Definition of Benign Ureteroenteric Anastomotic Strictures in Ileal Conduits After Radical Cystectomy: Experience From a Single Center and Previously Published Literature

OBJECTIVE

To evaluate a cohort of patients diagnosed with benign ureteroenteric stricture (UES) after radical cystectomy with ileal conduits using a strict predefined definition of strictures. Additionally, we want to illustrate the UES debut, regarding symptoms and clinical findings. UES is a well-known long-term complication after radical cystectomy, affecting up to 20% of all patients. In the literature, different incidence rates are reported. However, these are based on various definitions of strictures.

METHODS

We used strict predefined criteria to evaluate UES incidence including symptoms, timing, diagnostic methods, treatment, and outcome in all patients who underwent radical cystectomy with an ileal conduit between 2012 and 2018 at a single high-volume center.

RESULTS

Of a total of 693 patients who underwent radical cystectomy with ileal conduit, we found 109 patients with 135 UES in total, corresponding to 15.7% of patients (CI: 13.2-18.6) and 10% of all included ureteroenteric anastomosis (CI: 8.5-11.6) after radical cystectomy. Median follow-up was 24months (interquartile range (IQR): 12-31), and postoperatively UES was diagnosed after a median of 6months (IQR: 3-16). A total of 56% was diagnosed with elevated creatinine. Every UES underwent a median of two (IQR: 1-2) treatment attempts and 122 UES were treated successfully.

CONCLUSION

Benign UES is a significant cause of morbidity following radical cystectomy. Our findings contribute to the knowledge of timing, incidence, and recommended treatment of strictures. We argue the importance of establishing a clear gold standard when defining UES to ensure accurate reporting in future research.

DaBlaCa-16: Retrosigmoid Versus Conventional Ileal Conduit in Robot-assisted Radical Cystectomy, the MOSAIC Randomized Controlled Trial-Feasibility and 90-day Postoperative Complications

Background

Approximately 15% of patients undergoing radical cystectomy (RC) develop benign ureteroenteric strictures. Of these strictures, the majority are located in the left ureter. To lower the rate of strictures, a retrosigmoid ileal conduit has been suggested.

Objective

To investigate the feasibility and safety of a retrosigmoid ileal conduit during robot-assisted RC in bladder cancer patients.

Design setting and participants

This randomized controlled trial included 303 patients from all five cystectomy centers in Denmark from May 2020 to August 2022. Participants were diagnosed with bladder cancer and scheduled for robot-assisted RC with an ileal conduit.

Intervention

Intervention group: a retrosigmoid ileal conduit was constructed using approximately 25 cm of the terminal ileum and tunneled behind the sigmoid where the left ureter was anastomosed from end to side. Control group: the conventional ileal conduit ad modum Bricker with individual end-to-side anastomoses.

Outcome measurements and statistical analysis

Patients were analyzed by the intention-to-treat approach. Complications within 90 d were categorized using the Clavien-Dindo grading system and compared using Fisher's exact test. Wilcoxon's test was used for pre- and postoperative renal function.

Results and limitations

Of the 149 patients randomized for the retrosigmoid ileal conduit (MOSAIC), a total of 137 (92%) patients received the allocated conduit. Postoperative complications were distributed equally between the two groups. The relative risk of Clavien-Dindo complications of grade ≥III was 1.12 (95% confidence interval: 0.96-1.31) in the intervention group compared with the control group.

Conclusions

The retrosigmoid ileal conduit with robot-assisted RC was technically feasible. Early postoperative complications were not significantly different when comparing the two groups. Further investigation of long-term complications, including strictures, is needed.

Patient summary

We compared a conventional urinary diversion with a longer conduit to prevent constriction from developing in the ureters. The new conduit is feasible and safe within the first 90 d, with no differences in postoperative complications from those of the conventional diversion.

[Not Available]

Bladder cancer is the fifth most frequently diagnosed cancer in Europe, with major healthcare costs. For patients with non-muscle invasive bladder cancer, recurrences, treatment and surveillance regimes with multiple invasive procedures are a significant burden. Muscle invasive or metastatic disease is treated with radical surgery, radiation therapy and/or systemic chemo- or immunotherapy, with a five-year overall survival of around 50% and long-term quality of life issues for survivors. We present a brief overview of bladder cancer in various stages and give examples of new developments.

