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Adamczyk P, Pobłocki P, Kadlubowski M, Ostrowski A, Mikołajczak W, Drewa T, Juszczak K. Complication Rate after Radical Cystectomy Depends on the Surgical Technique and Patient's Clinical Status. Urol Int 2021; 106:163-170. [PMID: 34352785 DOI: 10.1159/000517787] [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: 12/16/2020] [Accepted: 06/02/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE This study aimed to explore the complication rates of radical cystectomy in patients with muscle-invasive bladder cancer and identify potential risk factors. METHODS A total of 553 patients were included: 131 were operated on via an open approach (ORC), 242 patients via a laparoscopic method (LRC), and 180 by a robot-assisted procedure (RARC). Patient age, gender, American Society of Anesthesiologists (ASA) score, urinary diversion type, preoperative albumin level, body mass index (BMI), pathological (TNM) stage, and surgical times were collected. The severity of complications was classified according to the Clavien-Dindo scale (Grades 1-5). RESULTS The surgical technique was significantly related to the number of complications (p < 0.00005). Grade 1 complications were observed most frequently following LRC (52.5%) and RARC (51.1%), whereas mostly Grade 2 complications were detected after ORC (78.6%). Those with less severe complications had significantly higher albumin levels than those with more severe complications (p < 0.05). Patients with an elevated BMI had fewer complications if a minimally invasive approach was used rather than ORC. The patient's general condition (ASA score) did not impact the number of complications, and urinary diversion type did not affect the severity of the complications. Mean surgical time differed according to the urinary diversion type in patients with a similar TNM stage (p < 0.005); however, no difference was found in those with more locally advanced disease. Longer operation time and lower protein concentration were associated with higher probability of complication rate, that is, Clavien-Dindo score 3-5. CONCLUSIONS The risk of complications after RC is not related to the type of urinary diversion, and can be reduced by using a minimally invasive surgical technique, especially in patients with high BMI.
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Affiliation(s)
- Przemysław Adamczyk
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland
| | - Paweł Pobłocki
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland
| | - Mateusz Kadlubowski
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland
| | - Adam Ostrowski
- Clinic of General and Oncologic Urology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Witold Mikołajczak
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland
| | - Tomasz Drewa
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland.,Clinic of General and Oncologic Urology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Kajetan Juszczak
- Clinic of General and Oncologic Urology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
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Huynh MJ, Wang Y, Chang SL, Tully KH, Chung BI, Wright JL, Mossanen M. The cost of obesity in radical cystectomy. Urol Oncol 2020; 38:932.e9-932.e14. [PMID: 32620482 DOI: 10.1016/j.urolonc.2020.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/13/2020] [Accepted: 05/11/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The prevalence of obesity is on the rise in the Unites States, and obesity has been associated with increased complications and costs in a variety of complex surgeries. However, the contribution of obesity to the overall costs of radical cystectomy has not been studied in detail using contemporary data. Our objective is to assess the variation in healthcare costs due to obesity on the index hospitalization for radical cystectomy in the United States between 2003 and 2015. MATERIALS AND METHODS This was a retrospective cohort study, using the Premier Healthcare Database, of 1,242 patients who underwent radical cystectomy and were either overweight (25 ≤ body mass index [BMI] < 30), obese (30 ≤ BMI < 40), or morbidly obese (BMI ≥ 40). The primary outcome costs of the index hospitalization for each BMI category. Multivariable median regression was used to identify drivers of increased costs. RESULTS The cost of the index hospitalization for cystectomy was $24,596 (95% confidence interval [CI], $22,599-$26,592) for overweight patients. The costs for obese and morbidly obese patients were $2,158 (95% CI, -$80 to $4,395, P = 0.059) and $5,308 (95% CI, $2,652-$7,964, P < 0.001) higher compared to overweight patients, respectively. After adjustment for operative time or length of stay in the multivariable models, there were no longer any differences in cost. Operative time was prolonged as BMI increased (median operative time for overweight, obese, and morbidly obese: 346, 391, and 420 minutes, respectively P = 0.0001). Median length of stay was 1 day shorter for overweight vs. morbidly obese patients (P = 0.0030), with each additional day costing $1,738 (95% CI, $1,654 to $1,821, P < 0.0001) on multivariable analysis. CONCLUSIONS The cost of radical cystectomy is greater for obese and morbidly obese patients compared to overweight patients. The increased financial cost is driven by increased operative times and longer length of stay.
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Affiliation(s)
- Melissa J Huynh
- Division of Urologic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Ye Wang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Steven L Chang
- Division of Urologic Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA
| | - Karl H Tully
- Division of Urologic Surgery, Brigham and Women's Hospital, Boston, MA; Department of Urology and Neurourology, Marien Hospital Herne, Ruhr-University Bochum, Herne, Germany
| | | | - Jonathan L Wright
- Department of Urology, University of Washington, Seattle, WA; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Matthew Mossanen
- Division of Urologic Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA.
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Sanchez A, Kissel S, Coletta A, Scott J, Furberg H. Impact of body size and body composition on bladder cancer outcomes: Risk stratification and opportunity for novel interventions. Urol Oncol 2020; 38:713-718. [PMID: 32312642 DOI: 10.1016/j.urolonc.2020.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/28/2020] [Accepted: 03/20/2020] [Indexed: 01/06/2023]
Abstract
Body size is emerging as a novel and clinically-relevant patient factor in bladder cancer research. Historically, a patient's body mass index (BMI) has been used as a proxy for obesity but it shows inconsistent associations with risk of developing the disease as well as with most clinical outcomes. More specific body composition features can be derived for patients using a variety of methods. To date, skeletal muscle measurements derived from preoperative computed tomography scans have shown the most consistent associations with clinical outcomes. Importantly, skeletal muscle can potentially be modified through resistance training and/or nutritional interventions. Large scale studies that evaluate the prognostic impact of not only body composition features at baseline but also describe changes in body composition post-treatment are needed to move the field forward to ultimately improve clinical outcomes for bladder cancer patients.
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Affiliation(s)
- Alejandro Sanchez
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Suzanne Kissel
- Cancer Control and Population Sciences Program, Huntsman Cancer Institute, Salt Lake City, UT
| | - Adriana Coletta
- Cancer Control and Population Sciences Program, Huntsman Cancer Institute, Salt Lake City, UT; Department of Health, Kinesiology, and Recreation, The University of Utah, Salt Lake City, UT
| | - Jessica Scott
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Helena Furberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
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Risk factors and reasons for reoperation after radical cystectomy. Urol Oncol 2020; 38:269-277. [DOI: 10.1016/j.urolonc.2019.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/25/2019] [Accepted: 10/22/2019] [Indexed: 12/21/2022]
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Özkaptan O, Balaban M, Sevinc C, Topsakal M, Karadeniz T. Pelvic dimensions do not impact on complications and operative difficulty in radical cystoprostatectomy and orthotopic neobladder. MINERVA UROL NEFROL 2019; 71:386-394. [PMID: 31086130 DOI: 10.23736/s0393-2249.19.03195-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKROUND To evaluate the factors including pelvic dimensions, which might influence operative difficulty and complications after open radical cystoprostatectomy and orthotopic neobladder reconstruction in men. METHODS A total of 198 RC patients operated in our institution with preoperative magnetic resonance (MRI) were analyzed were included in the study. Pelvic dimensions, including interspinous distance (ISD), bony femoral - (BFW) and soft tissue width (SW), apical prostate depth (AD), upper conjugate (UC), lower conjugate (LC) were measured by preoperative MRI. BFW, ISD, and SW indexes were defined as BFW/AD, ISD/AD, and SW/AD, respectively. Complicatons were classified according to the Clavien-Dindo classification system. As indicators of surgical difficulty; transfusion rate (TR), estimated blood loss (EBL), operative time (OT) and hospital stay (HS) were assessed. SPSS version 17.0 was used for statistical analyses. RESULTS A total of 239 complications developed in 143 of the 198 patients (72.2%). Correlation analysis revealed a significant indirect relationship between TR and SW/AD (P=0.023). For EBL, there were significant indirect correlations between the SW/AD, BFW/AD and ISD/AD indexes (P=0.026, P=0.05, P=0.009; respectively). Additionally, OT was directly correlated body mass index (BMI) (P=0.001); and indirectly correlated with UC, SW/AD, and BFW/AD (P=0.047, P=0.038, P=0.016, respectively). On multivariate logistic regression analyses higher American Society of Anesthesiologist (ASA) score was associated with major complications. Multivariate analyses revealed that pathological stage was a significant predictor of EBL. CONCLUSIONS Patients with smaller pelvises might undergo more difficult surgeries. However, it seems that small sized pelvis does not impact on operative difficulty and complication rate in radical cystoprostatectomy and orthotopic neobladder.
