Ileus and small bowel obstruction after radical cystectomy for bladder cancer: Analysis from the Nationwide Inpatient Sample

Nomogram for predicting postoperative ileus after radical cystectomy and urinary diversion: a retrospective single-center study

OBJECTIVE

To predict the incidence of postoperative ileus in bladder cancer patients after radical cystectomy.

METHODS

We retrospectively analyzed the perioperative data of 452 bladder cancer patients who underwent radical cystectomy with urinary diversion at the Second Hospital of Tianjin Medical University between 2016 and 2021. Univariate and multivariate logistic regression were used to identify the risk factors for postoperative ileus. Finally, a nomogram model was established and verified based on the independent risk factors.

RESULTS

Our study revealed that 96 patients (21.2%) developed postoperative ileus. Using multivariate logistic regression analysis, we found that the independent risk factors for postoperative ileus after radical cystectomy included age > 65.0 years, high or low body mass index, constipation, hypoalbuminemia, and operative time. We established a nomogram prediction model based on these independent risk factors. Validation by calibration curves, concordance index, and decision curve analysis showed a strong correlation between predicted and actual probabilities of occurrence.

CONCLUSION

Our nomogram prediction model provides surgeons with a simple tool to predict the incidence of postoperative ileus in bladder cancer patients undergoing radical cystectomy.

Global cost of postoperative ileus following abdominal surgery: meta-analysis

BACKGROUND

Following abdominal surgery, postoperative ileus is a common complication significantly increasing patient morbidity and cost of hospital admission. This is the first systematic review aimed at determining the average global hospital cost per patient associated with postoperative ileus.

METHODS

A systematic search of electronic databases was performed from January 2000 to March 2023. Studies included compared patients undergoing abdominal surgery who developed postoperative ileus to those who did not, focusing on costing data. The primary outcome was the total cost of inpatient stay. Risk of bias was assessed using the Newcastle-Ottawa assessment tool. Summary meta-analysis was performed.

RESULTS

Of the 2071 studies identified, 88 papers were assessed for full eligibility. The systematic review included nine studies (2005-2022), investigating 1 860 889 patients undergoing general, colorectal, gynaecological and urological surgery. These studies showed significant variations in the definition of postoperative ileus. Six studies were eligible for meta-analysis showing an increase of €8233 (95 per cent c.i. (5176 to 11 290), P < 0.0001, I2 = 95.5 per cent) per patient with postoperative ileus resulting in a 66.3 per cent increase in total hospital costs (95 per cent c.i. (34.8 to 97.9), P < 0.0001, I2 = 98.4 per cent). However, there was significant bias between studies. Five colorectal-surgery-specific studies showed an increase of €7242 (95 per cent c.i. (4502 to 9983), P < 0.0001, I2 = 86.0 per cent) per patient with postoperative ileus resulting in a 57.3 per cent increase in total hospital costs (95 per cent c.i. (36.3 to 78.3), P < 0.0001, I2 = 85.7 per cent).

CONCLUSION

The global financial burden of postoperative ileus following abdominal surgery is significant. While further multicentre data using a uniform postoperative ileus definition would be useful, reducing the incidence and impact of postoperative ileus are a priority to mitigate healthcare-related costs, and improve patient outcomes.

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

Background

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

Results

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

Conclusion

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

Risk factors of postoperative ileus following laparoscopic radical cystectomy and developing a points-based risk assessment scale

Background

Postoperative ileus (POI) is one of the most common complications after laparoscopic radical cystectomy (LRC). Albeit its high incidence, its risk factors are obscure, and few studies have attempted to explore them. Meanwhile, risk-assessing tools for predicting its happening are lacking.

Methods

Clinical data of 197 patients who underwent LRC between March 2014 and October 2019 were retrospectively collected. All cases of POI were identified and double-checked. Data pertaining to the following categories were extracted as well: patients' general characteristics, preoperative laboratory tests results and preparations, intraoperative and postoperative general items, pathological results. The correlation between candidate risk factors and ileus was analyzed by multivariable binary logistic regression. Clinical and pathophysiological explanations for those results were explored. Finally, a points-based prediction model was developed and validated for predicting the happening of POI.

Results

A total of 63 out of 197 patients (31.98%) suffered from POI. Multivariate logistic regression analysis showed chronic constipation, increased dosage of laxative, elevated preoperative serum creatinine level, delayed postoperative ambulation, intestine-related urine derivations were statistically significant for developing POI (P<0.05). No significant differences were found between POI and age, gender, body mass index (BMI), antibiotics, hypertension, diabetes, smoking, hard-drinking, preoperative hemoglobin level, preoperative albumin level, history of previous abdominal surgery, surgery time, intraoperative blood loss, blood transfusion, tumor size, lymph nodes yields, TNM staging and intensive care unit hospitalization. An external cohort had been used for testing the validation of the assessment scale, and the results were promising.

Conclusions

Early recognition is of great importance in protecting vulnerable patients from developing POI, knowing the above-mentioned risk factors and using the assessment scale should help to screen them better. Cases from diverse backgrounds might contribute to a more accurate and complete scale.

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

OBJECTIVE

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

DESIGN

Systematic review.

METHODS

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

RESULTS

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

CONCLUSION

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

PROSPERO REGISTRATION NUMBER

104937.