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Davidson T, Sjödahl R, Aldman Å, Lennmarken C, Kammerlind AS, Theodorsson E. Robot-assisted pelvic and renal surgery compared with laparoscopic or open surgery: Literature review of cost-effectiveness and clinical outcomes. Scand J Surg 2024; 113:13-20. [PMID: 37555486 DOI: 10.1177/14574969231186283] [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] [Indexed: 08/10/2023]
Abstract
BACKGROUND AND AIM The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations. METHODS A narrative review was carried out. RESULTS When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs. CONCLUSIONS Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.
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Affiliation(s)
- Thomas Davidson
- Department of Health, Medicine and Caring Sciences, Linköping University, SE 58183, Linkoping Sweden
| | - Rune Sjödahl
- Division of Surgery and Clinical Experimental Medicine, Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
| | - Åke Aldman
- Department of Surgery, Region Kalmar län, Kalmar, Sweden
| | - Claes Lennmarken
- Department for Medical Quality, Region Östergötland, Linkoping, Sweden
| | - Ann-Sofi Kammerlind
- Futurum, Jönköping, Sweden Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | - Elvar Theodorsson
- Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Linköping University, Linkoping, Sweden
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2
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Long J, Wang L, Dong N, Bai X, Chen S, Sun S, Liang H, Lin Y. Robotic-assisted versus standard laparoscopic radical cystectomy in bladder cancer: A systematic review and meta-analysis. Front Oncol 2022; 12:1024739. [PMID: 36439450 PMCID: PMC9681903 DOI: 10.3389/fonc.2022.1024739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background This study aimed to evaluate the efficacy and safety of robotic-assisted radical cystectomy (RARC) versus laparoscopic radical cystectomy (LRC) in the treatment of bladder cancer. Methods Two researchers independently searched PubMed, Embase, Cochrane, and CBM using the index words to identify the qualified studies which included randomized controlled trials (RCTs) and non-randomized controlled trials (prospective and retrospective studies), and the investigators scanned references of these articles to prevent missing articles. Differences in clinical outcomes between the two procedures were analyzed by calculating odds risk (OR) and mean difference (MD) with an associated 95% confidence interval (CI). Results Sixteen comparative studies were included in the meta-analysis with 1467 patients in the RARC group and 897 patients in the LRC group. The results indicated that RARC could significantly decrease blood loss (P = 0.01; MD: -82.56, 95% CI: -145.04 to -20.08), and complications 90 days or more after surgery, regardless of whether patients were Grade ≤ II (P = 0.0008; OR: 0.63, 95% CI: 0.48 to 0.82) or Grade ≥ III (P = 0.006; OR: 0.59, 95% CI: 0.40 to 0.86), as well as overall complications (P: 0.01; OR = 0.52; 95% CI: 0.32 to 0.85). However, there was no statistical difference between the two groups at total operative time, intraoperative complications, transfusion rate, short-term recovery, hospital stay, complications within 30 days of surgery, and bladder cancer-related mortality. Conclusions The meta-analysis demonstrates that RARC is a safe and effective treatment for bladder cancer, like LRC, and patients with RARC benefit from less blood loss and fewer long-term complications related to surgery, and should be considered a viable alternative to LRC. There still need high-quality, larger sample, multi-centric, long-term follow-up RCTs to confirm our conclusion.