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Affiliation(s)
| | - Muhsin Balaban
- Department of Urology, Biruni University School of Medicine, Istanbul, Turkey
| | - Cüneyd Sevinc
- Kartal Training and Training Hospital, Kartal, İstanbul
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Gierth M, Zeman F, Denzinger S, Vetterlein M, Fisch M, Bastian P, Syring I, Ellinger J, Müller S, Herrmann E, Gilfrich C, May M, Pycha A, Wagenlehner F, Vallo S, Bartsch G, Haferkamp A, Grimm MO, Roigas J, Protzel C, Hakenberg O, Fritsche HM, Burger M, Aziz A, Mayr R. Influence of Body Mass Index on Clinical Outcome Parameters, Complication Rate and Survival after Radical Cystectomy: Evidence from a Prospective European Multicentre Study. Urol Int 2018; 101:16-24. [DOI: 10.1159/000488466] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/14/2018] [Indexed: 01/24/2023]
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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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Dabi Y, El Mrini M, Duquesnes I, Delongchamps NB, Sibony M, Zerbib M, Xylinas E. Impact of body mass index on the oncological outcomes of patients treated with radical nephroureterectomy for upper tract urothelial carcinoma. World J Urol 2017; 36:65-71. [PMID: 29032451 DOI: 10.1007/s00345-017-2095-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 09/30/2017] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To evaluate the association between body mass index (BMI) and oncological outcomes in patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS We retrospectively reviewed 237 consecutive patients treated with RNU for UTUC at our institution between 1990 and 2012. Univariable and multivariable cox regression models investigated the association of BMI with disease recurrence, cancer-specific mortality, and overall mortality. RESULTS From the 237 patients, 104 (44%) had a BMI < 25 kg/m2, 88 (37%) had a BMI between 25 and 29.9 kg/m2, and 45 (19%) had a BMI ≥ 30 kg/m2 at the time of surgery. Within a median follow-up of 44 months (IQR: 24-79), 53 patients (22.4%) experienced a disease recurrence, 85 patients (35.9%) had bladder recurrence, and 44 patients (18.6%) died from the disease. The 5 year recurrence-free and cancer-specific survival rates were, respectively, 32 and 56% for BMI ≥ 30 kg/m2, 45 and 74% for patients with BMI 25-29.9 kg/m2, and 69 and 81% for patients with BMI < 25 kg/m2. In multivariable analyses that adjusted for the effects of the standard clinico-pathological features, BMI ≥ 30 kg/m2 was associated with a higher risk of disease recurrence (HR 3.23; 95% CI 2.3-6.6, p < 0.001) and cancer-specific mortality (HR 3.84; 95% CI 2.8-6.5; p < 0.001). CONCLUSIONS Obesity was independently associated with higher risks of disease recurrence and cancer-specific mortality in patients treated with RNU for UTUC.
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Affiliation(s)
- Yohann Dabi
- Department of Urology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Mohammed El Mrini
- Department of Urology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Igor Duquesnes
- Department of Urology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Nicolas Barry Delongchamps
- Department of Urology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Mathilde Sibony
- Department of Pathology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Marc Zerbib
- Department of Urology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Evanguelos Xylinas
- Department of Urology, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France.
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Ahmadi N, Clifford TG, Miranda G, Cai J, Aron M, Desai MM, Gill IS. Impact of body mass index on robot-assisted radical cystectomy with intracorporeal urinary diversion. BJU Int 2017; 120:689-694. [PMID: 28544311 DOI: 10.1111/bju.13916] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the impact of body mass index (BMI) on peri-operative and oncological outcomes after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion. PATIENTS AND METHODS A total of 216 patients undergoing RARC, extended lymphadenectomy and intracorporeal urinary diversion, between July 2010 and December 2015, were categorized into four BMI groups according to the 2004 World Health Organization obesity classification groups: <25 kg/m2 (normal); 25-29.9 kg/m2 (pre-obese); 30-34.9 kg/m2 (obese class I); and ≥35 kg/m2 (obese class II). Pre-, intra- and postoperative characteristics, oncological outcomes, and 90-day complications were compared using sas statistical software. RESULTS All 216 patients underwent intracorporeal urinary diversion, with 68 (32%) undergoing orthotopic neobladder construction. Demographics were similar among the BMI groups with regard to median (range) age (71.8 [35- 95] years), gender (80.6% men), Charlson comorbidity index (CCI) score (66.2% with CCI score 0-1), pathological stage (carcinoma in situ to T2: 55.1%, T3-T4/N0: 18.5%, Tx/N+: 26.4%), median (interquartile range) node count [41 (28, 53)] and positive soft tissue margin rate (4.2%). Obese patients had greater blood loss and longer operating time (P = 0.02 and P = 0.04, respectively). There were no significant differences in length of hospital stay, transfusion rates, readmission or 90-day overall and high-grade complication rates (P = 0.16, P = 0.96, P = 0.89, P = 0.22 and P = 0.51, respectively). At a median (range) follow-up of 13 months (15 days to 4.8 years), recurrence-free survival (P = 0.92) and overall survival (P = 0.68) were similar among the groups. CONCLUSION The results of the present study show that RARC with intracorporeal urinary diversion is safe and feasible in obese patients with bladder cancer. BMI was not associated with significant differences in peri-operative, pathological or early oncological outcomes.
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Affiliation(s)
- Nariman Ahmadi
- USC Institute of Urology, Keck Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Thomas G Clifford
- USC Institute of Urology, Keck Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Gus Miranda
- USC Institute of Urology, Keck Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Jie Cai
- USC Institute of Urology, Keck Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Monish Aron
- USC Institute of Urology, Keck Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Mihir M Desai
- USC Institute of Urology, Keck Medicine of USC, University of Southern California, Los Angeles, CA, USA
| | - Inderbir S Gill
- USC Institute of Urology, Keck Medicine of USC, University of Southern California, Los Angeles, CA, USA
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Parker WP, Tollefson MK, Heins CN, Hanson KT, Habermann EB, Zaid HB, Frank I, Thompson RH, Boorjian SA. Characterization of perioperative infection risk among patients undergoing radical cystectomy: Results from the national surgical quality improvement program. Urol Oncol 2016; 34:532.e13-532.e19. [PMID: 27503783 DOI: 10.1016/j.urolonc.2016.07.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/24/2016] [Accepted: 07/05/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the incidence, risk factors, and timing of infections following radical cystectomy (RC). METHODS The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patients undergoing RC for bladder cancer from 2006 to 2013. Characteristics including year of surgery, age, sex body mass index, diabetes, smoking, renal function, steroid usage, preoperative albumin, preoperative hematocrit, perioperative blood transfusion (PBT), and operative time were assessed for association with the risk of infection within 30 days of RC using multivariable logistic regression. RESULTS A total of 3,187 patients who had undergone RC were identified, of whom 766 (24.0%) were diagnosed with a postoperative infection, at a median of 13 days (interquartile ranges 8-19) after RC. Infections included surgical site infection (SSI) (404; 12.7%), sepsis/septic shock (405; 12.7%), and urinary tract infection (UTI) (309; 9.7%). On multivariable analysis, body mass index≥30kg/m2 (odds ratios [OR] = 1.52; P<0.01), receipt of a PBT (OR = 1.27; P<0.01), and operative time≥480 minutes (OR = 1.72; P<0.01) were significantly associated with the risk of infection. When the outcomes of UTI, SSI, and sepsis were analyzed separately, operative time≥480 minutes remained independently associated with increased infection risk in each model (OR = 2.11 for UTI, OR = 1.63 for SSI, and OR = 1.80 for sepsis/septic shock; all P<0.05), whereas PBT was associated with SSI and sepsis/septic shock (OR = 1.33 and OR = 1.29, respectively; both P< 0.05). CONCLUSIONS Approximately 25% of patients undergoing RC experience an infection within 30 days of surgery. Several potentially modifiable risk factors for infection were identified, specifically PBT and prolonged operative time, which may represent opportunities for future care improvement.
