 y.o). Twelve patients (50%) showed pT4 and pT2 respectively. Based on pathological result 20 patient (83.34%) had the urothelial carcinoma, three patients (12.5%) had squamous cell carcinoma, and one patient (4.1%) had adenocarcinoma. Two patients (8.3%) got neoadjuvant chemotherapy, and nine patient (37.5%) of patients followed adjuvant chemotherapy after surgery. Wound dehiscence, fistula enterocutan, prolong ileus, leakage anastomosis and sepsis were kind of complication after surgery. One year’s survival rate is 84%, mortality rate 20.8% and a recurrence rate of 20.8% in 4 years follow up. CONCLUSION: Radical cystectomy and ileal conduit type of urinary diversion still become the preferable procedure for nonmetastatic bladder cancer with good functional and oncological outcome.
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Affiliation(s)
- Yudiana Wayan
- Department of Surgery, Medical Faculty, Udayana University-Sanglah General Hospital, Bali, Indonesia
| | - Pratiwi Dinar Ayu
- Department of Surgery, Medical Faculty, Udayana University-Sanglah General Hospital, Bali, Indonesia
| | - Oka A A Gde
- Department of Surgery, Medical Faculty, Udayana University-Sanglah General Hospital, Bali, Indonesia
| | - Niryana Wayan
- Department of Surgery, Medical Faculty, Udayana University-Sanglah General Hospital, Bali, Indonesia
| | - I Putu Eka Widyadharma
- Department of Neurology, Medical Faculty, Udayana University-Sanglah General Hospital, Bali, Indonesia
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Alvimopan usage increasing following radical cystectomy. World J Urol 2018; 37:1151-1155. [DOI: 10.1007/s00345-018-2476-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/03/2018] [Indexed: 02/05/2023] Open
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Kulkarni JN, Agarwal H. Transperitoneal vs. extraperitoneal radical cystectomy for bladder cancer: A retrospective study. Int Braz J Urol 2018; 44:296-303. [PMID: 29219280 PMCID: PMC6050562 DOI: 10.1590/s1677-5538.ibju.2017.0441] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose Conventional transperitoneal radical cystectomy (TPRC) is the standard approach for muscle invasive bladder cancer. But, the procedure is associated with significant morbidities like urinary leak, ileus, and infection. To reduce these morbidities, the technique of extraperitoneal radical cystectomy (EPRC) was described by us in 1999. We compared these two approaches and the data accrued forms the basis of this report. Materials and Methods All patients who underwent radical cystectomy for bladder cancer by the author (JNK) with follow-up for at least 5 years were included. A total of 338 patients were studied, with 180 patients in EPRC group and 158 in TPRC group. Results There were 3 mortalities within 30 days in TPRC group and one in EPRC group. Early complication rate was 52% and 58% in EPRC and TPRC groups. Urinary leak occurred in 31 (9.2%) patients (13 in EPRC, 18 in TPRC, p=0.19). Gastrointestinal complications like ileus occurred in 9 (5%) patients in EPRC group and in 25 (15.8%) patients in TPRC group, (p<0.001). Wound dehiscence occurred in 29, and 36 patients in EPRC and TPRC groups respectively. The reoperation rate was 6.1% and 12% in EPRC and TPRC groups, (p=0.08). Intestinal obstruction were significantly less in EPRC group (1.7% vs. 7.8% in TPRC group, p=0.002). Uretero-enteric anastomosis stricture was seen in 10 patients (4 in EPRC, 6 in TPRC, p=0.39). Conclusions The EPRC is associated with decrease gastrointestinal complications, ease of management of urinary leaks, and low reoperation rates. Thus EPRC appears safe functionally and oncologically.
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Affiliation(s)
- Jagdeesh N Kulkarni
- Department of Urology, Bombay Hospital and Medical Research Centre, Mumbai, India
| | - Himanshu Agarwal
- Department of Urology, Bombay Hospital and Medical Research Centre, Mumbai, India
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Nutt M, Scaief S, Dynda D, Alanee S. Ileus and small bowel obstruction after radical cystectomy for bladder cancer: Analysis from the Nationwide Inpatient Sample. Surg Oncol 2018; 27:341-345. [PMID: 30217287 DOI: 10.1016/j.suronc.2018.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 05/08/2018] [Accepted: 05/11/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE To investigate prevalence and predictors of postoperative small bowel obstruction (SBO) and ileus in a large cohort of bladder cancer (BCa) patients treated with radical cystectomy (RC). METHODS All patients within the Nationwide Inpatient Sample who underwent RC for BCa between 2006 and 2012 were identified. First, prevalence of SBO and ileus was analyzed. Second, predictors of these bowel-related complications were identified using multivariable regression analyses. Third, the association between SBO, ileus, and length of stay was evaluated using logistic regression models adjusted for clustering. Prolonged length of stay was defined as hospital stay above mean stay of the population (>10 days). Fourth, the effect of SBO and ileus on mean inpatient cost of healthcare was examined. RESULTS Of overall 41,498 patients, 1071 (2.6%) experienced SBO, and 11,155 (26.9%) experienced ileus. Predictors of ileus included age, male gender, black race, hospital characteristics, anemia, chronic pulmonary disease, drug abuse, hypothyroidism, fluid and electrolyte disorders, and neurological disorders (all p < 0.05) Predictors of SBO included male gender, Asian/Pacific islander race, hospital characteristics, congestive heart failure, fluid and electrolyte disorders, and psychosis (all p < 0.05). . Postoperative SBO (odds ratio (OR) 19.587; 95% confidence interval (CI):15.869-24.167) and ileus (OR 5.646; 95% CI:5.336-5.974) were associated with prolonged length of stay (all p < 0.001).Median cost of hospital stay was $56.315 for patients who developed SBO, $32,472 for patients who developed ileus, and $24,600 for patients after cystectomy without ileus or SBO. CONCLUSIONS Significant prevalence of bowel-related complications in patients after RC was observed. These complications are strongly associated with prolonged length of stay and higher healthcare cost. Increasing awareness of SBO and ileus, identification of patients at risk prior to surgery, and implementation of protective strategies are strongly indicated in cystectomy patients.
