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Gavi F, Foschi N, Fettucciari D, Russo P, Giannarelli D, Ragonese M, Gandi C, Balocchi G, Francocci A, Bizzarri FP, Marino F, Filomena GB, Palermo G, Totaro A, Racioppi M, Bientinesi R, Sacco E. Assessing Trifecta and Pentafecta Success Rates between Robot-Assisted vs. Open Radical Cystectomy: A Propensity Score-Matched Analysis. Cancers (Basel) 2024; 16:1270. [PMID: 38610948 PMCID: PMC11011078 DOI: 10.3390/cancers16071270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/13/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND This study aimed to evaluate the surgical and oncological outcomes of robot-assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) using trifecta and pentafecta parameters. METHODS The clinical data of 41 patients who underwent RARC between 2018 and 2022 were prospectively collected and retrospectively compared to those of 330 patients undergoing ORC using 1:1 propensity score matching. Trifecta was defined as simultaneous negative surgical margins (SMs), a lymph node (LN) yield ≥ 16, and the absence of major complications (Clavien-Dindo grade III-V) within 90 days postoperatively. Pentafecta additionally included a 12-month recurrence-free rate and a time between the transurethral resection of a bladder tumor (TURBT) and radical cystectomy (RC) ≤ 3 months. The continuous variables were compared using the Mann-Whitney U test, and the categorical variables were analyzed using the chi-squared test. RESULTS No statistically significant differences in trifecta and pentafecta success rates were observed between the RARC and ORC cohorts after propensity score matching. However, the RARC group exhibited significantly reduced blood loss (RARC: 317 mL vs. ORC: 525 mL, p = 0.01). CONCLUSIONS RARC offers distinct advantages over ORC in terms of reduced blood loss, while trifecta and pentafecta success rates do not differ significantly between the two surgical approaches.
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Affiliation(s)
- Filippo Gavi
- Postgraduate School of Urology, Catholic University Medical School, Largo Francesco 6 Vito 1, 00168 Rome, Italy; (F.G.); (F.P.B.); (F.M.); (M.R.)
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Nazario Foschi
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Daniele Fettucciari
- Postgraduate School of Urology, Catholic University Medical School, Largo Francesco 6 Vito 1, 00168 Rome, Italy; (F.G.); (F.P.B.); (F.M.); (M.R.)
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Pierluigi Russo
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Diana Giannarelli
- Facility of Epidemiology and Biostatistics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy
| | - Mauro Ragonese
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Carlo Gandi
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Giovanni Balocchi
- Postgraduate School of Urology, Catholic University Medical School, Largo Francesco 6 Vito 1, 00168 Rome, Italy; (F.G.); (F.P.B.); (F.M.); (M.R.)
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Alessandra Francocci
- Postgraduate School of Urology, Catholic University Medical School, Largo Francesco 6 Vito 1, 00168 Rome, Italy; (F.G.); (F.P.B.); (F.M.); (M.R.)
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Francesco Pio Bizzarri
- Postgraduate School of Urology, Catholic University Medical School, Largo Francesco 6 Vito 1, 00168 Rome, Italy; (F.G.); (F.P.B.); (F.M.); (M.R.)
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Filippo Marino
- Postgraduate School of Urology, Catholic University Medical School, Largo Francesco 6 Vito 1, 00168 Rome, Italy; (F.G.); (F.P.B.); (F.M.); (M.R.)
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Giovanni Battista Filomena
- Postgraduate School of Urology, Catholic University Medical School, Largo Francesco 6 Vito 1, 00168 Rome, Italy; (F.G.); (F.P.B.); (F.M.); (M.R.)
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Giuseppe Palermo
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Angelo Totaro
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Marco Racioppi
- Postgraduate School of Urology, Catholic University Medical School, Largo Francesco 6 Vito 1, 00168 Rome, Italy; (F.G.); (F.P.B.); (F.M.); (M.R.)
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Riccardo Bientinesi
- Department of Urology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco 8 Vito 1, 00168 Rome, Italy (G.P.)
| | - Emilio Sacco
- Postgraduate School of Urology, Catholic University Medical School, Largo Francesco 6 Vito 1, 00168 Rome, Italy; (F.G.); (F.P.B.); (F.M.); (M.R.)
- Urology Department, Isola Tiberina Gemelli Isola Hospital, Catholic University Medical School, 00168 Rome, Italy
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Bizoń M, Olszewski M, Grabowska A, Mawlichanów K, Pilka R. Robotic surgery in endometrial cancer: first Polish experience. J Robot Surg 2024; 18:14. [PMID: 38216814 DOI: 10.1007/s11701-023-01752-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/24/2023] [Indexed: 01/14/2024]
Abstract
In Poland, robotic surgery is nowadays perceived as a new method of surgical treatment in endometrial cancer patients. We aim to present the first Polish group of endometrial cancer patients treated using robotic surgery. The analysis was based on 79 patients with mean age of 59.72 ± 11.709 (range 27-83) years and endometrial cancer scheduled for surgical treatment. Mean BMI was 31.38 ± 8.78 (range 19.03-65.97) kg/m2. The data were collected based on a questionnaire consisting of 19 questions concerning the patient's perception of robotic surgery before the procedure. Patients with a family history of neoplastic diseases indicate precision of movements as the most important reason for choosing robotic surgery (p = 0.0035). Patients after surgery procedures in the past named shorter hospitalization as a major benefit (p = 0.0037). Patients who chose robotic surgery for financial reasons stressed the cosmetic effect as a priority (p = 0.0319). Shorter length of hospital stay, less blood loss, enlarged view, and good visualization were statistically significant reasons for choosing robotic surgery (p < 0.05). Women who consider work, good material status, and well-being as the most important aspects of their lives cited the cosmetic effect as a benefit of robotic surgery (p = 0.0029 vs. p = 0.0074 vs. p = 0.01745, respectively). In the follow-up after operations, no patients regretted choosing robotic surgery. Good visualization, precise movements, less blood loss, and cosmetic effects are the most frequent reasons for choosing robotic surgery. Even patients after other types of surgery in the past decided on robot-assisted radical hysterectomy because of the clear benefits of this approach.
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Affiliation(s)
- Magdalena Bizoń
- LUX MED Oncology Hospital, św. Wincentego 103, Warsaw, Poland.
- Neohospital, Kostrzewskiego 47, Cracow, Poland.
- Lazarski University, Warsaw, Poland.
| | - Maciej Olszewski
- LUX MED Oncology Hospital, św. Wincentego 103, Warsaw, Poland
- Neohospital, Kostrzewskiego 47, Cracow, Poland
- Lazarski University, Warsaw, Poland
| | | | - Krzysztof Mawlichanów
- Neohospital, Kostrzewskiego 47, Cracow, Poland
- Andrzej Frycz Modrzewski Krakow University, Cracow, Poland
| | - Radovan Pilka
- Neohospital, Kostrzewskiego 47, Cracow, Poland
- Department of Obstetrics and Gynecology, University Hospital Olomouc, Palacky University Medical Faculty, Olomouc, Czech Republic
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Noh TI, Shim JS, Kang SG, Cheon J, Pyun JH, Kang SH. The learning curve for robot-assisted radical cystectomy with total intracorporeal urinary diversion based on radical cystectomy pentafecta. Front Oncol 2022; 12:975444. [PMID: 36330475 PMCID: PMC9623051 DOI: 10.3389/fonc.2022.975444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/28/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To analyze the learning curve for robot- assisted radical cystectomy (RARC) with total intracorporeal urinary diversion (ICUD) in terms of both time efficiency and quality of surgery based on radical cystectomy (RC)-pentafecta. Patients and methods We identified 203 consecutive patients who underwent RARC with ICUD of the ileal conduit (IC, 85) and orthotopic neobladder (ONB, 118) performed by a single surgeon between 2011 and 2021. We grouped ten consecutive patients into time-associated blocks according to the operation order. Process efficiency and operation quality were measured based on the surgeon’s console time and attainment/score sum of RC-pentafecta. The overcoming point of the learning curve was defined graphically and statistically. Results The mean follow-up period was 44.5 ± 30.7 months. Of the 203 patients, 109 (53.7%) attained the five criteria of RC-pentafecta (ONB vs IC, 50.6% vs. 55.9%, p = 0.35). The attainment rate and sum of the RC-pentafecta score of the third group were not significantly different from those of all patients (40.0% vs. 53.7%, p = 0.369, 4.00 ± 1.05 vs. 4.41 ± 0.75, p = 0.137, respectively), and the proficiency in operation quality was satisfactory in the third group. The console times continually improved and stabilized after the 140th case (IC, 60; ONB, 80), and the attainment rate and sum of the RC-pentafecta were significantly different between before and after the 140th case (p<0.001). Conclusion A single surgeon’s learning curve for RARC with ICUD and pelvic lymph node dissection (PLND) showed an acceptable level of proficiency after 30 consecutive cases in terms of the operation quality. However, for an expert surgeon, 140 cases were required to reach a plateau in time efficiency and second leap with the RC-pentafecta. RARC with ICUD and PLND can be performed safely without compromising functional outcomes and complications through sharing and transmission of standardized techniques.
