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Sowanthip D, Zennami K, Bejrananda T, Nukaya T, Takenaka M, Ichino M, Takahara K, Sasaki H, Kusaka M, Sumitomo M, Shiroki R. Older versus younger patients in robot-assisted radical cystectomy with intracorporeal ileal conduit comparing safety and clinical outcomes. Int J Urol 2024; 31:370-378. [PMID: 38180102 DOI: 10.1111/iju.15377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE To evaluate the safety and efficacy of robot-assisted radical cystectomy using an intracorporeal ileal conduit in older compared to younger patients. METHODS We retrospectively analyzed 122 patients who underwent robot-assisted radical cystectomy with an intracorporeal ileal conduit at Fujita Health University Hospital and Fujita Health University Okazaki Medical Center between 2012 and 2022. Patients were categorized into two groups: older (age ≥ 75 years; n = 53) and younger (age < 75 years; n = 69). Perioperative outcomes, complications, recurrence-free survival, cancer-specific survival, and overall survival were compared between the cohorts. RESULTS The groups had no significant differences in perioperative outcomes, such as estimated blood loss, operative time, and blood transfusion rate. However, hospital stay was longer in the older patients than in the younger group (19 vs. 16 days; p < 0.001). The 30-day minor and major complication rates were 33.3% and 13.0%, respectively, for the younger group and 50.9% and 9.4% for the older group (p = 0.11). Urinary tract infection and bowel ileus were the most common complications in both groups. No significant differences were observed in recurrence-free survival, cancer-specific survival, and overall survival between the groups (p = 0.58, p = 0.75, and p = 0.78), and subgroup analysis in ≥cT3 revealed the older group tended to have poorer cancer-specific survival and overall survival (p = 0.07 and p = 0.01). Multivariate analysis indicated that older age was not associated with high-grade complications and cancer-specific survival. CONCLUSIONS Robot-assisted radical cystectomy with an intracorporeal ileal conduit is a safe and effective treatment option for older patients.
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Affiliation(s)
- Dutsadee Sowanthip
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
- Division of Urology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, The Thai Red Cross Society, Bangkok, Thailand
| | - Kenji Zennami
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tanan Bejrananda
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
- Division of Urology, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Takuhisa Nukaya
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masashi Takenaka
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Manabu Ichino
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kiyoshi Takahara
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hitomi Sasaki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Mamoru Kusaka
- Department of Urology, Fujita Health University Okazaki Medical Center, Okazaki, Japan
| | - Makoto Sumitomo
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Ryoichi Shiroki
- Department of Urology, Fujita Health University School of Medicine, Toyoake, Japan
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Pan DL, Zhang LF, Li XJ, Zhang KP, Gao PF, Yang B, Li NC. Feasibility and safety of laparoscopic radical cystectomy for male octogenarians with muscle-invasive bladder cancer. BMC Cancer 2024; 24:159. [PMID: 38297199 PMCID: PMC10829394 DOI: 10.1186/s12885-024-11816-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/01/2024] [Indexed: 02/02/2024] Open
Abstract
This study was designed to evaluate the safety and feasibility of laparoscopic radical cystectomy (LRC) for male octogenarian patients with muscle-invasive bladder cancer (MIBC). Briefly, a total of 57 male octogenarian patients (A group) with bladder carcinoma were enrolled and underwent LRC and intracorporeal pelvic lymph node dissection with bilateral cutaneous ureterostomy from May 2016 to December 2022. Besides, 63 male patients (age < 80 years old) with bladder carcinoma undergoing LRC and 17 octogenarian male patients with bladder carcinoma undergoing open radical cystectomy (ORC) were enrolled in B and C groups as control. All perioperative clinical materials and outcomes of long-term follow-up, and complication were collected. The specific results were shown as follows. Compared with C group, the operation time and resected lymph node in A group was increased, and the estimated blood loss, the number of transfusion needed, duration of pelvic drainage and hospital stay after surgery was decreased. The death rate and ileus complication rate were higher in A group (12 cases) than in C group (15 cases). The cases of ureteral stricture in A group (13 cases) was decreased compared with that in C group. Overall, LRC and bilateral cutaneous ureterostomy are safe, feasible and better choices for the treatment of male octogenarian patients with MIBC. The octogenarian receiving cutaneous ureterostomy heals slowly and exists certain incomplete intestinal obstruction after surgery.