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Affiliation(s)
- Max Nutt
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Steve Scaief
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Danuta Dynda
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Shaheen Alanee
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA.
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Vukovic N, Dinic L. Enhanced Recovery After Surgery Protocols in Major Urologic Surgery. Front Med (Lausanne) 2018; 5:93. [PMID: 29686989 PMCID: PMC5900414 DOI: 10.3389/fmed.2018.00093] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/23/2018] [Indexed: 01/31/2023] Open
Abstract
The purpose of the review The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery. Recent findings ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function. Summary Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.
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Affiliation(s)
- Natalija Vukovic
- Anesthesiology and Reanimation Center, Clinical Center Nis, Nis, Serbia
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Abstract
Even with advances in perioperative medical care, anesthetic management, and surgical techniques, radical cystectomy (RC) continues to be associated with a high morbidity rate as well as a prolonged length of hospital stay. In recent years, there has been great interest in identifying multimodal and interdisciplinary strategies that help accelerate postoperative convalescence by reducing variation in perioperative care of patients undergoing complex surgeries. Enhanced recovery after surgery (ERAS) attempts to evaluate and incorporate scientific evidence for modifying as many of the factors contributing to the morbidity of RC as possible, and optimize how patients are cared for before and after surgery. In this chapter, we review the preoperative, intraoperative and postoperative elements of using an ERAS protocol for RC.
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Affiliation(s)
- Avinash Chenam
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, 1500 E. Duarte Rd, MOB L002H, Duarte, CA, 91010, USA
| | - Kevin G Chan
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, 1500 E. Duarte Rd, MOB L002H, Duarte, CA, 91010, USA.
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Effectiveness of Acupuncture for Early Recovery of Bowel Function in Cancer: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 2017:2504021. [PMID: 29422935 PMCID: PMC5750515 DOI: 10.1155/2017/2504021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/10/2017] [Accepted: 09/14/2017] [Indexed: 12/25/2022]
Abstract
Objectives The aim of this study was to evaluate the effects of acupuncture therapy to reduce the duration of postoperative ileus (POI) and to enhance bowel function in cancer patients. Methods A systematic search of electronic databases for studies published from inception until January 2017 was carried out from six databases. Randomized controlled trials (RCTs) involving the use of acupuncture and acupressure for POI and bowel function in cancer patients were identified. Outcomes were extracted from each study and pooled to determine the risk ratio and standardized mean difference. Results 10 RCTs involving 776 cancer patients were included. Compared with control groups (no acupuncture, sham acupuncture, and other active therapies), acupuncture was associated with shorter time to first flatus and time to first defecation. A subgroup analysis revealed that manual acupuncture was more effective on the time to first flatus and the time to first defecation; electroacupuncture was better in reducing the length of hospital stay. Compared with control groups (sham or no acupressure), acupressure was associated with shorter time to first flatus. However, GRADE approach indicated a low quality of evidence. Conclusions Acupuncture and acupressure showed large effect size with significantly poor or inferior quality of included trials for enhancing bowel function in cancer patients after surgery. Further well-powered evidence is needed.
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Semerjian A, Milbar N, Kates M, Gorin MA, Patel HD, Chalfin HJ, Frank SM, Wu CL, Yang WW, Hobson D, Robertson L, Wick E, Schoenberg MP, Pierorazio PM, Johnson MH, Stimson CJ, Bivalacqua TJ. Hospital Charges and Length of Stay Following Radical Cystectomy in the Enhanced Recovery After Surgery Era. Urology 2017; 111:86-91. [PMID: 29032237 DOI: 10.1016/j.urology.2017.09.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 08/10/2017] [Accepted: 09/08/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To report our center's experience with enhanced recovery after surgery (ERAS) pathway for radical cystectomy (RC), specifically evaluating complications, LOS, 30- and 90-day readmissions, and hospital charges. Pathways of this type have been shown to decrease the length of stay (LOS) and postoperative ileus. However, concerns persist that ERAS is costly and increases readmissions. To date, limited studies have evaluated these concerns. MATERIALS AND METHODS Our ERAS protocol was implemented for RC in December 2015. Outcomes in ERAS patients were compared with those in RC patients from the time period before ERAS. Patients were excluded if they underwent concomitant nephroureterectomy. RESULTS Fifty-six consecutive ERAS patients were compared with 54 pre-ERAS patients. The median charge for index hospitalization was $31,090 in the ERAS group and $35,489 in the pre-ERAS group (P = .036). The median LOS was 5.0 days in the ERAS group and 8.5 days in the pre-ERAS group (P = < .001). The pre-ERAS group had a significantly increased use of nasogastric tube (13.8% vs 30.0%) and parenteral nutrition (6.9% vs 20.4%). The overall complication rate (including infectious, renal, deep vein thrombosis and pulmonary embolism, myocardial infarction and stroke, and respiratory and gastrointestinal-related complications) was similar between the 2 groups (51.7% in the ERAS group and 62.0% in the pre-ERAS group, P = .28). Thirty- and 90-day readmissions also remained similar (19.0% vs 14.8%, P = .55, and 31.0% vs 27.7%, P = .64). The most common readmission reason was infection, specifically urinary tract infection. CONCLUSION Implementation of the ERAS pathway at our center resulted in significantly reduced LOS and total hospital charge, with comparable rates of complication and readmission, highlighting the need for ERAS pathways in patients undergoing RC.
