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Evaluation of Functional Outcomes and Quality of Life in Elderly Patients (>75 y.o.) Undergoing Minimally Invasive Radical Cystectomy with Single Stoma Ureterocutaneostomy vs. Bricker Intracorporeal Ileal Conduit Urinary Diversion. J Clin Med 2021; 11:jcm11010136. [PMID: 35011876 PMCID: PMC8745776 DOI: 10.3390/jcm11010136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Diversion after radical cystectomy (RC) is crucial when considering elderly subjects. Data on the quality of life (QoL) impact with different diversions is scarce. This study aims to compare complications and QoL in patients aged > 75 y.o., who underwent minimally invasive (MI) RC with Bricker intracorporeal urinary derivation and single stoma ureterocutaneostomy. Methods: We conducted a retrospective analysis of elderly patients who underwent MIRC and intracorporeal diversion. The 78 subjects were divided into two groups: group A, ileal conduit, and group B, single stoma ureterocutaneostomy. We evaluated the bowel’s recovery time and complications rate. We investigated QoL 3 and 6 months after surgery using the Stoma-QoL questionnaire. Results: Mean age was 77.2 in group A and 82.4 in group B. The mean ASA score and Charlson Comorbidity index were comparable between the two groups. Rates of complications were 57.6% and 37.4% in groups A and B, respectively. The mean postoperative Stoma-QoL score 3 months after surgery was 52.2 and 52.4 in groups A and B, respectively. At 6 months of follow-up the Stoma QoL mean score was 63.4, showing homogeneity between the groups. Conclusion: MIRC with single stoma ureterocutaneostomy represents an alternative to ileal conduit, with comparable QoL and ostomy management 6 months after surgery, reporting fewer complications.
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Yang H, Zhang Z, Zhao K, Zhang Y, Yin X, Zhu G, Lin C, Liu C, Wang Z, Sui Y, Li X, Li C, Wang K. Extraperitoneal Laparoscopic Radical Cystectomy With Preservation of Fertility for the Treatment of Ewing Sarcoma: The First Report of a Reliable Surgical Method. Urology 2021; 159:241-246. [PMID: 34653432 DOI: 10.1016/j.urology.2021.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/26/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To improve the complications of traditional laparoscopic radical cystectomy (LRC), a novel technique of extraperitoneal laparoscopic radical cystectomy (ELRC) with preservation of fertility was described. MATERIALS AND METHODS Selected patients with bladder cancer were treated with the ELRC technique. The seminal vesicles and the vas deferens were preserved. Patient's perioperative conditions, tumor prognosis, and follow-up data were analyzed retrospectively. RESULTS We successfully completed ELRC surgery in dozens of patients. The orthotopic ileal neobladder was placed in the extraperitoneal area, completely preserving the peritoneum. The postoperative complications caused by postoperative peritoneal loss were reduced. Moreover, the perioperative period was strictly managed with the concept of enhanced recovery after surgery (ERAS). We described the operation process in detail through a typical case of a child. All patients were free of complication at short-term follow-up, and reported satisfied sexual function with normal erections. CONCLUSION The ELRC technique has benefits in terms of decreased ileus, reoperation rates, hospital stay, ease of management of urinary leaks, and improves the patient quality of life. ELRC is also an oncologically safe approach with excellent significant functional outcomes in carefully selected transitional cell carcinoma (TCC) or non-TCC patients who expect to maintain sexual function and fertility, especially for young patients. In addition, more patient groups and longer follow-ups are needed to further understand the safety and practicality of the ELRC technology.
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Affiliation(s)
- Han Yang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Zongliang Zhang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Kai Zhao
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Yulian Zhang
- Department of Gynecology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Xinbao Yin
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Guanqun Zhu
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Chunhua Lin
- Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong, China
| | - Caihong Liu
- Health Bureau of Qingdao West Coast New Area, Qingdao, Shandong, China.
| | - Zhenlin Wang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Yuanming Sui
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Xueyu Li
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Chen Li
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China
| | - Ke Wang
- Department of Urology, The Affiliated Hospital of Qingdao University, Qingdao, Shangdong, China.