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Affiliation(s)
| | | | - Courtney N Heins
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | | | - Igor Frank
- Department of Urology, Mayo Clinic, Rochester, MN
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Dabi Y, Rouscoff Y, Anract J, Delongchamps NB, Sibony M, Saighi D, Zerbib M, Peyraumore M, Xylinas E. Impact of body mass index on the oncological outcomes of patients treated with radical cystectomy for muscle-invasive bladder cancer. World J Urol 2016; 35:229-235. [PMID: 27272203 DOI: 10.1007/s00345-016-1852-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/10/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Body mass index (BMI) has been associated with worse outcomes in several solid malignancies. We aimed to evaluate the association between BMI and oncological outcomes in patients treated with radical cystectomy (RC) for muscle-invasive urothelial carcinoma of the bladder (UCB). METHODS We retrospectively reviewed 701 consecutive patients treated with RC and pelvic lymphadenectomy for UCB at our institution between 1995 and 2011. Univariable and multivariable Cox regression models investigated the association of BMI with disease recurrence and cancer-specific mortality. BMI was analyzed as both continuous and categorical variable (<25 vs. 25-29 vs. ≥30 kg/m2). RESULTS From the 701 patients, 275 (39.2 %) had a BMI < 25 kg/m2, 280 (39.9 %) had a BMI between 25 and 29.9 kg/m2, and 146 (20.9 %) had a BMI ⩾ 30 kg/m2. Within a median follow-up of 45 months (IQR 23-75), 163 patients (23.3 %) experienced a disease recurrence and 127 (18.1 %) died from the disease. In univariable analyses, BMI ⩾ 30 kg/m2 was associated with a higher risk of disease recurrence and cancer-specific mortality (both p values <0.01). In multivariable analyses that adjusted for the effects of standard clinicopathological features, BMI ⩾ 30 kg/m2 was associated with both higher risks of disease recurrence (HR 1.58; 95 % CI 1.06-2.34, p = 0.02) and cancer-specific mortality (HR 1.58; 95 % CI 1.01-2.48; p = 0.04). CONCLUSIONS Obesity was independently associated with higher risks of disease recurrence and cancer-specific mortality in patients treated with RC for muscle-invasive UCB. BMI is a modifiable feature that may have significant individual and public health implications in patients with muscle-invasive UCB.
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Affiliation(s)
- Yohann Dabi
- Department of Urology, Cochin Hospital, APHP, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Yohann Rouscoff
- Department of Urology, Cochin Hospital, APHP, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Julien Anract
- Department of Urology, Cochin Hospital, APHP, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Nicolas Barry Delongchamps
- Department of Urology, Cochin Hospital, APHP, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Mathilde Sibony
- Department of Pathology, Cochin Hospital, APHP, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Djillali Saighi
- Department of Urology, Cochin Hospital, APHP, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Marc Zerbib
- Department of Urology, Cochin Hospital, APHP, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Michael Peyraumore
- Department of Urology, Cochin Hospital, APHP, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Evanguelos Xylinas
- Department of Urology, Cochin Hospital, APHP, Paris Descartes University, 27, rue du Faubourg Saint-Jacques, 75014, Paris, France.
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Parker WP, Toussi A, Tollefson MK, Frank I, Thompson RH, Zaid HB, Thapa P, Boorjian SA. Risk Factors and Microbial Distribution of Urinary Tract Infections Following Radical Cystectomy. Urology 2016; 94:96-101. [PMID: 27125878 DOI: 10.1016/j.urology.2016.03.049] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/08/2016] [Accepted: 03/29/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate clinicopathologic features associated with the risk of urinary tract infection (UTI) after radical cystectomy (RC), and determine the underlying organisms responsible for these events. MATERIALS AND METHODS We reviewed 1248 patients treated with RC for bladder cancer from 2000 to 2010 at Mayo Clinic. UTIs diagnosed within 90 days of surgery were recorded. Multivariable logistic regression analysis was performed to evaluate the association of clinicopathologic features with postoperative UTI. RESULTS UTI was diagnosed in 129 (10.3%) patients within 90 days of RC. Median time to UTI was 22.5 days (interquartile range 14,42). On multivariable analysis, factors associated with a significantly increased UTI risk were diabetes (odds ratio [OR] 2.27; P < .001), receipt of a perioperative blood transfusion (OR 1.58; P = .03), continent urinary diversion (OR 2.17;P < .001), and development of a urine leak (OR 3.42;P < .001). Culture-specific infection data were available for 88 of the patients, with a total of 113 UTIs diagnosed among this cohort. Of these, 36.8% of UTIs were polymicrobial. Drug-resistant Staphylococcus aureus and Enterococcus were isolated in 45.0% and 12.8% of infections, respectively. Fungal elements were present in 27 (23.9%) cultures, and were the sole organism in 15 (13.3%). No significant differences in microbial distribution or timing of infections were detected between patients who underwent conduit vs continent diversion. CONCLUSION We found that diabetes, perioperative blood transfusion, continent diversion, and urine leak were associated with UTI risk following RC. Multiple organisms, drug resistance, and fungal elements were commonly identified, supporting the use of initial broad-spectrum coverage, including consideration of antifungal therapy, upon diagnosis of UTI after RC.
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Affiliation(s)
| | - Amir Toussi
- Department of Urology, Mayo Clinic, Rochester, MN
| | | | - Igor Frank
- Department of Urology, Mayo Clinic, Rochester, MN
| | | | | | - Prabin Thapa
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
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Complications from robot-assisted radical cystectomy: Where do we stand? Actas Urol Esp 2016; 40:108-14. [PMID: 25914065 DOI: 10.1016/j.acuro.2015.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 03/13/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Radical cystectomy with extended lymphadenectomy is the surgical treatment of choice for muscle-invasive bladder cancer. The technical and technological improvements and the positive results from robot-assisted kidney and prostate surgery have led to the progressive development of robot-assisted radical cystectomy (RARC). We provide a global structured overview and an update on the complications of RARC, recorded according to the Clavien-Dindo classification system. ACQUISITION OF EVIDENCE We conducted a search on PubMed of all publications on RARC to date (2014). Of the 259 publications found, we excluded review articles and cost analyses, publications with less than 30 cases, updates of previous studies and those whose main objective was the study of other issues related to RARC other than complications, leaving a total of 38 articles for the final analysis. SUMMARY OF THE EVIDENCE The most common complications associated with RARC are gastrointestinal, infectious and genitourinary system, mainly Clavien 1-2, followed by Clavien 3-4. RARC had lower overall complication rates than open radical cystectomy and laparoscopic radical cystectomy and had a lower incidence of severe complications, less intraoperative bleeding and better postoperative recovery. CONCLUSIONS Although further scientific evidence is needed, RARC is an increasingly widespread technique that appears to reduce complications as well as the need for transfusion, and it improves recovery times.
