Identifying risk factors for potentially avoidable complications following radical cystectomy

Does radical cystectomy have a better prognosis than bladder conservative treatment in the real world?

PURPOSE

To compare the prognosis and quality of life between radical cystectomy and bladder conservative treatment for muscle invasive bladder cancer in the real world.

MATERIALS AND METHODS

Patients treated for muscle invasive bladder cancer without metastases were retrospectively evaluated for overall survival, progression-free survival, and rehospitalization.

RESULTS

Of the 141 patients, 62 underwent bladder conservative treatment and 79 underwent radical cystectomy. Patients who underwent radical cystectomy had significantly better progression-free survival (HR: 1.83, 95% CI: 1.12-3.00; p < 0.01) and overall survival (HR: 1.82, 95% CI: 0.99-3.34; p = 0.03) than those who underwent conservative treatment. However, there was no significant difference in prognosis between patients who refused to undergo radical cystectomy and those who underwent. In addition, rehospitalization rates for complications and additional treatment were significantly higher in patients who received conservative treatment (69.3% vs. 34.2%; p < 0.01), and the length of hospital stay was also prolonged compared to patients who received radical cystectomy (26 vs. 9 days; p = 0.03).

CONCLUSIONS

Overall, conservative treatment had a significantly poorer prognosis than radical cystectomy, but there was no significant difference in prognosis when comparing patients who refused radical cystectomy and received conservative treatment with those who received radical cystectomy. However, hospitalization rates and length of stay were significantly worse for patients who chose conservative treatment, which may lead to a decline in quality of life.

Urine Biopsy as Dynamic Biomarker to Enhance Clinical Staging of Bladder Cancer in Radical Cystectomy Candidates

PURPOSE

There is significant interest in identifying complete responders to neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) to potentially avoid removal of a pathologically benign bladder. However, clinical restaging after NAC is highly inaccurate. The objective of this study was to develop a next-generation sequencing-based molecular assay using urine to enhance clinical staging of patients with bladder cancer.

METHODS

Urine samples from 20 and 44 patients with bladder cancer undergoing RC were prospectively collected for retrospective analysis for molecular correlate analysis from two clinical trials, respectively. The first cohort was used to benchmark the assay, and the second was used to determine the performance characteristics of the test as it correlates to responder status as measured by pathologic examination.

RESULTS

First, to benchmark the assay, known mutations identified in the tissue (MT) of patients from the Accelerated Methotrexate, Vinblastine, Doxorubicin, Cisplatin trial (ClinicalTrials.gov identifier: NCT01611662, n = 16) and a cohort from University of California-San Francisco (n = 4) were cross referenced against mutation profiles from urine (MU). We then determined the correlation between MU persistence and residual disease in pre-RC urine samples from a second prospective clinical trial (The pT0 trial; ClinicalTrials.gov identifier: NCT02968732). Residual MU status correlated strongly with residual disease status (pT0 trial; n = 44; P = .0092) when MU from urine supernatant and urine pellet were assessed separately and analyzed in tandem. The sensitivity, specificity, PPV, and NPV were 91%, 50%, 86%, and 63% respectively, with an overall accuracy of 82% for this second cohort.

CONCLUSION

MU are representative of MT and thus can be used to enhance clinical staging of urothelial carcinoma. Urine biopsy may be used as a reliable tool that can be further developed to identify complete response to NAC in anticipation of safe RC avoidance.

Impact of Enhanced Recovery after Surgery® Protocol Compliance on Length of Stay, Bowel Recovery and Complications after Radical Cystectomy

BACKGROUND

Despite existing standardized surgical techniques and the development of new perioperative care protocols, radical cystectomy (RC) morbidity remains a serious challenge for urologists. Postoperative ileus (POI) is one of the most common postoperative complications, often leading to a longer length of stay (LOS). The aim of our study was to assess the impact of compliance to the Enhanced Recovery After Surgery (ERAS®) protocol on bowel recovery, 30-day complications and LOS after RC for bladder cancer (BC).

METHODS

Data from consecutive patients undergoing RC for BC within an ERAS® dedicated protocol were analyzed. Exclusion criteria were urinary diversion other than ileal conduit and palliative RC. Patients were divided into two groups according to their compliance (A: low-compliance and B: high-compliance). ERAS® compliance was extracted from the ERAS® Interactive Audit System (EIAS) database. Postoperative complications were prospectively recorded by a dedicated study nurse 30 days after RC. POI was defined as the placement of a nasogastric tube. Logistic regression analysis was used to identify predictors of 30-day complications and POI.

RESULTS

After considering the exclusion criteria, 108 patients were included for the final analysis. The median global compliance to the ERAS® protocol was 61%. A total of 78 (72%) patients had a compliance <65% (group A), while the remaining 30 (28%) had a compliance >65% (group B). No significant differences were found among the two groups regarding the 30-day complication rate (86% in group A versus 73% in group B, p = 0.82) and LOS (14 days in group A versus 15 days in group B, p = 0.82). The time to stool was significantly shorter in group B (4 days versus 6 days, p = 0.02), and the time to tolerate solid food was slightly faster in group B but not significant (8 versus 7 days, p = 0.23). The POI rate was significantly lower in patients with a higher ERAS® compliance (20% versus 46%, p = 0.01). A multivariate analysis showed that ERAS® compliance was not significantly associated with 30-day total complications. However, a lower compliance to the ERAS® protocol and age > 75 years were significant independent predictors of POI.

CONCLUSIONS

Our study provides further evidence to support the beneficial effect of the ERAS® protocol in patients undergoing RC, particularly in terms of facilitating a faster recovery of bowel function and preventing POI. Future research should focus on investigating novel approaches and interventions to improve compliance with the ERAS® protocol. This may involve patient education, multidisciplinary teamwork, and continuous quality improvement initiatives.

Laparoscopic Radical Cystectomy with Ileal Orthotopic Neobladder for Bladder Cancer: Current Indications and Outcomes

BACKGROUND

Laparoscopic radical cystectomy (LRC) with ileal orthotopic neobladder (IONB) reconstruction is one of the most promising methods for bladder cancer treatment; its advantages include a small incision size, less blood loss, improved perioperative outcome and tumor prognosis, and a positive self-image postoperatively. The short-term benefits of various IONB reconstruction procedures reported thus far include a simple process, short operative time, less intraoperative bleeding, few postoperative complications, and good postoperative neobladder function; in the long term, these benefits engender good quality of life of the patients. Here, we explored and summarized the more novel and available IONB reconstruction procedures to identify the safest, most efficient, and simplest IONB reconstruction techniques for patients with bladder cancer.

SUMMARY

LRC with IONB reconstruction is technically feasible; however, most of the relevant studies have been short, employing a small sample size and a retrospective design. However, long-term, large-scale, prospective studies identifying the most appropriate bowel segments for IONB reconstruction, comparing intracorporeal and extracorporeal IONB reconstruction, assessing currently available IONBs, and resolving relevant postoperative complications further, with a focus on patients with bladder cancer, are warranted.

KEY MESSAGE

Several procedures for LRC with IONB reconstruction have been reported thus far. However, there is no consensus regarding the IONB reconstruction procedures most beneficial to patients with bladder cancer. Our review may aid researchers in developing a simple, safe, and efficient LRC with IONB reconstruction procedure for patients with bladder cancer.

Extraperitoneal Versus Intraperitoneal Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

This study aimed to compare perioperative and oncologic outcomes of extraperitoneal radical cystectomy (EPRC) and transperitoneal radical cystectomy (TPRC).

METHODS

A systematical search of multiple scientific databases was performed in September 2022. The systematic review and cumulative meta-analysis of the primary outcomes of interest were performed according to the PRISMA and AMSTAR guidelines and registered in the PROSPERO database (PROSPERO [CRD42022359322]).

RESULTS

The review and analysis included eight studies with 989 participants. No significant differences were found between EPRC and TPRC in terms of operation time, estimated blood loss (EBL), hospital length of stay (LOS), or transfusion. A shorter exhaust time (standardized mean difference [SMD] - 0.59; 95 % confidence interval [CI] - 0.97 to 0.21; p = 0.002) and time to liquid intake (SMD, - 0.56; 95 % CI - 1.07 to 0.04; p = 0.03) were associated with EPRC. No clinically meaningful difference was observed in terms of postoperative infection, wound complications, postoperative genitourinary complications, late postoperative complications, early major complications, or late major complications. However, EPRC was related to lower incidences of early postoperative complications (odds ratio [OR], 0.66; 95 % CI 0.51-0.86; p = 0.002), gastrointestinal complications (OR 0.28; 95 % CI 0 0.17-0.46; p < 0.00001), and postoperative ileus (OR 0.38; 95 % CI 0.25-0.59; p < 0.0001). A higher incidence of postoperative lymphocele was associated with EPRC (OR 3.05; 95 % CI 1.13-8.25; p = 0.03). No clinically meaningful difference was found in terms of positive surgical margin (PSM), local recurrence, distant metastasis, or OS.