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Affiliation(s)
- Junhao Long
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ni Dong
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoli Bai
- Department of Anesthesiology, Eye Hospital of Hebei Province, Xingtai, China
| | - Siyu Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shujun Sun
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Shujun Sun, ; Yun Lin,
| | - Huageng Liang
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Lin
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Shujun Sun, ; Yun Lin,
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Lloyd P, Hong A, Furrer MA, Lee EWY, Dev HS, Coret MH, Adshead JM, Baldwin P, Knight R, Shamash J, Alifrangis C, Stoneham S, Mazhar D, Wong H, Warren A, Tran B, Lawrentschuk N, Neal DE, Thomas BC. A comparative study of peri-operative outcomes for 100 consecutive post-chemotherapy and primary robot-assisted and open retroperitoneal lymph node dissections. World J Urol 2022; 40:119-126. [PMID: 34599350 DOI: 10.1007/s00345-021-03832-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/30/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To describe and compare differences in peri-operative outcomes of robot-assisted (RA-RPLND) and open (O-RPLND) retroperitoneal lymph node dissection performed by a single surgeon where chemotherapy is the standard initial treatment for Stage 2 or greater non-seminomatous germ cell tumour. METHODS Review of a prospective database of all RA-RPLNDs (28 patients) and O-RPLNDs (72 patients) performed by a single surgeon from 2014 to 2020. Peri-operative outcomes were compared for patients having RA-RPLND to all O-RPLNDs and a matched cohort of patients having O-RPLND (20 patients). Further comparison was performed between all patients in the RA-RPLND group (21 patients) and matched O-RPLND group (18 patients) who had previous chemotherapy. RA-RPLND was performed for patients suitable for a unilateral template dissection. O-RPLND was performed prior to the introduction of RA-RPLND and for patients not suitable for RA-RPLND after its introduction. RESULTS RA-RPLND showed improved peri-operative outcomes compared to the matched cohort of O-RPLND-median blood loss (50 versus 400 ml, p < 0.00001), operative duration (150 versus 195 min, p = 0.023) length-of-stay (1 versus 5 days, p < 0.00001) and anejaculation (0 versus 4, p = 0.0249). There was no statistical difference in complication rates. RA-RPLND had lower median lymph node yields although not significant (9 versus 13, p = 0.070). These improved peri-operative outcomes were also seen in the post-chemotherapy RA-RPLND versus O-RPLND analysis. There were no tumour recurrences seen in either group with median follow-up of 36 months and 60 months, respectively. CONCLUSIONS Post-chemotherapy RA-RPLND may have decreased blood loss, operative duration, hospital length-of-stay and anejaculation rates in selected cases and should, therefore, be considered in selected patients. Differences in oncological outcomes require longer term follow-up.
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Affiliation(s)
- Paul Lloyd
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Anne Hong
- Department of Urology, Royal Melbourne Hospital, Melbourne, Australia
| | - Marc A Furrer
- Department of Urology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Urology, University Hospital of Bern, Bern, Switzerland.,The Australian Medical Robotics Academy, Melbourne, Australia
| | - Elaine W Y Lee
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Harveer S Dev
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Maurice H Coret
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | | | - Peter Baldwin
- Department of Gynae-Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - Richard Knight
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | | | | | - Sara Stoneham
- Department of Oncology, University College London Hospital, London, UK
| | - Danish Mazhar
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Han Wong
- Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Anne Warren
- Department of Pathology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Nathan Lawrentschuk
- Department of Urology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Surgery, University of Melbourne, Melbourne, Australia
| | - David E Neal
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Benjamin C Thomas
- Department of Urology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK. .,Department of Urology, Royal Melbourne Hospital, Melbourne, Australia. .,The Australian Medical Robotics Academy, Melbourne, Australia. .,Department of Surgery, University of Melbourne, Melbourne, Australia.
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Mermier M, Baron P, Roumiguie M, Bajeot AS, Pignot G, Lannes F, Ploussard G, Gasmi A, Bensalah K, Perrot O, Rouprêt M, Bruyere F, Pradere B, Verhoest G. Predictive factors of early postoperative complications after robot-assisted radical cystectomy for urothelial bladder carcinoma. J Endourol 2021; 36:634-640. [PMID: 34931545 DOI: 10.1089/end.2021.0617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To identify protective and risk factors of early postoperative complications after robot-assisted radical cystectomy for urothelial bladder carcinoma. METHODS Data of all robot-assisted cystectomy performed in six french centers between February 2010 and December 2019 were retrospectively reviewed. All robot-assisted radical cystectomy for bladder cancer (muscle-invasive and high-risk or BCG-resistant non muscle-invasive bladder cancer) were included. Perioperative outcomes and early postoperative complications (in the first 30 days) were collected. Multivariate analysis was performed to identify factors associated to early postoperative complications. RESULTS 270 patients were included. The overall incidence of early postoperative complications after robot-assisted radical cystectomy was 52.2% (27% of major complications). Most frequent complications were infectious complications (24.4%) and paralytic ileus (15.6%). Anticoagulant therapy (OR=2.909, 95%CI 1.003 to 8.432) and uretero-enteric anastomosis type Wallace II (OR=4.4, 95%CI 1.435 to 13.489) were associated with a higher rate of overall complications. Complete intracorporeal derivation was a protective factor (OR=0.399, 95%CI 0.222 to 0.718). Tabacco consumption, anticoagulant therapy, uretero-enteric anastomosis type Wallace II were associated with a higher rate of minor complications (OR=2.01, 95%CI 1.079 to 3.744; OR=2.495, 95%CI 1.022 to 6.089; OR=3.836, 95%CI 1.384 to 10.63 respectively). Opioid-Free Anaesthesia was associated with a lower rate of infectious complications (OR=0.148, 95%CI 0.034 to 0.644). CONCLUSION Early postoperative complications rate after robot-assisted radical cystectomy for urothelial bladder carcinoma is high. Encouraging complete intracorporeal diversion and promoting Opioid-Free Anaesthesia seem to reduce postoperative complications in the first 30 days. Prospective studies are needed to provide a high level of evidence.