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Affiliation(s)
- Alice Semerjian
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Niv Milbar
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Max Kates
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael A Gorin
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hiten D Patel
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Heather J Chalfin
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William W Yang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deb Hobson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lindsay Robertson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mark P Schoenberg
- Montefiore Medical Center and Albert Einstein College of Medicine, Department of Urology, Bronx, NY
| | - Phillip M Pierorazio
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael H Johnson
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C J Stimson
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
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Loftus CJ, Moore DC, Cohn JA, Milam DF, Dmochowski RR, Wood D, Kaufman MR, Wood HM. Postoperative Complications of Patients With Spina Bifida Undergoing Urologic Laparotomy: A Multi-institutional Analysis. Urology 2017. [DOI: 10.1016/j.urology.2017.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Villa G, Bresciani M, Boarin M, Manara DF. The impact of oral nutrition in patients after radical cystectomy: an overview. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2017. [DOI: 10.1111/ijun.12148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Giulia Villa
- School of Nursing; Vita-Salute San Raffaele University; Milan Italy
| | - Martina Bresciani
- Department of Polispecialistic Surgery; San Raffaele Hospital; Milan Italy
| | - Mattia Boarin
- Department of Urology; San Raffaele Hospital; Milan Italy
| | - Duilio F. Manara
- Associate Professor, School of Nursing; Vita-Salute San Raffaele University; Milan Italy
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Bazargani ST, Djaladat H, Ahmadi H, Miranda G, Cai J, Schuckman AK, Daneshmand S. Gastrointestinal Complications Following Radical Cystectomy Using Enhanced Recovery Protocol. Eur Urol Focus 2017; 4:889-894. [PMID: 28753885 DOI: 10.1016/j.euf.2017.04.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/23/2017] [Accepted: 04/03/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The development of enhanced recovery after surgery (ERAS) protocols for patients undergoing radical cystectomy (RC) represents a significant advance in perioperative care. OBJECTIVE To evaluate gastrointestinal (GI) complications following RC and urinary diversion (UD) using our institutional ERAS protocol. DESIGN, SETTING, AND PARTICIPANTS We identified 377 consecutive cases of open RC and UD for which our ERAS protocol was used from May 2012 to December 2015. Exclusion criteria were consent refusal; non-bladder primary disease; palliative, salvage, or additional surgery; and prolonged postoperative intubation. A matched cohort of 144 patients for whom a traditional postoperative protocol (pre-ERAS) was used between 2003 and 2012 was selected for comparison. RESULTS AND LIMITATIONS A total of 292 ERAS patients with median age of 70 yr were included in the study, 65% of whom received an orthotopic neobladder. The median time to first flatus and bowel movement was 2 d. The median length of stay was 4 d. GI complications occurred in 45 patients (15.4%) during the first 30 d following RC, 93% of which were of minor grade. The most common GI complication was postoperative ileus (POI) in 34 cases (11.6%). Some 22 patients (7.5%) required a nasogastric tube, and parenteral nutrition was required in three patients. The rate of 30-d GI complications was significantly lower in the ERAS cohort than in the control group (13% vs 27%; p=0.003), as was the rate of POI (7% vs 23%; p<0.001). This effect was independent of other variables (hazard ratio 0.38, 95% confidence interval 0.18-0.82; p=0.01). CONCLUSIONS Our institutional ERAS protocol for RC is associated with significantly improved perioperative GI recovery and lower rates of GI complications. This protocol can be tested in multi-institutional studies to reduce GI morbidity associated with RC. PATIENT SUMMARY In this study, we showed that an enhanced recovery protocol for patients undergoing radical cystectomy for bladder cancer was associated with a significantly shorter length of hospital stay and lower rates of gastrointestinal complications, especially postoperative ileus.