CONCLUSIONS

Although EPRC had a higher incidence of lymphoceles than TPRC, it was found to have similar oncologic outcomes and fewer early complications, particularly in terms of postoperative gastrointestinal complications and ileus. These results suggest that EPRC is a safe option both functionally and oncologically.

Risk factors for ureteroenteric stricture after radical cystectomy and urinary diversion: A systematic review

Introduction

Ureteroenteric stricture (UES) is the leading cause of renal function deterioration after radical cystectomy (RC) and urinary diversion (UD). The aim of the present review is to summarize studies that discussed the risk factors associated with UES development. Identifying the responsible factors is of importance to help surgeons to modify their treatment or follow-up strategies to reduce this serious complication.

Materials and Methods

A comprehensive search of the literature using the PubMed database was conducted. The target of the search was only studies that primarily aimed to identify risk factors of UES after RC and UD. References of searched papers were also checked for potential inclusion.

Results

The search originally yielded a total of 1357 articles, of which only 15 met our inclusion criteria, comprising 13, 481 patients. All the studies were observational, and retrospective published between 2013 and 2022. The natural history of UES and the reported risk factors varied widely across the studies. In 13 studies, a significant association between some risk factors and UES development was demonstrated. High body mass index (BMI) was the most frequently reported stricture risk factor, followed by perioperative urinary tract infection (UTI), robotic-assisted radical cystectomy (RARC), occurrence of post-operative Clavian grade ≥ 3 complications and urinary leakage. Otherwise, many other risk factors were reported only once.

Conclusion

The literature is still lacking well-designed prospective studies investigating predisposing factors of UES. The available data suggest that the high BMI, RARC and complicated postoperative course are the main risk factors for stricture formation.

Ileal conduit versus single stoma uretero-cutanoustomy after radical cystectomy in patients ≥ 75 years; which technique is better? a prospective randomized comparative study

PURPOSE

To compare the clinical results and patients' health-related quality of life (HR-QoL) of ileal conduit (IC) versus single stoma uretero-cutanoustomy (SSUC) after radical cystectomy in two groups of randomly selected patients ≥ 75 years.

METHODS

From January 2013 to March 2018, 100 patients ≥ 75 years with muscle invasive BCa underwent RCX and cutaneous diversion. Patients were divided in two groups; group I underwent IC (50 patients) and group II underwent SSUC (50 patients). Postoperative evaluation included clinical, laboratory, radiographic and HR-QoL. The latter was performed using the Functional Assessment of Cancer Therapy-Bladder Cancer (FACT-BL) after 12 months postoperatively.

RESULTS

Patients' characteristics were comparable between both groups. No intraoperative complications occurred. Early postoperative complications occurred in 27 patients [16 (35.5%) in group I and 11 (23.9%) in group II (p = 0.02)]. Delayed postoperative complications occurred in 26 patients [6 (13.3%) in group I and 20 (43.4%) in group II, (P = 0.002)]. No significant differences between both groups regarding the physical, social/family, emotional, functional and additional concerns scales of FACT-BL questionnaire were reported.

CONCLUSION

SSUC is a good alternative to IC in elderly frail patients  ≥ 75 years and those with multiple comorbidities who require rapid surgery in terms of perioperative complications and HR-QoL. However, the stomal complications and the possibility of a frequent stent exchange are considered its drawbacks.

Initial experience with 161 extraperitoneal laparoscopic radical cystectomy procedures: Comparison with transabdominal laparoscopic radical cystectomy

OBJECTIVES

There is substantial concern about traditional transperitoneal laparoscopic radical cystectomy (TLRC) due to multiple postoperative complications. In contrast, extraperitoneal laparoscopic radical cystectomy (ELRC) appears to cause a lower rate of morbidity. The present study aimed to compare the efficacy of ELRC and TLRC for bladder cancer (BCa).

METHODS

The clinical data of patients undergoing laparoscopic radical cystectomy for BCa from April 2018 to October 2021 were retrospectively analyzed, as ELRC and TLRC groups. The postoperative follow-up data of 275 patients were collected and the incidence of postoperative complications and other perioperative outcomes were compared between the two groups.

RESULTS

Surgery was successfully completed in all patients without conversion to open surgery. There was no significant difference in the duration of cystectomy surgery (67.32 ± 23.53 vs 72.17 ± 25.72 min, p = 0.106), intraoperative blood loss (178.06 ± 110.4 vs. 174.56 ± 127.40 ml, p = 0.413), or the number of lymph node dissection (15.1 ± 5.7 vs. 14.5 ± 5.1, p = 0.380) between the two groups. The length of stay (11.6 ± 3.8 vs 14.7 ± 5.6 d, p < 0.001), time to resume food intake after surgery (2.3 ± 0.9 vs 3.0 ± 1.3 d, p < 0.001), and the incidence of ileus (p < 0.001) in the ELRC group were significantly lower than in the TLRC group.

CONCLUSIONS

ELRC is a safe procedure that can reduce the incidence of postoperative complications, shorten postoperative hospital stay, reduce the duration of recovery of patients, and, therefore, should be promoted.

Sex-Related Differences in Acuity and Postoperative Complications, Mortality and Failure to Rescue

INTRODUCTION

Yentl syndrome describing sex-related disparities has been extensively studied in medical conditions but not after surgery. This retrospective cohort study assessed the association of sex, frailty, presenting with preoperative acute serious conditions (PASC), and the expanded Operative Stress Score (OSS) with postoperative complications, mortality, and failure-to-rescue.

METHODS

The National Surgical Quality Improvement Program from 2015 to 2019 evaluating 30-d complications, mortality, and failure-to-rescue.

RESULTS

Of 4,860,308 cases (43% were male; mean [standard deviation] age of 56 [17] y), 6.0 and 0.8% were frail and very frail, respectively. Frailty score distribution was higher in men versus women (P < 0.001). Most cases were low-stress OSS2 (44.9%) or moderate-stress OSS3 (44.5%) surgeries. While unadjusted 30-d mortality rates were higher (P < 0.001) in males (1.1%) versus females (0.8%), males had lower odds of mortality (adjusted odds ratio (aOR) = 0.92, 95% confidence interval [CI] = 0.90-0.94, P < 0.001) after adjusting for frailty, OSS, case status, PASC, and Clavien-Dindo IV (CDIV) complications. Males have higher odds of PASC (aOR = 1.33, CI = 1.31-1.35, P < 0.001) and CDIV complications (aOR = 1.13, CI = 1.12-1.15, P < 0.001). Male-PASC (aOR = 0.76, CI = 0.72-0.80, P < 0.001) and male-CDIV (aOR = 0.87, CI = 0.83-0.91, P < 0.001) interaction terms demonstrated that the increased odds of mortality associated with PASC or CDIV complications/failure-to-rescue were lower in males versus females.

CONCLUSIONS

Our study provides a comprehensive analysis of sex-related surgical outcomes across a wide range of procedures and health care systems. Females presenting with PASC or experiencing CDIV complications had higher odds of mortality/failure to rescue suggesting sex-related care differences. Yentl syndrome may be present in surgical patients; possibly related to differences in presenting symptoms, patient care preferences, or less aggressive care in female patients and deserves further study.

Analysis of Complications After Robot-Assisted Radical Cystectomy Between 2002-2021

OBJECTIVE

To identify trends in complications following robot-assisted radical cystectomy (RARC) using a multi-institutional database, the International Robotic Cystectomy Consortium (IRCC).

METHODS

A retrospective review of the IRCC database was performed (2976 patients, 26 institutions from 11 countries). Postoperative complications were categorized as overall or high grade (≥ Clavien Dindo III) and were further categorized based on type/organ site. Descriptive statistics was used to summarize the data. Multivariate analysis (MVA) was used to identify variables associated with overall and high-grade complications.  Cochran-Armitage trend test was used to describe the trend of complications over time.