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Affiliation(s)
- Marie Mermier
- CHU Rennes, 36684, 2 rue Henri Le Guilloux, Rennes, France, 35000;
| | | | - Mathieu Roumiguie
- Centre Hospitalier Universitaire de Toulouse, 36760, urology, Toulouse, Midi-Pyrénées, France;
| | | | | | | | - Guillaume Ploussard
- Clinique Capio La Croix du Sud, 538719, Quint-Fonsegrives, Occitanie, France;
| | | | - Karim Bensalah
- Rennes University Hospital (France), Urology, 2 rue Henri Le Guillou, Rennes, France, 35000;
| | | | - Morgan Rouprêt
- Pitié-Salpêtrière Academic Hospital, Department of Urology, Assistance Publique-Hôpitaux de Paris, Pierre and Marie Curie Medical School, Paris 6 University, Paris, France;
| | - Franck Bruyere
- CHRU Tours, 26928, urology, 2 bd Tonnellé, Tours, France, 37044;
| | - Benjamin Pradere
- CHU Tours, Department of urology, 2 boulevard tonnellé, Tours, France, 37000;
| | - Gregory Verhoest
- RENNES Univeristy Hospital, Urology, Henri Le Guillou St, RENNES, France, 35033;
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Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion. Actas Urol Esp 2021; 46:57-62. [PMID: 34840098 DOI: 10.1016/j.acuroe.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/23/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD. MATERIAL AND METHODS Retrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon. RESULTS The 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60 min between G1-G3 (p = 0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (p = 0.6) or the number of lymph nodes removed (p = 0.061). The postoperative complication rate was 77% and did not change during the LC (p = 0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (p = 0.217). CONCLUSIONS The inclusion of junior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.
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López-Molina C, Carrion A, Campistol M, Piñero A, Lozano F, Salvador C, Raventós CX, Trilla E. Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion. Actas Urol Esp 2021; 46:S0210-4806(21)00106-6. [PMID: 34334241 DOI: 10.1016/j.acuro.2021.05.005] [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: 04/17/2021] [Accepted: 05/23/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD. MATERIAL AND METHODS Retrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon. RESULTS The 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60minutes between G1-G3 (P=0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (P=0.6) or the number of lymph nodes removed (P=0.061). The postoperative complication rate was 77% and did not change during the LC (P=0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (P=0.217). CONCLUSIONS The inclusion of júnior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.
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Affiliation(s)
- C López-Molina
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - A Carrion
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España.
| | - M Campistol
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - A Piñero
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - F Lozano
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - C Salvador
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - C X Raventós
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - E Trilla
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
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Gul ZG, Katims AB, Winoker JS, Wiklund P, Waingankar N, Mehrazin R. Robotic assisted radical cystectomy versus open radical cystectomy: a review of what we do and don't know. Transl Androl Urol 2021; 10:2209-2215. [PMID: 34159104 PMCID: PMC8185680 DOI: 10.21037/tau.2019.11.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Radical cystectomy (RC) is the gold standard treatment for muscle-invasive and high-risk, noninvasive bladder cancer. Since 2003, robot-assisted radical cystectomy (RARC) has been gaining popularity. Metanalyses show that the primary advantage of RARC is less blood loss and the primary advantage of open radical cystectomy (ORC) is shorter operative times. There do not appear to be significant differences in complications, cancer-related outcomes or survival between the two approaches. Cost analyses comparing RARC and ORC are complicated by the often-ill-defined distinction between the cost to the hospital versus the cost to payors. However, it is likely that for both hospitals and payors, RARC is cost effective at high-volume centers. It is feasible that in the future, increased experience with RARC will lead to improved outcomes and justify the use of RARC over ORC.
