Risk factors and reasons for reoperation after radical cystectomy

Preoperative smoking and robot-assisted radical cystectomy outcomes & complications in multicenter KORARC database

To investigate the influence of preoperative smoking history on the survival outcomes and complications in a cohort from a large multicenter database. Many patients who undergo radical cystectomy (RC) have a history of smoking; however, the direct association between preoperative smoking history and survival outcomes and complications in patients with muscle-invasive bladder cancer (MIBC) who undergo robot-assisted radical cystectomy (RARC) remains unexplored. We conducted a retrospective analysis using data from 749 patients in the Korean Robot-Assisted Radical Cystectomy Study Group (KORARC) database, with an average follow-up duration of 30.8 months. The cohort was divided into two groups: smokers (n = 351) and non-smokers (n = 398). Propensity score matching was employed to address differences in sample size and baseline demographics between the two groups (n = 274, each). Comparative analyses included assessments of oncological outcomes and complications. After matching, smoking did not significantly affect the overall complication rate (p = 0.121). Preoperative smoking did not significantly increase the occurrence of complications based on complication type (p = 0.322), nor did it increase the readmission rate (p = 0.076). There were no perioperative death in either group. Furthermore, preoperative smoking history showed no significant impact on overall survival (OS) [hazard ratio (HR) = 0.87, interquartile range (IQR): 0.54-1.42; p = 0.589] and recurrence-free survival (RFS) (HR = 1.12, IQR: 0.83-1.53; p = 0.458) following RARC for MIBC. The extent of preoperative smoking (≤ 10, 10-30, and ≥ 30 pack-years) had no significant influence on OS and RFS in any of the categories (all p > 0.05). Preoperative smoking history did not significantly affect OS, RFS, or complications in patients with MIBC undergoing RARC.

A Procedure and Complication-Specific Assessment of Smoking in Aesthetic Surgery: A Systematic Review and Meta-Analysis

Background: The popularity of aesthetic surgery is on the rise, as is patients' expectations towards excellent surgical results. In order to meet these expectations, risk factors that hinder desired outcomes, such as smoking, need to be identified and addressed. To that end, the present study summarizes an updated systematic review focused on the effects of smoking on cosmetic surgical procedures and outcomes. Methods: A systematic review of studies comparing aesthetic surgical outcomes by procedure, between tobacco smokers and non-smokers was carried out, querying PubMed, Embase and the Cochrane databases. Data regarding surgical outcomes were extracted and meta-analyzed by a random effects model in conjunction with the Mantel-Haenszel statistical method. Results: Eighty-two studies were included in the final synthesis. Abdominoplasty/panniculectomy (n = 19 cohorts) and breast reduction (n = 27 cohorts) were the most common types of procedures included in this review. Other than mastopexy and rhinoplasty, smoking conferred a statistically significant increased risk of overall complications for all studied aesthetic procedures. Conclusions: The data demonstrates that smoking is a clear risk factor for the vast majority of aesthetic plastic surgeries studied. Although our meta-analysis suggests that smoking is not a risk factor for complications in mastopexies and rhinoplasties, these two specific analyses may have been biased, and should therefore be re-evaluated with future additional evidence. The results of this systematic review confirm the importance of smoking cessation and education relative to the outcomes of common cosmetic surgical procedures.

A retrospective analysis of the factors associated with increased risk of readmission within 30 days after primary transurethral resection of bladder tumor

Background

Transurethral resection of bladder tumor (TURBT) is associated with perioperative morbidity of 5% to 10%, which can lead to unplanned readmissions. In this study, we aimed to identify the factors that lead to an increased risk of unplanned readmissions within 30 days of primary TURBT.

Materials and methods

A retrospective study was conducted to identify patients who underwent primary TURBT at our institute from 2011 to 2019. Clinical and demographic factors, history of smoking, antiplatelet drugs intake, comorbidities, tumor size (<3 or >3 cm), multifocality, and histopathological type were abstracted. Patients who were readmitted were identified, and reasons for admission were recorded.

Results

A total of 435 patients were identified. The median age of the patients was 66 years. From 378 male patients (86.9%), 110 (25.3%) and 37 (8.5%) had a history of smoking and antiplatelet agents intake, respectively. In the cohort, 166 patients (38.2%) were diabetic, 239 (54.9%) were hypertensive, 72 (16.6%) had chronic obstructive pulmonary disease, and 78 (7.9%) had hypothyroidism. A total of 206 patients (47.4%) had a tumor >3 cm; multifocality was seen in 140 (32.2%) patients, whereas muscle invasive tumors were present in 161 patients (37%). A total of 22 patients (5.06%) had readmissions within 30 days, with hematuria being the most common etiology. On univariate and multivariate analyses, a history of smoking (p = 0.006 and p = 0.008, respectively) or antiplatelet agents intake (p < 0.001 and p < 0.001, respectively) was significantly associated with increased unplanned readmission.