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Affiliation(s)
- Tae Il Noh
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Ji Sung Shim
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Sung Gu Kang
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jun Cheon
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jong Hyun Pyun
- Department of Urology, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Seok Ho Kang, ; Jong Hyun Pyun,
| | - Seok Ho Kang
- Department of Urology, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
- *Correspondence: Seok Ho Kang, ; Jong Hyun Pyun,
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Venkatramani V, Reis IM, Gonzalgo ML, Castle EP, Woods ME, Svatek RS, Weizer AZ, Konety BR, Tollefson M, Krupski TL, Smith ND, Shabsigh A, Barocas DA, Quek ML, Dash A, Parekh DJ. Comparison of Robot-Assisted and Open Radical Cystectomy in Recovery of Patient-Reported and Performance-Related Measures of Independence: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2148329. [PMID: 35171260 PMCID: PMC8851298 DOI: 10.1001/jamanetworkopen.2021.48329] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE No data exist on time to recovery of patient-reported and performance-related measures of functional independence after radical cystectomy (open or robotic). OBJECTIVE To determine recovery of functional independence after radical cystectomy and whether robot-assisted radical cystectomy (RARC) is associated with any advantage over open procedures. DESIGN, SETTING, AND PARTICIPANTS Data for this secondary analysis from the RAZOR (Randomized Open vs Robotic Cystectomy) trial were used. RAZOR was a phase 3 multicenter noninferiority trial across 15 academic medical centers in the US from July 1, 2011, to November 18, 2014, with a median follow-up of 2 years. Participants included the per-protocol population (n = 302). Data were analyzed from February 1, 2017, to May 1, 2021. INTERVENTIONS Robot-assisted radical cystectomy or open radical cystectomy (ORC). MAIN OUTCOMES AND MEASURES Patient-reported (activities of daily living [ADL] and independent ADL [iADL]) and performance-related (hand grip strength [HGS] and Timed Up & Go walking test [TUGWT]) measures of independence were assessed. Patterns of postoperative recovery for the entire cohort and comparisons between RARC and ORC were performed. Exploratory analyses to assess measures of independence across diversion type and to determine whether baseline impairments were associated with 90-day complications or 1-year mortality were performed. FINDINGS Of the 302 patients included in the analysis (254 men [84.1%]; mean [SD] age at consent, 68.0 [9.7] years), 150 underwent RARC and 152 underwent ORC. Baseline characteristics were similar in both groups. For the entire cohort, ADL, iADL, and TUGWT recovered to baseline by 3 postoperative months, whereas HGS recovered by 6 months. There was no difference between RARC and ORC for ADL, iADL, TUGWT, or HGS scores at any time. Activities of daily living recovered 1 month after RARC (mean estimated score, 7.7 [95% CI, 7.3-8.0]) vs 3 months after ORC (mean estimated score, 7.5 [95% CI, 7.2-7.8]). Hand grip strength recovered by 3 months after RARC (mean estimated HGS, 29.0 [95% CI, 26.3-31.7] kg) vs 6 months after ORC (mean estimated HGS, 31.2 [95% CI, 28.8-34.2] kg). In the RARC group, 32 of 90 patients (35.6%) showed a recovery in HGS at 3 months vs 32 of 88 (36.4%) in the ORC group (P = .91), indicating a rejection of the primary study hypothesis for HGS. Independent ADL and TUGWT recovered in 3 months for both approaches. Hand grip strength showed earlier recovery in patients undergoing continent urinary diversion (mean HGS at 3 months, 31.3 [95% CI, 27.7-34.8] vs 33.9 [95% CI, 30.5-37.3] at baseline; P = .09) than noncontinent urinary diversion (mean HGS at 6 months, 27.4 [95% CI, 24.9-30.0] vs 29.5 [95% CI, 27.2-31.9] kg at baseline; P = .02), with no differences in other parameters. Baseline impairments in any parameter were not associated with 90-day complications or 1-year mortality. CONCLUSIONS AND RELEVANCE The results of this secondary analysis suggest that patients require 3 to 6 months to recover baseline levels after radical cystectomy irrespective of surgical approach. These data will be invaluable in patient counseling and preparation. Hand grip strength and ADL tended to recover to baseline earlier after RARC; however, there was no difference in the percentage of patients recovering when compared with ORC. Further study is needed to assess the clinical significance of these findings. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01157676.
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Affiliation(s)
- Vivek Venkatramani
- Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Isildinha M. Reis
- Division of Biostatistics, Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida
| | - Mark L. Gonzalgo
- Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Erik P. Castle
- Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Michael E. Woods
- Department of Urology, University of North Carolina at Chapel Hill
| | - Robert S. Svatek
- Department of Urology, Division of Urologic Oncology, University of Texas Health Science Center at San Antonio
| | - Alon Z. Weizer
- Department of Urology, University of Michigan, Ann Arbor
| | | | | | - Tracey L. Krupski
- Department of Urology, University of Virginia Health Science Center, Charlottesville
| | - Norm D. Smith
- Department of Urology, North Shore University Health System, Evanston, Illinois
| | | | - Daniel A. Barocas
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marcus L. Quek
- Department of Urology, Loyola University Medical Center, Maywood, Illinois
| | - Atreya Dash
- Department of Urology, University of Washington, Seattle
| | - Dipen J. Parekh
- Department of Urology, University of Miami Miller School of Medicine, Miami, Florida
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
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Stangl FP, Thalmann GN. Continent diversion: five decades of developments and evolution. BJU Int 2020; 126:653-660. [PMID: 32916771 DOI: 10.1111/bju.15239] [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] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To provide a chronological overview of the evolution of continent urinary diversion (CUD) over the last 50 years and to highlight important milestones. METHODS We performed an extensive literature review and analysed different forms of urinary diversion worldwide. After the evaluation of surgical techniques, we assessed the advantages and disadvantages of assorted CUD approaches based on published long-term follow-up data. RESULTS A wide variety of surgical options for CUD is available and feasible to date, although consensus among urologists regarding the 'gold standard' is still lacking. Several forms of orthotopic bladder substitutes and continent cutaneous urinary reservoirs have been shown to provide excellent long-term results. CONCLUSION The last 50 years of CUD have seen constant evolution and refinement of techniques, but the best surgical approach remains unclear and there is no 'one-size-fits-all' option, but rather tailor-made approaches are necessary to ensure patient satisfaction.
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Affiliation(s)
- Fabian P Stangl
- Department of Urology, University of Bern, Bern, Switzerland
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6
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Zhang S, Lin T, Zhang Q, Zhang S, Liu G, Ji C, Guo H. Comparison of perioperative outcomes in robot‐assisted radical cystectomy and laparoscopic radical cystectomy. Int J Med Robot 2020; 16:e2074. [PMID: 31922333 DOI: 10.1002/rcs.2074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 12/25/2019] [Accepted: 12/31/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Shiwei Zhang
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of UrologyNanjing University Nanjing China
| | - Tingsheng Lin
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of UrologyNanjing University Nanjing China
| | - Qing Zhang
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of UrologyNanjing University Nanjing China
| | - Shengjie Zhang
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of UrologyNanjing University Nanjing China
| | - Guangxiang Liu
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of UrologyNanjing University Nanjing China
| | - Changwei Ji
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of UrologyNanjing University Nanjing China
| | - Hongqian Guo
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of UrologyNanjing University Nanjing China
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Abstract
PURPOSE OF REVIEW We review historical aspects and current status of the emerging approach of robotic urinary diversion (rUD). Established surgical principles of constructing a low-pressure, large-capacity reservoir are described and the open surgical literature succinctly reviewed to establish the gold standard. Incontinent and continent rUD types [ileal conduit, orthotopic neobladder (all varieties), continent cutaneous diversion, cutaneous ureterostomy] and techniques (extra-corporeal, intra-corporeal) are discussed. Outcomes data (intra-operative, perioperative, intermediate-term, long-term), functional outcomes, complications and learning curve are presented. Outcomes data of open versus robotic urinary diversion are examined. Critiques, improvements, and pros-cons of rUD are discussed. RECENT FINDINGS Although the majority of centers performing rUD use the extracorporeal technique, use of intra-corporeal rUD is increasing. Although data are yet limited, intra-corporeal rUD may provide some benefits. For rUD, operative times are higher and complication rates comparable with open urinary diversion. SUMMARY The entire range of urinary diversion surgery has now been replicated robotically. At this writing, extracorporeal urinary diversion techniques still predominate following robotic cystectomy. However, all rUD options can now be performed intra-corporeally with success. As experience increases, the field of robotic urinary diversion is poised to grow.
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8
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Jones RP, Are C, Hugh TJ, Grünhagen DJ, Xu J, Balch CM, Poston GJ. Reshaping the critical role of surgeons in oncology research. Nat Rev Clin Oncol 2019; 16:327-332. [PMID: 30617343 DOI: 10.1038/s41571-018-0149-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Surgery remains a mainstay in the treatment of most solid cancers. Surgeons have always engaged in various forms of high-quality cancer research to optimize outcomes for their patients, for example, contributing to clinical research and outcomes research as well as health education and public health policy. Over the past decade, however, concerns have been raised about a global decline in the number of surgeons performing basic science research alongside clinical activity - so-called surgeon scientists. Herein, we describe some of the unique obstacles faced by contemporary trainee and practising surgeons engaged in research, as well as providing a perspective on the implications of the diminishing prominence of the surgeon scientist. Finally, we offer some thoughts on potential strategies and future directions for surgical engagement in oncology research to increase the number of research-active surgeons.
