Laparoscopic radical cystectomy: neobladder or ileal conduit, debate still goes on

Bowel obstruction incidence in urinary diversion patients: A meta-analysis study

Background

Bowel obstruction is a common complication that occurs in patient who underwent urinary diversion with an incidence of 0.7%-11%. Although previous studies have published risk factors, prevention and management of postoperative paralytic ileus, and data on urinary postdiversion bowel obstruction in the literature are still scarce and thus require further investigation of the diversion technique which allegedly has differences in pathogenesis, management, and results. To that end, this study conducted a systematic review study to compare two different diversion techniques, namely ileal conduit and continent diversion, especially orthotopic neobladder.

Methods

This study is a systematic review by searching study in online databases such as PubMed, EBSCOhost, and ProQuest. Inclusion criteria included are full-text articles, English language, and articles of the past 10 years. After searching, we analyzed quantitatively using the RevMan application for meta-analysis.

Results

From 3403 studies, we got 12 studies that were included in the analysis. In a study conducted from the study of van Hemelrijck et al. stated that intestinal obstruction has an incidence of 50.73-1000, the third-highest when compared with advanced complications such as death (145.07/1000 population) and urinary tract infections (127.03/1000 population). It was found that odds ratio was 0.64 (0.45-0.91).

Conclusion

The ileal conduit and orthotopic neobladder methods have no significant difference in the incidence of intestinal obstruction.

A systematic review and meta-analysis of the long-term outcomes of ileal conduit and orthotopic neobladder urinary diversion

INTRODUCTION

We aimed to perform a systematic review and meta-analysis on the long-term durability, incidence of complications, and patient satisfaction outcomes in ileal conduit (IC) and orthotopic neobladder (ONB).

METHODS

A systematic electronic literature search was performed in Medline, Embase, Cochrane Library, and Scopus using MeSH and free-text search terms "Urinary diversion" AND "Ileal conduit" AND "Neobladder." The search concluded June 19, 2018. Inclusion criteria were those patients who had a cystectomy and required urinary diversion by either IC or neobladder.

RESULTS

In total, 32 publications met the inclusion criteria. Data were available on 46 787 patients (n=36 719 for IC and n=10 068 for ONB). Meta-analyses showed that IC urinary diversions performed less favorably than ONB in terms of re-operation rates, Clavien-Dindo complications, and mortality rates; odds ratios (ORs) and 95% confidence intervals (CIs) were 1.76 (1.24, 2.50), p<0.01; 1.16 (1.09, 1.22), p<0.01; and 6.29 (5.30, 7.48), p<0.01, respectively. IC urinary diversion performed better than ONB in relation to urinary tract infection rates and ureteric stricture rates, OR and 95% CI 0.67 (0.58, 0.77), p<0.01; and 0.70 (0.55, 0.89), p<0.01, respectively.

CONCLUSIONS

Our results show that there is no significantly increased morbidity with ONB compared to IC. Selection of either urinary diversion technique should be based on factors such as tumor stage, comorbidities, surgical experience, and patient acceptance of postoperative sequalae.

Surgical techniques for facilitating laparoscopic intracorporeal orthotopic neobladder: initial experience

PURPOSE

To describe our technique and outcomes for laparoscopic intracorporeal ileal neobladder (ICNB) reconstruction.

MATERIALS AND METHODS

From April 2014 to November 2016, 21 patients underwent laparoscopic ICNB at our tertiary referral centre. ICNB with bilateral isoperistaltic afferent limbs and several technique improvements were introduced. Demographics, clinical, and pathological data were collected. Perioperative, 1-year oncologic, 1-year Quality of life and 1-year functional outcomes were reported.

RESULTS

ICNB was successfully performed in all 21 patients without open conversion and transfusion. Mean operative time was 345.6±66.9 min, including 106±22 min for LRC and PLND and 204±46.4 min for ICNB, respectively. Mean established blood loss was 192±146 mL. The overall incidence of 90-d complication was 33.3%, while major complication occurred in 4.8%. One-year daytime and night-time continence rates were 85.7% and 57.1%, respectively. One patient died from myocardial infarction six months postoperatively, and two patients had lung metastasis five months and six months respectively.

CONCLUSIONS

We described our experience of 3D LRC with a novel intracorporeal orthotopic ileal neobladder, and the technique improvements facilitate the procedure. However, further studies are required to evaluate long-term outcomes of the intracorporeal neobladder with bilateral isoperistaltic afferent limbs.

Complications and health-related quality of life after robot-assisted versus open radical cystectomy: a systematic review and meta-analysis of four RCTs

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.

Comparison of the clinical effectiveness of 3D and 2D imaging systems for laparoscopic radical cystectomy with pelvic lymph node dissection

Objective

To compare the clinical effectiveness of three-dimensional (3D) and two-dimensional (2D) laparoscopic imaging systems for radical cystectomy (RC) with pelvic lymph node dissection.

Methods

This was a retrospective analysis of data collected from all patients who underwent RC with pelvic lymph node dissection between January 2013 and May 2014, performed by a single surgeon in our clinic. Demographic characteristics and operative data from the procedure were collected and compared.

Results

Data were available from 42 patients (mean age 63 ± 6.7 years) of whom 18 were operated on using a 3D imaging laparoscope (Group 3D) and 24 were operated on using a conventional 2D laparoscope (Group 2D). There were no statistically significant differences in patient characteristics between the two groups (P > 0.05). There was no difference between groups in the mean (±SD) number of lymph nodes retrieved from each patient (13.2 ± 4.6 and 12.5 ± 4.3, for the 3D and 2D groups respectively), or in blood loss. PLND duration and total operative time were statistically significantly lower in Group 3D than in group 2D. There were no statistically significant between-group differences in postoperative hospital stay or total cost of the procedures. Serious postoperative complications occurred in one patient (5.6%) in group 3D, and four patients (16.7%) in group 2D (P = 0.075).

Conclusions

With the assistance of 3D stereoscopic imaging, surgeons may be able to reduce both the duration of lymph node dissection and overall operative time during laparoscopic RC with pelvic lymph node dissection, without increasing postoperative hospital stay or total cost.

Perioperative and survival outcomes of laparoscopic radical cystectomy for bladder cancer in patients over 70 years

Introduction

Radical cystectomy in elderly patients is a controversial issue that has noticed an increase in importance overtime because of the lengthening average life span. Our objective was to determine if there were significant differences in the perioperative outcomes of patients over 70 years with bladder cancer treated with laparoscopic radical cystectomy (LRC) compared to those of younger patients.

Material and methods

We selected 180 patients who underwent LRC in our department in the period between 2005-2012. We divided them into 2 groups: 57% <70 years and 43% >70 years, and we compared the different parameters such as: comorbidities, intraoperative and post-operative complications, TNM stage and overall survival.

Results

The group <70 years had less comorbidities when compared with the group >70 years. Heterotopic urinary diversion was the diversion of choice in the elderly patients (97.4%). Paralytic ileus and the worsening of renal function were the only complications with statistical differences between the groups. Mean hospital length of stay was not significantly different between the groups. Younger and older patients had similar pathological staging : pT1 or less: 26,2 vs. 18.2%, pT2: 19.4 vs. 16.9%, pT3 38.8 vs. 37.7% and pT4 15.6 vs. 17.2%. Kaplan-Meier curves did not show significant differences in survival.

Conclusions

Laparoscopic radical cystectomy in the elderly patient has similar rates of perioperative morbidity when compared with the younger patient and may be offered as a treatment option in selected elderly patients.