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Randomized Controlled Trial of Laparoscopic versus Open Radical Cystectomy in a Laparoscopic Naïve Center. Adv Urol 2021; 2021:4731013. [PMID: 34306069 PMCID: PMC8279872 DOI: 10.1155/2021/4731013] [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: 04/29/2021] [Accepted: 06/29/2021] [Indexed: 11/23/2022] Open
Abstract
Background Laparoscopic radical cystectomy is a challenging surgical procedure; however, it has been largely abandoned in favor of the more intuitive robotic-assisted cystectomy. Due to the prohibitive cost of robotic surgery, the adoption of laparoscopic cystectomy is of relevance in low-resource institutes. Methodology. This is a randomized controlled trial comparing laparoscopic radical cystectomy (LRC) to open radical cystectomy (ORC) at a single institute. Each group included thirty patients. The trial was designed to compare both approaches regarding operative time, blood loss, transfusion requirements, length of hospital stay, time to oral intake, requirement of opioid analgesia, and complications. Results LRC was associated with less hospital stay (9.8 vs. 13.8 days, P=0.001), less time to oral solid intake (6 vs. 8.6 days, P=0.031), and lower opioid requirements (23.3% vs. 53.3%, P=0.033). There was a trend towards lower blood loss and transfusion requirements, but this did not reach statistical significance. Overall complication rates were comparable. Conclusion Laparoscopic radical cystectomy was associated with comparable postoperative outcomes when compared to ORC in the first laparoscopic cystectomy experience in our center. Benefitting from the assistance of an experienced laparoscopic surgeon is recommended to shorten the learning curve.
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Regmi SK, Bearrick EN, Hannah PTF, Sathianathen N, Kalapara A, Konety BR. Drain fluid creatinine-to-serum creatinine ratio as an initial test to detect urine leakage following cystectomy: A retrospective study. Indian J Urol 2021; 37:153-158. [PMID: 34103798 PMCID: PMC8173937 DOI: 10.4103/iju.iju_396_20] [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: 07/09/2020] [Revised: 10/11/2020] [Accepted: 12/27/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction: Urine leak following radical cystectomy is a known complication. Among the various methods to diagnose this, assessment of drain fluid creatinine is a relatively easy procedure. We aimed to ascertain the validity of the drain fluid creatinine-to-serum creatinine ratio (DCSCR) as an initial indicator of urinary leak in patients undergoing radical cystectomy. Methods: We retrospectively identified consecutive patients with documentation of drain fluid creatinine in the postoperative period following cystectomy and urinary diversion at our institution between January 2009 and December 2018. All continent diversions and any patient with a DCSCR >1.5:1 underwent contrast study postoperatively. A diagnosis of urine leak was made following confirmatory imaging. Receiver operative characteristic curves were created, and Youden's index was used to determine the strength and clinical utility of DCSCR as a diagnostic test. Results: Two hundred forty-four of the 340 patients included in the study underwent cystectomy with conduit and 81 underwent neobladder creation. Sixteen out of 340 (4.7%) patients had radiologically confirmed urinary leak. DCSCR was elevated in all ureteric anastomotic leaks and in 1 out of the 7 neobladder-urethral anastomotic (NUA) leaks. The sensitivity and specificity of DCSCR to predict all urinary leaks were 68.8% and 80.9% at 1.12 (area under the curve [AUC] = 0.838), whereas at a value of 1.18 (AUC = 0.876) and with the exclusion of NUA leaks, the sensitivity was 77.8% and specificity was 87.6%. Conclusions: DCSCR is a good preliminary test for identifying patients who need prompt confirmatory testing for localizing urinary leaks. A drain creatinine level just 18% higher than the serum creatinine level can signify a urine leak. This is different from general assumptions of a higher DCSCR.