RESULTS

1777 (60%) patients developed postoperative complications following RARC, 51% of complications occurred within 30 days of RARC, 19% between 30-90 days, and 30% after 90 days. 835 patients (28%) experienced high-grade complications. Infectious complications (25%) were the most prevalent, while bleeding (1%) was the least. The incidence of complications was stable between 2002-2021. Gastrointestinal and neurologic postoperative complications increased significantly (P < .01, for both) between 2005 and 2020 while thromboembolic (P = .03) and wound complications (P < .01) decreased. On MVA, BMI (OR 1.03, 95%CI 1.01-1.05, P < .01), prior abdominal surgery (OR 1.26, 95%CI 1.03-1.56, P = .03), receipt of neobladder (OR 1.52, 95%CI 1.17-1.99, P < .01), positive nodal disease (OR 1.33, 95%CI 1.05-1.70, P = .02), length of inpatient stay (OR 1.04, 95%CI 1.02-1.05, P < .01) and ICU admission (OR 1.67, 95%CI 1.36-2.06, P < .01) were associated with high-grade complications.

CONCLUSION

Overall and high-grade complications after RARC remained stable between 2002-2021. GI and neurologic complications increased, while thromboembolic and wound complications decreased.

Effect of a Smoking and Alcohol Cessation Intervention Initiated Shortly Before Radical Cystectomy-the STOP-OP Study: A Randomised Clinical Trial

BACKGROUND

Evidence concerning the reduction of postoperative complications due to smoking and alcohol drinking in patients undergoing radical cystectomy is incomplete.

OBJECTIVE

To evaluate the efficacy of a 6-wk smoking and/or alcohol cessation intervention, initiated shortly before surgery and continued until 4 wk after, in reducing complications.

DESIGN, SETTING, AND PARTICIPANTS

Between 2014 and 2018, we enrolled 104 patients with high-risk bladder cancer who were daily smokers or consuming at least 3 units of alcohol daily in a multicentre randomised clinical trial.

INTERVENTION

Patients were randomised to a 6-wk intensive smoking and/or alcohol cessation intervention or treatment as usual.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was the number of patients developing any postoperative complication, or death, within 30 d after surgery. The secondary endpoints were successful quitters, health-related quality of life, length of stay, time back to habitual activity, and mortality. An intention-to-treat analysis was applied to evaluate treatment effect.

RESULTS AND LIMITATIONS

There were some differences in baseline demographic and lifestyle characteristics. Postoperatively, 64% in the intervention group versus 70% in the control group (risk ratio [RR] 0.91, confidence interval [CI] 0.68-1.21, p = 0.51) developed complications. Significantly fewer patients developed three or more complications after 30 d (RR 0.39; CI 0.18-0.84, p = 0.01). The rates of successful quitting were 51% in the intervention group and 27% in the control group (RR 2, CI 1.14-3.51, p = 0.01). The external validity of this trial may be limited because 53% of eligible patients refused participation.

CONCLUSIONS

Despite a significant effect on the quit rate at completion of the intervention, this multimodal prehabilitation did not show a significant difference regarding our primary outcome postoperative complications.

PATIENT SUMMARY

A 6-wk smoking and alcohol cessation intervention in relation to bladder cancer surgery did not reduce postoperative complications, but it was effective in supporting people to quit in the short term.

The impact of cardiopulmonary exercise testing (CPET) and Charlson comorbidity index (CCI) in a large contemporary cohort of patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion (RARC-ICUD)

Objective

The aim of this study was to investigate whether pre-operative comorbidity status measured by the Charlson comorbidity index (CCI) or cardiopulmonary exercise testing (CPET) is associated with postoperative complications and length of stay (LOS) in patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion (RARC-ICUD).

Patients and methods

We conducted a retrospective study of a prospectively maintained database of 428 consecutive patients who underwent RARC-ICUD at a tertiary referral centre between 2011 and 2019. CCI was correlated with peri-operative outcomes including postoperative LOS, Clavien-Dindo (CD) complications and survival. A planned subgroup analysis was performed to evaluate the relationship between pre-operative CPET, and the same outcomes utilising the threshold of anaerobic threshold (AT) ≥ 11/ <11 ml/kg/min were analysed.

Results

Of the total cohort, 350 patients undergoing RARC-ICUD with complete data were included in the final analysis. A CCI score ≥5 was associated with a higher rate of CD III-V complications at 30-day incidence rate ratio (IRR) = 3.033, (p = 0.02) and at 90-day IRR 2.495, (p = 0.04) postsurgery. LOS was not associated with CCI; the strongest association with LOS was a CD complication of any grading. CCI did not predict readmission or mortality rates after surgery. Subanalyses of patients who underwent pre-operative CPET found that CPET <11 ml/kg/min did not predict for LOS, CD complications or death within 1 year of surgery.

Conclusions

CCI score is a simple, reliable and cost-effective way of identifying patients at increased risk of complication after RARC-ICUD. Surgeons performing radical cystectomy should consider utilising CCI to augment pre-operative patient counselling prior to RARC-ICUD.

Ileal Conduit versus Continent Urinary Diversion in Radical Cystectomy: A Retrospective Cohort Study of 30-day Complications, Readmissions, and Mortality

OBJECTIVES

To quantify the short-term burden associated with continent diversion relative to ileal conduit creation.

METHODS

Bladder cancer patients who underwent radical cystectomy in 2019 and 2020 were identified in the American College of Surgeons National Surgical Improvement Program database using current procedural terminology codes and pathology reports. Patients were grouped by urinary diversion performed: ileal conduit versus continent diversion (neobladder or cutaneous reservoir). Multiple logistic regression was used to examine the association between type of urinary diversion and 30-day outcomes, including postoperative complications, all-cause readmissions, and mortality, adjusting for baseline differences.

RESULTS

Of 4,755 patients who underwent radical cystectomy, 677 underwent continent diversion (14.2%). These patients were significantly younger (median 62 vs. 71 years, p< 0.01) and less likely to have diabetes (13.6% vs. 20.1%, p<0.01), COPD (3.7% vs. 7.1%, p<0.01), and prior pelvic radiation (5.5% vs. 13.1%, p<0.01). A greater proportion of continent diversion patients experienced a postoperative complication (56.0% vs. 48.9%, p<0.01) and all-cause readmission (30.3% vs. 20.4%, p<0.0). After adjustment, continent diversion patients had 1.4 (95% CI: 1.1 - 1.7) and 1.7 (95% CI: 1.4 - 2.1) times the odds of experiencing a postoperative complication or all-cause readmission, respectively. There was no statistically significant difference in mortality (OR 1.2, 95% CI: 0.5 - 2.9).

CONCLUSIONS

Compared to ileal conduit creation, continent urinary diversion is associated with increased odds of postoperative complications and readmission to the hospital within 30 days of surgery. Bladder cancer patients undergoing cystectomy and seeking continent diversion should be counseled on the increased short-term morbidity associated with this specific type of diversion.

Future Perspectives on Prehabilitation Interventions in Cancer Surgery

OBJECTIVE

This article provides a map of key knowledge gaps regarding the evidence supporting prehabilitation and its integration with enhanced recovery after surgery (ERAS) programs. Filling this lack of knowledge with future research will further establish the effectiveness of prehabilitation.

DATA SOURCES

These are electronic databases including PubMed and CINAHL.

CONCLUSION

Future efforts must embrace the elderly frail or cognitively impaired patient with specific needs to further promote restoration of postoperative function throughout the surgical pathway. Prehabilitation should be coupled and integrated within the existent concept of the ERAS framework, to facilitate the continuous evolution of screening, assessment, and optimization of high-risk surgical patients who are at risk of not being restored to physical and psychological function after surgery, including independence.

IMPLICATIONS FOR NURSING PRACTICE

In the future, the ERAS nurse will be an essential figure of the prehabilitation program, proactively coordinating the assessment, optimization, and adjustment of perioperative comorbidity and guiding the rehabilitation process to improve patients' outcomes. These skills and characteristics will be required to provide optimal nursing care in the context of an integrated prehabilitation ERAS pathway.