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Affiliation(s)
- Robert P Jones
- School of Cancer Studies, Institute of Translational Medicine, University of Liverpool, Liverpool, UK. .,North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, UK.
| | - Chandrakanth Are
- Division of Surgical Oncology, Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Thomas J Hugh
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Jianmin Xu
- Department of Surgery, Shanghai Zhongshan Hospital, Shanghai, China
| | - Charles M Balch
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Graeme J Poston
- North Western Hepatobiliary Unit, Aintree University Hospital, Liverpool, UK
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Voigt M, Hemal K, Matthews C. Influence of Simple and Radical Cystectomy on Sexual Function and Pelvic Organ Prolapse in Female Patients: A Scoping Review of the Literature. Sex Med Rev 2019; 7:408-415. [DOI: 10.1016/j.sxmr.2019.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/13/2019] [Accepted: 03/31/2019] [Indexed: 01/27/2023]
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10
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Rangarajan K, Somani BK. Trends in quality of life reporting for radical cystectomy and urinary diversion over the last four decades: A systematic review of the literature. Arab J Urol 2019; 17:181-194. [PMID: 31489233 PMCID: PMC6711151 DOI: 10.1080/2090598x.2019.1600279] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 11/12/2022] Open
Abstract
Objective: To report the trends in quality of life (QoL) reporting for radical cystectomy (RC) and urinary diversion (UD) over the last four decades, as RC for bladder cancer is associated with significant morbidity and QoL issues. Material and methods: We searched PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane library for published studies from January 1980 to January 2017 in the English language. We divided the published articles into three time periods: period-1 (1980–1997), period-2 (1998–2007) and period-3 (2008–2017). Results: A total of 85 QoL studies (8417 patients) were identified, of which 3347 (39.8%) patients had an ileal conduit (IC), 1078 (12.8%) had a continent UD (CD), 3264 (38.8%) had a neobladder (NB), and in the remaining 728 (8.6%) the type of UD was not specified. Whilst there were 15, 24 and 41 studies in period-1, period-2 and period-3 respectively, two (13%), 20 (83%) and 37 (90%) used a validated QoL tool; and none, six (25%) and 23 (56%) used a urology specific QoL tool during these three time periods. Similarly, the number of prospective studies increased from one (7%) to four (17%) and 14 (34%) in these three time periods. The proportion of reported IC patients reduced from 65% (784 patients) to 36% (899) and 35% (1664) from period-1 to period-3, whereas the proportion of NB patients increased from 4.5% (54) to 44% (1105) and 44% (2105). Over the last few years there have been QoL studies on laparoscopic and robotic IC and NB UDs. Conclusion: Our review suggests an increasing use of validated, bladder cancer-specific questionnaires with UD-specific constructs. Abbreviations: BCI: Bladder Cancer Index; BDI: Beck Depression Inventory; BIS: Body Image Scale; CD: continent urinary diversion; EORTC QLQ-30C: European Organisation for the Research and Treatment of Cancer Quality of Life 30-item core questionnaire; ERAS: enhanced recovery after surgery; FACT(-BL)(-G)(-VCI): Functional Assessment of Cancer Therapy(-Bladder Cancer)(-General)(-Vanderbilt Cystectomy Index); IC: ileal conduit; NB: neobladder; (HR)QoL: (health-related) quality of life; (RA)RC: (robot-assisted) radical cystectomy; SF-36: 36-item short-form health survey; SIP: Sickness Impact Profile; UD: urinary diversion
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Wijburg CJ, Michels CTJ, Oddens JR, Grutters JPC, Witjes JA, Rovers MM. Robot assisted radical cystectomy versus open radical cystectomy in bladder cancer (RACE): study protocol of a non-randomized comparative effectiveness study. BMC Cancer 2018; 18:861. [PMID: 30176832 PMCID: PMC6122745 DOI: 10.1186/s12885-018-4779-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/23/2018] [Indexed: 11/10/2022] Open
Abstract
Background Despite the fact that the cost-effectiveness of robot-assisted radical cystectomy (RARC) is not yet proven, and open radical (ORC) cystectomy is recommended as the standard of care in patients with high-risk non-muscle-invasive and muscle-invasive bladder cancer, the use of RARC is still increasing. The objective of the current ongoing comparative effectiveness trial therefore is to study the (cost-)effectiveness of RARC compared to ORC, both in terms of objective (complication rates, oncological outcomes) and patient-reported (health-related quality of life) outcome measures. Methods This study is designed as a non-randomized, multicentre comparative effectiveness trial. Centres with an annual caseload of > 20 radical cystectomies can include patients after informed consent has been given. Centres that perform RARC must have passed the (initial) learning curve of 40 cases. A total of 338 (2 × 169) patients will be enrolled from 23 participating centres (12 ORC, 10 RARC and 1 LRC). Follow-up visits will be scheduled at 1, 3, 6 and 12 months. During each follow-up visit, clinical data and health-related quality of life questionnaires will be administered. Costs will be studied using a monthly resource usage questionnaire. Impact on complications and quality of life will be calculated as the average difference between the groups with 95% confidence intervals, adjusted for potential baseline differences by means of propensity score matching. Discussion This study aims to contribute to the development of evidence-based guidelines regarding the most cost-effective surgical technique for radical cystectomy. Trial registration Nederlands Trial Register/Dutch Trial Registry, trial identifying number: NTR5362. Registered on 14 August 2015. (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5362).
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Affiliation(s)
- C J Wijburg
- Department of Urology, Rijnstate Hospital, Wagnerlaan 55, 6815, AD, Arnhem, The Netherlands.
| | - C T J Michels
- Department of Urology, Rijnstate Hospital, Wagnerlaan 55, 6815, AD, Arnhem, The Netherlands
| | - J R Oddens
- Department of Urology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J P C Grutters
- Departments of Operating Rooms and Health Evidence, Radboud university medical center, Geert Grooteplein Noord 21, 6500, HB, Nijmegen, The Netherlands
| | - J A Witjes
- Department of Urology, Radboud university medical center, Geert Grooteplein Noord 21, 6500, HB, Nijmegen, The Netherlands
| | - M M Rovers
- Departments of Operating Rooms and Health Evidence, Radboud university medical center, Geert Grooteplein Noord 21, 6500, HB, Nijmegen, The Netherlands
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12
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Catto JWF, Khetrapal P, Ambler G, Sarpong R, Khan MS, Tan M, Feber A, Dixon S, Goodwin L, Williams NR, McGrath J, Rowe E, Koupparis A, Brew-Graves C, Kelly JD. Robot-assisted radical cystectomy with intracorporeal urinary diversion versus open radical cystectomy (iROC): protocol for a randomised controlled trial with internal feasibility study. BMJ Open 2018; 8:e020500. [PMID: 30093510 PMCID: PMC6089318 DOI: 10.1136/bmjopen-2017-020500] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Bladder cancer (BC) is a common malignancy and one of the most expensive to manage. Radical cystectomy (RC) with pelvic lymphadenectomy is a gold standard treatment for high-risk BC. Reductions in morbidity and mortality from RC may be achieved through robot-assisted RC (RARC). Prospective comparisons between open RC (ORC) and RARC have been limited by sample size, use of extracorporeal reconstruction and use of outcomes important for ORC. Conversely, while RARC is gaining in popularity, there is little evidence to suggest it is superior to ORC. We are undertaking a prospective randomised controlled trial (RCT) to compare RARC with intracorporeal reconstruction (iRARC) and ORC using multimodal outcomes to explore qualitative and quantitative recovery after surgery. METHODS AND ANALYSIS: iROC is a multicentre prospective RCT in English National Health Service (NHS) cancer centres. We will randomise 320 patients undergoing RC to either iRARC or ORC. Treatment allocation will occur after trial entry and consent. The primary outcome is days alive and out of hospital within the first 90 days from surgery. Secondary outcomes will measure functional recovery (activity trackers, chair-to-stand tests and health related quality of life (HRQOL) questionnaires), morbidity (complications and readmissions), cost-effectiveness (using EuroQol-5 Domain-5 levels (EQ-5D-5L) and unit costs) and surgeon fatigue. Patients will be analysed according to intention to treat. The primary outcome will be transformed and analysed using regression. All statistical assumptions will be investigated. Secondary outcomes will be analysed using appropriate regression methods. An internal feasibility study of the first 30 patients will evaluate recruitment rates, acceptance of randomised treatment choice, compliance outcome collection and to revise our sample size. ETHICS AND DISSEMINATION The study has ethical approval (REC reference 16/NE/0418). Findings will be made available to patients, clinicians, funders and the NHS through peer-reviewed publications, social media and patient support groups. TRIAL REGISTRATION NUMBERS ISRCTN13680280 and NCT03049410.
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Affiliation(s)
- James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Pramit Khetrapal
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Rachael Sarpong
- Surgical and Interventional Trials Unit (SITU), Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Melanie Tan
- Surgical and Interventional Trials Unit (SITU), Division of Surgery and Interventional Science, University College London, London, UK
| | - Andrew Feber
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Simon Dixon
- Health Economics and Decision Science, NIHR Research Design Service Yorkshire and the Humber, University of Sheffield, Sheffield, UK
| | - Louise Goodwin
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Norman R Williams
- Surgical and Interventional Trials Unit (SITU), Division of Surgery and Interventional Science, University College London, London, UK
| | - John McGrath
- Department of Urology, Royal Devon and Exeter NHS Trust, Exeter, UK
| | - Edward Rowe
- Department of Urology, North Bristol NHS Trust, Bristol, UK
| | | | - Chris Brew-Graves
- Surgical and Interventional Trials Unit (SITU), Division of Surgery and Interventional Science, University College London, London, UK
| | - John D Kelly
- Division of Surgery and Interventional Science, University College London, London, UK
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13
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Parekh DJ, Reis IM, Castle EP, Gonzalgo ML, Woods ME, Svatek RS, Weizer AZ, Konety BR, Tollefson M, Krupski TL, Smith ND, Shabsigh A, Barocas DA, Quek ML, Dash A, Kibel AS, Shemanski L, Pruthi RS, Montgomery JS, Weight CJ, Sharp DS, Chang SS, Cookson MS, Gupta GN, Gorbonos A, Uchio EM, Skinner E, Venkatramani V, Soodana-Prakash N, Kendrick K, Smith JA, Thompson IM. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet 2018; 391:2525-2536. [PMID: 29976469 DOI: 10.1016/s0140-6736(18)30996-6] [Citation(s) in RCA: 457] [Impact Index Per Article: 76.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/20/2018] [Accepted: 04/25/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Radical cystectomy is the surgical standard for invasive bladder cancer. Robot-assisted cystectomy has been proposed to provide similar oncological outcomes with lower morbidity. We aimed to compare progression-free survival in patients with bladder cancer treated with open cystectomy and robot-assisted cystectomy. METHODS The RAZOR study is a randomised, open-label, non-inferiority, phase 3 trial done in 15 medical centres in the USA. Eligible participants (aged ≥18 years) had biopsy-proven clinical stage T1-T4, N0-N1, M0 bladder cancer or refractory carcinoma in situ. Individuals who had previously had open abdominal or pelvic surgery, or who had any pre-existing health conditions that would preclude safe initiation or maintenance of pneumoperitoneum were excluded. Patients were centrally assigned (1:1) via a web-based system, with block randomisation by institution, stratified by type of urinary diversion, clinical T stage, and Eastern Cooperative Oncology Group performance status, to receive robot-assisted radical cystectomy or open radical cystectomy with extracorporeal urinary diversion. Treatment allocation was only masked from pathologists. The primary endpoint was 2-year progression-free survival, with non-inferiority established if the lower bound of the one-sided 97·5% CI for the treatment difference (robotic cystectomy minus open cystectomy) was greater than -15 percentage points. The primary analysis was done in the per-protocol population. Safety was assessed in the same population. This trial is registered with ClinicalTrials.gov, number NCT01157676. FINDINGS Between July 1, 2011, and Nov 18, 2014, 350 participants were randomly assigned to treatment. The intended treatment was robotic cystectomy in 176 patients and open cystectomy in 174 patients. 17 (10%) of 176 patients in the robotic cystectomy group did not have surgery and nine (5%) patients had a different surgery to that they were assigned. 21 (12%) of 174 patients in the open cystectomy group did not have surgery and one (1%) patient had robotic cystectomy instead of open cystectomy. Thus, 302 patients (150 in the robotic cystectomy group and 152 in the open cystectomy group) were included in the per-protocol analysis set. 2-year progression-free survival was 72·3% (95% CI 64·3 to 78·8) in the robotic cystectomy group and 71·6% (95% CI 63·6 to 78·2) in the open cystectomy group (difference 0·7%, 95% CI -9·6% to 10·9%; pnon-inferiority=0·001), indicating non-inferiority of robotic cystectomy. Adverse events occurred in 101 (67%) of 150 patients in the robotic cystectomy group and 105 (69%) of 152 patients in the open cystectomy group. The most common adverse events were urinary tract infection (53 [35%] in the robotic cystectomy group vs 39 [26%] in the open cystectomy group) and postoperative ileus (33 [22%] in the robotic cystectomy group vs 31 [20%] in the open cystectomy group). INTERPRETATION In patients with bladder cancer, robotic cystectomy was non-inferior to open cystectomy for 2-year progression-free survival. Increased adoption of robotic surgery in clinical practice should lead to future randomised trials to assess the true value of this surgical approach in patients with other cancer types. FUNDING National Institutes of Health National Cancer Institute.