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Affiliation(s)
| | | | - Peter T F Hannah
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | | | - Arveen Kalapara
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
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Aly A, Johnson C, Doleh Y, Shenolikar R, Botteman MF, Hussain A. Medical oncology referral and systemic therapy of patients with advanced stage urothelial carcinoma. J Comp Eff Res 2020; 9:945-957. [PMID: 32964721 DOI: 10.2217/cer-2020-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To understand physician visit patterns among patients with stage IV (including nonmetastatic [M0] and metastatic [M1] disease) urothelial carcinoma (UC) and understand factors associated with a timely referral to a medical oncologist and systemic treatment. Patients & methods: Retrospective analysis of Surveillance, Epidemiology and End Results-Medicare data. Results: First physician encounter was with a urologist (M0: 69%; M1: 53%) or primary care physician ([PCP]; M0: 19%, M1: 25%) for the majority of patients around UC diagnosis. After the index urologist encounter, most patients had a subsequent medical oncologist visit at a median of 52 days (M0: 69.5 days, M1: 33 days). In an adjusted model, older age, index PCP visit, higher comorbidities and M0 disease were negatively associated with a medical oncologist referral. Among those referred to a medical oncologist, older age, Hispanic or non-Hispanic Black race and not being married were negatively associated with subsequent chemotherapy receipt (p < 0.05). Conclusion: Many patients with advanced UC encounter multiple specialists during their disease course. Older patients or those with a first UC-related encounter with a PCP are less likely to be referred to medical oncology. Once referred to medical oncology, social determinants, including race and marital status, are relevant predictors of receiving chemotherapy.
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Affiliation(s)
- Abdalla Aly
- AstraZeneca, 200 Orchard Ridge Drive, Gaithersburg, MD 20878, USA
| | - Courtney Johnson
- Pharmerit International, 4350 East-West Hwy, Suite 1110, Bethesda, MD 20814, USA
| | - Yunes Doleh
- AstraZeneca, 200 Orchard Ridge Drive, Gaithersburg, MD 20878, USA
| | - Rahul Shenolikar
- AstraZeneca, 200 Orchard Ridge Drive, Gaithersburg, MD 20878, USA
| | - Marc F Botteman
- Pharmerit International, 4350 East-West Hwy, Suite 1110, Bethesda, MD 20814, USA
| | - Arif Hussain
- Marlene & Stewart Greenbaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA.,Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.,Veterans Affairs Medical Center, Baltimore, MD 21201, USA
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Azam A, Rottenberg G. Multimodality Imaging Findings Postcystectomy: Postoperative Anatomy, Surgical Complications, and Surveillance Imaging. Semin Ultrasound CT MR 2020; 41:392-401. [PMID: 32620229 DOI: 10.1053/j.sult.2020.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Various surgical techniques exist for urinary diversion post cystectomy and each have different imaging features. This diverse range of surgical procedures can make imaging interpretation difficult and so familiarity with the postoperative anatomy is essential. Multiple imaging modalities and techniques are available for the radiologist's assessment including fluoroscopic studies, computed tomography, magnetic resonance, and radionuclide imaging. Knowledge of when each of these modalities is indicated and the typical imaging appearances is essential for early identification of postoperative complications and detection of tumor recurrence. This information enables the radiologist to make an accurate and early diagnosis and subsequently guide the management pathway for these patients.
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Affiliation(s)
- Aishah Azam
- Department of Radiology, Guy's and St Thomas' NHS Trust, London, United Kingdom
| | - Giles Rottenberg
- Department of Radiology, Guy's and St Thomas' NHS Trust, London, United Kingdom.
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Liaw CW, Winoker JS, Wiklund P, Sfakianos J, Galsky MD, Mehrazin R. The clinical and economic burden of perioperative complications of radical cystectomy. Transl Androl Urol 2019; 8:S277-S279. [PMID: 31392144 DOI: 10.21037/tau.2019.03.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Christine W Liaw
- Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jared S Winoker
- Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Wiklund
- Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Sfakianos
- Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew D Galsky
- Division of Hematology/Oncology, Department of Medicine, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Reza Mehrazin
- Department of Urology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Prakash G, Pal M, Odaiyappan K, Shinde R, Mishra J, Jalde D, Rajkumar B, Prabhash K, Joshi A, Noronha V, Murthy V, Krishnatry R, Desai S, Menon S, Sable N, Popat P, Rangarajan V, Agrawal A, Bakshi G. Bladder cancer demographics and outcome data from 2013 at a tertiary cancer hospital in India. Indian J Cancer 2019; 56:54-58. [PMID: 30950446 DOI: 10.4103/ijc.ijc_351_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Bladder cancer (BCa) is the ninth most common cancer accounting for 3.9% of all cancer cases as per the Indian Cancer Registry data. There is a scarcity of data on urinary Bca from India. AIM The aim of this study was to know demographic background, stage distribution, utilization of various treatment modalities, and oncological outcome in Indian patients presenting with bladder cancer to a tertiary care cancer center in Mumbai. METHODOLOGY We performed a retrospective audit of all patients registered as urinary BCa in our hospital from January 1, 2013 to December 31, 2013. Electronic medical records of these patients were checked for most of the information gathered. RESULTS Median age of patients at presentation was 59 years with a range of 18-88 years. There were 84% male and 16% female patients. Forty seven percent of patients had nonmuscle invasive bladder cancer (NMIBC), 36% had muscle invasive bladder cancer and locally advanced disease, and 17% had metastatic disease. Eight patients were treated with trimodality bladder preservation protocol. Recurrence was seen in 38 (22.6%) patients with NMIBC. Out of them. 44.7% and 55.3% were in low- and high-grade tumors, respectively. Overall survival and disease-free survival estimated for 3 years were 63% and 57%, respectively. CONCLUSION Bladder cancer has a varied spectrum of presentation. Bladder cancer patients presenting to our hospital generally have a higher stage and grade of disease compared with that in the west.