Perioperative Complications and Oncologic Outcomes after Radical Cystectomy in End-Stage Renal Disease Patients with Bladder Cancer Obtained Using a Standardized Reporting System

Background: We investigated the use of a standardized reporting system to study perioperative complications and oncologic outcomes after radical cystectomy in end-stage renal disease (ESRD) patients with bladder cancer. Methods: We reviewed retrospective outcomes in 141 ESRD patients with bladder cancer who underwent radical cystectomy between 2004 and 2015. Complications were graded using the Clavien−Dindo classification system with 0−2 classified as “No Major Complications” and Clavien 3−5 as “Major Complications”. Low-volume surgeons were classified as those performing fewer than nine cases during the study. Fisher’s exact test along with the chi-squared test, two-tailed t tests, logistic regression, and the Cox proportional hazard model were used to evaluate all clinically meaningful covariates. Results: Ninety-nine (99, 70.2%) patients had no major complications, and forty-two (29.8%) patients had major complications. Patients in the major complications group were older, had a higher Charlson comorbidity index (CCI), and had a longer hospitalization duration than those in the no major complications group (all, p < 0.05). Major complications were also more common when the procedure was performed by low-volume surgeons (p = 0.003). In multivariate logistic regression models, CCI ≥ 5 (p = 0.006) and low-volume surgeon (p = 0.004) were independent predictors of major complications. According to multivariate analysis with the Cox hazards regression, male sex, age > 70 years, CCI ≥ 5, bladder cancer stage ≥ 3, lymphovascular invasion, and experiencing major complications were significant poor prognostic factors for overall survival (all, p < 0.05). Conclusions: Accurate reporting of complications is necessary for preoperative counseling, identifying modifiable risk factors, and planning risk mitigation strategies. High comorbidity and low-volume surgeons were interrelated as notable risk factors for major complications. In addition to tumor-related factors, male sex, older age, and major complications significantly influence overall survival.

Mesane kanserinde radikal sistektomi üriner diversiyon operasyonu yapılan hastalarda perioperatif parametrelerin değerlendirilmesi

Purpose: The aim of this study was to evaluate the effect of red blood cell transfusion and/or inotropic/vasopressor agent infusion during intraoperative and postoperative first 24-hour period on 30-day and one-year survival. Materials and Methods: In the final analysis, 133 patients who underwent radical cystectomy and urinary diversion surgery between November 2011 and January 2019 were included in this study. Perioperative anesthesia management early postoperative intensive care patient follow-ups were based on. Results: A statistically significant relationship was found between intraoperative red blood cell transfusion and one-year mortality rates. A statistically significant relationship was found between red blood cell transfusion in the intensive care unit and postoperative 30-day mortality rates. The relationship between vasopressor/inotrope agent infusion in intensive care unit and postoperative 30-day mortality was statistically significant. Conclusion: In radical cystectomy and urinary diversion, intraoperative red blood cell and/or inotrope/vasopressor drug administration, and red blood cell transfusion within first 24 postoperative hours in intensive care unit are associated with lower survival rates in both early and late periods. Future studies should focus on developing and implementing different strategies for perioperative blood management and maintenance of patient hemodynamics that may affect early and late outcomes.

Machine learning decision support model for radical cystectomy discharge planning

PURPOSE

Timely and appropriate discharge placement for patients who have undergone radical cystectomy (RC) remains challenging. Our objective was to improve the discharge planning process by creating a machine learning model that helps to predict the need for non-home hospital discharge to a higher level of care.

MATERIALS AND METHODS

Patients undergoing elective radical cystectomy for bladder cancer from 2014-2019 were identified in the ACS-NSQIP database. A gradient boosted decision tree was trained on selected predischarge variables to predict discharge location, dichotomized into home and non-home. We used threshold-moving to calibrate model predictions and evaluated model performance on a testing set using receiver operating characteristic and precision recall curves. Model performance was further examined in subgroups of interest.

RESULTS AND CONCLUSIONS

A total of 11,881 patients met inclusion criteria with a mean age of 68.6 years. 10.6% of patients undergoing RC had non-home discharges. Our model predicting non-home discharge achieved an area under the receiver operating characteristic curve of 0.80 and an average precision of 0.33. After threshold-moving, our model had a recall of 0.757 and a precision of 0.211. Top variables by importance were septic shock occurrence, ventilator-use greater than 48 hours, organ space surgical site infection and unplanned intubation. Our model shows strong performance in identifying patients who required non-home discharge to higher levels of care, outperforming commonly used clinical indices and prior work. Modern machine learning techniques may be applied to support more timely and appropriate clinical decision making.

Post-cesarean ileus: An assessment of incidence, risk factors and outcomes

OBJECTIVE

To estimate the frequency of post cesarean paralytic ileus and to identify associated risk factors and outcomes.

STUDY DESIGN

A retrospective cohort study of woman who underwent cesarean delivery between 2005 and 2019. All parturients who had cesarean delivery were stratified and compared according to whether or not they were diagnosed with a paralytic ileus. Women were excluded if they had an intestinal injury or repair during the cesarean or if they suffered from a post cesarean mechanical bowel obstruction diagnosed during re-laparotomy. Basic demographics, obstetric history, current delivery characteristics, re-suturing indications and outcomes were obtained and analyzed. Univariate analyses were followed by a multivariate analysis (adjusted Odds Ratio (aORs) ; [95% Confidence Interval]).

RESULTS

A total of 23,486 women met the inclusion and exclusion criteria of which 135 (0.6%) were diagnosed with paralytic ileus whilst 23,347 (99.4%) did not and served as the control group. Multivariate analysis revealed that an estimated intra-operative blood loss ≥ 1000 ml was the most significant risk factor for post cesarean paralytic ileus (aOR 2.27 (1.18-4.36)), followed by multifetal gestation (aOR 2.08 (1.24-3.51)), corporeal uterine incision (aOR 1.97 (1.07-3.63)), use of topical hemostatic agents (aOR 1.78 (1.19-2.66)) and increasing maternal age (aOR 1.78 (1.19-2.66)). Regarding maternal outcomes, post cesarean paralytic ileus was associated with higher rates of postpartum hemorrhage (44.4% vs. 13.4%, p < 0.01), transfusion of blood products (23.7% vs. 3.9%, p < 0.01), post-cesarean exploratory laparotomy (4.4% vs. 0.1%, p < 0.01) and prolonged hospital stay (32.6% vs. 5.2%, p < 0.01).

CONCLUSION

In our population, whilst post cesarean paralytic ileus is infrequent, when it occurs it is associated with increased short-term maternal morbidity.

Risk factors for wound dehiscence following radical cystectomy: a prediction model

Objectives:

Radical cystectomy (RC) is a complex urologic procedure performed for the treatment of bladder cancer and causes significant morbidity. Wound dehiscence (WD) is a major complication associated with RC and is associated with multiple risk factors. The objectives of this study are to identify clinical risk factors for incidence of WD and develop a risk-prediction model to aid in patient risk-stratification and improvement of perioperative care.

Materials and Methods:

The American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database was used to derive the study cohort. A univariate analysis provided nine variables eligible for multivariate model entry. A stepwise logistic regression analysis was conducted and refined considering clinical relevance of the variables, and then bootstrapped with 1000 samples, resulting in a five-factor model. Model performance and calibration were assessed by a receiver operated curve (ROC) analysis and the Hosmer–Lemeshow test for goodness of fit, respectively.

Results:

A cohort of 11,703 patients was identified from years 2005 to 2017, with 342 (2.8%) incidences of WD within 30 days of operation. The final five-factor model included male gender [odds ratio (OR) = 2.5, p < 0.001], surgical site infection (OR = 6.3, p < 0.001), smoking (OR = 1.8, p < 0.001), chronic obstructive pulmonary disease (COPD) (OR = 1.9, p < 0.001), and weight class; morbidly obese patients had triple the odds of WD (OR = 2.9, p < 0.001). The ROC analysis provided a C-statistic of 0.76 and calibration R² was 0.99.

Conclusion:

The study yields a statistically robust and clinically beneficial five-factor model for estimation of WD incidence risk following RC, with good performance and excellent calibration. These factors may assist in identifying high-risk patients, providing preoperative counseling and thus leading to improvement in perioperative care.

Robotic-assisted radical cystectomy is associated with lower perioperative mortality in octogenarians

OBJECTIVES

To compare perioperative outcomes between robotic and open radical cystectomy in octogenarians using real-world data SUBJECTS AND METHODS: Using the Premier Healthcare Database, we found 13,127 patients who underwent robotic-assisted radical cystectomy (RARC) between 2008 and 2017, of which 15.1% were ≥80 years old. Perioperative mortality was the primary outcome of interest. Secondary outcomes include complications, hospital length of stay, readmission rates, and disposition after discharge. Multivariable regression analysis was used to adjust for patient and hospital characteristics.