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Affiliation(s)
- Dipen J Parekh
- Department of Urology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA.
| | - Isildinha M Reis
- Division of Biostatistics, Department of Public Health Sciences, Sylvester Biostatistics and Bioinformatics Shared Resource, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Erik P Castle
- Department of Urology, Mayo Clinic, Phoenix, AZ, USA
| | - Mark L Gonzalgo
- Department of Urology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Michael E Woods
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert S Svatek
- Department of Urology, Division of Urologic Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Alon Z Weizer
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Tracey L Krupski
- Department of Urology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Norm D Smith
- Department of Urology, University of Chicago, Chicago, IL, USA
| | - Ahmad Shabsigh
- Department of Urology, Ohio State University, Columbus, OH, USA
| | - Daniel A Barocas
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marcus L Quek
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Atreya Dash
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Adam S Kibel
- Harvard Medical School, Boston, MA, USA; Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Raj S Pruthi
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - David S Sharp
- Department of Urology, Ohio State University, Columbus, OH, USA
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael S Cookson
- Department of Urology, Oklahoma University of Oklahoma, Norman, OK, USA
| | - Gopal N Gupta
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Alex Gorbonos
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Edward M Uchio
- Department of Urology, University of California at Irvine, Irvine, CA, USA
| | - Eila Skinner
- Department of Urology, Stanford University, Stanford, CA, USA
| | - Vivek Venkatramani
- Department of Urology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Nachiketh Soodana-Prakash
- Department of Urology, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Kerri Kendrick
- Department of Urology, Division of Urologic Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Joseph A Smith
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ian M Thompson
- Department of Urology, Division of Urologic Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA; CHRISTUS Santa Rosa Medical Center Hospital, San Antonio, TX, USA
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14
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Abstract
INTRODUCTION Radical cystectomy and extended pelvic lymph node dissection (ePLND) are the gold standard treatment for muscle-invasive bladder cancer and BCG unresponsive nonmuscle-invasive bladder cancer. In this article, we review the rationale for ePLND in the treatment of bladder cancer and the evidence supporting the equipoise between robot-assisted (RA) and open ePLND. A step-by-step guide of robot-assisted ePLND (RA ePLND) is provided to illustrate the techniques currently employed at our institution. MATERIALS AND METHODS Medline and PubMed electronic databases were queried for English language articles on bladder cancer, ePLND, and RA ePLND. In addition, a step-by-step video of RA ePLND was assembled with narration and accompanying explanations of each step to illustrate our current techniques. Key images from the video were selected for illustration of the relevant anatomical landmarks. RESULTS ePLND with a minimum nodal yield of 10 to 14 is tantamount in the treatment of bladder cancer. The number of lymph nodes resected influenced survival in both pathologically node positive and negative patients. In addition, RA ePLND was found to have equipoise as open ePLND by several groups. In our surgical atlas video, we illustrate key surgical steps, including port placement and exposure. Also, anatomic landmarks of dissection for the internal iliac, external iliac/obturator, and higher nodal packets are described in detail. CONCLUSIONS We illustrate the techniques for a thorough RA ePLND, with the intention to help the robotic surgeon to meet the 10 to 14 nodal yield mandated by the Bladder Cancer Collaborative Group.
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Affiliation(s)
- Roger Li
- Department of Urology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Firas G Petros
- Department of Urology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - John W Davis
- Department of Urology, The University of Texas MD Anderson Cancer Center , Houston, Texas
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15
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Abstract
Twenty years after it was introduced, robotic surgery has become more commonplace in urology – we examine its current uses and controversies
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16
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Simone G, Tuderti G, Misuraca L, Anceschi U, Ferriero M, Minisola F, Guaglianone S, Gallucci M. Perioperative and mid-term oncologic outcomes of robotic assisted radical cystectomy with totally intracorporeal neobladder: Results of a propensity score matched comparison with open cohort from a single-centre series. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:1432-1438. [PMID: 29699838 DOI: 10.1016/j.ejso.2018.04.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/29/2018] [Accepted: 04/06/2018] [Indexed: 10/17/2022]
Abstract
AIM In this study, we compared perioperative and oncologic outcomes of patients treated with either open or robot-assisted radical cystectomy and intracorporeal neobladder at a tertiary care center. METHODS The institutional prospective bladder cancer database was queried for "cystectomy with curative intent" and "neobladder". All patients underwent robot-assisted radical cystectomy and intracorporeal neobladder or open radical cystectomy and orthotopic neobladder for high-grade non-muscle invasive bladder cancer or muscle invasive bladder cancer with a follow-up length ≥2 years were included. A 1:1 propensity score matching analysis was used. Kaplan-Meier method was performed to compare oncologic outcomes of selected cohorts. Survival rates were computed at 1,2,3 and 4 years after surgery and the log rank test was applied to assess statistical significance between the matched groups. RESULTS Overall, 363 patients (299 open and 64 robotic) were included. Open radical cystectomy patients were more frequently male (p = 0.08), with higher pT stages (p = 0.003), lower incidence of urothelial histologies (p = 0.05) and lesser adoption of neoadjuvant chemotherapy (<0.001). After applying the propensity score matching, 64 robot-assisted radical cystectomy patients were matched with 46 open radical cystectomy cases (all p ≥ 0.22). Open cohort showed a higher rate of perioperative overall complications (91.3% vs 42.2%, p 0.001). At Kaplan-Meier analysis robotic and open cohorts displayed comparable disease-free survival (log-rank p = 0.746), cancer-specific survival (p = 0.753) and overall-survival rates (p = 0.909). CONCLUSIONS Robot-assisted radical cystectomy and intracorporeal neobladder provides comparable oncologic outcomes of open radical cystectomy and orthotopic neobladder at intermediate term survival analysis.
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Affiliation(s)
- Giuseppe Simone
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy.
| | - Gabriele Tuderti
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Leonardo Misuraca
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Umberto Anceschi
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | | | - Francesco Minisola
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | | | - Michele Gallucci
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
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17
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Abstract
Retrospective observational studies support the utility of robotic-assisted radical cystectomy (RARC). Randomized controlled trials (RCTs) have shown that RARC with extracorporeal urinary diversion may lead to decreased estimated blood loss, decreased rate of transfusion, similar oncologic outcomes, cost-effectiveness, and variable increased operative times. Although RCTs comparing RARC with open radical cystectomy are currently ongoing, it may be several years before the utility of RARC is known. The discussion on the role of cystectomy, indications, outcomes, care pathways, access to high-volume care centers, and efforts to decrease complications may prove as important as the technique itself.
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Affiliation(s)
- Danica May
- Department of Urology, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Room 547, New Orleans, LA 70112, USA
| | - Jessie Gills
- Department of Pl Urology, Louisiana State University Healthcare Network, 1542 Tulane Avenue, Room 547, New Orleans, LA 70112, USA.
| | - Scott E Delacroix
- Department of Pl Urology, Louisiana State University Healthcare Network, 1542 Tulane Avenue, Room 547, New Orleans, LA 70112, USA
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18
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Abstract
Robot-assistance is being increasingly used for radical cystectomy (RC). Fifteen years of surgical evolution might be considered a short period for a radical procedure to be established as the treatment of choice, but robot assisted radical cystectomy (RARC) is showing promising results when compared with the current gold standard, open RC (ORC). In this review, we describe the current status of RARC and continue the discussion on the on-going RARC versus ORC debate.
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Affiliation(s)
- Stavros Ioannis Tyritzis
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Nils Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
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19
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Abstract
Even with advances in perioperative medical care, anesthetic management, and surgical techniques, radical cystectomy (RC) continues to be associated with a high morbidity rate as well as a prolonged length of hospital stay. In recent years, there has been great interest in identifying multimodal and interdisciplinary strategies that help accelerate postoperative convalescence by reducing variation in perioperative care of patients undergoing complex surgeries. Enhanced recovery after surgery (ERAS) attempts to evaluate and incorporate scientific evidence for modifying as many of the factors contributing to the morbidity of RC as possible, and optimize how patients are cared for before and after surgery. In this chapter, we review the preoperative, intraoperative and postoperative elements of using an ERAS protocol for RC.