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Affiliation(s)
- Gagan Prakash
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Mahendra Pal
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - K Odaiyappan
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajesh Shinde
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jeeban Mishra
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Devendra Jalde
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Barath Rajkumar
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Kumar Prabhash
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Amit Joshi
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sangeeta Desai
- Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Santosh Menon
- Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nilesh Sable
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Palak Popat
- Department of Radiodiagnosis, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Archi Agrawal
- Department of Nuclear Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Ganesh Bakshi
- Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Open versus robot-assisted radical cystectomy: 30-day perioperative comparison and predictors for cost-to-patient, complication, and readmission. J Robot Surg 2018; 13:129-140. [PMID: 29948875 DOI: 10.1007/s11701-018-0832-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/03/2018] [Indexed: 12/29/2022]
Abstract
The objectives of this study are to evaluate if robotic cystectomy demonstrates reduced complications, readmissions, and cost-to-patient compared to open approach 30-day post-operatively, and to identify predictors of complication, readmission, and cost-to-patient. This retrospective cohort study analyzed 249 patients who underwent open (n = 149) or robotic (n = 100) cystectomy from 2009 to 2015 at our institution. Outcomes included 30-day post-operative complication, readmission, and cost-to-patient charges. We used modified Clavien-Dindo/MSKCC classifications. Multivariable logistic and linear regression models were used to evaluate associations to outcomes and to build predictive models. Patient, clinical, and surgical characteristics differed by open and robotic groups, respectively, only for estimated blood loss (median: 600 versus 150 cc, p < 0.01), operative time (mean: 6.19 versus 6.85 h, p < 0.01), and length of stay (median: 7 versus 5 days, p < 0.01). Complication: frequency of patients with at least one 30-day complication was 85% compared to 66% (p < 0.01). Minor gastrointestinal and bleeding complications were increased in the open group (50% versus 41%, p = 0.01; 52% versus 11%, p < 0.01, respectively). Fifty percent of patients required blood transfusion in open compared to 11% (p < 0.01). Patients in the open group experienced more major complications (19% versus 10%, p = 0.04). Robotic approach was a predictor for fewer complications (OR 0.44, 95% CI 0.20-0.99, p = 0.049). Readmission: no significant difference in number of patients readmitted was found. Cost-to-patient: Robotic approach predicted an 18% reduction in total cost-to-patient compared to open approach (p < 0.01). Robotic cystectomy demonstrated reduced total cost-to-patient when taking into account all 30-day post-operative services with fewer complications compared to open cystectomy.
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Kulkarni JN, Agarwal H. Transperitoneal vs. extraperitoneal radical cystectomy for bladder cancer: A retrospective study. Int Braz J Urol 2018; 44:296-303. [PMID: 29219280 PMCID: PMC6050562 DOI: 10.1590/s1677-5538.ibju.2017.0441] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Jagdeesh N Kulkarni
- Department of Urology, Bombay Hospital and Medical Research Centre, Mumbai, India
| | - Himanshu Agarwal
- Department of Urology, Bombay Hospital and Medical Research Centre, Mumbai, India
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Vukovic N, Dinic L. Enhanced Recovery After Surgery Protocols in Major Urologic Surgery. Front Med (Lausanne) 2018; 5:93. [PMID: 29686989 PMCID: PMC5900414 DOI: 10.3389/fmed.2018.00093] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/23/2018] [Indexed: 01/31/2023] Open
Abstract
The purpose of the review The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery. Recent findings ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function. Summary Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.
