Evaluation of findings during re-exploration for obstructive ileus after radical cystectomy and ileal-loop urinary diversion: insight into potential technical improvements

Retroperitonealization of the pancreatic stump in distal pancreatectomy: a novel technique to reduce postoperative pancreatic fistula

PURPOSE

To evaluate the efficacy and safety of retroperitonealization of the pancreatic stump in distal pancreatectomy.

METHODS

Clinical data from the Tongji Hospital pancreatic database were retrospectively reviewed in this study. The data of 68 patients who underwent retroperitonealized distal pancreatectomy from January, 2019, to April, 2021, were collected and analyzed. Sixty-four patients who underwent conventional distal pancreatectomy during the same period were matched. We compared and analyzed the operative outcomes and postoperative complications between the patients in the two groups before and after propensity score matching (PSM).

RESULTS

Before PSM, the operative outcomes and postoperative complications were comparable between the two groups. After PSM, the retroperitonealized group had a lower incidence of postoperative pancreatic fistula (POPF) (10.53% vs 31.58%, P = 0.047) and shorter time until drainage removal (10.00, 8.00-13.00 days vs 13.00, 10.00-18.00 days, P = 0.005). In the univariate and multivariate regression analyses, non-retroperitonealization and intra-abdominal infection were found to be independent risk factors for postoperative pancreatic fistula (POPF).

CONCLUSION

Retroperitonealization of the pancreatic stump can reduce the incidence of POPF after distal pancreatectomy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).

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

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

A modified cutaneous ureterostomy provides satisfactory short and midterm outcomes in select cases

OBJECTIVE

We present the outcomes of modification of cutaneous ureterostomy by extreme lateralization of the stoma and use of skin flap for formation of ureterostomy.

MATERIAL AND METHODS

Between June 2012 and June 2016, 36 patients had modified cutaneous ureterostomy for ureteral obstruction due to pelvic malignancy or genitourinary tuberculosis. Transureteroureterostomy was made with cutaneous stoma at anterior axillary line between iliac crest and lower rib cage, instead of spinoumbilical line. To prevent stenosis a 'V' shaped skin was fed into the stoma. Double J stents were used in all patients for 6 weeks. Perioperative morbidity and mortality were evaluated. All patients were followed up at 3 month intervals.

RESULTS

Of 36 patients, 22 had radical cystoprostatectomy (including nephroureterectomy in 2 patients) and 7 had palliative cystectomy. Others had locally advanced prostate cancer (n=1), locally advanced cervical cancer (n=3), ovarian cancer (n=1) and genitourinary tuberculosis with small capacity bladder along with a large vesicovaginal fistula (n=1). One patient developed ureteral necrosis requiring conversion to ileal conduit. Three patients developed stomal stenosis: two were managed by self-dilatation while one required revision of stoma. Thirteen patients died of the disease at a median follow up of 6 months with functioning stoma. Remaining 19 patients survived without any complications at a median follow-up of 20.5 months (5.5-43.5 months). None of the patients had any problem related to ureterostomy bag application.

CONCLUSION

Modified lateral cutaneous ureterostomy provides relatively straighter and shorter retroperitoneal course of ureter with acceptable morbidity and avoids use of bowel in selected patients.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusions

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

Role of bowel suspension technique to prevent early intestinal obstruction after radical cystectomy with ileal orthotopic neobladder: A retrospective cohort study

OBJECTIVE

We investigate the impact of the bowel suspension technique (BST) on paralytic ileus and early intestinal obstruction (≤60days) after radical cystectomy (RC) with ileal orthotopic neobladder (IONB).

METHODS

We retrospectively reviewed 310 patients who underwent RC with IONB for bladder cancer between 2001 and 2017. After forming the Studer IONB, ileal continuity was restored by side-to-side stapled anastomosis. Then, we suspended stapled anastomotic portion of bowel on the posterior peritoneum not to fall into the pelvic cavity. The clinicopathologic characteristics of patients were examined and the onset of paralytic ileus and early intestinal obstruction were identified. Logistic regression analysis was used to identify predictors associated with paralytic ileus and early intestinal obstruction.

RESULTS

Of the 310 total patients, paralytic ileus and early intestinal obstruction were identified in 100 (32.3%) and 15 (4.8%), respectively. When patients were divided into two groups (BST [-] vs. BST [+]), the rates of paralytic ileus were not significantly different (64/205[31.2%] vs. 36/105[34.3%], P = 0.585). However, early intestinal obstruction that required surgical treatment was significantly decreased (14/205[6.8%] vs. 1/105[1.0%], P = 0.024). On multivariate analysis, older age was commonly associated with paralytic ileus and early intestinal obstruction (P = 0.008 and P = 0.016). BST was inversely associated with early intestinal obstruction (95% CI: 0.01-0.85, P = 0.034), but not related to paralytic ileus.

CONCLUSION

BST significantly reduced early intestinal obstruction without increasing paralytic ileus after RC with IONB. BST could be used as useful technique to reduce severe bowel complications.

Surgical Complications of Urinary Diversion

Urinary diversion (UD) with an intestinal segment has significant risks of short- and long-term complications. With modern reporting criteria, understanding of the true prevalence and spectrum of these complications has improved. Methods to minimize early postoperative complications include enhanced recovery pathways, restricted intraoperative fluid protocols, and referral to high-volume centers. With long-term follow-up after UD, the risk of complications steadily rises. Late surgical complications include ureterointestinal anastomotic strictures, urolithiasis, and stomal issues. Patients with UDs require close surveillance to monitor for anatomic, infectious, and metabolic complications and surgeons who perform UD should be aware of the risk and timing of postoperative complications.

A feasibility study of peritoneum preservation in radical cystectomy with extraperitonealization of orthotopic neobladder for invasive high-grade bladder cancer: a preliminary analysis

OBJECTIVE

To describe a technique for radical cystectomy with extraperitonealization of orthotopic neobladder (RCEN) that reduces bowel-related complications by preservation of the peritoneum.

MATERIALS AND METHODS

Fifteen patients with non-metastatic bladder cancer underwent RCEN by a peritoneum preserving technique. The study included 13 patients with T1 high-grade bladder cancer and 2 with T2a bladder cancer. To compare perioperative outcomes including bowel-related complications, we also reviewed 15 patients who underwent traditional cystectomy with ileal Studer neobladder who were matched for age, sex, body mass index, American Society of Anesthesiologists (ASA) score, tumor stage, tumor grade, tumor size, and location. Female genital organs were preserved in five female patients who underwent the RCEN technique.

RESULTS

There was no significant difference between the two cohorts (RECN vs. traditional technique) with respect to age, body mass index, ASA score, or tumor characteristics. The mean operative time was similar between the two groups. The patients who underwent RECN exhibited earlier recovery of normal gas pattern on plain abdominal X-ray during the postoperative period and an earlier resumption of normal diet. The mean hospital stay was shorter in the RECN group than the traditional group.

CONCLUSIONS

The RECN technique preserving the whole peritoneum is a feasible approach that significantly reduces bowel-related complications in selected patients.