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Affiliation(s)
- Zeynep G Gul
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew B Katims
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jared S Winoker
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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The association between N-methylnaltrexone, a peripherally acting mu-opioid receptor antagonist, and clinical outcomes in patients undergoing robotic-assisted radical cystectomy. World J Urol 2020; 38:3113-3119. [PMID: 32072229 DOI: 10.1007/s00345-020-03117-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/03/2020] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To assess the impact of N-methylnaltrexone, a peripherally acting mu-opioid receptor antagonist, on the post-operative recovery of patients undergoing robotic-assisted radical cystectomy for bladder cancer. METHODS We retrospectively reviewed patients undergoing robotic-assisted radical cystectomy by a single surgeon (KC) prior to (control group) and after (treatment group) the routine use of N-methylnaltrexone. Kaplan-Meier curves and the log-rank test were used to quantify time to flatus, bowel movement, and discharge. Daily mean opioid use, daily pain assessment rating, and episodes of severe pain (7-10/10) were compared. Gastrointestinal-related complications, including ileus, emesis, and/or need for post-op nasogastric tube placement, and 30-day readmissions were also compared between groups. Charge capture data were compared between groups to analyze cost impact. RESULTS 29 patients each in the control and treatment group met inclusion criteria. Patients receiving N-methylnaltrexone had reduced length of stay compared with no N-methylnaltrexone (median 4 vs. 7 days, p < 0.01). Time to flatus and bowel movement, however, were similar. In a multivariable analysis controlling for possible confounders, however, the improvement in length of stay associated with N-methylnaltrexone use did not reach statistical significance (p = 0.11). Episodes of severe pain and composite gastrointestinal-related complications were reduced in the N-methylnaltrexone group (44.8% vs. 10.3%, p < 0.01). The reduction in length of stay was associated with approximately $10,500 in cost savings per patient. CONCLUSIONS In this study, N-methylnaltrexone was associated with reduced length of stay, fewer episodes of severe pain, and reduced costs. These results provide the impetus for further study.
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Shi H, Li J, Li K, Yang X, Zhu Z, Tian D. Minimally invasive versus open radical cystectomy for bladder cancer: A systematic review and meta-analysis. J Int Med Res 2019; 47:4604-4618. [PMID: 31638461 PMCID: PMC6997785 DOI: 10.1177/0300060519864806] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background We performed a systematic review and meta-analysis to evaluate the efficacy and safety of minimally invasive radical cystectomy (MIRC) versus open radical cystectomy (ORC) for bladder cancer. Methods We searched the EMBASE and MEDLINE databases to identify randomized controlled trials (RCTs) of MIRC versus ORC in the treatment of bladder cancer. Results Eight articles describing nine RCTs (803 patients) were analyzed. No significant differences were found between MIRC and ORC in two oncologic outcomes: the recurrence rate and mortality. Additionally, no significant differences were found in three pathologic outcomes: lymph node yield, positive lymph nodes, and positive surgical margins. With respect to perioperative outcomes, however, MIRC showed a significantly longer operating time, less estimated blood loss, lower blood transfusion rate, shorter time to regular diet, and shorter length of hospital stay than ORC. The incidence of complications was similar between the two techniques. We found no statistically significant differences in the above outcomes between robot-assisted radical cystectomy and ORC or between laparoscopic radical cystectomy and ORC with the exception of the complication rate. Conclusions MIRC is an effective and safe surgical approach in the treatment of bladder cancer. However, a large-scale multicenter RCT is needed to confirm these findings.