Conclusions

Our study revealed smoking and antiplatelet agents intake as factors leading to an increased risk of unplanned readmissions.

Bladder cancer patient and provider perspectives on smoking cessation

BACKGROUND

Smoking is the most common risk factor for bladder cancer and is associated with adverse clinical and cancer-related outcomes. Increasing understanding of the patient and provider perspectives on smoking cessation may provide insight into improving smoking cessation rates among bladder cancer survivors. We sought to inform strategies for providers promoting cessation efforts and help patients quit smoking.

METHODS

Using a modified Delphi process with multidisciplinary input from bladder cancer providers, researchers, and a patient advocate, 2 surveys were created for bladder cancer patients and providers. Surveys included multiple-choice questions and free answers. The survey was administered electronically and queried participants' perspectives on barriers and facilitators associated with smoking cessation. Survey responses were anonymous, and participants were provided with a $20 Amazon gift card for participating. Patients were approached through the previously established Bladder Cancer Advocacy Network (BCAN) Patient Survey Network, an online bladder cancer patient and caregiver community. Providers were recruited from the Society of Urologic Oncology (SUO) and the Large Urology Group Practice Association (LUGPA).

RESULTS

From May to June 2021, 308 patients and 103 providers completed their respective surveys. Among patients who quit smoking, most (64%) preferred no pharmacologic intervention ("cold turkey") followed by nicotine replacement therapy (28%). Repeated efforts at cessation commonly occurred, and 67% reported making more than one attempt at quitting prior to eventual smoking cessation. Approximately 1 in 10 patients were unaware of the association between bladder cancer and smoking. Among providers, 75% felt that barriers to provide cessation include a lack of clinical time, adequate training, and reimbursement concerns. However, 79% of providers endorsed a willingness to receive continuing education on smoking cessation.

CONCLUSIONS

Bladder cancer patients utilize a variety of cessation strategies with "cold turkey" being the most used method, and many patients make multiple attempts at smoking cessation. Providers confront multiple barriers to conducting smoking cessation, including inadequate time and training in cessation methods; however, most would be willing to receive additional education. These results inform future interventions tailored to bladder cancer clinicians to better support provider efforts to provide smoking cessation counseling.

Association of smoking history on health-related quality of life in patients undergoing radical cystecomy

PURPOSE

Radical cystectomy (RC) has the potential to impact health-related quality of life (HRQOL). Many patients who undergo RC are current or former smokers. To better inform preoperative patient counseling, we examined the association between smoking status and HRQOL after RC.

MATERIALS AND METHODS

A secondary analysis was performed on a prospective, longitudinal study (2008-2014) examining HRQOL in patients undergoing RC for bladder cancer. We analyzed 12 validated patient-reported outcome measures that focused on functional, symptomatic, psychosocial, and global HRQOL domains. Measures were collected pre-operatively and 3-, 6-, 12-, 18-, and 24-months postoperatively. For each HRQOL domain, we estimated the mean domain scores using a generalized estimation equation linear regression model. Each model included survey time, smoking status, and time-smoking interaction as covariates. Pairwise comparisons of current, former, and never smokers were estimated from the models.

RESULTS

Of the 411 patients available for analysis, 29% (n = 119) never smoked, 59% (n = 244) were former smokers, and 12% (n = 48) were current smokers. Over the follow-up period, never smokers compared to current smokers had better global QOL scores (mean difference = +8.9; 95% CI 1.3-16; p = 0.023) and lower pain levels (mean difference = -10; 95% CI -19 to -0.54; p = 0.036). Compared to current smokers, former smokers had marginal improvements in global QOL (+6.9 points) and pain (-7.5 points) during the follow-up period.

CONCLUSIONS

Current smokers reported worse HRQOL recovery in the 24-months after RC. These findings can be used to counsel patients who smoke on recovery expectations.

Comparative Analysis of Elderly Patients Undergoing Radical Cystectomy With Ureterocutaneostomy or Ileal Conduit With a Special Focus on Bowl Complications Requiring Surgical Revision

Objectives

Ileal conduits (ICs) carry an additional perioperative complication risk due to the bowel procedure. This analysis compares surgical outcomes in patients ≥75 years of age with ureterocutaneostomy (UCN) and IC after cystectomy (Cx).

