Extended Case Duration and Hypotension Are Associated With Higher-grade Postoperative Complications After Urinary Diversion for Non-oncological Disease

Urinary Diversion With or Without Concomitant Cystectomy for Benign Conditions: A Comparative Morbidity Assessment According to the Updated European Association of Urology Guidelines on Reporting and Grading of Complications

BACKGROUND

Evidence is scarce on morbidity after urinary diversion ± cystectomy as treatment for benign bladder indications.

OBJECTIVE

To conduct a morbidity assessment and to evaluate the impact of concomitant subtrigonal cystectomy (SC) versus urinary diversion (UD) alone.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective study of 97 patients with benign bladder conditions between 2009 and 2017.

INTERVENTION

Open UD and/or concomitant SC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Data for 30-d complications were extracted using a procedure-specific catalog and were graded according to the Clavien-Dindo classification (CDC), and Comprehensive Complication Index (CCI) values were calculated. Traditional morbidity endpoints focused on the comparative morbidity of UD + SC versus UD alone. Multivariable regressions were computed to evaluate the impact of SC versus UD alone on cumulative morbidity. Subgroup analyses were repeated for patients with previous irradiation.

RESULTS AND LIMITATIONS

Of 97 patients, 46 (47%) underwent UD + SC and 51 (53%) underwent UD alone. Forty-nine patients (51%) had a history of abdominopelvic radiotherapy. Overall, 69 (71%) patients underwent continent UD and 26 (27%) underwent a Mitrofanoff procedure. We registered 390 complications in 97 (100%) patients, the majority of which were classified as minor (CDC grade ≤IIIa; 93%). Overall, three patients (3.1%) were readmitted and no patient died within 30 d. On multivariable analyses, neither concomitant SC nor previous radiotherapy was associated with higher cumulative morbidity (all p = 0.2). Similarly, concomitant SC was not predictive of a higher complication burden in the irradiation subgroup (all p ≥ 0.05). Limitations include heterogeneity for indications and a lack of information on the radiation dose and field.

CONCLUSIONS

In a high-volume referral center, neither SC nor abdominopelvic radiotherapy increased perioperative cumulative morbidity for patients with benign bladder conditions undergoing UD. This is particularly relevant for patients who would benefit from concomitant SC to avert adverse sequelae related to the retained bladder.

PATIENT SUMMARY

Urinary diversion (UD) is a surgical procedure to create a new way for urine to exit the body. We found that among patients undergoing UD for benign bladder conditions, those who also have their bladder removed and patients who have received previous radiotherapy do not experience more complications.

Urinary diversions for benign and oncologic indications: what did we learn about short term complications in the last 24 months?

PURPOSE OF THE REVIEW

Urinary diversion (UD) with or without cystectomy is a procedure with high short term complication rates. In this review, we summarize the most relevant findings of the last 2 years.

RECENT FINDINGS

The use of a prophylactic mesh decreases the risk of parastomal hernia after ileal conduit (IC) surgery without adding mesh-related complications according to a recent randomized multicentre trial. Robot-assisted surgery is increasingly applied for UD and is evolving from extra- to intra-corporeal reconstruction in both continent and incontinent diversions, but there is still a need for appropriately designed studies assessing both short- and long-term complications. Promising techniques to decrease ureterointestinal stricture rates have been reported from small series, such as retrosigmoid placement of the proximal IC to avoid transpositioning of the left ureter, or in robot-assisted surgery the use of indocyanine green with near-infrared light to improve visualisation of distal ureteral viability.

SUMMARY

Most recent reports derive from observational data. Appropriate randomized studies are warranted for the evaluation of new techniques to be implemented in a surgical area that still is associated with high complication rates.

Association of intraoperative hypotension with postoperative morbidity and mortality: systematic review and meta-analysis

Background

Intraoperative hypotension, with varying definitions in literature, may be associated with postoperative complications. The aim of this meta-analysis was to assess the association of intraoperative hypotension with postoperative morbidity and mortality.