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Bachir BG, Aprikian AG, Izawa JI, Chin JL, Fradet Y, Fairey A, Estey E, Jacobsen N, Rendon R, Cagiannos I, Lacombe L, Lattouf JB, Kapoor A, Matsumoto E, Saad F, Bell D, Black PC, So AI, Drachenberg D, Kassouf W. Effect of body mass index on the outcomes of patients with upper and lower urinary tract cancers treated by radical surgery: results from a Canadian multicenter collaboration. Urol Oncol 2014; 32:441-8. [PMID: 24412632 DOI: 10.1016/j.urolonc.2013.10.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 10/22/2013] [Accepted: 10/25/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effect of body mass index (BMI) on the outcomes of patients with urinary tract carcinoma treated with radical surgery. MATERIALS AND METHODS Data were collected from 10 Canadian centers on patients who underwent radical cystectomy (RC) (1998-2008) or radical nephroureterectomy (RNU) (1990-2010). Various parameters among subsets of patients (BMI < 25, 25 ≤ BMI < 30, and BMI ≥ 30 kg/m(2)) were analyzed. Kaplan-Meier and multivariate analyses were performed to assess the effect of BMI on overall survival, disease-specific survival, and recurrence-free survival (RFS). RESULTS Among the 847 RC and 664 RNU patients, there was no difference in histology, stage, grade, and margin status among the 3 patient subsets undergoing either surgery. However, RC patients with lower BMIs (< 25 kg/m(2)) were significantly older (P = 0.004), had more nodal metastasis (P = 0.03), and trended toward higher stage (P = 0.052). RNU patients with lower BMIs (< 25 kg/m(2)) were significantly older (P = 0.0004) and fewer received adjuvant chemotherapy (P = 0.04) compared with those with BMI ≥ 30 kg/m(2); however, there was no difference in tumor location (P = 0.20), stage (P = 0.48), and management of distal ureter among the groups (P = 0.30). On multivariate analysis, BMI was not prognostic for overall survival, disease-specific survival, and RFS in the RC group. However, BMI ≥ 30 kg/m(2) was associated with more bladder cancer recurrences and worse RFS in the RNU group (HR = 1.588; 95% CI: 1.148-2.196; P = 0.0052). CONCLUSIONS Increased BMI did not influence survival among RC patients. BMI ≥ 30 kg/m(2) is associated with worse bladder cancer recurrences among RNU patients; whether this is related to difficulty in obtaining adequate bladder cuff in patients with obesity requires further evaluation.
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Affiliation(s)
- Bassel G Bachir
- Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada
| | - Armen G Aprikian
- Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada
| | - Jonathan I Izawa
- Department of Surgery (Urology), Western University, London, Ontario, Canada
| | - Joseph L Chin
- Department of Surgery (Urology), Western University, London, Ontario, Canada
| | - Yves Fradet
- Department of Surgery (Urology), Laval University, Quebec City, Quebec, Canada
| | - Adrian Fairey
- Department of Surgery (Urology), University of Alberta, Edmonton, Alberta, Canada
| | - Eric Estey
- Department of Surgery (Urology), University of Alberta, Edmonton, Alberta, Canada
| | - Niels Jacobsen
- Department of Surgery (Urology), University of Alberta, Edmonton, Alberta, Canada
| | - Ricardo Rendon
- Department of Surgery (Urology), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ilias Cagiannos
- Department of Surgery (Urology), University of Ottawa, Ottawa, Ontario, Canada
| | - Louis Lacombe
- Department of Surgery (Urology), Laval University, Quebec City, Quebec, Canada
| | | | - Anil Kapoor
- Department of Surgery (Urology), McMaster University, Hamilton, Ontario, Canada
| | - Edward Matsumoto
- Department of Surgery (Urology), McMaster University, Hamilton, Ontario, Canada
| | - Fred Saad
- Department of Surgery (Urology), University of Montreal, Montreal, Quebec, Canada
| | - David Bell
- Department of Surgery (Urology), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Peter C Black
- Department of Surgery (Urology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Alan I So
- Department of Surgery (Urology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Darrel Drachenberg
- Department of Surgery (Urology), University of Manitoba, Winnipeg, Manitoba, Canada
| | - Wassim Kassouf
- Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada.
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Kaufman MR. Management of Stress Urinary Incontinence in the Neobladder Patient. CURRENT BLADDER DYSFUNCTION REPORTS 2013. [DOI: 10.1007/s11884-013-0207-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Silber JH, Rosenbaum PR, Ross RN, Even-Shoshan O, Kelz RR, Neuman MD, Reinke CE, Ludwig JM, Kyle FA, Bratzler DW, Fleisher LA. Racial disparities in operative procedure time: the influence of obesity. Anesthesiology 2013; 119:43-51. [PMID: 23719571 PMCID: PMC3889464 DOI: 10.1097/aln.0b013e31829101de] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Using Pennsylvania Medicare claims from 1995 to 1996, the authors previously reported that anesthesia procedure length appears longer in blacks than whites. In a new study using a different and larger data set, the authors now examine whether body mass index (BMI), not available in Medicare claims, explains this difference. The authors also examine the relative contributions of surgical and anesthesia times. METHODS The Obesity and Surgical Outcomes Study of 47 hospitals throughout Illinois, New York, and Texas abstracted chart information including BMI on elder Medicare patients (779 blacks and 14,596 whites) undergoing hip and knee replacement and repair, colectomy, and thoracotomy between 2002 and 2006. The authors matched all black Medicare patients to comparable whites and compared procedure lengths. RESULTS Mean BMI in the black and white populations was 30.24 and 28.96 kg/m, respectively (P<0.0001). After matching on age, sex, procedure, comorbidities, hospital, and BMI, mean white BMI in the comparison group was 30.1 kg/m (P=0.94). The typical matched pair difference (black-white) in anesthesia (induction to recovery room) procedure time was 7.0 min (P=0.0019), of which 6 min reflected the surgical (cut-to-close) time difference (P=0.0032). Within matched pairs, where the difference in procedure times was greater than 30 min between patients, blacks more commonly had longer procedure times (Odds=1.39; P=0.0008). CONCLUSIONS Controlling for patient characteristics, BMI, and hospital, elder black Medicare patients experienced slightly but significantly longer procedure length than their closely matched white controls. Procedure length difference was almost completely due to surgery, not anesthesia.
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Affiliation(s)
- Jeffrey H Silber
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Abstract
OBJECTIVE To analyze incidence, outcomes, and utilization of health care resources in liver transplantation (LT) for nonalcoholic steatohepatitis (NASH). SUMMARY OF BACKGROUND DATA With the epidemic of obesity and metabolic syndrome in nearly 33% of the US population, NASH is projected to become the leading indication for LT in the next several years. Data on predictors of outcome and utilization of health care resources after LT in NASH is limited. METHODS We conducted an analysis from our prospective database of 144 adult NASH patients who underwent LT between December 1993 and August 2011. Outcomes and resource utilization were compared with other common indications for LT. Independent predictors of graft and patient survival were identified. RESULTS The average Model for End-Stage Liver Disease score was 33. The frequency of NASH as the primary indication for LT increased from 3% in 2002 to 19% in 2011 to become the second most common indication for LT at our center behind hepatitis C. NASH patients had significantly longer operative times (402 vs 322 minutes; P < 0.001), operative blood loss (18 vs 14 packed red blood cell units; P = 0.001), and posttransplant length of stay (35 vs 29 days; P = 0.032), but 1-, 3-, and 5-year graft (81%, 71%, 63%) and patient (84%, 75%, 70%) survival were comparable with other diagnoses. Age greater than 55 years, pretransplant intubation, dialysis, hospitalization, presence of hepatocellular carcinoma on explant, donor age greater than 55 years, and cold ischemia time greater than 550 minutes were significant independent predictors of survival for all patients, whereas body mass index greater than 35 was a predictor in NASH patients only. CONCLUSIONS We report the largest single institution experience of LT for NASH. Over a 10-year period, the frequency of LT for NASH has increased 5-fold. Although outcomes are comparable with LT for other indications, health care resources are stressed significantly by this new and increasing group of transplant candidates.