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Affiliation(s)
- Natalija Vukovic
- Anesthesiology and Reanimation Center, Clinical Center Nis, Nis, Serbia
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12
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Longo N, Imbimbo C, Fusco F, Ficarra V, Mangiapia F, Di Lorenzo G, Creta M, Imperatore V, Mirone V. Complications and quality of life in elderly patients with several comorbidities undergoing cutaneous ureterostomy with single stoma or ileal conduit after radical cystectomy. BJU Int 2016; 118:521-6. [DOI: 10.1111/bju.13462] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Nicola Longo
- Department of Neurosciences, Sciences of Reproduction and Odontostomatology; University Federico II of Naples; Naples Italy
| | - Ciro Imbimbo
- Department of Neurosciences, Sciences of Reproduction and Odontostomatology; University Federico II of Naples; Naples Italy
| | - Ferdinando Fusco
- Department of Neurosciences, Sciences of Reproduction and Odontostomatology; University Federico II of Naples; Naples Italy
| | | | - Francesco Mangiapia
- Department of Neurosciences, Sciences of Reproduction and Odontostomatology; University Federico II of Naples; Naples Italy
| | | | | | | | - Vincenzo Mirone
- Department of Neurosciences, Sciences of Reproduction and Odontostomatology; University Federico II of Naples; Naples Italy
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Comploj E, West J, Mian M, Kluth LA, Karl A, Dechet C, Shariat SF, Stief CG, Trenti E, Palermo S, Lodde M, Horninger W, Madersbacher S, Pycha A. Comparison of Complications from Radical Cystectomy between Old-Old versus Oldest-Old Patients. Urol Int 2014; 94:25-30. [DOI: 10.1159/000358731] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 01/15/2014] [Indexed: 11/19/2022]
Abstract
Introduction: The purpose of this study was to evaluate and compare complications after radical cystectomy in patients aged ≥75 years. Materials and Methods: 251 patients aged 75-95 years (median 79) underwent radical cystectomy between 2000 and 2012 at four institutions. The patients were divided into two groups: ≥75-84 years of age (group 1) versus ≥85 years of age (group 2). Comorbidities, body mass index, and complications were obtained retrospectively, except at the Central Hospital of Bolzano and Weill Cornell Medical Center, which collected data prospectively. Cancer-specific survival, overall mortality, hospital stay, clinical outcome and complications were assessed. Complications were categorized using the Clavien-Dindo classification reporting system. The mean follow-up was 21 months. Results: The median hospital stay was 17 (2-91) days. Perioperative Clavien-Dindo grade ≥III complications were seen in 24.1% (48/199) of group 1 patients and 19.2% (10/52) of group 2 patients (p = 0.045). 30- and 90-day mortality was 4.5 and 13.5% in group 1 and 6.5 and 32.3% in group 2, respectively. Only the 90-day mortality rate was statistically significant (p < 0.05) between the two groups. The 3-year overall survival was 40% in group 1 and 34% in group 2. The 3-year cancer-specific survival was 52% in group 1 and 50% in group 2. Conclusions: We evaluated a large series of elderly (≥75 years) patients undergoing radical cystectomy at four institutions. Comparing patients aged ≥75-84 and ≥85 years revealed no significant difference in complications, 30-day mortality, overall and cancer-specific survival rates. Only 90-day mortality rates were significantly higher in the ≥85-year-old patients.