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Affiliation(s)
- Avinash Chenam
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, 1500 E. Duarte Rd, MOB L002H, Duarte, CA, 91010, USA
| | - Kevin G Chan
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, 1500 E. Duarte Rd, MOB L002H, Duarte, CA, 91010, USA.
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20
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Ram D, Rajappa SK, Rawal S, Singh A, Singh PB, Dewan AK. Is robot-assisted radical cystectomy superior to standard open radical cystectomy? An Indian perspective. J Minim Access Surg 2018; 14:298-303. [PMID: 29483372 PMCID: PMC6130186 DOI: 10.4103/jmas.jmas_150_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Open radical cystectomy (ORC) has been the standard treatment for muscle-invasive bladder cancer, but this is associated with significant morbidity and mortality. Robot-assisted radical cystectomy (RARC) has been proposed as minimally invasive alternative with improved morbidity and acceptable oncological outcomes, but a large series featuring RARC and their comparison with ORC is still lacking in India despite more than a decade of its inception. We have conducted this study with an objective to see the feasibility of RARC in the Indian context and compare it with contemporary standard. Methods: This is a prospective cohort study conducted at two tertiary cancer institutes. We have evaluated the patients pertaining to operative and early post-operative factors from January 2014 to December 2015. Necessary statistical tests applied to see comparability of the arms and their outcomes. Results: A total of 170 patients underwent surgery for carcinoma bladder (45 ORC while 125 RARC). Intraoperative blood loss (RARC and ORC: 228 and 529 ml) and average transfusion rate were lower with RARC. A trend towards benefit was noted in favour of robotic arm in terms of mean complication rate (RARC and ORC: 54 and 39%). Conclusions: The present study has shown comparable surgical and early post-operative outcomes with clear advantage of robotic approach in terms of intraoperative blood transfusion and lymph node yield. Although the study was non-randomised in nature, it should provide substantial evidence on safety and feasibility of RARC in the Indian context and a reference point of evidence to look ahead.
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Affiliation(s)
- Dharma Ram
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Suhas K Rajappa
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Sudhir Rawal
- Department of Uro-oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Amitabh Singh
- Department of Uro-oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Prem B Singh
- Department of Urological Services, Max Superspeciality Hospital, New Delhi, India
| | - Ajay K Dewan
- Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
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21
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Tyritzis SI, Wiklund NP. Is the open cystectomy era over? An update on the available evidence. Int J Urol 2017; 25:187-195. [PMID: 29178344 DOI: 10.1111/iju.13497] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/18/2017] [Indexed: 12/24/2022]
Abstract
In 2018, robot-assisted radical cystectomy will enter its 15th year. In an era where an effort is being made to standardize complication reporting and videos of the procedure are readily available, it is inevitable and justified that like everything novel, robot-assisted radical cystectomy should be scrutinized against the gold standard, open radical cystectomy. The present comparison is focused on several parameters: oncological, functional and complication outcomes, and direct and indirect costs. Meta-analysis and prospective randomized trials comparing robot-assisted radical cystectomy versus open radical cystectomy have been published, showing an oncological equivalence and in some cases an advantage of robot-assisted radical cystectomy in terms of postoperative morbidity. In the present review, we attempt to update the available knowledge on this debate and discuss the limitations of the current evidence that prevent us from drawing safe conclusions.
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Affiliation(s)
- Stavros I Tyritzis
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - N Peter Wiklund
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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22
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Aro T, Mullerad M, Amiel GE. Expanding the Utilization of Robotic Procedures in Urologic Surgery. Rambam Maimonides Med J 2017; 8:RMMJ.10320. [PMID: 29059044 PMCID: PMC5652935 DOI: 10.5041/rmmj.10320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Although the word "robot" was coined in 1921, only close to 70 years later were robotic devices developed to assist during surgery. Urology has always been at the forefront of endoscopic, minimally invasive, and robotic developments in medicine. Robotic prostatectomy signaled the emerging role of robotic surgery in urology, but since then it has been applied to every urologic laparoscopic procedure.
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Affiliation(s)
- Tareq Aro
- Urology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Michael Mullerad
- Urology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gilad E Amiel
- Urology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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23
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Khetrapal P, Tan WS, Lamb B, Tan M, Baker H, Thompson J, Sridhar A, Kelly JD, Briggs T. The Role of Robotics in the Invasive Management of Bladder Cancer. Curr Urol Rep 2017. [PMID: 28634646 DOI: 10.1007/s11934-017-0706-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Robot-assisted radical cystectomy (RARC) has been adopted widely in many centres, owed largely to the success of robot-assisted laparoscopic prostatectomy (RALP). It aims to replicate the oncological outcomes of open radical cystectomy (ORC), while providing a shorter recovery period. Despite this, previous RCTs have failed to show a benefit for RARC over ORC. These trials have compared extracorporeal RARC (eRARC) with ORC, which requires a further incision to mobilise the bowel for urinary reconstruction with an open technique. For intracorporeal RARC (iRARC), this urinary reconstruction is performed robotically without further incisions. There are theoretical benefits to this approach such as reduced recovery time for the bowel and reduced ileus rates, but no level 1 evidence currently exists to support this. While there has been an improvement in patient outcomes since the adoption of RARC, various other factors, such as enhanced recovery programmes and surgical learning curve, have made it difficult to attribute this solely to the robotic approach as many centres performing ORC have also shown similar improvements. In this review, we will discuss implementation of RARC as well as perioperative measures that have helped improve outcomes, offer a comparison of outcomes between ORC and RARC and highlight upcoming RCTs that may offer new evidence for or against a paradigm shift in the future of bladder cancer surgery.
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Affiliation(s)
- Pramit Khetrapal
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK. .,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK.
| | - Wei Shen Tan
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK.,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK
| | - Benjamin Lamb
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Melanie Tan
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Hilary Baker
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - James Thompson
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Ashwin Sridhar
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - John D Kelly
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK.,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK
| | - Tim Briggs
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
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24
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Palazzetti A, Sanchez-Salas R, Capogrosso P, Barret E, Cathala N, Mombet A, Prapotnich D, Galiano M, Rozet F, Cathelineau X. Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy. Actas Urol Esp 2017; 41:416-425. [PMID: 27908634 DOI: 10.1016/j.acuro.2016.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 11/30/2022]
Abstract
Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.
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Affiliation(s)
- A Palazzetti
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - R Sanchez-Salas
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia.
| | - P Capogrosso
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - E Barret
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - N Cathala
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - A Mombet
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - D Prapotnich
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - M Galiano
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - F Rozet
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - X Cathelineau
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
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25
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Lauridsen SV, Tønnesen H, Jensen BT, Neuner B, Thind P, Thomsen T. Complications and health-related quality of life after robot-assisted versus open radical cystectomy: a systematic review and meta-analysis of four RCTs. Syst Rev 2017; 6:150. [PMID: 28768530 PMCID: PMC5541663 DOI: 10.1186/s13643-017-0547-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 07/20/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Radical cystectomy is associated with high rates of perioperative morbidity. Robotic-assisted radical cystectomy (RARC) is widely used today despite limited evidence for clinical superiority. The aim of this review was to evaluate the effect of RARC compared to open radical cystectomy (ORC) on complications and secondary on length of stay, time back to work and health-related quality of life (HRQoL). METHODS The databases PubMed, The Cochrane Library, Embase and CINAHL were searched. A systematic review according to the PRISMA guidelines and cumulative analysis was conducted. Randomized controlled trials (RCTs) that examined RARC compared to ORC were included in this review. We assessed the quality of evidence using the Cochrane Collaboration's 'Risk of bias' tool and Grading of Recommendations Assessment, Development and Evaluation approach. Data were extracted and analysed. RESULTS The search retrieved 273 articles. Four RCTs were included involving overall 239 patients. The quality of the evidence was of low to moderate quality. There was no significant difference between RARC and ORC in the number of patients developing complications within 30 or 90 days postoperatively or in overall grade 3-5 complications within 30 or 90 days postoperatively. Types of complications differed between the RARC and the ORC group. Likewise, length of stay and HRQoL at 3 and 6 months did not differ. CONCLUSION Our review presents evidence for RARC not being superior to ORC regarding complications, LOS and HRQoL. High-quality studies with consistent registration of complications and patient-related outcomes are warranted. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016038232.
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Affiliation(s)
- Susanne Vahr Lauridsen
- Department of Urology, Copenhagen University Hospital, 2112, Rigshospitalet, 2100, Copenhagen, Denmark.
| | - Hanne Tønnesen
- Clinical Health Promotion Centre, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospitals, Copenhagen, Denmark.,Clinical Health Promotion Centre, Health Sciences, Lund University, Lund, Sweden.,Health Science, University of Southern Denmark, Odense, Denmark
| | - Bente Thoft Jensen
- Department of Urology, Aarhus University Hospital and Centre of Research in Rehabilitation, Aarhus University, Aarhus, Denmark
| | - Bruno Neuner
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Thind
- Department of Urology, Copenhagen University Hospital, 2112, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Thordis Thomsen
- Abdominal Centre, University Hospital of Copenhagen, Health and Medical Sciences, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
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26
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Steffens D, Thanigasalam R, Leslie S, Maneck B, Young JM, Solomon M. Robotic Surgery in Uro-oncology: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Urology 2017; 106:9-17. [PMID: 28336286 DOI: 10.1016/j.urology.2017.03.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 01/23/2017] [Accepted: 03/08/2017] [Indexed: 11/20/2022]
Abstract
Robotic surgery represents a new horizon in minimally invasive urologic surgery. This systematic review of the literature and meta-analysis examines the effectiveness of robotic surgery compared with laparoscopic or open surgery for major uro-oncological procedures. Twenty-five articles reported findings from 8 trials of prostatectomy (4 trials) and cystectomy (4 trials) including 1033 participants. Robotic surgery is comparable with laparoscopic or open surgery for oncological outcomes and overall complications, and provides somewhat better functional outcome when compared with laparoscopic and open surgery.