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Affiliation(s)
- Soroush T Bazargani
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Hooman Djaladat
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Hamed Ahmadi
- Urology Department, Oregon Health & Science University, Portland, OR, USA
| | - Gus Miranda
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jie Cai
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Anne K Schuckman
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Siamak Daneshmand
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
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El-Hefnawy AS, Helmy T, Laimon M, El-Halwagy S, Abol-Enein H. Late intestinal obstruction after radical cystectomy and urinary diversion: urological and oncological perspectives. Scand J Urol 2016; 50:433-438. [DOI: 10.1080/21681805.2016.1204623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Ahmed S. El-Hefnawy
- Faculty of Medicine, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Tamer Helmy
- Faculty of Medicine, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mahmoud Laimon
- Faculty of Medicine, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Samer El-Halwagy
- Faculty of Medicine, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Hassan Abol-Enein
- Faculty of Medicine, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Azhar RA, Bochner B, Catto J, Goh AC, Kelly J, Patel HD, Pruthi RS, Thalmann GN, Desai M. Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs. Eur Urol 2016; 70:176-187. [PMID: 26970912 PMCID: PMC5514421 DOI: 10.1016/j.eururo.2016.02.051] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 02/17/2016] [Indexed: 02/08/2023]
Abstract
CONTEXT Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times. OBJECTIVE To overview the use and key elements of ERAS pathways, and define needs for future clinical trials. EVIDENCE ACQUISITION A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms "postoperative period," "postoperative care," "enhanced recovery after surgery," "enhanced recovery," "accelerated recovery," "fast track recovery," "recovery program," "recovery pathway", "ERAS," and "urology" or "cystectomy" or "urologic surgery." EVIDENCE SYNTHESIS We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6h and perioperative liquid-carbohydrate loading up to 2h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters. CONCLUSIONS ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery. PATIENT SUMMARY This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.
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Affiliation(s)
- Raed A Azhar
- Urology Department, King Abdulaziz University, Jeddah, Saudi Arabia; USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Bernard Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - James Catto
- Academic Units of Urology and Molecular Oncology, University of Sheffield, Sheffield, South Yorkshire, UK
| | - Alvin C Goh
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - John Kelly
- Division of Surgery and Interventional Science, UCL Medical School, University College London, London, UK
| | - Hiten D Patel
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Raj S Pruthi
- Division of Urologic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - George N Thalmann
- Department of Urology, University Hospital Inselspital, Bern, Switzerland
| | - Mihir Desai
- USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Djaladat H, Daneshmand S. Gastrointestinal Complications in Patients Who Undergo Radical Cystectomy with Enhanced Recovery Protocol. Curr Urol Rep 2016. [PMID: 27125653 DOI: 10.1007/s11934.016-0607-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Gastrointestinal (GI) complications are among the most common complications following radical cystectomy and urinary diversion. The most common is postoperative ileus, although its precise pathophysiology is not completely understood. Enhanced recovery after surgery (ERAS) protocols include evidence-based steps to optimize postoperative recovery and shorten hospital stay, mainly through expedited GI function recovery. They include avoiding bowel preparation and postoperative nasogastric tube, early feeding, non-narcotic pain management, and the use of cholinergic and mu-receptor opioid antagonists. We reviewed the literature in regard to GI complications using enhanced recovery protocols and share our institutional experience with over 300 patients.
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Affiliation(s)
- Hooman Djaladat
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, 90089, Los Angeles, CA, USA
| | - Siamak Daneshmand
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, 90089, Los Angeles, CA, USA.
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Gastrointestinal Complications in Patients Who Undergo Radical Cystectomy with Enhanced Recovery Protocol. Curr Urol Rep 2016; 17:50. [DOI: 10.1007/s11934-016-0607-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Tsaturyan A, Petrosyan V, Crape B, Sahakyan Y, Abrahamyan L. Risk factors of postoperative complications after radical cystectomy with continent or conduit urinary diversion in Armenia. SPRINGERPLUS 2016; 5:134. [PMID: 26933633 PMCID: PMC4761360 DOI: 10.1186/s40064-016-1757-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 02/12/2016] [Indexed: 02/07/2023]
Abstract
To estimate the surgical volume and the incidence of in-hospital complications of RC in Armenia from 2005 to 2012, and to investigate potential risk factors of complications. The study utilized a retrospective chart review in a cohort of patients who had RC followed by either continent or conduit urinary diversion in all hospitals of Armenia from 2005 to 2012. A detailed chart review was conducted abstracting information on baseline demographic and clinical characteristics, surgical procedural details, postoperative management and in-hospital complications. Multivariable logistic regression analysis was applied to estimate the independent risk factors for developing ‘any postoperative complication’. The total study sample included 273 patients (mean age = 58.5 years, 93.4 % men). Overall, 28.9 % (n = 79) of patients had at least one in-hospital complication. The hospital mortality rate was 4.8 % (n = 13). The most frequent types of complications were wound-related (10.3 %), gastrointestinal (9.2 %) and infectious (7.0 %). The ischemic heart disease (OR = 3.3, 95 % CI 1.5–7.4), perioperative transfusion (OR = 2.0, 1.1–3.6), glucose level [OR = 0.71 (0.63–0.95)], and hospital type (OR = 2.3, 95 % CI 1.1–4.7) were independent predictors of postoperative complications. The rate of RC complications in Armenia was similar to those observed in other countries. Future prospective studies should evaluate the effect of RC complications on long-term outcomes and costs in Armenia. Policy recommendations should address the issues regarding surgeon training and hospital volume to decrease the risk of RC complications.