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Affiliation(s)
- Dong-Liang Pan
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Lu-Fang Zhang
- Department of Urology, Weifang People's Hospital, Weifang, Shandong, 261041, China.
| | - Xiao-Jian Li
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Ke-Ping Zhang
- Department of Urology, Weifang People's Hospital, Weifang, Shandong, 261041, China
| | - Peng-Fei Gao
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Bing Yang
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Ning-Chen Li
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
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Alfred Witjes J, Max Bruins H, Carrión A, Cathomas R, Compérat E, Efstathiou JA, Fietkau R, Gakis G, Lorch A, Martini A, Mertens LS, Meijer RP, Milowsky MI, Neuzillet Y, Panebianco V, Redlef J, Rink M, Rouanne M, Thalmann GN, Sæbjørnsen S, Veskimäe E, van der Heijden AG. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2023 Guidelines. Eur Urol 2024; 85:17-31. [PMID: 37858453 DOI: 10.1016/j.eururo.2023.08.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/18/2023] [Indexed: 10/21/2023]
Abstract
CONTEXT We present an overview of the updated 2023 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC). OBJECTIVE To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the MMIBC guidelines has been performed annually since 2017. Searches cover the Medline, EMBASE, and Cochrane Libraries databases for yearly guideline updates. A level of evidence and strength of recommendation are assigned. The evidence cutoff date for the 2023 MIBC guidelines was May 4, 2022. EVIDENCE SYNTHESIS Patients should be counselled regarding risk factors for bladder cancer. Pathologists should describe tumour and lymph nodes in detail, including the presence of histological subtypes. The importance of the presence or absence of urothelial carcinoma (UC) in the prostatic urethra is emphasised. Magnetic resonance imaging (MRI) of the bladder is superior to computed tomography (CT) for disease staging, specifically in differentiating T1 from T2 disease, and may lead to a change in treatment approach in patients at high risk of an invasive tumour. Imaging of the upper urinary tract, lymph nodes, and distant metastasis is performed with CT or MRI; the additional value of flurodeoxyglucose positron emission tomography/CT still needs to be determined. Frail and comorbid patients should be evaluated by a multidisciplinary team. Postoperative histology remains the most important prognostic variable, while circulating tumour DNA appears to be an interesting predictive marker. Neoadjuvant systemic therapy remains cisplatin-based. In motivated and selected women and men, sexual organ-preserving cystectomy results in better functional outcomes without compromising oncological outcomes. Robotic and open cystectomy have comparable outcomes and should be combined with (extended) lymph node dissection. The diversion type is an individual choice after taking patient and tumour characteristics into account. Radical cystectomy remains a highly complex procedure with considerable morbidity and risk of mortality, although lower rates are observed for higher hospital volumes (>20 cases/yr). With proper patient selection, trimodal therapy (chemoradiation) has comparable outcomes to radical cystectomy. Adjuvant chemotherapy after surgery improves disease-specific survival and overall survival (OS) in patients with high-risk disease who did not receive neoadjuvant treatment, and is strongly recommended. There is a weak recommendation for adjuvant nivolumab, as OS data are not yet available. Health-related quality of life should be assessed using validated questionnaires at baseline and after treatment. Surveillance is needed to monitor for recurrent cancer and functional outcomes. Recurrences detected on follow-up seem to have better prognosis than symptomatic recurrences. CONCLUSIONS This summary of the 2023 EAU guidelines provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology guidelines panel on muscle-invasive and metastatic bladder cancer has released an updated version of the guideline containing information on diagnosis and treatment of this disease. Recommendations are based on studies published up to May 4, 2022. Surgical removal of the bladder and bladder preservation are discussed, as well as updates on the use of chemotherapy and immunotherapy in localised and metastatic disease.