RESULTS

In octogenarians, mortality at the index admission was 2.2% in those who underwent RARC, compared to 4.6% in those who underwent open surgery (P = 0.027). On multivariable analysis, robotic surgery was associated with lower in-hospital mortality in octogenarians (OR 0.46, 95% CI 0.22-0.99, P = 0.047) even after controlling for patient, and hospital characteristics.

CONCLUSION

RARC is safe and feasible in octogenarians. Elderly patients may derive more benefit from minimally invasive radical cystectomy compared to a younger cohort.

Can maneuverability in the robot assisted laparoscopic stapler during ileoileal anastomosis compensate for shorter stapler length? - A randomized experimental porcine study

BACKGROUND

Ileal anastomosis is imperative in patients given a urinary diversion during radical cystectomy. Proper handling and staplers with a certain length are important to prevent stenosis of the bowel. The study aim was to compare the circumference and diameter of ileoileal anastomoses using the Endo GIA tri-stapler 45 mm and 60 mm iDrive systems compared to the RAL Endowrist DaVinci 45 mm. This was to investigate if the better maneuverability of the robotic stapler would compensate for the shorter stapler length in the RAL Endowrist DaVinci 45.

MATERIALS AND METHODS

Twenty ileoileal anastomoses were performed in a total of three pigs after randomization according to the type of anastomosis technique used (depending on stapler and robotic system) allocated to four groups (each with five anastomoses): (1) iDrive 45 mm, (2) iDrive 60 mm, (3) RAL DaVinci 45 mm (Si-system), and (4) RAL DaVinci 45 mm (Xi-system). Diameter (mm) and circumference (mm) were measured and compared.

RESULTS

Diameters and circumferences in Group 1 were significantly smaller compared to all the other groups, which did not differ from each other, except in Group 2 where anastomoses had a significantly higher circumference than Group 4.

CONCLUSION

The iDrive 60 mm makes the anastomoses with the widest diameter and highest circumference compared to the iDrive 45 mm. With the RAL DaVinci 45 mm, the diameter and circumference were comparable to the iDrive 60 mm and significantly better than the iDrive 45 mm. An explanation may be the better maneuverability and surgeon control of the RAL DaVinci stapler.

Radical cystectomy and perioperative chemotherapy in octogenarians with bladder cancer

INTRODUCTION

We aimed to compare the treatment patterns and oncological outcomes, including postoperative morbidity and chemotherapy use, between octogenarians and patients <80 years of age who underwent radical cystectomy for bladder cancer.

METHODS

We conducted a retrospective analysis of 119 patients who underwent radical cystectomy for bladder cancer at our center between January 2013 and April 2019. Comorbidities, clinical and pathological data, 30-day postoperative morbidity, and perioperative chemotherapy use were compared between octogenarians (n=31) and younger patients (n=88). Cancer-specific and overall survival rates were estimated with the Kaplan-Meier method and compared between the groups.

RESULTS

No significant differences were found between the age groups in the clinical and pathological findings, including Charlson comorbidity index, modified frailty index, albumin level, renal function, and TNM stage. The median followup for survivors was 19 months (interquartile range [IQR] 11-30). Major complications (Clavien-Dindo grade ≥3) and 30-day postoperative mortality rates did not differ between the age groups (p=0.3 and p=0.18, respectively). Despite no difference in baseline glomerular filtration rates, perioperative chemotherapy utilization rate was lower among octogenarians compared to younger patients (13% vs. 34%, p=0.03). Estimated two-year cancer-specific survival rates for octo-generians and younger patients were 40% and 75%, respectively. Similarly, estimated two-year overall survival rates were 30% and 69%, respectively. Both cancer-specific and overall survival rates were significantly lower in octogenarians (p=0.007 and p=0.001, respectively).

CONCLUSIONS

Radical cystectomy in octogenarians results in comparable short-term outcomes as in younger patients. However, in the elderly population, perioperative chemotherapy utilization rates are lower and survival is inferior.

Current application of the enhanced recovery after surgery protocol for patients undergoing radical cystectomy: lessons learned from European excellence centers

PURPOSE

There is no consensus on which items of Enhanced Recovery After Surgery (ERAS) should and should not be implemented in radical cystectomy (RC). The aim of this study is to report current practices across European high-volume RC centers involved in ERAS.

METHODS

Based on the recommendations of the ERAS society, we developed a survey with 17 questions that were validated by the Young Academic Urologists-urothelial group. The survey was distributed to European expert centers that implement ERAS for RC. Only one answer per-center was allowed to keep a representative overview of the different centers.

RESULTS

70 surgeons fulfilled the eligibility criteria. Of note, 28.6% of surgeons do not work with a referent anesthesiologist and 25% have not yet assessed the implementation of ERAS in their center. Avoiding bowel preparation, thromboprophylaxis, and removal of the nasogastric tube were widely implemented (> 90%application). On the other hand, preoperative carbohydrate loading, opioid-sparing anesthesia, and audits were less likely to be applied. Common barriers to ERAS implementation were difficulty in changing habits (55%), followed by a lack of communication across surgeons and anesthesiologist (33%). Responders found that performing a regular audit (14%), opioid-sparing anesthesia (14%) and early mobilization (13%) were the most difficult items to implement.

CONCLUSION

In this survey, we identified the ERAS items most and less commonly applied. Collaboration with anesthesiologists as well as regular audits remain a challenge for ERAS implementation. These results support the need to uniform ERAS for RC patients and develop strategies to help departments implement ERAS.

Short-term morbidity and mortality following radical cystectomy: a systematic review

OBJECTIVE

To study short-term (<90 days) morbidity and mortality following radical cystectomy (RC) for bladder cancer and identify modifiable risk factors associated with these.

DESIGN

Systematic review.

METHODS

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and EMBASE were searched for relevant papers on 11 June 2019 and rerun on 27 May 2020. Studies reporting complications, reoperations, length of stay and mortality within 90 days were included. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine and the quality of evidence was assessed using the Newcastle-Ottawa Scale.

RESULTS

The search retrieved 1957 articles. Sixty-six articles were included. The quality of evidence was poor to good. Most studies were retrospective, and no randomised clinical trials were identified. Of included studies a median of 6 Martin criteria for reporting complications after surgery were fulfilled. The Clavien-Dindo classification for grading complications was most frequently used. The weighted overall complication rate after RC was 34.9% (range 28.8-68.8) for in-house complications, 39.0% (range 27.3-80.0) for 30-day complications and 58.5% (range 36.1-80.5) for 90-day complications. The most common types of complications reported were gastrointestinal (29.0%) and infectious (26.4%). The weighted mortality rate was 2.4% (range 0.9-4.7) for in-house mortality, 2.1% (0.0-3.7) for 30-day mortality and 4.7% (range 0.0-7.0) for 90-day mortality. Age and comorbidity were identified as the best predictors for complications following RC.

CONCLUSION

Short-term morbidity and mortality are high following RC. Reporting of complications is heterogeneous and the quality of evidence is generally low. There is a continuous need for randomised studies to address any intervention that can reduce morbidity and mortality following RC.

PROSPERO REGISTRATION NUMBER

104937.

[Enhanced Recovery After Surgery (ERAS®) after radical cystectomy-current data]

BACKGROUND

Radical cystectomy is associated with considerable morbidity and mortality. Based on the solid evidence in colorectal surgery, fast-track/ERAS® (Enhanced Recovery After Surgery) protocols have been developed to improve the perioperative management of patients undergoing radical cystectomy.

OBJECTIVES

To review the literature and guidelines and evaluate the evidence regarding the different components of ERAS® protocols.

MATERIALS AND METHODS

Systemic literature search and evaluation of relevant guidelines.

RESULTS

The majority of ERAS® recommendations for radical cystectomy are based on extrapolations of abdominal surgery studies. Four randomized, controlled trials and one ERAS® guideline were published for radical cystectomy. ERAS® seems to shorten length of stay without increasing the complication rate. Key elements are no bowel preparation, no nasogastric tube, optimized fluid substitution, multimodal pain management, early mobilization, and oral diet.

CONCLUSIONS

Implementation of ERAS® requires multidisciplinary collaboration. Individualization of an ERAS® program, identification of the most important components and adaption to the specific needs of radical cystectomy patients are future goals.

The Potential of Prehabilitation in Radical Cystectomy Pathways: Where Are We Now?

OBJECTIVE

The growing recognition of prehabilitation has caused an emerging paradigm shift in surgical cancer care and an integrated component of the cancer care continuum. This narrative review aims to update and inform the urological community of the potential of prehabilitation before radical cystectomy.