Methods

Data of 527 patients included in a retrospective cystectomy database of two high volume centers (2008–2020) were queried to identify elderly patients (≥75 years) who underwent Cx either with IC or UCN. Patient characteristics of all patients [age, BMI, Charlson Comorbidity Index (CCI)], perioperative parameters (operation time, blood loss, transfusions, tumor stage), and postoperative complications (clavien &gt;IIIA, intensive care unit (ICU) stay) were compared. As special focus, bowel complications requiring surgical revision (rBCs) were analyzed. In patients with IC, the rate of ureteral implantation stenosis (USt) was recorded. As a population of special interest, patients ≥80 years of age were analyzed separately. Categorical data were compared using Fisher exact test, and continuous data were compared using Mann–Whitney U test.

Results

A total of 163 patients ≥75 years of age (125 IC, 38 UCN) were identified. Patients with UCN were older and presented with a higher CCI, though differences were not statistically different. Surgery with palliative intent was more frequent in patients with UCN (37 vs. 10%). Operation time in UCN was significantly shorter (233 vs. 305 min, p = 0.02), while blood loss and transfusion rate were comparable. Overall complication rate (Clavien-Dindo grade IIIA–IVB) was comparable (UCN 34% vs. IC 37%). However, rBC was a rare complication in UCN (3/38) as compared to patients with IC (15/125). Frequency of postoperative ICU stay (UCN 16% vs. IC 16%) and 90-day mortality did not differ (UCN 3/38 patients, IC 5/125 patients). Regarding long-term follow-up, USt requiring revision or permanent stenting was seen in 18/125 (14%) patients with IC. In patients &gt;80 years of age, results were comparable to the main cohort. Low event rate regarding complications and bias inherent of a retrospective analysis (selection bias, unequal distribution in case numbers) precludes detection of statistical differences regarding patients' characteristics and overall complication rate.

Conclusion

UCN is an alternative to IC in elderly and/or frail patients. Severe bowel complications are numerically less frequent and operation time is minimized.

Effects of antihypertensive drugs on surgical outcomes of breast reconstruction: a nationwide population-based claim study

Background

Experimental studies have reported that angiotensin receptor blockers (ARBs) increase the risk of surgical complications. However, clinical data on their effect on surgical outcomes are limited. The aim of this study was to investigate the impact of perioperative use of ARBs on the outcomes of breast reconstruction using population-based claim data.

Methods

Data of patients who underwent direct-to-implant or abdomen-based autologous breast reconstruction after total mastectomy from April 2015 to December 2018 were obtained from the Health Insurance Review and Assessment Service database. The patients were categorized as ARB, non-ARB, control, and non-hypertension groups. The effects of ARBs on surgical complications, length of hospital stay, and complication-related medical costs were evaluated.

Results

Of the 9,036 patients who met the inclusion criteria, 5,192 underwent direct-to-implant reconstruction, and 3,844 underwent abdomen-based autologous reconstruction. The length of hospital stay was the longest and the surgical complication rate and complication-related medical cost were the highest in the ARB group after both reconstruction methods. Compared with non-treatment with antihypertensive drugs, ARB use was found to be an independent risk factor for surgical complications in direct-to-implant reconstruction [odds ratio (OR), 1.96; 95% confidence interval (CI), 1.09-3.50; P=0.0237] and complication-related medical cost (OR, 1.93; 95% CI, 1.10-3.40; P=0.0221) in abdomen-based autologous reconstruction.

Conclusions

Perioperative ARB use was associated with adverse postoperative breast reconstruction outcomes. These findings might have a significant impact on perioperative antihypertensive management; nevertheless, further studies are warranted to confirm the study findings.

The Epidemiology of Bladder Cancer

There are many risk factors for bladder cancer. During an initial assessment of a patient with bladder cancer, a careful discussion and history assessment is important. Particular focus should include social history with details regarding occupational background and discussion of any environmental exposure history.

The impact of smoking on radical cystectomy complications increases in elderly patients

BACKGROUND

Smoking, the most common risk factor for bladder cancer (BC), is associated with increased complications after radical cystectomy (RC), poorer oncologic outcomes, and higher mortality. The authors hypothesized that the effect of smoking on the probability of major complications increases with increasing age among patients who undergo RC.

METHODS

The authors analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2011-2017), identified all patients undergoing RC using Current Procedural Terminology codes, and formed two groups according to smoking status (active smoker and nonsmoker [included former and never-smokers]). Patient characteristics and 30-day postoperative complications using the Clavien-Dindo Classification (CDC) were assessed. A multivariable logistic regression model was constructed that included age, sex, race, body mass index, operative time, comorbidities, chemotherapy status, and type of diversion with major complications (CDC ≥III) as the outcome variable, and explored the interaction between age and smoking status.