The transferability of laparoscopic and open surgical skills to robotic surgery

BACKGROUND

Within the last decades, robotic surgery has gained popularity. Most robotic surgeons have changed their main surgical activity from open or laparoscopic without prior formal robotic training. With the current practice, it is of great interest to know whether there is a transfer of surgical skills. In visualization, motion scaling, and freedom of motion, robotic surgery resembles open surgery far more than laparoscopic surgery. Therefore, our hypothesis is that open-trained surgeons have more transfer of surgical skills to robotic surgery, compared to surgeons trained in laparoscopy.

METHODS

Thirty-six surgically inexperienced medical students were randomized into three groups for intensive simulation training in an assigned modality: open surgery, laparoscopy, or robot-assisted laparoscopy. The training period was, for all study subjects, followed by performing a robot-assisted bowel anastomosis in a pig model. As surrogate markers of surgical quality, the anastomoses were tested for resistance to pressure, and video recordings of the procedure were evaluated by two blinded expert robotic surgeons, using a global rating scale of robotic operative performance (Global Evaluative Assessment of Robotic Skills (GEARS)).

RESULTS

The mean leak pressure of bowel anastomosis was 36.25 (7.62-64.89) mmHg in the laparoscopic training group and 69.01 (28.02-109.99) mmHg in the open surgery group, and the mean leak pressure for the robotic training group was 108.45 (74.96-141.94) mmHg. The same pattern was found with GEARS as surrogate markers of surgical quality. GEARS score was 15.71 (12.37-19.04) in the laparoscopic training group, 18.14 (14.70-21.58) in the open surgery group, and 22.04 (19.29-24.79) in the robotic training group. In comparison with the laparoscopic training group, the robotic training group had a statistically higher leak pressure (p = 0.0015) and GEARS score (p = 0.0023). No significant difference, for neither leak pressure nor GEARS, between the open and the robotic training group.

CONCLUSION

In our study, training in open surgery was superior to training in laparoscopy when transitioning to robotic surgery in a simulation setting performed by surgically naive study subjects.

Validation of a novel assessment tool identifying proficiency in Transurethral Bladder Tumour Resection: The OSATURBS assessment tool

BACKGROUND

Competence in transurethral bladder tumour resection (TURB) is critical in bladder cancer management and should be ensured before independent practice.

OBJECTIVE

Develop an assessment tool for TURB and explore validity evidence in a clinical context.

DESIGN, SETTING, AND PARTICIPANTS

July 2019-March 2021, a total of 33 volunteer doctors from three hospitals were included. Participants performed two TURB procedures on patients with bladder tumours. A newly developed assessment tool (OSATURBS) was used for direct observation assessment, self-assessment, and blinded video-assessment. Outcome measurements and statistical analysis: Cronbach's alpha and Pearson's r were calculated for across items internal consistency reliability, inter-rater reliability, and test-retest reliability. Correlation between OSATURBS scores and the operative experience was calculated with Pearson's r and a pass/fail score was established. Differences in assessment scores were explored with paired t-test and independent samples t-test.

RESULTS AND LIMITATIONS

The internal consistency reliability across items Cronbach's alpha was 0.94 (n = 260, p < 0.001). Inter-rater reliability = 0.80 (n = 64, p < 0.001). Test-retest correlation was high, r = 0.71 (n = 32, p < 0.001). Relation to TURB experience was high, r = 0.71 (n = 32, p < 0.001). Pass/fail score = 19 points. Direct observation assessments were strongly correlated with video ratings (r = 0.85, p < 0.001) but with a significant social bias with lower scores for inexperienced and higher scores for experienced participants. Participants tended to overestimate their own performances.

CONCLUSIONS

OSATURBS assessment tool for TURB can be used for assessment of surgical proficiency in the clinical setting. Direct observation assessment and self-assessment are biased, and blinded video-assessment of TURB performances is advised.

Prospective versus retrospective recordings of comorbidities and complications in bladder cancer patients undergoing radical cystectomy - a randomized controlled trial

BACKGROUND

Patients undergoing radical cystectomy are predominantly elderly with many comorbidities and high risk of complications. Studies on comorbidity and complications following cancer surgery are often based on data collected retrospectively from records. However, prospective registration is often considered a more valid source of information. Therefore, it is relevant to investigate if the amount and severity of complications and comorbidities is valid when using retrospective registration compared to a more meticulous prospective registration.

OBJECTIVE

To investigate the difference in registered comorbidities and complications between prospective and retrospective data collection in patients with bladder cancer undergoing radical cystectomy.