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Affiliation(s)
- J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - Harman Max Bruins
- Department of Urology, Zuyderland Medisch Centrum, Sittard/Heerlen, The Netherlands
| | - Albert Carrión
- Department of Urology, Vall Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Richard Cathomas
- Department of Medical Oncology, Kantonsspital Graubünden, Chur, Switzerland
| | - Eva Compérat
- Department of Pathology, Medical University Vienna General Hospital, Vienna, Austria
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Rainer Fietkau
- Department of Radiation Therapy, University of Erlangen, Erlangen, Germany
| | - Georgios Gakis
- Department of Urology and Pediatric Urology, University of Würzburg, Würzburg, Germany
| | - Anja Lorch
- Department of Medical Oncology and Hematology, University Hospital Zürich, Zürich, Switzerland
| | - Alberto Martini
- Department of Urology, Institut Universitaire du Cancer-Toulouse-Oncopole, Toulouse, France; Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Laura S Mertens
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Richard P Meijer
- Department of Oncological Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthew I Milowsky
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Yann Neuzillet
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - Valeria Panebianco
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | - John Redlef
- Patient Representative, European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Michael Rink
- Department of Urology, Marienkrankenhaus Hamburg, Hamburg, Germany
| | - Mathieu Rouanne
- Department of Urology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines, Suresnes, France
| | - George N Thalmann
- Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Sæbjørn Sæbjørnsen
- Patient Representative, European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Erik Veskimäe
- Department of Urology, Tampere University Hospital, Tampere, Finland
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Sucandy I, Marques HP, Lippert T, Magistri P, Coelho JS, Ross SB, Chumbinho B, Di Sandro S, DiBenedetto F. Clinical Outcomes of Robotic Resection for Perihilar Cholangiocarcinoma: A First, Multicenter, Trans-Atlantic, Expert-Center, Collaborative Study. Ann Surg Oncol 2024; 31:81-89. [PMID: 37718337 DOI: 10.1245/s10434-023-14307-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/01/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Perihilar cholangiocarcinoma is a difficult cancer to treat with frequent vascular invasion, local recurrence, and poor survival. Due to the need for biliary anastomosis and potential vascular resection, the standard approach is an open operation. Suboptimal outcomes after laparoscopic resection had been sporadically reported by high-volume centers. In this first, Trans-Atlantic, multicenter study, we report our outcomes of robotic resection for perihilar cholangiocarcinoma. This is the largest study of its kind in the Western hemisphere. METHODS Between 2016 and 2023, we prospectively followed patients undergoing robotic resection for perihilar cholangiocarcinoma at three, high-volume, robotic, liver-surgery centers. RESULTS Thirty-eight patients underwent perihilar cholangiocarcinoma utilizing the robotic technique; Klatskin type-3 was the most common. The median age was 72 years, and 82% of the patients underwent preoperative biliary drainage. Median operative time was 481 minutes with a median estimated blood loss of 200 mL. The number of harvested lymph nodes was seven, and 11 (28%) patients yielded positive lymph nodes. Three patients required vascular reconstruction; 18% of patients had >1 biliary anastomosis. R0 resection margins were achieved in 82% of patients. Clavien-Dindo Grade ≥3 complications were seen in 16% of patients. The length of stay was 6 days. Five patients had an unplanned readmission within 30 days. One patient died within 30 days. With a median follow-up of 15 months, 68% of patients are alive without disease, 13% recurred, and 19% died. CONCLUSIONS Application of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with acceptable short-term clinical and oncological outcomes.
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Affiliation(s)
| | - Hugo P Marques
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Trenton Lippert
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Joao Santos Coelho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | | | - Beatriz Chumbinho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio DiBenedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
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Dell'Oglio P, Tappero S, Panunzio A, Antonelli A, Salvador D, Xylinas E, Alvarez-Maestro M, Hurle R, Salas RS, Colomer A, Simone G, Hendricksen K, Peroni A, Lonati C, Olivero A, Rouprêt M, Roumiguié M, Soria F, Umari P, D'Andrea D, Terrone C, Galfano A, Moschini M, Trapani ED. Age represents the main driver of surgical decision making in patients candidate to radical cystectomy. J Surg Oncol 2023. [PMID: 37126407 DOI: 10.1002/jso.27255] [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: 12/20/2022] [Revised: 02/10/2023] [Accepted: 03/13/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Age might influence the choice of surgical approach, type of urinary diversion (UD) and lymph node dissection (LND) in patients candidate to radical cystectomy (RC) for urothelial bladder cancer (UBC). Similarly, age may enhance surgical morbidity and worsen perioperative outcomes. We tested the impact of age (octogenarian vs. younger patients) on surgical decision making and peri- and postoperative outcomes of RC. METHODS Non-metastatic muscle-invasive UBC patients treated with RC at 18 high-volume European institutions between 2006 and 2021 were identified and stratified according to age (≥80 vs. <80 years). Intraoperative Complications Assessment and Reporting with Universal Standards and European Association of Urology guidelines recommendations were accomplished in collection and reporting of, respectively, intraoperative and postoperative complications. Multivariable logistic regression models (MVA) tested the impact of age on outcomes of interest. Sensitivity analyses after 1:3 propensity score matching were performed. RESULTS Of 1955 overall patients, 251 (13%) were ≥80-year-old. Minimally invasive RC was performed in 18% and 40% of octogenarian and younger patients, respectively (p < 0.001). UD without bowel manipulation (ureterocutaneostomy, UCS) was performed in 31% and 7% of octogenarian and younger patients (p < 0.001). LND was delivered to 81% and 93% of octogenarian and younger patients (p < 0.001). At MVA, age ≥80 years independently predicted open approach (odds ratio [OR]: 1.55), UCS (OR: 3.70), and omission of LND (OR: 0.41; all p ≤ 0.02). Compared to their younger counterparts, octogenarian patients experienced higher rates of intraoperative (8% vs. 4%, p = 0.04) but not of postoperative complications (64% vs. 61%, p = 0.07). At MVA, age ≥80 years was not an independent predictor of length of stay, intraoperative or postoperative transfusions and complications, and readmissions (all p values >0.1). These results were replicated in sensitivity analyses. CONCLUSIONS Age ≥80 years does not independently portend worse surgical outcomes for RC. However, octogenarians are unreasonably more likely to receive open approach and UCS diversion, and less likely to undergo LND.