DATA SOURCES

A nonsystematic narrative review was performed through a database search in PubMed, and CINAHL using the following search terms: enhanced recovery after surgery (ERAS); Frailty; Prehabilitation and/or Rehabilitation; Physical Activity and/or exercises; Nutrition; Nutritional Care; Smoking cessation; Alcohol cessation; Prevention; Supportive Care; and combined with Radical Cystectomy.

CONCLUSION

A multimodal and multi-professional approach during the preoperative period may offer an opportunity to preserve or enhance physiological integrity and optimize surgical recovery. Studies indicate a positive effect of prehabilitation on postoperative functional capacity and earlier return to daily activities and health related quality of life. Meaningful outcomes that reflect recovery from a patient's perspective and clinical outcome measures, as well as validating metrics, are necessary to establish whether prehabilitation diminish the risk of developing long-term disability in high-risk patients.

IMPLICATIONS FOR NURSING PRACTICE

Uro-oncology nurses are at the forefront in every ERAS program and vital in screening patients ahead of surgery for common risk factors, current impairments, and limitations that can compromise baseline functional capacity. The growing movement to standardize clinical implementation of prehabilitation, indicate there is a clear need for further investigation, optimization of a multimodal approach and an open discussion between health care providers from different areas of expertise who might best support and promote these initiatives.

[Implementation of Enhanced Recovery after Surgery (ERAS®) protocol in radical cystectomy at the University Medical Center Mainz]

BACKGROUND

In surgical fields there has been a perceivable paradigm shift during the last decade concerning patient pre- and rehabilitation. Current literature suggests close interdisciplinary collaboration after complex procedures such as radical cystectomy in order to optimize perioperative patient care for the benefit of "fast-track" surgery.

OBJECTIVES

To compose a catalogue of standardized measures after radical cystectomy based on guidelines set by the ERAS®-Society.

RESULTS

The protocol commences with preoperative education in order to improve the physical and psychological condition of the patient. Crucial aspects in peri- and postoperative patient care are gentle surgical technique, adequate pain management, early mobilization and oral food intake, early removal of drains and foreign material and a seamless return to normal, daily life.

CONCLUSIONS

Prospective data analysis will be the next step in order to establish the effectiveness of the protocol especially regarding postoperative complications and median duration of hospital stay.

Enhanced recovery after surgery of patients undergoing radical cystectomy for bladder cancer

Radical cystectomy (RC) is the standard treatment for patients diagnosed with muscle invasive bladder cancer, but is associated with significant morbidity and long hospital stays. Enhanced recovery after surgery (ERAS) is based on a variety of interventions during the peri-treatment stage. It is designed to improve morbidity, enhance recovery, and reduce hospital stays after RC. The study provides an overview of the key elements of the ERAS protocol recommended for patients undergoing RC and directions for further research. We have analyzed the rationale for 15 key elements related to the ERAS protocol: preoperative patient counseling and education, preoperative medical optimization and nutrition, mechanical bowel preparation, preoperative fasting and carbohydrate loading, pre-anesthetic medication, thromboembolic prophylaxis, minimally invasive surgical approach, resection-site drainage, preventing intraoperative hypothermia, perioperative fluid management, perioperative analgesia, urinary drainage, prevention of postoperative ileus, nausea and vomiting, early oral feeding, and early mobilization. Several studies have shown that ERAS improves the recovery of RC patients. Evidence suggests that ERAS facilitates the recovery of RC patients. However, additional randomized controlled studies or large prospective studies are needed to demonstrate the effectiveness of ERAS in RC patients.

Predicting morbidity and mortality after radical cystectomy using risk calculators: A comprehensive review of the literature

INTRODUCTION

Radical cystectomy (RC) with urinary diversion is associated with significant perioperative morbidity and mortality, varying between 30% and 70% and between 0.3% and 10.6%, respectively. Risk calculators have been extensively studied in the general surgery literature to predict 30- and 90-day postoperative morbidity and mortality but have not been widely accepted in the RC literature.

MATERIALS AND METHODS

We performed a search of MEDLINE and Embase databases during May 2020 to identify all relevant studies using the following keywords: radical cystectomy, surgical complication predictive model, surgical complication predictive equation, surgical complication predictive nomogram, surgical risk calculator, morbidity, and mortality. We determined the existing surgical predictive nomograms, calculators, and indices and their accuracy in predicting morbidity, mortality, and major complications after RC.

RESULTS

National Surgical Quality Improvement Program had poor accuracy at predicting 30-day morbidity at mortality (AUC 0.5-0.6). LACE index showed good discrimination at predicting 90-day mortality (AUC 0.7). The various frailty and sarcopenia indices have shown poor to fair accuracy at predicting (AUC 0.5-0.7). The Isbarn and Aziz nomograms have equivalent accuracy at predicting 90-day mortality (AUC 0.7) but are limited by inclusion of tumor histology and presence of metastatic disease as variables. POSSUM and P-POSSUM have poor ability at predicting morbidity and mortality (AUC 0.5) and are cumbersome calculators. The surgical Apgar score has been able to predict 30-day morbidity and mortality but can only be used in the postoperative setting.

DISCUSSION

The currently available surgical risk calculators have either poor accuracy at predicting post-RC morbidity and mortality or are limited by types of variables included. An ideal risk calculator would be comprised of preoperative factors only and have a high accuracy to serve as a tool for preoperative patient counseling prior to surgery.

CONCLUSION

There exists a strong need to develop a comprehensive and accurate preoperative risk calculator that predicts morbidity and mortality after RC.

Impact of Prognostic Nutritional Index on Postoperative Pulmonary Complications in Radical Cystectomy: A Propensity Score-Matched Analysis

BACKGROUND

Radical cystectomy is a standard treatment for muscle-invasive bladder cancer but frequently entails postoperative pulmonary complications (PPCs). Nutrition is closely associated with postoperative outcomes. Therefore, we evaluated the impact of preoperative prognostic nutritional index (PNI) on PPCs in radical cystectomy.

METHODS

PNI was calculated as 10 × (serum albumin) + 0.005 × (total lymphocyte count). The risk factors for PPCs were evaluated using multivariate logistic regression analysis. A receiver operating characteristic curve analysis of PNI was performed, and an optimal cut-off value was identified. Propensity score-matched analysis was used to determine the impact of PNI on PPCs. Postoperative outcomes were also evaluated.

RESULTS

PPCs occurred in 112 (13.6%) of 822 patients. Multivariate logistic regression analysis identified PNI, age, and serum creatinine level as risk factors. The area under the receiver operating characteristic curve of PNI for predicting PPCs was 0.714 (optimal cut-off value: 45). After propensity score matching, the incidence of PPCs in the PNI ≤ 45 group was significantly higher compared with the PNI > 45 group (20.8% vs. 6.8%; p < 0.001), and PNI ≤ 45 was associated with a higher incidence of PPCs (odds ratio 3.308, 95% confidence interval 1.779-6.151; p < 0.001). The rates of intensive care unit admission and prolonged (> 2 days) stay thereof were higher in patients who developed PPCs.

CONCLUSIONS

Preoperative PNI ≤ 45 was associated with a higher incidence of PPCs in radical cystectomy, suggesting that PNI provides useful information regarding pulmonary complications after radical cystectomy.

Alcohol consumption does not increase the risk of surgical wound complications in breast cancer patients

Alcohol consumption, despite influencing several organic processes, has been scarcely studied regarding the risk of developing surgical wound complications after surgical breast cancer treatment. The aim of this study was to analyse the association between alcohol consumption and the development of surgical wound complications in women undergoing surgical treatment for breast cancer. A prospective cohort study was conducted, comprising 486 women between 40 and 69 years old, interviewed during the preoperative period and followed up for 30 days. The occurrence of seroma, necrosis, surgical site infection (SSI), dehiscence, ecchymosis, and hematoma were considered as outcomes. Alcohol consumption during the 30 days prior to surgery was reported by 20.8% of the patients, with 8.4% being occasional consumers and 12.4% regular consumers. Binge drinking was reported by 10.2% of the women. The presence of surgical wound complications was observed in 65.2%. The most frequent complications were seroma (54.3%), necrosis (17.7%), and SSI (7.8%). No statistically significant association between alcohol consumption and the development of cicatricial complications was observed.