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Kim SH, Yu A, Jung JH, Lee YJ, Lee ES. Incidence and Risk Factors of 30-Day Early and 90-Day Late Morbidity and Mortality of Radical Cystectomy During a 13-Year Follow-up: A Comparative Propensity-score Matched Analysis of Complications Between Neobladder and Ileal Conduit. Jpn J Clin Oncol 2014; 44:677-85. [DOI: 10.1093/jjco/hyu051] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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15
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van Hemelrijck M, Thorstenson A, Smith P, Adolfsson J, Akre O. Risk of in-hospital complications after radical cystectomy for urinary bladder carcinoma: population-based follow-up study of 7608 patients. BJU Int 2013; 112:1113-20. [PMID: 23906011 PMCID: PMC3935410 DOI: 10.1111/bju.12239] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objective Patients and Methods Results Conclusions
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Affiliation(s)
- Mieke van Hemelrijck
- Division of Cancer Studies, Cancer Epidemiology Group, School of Medicine, King's College London, London, UK
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Friedrich-Freksa M, Schulz E, Nitzke T, Wenzel O, Popken G. Performing radical cystectomy and urinary diversion in regional anesthesia: potential risk reduction in the treatment of bladder cancer. Urol Int 2013; 91:103-8. [PMID: 23752480 DOI: 10.1159/000348542] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/18/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA), avoiding the adverse effects of general anesthesia. MATERIALS AND METHODS In our hospital, radical cystectomy with extended pelvic and iliac lymphadenectomy and urinary diversion was performed on 28 patients using CSTEA without applying general anesthesia, in 2011 and 2012. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Outcome measurements included operative time, blood loss, start of oral nutrition, start of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), postoperative complications according to the Clavien-Dindo classification and length of hospital stay. RESULTS All surgical procedures were performed without any complications and caused no anesthesiologically or surgically untoward effects. We observed no more severe complications than grade 1 according to the Clavien-Dindo classification. CONCLUSIONS Our data show that CSTEA is an effective and safe technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks, especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes and complications of CSTEA.
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Rao AR, Stegemann AP, Rehman S, Poch MA, Green D, Guru KA. Status of Robot-Assisted Radical Cystectomy (RARC) in 2012. Indian J Surg Oncol 2013; 3:85-90. [PMID: 23730095 DOI: 10.1007/s13193-012-0123-9] [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: 01/09/2012] [Accepted: 01/17/2012] [Indexed: 10/28/2022] Open
Abstract
Robot-assisted radical cystectomy (RARC) for bladder cancer is increasingly becoming popular in specialist centres around the world. RARC has the advantage of being minimally invasive and also the dexterity of the instruments allow reconstruction such as ileal conduit urinary diversion or neobladder formation. Starting from the initial series demonstrating the feasibility of RARC and extended pelvic lymph node dissection, we now have mature series demonstrating equal oncological and functional outcomes in the medium term follow-up. In addition, literature suggests decreased hospital stay, less blood loss equating to less blood transfusion and a trend towards decreased complications as well. In the near future we would anticipate further refinement and reduced operating times with increased benefits for the patient undergoing RARC.
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Affiliation(s)
- Amrith R Rao
- Department of Urology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263 USA
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Punjani N, Lavallée LT, Momoli F, Fergusson D, Witiuk K, Mallick R, Morash C, Cagiannos I, Breau RH. Blood transfusion and hemostatic agents used during radical cystectomy. Can Urol Assoc J 2013; 7:E275-80. [PMID: 23766829 PMCID: PMC3668410 DOI: 10.5489/cuaj.1002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Radical cystectomy may result in significant blood loss necessitating transfusion. The purpose of this study was to determine what intra-operative techniques and hemostatic agents are currently used by uro-oncologists to prevent and control blood loss during radical cystectomy. METHODS In August 2011, members of the Society of Urologic Oncology (SUO) were solicited to complete an online survey. Residents, fellows and non-urologists were excluded. Canadian members received a personal email invitation. Respondents were asked to provide demographic information and opinions regarding blood loss and transfusion. Participants were also asked to report techniques used to reduce blood loss. RESULTS Of the 34 Canadian SUO members with registered email addresses, 27 (79%) completed the survey and met inclusion criteria as staff urologists who perform radical cystectomy. In addition, 52 non-Canadian SUO members were included in the analysis. Among all SUO respondents, a high proportion (73; 88%) reported using topical hemostatic agents during cystectomy. Thirty-six (46%) surgeons reported occasionally using procedural techniques and 9 (11%) using systemic hemostatic agents. Number of years since training was associated with decreased use of topical agents and increased use of procedural techniques (p < 0.01). Number of cystectomies per year was associated with decreased use of topical hemostatic agents (p < 0.01). INTERPRETATION Based on a survey of practice, there is significant risk of blood loss requiring transfusion during radical cystectomy. Surgeons frequently use topical hemostatic agents and rarely use systemic drugs to prevent or control blood loss. Trials evaluating agents and techniques to reduce blood loss during radical cystectomy are needed.