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Xylinas E, Rink M, Novara G, Green DA, Clozel T, Fritsche HM, Guillonneau B, Lotan Y, Kassouf W, Tilki D, Babjuk M, Karakiewicz PI, Montorsi F, Abdennabi J, Trinh QD, Svatek RS, Scherr DS, Zerbib M, Shariat SF. Predictors of Survival in Patients With Soft Tissue Surgical Margin Involvement at Radical Cystectomy. Ann Surg Oncol 2012; 20:1027-34. [DOI: 10.1245/s10434-012-2708-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Indexed: 11/18/2022]
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Abstract
OBJECTIVE To study the medical and financial outcomes associated with surgery in elderly obese patients and to ask if obesity itself influences outcomes above and beyond the effects from comorbidities that are known to be associated with obesity. BACKGROUND Obesity is a surgical risk factor not present in Medicare's risk adjustment or payment algorithms, as BMI is not collected in administrative claims. METHODS A total of 2045 severely or morbidly obese patients (BMI ≥ 35 kg/m, aged between 65 and 80 years) selected from 15,914 elderly patients in 47 hospitals undergoing hip and knee surgery, colectomy, and thoracotomy were matched to 2 sets of 2045 nonobese patients (BMI = 20-30 kg/m). A "limited match" controlled for age, sex, race, procedure, and hospital. A "complete match" also controlled for 30 additional factors such as diabetes and admission clinical data from chart abstraction. RESULTS Mean BMI in the obese patients was 40 kg/m compared with 26 kg/m in the nonobese. In the complete match, obese patients displayed increased odds of wound infection: OR (odds ratio) = 1.64 (95% CI: 1.21, 2.21); renal dysfunction: OR = 2.05 (1.39, 3.05); urinary tract infection: OR = 1.55 (1.24, 1.94); hypotension: OR = 1.38 (1.07, 1.80); respiratory events: OR = 1.44 (1.19, 1.75); 30-day readmission: OR = 1.38 (1.08, 1.77); and a 12% longer length of stay (8%, 17%). Provider costs were 10% (7%, 12%) greater in obese than in nonobese patients, whereas Medicare payments increased only 3% (2%, 5%). Findings were similar in the limited match. CONCLUSIONS Obesity increases the risks and costs of surgery. Better approaches are needed to reduce these risks. Furthermore, to avoid incentives to underserve this population, Medicare should consider incorporating incremental costs of caring for obese patients into payment policy and include obesity in severity adjustment models.
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Horstmann M, Kugler M, Anastasiadis AG, Walcher U, Herrmann T, Nagele U. Laparoscopic radical cystectomy: initial experience using the single-incision triangulated umbilical surgery (SITUS) technique. World J Urol 2012; 30:619-24. [DOI: 10.1007/s00345-012-0909-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/09/2012] [Indexed: 02/07/2023] Open
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Chromecki TF, Cha EK, Fajkovic H, Rink M, Ehdaie B, Svatek RS, Karakiewicz PI, Lotan Y, Tilki D, Bastian PJ, Daneshmand S, Kassouf W, Durand M, Novara G, Fritsche HM, Burger M, Izawa JI, Brisuda A, Babjuk M, Pummer K, Shariat SF. Obesity is associated with worse oncological outcomes in patients treated with radical cystectomy. BJU Int 2012; 111:249-55. [DOI: 10.1111/j.1464-410x.2012.11322.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
| | - Eugene K. Cha
- Weill Medical College of Cornell University; New York; NY; USA
| | | | | | - Behfar Ehdaie
- Weill Medical College of Cornell University; New York; NY; USA
| | - Robert S. Svatek
- University of Texas Health Science Center San Antonio; San Antonio; TX; USA
| | | | - Yair Lotan
- University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - Derya Tilki
- Ludwig-Maximilians-University Munich, Klinikum Grosshadern; Munich; Germany
| | - Patrick J. Bastian
- Ludwig-Maximilians-University Munich, Klinikum Grosshadern; Munich; Germany
| | - Siamak Daneshmand
- University of Southern California Keck School of Medicine and Norris Comprehensive Cancer Center; Los Angeles; CA; USA
| | | | - Matthieu Durand
- Weill Medical College of Cornell University; New York; NY; USA
| | | | | | - Maximilian Burger
- Caritas St Josef Medical Centre; University of Regensburg; Regensburg; Germany
| | | | - Antonin Brisuda
- Hospital Moto; 2nd Faculty of Medicine; Charles University; Praha; Czech Republic
| | - Marek Babjuk
- Hospital Moto; 2nd Faculty of Medicine; Charles University; Praha; Czech Republic
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Poch MA, Stegemann A, Chandrasekhar R, Hayn M, Wilding G, Guru KA. Does body mass index impact the performance of robot-assisted intracorporeal ileal conduit? J Endourol 2012; 26:857-60. [PMID: 22332715 DOI: 10.1089/end.2011.0554] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Body mass index (BMI) has been shown to influence perioperative outcomes for patients undergoing open radical cystectomy and urinary diversion. The impact of BMI on robot-assisted intracorporeal ileal conduit has not been studied. PATIENTS AND METHODS All patients undergoing robot-assisted radical cystectomy (RARC) with ileal conduit at our institution were offered intracorporeal ileal conduit beginning May 2009. Fifty-six consecutive patients underwent robot-assisted radical cystectomy with intracorporeal ileal conduit from May of 2009 to July 2010. Patients were categorized into three groups based on BMI: Normal (BMI < 25 kg/m(2)), overweight (BMI=25-29 kg/m(2)), and obese (BMI ≥ 30 kg/m(2)). The effect of BMI on intraoperative and postoperative outcomes was assessed by retrospective review of a comprehensive RARC quality assurance database. RESULTS Median age at cystectomy was 72 (range 42-87 y), and 75% of patients were male. Median follow-up for the entire cohort was 5 months (range 12 d-16 mos). Median BMI was 27 kg/m(2) (range 19-47 kg/m(2)), and 75% of patients were overweight or obese. Age, ASA score, and overall operative time were not significantly different among the normal, overweight, and obese patients. Median urinary diversion times were 95, 151, and 124 minutes for normal, overweight, and obese patients, respectively (P=0.13). CONCLUSIONS Robot-assisted intracorporeal ileal conduit can be safely performed in all body mass indices. Further studies are needed to assess long-term conduit function and stomal complications.
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Affiliation(s)
- Michael A Poch
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York 14263, USA.