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Affiliation(s)
- Arman Tsaturyan
- School of Public Health, American University of Armenia, 40 Marshal Baghramyan Ave., 0019 Yerevan, Armenia ; Armenia Republican Medical Center, Yerevan, Armenia
| | - Varduhi Petrosyan
- School of Public Health, American University of Armenia, 40 Marshal Baghramyan Ave., 0019 Yerevan, Armenia
| | - Byron Crape
- Nazarbayev University School of Medicine, Astana, Kazakhstan
| | - Yeva Sahakyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, Canada
| | - Lusine Abrahamyan
- School of Public Health, American University of Armenia, 40 Marshal Baghramyan Ave., 0019 Yerevan, Armenia ; Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, Canada
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Effect of alvimopan on accelerates gastrointestinal recovery after radical cystectomy: A systematic review and meta-analysis. Int J Surg 2016; 25:1-6. [DOI: 10.1016/j.ijsu.2015.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 09/06/2015] [Accepted: 11/12/2015] [Indexed: 01/05/2023]
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Ortega-Lucea S, Martínez-Ubieto J, Júdez-Legaristi D, Muñoz-Rodriguez L, Gil-Bona J, Pascual-Bellosta A. The results of implementing a fast-track protocol in radical cystectomy in a tertiary hospital. Actas Urol Esp 2015; 39:620-7. [PMID: 26142895 DOI: 10.1016/j.acuro.2015.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/24/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Radical cystectomy (RC) is the urological procedure associated with the highest rates of morbidity, mortality and hospital stay. The implementation of fast-track programs seeks to speed postsurgical recovery. Its application to radical cystectomy has yielded positive results. OBJECTIVES To assess the results of the fast-track protocol in RC at our hospital, in terms of morbidity, mortality and hospital stay, comparing these results with those of patients who underwent RC following the classic protocol. To thereby ascertain whether the implementation of the fast-track protocol represents a reduced number and severity of complications and shorter hospital stays. MATERIAL AND METHODS Ambispective cohort study of patients who underwent RC between January 2010 and October 2012 by either protocol (classic and fast-track). We analyzed the patient characteristics, intraoperative variables, postoperative complications (according to the Clavien classification), hospital stay and recovery stay. RESULTS Ninety-nine patients were included, 51 following the classic protocol and 48 following the fast-track protocol. The groups were homogeneous. The hospital stay and recovery stay were longer in the classic group than in the fast-track group (29 and 2 days, respectively, vs. 17 and 1 day). There was less intraoperative bleeding in the fast track group (600mL) than in the traditional group (1,000mL). Of the 99 patients, 31 (60.8%) of the classic group presented a postoperative complication, while the fast-track group had 14 (29.2%), most of which were minor (Clavien degrees 1 and 2). In the multivariate analysis, the type of protocol and the number of comorbidities were significant. CONCLUSIONS The implementation of the fast-track protocol in RC was associated with a significant reduction in intraoperative and postoperative complications and hospital stay.
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Daneshmand S, Lerner SP. Radical cystectomy. Bladder Cancer 2015. [DOI: 10.1002/9781118674826.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Collins JW, Adding C, Hosseini A, Nyberg T, Pini G, Dey L, Wiklund PN. Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service. Scand J Urol 2015; 50:39-46. [PMID: 26313582 DOI: 10.3109/21681805.2015.1076514] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to assess the effect of introducing an enhanced recovery programme (ERP) to an established robot-assisted radical cystectomy (RARC) service. MATERIALS AND METHODS Data were prospectively collected on 221 consecutive patients undergoing totally intracorporeal RARC between December 2003 and May 2014. The ERP was specifically designed to support an evolving RARC service, where increasing proportions of patients requiring radical cystectomy underwent RARC. Patient demographics and outcomes before and after implementation of the ERP were compared. The primary endpoint was length of stay (LOS). Secondary outcomes included age, American Society of Anesthesiologists (ASA) score, preoperative staging, operative time, complications and readmissions. Differences in outcomes between patients before and after implementation of ERP were tested with the Jonckheere-Terpstra trend test and quantile regression with backward selection. RESULTS Following implementation of the ERP, the demographics of the patients (n = 135) changed, with median age increasing from 66 to 70 years (p < 0.01), higher ASA grade (p < 0.001), higher preoperative stage cancer (pT ≥ 2, p < 0.05) and increased likelihood of undergoing an ileal conduit diversion (p < 0.001). Median LOS before ERP was 9 days [interquartile range (IQR) 8-13 days] and after ERP was 8 days (IQR 6-10 days) (p < 0.001). ASA grade and neoadjuvant chemotherapy also affected LOS (p < 0.05 and p < 0.01, respectively). There was no significant difference in 30 day complication rates, readmission rates or 90 day mortality, with 59% experiencing complications before ERP implementation and 57% after implementation. The majority of complications were low grade. CONCLUSIONS Patient demographics changed as the RARC service evolved from selected patients to a general service. Despite worsening demographics, LOS decreased following ERP implementation. This evidence-based ERP safely standardized perioperative care, resulting in decreased LOS and decreased variability in LOS.