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Affiliation(s)
- Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia.
| | - Ruban Thanigasalam
- The Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
| | - Scott Leslie
- The Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
| | - Bharvi Maneck
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, Australia
| | - Jane M Young
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia; The Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia; The Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
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27
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Cusano A, Haddock P, Jackson M, Staff I, Wagner J, Meraney A. A comparison of preliminary oncologic outcome and postoperative complications between patients undergoing either open or robotic radical cystectomy. Int Braz J Urol 2017; 42:663-70. [PMID: 27564275 PMCID: PMC5006760 DOI: 10.1590/s1677-5538.ibju.2015.0393] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/23/2016] [Indexed: 12/03/2022] Open
Abstract
Purpose: To compare complications and outcomes in patients undergoing either open radical cystectomy (ORC) or robotic-assisted radical cystectomy (RRC). Materials and Methods: We retrospectively identified patients that underwent ORC or RRC between 2003- 2013. We statistically compared preliminary oncologic outcomes of patients for each surgical modality. Results: 92 (43.2%) and 121 (56.8%) patients underwent ORC and RRC, respectively. While operative time was shorter for ORC patients (403 vs. 508 min; p<0.001), surgical blood loss and transfusion rates were significantly lower in RRC patients (p<0.001 and 0.006). Length of stay was not different between groups (p=0.221). There was no difference in the proportion of lymph node-positive patients between groups. However, RRC patients had a greater number of lymph nodes removed during surgery (18 vs. 11.5; p<0.001). There was no significant difference in the incidence of pre-existing comorbidities or in the Clavien distribution of complications between groups. ORC and RRC patients were followed for a median of 1.38 (0.55-2.7) and 1.40 (0.582.59) years, respectively (p=0.850). During this period, a lower proportion (22.3%) of RRC patients experienced disease recurrence vs. ORC patients (34.8%). However, there was no significant difference in time to recurrence between groups. While ORC was associated with a higher all-cause mortality rate (p=0.049), there was no significant difference in disease-free survival time between groups. Conclusions: ORC and RRC patients experience postoperative complications of similar rates and severity. However, RRC may offer indirect benefits via reduced surgical blood loss and need for transfusion.
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Affiliation(s)
- Antonio Cusano
- Urology Division, Hartford Healthcare Medical Group, Hartford, USA
| | - Peter Haddock
- Urology Division, Hartford Healthcare Medical Group, Hartford, USA
| | - Max Jackson
- Urology Division, Hartford Healthcare Medical Group, Hartford, USA
| | - Ilene Staff
- Urology Division, Hartford Healthcare Medical Group, Hartford, USA
| | - Joseph Wagner
- Urology Division, Hartford Healthcare Medical Group, Hartford, USA
| | - Anoop Meraney
- Urology Division, Hartford Healthcare Medical Group, Hartford, USA
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28
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Lobo N, Mount C, Omar K, Nair R, Thurairaja R, Khan MS. Landmarks in the treatment of muscle-invasive bladder cancer. Nat Rev Urol 2017; 14:565-574. [DOI: 10.1038/nrurol.2017.82] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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29
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Attalla K, Kent M, Waingankar N, Mehrazin R. Robotic-assisted radical cystectomy versus open radical cystectomy for management of bladder cancer: review of literature and randomized trials. Future Oncol 2017. [PMID: 28650267 DOI: 10.2217/fon-2017-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Among the many milestones in the last several decades in the management of muscle-invasive bladder cancer and high-risk nonmuscle-invasive bladder cancer including the extension of the standard lymph node dissection and the use of neoadjuvant chemotherapy, minimally invasive techniques have gained traction as an attractive option for radical cystectomy. Open radical cystectomy is plagued with high rates of perioperative and postoperative morbidity and mortality, and as robotic assistance has demonstrated benefits in other arenas of surgery and urology, the evolution of the approach to radical cystectomy has likewise incorporated robotic assistance. We thus sought to critically review the literature comparing open radical cystectomy with robotic-assisted radical cystectomy. Perioperative and oncologic outcomes as well as cost analyses and health-related quality of life were compared between the two approaches, and identified manuscripts were categorized according to level of evidence.
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Affiliation(s)
- Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Marissa Kent
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
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30
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Autorino R, Porpiglia F, Dasgupta P, Rassweiler J, Catto JW, Hampton LJ, Lima E, Mirone V, Derweesh IH, Debruyne FMJ. Precision surgery and genitourinary cancers. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2017; 43:893-908. [PMID: 28254473 DOI: 10.1016/j.ejso.2017.02.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/08/2017] [Indexed: 02/06/2023]
Abstract
The landscape of the surgical management of urologic malignancies has dramatically changed over the past 20 years. On one side, better diagnostic and prognostic tools allowed better patient selection and more reliable surgical planning. On the other hand, the implementation of minimally invasive techniques and technologies, such as robot-assisted laparoscopy surgery and image-guided surgery, allowed minimizing surgical morbidity. Ultimately, these advances have translated into a more tailored approach to the management of urologic cancer patients. Following the paradigm of "precision medicine", contemporary urologic surgery has entered a technology-driven era of "precision surgery", which entails a range of surgical procedures tailored to combine maximal treatment efficacy with minimal impact on patient function and health related quality of life. Aim of this non-systematic review is to provide a critical analysis of the most recent advances in the field of surgical uro-oncology, and to define the current and future role of "precision surgery" in the management of genitourinary cancers.
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Affiliation(s)
- R Autorino
- Urology Institute, University Hospitals, Case Western Reserve University, Cleveland, OH, USA.
| | - F Porpiglia
- Division of Urology, University of Turin, San Luigi Hospital, Orbassano, Italy.
| | - P Dasgupta
- King's College London, Guy's Hospital, London, UK.
| | - J Rassweiler
- Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heidelberg, Germany.
| | - J W Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK.
| | - L J Hampton
- Division of Urology, Virginia Commonwealth University, Richmond, VA, USA.
| | - E Lima
- Life and Health Sciences Research Institute, The Clinic Academic Center, University of Minho, and Department of CUF Urology, Braga, Portugal.
| | - V Mirone
- Department of Urology, Federico II University, Naples, Italy.
| | - I H Derweesh
- Department of Urology, UC San Diego Health System, La Jolla, CA, USA.
| | - F M J Debruyne
- Andros Men's Health Institutes, Arnhem, The Netherlands.
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31
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A comprehensive guide to perioperative management and operative technique for robotic cystectomy with intracorporeal urinary diversion. Urologia 2017; 84:71-78. [PMID: 28256704 DOI: 10.5301/uj.5000224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 12/20/2022]
Abstract
Robotic-assisted radical cystectomy (RARC) represents an evolution of open radical cystectomy (ORC) with the aim of reducing patient morbidity and improving return to normal function, whilst maintaining oncological equivalence. RARC is gaining popularity, especially in high-volume centres, although there remains a lack of level 1 evidence to demonstrate any superiority of RARC over ORC. All previously reported studies that randomised ORC and RARC have utilised a technique for RARC requiring a conversion to open surgery for urinary diversion. Conversion to open surgery invariably masks the benefits of a truly minimally invasive approach. Moreover, such studies tend to report a small sample size, likely reflecting early surgical experience that may contribute to the lack of observed benefit. Nonetheless, it is established that short-term oncological outcomes following RARC are comparable to those after ORC. It is likely that the benefits of RARC are only observed in cases wherein intracorporeal urinary diversion (iRARC) is performed by a surgical team with high volume experience, which will minimise morbidity and maximise early return to normal function. In this review, we will discuss a holistic approach to iRARC, including patient selection, perioperative optimisation, the surgical technique for iRARC with urinary diversion reconstruction, the use of enhanced recovery protocol, oncological outcomes and perioperative complications.
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32
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Abstract
Bladder cancer is a highly prevalent disease and is associated with substantial morbidity, mortality and cost. Environmental or occupational exposures to carcinogens, especially tobacco, are the main risk factors for bladder cancer. Most bladder cancers are diagnosed after patients present with macroscopic haematuria, and cases are confirmed after transurethral resection of bladder tumour (TURBT), which also serves as the first stage of treatment. Bladder cancer develops via two distinct pathways, giving rise to non-muscle-invasive papillary tumours and non-papillary (solid) muscle-invasive tumours. The two subtypes have unique pathological features and different molecular characteristics. Indeed, The Cancer Genome Atlas project identified genetic drivers of muscle-invasive bladder cancer (MIBC) as well as subtypes of MIBC with distinct characteristics and therapeutic responses. For non-muscle-invasive bladder cancer (NMIBC), intravesical therapies (primarily Bacillus Calmette-Guérin (BCG)) with maintenance are the main treatments to prevent recurrence and progression after initial TURBT; additional therapies are needed for those who do not respond to BCG. For localized MIBC, optimizing care and reducing morbidity following cystectomy are important goals. In metastatic disease, advances in our genetic understanding of bladder cancer and in immunotherapy are being translated into new therapies.
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33
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Kukreja JB, Shah JB. Advances in surgical management of muscle invasive bladder cancer. Indian J Urol 2017; 33:106-110. [PMID: 28469297 PMCID: PMC5396397 DOI: 10.4103/0970-1591.203416] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/22/2016] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Bladder cancer remains a disease of the elderly with relatively few advances that have improved survival over the last 20 years. Radical cystectomy (RC) has long remained the principal treatment for muscle-invasive bladder cancer (MIBC). METHODS A literature search of PubMed was performed. The content was reviewed for continuity with the topic of surgical advances in MIBC. Articles and society guidelines were included in this review. RESULTS Despite the associated morbidity, even in the elderly, RC is still a reasonable option. Modifications during RC may have a positive or negative impact on survival and quality of life. The extent of pelvic lymph node dissection is one such factor which may positively impact survival outcomes. In addition, preservation of pelvic organs, robotic surgery and the adoption of enhanced recovery after surgery principles continues to improve the postoperative recovery and quality of life in RC patients. CONCLUSION There are some ongoing studies in many of these areas, but overall the new advances in MIBC may improve patient quality and quantity of life. The advances in surgical treatment of MIBC are important and the focus of the review here.