METHOD

Seventy-three bladder cancer patients undergoing radical cystectomy were randomized to receive prospective or retrospective collection of data regarding comorbidities and complications. Data in the prospective arm was collected daily during hospitalization, 14-days after discharge and 90-days postoperatively. In the retrospective arm, medical records were reviewed retrospectively at 90-days. Comorbidities were compared using the Charlson Comorbidity Index (CCI) and complications were reported as overall, minor and major dependent on Clavien Dindo Classification (CDC). The primary endpoint was the difference in overall complication rate.

RESULTS

No statistically significant difference in CCI was observed with median [IQR] 2[0;3] and 1[0;2] (p = 0.21). No statistically significant difference was found regarding all, minor (CDC I-II) or major (CDC III-V) complications at all three time points.

CONCLUSION

No statistically significant difference in comorbidity and complications between retrospectively and prospectively collected data was observed. We find that retrospective collected data is reliable when strict reporting guidelines are used in this single-centre study.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Potential candidates for en bloc resection among patients with primary and recurrent bladder tumours

INTRODUCTION

Transurethral resection (TURB) is the gold standard treatment for non-muscle invasive bladder cancer (NMIBC). However, conventional TURB is possibly part of the mechanism leading to the high recurrence rate in NMIBC and the need for repeated procedures, as the method with piecemeal resection of the tumour violates basic oncological principles and compromises pathological examination. En bloc resection (EBR) could potentially overcome these flaws by improving pathological quality and thereby reducing the need for re-resections and could potentially also lower the risk of tumour seeding leading to early recurrences. With this study, we aimed to evaluate tumour characteristics in a consecutive cohort of patients undergoing conventional TURB in order to estimate the proportion of procedures eligible for EBR, findings at re-resection, and early recurrence rate.

METHODS

All TURBs performed at a single large University Hospital in a 12 month period were manually reviewed. Based on tumour size and appearance, patients were registered as candidates or non-candidate for EBR.

RESULTS

A total of 600 TURBs were reviewed. Overall, 25% of procedures were found to be eligible for EBR. The most frequent reason for not being a candidate was tumour diameter <1 cm. Re-resections were done after 10.5% of the procedures, where the residual tumour was found in 28.6% of these. Within 6 months, 21.2% had a recurrence.

CONCLUSION

We found approximately 25% of all TURBs to be eligible for EBR. Based on a relatively low recurrence rate, we conclude that future studies on EBR with recurrence rate as the primary endpoint will require large patient cohorts.

Correlation between organ-specific co-morbidities and complications in bladder cancer patients undergoing radical cystectomy

OBJECTIVE

To evaluate the association between patients' organ-specific co-morbidities and post-operative complications following radical cystectomy for bladder cancer.

PATIENTS AND METHODS

All patients who underwent radical cystectomy at Aarhus University Hospital during the period from January 2006 to February 2014 were included retrospectively. A total of 40 comorbidities and 59 complications were registered meticulously. Univariate and multivariate analyses were used to detect associations between the individual comorbidities and specific post-operative complications.

RESULTS

Ninety-two per cent (575/625) of patients experienced one or more complications following radical cystectomy. Clavien-Dindo grade 3-5 complications were observed in 40.8% of patients, and 6.2% had severe complications (Clavien-Dindo grade 4-5). The mortality rate was 2.2%. High BM, previous myocardial infarction and chronic obstructive pulmonary disease were noted to be associated with moderate-to-severe post-operative complications (Clavien-Dindo grade 3-5), while diabetes and lymphoproliferative disorders were significantly associated with severe complications (Clavien-Dindo grade 4-5).

CONCLUSION

This study demonstrates that overall complications to radical cystectomy are high (92%). The associations between specific comorbidities and complications need to be further investigated in order to evaluate whether pre-operative assessment can be more optimally used in a prevention strategy tailored to the individual patient.

Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion vs. open mini-laparotomy cystectomy: evaluation of surgical inflammatory response and immunosuppressive ability of CO2-pneumoperitoneum in an experimental porcine study

OBJECTS

To compare surgical inflammatory response (SIR) after radical cystectomy (RC) in a porcine model using minimal invasive techniques. Additionally we aimed to investigate the potential immunosuppressive ability of preoperative CO₂-pneumoperitoneum (CO₂P).

MATERIALS AND METHODS

Forty female landrace pigs were randomized to five groups: Three intervention groups all having a cystectomy and an ileal conduit either done by robot-assisted laparoscopic technique with intracorporeal urinary diversion (RALC) or an open mini-laparotomy with or without prior CO₂P (OMC ± CO₂P). Two control sham groups with or without prior CO₂P (S ± CO₂P). Serum samples were obtained preoperatively, immediately postoperative, 24, 48 and 72 hours postoperatively, and the inflammatory mediators CRP, Haptoglobin, Ceruloplasmin, Albumin, Cortisol, IL-4, IL-6, IL-12 and IFN-α were measured.