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Affiliation(s)
- Justin W Collins
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Christofer Adding
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Abolfazl Hosseini
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Tommy Nyberg
- b 2 Division of Clinical Cancer Epidemiology, Department of Oncology-Pathology, Karolinska Institutet , Stockholm, Sweden
| | - Giovannalberto Pini
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Linda Dey
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
| | - Peter N Wiklund
- a 1 Department of Urology, Karolinska University Hospital , Stockholm, Sweden
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Laparoscopic Radical Cystectomy Versus Extraperitoneal Radical Cystectomy: Is the Extraperitoneal Technique Rewarding? Clin Genitourin Cancer 2015; 13:e271-e277. [DOI: 10.1016/j.clgc.2015.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/06/2015] [Accepted: 01/16/2015] [Indexed: 11/19/2022]
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Jacobsohn K, Davis TD, El-Arabi AM, Tlachac J, Langenstroer P, O'Connor RC, Guralnick ML, See WA, Schlosser R. Initial experience with ketamine-based analgesia in patients undergoing robotic radical cystectomy and diversion. Can Urol Assoc J 2015. [PMID: 26225179 DOI: 10.5489/cuaj.2790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We instituted a ketamine-predominant analgesic regimen in the peri- and postoperative periods to limit the effects of narcotic analgesia on bowel function in patients undergoing radical cystectomy. The primary end points of interest were time to return of bowel function, time to discharge, and efficacy of the analgesic regimen. METHODS We performed a retrospective chart review of patients undergoing robotic-assisted laparoscopic cystectomy (RARC) with urinary diversion by a single surgeon at our institution from January 1, 2011 to June 30, 2012. Patients receiving the opioid-minimizing ketamine protocol were compared to a cohort of patients undergoing RARC with an opioid-predominant analgesic regimen. RESULTS In total, 15 patients (Group A) were included in the ketamine-predominant regimen and 25 patients (Group B) in the opioid-predominant control group. Three patients (19%) in Group A discontinued the protocol due to ketamine side effects. The mean time to bowel movement and length of stay in Group A versus Group B was 3 versus 6 days (p < 0.001), and 4 versus 8 days, respectively (p < 0.001). Group A patients received an average of 13.0 mg of morphine versus 97.5 mg in Group B (p < 0.001). CONCLUSIONS Patients who received our ketamine pain control regimen had a shorter time to return of bowel function and length of hospitalization after RARC. Our study has its limitations as a retrospective, single surgeon, single institution study and the non-randomization of patients. Notwithstanding these limitations, this study was not designed to show inferiority of one approach, but instead to show that our protocol is safe and efficacious, warranting further study in a prospective fashion.
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Affiliation(s)
| | - Tanya D Davis
- Children's National Medical Center, Washington, D.C.
| | - Ahmad M El-Arabi
- Department of Urology, Medical College of Wisconsin, Milwaukee, WI
| | - Jonathan Tlachac
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | | | - R Corey O'Connor
- Department of Urology, Medical College of Wisconsin, Milwaukee, WI
| | | | - William A See
- Department of Urology, Medical College of Wisconsin, Milwaukee, WI
| | - Robert Schlosser
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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Declercq P, De Win G, Van der Aa F, Beels E, Elodie B, Van der Linden L, Van Poppel H, Willems L, Ludo W, Spriet I, Isabel S. Reduced length of stay in radical cystectomy patients with oral versus parenteral post-operative nutrition protocol. Int J Clin Pharm 2015; 37:379-86. [PMID: 25666940 DOI: 10.1007/s11096-015-0072-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 01/27/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND In Europe, parenteral nutrition is often used after radical cystectomy to avoid postoperative malnourishment. To the best of our knowledge, however, there is a paucity of data to conclude on the best modality for delivering nutritional support to this patient group. OBJECTIVE The parenteral nutrition policy was reconsidered and an oral nutrition protocol was implemented by the clinical pharmacist and evaluated in terms of length of stay, number and type of postoperative complications and parenteral nutrition avoided costs. SETTING A prospective interventional non-randomized before-after study was conducted. Regular radical cystectomy patients presenting without preoperative contra-indications for enteral nutrition were eligible. METHODS Postoperatively, in the control group, the parenteral nutrition policy from the ward was applied. Parenteral nutrition was initiated systematically and continued until the patient was able to tolerate solid food. In the interventional group, an oral nutrition protocol was implemented. Parenteral nutrition could be initiated if oral intake remained insufficient after 5 days. Main outcome measure The primary end point was postoperative length of stay. Secondary endpoints included the number of patients in whom the oral nutrition protocol was implemented successfully, as well as the number and type of postoperative complications. RESULTS A total of 94 eligible patients was assigned consecutively to the control (n = 48) and to the interventional group (n = 46). Baseline demographics were comparable. A significant reduction in median length of stay was associated with the oral nutrition protocol [18 days (IQR 15-22) in the control group vs. 14 days (IQR 13-18) in the interventional group (p < 0.001)]. In 40 out of 46 patients from the interventional group, the oral nutrition protocol was implemented successfully. The number and type of postoperative complications did not differ significantly. Implementing the oral nutrition protocol resulted in a direct parenteral nutrition infusion bag cost saving of approximately €512 and a reduction in hospitalization cost of €2,608 per patient. CONCLUSION The findings of our study showed that an oral nutrition protocol, when compared to the systematic postoperative use of parenteral nutrition, was associated with a decreased length of stay and costs in a regular radical cystectomy patient population.
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Affiliation(s)
- Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium,
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Kramer MW, von Klot CA, Kabbani M, Kabbani AR, Tezval H, Peters I, Herrmann TRW, Kuczyk MA, Merseburger AS. Long-term bowel disorders following radial cystectomy: an underestimated issue? World J Urol 2015; 33:1373-80. [PMID: 25552205 DOI: 10.1007/s00345-014-1466-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 12/12/2014] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Patients after radical cystectomy (RC) frequently complain about bowel disorders (BDs). Reports addressing related long-term complications are sparse. This cross-sectional study assessed changes in bowel habits (BH) after RC. METHODS A total of 89 patients with a minimum follow-up ≥1 year after surgery were evaluated with a questionnaire. Patients with BD prior to surgery were excluded. Symptoms such as diarrhea, constipation, bloating/flatulence, incomplete defecation, uncontrolled stool loss, and impact on quality of life (QoL) were assessed. RESULTS A total of 46.1 % of patients reported changes in BH; however, only 25.8 % reported experiencing related dissatisfaction. Primary causes of dissatisfaction were diarrhea and uncontrolled stool loss. The most common complaints were bloating/flatulence and the feeling of incomplete defecation, but these symptoms did not necessarily lead to dissatisfaction or impairment in quality of life. No difference was identified between an orthotopic neobladder and ileal conduit, and even patients without bowel surgery were affected. QoL, health status, and energy level were significantly decreased in unsatisfied patients. CONCLUSIONS About 25 % of patients complain about BDs after RC. More prospective studies assessing symptoms, comorbidities, and dietary habits are necessary to address this issue and to identify strategies for follow-up recommendations.