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Affiliation(s)
- Janet Baack Kukreja
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jay B. Shah
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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34
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Son SK, Lee NR, Kang SH, Lee SH. Safety and Effectiveness of Robot-Assisted Versus Open Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2017; 27:1109-1120. [PMID: 28350238 DOI: 10.1089/lap.2016.0437] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES To evaluate the safety and effectiveness of robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC) in bladder cancer. METHODS A literature search for the systematic review was conducted using international databases as well as domestic databases up to April 2015. Outcomes of interest included baseline characteristics, complication rates, perioperative, and oncologic outcomes. RESULTS Twenty-four articles were finally selected for inclusion in the meta-analysis. Complication rates of RARC were similar to those of ORC, except for 90-day overall complication rate, wound dehiscence, abscess, pneumonia, respiratory failure, and sepsis, which was lower after RARC. RARC was also associated with a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield, whereas ORC was associated with a shorter operation time and lower rate of stricture. Considering oncologic outcomes, there were no differences between RARC and ORC. CONCLUSIONS RARC seems to be associated with equivalent complication rates, a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield. Randomized controlled trials with a large sample size and comparative studies with long-term follow-up data are warranted to assess our findings and the oncologic effectiveness of RARC.
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Affiliation(s)
- Soo Kyung Son
- 1 Division for Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,2 Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University , Seoul, Korea
| | - Na Rae Lee
- 1 Division for Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,2 Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University , Seoul, Korea
| | - Seok Ho Kang
- 3 Department of Urology, College of Medicine, Korea University , Seoul, Korea
| | - Seon Heui Lee
- 4 Department of Nursing Science, College of Nursing, Gachon University , Incheon, Korea
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35
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Abstract
Bladder cancer is a complex disease associated with high morbidity and mortality rates if not treated optimally. Awareness of haematuria as the major presenting symptom is paramount, and early diagnosis with individualised treatment and follow-up is the key to a successful outcome. For non-muscle-invasive bladder cancer, the mainstay of treatment is complete resection of the tumour followed by induction and maintenance immunotherapy with intravesical BCG vaccine or intravesical chemotherapy. For muscle-invasive bladder cancer, multimodal treatment involving radical cystectomy with neoadjuvant chemotherapy offers the best chance for cure. Selected patients with muscle-invasive tumours can be offered bladder-sparing trimodality treatment consisting of transurethral resection with chemoradiation. Advanced disease is best treated with systemic cisplatin-based chemotherapy; immunotherapy is emerging as a viable salvage treatment for patients in whom first-line chemotherapy cannot control the disease. Developments in the past 2 years have shed light on genetic subtypes of bladder cancer that might differ from one another in response to various treatments.
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Affiliation(s)
- Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Noah M Hahn
- Departments of Oncology and Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Seth P Lerner
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
| | - Per-Uno Malmström
- Department of Surgical Sciences, Urology, Uppsala University, Uppsala, Sweden
| | - Woonyoung Choi
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles C Guo
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
| | - Wassim Kassouf
- Department of Surgery (Urology), McGill University Health Center, Montreal, QC, Canada
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36
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Minimally Invasive Approaches to Continent Urinary Diversion. CURRENT BLADDER DYSFUNCTION REPORTS 2016. [DOI: 10.1007/s11884-016-0393-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Tran T, Raison N, Doeuk N, Dasgupta P. Final robotic frontier: the evolution and current state of robot-assisted radical cystectomy. BJU Int 2016; 118:675-676. [PMID: 26940142 DOI: 10.1111/bju.13471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Tony Tran
- Metro Heath Hospital, Michigan State University, Chicago, MI, USA
| | - Nicholas Raison
- MRC Centre for Transplantation, King's College London, Guys Hospital, London, UK.
| | | | - Prokar Dasgupta
- MRC Centre for Transplantation, King's College London, Guys Hospital, London, UK
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38
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Danna BJ, Wood EL, Baack Kukreja JE, Shah JB. The Future of Enhanced Recovery for Radical Cystectomy: Current Evidence, Barriers to Adoption, and the Next Steps. Urology 2016; 96:62-68. [DOI: 10.1016/j.urology.2016.04.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 04/15/2016] [Accepted: 04/28/2016] [Indexed: 02/08/2023]
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39
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Matulewicz RS, DeLancey JOL, Manjunath A, Tse J, Kundu SD, Meeks JJ. National comparison of oncologic quality indicators between open and robotic-assisted radical cystectomy. Urol Oncol 2016; 34:431.e9-431.e15. [DOI: 10.1016/j.urolonc.2016.05.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/10/2016] [Accepted: 05/03/2016] [Indexed: 11/25/2022]
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40
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Scarpato KR, Kappa SF, Goggins KM, Chang SS, Smith JA, Clark PE, Penson DF, Resnick MJ, Barocas DA, Idrees K, Kripalani S, Moses KA. The Impact of Health Literacy on Surgical Outcomes Following Radical Cystectomy. JOURNAL OF HEALTH COMMUNICATION 2016; 21:99-104. [PMID: 27661137 PMCID: PMC5080660 DOI: 10.1080/10810730.2016.1193916] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Health literacy is the ability to obtain, comprehend, and act on medical information and is an independent predictor of health outcomes in patients with chronic health conditions. However, little has been reported regarding the potential association of health literacy and surgical outcomes. We hypothesized that patient complications after radical cystectomy would be associated with health literacy. In a sample of 368 patients, we found that higher health literacy scores (as determined by the Brief Health Literacy Screen) were associated with decreased odds of developing minor complications (odds ratio = 0.90, 95% confidence interval [0.83, 0.97]). Health literacy should be considered when caring for patients undergoing radical cystectomy and should serve as a potential indicator of the need for additional resources to improve postoperative outcomes.
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Affiliation(s)
- Kristen R. Scarpato
- Vanderbilt University Medical Center, Department of Urologic Surgery, 1161 21 Ave South, A-1302 MCN, Nashville, TN 37232,
| | - Stephen F. Kappa
- Vanderbilt University Medical Center, Department of Urologic Surgery, 1161 21 Ave South, A-1302 MCN, Nashville, TN 37232,
| | - Kathryn M. Goggins
- Vanderbilt University Medical Center, Center for Health Services Research, 1215 21 Ave. South, MCE Suite 6000, Nashville, TN 37232,
| | - Sam S. Chang
- Vanderbilt University Medical Center, Department of Urologic Surgery, 1161 21 Ave South, A-1302 MCN, Nashville, TN 37232,
| | - Joseph A. Smith
- Vanderbilt University Medical Center, Department of Urologic Surgery, 1161 21 Ave South, A-1302 MCN, Nashville, TN 37232,
| | - Peter E. Clark
- Vanderbilt University Medical Center, Department of Urologic Surgery, 1161 21 Ave South, A-1302 MCN, Nashville, TN 37232,
| | - David F. Penson
- Vanderbilt University Medical Center, Department of Urologic Surgery, 1161 21 Ave South, A-1302 MCN, Nashville, TN 37232,
| | - Matthew J. Resnick
- Vanderbilt University Medical Center, Department of Urologic Surgery, 1161 21 Ave South, A-1302 MCN, Nashville, TN 37232,
| | - Daniel A. Barocas
- Vanderbilt University Medical Center, Department of Urologic Surgery, 1161 21 Ave South, A-1302 MCN, Nashville, TN 37232,
| | - Kamran Idrees
- Vanderbilt University Medical Center, Department of Surgery, 2220 Pierce Ave, 597 PRB, Nashville, TN 37232-6860,
| | - Sunil Kripalani
- Vanderbilt University Medical Center, Department of Medicine, 6 Floor, MCE, Nashville, TN 37232-8300,
| | - Kelvin A. Moses
- Vanderbilt University Medical Center, Department of Urologic Surgery, 1161 21 Ave South, A-1302 MCN, Nashville, TN 37232,
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Satkunasivam R, Wallis CJD, Nam RK, Desai M, Gill IS. Contemporary evidence for robot-assisted radical cystectomy for treating bladder cancer. Nat Rev Urol 2016; 13:533-9. [DOI: 10.1038/nrurol.2016.139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Deboudt C, Perrouin-Verbe MA, Le Normand L, Perrouin-Verbe B, Buge F, Rigaud J. Comparison of the morbidity and mortality of cystectomy and ileal conduit urinary diversion for neurogenic lower urinary tract dysfunction according to the approach: Laparotomy, laparoscopy or robotic. Int J Urol 2016; 23:848-853. [DOI: 10.1111/iju.13166] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/17/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - Loic Le Normand
- Department of Urology; University Hospital of Nantes; Nantes France
| | - Brigitte Perrouin-Verbe
- Department of Physical Medicine and Rehabilitation; University Hospital of Nantes; Nantes France
| | - François Buge
- Department of Urology; University Hospital of Nantes; Nantes France
| | - Jérôme Rigaud
- Department of Urology; University Hospital of Nantes; Nantes France
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Abstract
BACKGROUND The application and use of robotics during radical cystectomy for the treatment of bladder cancer are still being defined. METHODS A systematic literature search was conducted, with an emphasis on studies published within the previous 5 years. Areas of interest included patient selection, outcomes, cost, and comparisons of robotic-assisted radical cystectomy to open surgery. RESULTS Although data are lacking in this field, using robotic assistance for radical cystectomy may lead to improvements in estimated blood loss, time to bowel activity, and reduced hospital stay; however, these improvements come at the cost of increased operative time and have a learning curve. CONCLUSIONS The widespread adoption of robotic-assisted radical cystectomy has not gained acceptance due to lack of evidence and clinical trials showing superiority over open surgery.
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Affiliation(s)
- Adam M Luchey
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA.