RESULTS

A total of 10,528 patients underwent RC, including 22.8% who were active smokers. The authors identified an interaction between age and smoking status (P = .045). Older patients were found to experience a stronger smoking effect than younger patients with regard to the probability of major complications. The risk of a major complication was the same for 50-year-old nonsmokers and smokers, but it increased from 17.8% to 21.7% for 70-year-old nonsmokers and smokers, respectively (P < .001).

CONCLUSIONS

Up to 20% of patients who undergo RC are active smokers, and these individuals have an increased risk of major complications. The effect of smoking is stronger with increasing age; the difference with regard to complications for smokers versus nonsmokers was found to increase substantially, wherein older smokers are at an especially high risk of complications.

Obesity is associated with adverse short-term perioperative outcomes in patients treated with open and robot-assisted radical cystectomy for bladder cancer

BACKGROUND

Obese patients may be predisposed to adverse perioperative outcomes and it is uncertain whether robot-assisted radical cystectomy (RARC) benefits obese patients in comparison to open radical cystectomy (ORC). Thus, we tested the effect of obesity and surgical approach on perioperative outcomes and total hospital charges.

METHODS

Within the National Inpatient Sample database (2008-2015), we identified obese (body mass index ≥30 kg/m2) vs. non-obese patients with non-metastatic bladder cancer treated with RARC or ORC. Estimated annual percent changes and weighted multivariable logistic and linear regression models adjusted for clustering as well as age, comorbidities, hospital volume, and respectively surgical approach, lengths of stay, and/or complications were used.

RESULTS

Of all 11,594 patients (unweighted patient count), 1,119 (9.7%) were obese vs. 10,475 (90.3%) were not-obese. Obesity rate increased significantly over time (5.5%-13.3%, annual change: 11%, P = 0.001). RARC, as well as treatment in high volume hospitals was more prevalent in obese vs. non-obese patients (18.3 vs. 14.5% and 40.9 vs. 37.0%, both P < 0.01). In multivariable regression models, obesity independently predicted overall complications (odds ratio [OR] 1.23, confidence interval [CI]: 1.09-1.42), major complications (OR 1.63, CI: 1.41-1.87), longer hospital stay (OR 1.17, CI: 1.02-1.34) and higher total hospital charges ($+8,260, CI: 3951-12,570), all P < 0.01). In subgroup analyses in obese patients, RARC was not associated with overall (OR 1.15, P = 0.4) and major complications (OR 1.10, P = 0.6) or length of stay (OR 0.78, P = 0.1) compared with ORC but with higher hospital charges (+$16,794, P = 0.005).

CONCLUSION

Obesity predisposes to higher rates of adverse perioperative outcomes at radical cystectomy. The benefit of RARC could not be validated in obese patients.

The impact of preoperative nutritional status on post-surgical complication and mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review of the literature

PURPOSE

To investigate the impact of preoperative nutritional factors [body mass index (BMI)], hypoalbuminemia (< 3.5 g/dL, sarcopenia) on complication and mortality rates after radical cystectomy (RC) for bladder cancer.

METHODS

The PubMed database was systematically searched for studies investigating the effect of nutritional status on postoperative outcomes after RC. English-language articles published between March 2010 and March 2020 were reviewed. For statistical analyses odds ratios (ORs) and hazard ratios (HRs) weighted mean was applied.

RESULTS

Overall, 81 studies were included. Twenty-nine studies were enrolled in the final analyses. Patients with a 25-29.9 kg/m² BMI (OR 1.55, 95% confidence interval [CI] 1.14-2.07) and those with a BMI ≥ 30 kg/m² (OR 1.73, 95% CI 1.29-2.40) had a significantly increased risk of 30 day complications after RC. Preoperative hypoalbuminemia increased the risk of 30 day complications (OR 1.56, 95% CI 1.07-2.35); it was a predictor of worse 3 year overall survival (OS) (HR 1.86, 95% CI 1.32-2.66). Sarcopenic patients had a higher risk of 90 day complications than non-sarcopenic ones (OR 2.49, 95% CI 1.22-5.04). Sarcopenia was significantly associated with unfavorable 5 year cancer-specific survival (CSS) (HR 1.73, 95% CI 1.07-2.80), and OS (HR 1.60, 95% CI 1.13-2.25).

CONCLUSION

High BMI, hypoalbuminemia, and sarcopenia significantly increased the complication rate after RC. Hypoalbuminemia predicted worse 3 year OS and sarcopenia predicted unfavorable 5 year CSS and OS. Preoperative assessment of RC patients' nutritional status is a useful tool to predict perioperative and survival outcomes.