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Affiliation(s)
- Mario W Kramer
- Department of Urology and Urologic-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christoph A von Klot
- Department of Urology and Urologic-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Mohammad Kabbani
- Department of Urology and Urologic-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Abdul-Rahman Kabbani
- Department of Urology and Urologic-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Hossein Tezval
- Department of Urology and Urologic-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Inga Peters
- Department of Urology and Urologic-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Thomas R W Herrmann
- Department of Urology and Urologic-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Markus A Kuczyk
- Department of Urology and Urologic-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Axel S Merseburger
- Department of Urology and Urologic-Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Senol Celik S, Tuna Z, Yildirim M. The experience of urostomists who do not have access to pre-operative and post-operative stoma care nursing intervention. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2014. [DOI: 10.1111/ijun.12068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Zahide Tuna
- Hacettepe University Faculty of Nursing; Ankara Turkey
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Patient Selection, Operative Technique, and Contemporary Outcomes of Continent Catheterizable Diversion: the Indiana Pouch. CURRENT BLADDER DYSFUNCTION REPORTS 2014. [DOI: 10.1007/s11884-014-0265-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Pai A, Nair R, Ayres B, Tsoi H, Sooriakumaran P, Issa R, Perry M. Comparative outcomes of open and robotic-assisted radical cystectomy in an enhanced recovery programme era. JOURNAL OF CLINICAL UROLOGY 2014. [DOI: 10.1177/2051415814553650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aim: The aim of this study was to determine the added value of robotic surgery for radical cystectomy in the context of an established enhanced recovery programme (ERP). Background: We have previously reported on ERP in open radical cystectomy (ORC) and shown that it is safe and not associated with an increase in complications or readmissions. Further, it is associated with reductions in ICU stay, length of hospital stay and duration of postoperative ileus. The recent introduction of robotic-assisted radical cystectomy (RARC), with its perceived benefit of minimal invasiveness, has led to the question of whether patients who have their radical cystectomy in the environment of ERP would experience an added benefit if the surgery were performed robotically. We implemented the ERP for all patients undergoing radical cystectomy in 2008. In 2010 we started to offer RARC as the first line treatment for all bladder cancer patients with an indication for bladder extirpation. In this study we compare the perioperative results of the last 50 RARC patients with the last 50 ORC. The same ERP protocol was implemented in all patients. Patients and methods: We used our prospectively kept electronic database to identify the last 50 ORC and 50 RARC patients (we excluded the first 10 RARC in our series to reduce learning curve effect). We compared preoperative (age, sex, comorbidity), intraoperative (diversion type, fluid loss, blood transfusion, conversion and number of lymph node dissections (LND)) and post-operative (length of stay LOS, nodal yield and pathological T stage) variables. We also reported on the 30 day complications according to Clavien–Dindo classification. Results: The two groups did not differ significantly in their preoperative variables, number of LND performed and pathological T and N stage. Patients in the RARC arm were more likely to have continent diversion and had significantly less intraoperative fluid loss. LOS and lymph nodal yield was no worse in the RARC cohort in comparison to the ORC patients. The RARC patients had significantly lower transfusion rates and overall 30-day complication rates. Conclusions: We have shown that robotic surgery offers an added value to patients undergoing radical cystectomy for bladder cancer in addition to the benefits gained from enrolling in an ERP. This is likely due to the minimally invasive nature of robotic surgery, and thus an attenuation of its physiological insult, which is the cornerstone of ERP theory.
