In-hospital death and hospital-acquired complications among patients undergoing partial cystectomy for bladder cancer in the United States

Bladder preservation or complete cystectomy during pelvic exenteration of patients with locally advanced or recurrent rectal cancer, what should we do?

INTRODUCTION

In patients with locally advanced (LARC) or locally recurrent (LRRC) rectal cancer and bladder involvement, pelvic exenteration (PE) with partial (PC) or radical (RC) cystectomy can potentially offer a cure. The study aim was to compare PC and RC in PE patients in terms of oncological outcome, post-operative complications and quality-of-life (QoL).

MATERIALS & METHODS

This was a retrospective cohort analysis of a prospectively maintained surgical database. Patients who underwent PE for LARC or LRRC cancer with bladder involvement between 1998 and 2021 were included. Post-operative complications and overall survival were compared between patients with PC and RC.

RESULTS

60 PC patients and 269 RC patients were included. Overall R0 resection was 84.3%. Patients with LRRC and PC had poorest oncological outcome with 69% R0 resection; patients with LARC and PC demonstrated highest R0 rate of 96.3% (P = 0.008). Overall, 1-, 3- and 5-year OS was 90.8%, 68.1% and 58.6% after PC, and 88.7%, 62.2% and 49.5% after RC. Rates of urinary sepsis or urological leaks did not differ between groups, however, RC patients experienced significantly higher rates of perineal wound- and flap-related complications (39.8% vs 25.0%, P = 0.032).

CONCLUSION

PC as part of PE can be performed safely with good oncological outcome in patients with LARC. In patients with LRRC, PC results in poor oncological outcome and a more aggressive surgical approach with RC seems justified. The main benefit of PC is a reduction in wound related complications compared to RC, although more urological re-interventions are observed in this group.

Benchmarking hospital safety and identifying determinants of hospital-acquired complication: the case of Queensland cardiac linkage longitudinal cohort

BACKGROUND

Hospital-acquired complications (HACs) are costly and associated with adverse health outcomes, although they can be avoided. Administrative linkage health data have become more accessible and can be used to monitor and reduce HAC.

AIMS

This study aims to use linkage administrative data to benchmark the safety performance of hospitals and estimate the feasible magnitude that HAC can be reduced. We also identify risk factors associated with HACs, and estimate the effects of HACs on adverse health outcomes and hospital costs.

METHODS

This is a retrospective linkage cohort study. The cohort includes 371,040 inpatient multiple-day admissions of 83,025 cardiovascular disease patients admitted to public hospitals in 2010 with follow-ups until 2015.Data envelopment analysis was applied to benchmark the patient safety performance of hospitals. Logistic regression was used to examine the odds of HAC and its effects on in-hospital mortality and 30-day readmission. Generalised linear models were used to identify the impacts of HACs on hospital costs and the length of hospital stay.

FINDINGS

On average, 9.3% of multiple-day hospital admissions were associated with HACs. The average HAC rate can be reduced by two percentage points if all hospitals achieve the safety record of best-practice hospitals. Old age and multiple comorbidities were major driving factors of HACs.

CONCLUSIONS

Cardiovascular disease patients with HAC have a higher risk of death, stay longer in hospitals and incur higher health care costs. The average HAC rates can be reduced by two percentage points by learning from best-practice hospitals operating in the same region.

Bladder preservation in urothelial carcinoma: current trends and future directions

PURPOSE OF REVIEW

To provide a contemporary rationale for bladder preservation as a treatment strategy for muscle-invasive urothelial carcinoma of the bladder. Although the standard of care for this important and serious clinical condition has been radical cystectomy augmented with neoadjuvant systemic chemotherapy, it is associated with substantial morbidity and quality of life (QoL) implications. This article explores the bladder sparing alternatives to radical cystectomy and urinary diversion to assist Urologists, Medical Oncologists, and Palliative Care providers in their informed decision making with patients.

RECENT FINDINGS

Bladder sparing strategies such as partial cystectomy and trimodality therapy offer long-term cancer outcomes comparable to radical cystectomy in carefully selected patients. Moreover, the toxicity profile in patients, having improved over time, is acceptable, including a low risk of salvage cystectomy.

SUMMARY

Bladder preservation therapy offers an alternative to radical cystectomy. In some patients, it can be done with curative intent and in others it can assist with symptom palliation. Bladder preservation can maintain QoL and provide similar oncologic outcomes to radical surgery, although randomized controlled trials have not been performed. Understanding patient selection is a critical step in balancing bladder preservation and cancer survival.