Extraperitoneal Antegrade vs Transperitoneal Open Radical Cystectomy: Single Center Experiences with 200 Cases

BACKGROUND: Radical cystectomy (RC) is one of the most complex surgeries and has a high rate of morbidity. Gastrointestinal complications are the most common type of complications. To reduce these complications some modifications have been described. OBJECTIVE: To evaluate perioperative outcomes of our extraperitoneal antegrade RC technique (EARTC), where the peritoneum is opened at the end of cystectomy just before of ileal reconstruction. METHODS: Group 1 included 120 patients who were operated with a standard RC technique and Group 2 included 80 patients who were operated with the EARC technique in this study. Groups were compared according to preoperative variables including patient characteristics, perioperative parameters, pathologic data, and postoperative overall and gastrointestinal complications. RESULTS: There were no significant differences between the two groups in terms of preoperative characteristics and mean operative time. The group 1 has longer time for the exposure of abdominal cavity to the atmosphere (p < 0.01). Hospitalization time was significantly lower in Group 2 (p < 0.01). Concerning the rate of 90-day overall perioperative complication, no statistically significant difference was determined between the groups. Gastrointestinal complication was significantly higher in Group 1 (p:0.048). The average number of removed lymph nodes was similar between the groups (p:0.85). The time for recovery of bowel function, the time for passage of stool and the rate of postoperative ileus were significantly lower in Group 2 (p < 0.01, p < 0.01 and p < 0.043) respectively). CONCLUSIONS: EARC provides advantages over the standard technique in terms of gastrointestinal symptoms and poses no disadvantage when the oncological outcome and operative difficulty were considered.

Preoperative Risk Factors Predicting Postoperative Complications in Radical Cystectomy for Bladder Cancer

BACKGROUND AND OBJECTIVE: While radical cystectomy (RC) is the gold-standard treatment for patients with muscle-invasive bladder cancer, it is associated with a significant rate of complications. We aim to develop a prediction model to assess the risk of complications in the postoperative period using routinely collected data in the course of preoperative evaluation in patients undergoing RC for bladder cancer. METHODS: We retrospectively reviewed 508 patients who underwent RC for bladder cancer from January 2008 to October 2016. Potential preoperative risk predictors were collected. Postoperative complications were graded using the Clavien-Dindo scale. Prediction models were developed using variables with the highest predictive value for postoperative complications. The accuracy of themodels was assessed using the area under the receiver operating characteristic curve (AUROC) and cross-validation. RESULTS: Variables achieved the highest prediction accuracy for major postoperative complications in the 31 to 90-day postoperative period. In this period, 14 variables were predictive of major postoperative complications. The three most predictive individual variables were BMI, neoadjuvant chemotherapy, and creatinine with AUROC/odds ratios of 0.643/1.09, 0.609/2.43, and 0.597/1.22, respectively. This postoperative period also had the best performing prediction model for major complications, which utilized four variables to achieve an AUROC of 0.727. CONCLUSION: Routinely collected preoperative variables may be useful for determining patient risk for short-term postoperative complications after RC. Prediction models can help identify patients who may benefit from patient education, counseling and development of risk reduction strategies. Interactions between individual variables should be evaluated to further improve accuracy of the prediction models.

Comparison of the Perioperative and Postoperative Outcomes of Ileal Conduit and Cutaneous Ureterostomy: A Propensity Score-Matched Analysis

INTRODUCTION

To compare perioperative and postoperative outcomes related to urinary diversion (UD) between ileal conduit and cutaneous ureterostomy following open radical cystectomy (ORC).

METHODS

This retrospective study included 232 patients with bladder cancer who underwent ORC and subsequent UD (ileal conduit, n = 123; cutaneous ureterostomy, n = 109) at Kobe University and related hospitals between January 2007 and December 2016. A propensity score method was used to adjust the preoperative status of the two groups, and the perioperative and postoperative outcomes were compared between matched cohorts. In addition, we evaluated several factors predicting renal deterioration.

RESULTS

In the matched cohorts, 87 patients were included in each group. While the operative time and postoperative fasting periods were significantly longer in patients with ileal conduit in comparison to those with cutaneous ureterostomy (both p < 0.001), there were no differences in blood loss or duration of hospitalization. Although the incidence of grade ≥III perioperative complications was similar between the two groups, the incidence of postoperative recurrent pyelonephritis in the cutaneous ureterostomy group was significantly higher than that in the ileal conduit group (25.3 and 11.4%, respectively; p = 0.030), and cutaneous ureterostomy was identified as a significant predictor of a decrease in the estimated glomerular filtration rate with an odds ratio of 2.13 (95% confidence interval, 1.19-3.85; p = 0.010).

CONCLUSIONS

The perioperative safety of ileal conduit was comparable to that of cutaneous ureterostomy, and cutaneous ureterostomy was a significant risk factor for pyelonephritis and subsequent renal deterioration, suggesting that ileal conduit may be preferable to cutaneous ureterostomy.

Internal hernia from the interureteric space after robot-assisted radical cystectomy and urinary diversion: Two case reports

RATIONALE

Radical cystectomy and urinary diversion remains the definite management for muscle invasive bladder urothelial cancer. Internal herniation caused by ureteral adhesion is an extremely rare complication after the procedure. To the best of our knowledge, this is the first case report of small bowel obstruction and internal herniation occurring between bilateral ureters and urinary diversion after robot-assisted radical cystectomy (RARC).

PATIENT CONCERNS

A 64-year-old woman presented with symptom of small bowel obstruction such as nausea, vomiting, and abdominal fullness after RARC and Indiana pouch. Another 61-year-old man presented with left obstructive hydronephrosis and recurrent pyelonephritis after RARC and ileal conduit.

DIAGNOSIS

Both patients received computed tomography scans and the results were suggestive of small bowel herniation between bilateral ureters and urinary diversion.

INTERVENTIONS

The 2 patients underwent open ureterolysis and internal hernia reduction. During the operation, bowel loop herniation between the interureteral spaces were found.

OUTCOMES

Both patients recovered smoothly after second operation.

LESSONS

The incidence of internal herniation may increase by the growing use of RARC. Suitable stoma position, appropriate length of ureter dissection, and retroperitonealization can help prevent this complication.

Pelvic dimensions do not impact on complications and operative difficulty in radical cystoprostatectomy and orthotopic neobladder

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.

Semi-competing risk model to predict perioperative and oncologic outcomes after radical cystectomy

Background

To utilize a semi-competing risk model to predict perioperative and oncologic outcomes after radical cystectomy and to compare the findings with the univariate Cox regression model.

Methods

We reviewed the Institutional Review Board approved database of radical cystectomy of 316 patients who had undergone robot-assisted radical cystectomy (RARC) or open radical cystectomy between 2006 and 2016. Demographic data, perioperative outcomes, complications, metastasis, and survival were analyzed. The Bayesian variable selection method was utilized to obtain models for each hazard function in the semi-competing risks.

Results

Of 316 patients treated, 48% and 18% experienced any or major complication respectively within 30 days. Intracorporeal RARC was associated with decreased metastasis risk. Extracorporeal RARC was associated with marginally decreased risks of overall complications or major complications. Patients with advanced cancer had an increased risk of metastasis, death after metastasis and death after complication. Positive nodes were associated with an increased risk of death without overall or major complications and increased risk of death after metastasis occurs. When a serious complication was taken into account there was no significant difference in mortality, irrespective of disease stage.

Conclusions

A semi-competing risk model provides relatively more accurate information in comparison to Cox regression analysis in predicting risk factors for complications and metastasis in patients undergoing radical cystectomy.

Effectiveness of hyaluronic acid/carboxymethylcellulose in preventing adhesive bowel obstruction after laparoscopic radical cystectomy

BACKGROUND/OBJECTIVE

Adhesive bowel obstruction is one of the most frequent complications after radical cystectomy, prolonging hospital stay and fasting period and increasing medical expenses. This study evaluated the effectiveness of hyaluronic acid/carboxymethylcellulose (HA/CMC) in preventing adhesive bowel obstruction after laparoscopic radical cystectomy.

METHODS

Randomized, controlled, single-blinded study was performed. Of 76 patients who underwent laparoscopic radical cystectomy for bladder cancer, 38 received HA/CMC instillation and 38 did not. The primary endpoint was the rate of postoperative adhesive bowel obstruction. The secondary endpoint was the rate of other postoperative outcomes.

RESULTS

None of the patients who received HA/CMC instillation experienced postoperative adhesive bowel obstructions, compared with six (15.79%) patients in the control group (p = 0.025). Of the six patients with ileus, two underwent adhesiolysis. There were no significant differences between the two groups in other postoperative outcomes.

CONCLUSION

HA/CMC instillation during laparoscopic radical cystectomy may reduce the incidence of postoperative adhesive bowel obstruction without adverse effects.