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Stewart SB, Freedland SJ. Influence of obesity on the incidence and treatment of genitourinary malignancies. Urol Oncol 2011; 29:476-86. [DOI: 10.1016/j.urolonc.2009.12.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2009] [Revised: 12/11/2009] [Accepted: 12/15/2009] [Indexed: 11/29/2022]
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Shariat SF, Lee R, Lowrance WT, Bochner BH. The effect of age on bladder cancer incidence, prognosis and therapy. ACTA ACUST UNITED AC 2010. [DOI: 10.2217/ahe.10.61] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Age is now widely accepted as the single greatest risk factor for developing urothelial carcinoma of the bladder (UCB). The aim of this article is to assess the incidence, prognosis and therapy of UCB in the elderly. Using MEDLINE, we performed a search of the literature between January 1966 and July 2009. The link between aging and cancer is more complex than the simple passage of time; certain genes may be activated while others may be suppressed with advancing age. Treatments for nonmuscle-invasive UCB are generally well-tolerated by the elderly. However, several studies have demonstrated a lower response rate to intravesical immunotherapy in the elderly. While elderly patients have a higher rate of perioperative complication and mortality after radical cystectomy, the difference is too small and insufficient to avoid radical cystectomy in these patients. Similarly, in certain selected cases, centers of excellence report similar complication rates in elderly patients, regardless of the type of urinary diversion. The optimal application of perioperative chemotherapy is dependent on the degree of compromise of the organ systems through comorbid conditions and physiologic deterioration. Restrictive case selection and proactive postoperative rehabilitation are important for elderly patients to obtain good results. Age alone does not preclude optimal treatment for patients with aggressive UCB. Radical surgery, urinary diversion and systemic chemotherapy are feasible, safe and efficacious in the treatment of adequately selected elderly UCB patients. It is imperative that healthcare practitioners and researchers from disparate disciplines collectively focus their efforts to appropriately meet the multifaceted medical and psychosocial needs of the elderly.
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Affiliation(s)
- Shahrokh F Shariat
- Urology Service/Department of Surgery, Memorial Sloan-Kettering Cancer Center, NY, USA
- Department of Urology, Weill Medical College of Cornell University, 525 East 68th Street, NY, USA
| | - Richard Lee
- Urology Service/Department of Surgery, Memorial Sloan-Kettering Cancer Center, NY, USA
- Department of Urology, Weill Medical College of Cornell University, 525 East 68th Street, NY, USA
| | - William T Lowrance
- Urology Service/Department of Surgery, Memorial Sloan-Kettering Cancer Center, NY, USA
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Age and body mass index are independent risk factors for the development of postoperative paralytic ileus after radical cystectomy. Urology 2010; 76:1419-24. [PMID: 20472264 DOI: 10.1016/j.urology.2010.02.053] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 02/15/2010] [Accepted: 02/15/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To identify the risk factors that would aid in the identification of patients at the greatest risk of developing postoperative paralytic ileus (POI). POI is a common complication after radical cystectomy and can result in a prolonged hospital stay and delayed recovery. METHODS A retrospective cohort study design was used to analyze data from consecutive patients presenting to our institution for radical cystectomy with pelvic nodal dissection. POI was declared if patients were without evidence of bowel function beyond the anticipated discharge goal of 6 days. The association between several clinical features and the occurrence of POI was examined. RESULTS Of 283 patients, 43 (15.2%) developed POI. Of the 43 patients, 38 (88.4%) were given total parenteral nutrition for nutritional supplementation. No difference in the incidence of POI was observed between the sexes, previous abdominal operations, estimated blood loss, transfusion requirement, operative time, neoadjuvant chemotherapy, or previous radiotherapy. POI was observed in 11.3% of normal and overweight patients (body mass index [BMI] <30.0 kg/m(2)) compared with 25.6% of obese patients (BMI ≥30.0 kg/m(2); P = .005). On multivariate analysis adjusted for the influence of competing variables, increasing age (hazard ratio 1.09, 95% confidence interval 1.02-1.16, P = .008) and BMI (hazard ratio 1.09, 95% confidence interval 1.03-1.17, P = .007) were significantly associated with the presence of POI. CONCLUSIONS Our results showed that increasing age and BMI were significantly associated with the presence of POI in patients undergoing radical cystectomy for bladder cancer.
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Batsis JA, Huddleston JM, Melton LJ, Huddleston PM, Larson DR, Gullerud RE, McMahon MM. Body mass index (BMI) and risk of noncardiac postoperative medical complications in elderly hip fracture patients: a population-based study. J Hosp Med 2009; 4:E1-9. [PMID: 19824100 PMCID: PMC2780331 DOI: 10.1002/jhm.527] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Obese patients are thought to be at higher risk of postoperative medical complications. We determined whether body mass index (BMI) is associated with postoperative in-hospital noncardiac complications following urgent hip fracture repair. METHODS We conducted a population-based study of Olmsted County, Minnesota, residents operated on for hip fracture in 1988 to 2002. BMI was categorized as underweight (<18.5 kg/m2), normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (> or = 30 kg/m2). Postoperative inpatient noncardiac medical complications were assessed. Complication rates were estimated for each BMI category and overall rates were assessed using logistic regression modeling. RESULTS There were 184 (15.6%) underweight, 640 (54.2%) normal, 251 (21.3%) overweight, and 105 (8.9%) obese hip fracture repairs (mean age, 84.2 +/- 7.5 years; 80% female). After adjustment, the risk of developing an inpatient noncardiac complication for each BMI category, compared to normal BMI, was: underweight (odds ratio [OR], 1.33; 95% confidence interval [CI], 0.95-1.88; P = 0.10), overweight (OR, 1.01; 95% CI, 0.74-1.38; P = 0.95), and obese (OR, 1.28; 95% CI, 0.82-1.98; P = 0.27). Multivariate analysis demonstrated that an ASA status of III-V vs. I-II (OR, 1.84; 95% CI, 1.25-2.71; P = 0.002), a history of chronic obstructive pulmonary disease (COPD) or asthma (OR, 1.58; 95% CI, 1.18-2.12; P = 0.002), male sex (OR, 1.49; 95% CI, 1.10-2.02; P = 0.01), and older age (OR, 1.05; 95% CI, 1.03-1.06; P < 0.001) contributed to an increased risk of developing a postoperative noncardiac inpatient complication. Underweight patients had higher in-hospital mortality rates than normal BMI patients (9.3 vs. 4.4%; P = 0.01). CONCLUSIONS BMI has no significant influence on postoperative noncardiac medical complications in hip-fracture patients. These results attenuate concerns that obese or frail, underweight hip-fracture patients may be at higher risk postoperatively for inpatient complications.
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Affiliation(s)
- John A Batsis
- Section of General Internal Medicine, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03755, USA.
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Abstract
The surgical management of clinically localized bladder cancer is challenging, and the quality of care delivered to patients with bladder cancer is a subject of increasing interest. Multiple large studies have examined the association between surgical volume and outcomes after radical cystectomy. These studies generally find lower mortality and complication rates at high-volume centers, though interpretation of the data must be tempered by limitations of the datasets driving the studies. Benefits of regionalization of care also must be weighed against other measures proven to predict outcomes; a delay in time to cystectomy beyond 3 months, for example, is strongly associated with increased mortality. Other candidate process measures supported by existing literature include adequacy of lymphadenectomy as measured by nodal yield and availability or offering of orthotopic diversion when appropriate. Assessment and reporting of bladder cancer outcomes should be risk adjusted based on oncologic risk factors and patient comorbid illness. Perioperative morbidity and mortality, cause-specific survival, and overall survival are all key measures. Assessment of health-related quality of life after bladder cancer treatment should also be standardized for reporting. Multiple survey instruments have been developed in recent years, but none has yet been well validated or widely adopted. In particular, capturing variation in quality of life outcomes between patients undergoing bladder-sparing protocols vs. continent diversion vs. incontinent diversion is an important but difficult goal that has not yet been met. The urologic oncology community should take a strong lead in achieving consensus regarding the definition, assessment, and reporting of quality of care data for bladder cancer.