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Affiliation(s)
- Hongbin Shi
- Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Jiangsong Li
- Department of Urology, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Kui Li
- Department of Urology Surgery, The People's Hospital of Yucheng, Yucheng, China
| | - Xiaobo Yang
- Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Zaisheng Zhu
- Department of Urology, Jinhua Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Daxue Tian
- Department of Urology, Jinhua Hospital, Zhejiang University School of Medicine, Zhejiang, China
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10
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Chen J, Djaladat H, Schuckman AK, Aron M, Desai M, Gill IS, Clifford TG, Ghodoussipour S, Miranda G, Cai J, Daneshmand S. Surgical approach as a determinant factor of clinical outcome following radical cystectomy: Does Enhanced Recovery After Surgery (ERAS) level the playing field? Urol Oncol 2019; 37:765-773. [DOI: 10.1016/j.urolonc.2019.06.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/28/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023]
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11
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Tzelves L, Skolarikos A, Mourmouris P, Lazarou L, Kostakopoulos N, Manatakis DK, Kural AR. Does the Use of a Robot Decrease the Complication Rate Adherent to Radical Cystectomy? A Systematic Review and Meta-Analysis of Studies Comparing Open with Robotic Counterparts. J Endourol 2019; 33:971-984. [PMID: 31161777 DOI: 10.1089/end.2019.0226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction: Radical cystectomy (RC) is the mainstay of treatment for muscle-invasive bladder cancer. In 2003, the first robot-assisted radical cystectomy (RARC) was performed and since then many studies, mainly observational, were conducted to compare robotic and open methods. This study aims to assess perioperative outcomes between the two methods based on pooled data from existing literature. Methods: A literature search of articles in English and French languages was performed in three databases (Medline, Embase, and Cochrane) until 30th of June 2018, as well as in urology conference programs and reference lists of included studies. The study protocol was registered at PROSPERO (CRD42018103063). Terms such as "robotic," "open," and "radical cystectomy" and synonyms were used for the searching algorithm. The primary outcome was the number of minor and major postoperative complications (Clavien grading system). Risk of bias was assessed with the Cochrane tool and Newcastle-Ottawa scale. Comparison of continuous outcomes was performed with weighted mean differences, while for dichotomous outcomes, odds ratios (ORs) were used. Review Manager 5.3 was used. Results: Fifty-four studies (5 randomized trials and 49 observational) were eligible, including 29,697 patients (6500 in the RARC group and 23,197 in the open radical cystectomy group). Minor complications (grade 1-2) in pooled data of 29 studies were fewer in the RARC group (OR = 0.54, 95% confidence interval [CI]: 0.38-0.76, p < 0.001), a difference persisting after sensitivity analysis for 30 and 90 days. Major complications (grade 3-5) in 31 studies were fewer in the RARC group (OR = 0.78, 95% CI: 0.65-0.94, p = 0.009), but this difference disappeared in the 30-day subanalysis. RARC was associated with lower blood transfusion rates (p < 0.001), lower length of stay (p < 0.001), faster return to regular diet (p < 0.001), and lower postoperative mortality rates (p < 0.001), but longer operating time. Conclusions: RARC appears to be associated with fewer complications and favoring perioperative outcomes in comparison with the open method. Due to the observational nature of most studies, larger randomized trials are needed to confirm these findings.
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Affiliation(s)
- Lazaros Tzelves
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas Skolarikos
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Mourmouris
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Lazaros Lazarou
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Kostakopoulos
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ali Riza Kural
- Department of Urology, School of Medicine, Acibadem Maslak Hospital, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
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12
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Carrion A, Piñero A, Raventós C, Lozano F, Díaz F, Morote J. Comparison of perioperative outcomes and complications of robot assisted radical cystectomy with extracorporeal vs intracorporeal urinary diversion. Actas Urol Esp 2019; 43:277-283. [PMID: 31036392 DOI: 10.1016/j.acuro.2019.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/21/2018] [Accepted: 01/04/2019] [Indexed: 01/30/2023]
Abstract
OBJECTIVES To compare perioperative outcomes and complications of robot assisted radical cystectomy (RARC) with extracorporeal (ECUD) vs. intracorporeal urinary diversion (ICUD) for bladder cancer. MATERIAL AND METHODS Retrospective revision of 43 patients who underwent RARC for bladder cancer between 2015-2018 with at least 3 months of follow-up. The analysis included the initial series of RARC performed by one surgeon with extensive experience in open radical cystectomy. RESULTS Forty-three patients, 40 men (93%) and 3 women (7%), with a median age of 65 years (44-83) and mean follow-up of 27.7 months (±20.1) underwent RARC. A ECUD was performed in 22 cases (51%), of whom 10 were ileal conduits (45.5%) and 12 neobladders (54.5), and ICUD in 21 cases (49%), of whom 14 were ileal conduits (66.7%) and 7 neobladders (33.3%). Clinical and preoperative characteristics were similar in both groups. The median operative time was 360 minutes (240-540) and length of hospital stay was 12 days (7-73). Thirty-five patients (81%) had postoperative complications, of whom 10 (23%) were major. Operative time, peroperative complications, pathological stage, positive margins, and number of lymph nodes removed did not significantly differ among groups. Patients who underwent ECUD had a higher rate of uretero-ileal strictures than those with ICUD (45.5% vs. 14.3%, P=.026). Among the neobladders, the ECUD developed a higher rate of urethro-neobladder stricture than the ICUD (33% vs. 0%, P=.044). CONCLUSIONS RARC with ICUD achieved peroperative outcomes and complication rates comparable than those with ECUD. The ICUD could reduce the risk of developing uretero-ileal and urethro-neobladder strictures.