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Affiliation(s)
- Paolo Dell'Oglio
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Urology, Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - Stefano Tappero
- Department of Urology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
- Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, Montreal, Quebec, Canada
| | - Andrea Panunzio
- Department of Urology, Azienda Ospedaliera Universitaria Integrata, University of Verona, Verona, Italy
| | - Alessandro Antonelli
- Department of Urology, Azienda Ospedaliera Universitaria Integrata, University of Verona, Verona, Italy
| | - Daniel Salvador
- Department of Urology, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Evanguelos Xylinas
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Department of Urology Cochin Hospital, APHP, Paris Descartes University, Paris, France
| | | | - Rodolfo Hurle
- Department of Urology, Istituto Clinico Humanitas Istituto di Ricovero e Cura a Carattere Scientifico-Clinical and Research Hospital, Milan, Italy
| | | | - Anna Colomer
- Department of Urology, Institut Mutualiste Montsouris, Paris, France
| | - Giuseppe Simone
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Kees Hendricksen
- Department of Urology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Angelo Peroni
- Department of Urology, ASST Spedali Civili, Brescia, Italy
| | - Chiara Lonati
- Department of Urology, ASST Spedali Civili, Brescia, Italy
| | - Alberto Olivero
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Morgan Rouprêt
- Department of Urology, Pierre and Marie Curie Medical School, Pitié-Salpêtrière Academic Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Sorbonne, Paris, France
| | - Mathieu Roumiguié
- Department of Urology, Institut Universitaire du Cancer, Oncopole, Toulouse, France
| | - Francesco Soria
- Department of Surgical Sciences, Division of Urology, Torino School of Medicine, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Paolo Umari
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - David D'Andrea
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Carlo Terrone
- Department of Urology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
| | - Antonio Galfano
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Moschini
- University Vita-Salute San Raffaele, Milan, Italy
- Division of Experimental Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ettore Di Trapani
- Division of Urology, IEO-European Institute of Oncology, IRCCS, Milan, Italy
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Neuzillet Y, Audenet F, Loriot Y, Allory Y, Masson-Lecomte A, Leon P, Pradère B, Seisen T, Traxer O, Xylinas E, Roumiguié M, Roupret M. French AFU Cancer Committee Guidelines - Update 2022-2024: Muscle-Invasive Bladder Cancer (MIBC). Prog Urol 2022; 32:1141-1163. [PMID: 36400480 DOI: 10.1016/j.purol.2022.07.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To update the CCAFU recommendations for the management of muscle invasive bladder carcinoma (MIBC). METHODS A systematic review (Medline) of the literature from 2020 to 2022 was performed taking account of the diagnosis, treatment options and surveillance of NMIBC and MIBC, while evaluating the references with their levels of evidence. RESULTS MIBC is diagnosed after the most complete tumour resection possible. MIBC grading is based on CTU along with chest CT. Multiparametric pelvic MRI could be an alternative. Cystectomy with extensive lymphadenectomy is the gold standard treatment for non-metastatic MIBC. It should be preceded by platinum-based neoadjuvant chemotherapy in patients in good general health with satisfactory renal function. Enterocystoplasty is proposed in men and women in the absence of contraindications and when the urethral resection is negative on extemporaneous examination. Otherwise, transileal cutaneous ureterostomy is the recommended method of urinary diversion. Inclusion of all patients in an ERAS (Enhanced Recovery After Surgery) protocol is recommended. For metastatic MIBC, first line treatment with platinum-based chemotherapy (GC or MVAC) is recommended, if general health (PS>1) and renal function (clearance>60mL/min) so allow (only 50% of the cases). Pembrolizumab immunotherapy has demonstrated an overall survival benefit in second-line treatment. CONCLUSION Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and decision-making concerning MIBC treatment.