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Affiliation(s)
- Matthew R Cooperberg
- Department of Urology, University of California, San Francisco, San Francisco, CA 94143, USA
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Froehner M, Brausi MA, Herr HW, Muto G, Studer UE. Complications following radical cystectomy for bladder cancer in the elderly. Eur Urol 2009; 56:443-54. [PMID: 19481861 DOI: 10.1016/j.eururo.2009.05.008] [Citation(s) in RCA: 196] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 05/05/2009] [Indexed: 02/07/2023]
Abstract
CONTEXT The incidence of bladder cancer increases with advancing age. Considering the increasing life expectancy and the increasing proportion of elderly people in the general population, radical cystectomy will be considered for a growing number of elderly patients who suffer from muscle-invasive or recurrent bladder cancer. OBJECTIVE This article reviews contemporary complication and mortality rates after radical cystectomy in elderly patients and the relationship between age and short-term outcome after this procedure. EVIDENCE ACQUISITION A literature review was performed using the PubMed database with combinations of the following keywords cystectomy, elderly, complications, and comorbidity. English-language articles published in the year 2000 or later were reviewed. Papers were included in this review if the authors investigated any relationship between age and complication rates with radical cystectomy for bladder cancer or if they reported complication rates stratified by age groups. EVIDENCE SYNTHESIS Perioperative morbidity and mortality are increased and continence rates after orthotopic urinary diversion are impaired in elderly patients undergoing radical cystectomy. Complications are frequent in this population, particularly when an extended postoperative period (90 d instead of 30 d) is considered. CONCLUSIONS Although age alone does not preclude radical cystectomy for muscle-invasive or recurrent bladder cancer or for certain types of urinary diversion, careful surveillance is required, even after the first 30 d after surgery. Excellent perioperative management may contribute to the prevention of morbidity and mortality of radical cystectomy, supplementary to the skills of the surgeon, and is probably a reason for the better perioperative results obtained in high-volume centers.
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Affiliation(s)
- Michael Froehner
- Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
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Butt ZM, Fazili A, Tan W, Wilding GE, Filadora V, Kim HL, Mohler JL, O'Leary KA, Guru KA. Does the presence of significant risk factors affect perioperative outcomes after robot-assisted radical cystectomy? BJU Int 2009; 104:986-90. [PMID: 19549262 DOI: 10.1111/j.1464-410x.2009.08539.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the effect of preoperative risk factors on perioperative outcomes up to 3 months after robot-assisted radical cystectomy (RARC), as RC continues to be associated with a high rate of morbidity and mortality. PATIENTS AND METHODS From 2005 to 2007, 66 consecutive patients had RARC at Roswell Park Cancer Institute. Patient demographics, preoperative risk factors and complications up to 3 months after RARC were reviewed from a prospective quality-assurance database. Patients were stratified into high- and low risk groups based on age, previous abdominal surgery, chronic obstructive pulmonary disease (COPD), body mass index (BMI), Revised Cardiac Risk Index (RCRI) and American Society of Anesthesiologists (ASA) score. RESULTS Age, previous abdominal surgery, COPD, BMI, RCRI score and ASA score did not significantly influence complications during or up to 3 months following RARC (P > 0.05). Advanced age was associated with a higher RCRI score (P = 0.014) and an increased likelihood of admission to the Intensive Care Unit (P = 0.007). A higher ASA score was associated with an increased overall hospital stay (P = 0.039). Previous abdominal surgery was associated with more frequent unscheduled postoperative clinic visits (P = 0.014). Operative duration did not significantly influence complication rates (P > 0.05). Fifteen of 62 patients (24%) had a major complication, while 15 (24%) had minor complications within 3 months of surgery. The reoperation rate was 11% and the overall mortality rate was 1.6%. CONCLUSIONS RARC appears to be well tolerated, independent of comorbid risk factors such as age, BMI, RCRI and ASA score.
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Affiliation(s)
- Zubair M Butt
- Urologic Oncology, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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Su Z, Koga R, Saiura A, Natori T, Yamaguchi T, Yamamoto J. Factors influencing infectious complications after pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:174-9. [PMID: 19517055 DOI: 10.1007/s00534-009-0128-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2008] [Accepted: 05/18/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND/PURPOSE Rates of postoperative morbidity, particularly infectious complications, remain high after pancreatoduodenectomy. METHODS Subjects comprised 101 patients who had undergone pancreatoduodenectomy, analyzed according to presence or absence of infectious postoperative complications. Nineteen perioperative variables were analyzed to identify risk factors associated with postoperative infectious complications. RESULTS Postoperative infectious complications occurred in 56 patients (55%); among them 29 had serious infectious morbidity, including bacteremia (13%), intra-abdominal infection (18%) and pneumonia (12%). One patient (1%) died of multiple organ failure subsequent to a severe septic attack. Only body mass index (BMI) differed significantly between patients with and without serious infection. Logistic regression analysis identified BMI >25 as an independent factor for occurrence of serious postoperative infectious complications. BMI >25 was a common risk factor for individual infection, including bacteremia, intra-abdominal infection, and pneumonia. As for the influence of BMI on perioperative parameters, the high BMI significantly affected the operation time. Meanwhile preoperative biliary drainage had no influence on overall and individual infectious morbidities. CONCLUSIONS This study demonstrates the need for careful postoperative monitoring in the patient with high BMI.
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Affiliation(s)
- Zhongxue Su
- Department of Surgery, Shandong Provincial Hospital, Shandong, China
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Wang SZ, Chen LW, Chen W, Chen JX, Lin HY. Hand-assisted versus pure laparoscopic radical cystectomy: A clinical outcome comparison. Int J Urol 2009; 16:360-3. [DOI: 10.1111/j.1442-2042.2009.02267.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Bagrodia A, Grover S, Srivastava A, Gupta A, Bolenz C, Sagalowsky AI, Lotan Y. Impact of body mass index on clinical and cost outcomes after radical cystectomy. BJU Int 2009; 104:326-30. [PMID: 19220244 DOI: 10.1111/j.1464-410x.2009.08358.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the effect of body mass index (BMI, kg/m(2)) on the cost and clinical variables after radical cystectomy (RC), as studies show that obesity might adversely affect the outcomes after RC. PATIENTS AND METHODS The charts of patients who had RC from January 2004 to March 2007 were reviewed retrospectively. Complete cost and clinical information was available for 99 patients; the patient and tumour characteristics and peri-operative outcomes were recorded. Detailed cost information (room and board, laboratory, pharmacy, radiology, operating room, surgical supply, anaesthesia, and recovery room) was obtained from hospital billing. Patients were stratified and compared in three groups of BMI, i.e. normal weight (<25), overweight (25-<30) and obese (> or =30). RESULTS The mean age of the patients was 66 years; 27% were normal weight, 38% were overweight and 34% were obese. Of obese patients, 24% had an Eastern Cooperative Oncology Group performance score of 0, vs none and 2.6% in the normal and overweight groups, respectively (P = 0.001). Those of normal weight had the highest overall and major complication rates (P = 0.57 and 0.28, respectively). Obese patients had insignificantly higher transfusion rates (P = 0.28). The direct cost was higher in normal weight ($14,314) than overweight ($13,808) and obese ($13,666) patients (P = 0.47). Higher room and board cost in normal-weight patients was the only significant cost difference (P = 0.008). CONCLUSION BMI was not associated with increased costs of cystectomy. The absence of differences in cost-related and clinical outcomes might be attributable to variable comorbidity among groups and the experience of a high-volume surgeon and staff at a tertiary-care referral centre that routinely cares for obese patients.