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Affiliation(s)
- A Carrion
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España.
| | - A Piñero
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - C Raventós
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - F Lozano
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - F Díaz
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - J Morote
- Departamento de Urología, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
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13
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Tyritzis SI, Gaya JM, Wallestedt-Lantz A, Pini G, Everaerts W, de Naeyer G, Palou J, Kelly J, Wiklund NP. Current role of robotic bladder cancer surgery. MINERVA UROL NEFROL 2019; 71:301-308. [PMID: 31086134 DOI: 10.23736/s0393-2249.19.03435-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in urology, that is not devoid of postoperative complications. Minimally invasive surgery, and especially robot-assisted RC (RARC) has emerged as an alternative to open RC (ORC) in an attempt to minimize surgical morbidity and facilitate the surgical approach. The aim of this paper was to present the current knowledge on the oncological efficacy and complication outcomes of RARC. EVIDENCE ACQUISITION A non-systematic review on all relevant studies with the keywords "Radical cystectomy," "Open," "Robot-assisted," "Complications," "Recurrence," "Survival," "Neobladder," "Potency," "Continence" and "Intracorporeal" was performed using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) Guidelines. EVIDENCE SYNTHESIS RARC shows similar lymph node yields and positive surgical margin rates as well as perioperative complication outcomes compared with ORC. RARC exhibits significantly less blood loss and less intra- and postoperative blood transfusion. Moreover, survival and recurrence rates are not related to the surgical approach. Finally, RARC seems to be more expensive and has a longer operating time compared to the open technique. CONCLUSIONS As current evidence shows, RARC seems as a technically feasible and safe procedure, providing equivalent perioperative and oncological results compared to ORC. More prospective, randomized-controlled trials are necessary to draw definitive conclusions on all comparative aspects.
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Affiliation(s)
- Stavros I Tyritzis
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden - .,Department of Urology, HYGEIA Hospital, Athens, Greece -
| | - Josep M Gaya
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - Anna Wallestedt-Lantz
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden
| | - Giovannalberto Pini
- Department of Urology, San Raffaele Turro Hospital, San Raffaele University, Milan, Italy
| | - Wouter Everaerts
- Department of Urology, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Joan Palou
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - John Kelly
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospital, London, UK
| | - Nils P Wiklund
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden.,ICAHN School of Medicine, Mount Sinai Hospital, New York, NY, USA
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14
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[Urology - what are the most important trends over the last decade?]. MMW Fortschr Med 2018; 160:99-102. [PMID: 30421185 DOI: 10.1007/s15006-018-1134-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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15
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The age of robotic surgery - Is laparoscopy dead? Arab J Urol 2018; 16:262-269. [PMID: 30140462 PMCID: PMC6104663 DOI: 10.1016/j.aju.2018.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/24/2018] [Accepted: 07/10/2018] [Indexed: 01/06/2023] Open
Abstract
Introduction Robot-assisted laparoscopic surgery (RALS) has become a widely used technology in urology. Urological procedures that are now being routinely performed robotically are: radical prostatectomy (RP), radical cystectomy (RC), renal procedures - mainly partial nephrectomy (PN), and pyeloplasty, as well as ureteric re-implantation and adrenalectomy. Methods This non-systematic review of the literature examines the effectiveness of RALS compared with conventional laparoscopic surgery for the most relevant urological procedures. Results For robot-assisted RP there seems to be an advantage in terms of continence and potency over laparoscopy. Robot-assisted RC seems equal in terms of oncological outcome but with lower complication rates; however, the effect of intracorporeal urinary diversion has hardly been examined. Robotic PN has proven safe and is most likely superior to conventional laparoscopy, whereas there does not seem to be a real advantage for the robot in radical nephrectomy. For reconstructive procedures, e.g. pyeloplasty and ureteric re-implantation, there seems to be advantages in terms of operating time. Conclusions We found substantial, albeit mostly low-quality evidence, that robotic operations can have better outcomes than procedures performed laparoscopically. However, in light of the significant costs and because high-quality data from prospective randomised trials are still missing, conventional urological laparoscopy is certainly not 'dead' yet.