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Affiliation(s)
- Y Neuzillet
- Service d'urologie, hôpital Foch, université Paris Saclay, Suresnes, France.
| | - F Audenet
- Service d'urologie, hôpital européen Georges-Pompidou, AP-HP Centre, université Paris Cité, Paris, France
| | - Y Loriot
- Service d'oncologie médicale, institut Gustave Roussy, Villejuif, France
| | - Y Allory
- Service d'anatomopathologie, institut Curie, université Paris Saclay, Saint-Cloud, France
| | - A Masson-Lecomte
- Service d'urologie, hôpital Saint-Louis, AP-HP, université Paris Cité, France
| | - P Leon
- Service d'urologie, clinique Pasteur, Royan, France
| | - B Pradère
- Service d'urologie UROSUD, Clinique Croix Du Sud, 31130 Quint-Fonsegrives, France
| | - T Seisen
- Sorbonne université, GRC 5 Predictive Onco-Uro, AP-HP, urologie, hôpital Pitié-Salpêtrière, 75013 Paris, France
| | - O Traxer
- Sorbonne université, GRC#20 Lithiase Urinaire et EndoUrologie, AP-HP, urologie, hôpital Tenon, 75020 Paris, France
| | - E Xylinas
- Service d'urologie, hôpital Bichat-Claude Bernard, AP-HP, université Paris Cité, Paris, France
| | - M Roumiguié
- Service d'urologie, CHU de Toulouse, UPS, université de Toulouse, Toulouse, France
| | - M Roupret
- Sorbonne université, GRC 5 Predictive Onco-Uro, AP-HP, urologie, hôpital Pitié-Salpêtrière, 75013 Paris, France
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Influence of steep Trendelenburg position on postoperative complications: a systematic review and meta-analysis. J Robot Surg 2021; 16:1233-1247. [PMID: 34972981 PMCID: PMC9606098 DOI: 10.1007/s11701-021-01361-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022]
Abstract
Intraoperative physiologic changes related to the steep Trendelenburg position have been investigated with the widespread adoption of robot-assisted pelvic surgery (RAPS). However, the impact of the steep Trendelenburg position on postoperative complications remains unclear. We conducted a meta-analysis to compare RAPS to laparoscopic/open pelvic surgery with regards to the rates of venous thromboembolism (VTE), cardiac, and cerebrovascular complications. Meta-regression was performed to evaluate the influence of confounding risk factors. Ten randomized controlled trials (RCTs) and 47 non-randomized controlled studies (NRSs), with a total of 380,125 patients, were included. Although RAPS was associated with a decreased risk of VTE and cardiac complications compared to laparoscopic/open pelvic surgery in NRSs [risk ratio (RR), 0.59; 95% CI 0.51–0.72, p < 0.001 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively], these differences were not confirmed in RCTs (RR 0.92; 95% CI 0.52–1.62, p = 0.77 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively). In subgroup analyses of laparoscopic surgery, there was no significant difference in the risk of VTE and cardiac complications in both RCTs and NRSs. In the meta-regression, none of the risk factors were found to be associated with heterogeneity. Furthermore, no significant difference was observed in cerebrovascular complications between RAPS and laparoscopic/open pelvic surgery. Our meta-analysis suggests that the steep Trendelenburg position does not seem to affect postoperative complications and, therefore, can be considered safe with regard to the risk of VTE, cardiac, and cerebrovascular complications. However, proper individualized preventive measures should still be implemented during all surgeries including RAPS to warrant patient safety.