Methods

MEDLINE, Embase and Cochrane databases were searched for studies published between January 1990 and August 2018. The primary endpoints were postoperative overall morbidity and mortality. Secondary endpoints were postoperative cardiac outcomes, acute kidney injury, stroke, delirium, surgical outcomes and combined outcomes. Subgroup analyses, sensitivity analyses and a meta-regression were performed to test the robustness of the results and to explore heterogeneity.

Results

The search identified 2931 studies, of which 29 were included in the meta-analysis, consisting of 130 862 patients. Intraoperative hypotension was associated with an increased risk of morbidity (odds ratio (OR) 2.08, 95 per cent confidence interval 1.56 to 2.77) and mortality (OR 1.94, 1.32 to 2.84). In the secondary analyses, intraoperative hypotension was associated with cardiac complications (OR 2.44, 1.52 to 3.93) and acute kidney injury (OR 2.69, 1.31 to 5.55). Overall heterogeneity was high, with an I² value of 88 per cent. When hypotension severity, outcome severity and study population variables were added to the meta-regression, heterogeneity was reduced to 50 per cent.

Conclusion

Intraoperative hypotension during non-cardiac surgery is associated with postoperative cardiac and renal morbidity, and mortality. A universally accepted standard definition of hypotension would facilitate further research into this topic.

Long-term outcome of spiral ileal neobladder with orthotopic ureteral reimplantation

PURPOSE

The purpose of this study was to analyze long-term complications, urodynamics, and quality of life (QoL) of patients after orthotopic ileal neobladder with orthotopic ureteral reimplantation to enrich clinical data and provide a basis for clinical use of this surgery.

METHODS

Between January 2007 and January 2013, 72 consecutive patients who underwent spiral ileal neobladder following radical cystectomy were enrolled. The neobladder was created using a modified Camey-II technique. Complications were reviewed and staged according to Clavien-Dindo classification and evaluated in long-term follow-up. Urodynamics were performed, and QoL was assessed by the Functional Assessment of Cancer Therapy for Bladder Cancer (FACT-BL) instrument.

RESULTS

The total follow-up time was 60 months, and the total survival rates at 3 and 5 years after surgery were 76.4% (55/72) and 65.3% (47/72), respectively. There were 34 (47.2%) early complications in 23 (31.9%) patients and 42 (58.3%) late complications in 35 (48.6%) patients. The total satisfactory control rates were 69.1% and 66.0% at 3 and 5 years after the surgery, respectively. Urodynamic studies were performed in some patients, and the receiver operating characteristic curve analysis showed that pressure at maximum capacity, compliance, and post void residual urine had predictive value for mortality (P < 0.05). The total FACT-BL scores of patients at 1, 3, and 5 years postoperation were 125.0 ± 15.2, 127.0 ± 16.2, and 120.6 ± 13.5, respectively, and it decreased at 5 years postoperation (P < 0.05).

CONCLUSION

Spiral ileal neobladder with orthotopic ureteral reimplantation offers satisfactory long-term results, and urodynamic monitoring might have prognostic value.

Neurogenic bowel management for the adult spinal cord injury patient

BACKGROUND

Bowel function can be markedly changed after a spinal cord injury (SCI). These changes, and the care associated with managing the changes, can greatly impact a person's quality of life over a lifetime.

PURPOSE

The purpose of the SIU-ICUD workgroup was to identify, assess, and summarize evidence and expert opinion-based themes and recommendations regarding bowel function and management in SCI populations.

METHODS

As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury, a workgroup was formed and comprehensive literature search of English language manuscripts regarding bowel physiology and management plans for the SCI patient. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).

RESULTS

Neurogenic bowel symptoms are highly prevalent in the SCI population. Patients with injuries above the conus medullaris have increased bowel motility and poor anorectal sphincter relaxation. Patients with injuries below the conus are more likely to have an areflexic colon and low sphincter tone. Conservative management strategies include diet modification and anorectal stimulation. There are few evidence-based pharmacologic interventions, which improve fecal transit time. Intestinal ostomy can be an effective treatment for reducing hours spent per week on bowel management and colostomy may be easier to manage than ileostomy due to solid vs liquid stool.

CONCLUSIONS

By understanding physiology and treatment options, patients and care teams can work together to achieve goals and maximize quality of life after injury.