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Li AY, Filson CP, Hollingsworth JM, He C, Weizer AZ, Hollenbeck BK, Gilbert SM, Hafez KS, Lee CT, Dunn RL, Montgomery JS. Patient-Reported Convalescence and Quality of Life Recovery: A Comparison of Open and Robotic-Assisted Radical Cystectomy. Surg Innov 2016; 23:598-605. [PMID: 27354552 DOI: 10.1177/1553350616656284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Robotic-assisted radical cystectomy (RARC) is gaining traction as a surgical approach, but there are limited data on patient-reported outcomes for this technique compared to open radical cystectomy (ORC). Objective To compare health-related quality of life (HRQoL) and short-term convalescence among bladder cancer patients who underwent ORC and RARC. Methods Review of a single-institution bladder cancer database was conducted. Baseline and postoperative HRQoL was evaluated using the Bladder Cancer Index (BCI) for 324 patients who had ORC (n = 267) or RARC (n = 57) between 2008 and 2012. The BCI assesses function and bother in urinary, bowel, and sexual domains. Among 87 distinct patients (ORC n = 67, RARC n = 20), we also evaluated short-term postoperative convalescence using the Convalescence and Recovery Evaluation (CARE) questionnaire. Our primary outcomes were HRQoL within 12 months and short-term convalescence within 6 weeks following cystectomy. We fit generalized estimating equation regression models to estimate longitudinal changes in BCI scores within domains, and CARE domain score differences were tested with Wilcoxon rank-sum tests. Results Clinical characteristics and baseline BCI/CARE scores were similar between the 2 groups (all P > .05). Within 1 year after surgery, recovery of HRQoL across all BCI domains was comparable, with scores nearly returning to baseline at 1 year for all patients. CARE scores at 4 weeks revealed that patients treated with ORC had better pain (29.1 vs 20.0, P = .02) domain scores compared to RARC. These differences abated by week 6. Conclusions HRQoL recovery and short-term convalescence were similar in this cohort following ORC and RARC.
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Affiliation(s)
- Amy Y Li
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - Chang He
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - Scott M Gilbert
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Williams SB, Ghaffary CK, Dafashy TJ, Orihuela E. Re: Jim C. Hu, Bilal Chughtai, Padraic O'Malley, et al. Perioperative Outcomes, Health Care Costs, and Survival After Robotic-assisted Versus Open Radical Cystectomy: A National Comparative Effectiveness Study. Eur Urol 2016;70:195-202: Comparative Effectiveness of Robotic-assisted versus Open Radical Cystectomy: Big Data but Meaningful Conclusions? Eur Urol 2016; 71:e14-e15. [PMID: 27292866 DOI: 10.1016/j.eururo.2016.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 05/25/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA.
| | - Cameron K Ghaffary
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Tamer J Dafashy
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Eduardo Orihuela
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, Galveston, TX, USA
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De Groote R, Gandaglia G, Geurts N, Goossens M, Pauwels E, D'Hondt F, Gratzke C, Fossati N, De Naeyer G, Schatteman P, Carpentier P, Novara G, Mottrie A. Robot-Assisted Radical Cystectomy for Bladder Cancer in Octogenarians. J Endourol 2016; 30:792-8. [PMID: 26914490 DOI: 10.1089/end.2016.0050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate perioperative morbidity and mortality rate, a 3-year recurrence-free survival, and cancer-specific mortality rate in patients older than 80 years undergoing robot-assisted radical cystectomy (RARC). MATERIALS AND METHODS We retrospectively collected data of 155 consecutive patients who received RARC for muscle-invasive or high-risk nonmuscle-invasive urothelial carcinoma of the bladder between 2003 and 2014 at a high-volume robotic center. Diversion was performed intra- or extracorporeally according to the surgeon's preferences. Complications were graded according to the Clavien-Dindo system. Logistic regression analyses were used to assess the impact of age on postoperative outcomes. RESULTS Of 155 consecutive patients, 22 (14.2%) patients were 80 years or older. Octogenarians did not significantly differ from younger patients in ASA score (p = 0.4) and Charlson comorbidity index (p = 0.4). Prevalence of any grade and high-grade complications was similar in both groups (all p ≥ 0.6). Older patients had a significantly higher pathologic tumor grade (p = 0.04) and a lower use of pelvic lymphadenectomy (p < 0.001). No perioperative mortality rate was recorded within 90 days from surgery. Elderly patients had a similar risk of 3-year oncologic recurrence after surgery compared with their younger counterparts (odds ratio [OR] 1.63; p = 0.2). Conversely, the risk of cancer-specific mortality rate was significantly higher (OR 2.78; p = 0.02). CONCLUSIONS Patients 80 years or older undergoing RARC for bladder cancer did not have a higher risk of peri- and postoperative morbidity and mortality rate and had a similar 3-year recurrence-free survival, suggesting that RARC can be safely performed in selected elderly patients by experienced surgeons.
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Affiliation(s)
| | - Giorgio Gandaglia
- 1 Department of Urology, O.L.V. Hospital , Aalst, Belgium .,2 O.L.V. Vattikuti Robotic Surgery Institute , Melle, Belgium .,3 Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele , Milan, Italy
| | - Nicolas Geurts
- 1 Department of Urology, O.L.V. Hospital , Aalst, Belgium
| | | | | | | | - Christian Gratzke
- 4 Urologische Klinik und Poliklinik, Klinikum der Universität München, Ludwig-Maximilians Universität München , Munich, Germany
| | - Nicola Fossati
- 1 Department of Urology, O.L.V. Hospital , Aalst, Belgium .,2 O.L.V. Vattikuti Robotic Surgery Institute , Melle, Belgium .,3 Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele , Milan, Italy
| | | | | | | | - Giacomo Novara
- 2 O.L.V. Vattikuti Robotic Surgery Institute , Melle, Belgium .,5 Department of Surgery, Oncology, and Gastroenterology, Urology Clinic, University of Padua , Padua, Italy
| | - Alexandre Mottrie
- 1 Department of Urology, O.L.V. Hospital , Aalst, Belgium .,2 O.L.V. Vattikuti Robotic Surgery Institute , Melle, Belgium
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Erlich A, Zlotta AR. Treatment of bladder cancer in the elderly. Investig Clin Urol 2016; 57 Suppl 1:S26-35. [PMID: 27326404 PMCID: PMC4910758 DOI: 10.4111/icu.2016.57.s1.s26] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/12/2016] [Indexed: 12/16/2022] Open
Abstract
As the population ages and life expectancy increases in the human population, more individuals will be diagnosed with bladder cancer (BC). The definition of who is elderly is likely to change in the future from the commonly used cut-off of ≥75 years of age. Physiological rather than chronological age is key. BC care in the elderly is likely to become a very common problem in daily practice. Concerns have been raised that senior BC patients are not given treatments that could cure their disease. Clinicians lack quantitative and reliable estimates of competing mortality risks when considering treatments for BC. Majority of patients diagnosed with BC are elderly, making treatment decisions complex with their increasing number of comorbidities. A multidisciplinary approach to these patients may be a way to incorporate discussion from various disciplines regarding treatment options available. Here we review various treatment options for elderly patients with muscle invasive BC and nonmuscle invasive BC. We include differences in treatments from robotic versus open radical cystectomy, various urinary diversion techniques, chemotherapy, radiation therapy and combination treatments. In clinical practice, treatment decisions for elderly patients should be done on a case-by-case basis, tailored to each patient with their specific histories and comorbidities considered. Some healthy elderly patients may be better candidates for extensive curative treatments than their younger counterparts. This implies that these important, life-altering decisions cannot be solely based on age as many other factors can affect patient survival outcomes.
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Affiliation(s)
- Annette Erlich
- Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Alexandre R Zlotta
- Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.; Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Perioperative Outcomes, Health Care Costs, and Survival After Robotic-assisted Versus Open Radical Cystectomy: A National Comparative Effectiveness Study. Eur Urol 2016; 70:195-202. [PMID: 27133087 DOI: 10.1016/j.eururo.2016.03.028] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 03/16/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Radical cystectomy is the gold-standard management for muscle-invasive bladder cancer, and there is debate concerning the comparative effectiveness of robotic-assisted (RARC) versus open radical cystectomy (ORC). OBJECTIVE To compare utilization, perioperative, cost, and survival outcomes of RARC versus ORC. DESIGN, SETTING, AND PARTICIPANTS We identified bladder urothelial carcinoma treated with RARC (n=439) or ORC (n=7308) during 2002-2012 using the Surveillance, Epidemiology, and End Results Program-Medicare linked data. INTERVENTION Comparison of RARC versus ORC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We used propensity score matching to compare perioperative and survival outcomes, including lymph node yield, perioperative complications, and healthcare costs. RESULTS AND LIMITATIONS Utilization of RARC increased from 0.7% of radical cystectomies in 2002 to 18.5% in 2012 (p<0.001). Women comprised 13.9% versus 18.1% (p=0.007) of RARC versus ORC, respectively. RARC was associated with greater lymph node yield with 41.5% versus 34.9% having ≥10 lymph nodes removed (relative risk 1.1, 95% confidence interval [CI] 1.01-1.22, p=0.03) and shorter mean length of hospitalization at 10.1 (± standard deviation 7.1) d versus 11.2 (± 8.6) d (p=0.004). While inpatient costs were similar, RARC was associated with increased home healthcare utilization (relative risk 1.14, 95% CI 1.04-1.26, p=0.009) and higher 30-d (p<0.01) and 90-d (p<0.01) costs. With a median follow-up of 44 mo (interquartile range 16-78), overall survival (hazard ratio 0.88, 95% CI 0.74-1.05) and cancer-specific survival (hazard ratio 0.91, 95% CI 0.66-1.26) were similar. CONCLUSIONS RARC provides equivalent perioperative and intermediate term outcomes to ORC. Additional long-term and randomized studies are needed for continued comparative effectiveness assessment of RARC versus ORC. PATIENT SUMMARY Our population-based US study demonstrates that robotic-assisted radical cystectomy has similar perioperative and survival outcomes albeit at higher costs.
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