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Key Words
- (RA)PN, (robot-assisted) partial nephrectomy
- (RA)RN, (robot-assisted) radical nephrectomy
- (RA)RP, (robot-assisted) radical prostatectomy
- (RA-)RPLND, (robot-assisted) retroperitoneal lymphadenectomy (RA)RC, (robot-assisted) radical cystectomy
- 3D, three-dimensional
- EAU, European Association of Urology
- ICG, indocyanine green
- IVC, inferior vena cava
- Laparoscopic
- NSGCT, non-seminomatous germ cell tumour
- PSM, positive surgical margin
- RAIL, robot-assisted inguinal lymphadenectomy
- RALS, robot-assisted laparoscopic surgery
- RALUR, robot-assisted laparoscopic ureteric re-implantation
- Robotic
- Robotic urological surgery
- Robotic-assisted radical prostatectomy
- WIT, warm ischaemia time
- dVSS, da Vinci Surgical System
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Kwon SY, Ha YS, Kim TH, Kwon TG. Erectile Function and Long-term Oncologic Outcomes of Nerve-Sparing Robot-Assisted Radical Cystectomy: Comparison With Open Radical Cystectomy. ACTA ACUST UNITED AC 2018. [DOI: 10.22465/kjuo.2018.16.1.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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17
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Abstract
Robot-assistance is being increasingly used for radical cystectomy (RC). Fifteen years of surgical evolution might be considered a short period for a radical procedure to be established as the treatment of choice, but robot assisted radical cystectomy (RARC) is showing promising results when compared with the current gold standard, open RC (ORC). In this review, we describe the current status of RARC and continue the discussion on the on-going RARC versus ORC debate.
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Affiliation(s)
- Stavros Ioannis Tyritzis
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Nils Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
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Tyritzis SI, Wiklund NP. Is the open cystectomy era over? An update on the available evidence. Int J Urol 2017; 25:187-195. [PMID: 29178344 DOI: 10.1111/iju.13497] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/18/2017] [Indexed: 12/24/2022]
Abstract
In 2018, robot-assisted radical cystectomy will enter its 15th year. In an era where an effort is being made to standardize complication reporting and videos of the procedure are readily available, it is inevitable and justified that like everything novel, robot-assisted radical cystectomy should be scrutinized against the gold standard, open radical cystectomy. The present comparison is focused on several parameters: oncological, functional and complication outcomes, and direct and indirect costs. Meta-analysis and prospective randomized trials comparing robot-assisted radical cystectomy versus open radical cystectomy have been published, showing an oncological equivalence and in some cases an advantage of robot-assisted radical cystectomy in terms of postoperative morbidity. In the present review, we attempt to update the available knowledge on this debate and discuss the limitations of the current evidence that prevent us from drawing safe conclusions.
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Affiliation(s)
- Stavros I Tyritzis
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - N Peter Wiklund
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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Balbay MD, Koc E, Canda AE. Robot-assisted radical cystectomy: patient selection and special considerations. ROBOTIC SURGERY (AUCKLAND) 2017; 4:101-106. [PMID: 30697568 PMCID: PMC6193425 DOI: 10.2147/rsrr.s119858] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Robot-assisted (RA) procedures are increasingly being performed as minimally invasive surgical approaches. Less insensible losses due to a closed abdomen, smaller incisions with less retractor strain, decreased analgesic requirements, and earlier postoperative ambulation are suggested advantages of robot-assisted radical cystectomy (RARC). Patients who undergo open radical cystectomy are also candidates for RARC procedure. However, the steep Trendelenburg position and pneumoperitoneum develop a non-physiological condition. Intra-abdominal adhesions preventing the placement of the ports and patients who cannot tolerate the pneumoperitoneum and/or steep Trendelenburg position are special contraindications of RARC. Besides, body mass index >30 kg/m2, presence of extravesical disease, bulky lymphadenopathy, previous vascular surgery, previous distal colorectal surgery, previous pelvic radiation, previous pelvic trauma, and/or preexisting cardiovascular/pulmonary disease that is compromised with positioning are not certainly contraindicated but unwanted conditions in which the RARC may be performed successfully as the surgeons gain experience.
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Affiliation(s)
| | - Erdem Koc
- Department of Urology, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
| | - Abdullah Erdem Canda
- Department of Urology, School of Medicine, Ankara Ataturk Training and Research Hospital, Yildirim Beyazit University, Ankara, Turkey
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