RESULTS

Operative time was significantly longer in RALC compared to open groups (OMC ± CO₂P) (p's < .0001). CRP and Haptoglobin levels were significantly higher for surgical intervention groups (SIG) compared to controls 24, 48 and 72 hours postoperatively (p's < .001). At 48 hours, CRP was higher for RALC vs OMC + CO₂P (p = .029). At 72 hours, Haptoglobin was higher for RALC vs open groups (p's < .024). Ceruloplasmin, cortisol, albumin, IL-4, IL-6, IL-12 and IFN-α, revealed no significant differences between SIG.

CONCLUSIONS

No major differences were found between RALC and OMC regarding the degree of tissue trauma quantified by inflammatory markers. Thirty minutes of CO_2-insufflation preoperative appears to have a transient immunosuppressive effect of the innate postoperative SIR, whereas prolonged CO₂P apparently diminishes this effect.

Aquaporin expression in the fetal porcine urinary tract changes during gestation

The expression of aquaporins (AQPs) in the fetal porcine urinary tract and its relation to gestational age has not been established. Tissue samples from the renal pelvis, ureter, bladder and urethra were obtained from porcine fetuses. Samples were examined by RT-PCR (AQPs 1-11), QPCR (AQPs positive on RT-PCR), and immunohistochemistry. Bladder samples were additionally examined by Western blotting. RNA was extracted from 76 tissue samples obtained from 19 fetuses. Gestational age was 60 (n=11) or 100 days (n=8). PCR showed that AQP1, 3, 9 and 11 mRNA was expressed in all locations. The expression of AQP3 increased significantly at all four locations with gestational age, whereas AQP11 significantly decreased. AQP1 expression increased in the ureter, bladder and urethra. AQP9 mRNA expression increased in the urethra and bladder, but decreased in the ureter. AQP5 was expressed only in the urethra. Immunohistochemistry showed AQP1 staining in sub-urothelial vessels at all locations. Western blotting analysis confirmed increased AQP1 protein levels in bladder samples during gestation. Expression levels of AQP1, 3, 5, 9 and 11 in the urinary tract change during gestation, and further studies are needed to provide insights into normal and pathophysiological water handling mechanisms in the fetus.

Postoperative C-reactive protein concentration and clinical outcome: comparison of open cystectomy to robot-assisted laparoscopic cystectomy with extracorporeal or intracorporeal urinary diversion in a prospective study

OBJECTIVE

This study aimed to compare clinical outcome and postoperative systemic inflammatory response using C-reactive protein (CRP) levels, to quantify the degree of tissue injury in open mini-laparotomy cystectomy (OMC) versus robot-assisted laparoscopic cystectomy with extracorporeal (RALC-EUD) or intracorporeal urinary diversion (RALC-IUD).

MATERIALS AND METHODS

From September 2012 to September 2015, 309 patients diagnosed with bladder cancer underwent radical cystectomy with urinary diversion. Of these, 175 patients were eligible for the study and underwent OMC (n = 125), RALC-EUD (n = 12) or RALC-IUD (n = 38). Blood samples were obtained preoperatively and postoperatively on days 1-7. Clinical and perioperative parameters, including demographics, comorbidity, tumour stage and postoperative outcomes, were collected from medical records.

RESULTS

Age, American Society of Anesthesiologists score and Charlson score were significantly higher in OMC than in the robotic groups (p = 0.020, 0.012 and 0.008, respectively). Other demographic data showed no significant group differences. Estimated blood loss and blood transfusion volume were higher in OMC (p < 0.001) and operative time was longer in the robotic groups (p < 0.001); no difference was found between RALC groups. Postoperative CRP levels changed over time (p < 0.001) and RALC-IUD appeared to have significantly higher CRP levels on postoperative days 3-7 compared to OMC and RALC-EUD (p < 0.031), but OMC CRP levels were higher than RALC-EUD.

CONCLUSIONS

In this study, robotic techniques seem less traumatic overall than open surgery, as OMC had higher postoperative CRP levels than RALC-EUD. The higher CRP levels in RALC-IUD may be more reflective of the urinary diversion technique than the true tissue trauma.