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Affiliation(s)
- Aditya Bagrodia
- Department of Urology, UT Southwestern Medical Center at Dallas, Dallas, TX 75390-9110, USA
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Quality of Care Indicators for Radical Cystectomy. Bladder Cancer 2009. [DOI: 10.1007/978-1-59745-417-9_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Development of an index to characterize the "invasiveness" of spine surgery: validation by comparison to blood loss and operative time. Spine (Phila Pa 1976) 2008; 33:2651-61; discussion 2662. [PMID: 18981957 DOI: 10.1097/brs.0b013e31818dad07] [Citation(s) in RCA: 150] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE To create and validate an index describing the extent of spine surgical intervention to allow fair comparisons of complication rates among patients treated by different surgeons, devices, or hospitals. SUMMARY OF BACKGROUND DATA Safety comparisons in spine surgery are limited by lack of methods that adjust for important variations in the surgical "case-mix." Among other factors, the magnitude of an operation is likely to have a substantial influence on the likelihood of complications. METHODS We created a spine surgery invasiveness index defined as the sum, across all vertebral levels, of 6 possible interventions on each operated vertebra: anterior decompression, anterior fusion, anterior instrumentation, posterior decompression, posterior fusion, and posterior instrumentation. We assessed the validity of this index by examining its association with blood loss and surgery duration in 1723 spine surgeries, adjusting for important factors including age, gender, body mass index, diagnosis, neurologic deficit, revision surgery, and vertebral level of surgery. RESULTS Blood loss increased by 11.5% and surgery duration increased by 12.8 minutes for each unit increase in the invasiveness index. The invasiveness index explained 44% of the variation in blood loss and 52% of the variation in surgery duration. For specific surgical components, blood loss increased by 9.4% and surgery duration by 11.4 minutes for each vertebral level of anterior decompression, 19.4% and 33.8 minutes for each segment of anterior instrumentation, 12.9% and 22.7 minutes for each level of posterior decompression, and 25.1% and 18.8 minutes for each segment of posterior instrumentation. CONCLUSION An "invasiveness" index based on the number of vertebrae decompressed, fused, or instrumented showed the expected associations with both blood loss and surgery duration. This quantitative description of surgery invasiveness may be useful to adjust for surgical variations when making safety comparisons in spine surgery.
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Boström PJ, Kössi J, Laato M, Nurmi M. Risk factors for mortality and morbidity related to radical cystectomy. BJU Int 2008; 103:191-6. [PMID: 18671789 DOI: 10.1111/j.1464-410x.2008.07889.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the risk factors for mortality and morbidity related to radical cystectomy (RC) in a medium-sized academic centre, and to analyse the rate and trends of perioperative morbidity and mortality, as although complications related RC to are lower in modern than historic series, RC is still associated with marked risks. PATIENTS AND METHODS The study included 258 patients undergoing RC for bladder cancer in Turku University Hospital in 1986-2005. Basic patient characteristics and in-hospital, early (from hospital discharge to 3 months) and combined morbidity and mortality were analysed. Risk analysis included 16 risk factors for complications. Trends were analysed by comparing the two study decades (1986-1995 vs 1996-2005). RESULTS The total complication rate was 34%, with minor and major complications in 26%, and 11% of patients, respectively. There were no significant changes in total morbidity, but the number of myocardial infarctions and atrial fibrillations decreased significantly (P = 0.045). Operative mortality was 2.7%, with an insignificant decrease (4.2% to 0.9%, P = 0.11) over time. Salvage RC, high American Society of Anesthesiologists (ASA) score (> or = 3), extensive blood loss (>3 L), a high number of transfusions (five or more), several comorbidities (two or more), age (> or = 65 vs <65 years), and extravesical tumours were significant risk factors for major complications. An ASA score of > or = 3 and five or more transfusions were the only factors associated with mortality. A high ASA score (odds ration 3.25, 95% confidence interval 1.08-9.74) and high number of transfusions (2.74, 1.05-7.15) were independent risk factors for major complications. CONCLUSION Although RC is associated with acceptable morbidity, attention should be given to risk factors identified at the time of patient selection, and to meticulous haemostasis at the time of surgery. A predictable outcome comparable to that in high-volume centres is also possible in a medium-sized hospital.
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Affiliation(s)
- Peter J Boström
- Department of Surgery, Division of Urology, Turku University Hospital, Turku, Finland.
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Effect of obesity on technical feasibility and postoperative outcomes of laparoscopy-assisted distal gastrectomy--comparison with open distal gastrectomy. J Gastrointest Surg 2008; 12:997-1004. [PMID: 17955310 DOI: 10.1007/s11605-007-0374-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 09/21/2007] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to compare outcomes between laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG) in obese and non-obese patients. METHODS Subjects comprised 248 consecutive patients who underwent distal gastrectomy for gastric cancer between January 1999 and December 2005. Patients with body mass index (BMI) > or = 25 kg/m2 were defined as obese, and patients with BMI < 25 kg/m2 were defined as non-obese. Parameters analyzed included patients characteristics, tumor characteristics, operative details, postoperative outcomes, and prognosis. RESULTS For LADG, 35 patients were considered obese, and 106 patients were non-obese. For ODG, 25 patients were considered obese, and 82 patients were non-obese. Mean operative times in each procedure were significantly longer for the obese group than for the non-obese group (ODG: 241.4 min vs. 199.5 min, p < 0.0001; LADG: 279.6 min vs. 255.3 min, p = 0.03). Blood loss was significantly higher for the obese group than for the non-obese group in ODG (300 ml vs. 400 ml, p = 0.024), but no significant differences were observed between obese and non-obese groups for LADG. Incidence of major postoperative complications, number of retrieved lymph nodes, and disease-free survival rates were similar in obese and non-obese groups for each procedure. CONCLUSIONS Our analysis revealed that LADG can be safely performed in obese patients, with complication rates and operation outcomes similar to those for non-obese patients.
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Impact of body mass index on outcomes after robot assisted radical prostatectomy. World J Urol 2007; 26:91-5. [DOI: 10.1007/s00345-007-0217-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Accepted: 09/22/2007] [Indexed: 12/14/2022] Open
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Reyes MA, Nieder AM, Kava BR, Soloway MS, Manoharan M. Does Body Mass Index Affect Outcome After Reconstruction of Orthotopic Neobladder? Urology 2007; 69:475-8. [PMID: 17382148 DOI: 10.1016/j.urology.2006.11.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Revised: 09/06/2006] [Accepted: 11/20/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the impact of body mass index (BMI) on outcome after orthotopic neobladder (NB) reconstruction. METHODS We performed a retrospective analysis of patients who underwent radical cystectomy and NB from 1992 to 2004. The patients were categorized according to BMI into group 1, BMI less than 25 kg/m2; group 2, BMI 25 to 29.9 kg/m2; and group 3, BMI greater than 30 kg/m2. The relationships among the BMI categories, the predominant complications (eg, urinary tract infection [UTI]; pyelonephritis; ureteral, bladder neck, and urethral stricture), other complications, and continence were analyzed. RESULTS Of the 343 patients who underwent radical cystectomy, 116 had an NB. The patient characteristics among the BMI groups were similar. Group 1 had fewer complications compared with the other groups (P <0.012). The principal complications observed were UTI, stricture, and pyelonephritis. The incidence of UTI, pyelonephritis, and wound infection were less in group 1 than in the other groups, with statistically significant differences (P = 0.001, P = 0.04, and P = 0.04, respectively). At the last follow-up visit, only 10% of the patients required clean intermittent catheterization to empty the NB, and no statistically significant differences were found in the continence status and voiding pattern among the groups. CONCLUSIONS An increased incidence of UTI, pyelonephritis, and wound infection was found in patients with increased BMI. However, they were transient and not life threatening. The continence and voiding patterns were relatively similar. Hence, an NB can be offered to patients with an increased BMI, and they should be formally counseled.
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Affiliation(s)
- Martha A Reyes
- Department of Urology, University of Miami Miller School of Medicine, Miami, Florida 33101, USA
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Abstract
Obesity has become the number one health problem in the United States. The patients who is obese and undergoing a surgical procedure that results in the formation of fecal or urinary diversion requires advanced skills of a multidisciplinary healthcare team. Patients who are obese carry a high risk of wound and cardiopulmonary complications and often present a serious challenge in terms of stoma creation and management. The purpose of this article is to examine the risk factors that face the patient who is obese and undergoing stoma surgery, the challenges of stoma creation, and the resultant stoma management problems.
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Affiliation(s)
- Janice C Colwell
- Clinical Nurse Specialist, University of Chicago Hospitals, IL 60637, USA.
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