Pathological Profile, Early Complications, Functional and Oncological Outcome after Radical Cystectomy - Ileal Conduit for Bladder Cancer Patients in Sanglah General Hospital between January 2013 and December 2016

BACKGROUND:

Radical cystectomy is the standard treatment for nonmetastatic bladder cancer (muscle-invasive and selective superficial bladder cancer). There are many types of urinary diversion after this procedure; the ileal conduit is the most and simplest one.

AIM:

To asses clinical, pathological profile, early complication, functional and oncological outcome after radical cystectomy and ileal conduit for muscle-invasive bladder cancer patients.

METHOD:

Between January 2013 and December 2016, there were 68 patients diagnosed with bladder cancer. From those patients, 24 (35.29%) patients had been performed radical cystectomy with ileal conduit type for urinary diversion (100%). Patients demographic, clinical and pathological profile, early postoperative complication, functional and oncological outcome were collected from the medical record.

RESULT:

Among the 24 patients who underwent radical cystectomy, 20 patients were male (83.3%) with the mean age was 57.3 y.o (33–77 y.o). Twelve patients (50%) showed pT4 and pT2 respectively. Based on pathological result 20 patient (83.34%) had the urothelial carcinoma, three patients (12.5%) had squamous cell carcinoma, and one patient (4.1%) had adenocarcinoma. Two patients (8.3%) got neoadjuvant chemotherapy, and nine patient (37.5%) of patients followed adjuvant chemotherapy after surgery. Wound dehiscence, fistula enterocutan, prolong ileus, leakage anastomosis and sepsis were kind of complication after surgery. One year’s survival rate is 84%, mortality rate 20.8% and a recurrence rate of 20.8% in 4 years follow up.

CONCLUSION:

Radical cystectomy and ileal conduit type of urinary diversion still become the preferable procedure for nonmetastatic bladder cancer with good functional and oncological outcome.

Comparison of Postradical Cystectomy Ileus Rates Using GIA-80 Versus GIA-60 Intestinal Stapler Device

OBJECTIVE

To assess the impact on recovery of bowel function using an 80 mm versus 60 mm gastrointestinal anastomosis (GIA) stapler following radical cystectomy and urinary diversion (RC/UD) for bladder cancer.

METHODS

We identified 696 patients using a prospectively maintained RC/UD database from January 2006 to November 2010. Two nonrandomized consecutive cohorts were compared. Patients between January 2006- and December 2007 (n = 180) were treated using a 60 mm GIA stapler, and 331 patients between January 2008 and December 2010 were subject to an 80 mm GIA stapler. All patients were treated on the same standardized postoperative recovery pathway. After accounting for baseline patient and perioperative characteristics, using a multivariable logistic regression model, we directly compared rates of postoperative ileus using a standardized definition.

RESULTS

Of 511 evaluable patients, ileus was observed in 32% (57/180) for 60 mm GIA versus 33% (110/331) for the 80 mm GIA. Preoperative renal function, age, gender, body mass index, and type of diversion were comparable between cohorts. On multivariate analysis, stapler size was not significantly associated with the development of ileus (GIA-60 vs GIA-80: OR 1.11; 95% CI 0.75, 1.66; P = .6). Positive fluid balance was associated with an increased risk (P = .019) and female sex a decreased risk (P = .008) of developing ileus compared to patients with negative fluid balance.

CONCLUSION

The size of the intestinal bowel anastomosis (GIA 80 mm vs 60 mm) does not independently impact the time to bowel recovery following RC/UD.

Complications After Ileal Urinary Derivations

Introduction

The aim of the study was to determine the most frequent early and late complications in different types of ileal urinary diversions.

Patients and methods

The study was conducted in a five-year period, on 106 patients who were diagnosed with invasive urinary bladder cancer and who had indication for radical cystectomy with one of the investigated types of urine derivation. They were divided into 2 groups, based on the type of ileal urinary diversions.

Results

The colonization of bacteria was more prominently present in the ileal conduit urinary diversion group (97%) compared to Ghoneim (25%) and Hautmann (10%) group, Ureteral stenosis was slightly less represented in the conduit group (9.1%). Wound infections were significantly more represented in the conduit (21.2%) than in the Ghoneim group (5%) Nighttime incontinence was present in 20% of patients in both groups or 4 patients in each group. Daytime incontinence in the Ghoneim group was present in 3 patients (15%) and in the Hautmann group 2 patients (10%). Late complications correlate significantly negative with the type of surgery and slightly negative with the grade, and significantly positively with the examined group and T stage, and slightly correlate positively to the N and R stages. Early complications correlate slightly negative with the type of surgery, slightly negative with the grade, and significantly positively with T stage, and slightly positively correlates with the N and R stage.

Conclusion

The most commonly reported complications in ileal conduit are: prolonged ileus, stoma infection, wound dehiscence and bacterial colonization, followed by peristomal skin complications and complications related only to the stoma, such as stenosis and stoma retraction, and prolaps of ileostoma and ileointestinal stenosis. The ileus rate in orthotopic derivation was significantly lower than that of the ileal conduit group, which led to the conclusion that the neomybladder position does not disturb the anatomic abdominal structure.

Cystectomy for bladder cancer in elderly patients is not associated with increased 30- and 90-day mortality or readmission, length of stay, and cost: propensity score matching using a population database

Purpose

Radical cystectomy (RC) is an effective but underused treatment for bladder cancer in elderly patients. This study performed analysis of propensity scores (PSs) to determine the outcomes of RC for elderly patients, with results generalizable at the population-based level.

Patients and methods

We conducted a population-based, retrospective cohort study of patients who underwent RC in Taiwan during 2000–2010. Multivariable logistic regression was implemented to evaluate 30- and 90-day mortality and readmission rates, length of intensive care unit (ICU) stay, length of hospital stay (LOS), and cost. Enrolled patients were divided into younger (≤75 years) and older groups (>75 years) who were matched according to their PSs.

Results

We identified 430 patients with bladder cancer who underwent RC between 2000 and 2010. Older age was not significantly associated with 30-day readmission (odds ratio [OR] = 0.80, 95% confidence interval [CI] = 0.38–1.70), 90-day readmission (OR = 1.10, 95% CI = 0.60–2.00), 30-day mortality (OR = 3.07, 95% CI = 0.31–30.0), or 90-day mortality (OR = 2.98, 95% CI = 0.91–9.70) in the PS-matched group. Similar trends were also observed for both groups regarding the mean length of ICU stay, LOS, and overall medical expenditure within the same admission.

Conclusion

No significant differences existed between the older and younger groups for 30-and 90-day mortality and readmission rates, length of ICU stay, LOS, and medical expenditure in patients undergoing RC for bladder cancer. Some healthy elderly patients may be good candidates for this extensive curative treatment.

Transperitoneal vs. extraperitoneal radical cystectomy for bladder cancer: A retrospective study

Purpose

Conventional transperitoneal radical cystectomy (TPRC) is the standard approach for muscle invasive bladder cancer. But, the procedure is associated with significant morbidities like urinary leak, ileus, and infection. To reduce these morbidities, the technique of extraperitoneal radical cystectomy (EPRC) was described by us in 1999. We compared these two approaches and the data accrued forms the basis of this report.

Materials and Methods

All patients who underwent radical cystectomy for bladder cancer by the author (JNK) with follow-up for at least 5 years were included. A total of 338 patients were studied, with 180 patients in EPRC group and 158 in TPRC group.

Results

There were 3 mortalities within 30 days in TPRC group and one in EPRC group. Early complication rate was 52% and 58% in EPRC and TPRC groups. Urinary leak occurred in 31 (9.2%) patients (13 in EPRC, 18 in TPRC, p=0.19). Gastrointestinal complications like ileus occurred in 9 (5%) patients in EPRC group and in 25 (15.8%) patients in TPRC group, (p<0.001). Wound dehiscence occurred in 29, and 36 patients in EPRC and TPRC groups respectively. The reoperation rate was 6.1% and 12% in EPRC and TPRC groups, (p=0.08). Intestinal obstruction were significantly less in EPRC group (1.7% vs. 7.8% in TPRC group, p=0.002). Uretero-enteric anastomosis stricture was seen in 10 patients (4 in EPRC, 6 in TPRC, p=0.39).

Conclusions

The EPRC is associated with decrease gastrointestinal complications, ease of management of urinary leaks, and low reoperation rates. Thus EPRC appears safe functionally and oncologically.