Perioperative Systemic Inflammatory Response following Robot-Assisted Laparoscopic Cystectomy vs. Open Mini-Laparotomy Cystectomy: A Prospective Study

INTRODUCTION

Surgeries, such as radical cystectomy (RC), induce a systemic inflammatory response (SIR). SIR plays an important role in controlling the human immune system. This study aims at comparing the SIR in robot-assisted laparoscopic cystectomy (RALC) to open mini-laparotomy cystectomy (OMC) with a urinary diversion (UD). Comparison was based on immunologic markers of SIR, thus quantifying the degree of tissue trauma.

MATERIALS AND METHODS

Forty-two male patients underwent RC with an ileal conduit. Either OMC RC (OMC; n = 20), RALC with extracorporeal UD (RALC-EUD; n = 13), or RALC with intracorporeal UD (RALC-IUD; n = 9) was performed. Blood samples were obtained preoperatively (PREOP), immediately after surgery (POD0), 24 (POD1) and 48 h (POD2) postoperatively. Clinical parameters were collected from medical records.

RESULTS

Estimated blood loss and blood transfusion volume was higher in OMC (p's < 0.001). The operative time was longer in RALC groups (p < 0.001). On POD0, interleukin (IL)-6 showed significant lower level in RALC-IUD compared to OMC (p = 0.016). IL-10 level was higher at POD0 (p = 0.029) and POD1 (p = 0.038) in OMC vs. RALC-EUD. MCP-1 levels for RALC-IUD were significantly lower compared to RALC-EUD (p = 0.027).

CONCLUSIONS

This study found that postoperative SIR was overall less pronounced in RALC, thus depicting reduced tissue trauma. No major clinical differences between RALC-IUD and -EUD were found.

Evaluation of robot-assisted laparoscopic versus open cystectomy and effect of carbon dioxide-pneumoperitoneum on histopathological findings in ureteroenteric anastomoses: results from an experimental randomized porcine study

OBJECTIVE

The aim of this study was to investigate the histopathology of ureteroenteric anastomoses (UEAs) after radical cystectomy (RC) with an ileal conduit in a porcine model using different surgical techniques. The study also evaluated the potential anti-inflammatory effect of preoperative carbon dioxide-pneumoperitoneum (CO₂P).

MATERIALS AND METHODS

Forty female Danish Landrace pigs were randomized to four groups: three intervention groups [open surgery ± prior CO₂P and robot-assisted laparoscopic cystectomy (RALC)], all subjected to RC and an ileal conduit, and one control group. After euthanization, UEAs were harvested and histopathologically evaluated.

RESULTS

Five pigs were excluded from the study owing to postoperative complications. Operating room time and clamping of the right and left ureters were significantly longer in the robotic than in the open groups (p < .01). Inflammatory infiltration grade of the left ureter was significantly higher in RALC (p = .032). No statistically significant difference was observed between the open groups receiving prior CO₂P or not.

CONCLUSIONS

Results showed a statistically significant higher inflammatory infiltration grade of the left ureter in RALC, emphasizing the importance of using meticulous techniques when mobilizing the left ureter using the robot. It was not possible to conclude with certainty whether CO₂P could constitute an anti-inflammatory agent for local inflammation.

[Acute urinary retention in a young woman with Lyme borreliosis]

Acute urinary retention (AUR) in females is a rare condition (annual incidence 3-7/100,000/year). In the past AUR was considered to be of psychogenic origin. Today diagnostic tools have improved and aetiologic factors for AUR are more easily diagnosed and managed. Causes of AUR can be of infectious, pharmacological, neurological, anatomical, myopathic and functional origin. We report a case of a woman aged 34 who presented with AUR caused by Lyme borreliosis. The patient fully recovered after intravenous antibiotic treatment and micturition returned to the habitual condition.

Paediatric urachal benign teratoma: a case report and review of the literature

Urachal anomalies are most often seen in children, seldom in adults, but are in general considered rare. The estimated incidence is one in 5000-7000 live births and appears twice as common in males. Despite their rarity, they need to be considered by clinicians, as diseases in the urachus can mimic many abdominal and pelvic conditions and constitute an important differential diagnosis to these. Diagnosis can be made by clinical examination and imaging modalities (computed tomography, ultrasonography, magnetic resonance imaging, voiding cystourethrogram), but some are discovered incidentally. Management of symptomatic urachal anomalies is surgery. Histological examination of the specimen should always be performed to rule out malignancy. We report on the first adolescent described in the literature diagnosed with a urachal sinus harboring a benign teratoma. A combination of the two pathologies is by inference an extremely rare condition, which we here report on and we review the relevant literature on this topic.