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Mortezavi A, Crippa A, Edeling S, Pokupic S, Dell'Oglio P, Montorsi F, D'Hondt F, Mottrie A, Decaestecker K, Wijburg CJ, Collins J, Kelly JD, Tan WS, Sridhar A, John H, Canda AE, Schwentner C, Rönmark EP, Wiklund P, Hosseini A. Morbidity and mortality after robot-assisted radical cystectomy with intracorporeal urinary diversion in octogenarians: results from the European Association of Urology Robotic Urology Section Scientific Working Group. BJU Int 2020; 127:585-595. [PMID: 33058469 PMCID: PMC8246851 DOI: 10.1111/bju.15274] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objectives To evaluate the postoperative complication and mortality rate following laparoscopic radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in octogenarians. Patients and Methods We conducted a retrospective analysis comparing postoperative complication and mortality rates depending on age in a consecutive series of 1890 patients who underwent RARC with ICUD for bladder cancer between 2004 and 2018 in 10 European centres. Outcomes of patients aged <80 years and those aged ≥80 years were compared with regard to postoperative complications (Clavien–Dindo grading) and mortality rate. Cancer‐specific mortality (CSM) and other‐cause mortality (OCM) after surgery were calculated using the non‐parametric Aalen‐Johansen estimator. Results A total of 1726 patients aged <80 years and 164 aged ≥80 years were included in the analysis. The 30‐ and 90‐day rate for high‐grade (Clavien–Dindo grades III–V) complications were 15% and 21% for patients aged <80 years compared to 11% and 13% for patients aged ≥80 years (P = 0.2 and P = 0.03), respectively. In a multivariable logistic regression analysis adjusting for pre‐ and postoperative variables, age ≥80 years was not an independent predictor of high‐grade complications (odds ratio 0.6, 95% confidence interval 0.3–1.1; P = 0.12). The non‐cancer‐related 90‐day mortality was 2.3% for patients aged ≥80 years and 1.8% for those aged <80 years, respectively (P = 0.7). The estimated 12‐month CSM and OCM rates for those aged <80 years were 8% and 3%, and for those aged ≥80 years, 15% and 8%, respectively (P = 0.009 and P < 0.001). Conclusions The minimally invasive approach to RARC with ICUD for bladder cancer in well‐selected elderly patients (aged ≥80 years) achieved a tolerable high‐grade complication rate; the 90‐day postoperative mortality rate was driven by cancer progression and the non‐cancer‐related rate was equivalent to that of patients aged <80 years. However, an increased OCM rate in this elderly group after the first year should be taken into account. These results will support clinicians and patients when balancing cancer‐related vs treatment‐related risks and benefits.
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Affiliation(s)
- Ashkan Mortezavi
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.,Department of Urology, University Hospital Zurich, Zurich, Switzerland.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Alessio Crippa
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sebastian Edeling
- Department of Urology, Vinzenzkrankenhaus Hannover, Hannover, Germany
| | - Sasa Pokupic
- Department of Urology, Vinzenzkrankenhaus Hannover, Hannover, Germany
| | - Paolo Dell'Oglio
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.,Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.,ORSI Academy, Melle, Belgium
| | - Francesco Montorsi
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Alexandre Mottrie
- Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.,ORSI Academy, Melle, Belgium
| | | | - Carl J Wijburg
- Department of Urology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Justin Collins
- Department of Urology, University College London Hospital, London, UK
| | - John D Kelly
- Department of Urology, University College London Hospital, London, UK
| | - Wei Shen Tan
- Department of Urology, University College London Hospital, London, UK
| | - Ashwin Sridhar
- Department of Urology, University College London Hospital, London, UK
| | - Hubert John
- Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | | | | | - Erik Peder Rönmark
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden.,Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abolfazl Hosseini
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
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9
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Babus LW, Gainsburg DM. Dynamic Tracheobronchial Compression in Steep Trendelenburg Position With Pneumoperitoneum for Robotic-Assisted Cystectomy: A Case Report. A A Pract 2020; 14:18-20. [PMID: 31789827 DOI: 10.1213/xaa.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tracheobronchomalacia is a weakness of the trachea and bronchi due to abnormal cartilage and muscular support leading to airway obstruction. We report a case of an adult former smoker without pulmonary symptoms who underwent robotic-assisted laparoscopic cystectomy in the steep Trendelenburg position. After repeated episodes of hypoxemia, bronchoscopic examination revealed collapse of the distal trachea and bronchi, supporting a diagnosis of tracheobronchomalacia. Tracheomalacia is an underdiagnosed condition in patients with a smoking history and may mimic other obstructive diseases. The anesthesiologist should remain vigilant to the possibility of airway collapse in former smokers, specifically in cases of increased intrathoracic pressure.
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Affiliation(s)
- Lenard W Babus
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine, The Mount Sinai Hospital, New York, New York
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10
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Age Differences in Patient-reported Psychological and Physical Distress Symptoms in Bladder Cancer Patients – A Cross Sectional Study. Urology 2019; 134:154-162. [DOI: 10.1016/j.urology.2019.08.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/12/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
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