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Affiliation(s)
- Aakash Pai
- Urology Department, St Georges NHS Trust, London, UK
| | - Rajesh Nair
- Urology Department, St Georges NHS Trust, London, UK
| | | | - Hermione Tsoi
- Urology Department, St Georges NHS Trust, London, UK
| | | | - Rami Issa
- Urology Department, St Georges NHS Trust, London, UK
| | - Matthew Perry
- Urology Department, St Georges NHS Trust, London, UK
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Re: Cheryl T. Lee, Sam S. Chang, Ashish M. Kamat, et al. Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Eur urol 2014;66:265-72. Eur Urol 2014; 67:e29. [PMID: 25288191 DOI: 10.1016/j.eururo.2014.09.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 09/26/2014] [Indexed: 11/24/2022]
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Tobis S, Heinlen JE, Ruel N, Lau C, Kawachi M, Wilson T, Chan K. Effect of Alvimopan on Return of Bowel Function After Robot-Assisted Radical Cystectomy. J Laparoendosc Adv Surg Tech A 2014; 24:693-7. [DOI: 10.1089/lap.2014.0170] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Scott Tobis
- City of Hope National Medical Center, Duarte, California
| | | | - Nora Ruel
- City of Hope National Medical Center, Duarte, California
| | - Clayton Lau
- City of Hope National Medical Center, Duarte, California
| | - Mark Kawachi
- City of Hope National Medical Center, Duarte, California
| | - Timothy Wilson
- City of Hope National Medical Center, Duarte, California
| | - Kevin Chan
- City of Hope National Medical Center, Duarte, California
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Identification of clinical outcome measures for recovery of gastrointestinal motility in postoperative ileus. Ann Surg 2014; 259:708-14. [PMID: 23657087 DOI: 10.1097/sla.0b013e318293ee55] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To identify clinical hallmarks associated with recovery of gastrointestinal transit. BACKGROUND Impaired gastrointestinal transit or postoperative ileus largely determines clinical recovery after abdominal surgery. However, validated clinical hallmarks of gastrointestinal recovery to evaluate new treatments and readiness for discharge from the hospital are lacking. METHODS Gastric emptying and colonic transit were scintigraphically assessed from postoperative day 1 to 3 in 84 patients requiring elective colonic surgery and were compared with clinical parameters. The clinical hallmark that best reflected recovery of gastrointestinal transit was validated using data from a multicenter trial of 320 segmental colectomy patients. RESULTS Seven of 84 patients developed a major complication with paralytic ileus characterized by total inhibition of gastrointestinal motility and were excluded from further analysis. In the remaining patients, recovery of colonic transit (defined as geometric center of radioactivity ≥2 on day 3), but not gastric emptying, was significantly correlated with clinical recovery (ρ = -0.59, P < 0.001). Conversely, the combined outcome measure of tolerance of solid food and having had defecation (SF + D) (area under the curve = 0.9, SE = 0.04, 95% CI = 0.79-0.95, P < 0.001), but not time to first flatus, best indicated recovery of gastrointestinal transit with a positive predictive value of 93% (95% CI = 78-99). Also in the main clinical trial, multiple regression analysis revealed that SF + D best predicted the duration of hospital stay. CONCLUSIONS Our data indicate that the time to SF + D best reflects recovery of gastrointestinal transit and therefore should be considered as primary outcome measure in future clinical trials on postoperative ileus.(Netherlands National Trial Register, number NTR1884 and NTR222).
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Autran Gomez AM, Clarke C, Smith D, Yutkin V, Alzahrani A, Izawa JI. Is postoperative epidural analgesia better than patient-controlled analgesia for radical cystectomy? JOURNAL OF CLINICAL UROLOGY 2014. [DOI: 10.1177/2051415813500954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | - Colin Clarke
- Department of Anesthesia, Western University, Canada
| | - David Smith
- Department of Anesthesia, Western University, Canada
| | | | | | - Jonathan I Izawa
- Departments of Surgery, Oncology and Pathology, Western University, Canada
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Deng S, Dong Q, Wang J, Zhang P. The role of mechanical bowel preparation before ileal urinary diversion: a systematic review and meta-analysis. Urol Int 2014; 92:339-48. [PMID: 24642687 DOI: 10.1159/000354326] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/11/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although the use of mechanical bowel preparation (MBP) is still widely promoted as the dogma before patients undergo ileal urinary diversion, an increasing number of clinical trials have suggested that there is no benefit. Thus, we performed a meta-analysis to evaluate the efficacy of MBP in ileal urinary diversion surgery. METHODS A literature search was performed in electronic databases, including PubMed, Embase, Science Citation Index Expanded as well as the Cochrane Library and the Cochrane Clinical Trials Registry, from 1966 to January 1, 2013. Clinical trials comparing outcomes of MBP versus no MBP for ileal urinary diversion surgery were included in the meta-analysis. Pooled odds ratios with 95% confidence intervals were calculated using the fixed- or random-effects models. RESULTS In total, two randomized controlled trials and five cohort studies were included in this meta-analysis. The primary outcomes, such as bowel leak and bowel obstruction, showed no statistical difference between the two groups. Additionally, the overall mortality rate and death rate related to operation also manifested that MBP does not offer an advantage over the no MBP. CONCLUSION This meta-analysis suggests that MBP does not reduce the incidence of perioperative complications in urinary diversion compared with no MBP. However, large randomized controlled clinical trials are needed to confirm this finding.
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Affiliation(s)
- Shi Deng
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
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Lee CT, Chang SS, Kamat AM, Amiel G, Beard TL, Fergany A, Karnes RJ, Kurz A, Menon V, Sexton WJ, Slaton JW, Svatek RS, Wilson SS, Techner L, Bihrle R, Steinberg GD, Koch M. Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Eur Urol 2014; 66:265-72. [PMID: 24630419 DOI: 10.1016/j.eururo.2014.02.036] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 02/13/2014] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
| | - Sam S Chang
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ashish M Kamat
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gilad Amiel
- Baylor University, Baylor College of Medicine, Houston, TX, USA
| | | | - Amr Fergany
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Andrea Kurz
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Venu Menon
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Wade J Sexton
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Joel W Slaton
- The University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Robert S Svatek
- The University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | | | - Lee Techner
- Cubist Pharmaceuticals, Inc., Lexington, MA, USA
| | - Richard Bihrle
- Indiana University Medical Center, Indianapolis, IN, USA
| | | | - Michael Koch
- Indiana University Medical Center, Indianapolis, IN, USA
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