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Affiliation(s)
- Nahid Punjani
- University of Ottawa Medical School, University of Ottawa, Ottawa, ON
| | - Luke T. Lavallée
- Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | | | | | | | | | - Christopher Morash
- Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Ilias Cagiannos
- Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
| | - Rodney H. Breau
- Division of Urology, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
- Ottawa Hospital Research Institute, Ottawa, ON
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Friedrich-Freksa M, Schulz E, Nitzke T, Wenzel O, Popken G. Cystectomy and urinary diversion in the treatment of bladder cancer without artificial respiration. Int Braz J Urol 2012; 38:645-51. [PMID: 23131521 DOI: 10.1590/s1677-55382012000500009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2012] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA). MATERIALS AND METHODS In 2011 radical cystectomy with extended pelvic and iliac lymphadenectomy was performed on 14 patients using urinary diversion without applying general anesthesia. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Postoperatively, pain management took three days with the remaining epidural catheter before oral analgesics were administered. Mobilization and diet restoration were carried out according to the fast-track concept. Outcome measurements included operative time, blood loss, beginning of oral nutrition, beginning of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), length of hospital stay. RESULTS All surgical procedures were performed without any complications. The absence of general anesthesia did not result in any relevant disadvantages. The postoperative progress was normal in all patients. Particularly, cardiopulmonary complications and enteroparesis did not occur. The provided palliative care proved sufficient (NAS max. 3-4). Discharge followed 10 to 22 days after surgery. At the time of discharge, the patients described the procedure to be relatively positive. CONCLUSIONS Our data show that CSTEA is an effective technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes, and complications of CSTEA.
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Shu'aibu S, Liman H, Akpayak I, Ofoha C, Ramyil V, Dakum N. Preliminary experience with radical cystectomy and w-ileal pouch for muscle invasive transitional cell bladder carcinoma. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2012; 2:25-37. [PMID: 25452976 PMCID: PMC4170286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Radical cystectomy and bilateral pelvic lymphadenectomy is considered the treatment of choice for patients with muscle invasive transitional cell bladder cancer. Following radical cystectomy the surgeon would choose an appropriate modality of urinary diversion from a plethora of methods. Radical cystectomy with any type of diversion remains a complication-prone surgery. This study aims at reviewing the peri-operative challenges and morbidities experienced with radical cystectomy and W-ileal pouch urinary diversion in a tertiary hospital in Nigeria. AIMS & OBJECTIVE To report experience with radical cystectomy and W-ileal pouch construction in patients with muscle invasive transitional cell urinary bladder carcinoma. PATIENTS & METHODS The case notes of patients diagnosed with muscle invasive transitional cell bladder carcinoma (T2/3NoMo) who underwent radical cystectomy and W-ileal pouch construction from December 2006 to December 2011 at the Jos University Teaching Hospital, Jos, Nigeria were retrospectively studied. Patients were evaluated for age, sex, duration of surgery, estimated blood loss, duration of hospital stay, and complications after surgery. RESULTS Six patients had their records reviewed. Mean age was 55.8 years (range 32 - 66years). Male to female ratio was 5:1. Mean hospital stay was 31 days, with all of the patients requiring intensive care for a mean of 24 hours (range 24-72 hours). Mean hospital stay was 31 days (range 21-40 days). Mean estimated blood loss was 891 ml (range 720-1500ml). Mean duration of surgery was 10.3 hours (range 8-12 hours). Commonest complication was urine retention secondary to mucus plug in 50%. Operative mortality was 16.7%. CONCLUSION Radical cystectomy and W-ileal pouch construction due to its technical complexity and challenging postoperative management necessitates a team approach with experienced surgeons, anesthetists, intensivists and stoma care specialist, among others.
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Affiliation(s)
- Si Shu'aibu
- Division of Urology, Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria
| | - Hu Liman
- Division of Urology, Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria
| | - Ic Akpayak
- Division of Urology, Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria
| | - Cg Ofoha
- Division of Urology, Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria
| | - Vm Ramyil
- Division of Urology, Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria
| | - Nk Dakum
- Division of Urology, Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria
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