Oncological outcomes, quality of life outcomes and complications of partial cystectomy for selected cases of muscle-invasive bladder cancer

To evaluate the oncological results, associated complications, and postoperative health-related quality of life (HR-QoL) in patients treated with partial cystectomy (PC) for muscle-invasive bladder cancer (MIBC). 27 patients who underwent open PC for cT2 MIBC were included. A simple Cox's proportional hazards regression model was used to assess the association of several potential prognostic factors with survival. Postoperative HR-QoL was assessed with the EORTC (European Organisation for the Research and Treatment of Cancer) QLQ-C30 questionnaire version 3.0. Final pathological tumour stages in PC specimen were: pT0: 18.5%, non-MIBC: 3.7%, MIBC: 74.1%, pCIS: 14.8%. Estimated 5-year overall- and progression-free survival rates were 53.7% and 62.1%. Five (18.5%) patients experienced local recurrence with MIBC. Overall, the salvage cystectomy rate was 18.5%. The 90-day mortality rate was 0%. Significant risk factors for progression-free survival were vascular invasion (HR 5.33) and tumour multilocularity (HR 4.5) in the PC specimen, and a ureteric reimplantation during PC (HR 4.53). The rates of intraoperative complications, 30- and 90-day major complications were 7.4%, respectively and 14.8% for overall long-term complications. Postoperatively, median (IQR) global health status and QoL in our PC cohort was 79.2 (52.1-97.9). Open PC can provide adequate cancer control of MIBC with good HR-QoL in highly selected cases. Open PC can lead to long-term bladder preservation and shows an acceptable rate of severe perioperative complications, even in highly comorbid patients.

Radical cystectomy for recurrent urothelial carcinoma after prior partial cystectomy: perioperative and oncologic outcomes

PURPOSE

To evaluate perioperative and oncologic outcomes of patients undergoing radical cystectomy (RC) for recurrence of urothelial carcinoma (UC) after prior partial cystectomy (PC), and to compare these outcomes to patients undergoing primary RC.

METHODS

Patients who underwent RC for recurrence of UC after prior PC were matched 1:3 to patients undergoing primary RC based on age, pathologic stage, and decade of surgery. Perioperative and oncologic outcomes were compared using Wilcoxon sign-rank test, McNemars test, the Kaplan-Meier method, and Cox proportional hazards regression analyses.

RESULTS

Overall, the cohorts were well matched on clinical and pathological characteristics. No difference was noted in operative time (median 322 versus 303 min; p = 0.41), estimated blood loss (median 800 versus 700 cc, p = 0.10) or length of stay (median 9 versus 10 days; p = 0.09). Similarly, there were no differences in minor (51.7 versus 44.3%; p = 0.32) or major (10.3 versus 12.6%; p = 0.66) perioperative complications. Median follow-up after RC was 5.0 years (IQR 1.5, 13.1 years). Notably, CSS was significantly worse for patients who underwent RC after PC (10 year-46.8 versus 65.9%; p = 0.03). On multivariable analysis, prior PC remained independently associated with an increased risk of bladder cancer death (HR 2.28; 95% CI 1.17, 4.42).

CONCLUSIONS

RC after PC is feasible, without significantly adverse perioperative outcomes compared to patients undergoing primary RC. However, the risk of death from bladder cancer may be higher, suggesting the need for careful patient counseling prior to PC and the consideration of such patients for adjuvant therapy after RC.

Perioperative outcomes of robot-assisted laparoscopic partial cystectomy

Reports of surgical outcomes after robotic partial cystectomy are limited. The objective of this study is to review surgical outcomes after robotic partial cystectomy at a large tertiary referral center and compare outcomes with patients undergoing open partial cystectomy. Patients undergoing robotic partial cystectomy between 2003 and 2014 were identified. Patients were matched 2:1 based on gender, age, and Charlson Comorbidity Score with patients undergoing open partial cystectomy during the same time period. Patient charts were reviewed for surgical outcomes. Conditional logistic regression adjusted for matching was used to compare outcomes. At our institution, 11 patients underwent robotic partial cystectomy between 2003 and 2014. Median operative time was significantly longer in the robotic group, 214 (IQR 93, 230) minutes, than the open group, 93 (IQR 58, 143) minutes (p = 0.01). There was no difference in median estimated blood loss (p = 0.1). No patient required transfusion. There were no intraoperative complications. Median hospital stay was significantly shorter in the robotic partial cystectomy group, 1 (IQR 1, 2) day, than the open partial cystectomy group, 2 (IQR 2, 4) days (p = 0.01). Median duration of catheterization and complications within 30 days of surgery were not statistically different between the two groups. Median follow-up was 15.5 (IQR 8.6, 19.7) months for the robotic partial cystectomy group and 40.7 (IQR 6.5, 69.4) months for the open partial cystectomy group. Robotic partial cystectomy is safe, effective, and is associated with minimal morbidity when performed in properly selected patients for benign and malignant indications. When compared with open partial cystectomy, robotic partial cystectomy is associated with a longer operative time, but results in a shorter postoperative hospital stay.