Robot-assisted-radical-cystectomy with total intracorporeal Y neobladder: Analysis of postoperative complications and functional outcomes with urodynamics findings

ObjectivesTo describe our robotic Y intracorporeal neobladder (ICNB) technique and to report its post-operative complications and urodynamics (UD) findings.Subjectsand Methods: In this prospective study we enrolled patients affected by MIBC (T1-T4N0–N1M0) from 01/2017 to 06/2021 at our Centers. All the patients underwent robotic radical cystectomy (RARC) with Y–ICNB reconfiguration. Early and late complications were collected and classified according to Clavien-Dindo. Continence and potency at 1, 3, 6 and 12 months were evaluated. At the 3rd month of follow-up patients underwent UD. Finally, in a retrospective match paired analysis the functional outcomes of Y RARC patients were compared with a cohort of open Y radical cystectomy.Results45 patients were enrolled. Overall 30-day complications were observed in 25 (55,5%) patients and 30 to 90-days complications in 4 (8,9%). 9 patients (20%) had Clavien ≥3 complications. UDs revealed median neobladder capacity of 268 cc, with a median compliance of 13 ml/cm H20; the voiding phase showed a voiding volume and a post void residual (PVR) of 154 cc and 105 cc respectively. At 12 months of follow-up 4.4%, 15.5% and 4.4% of the patients experienced urge, stress and mix urinary incontinence respectively. The comparison between Y RARC and Y open RC revealed a higher neobladder capacity with open approach (p = 0.049) with subsequent better findings during the voiding phase in terms of maximum flow (p = 0.002), voiding volume (p = 0.001) and PVR (p = 0.01). Focusing on continence recovery, a slight trend in favor of RARC was shown without reaching the statistical significance.ConclusionsRobotic Y–ICNB is feasible and safe as shown by the low rate of postoperative complications. Satisfying UD functional outcomes are achievable, both during filling and voiding phase.     

TURBT结合表柔比星治疗浅表性膀胱癌的预后分析

目的 探讨经尿道膀胱肿瘤切除术（TURBT）结合表柔比星对浅表性膀胱癌患者生存预后的影响。方法 选取2011年6月至2014年6月在本院行TURBT术的浅表性膀胱癌患者100例，依据随机分配原则分为霉素组和比星组，各50例。霉素组术后给予40 mg丝裂霉素治疗，比星组术后给予30 mg表柔比星治疗。结果 霉素组和比星组治疗后3、6个月血清血管内皮生长因子（VEGF）水平低于治疗前，比星组治疗后3、6个月VEGF水平明显高于霉素组，差异有统计学意义（P<0.05）。霉素组和比星组不良反应发生率基本相同，差异无统计学意义（P>0.05）。比星组在第1、2、3年累积生存率明显高于霉素组，比星组在第1、2、3年累积复发率明显低于霉素组，差异有统计学意义（P<0.05）。结论 TURBT术结合表柔比星可有效减少浅表性膀胱癌患者术后复发和改善生存预后，其可能与降低患者血清VEGF水平有关，且具有良好的安全性，值得临床推广。     

Induction Chemotherapy Followed by Surgery Versus Upfront Radical Cystectomy in Patients With Clinically Node-positive Muscle-invasive Bladder Cancer

BackgroundThe aim of this study was to compare survival outcomes in patients with clinically node-positive muscle-invasive bladder cancer receiving induction chemotherapy (IC) followed by surgery and those who underwent upfront radical cystectomy (RC).Patients and MethodsOutcomes were reviewed in patients with cT2-4N1-3M0 bladder cancer treated with IC followed by surgery or upfront RC between January 1995 and June 2017. Survival outcomes were analyzed using a propensity score matched cohort analysis.ResultsOf the 340 eligible patients, 106 received IC and 234 underwent upfront RC. The overall 3-year metastasis-free survival rate and 5-year cancer-specific survival rate of patients in the IC and RC groups were similar (49.4% vs. 46.0% and 49.6% vs. 49.8%, respectively). The 5-year cancer-specific survival rate of cN1-2 patients was higher in the IC group than the RC group (68.1% vs. 52.9%; P = .035). However, the 5-year cancer-specific survival rate of patients with cN3 cancers was significantly lower in the IC group than the RC group (19.2% vs. 44.5%; P = .015).ConclusionsIn this study, IC was seen to improve cancer-specific survival in patients with cN1-2 muscle-invasive bladder cancers but was associated with poorer survival outcomes than upfront RC in patients with cN3 cancers. Further investigation in prospective, randomized studies is warranted.     

Downstaging of Muscle-Invasive Bladder Cancer Using Neoadjuvant Gemcitabine and Cisplatin or Dose-Dense Methotrexate,Vinblastine, Doxorubicin,and Cisplatin as Single Regimens or as Switch Therapy Modalities

BackgroundConsensus guidelines recommend gemcitabine and cisplatin (GC) or dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (ddMVAC) as equally preferable neoadjuvant chemotherapy before cystectomy for muscle-invasive bladder cancer. This study sought to compare the ability of GC and ddMVAC to achieve pathologic response; and to evaluate the benefit of switching regimens after 1 or 2 cycles of the other.Patients and MethodsPatients aged ≥ 18 with muscle-invasive bladder cancer (≥ cT2) and who had received either GC or ddMVAC as neoadjuvant chemotherapy followed by cystectomy were retrospectively evaluated using the electronic medical record. Patients who received 1 or 2 cycles of one regimen followed by several cycles of the other regimen before cystectomy were classified as switch therapy patients. This study assessed the rates of pathologic complete response (pCR) and any degree of downstaging.ResultsAmong 109 patients who received GC or ddMVAC, 7 (21%) of 33 ddMVAC patients demonstrated pCR, and 19 (25%) of 76 GC patients demonstrated pCR (odds ratio, 1.24; 95% confidence interval, 0.46-3.31; P = .67). Downstaging rates were 39% for ddMVAC and 50% for GC (P = .31). Thirty-three of 36 patients aged ≥ 70 years received GC (P < .001). Four of 7 patients treated with switch therapy showed downstaging, and 2 of 7 experienced pCR.ConclusionThere was no difference in pCR rates between GC and ddMVAC, and patients were most often able to receive 3 or 4 cycles of treatment. Switch therapy may be of benefit in patients whose disease has a poor initial response.     

Implications of micropapillary urothelial carcinoma variant on prognosis following radical cystectomy: A multi-institutional investigation

Purpose

To determine the association of micropapillary urothelial carcinoma (MUC) variant histology with bladder cancer outcomes after radical cystectomy.

Massage and reflexology for post-operative cancer cystectomy patients: Evaluation of a pilot service

Backgroundand purpose: Radical cystectomy is a gold standard treatment for invasive bladder cancer. However the length of the operation is long and recovery is usually slow and painful. There is growing recognition of the importance of health related quality of life among patients undergoing invasive surgical procedures. In response, a massage and reflexology service was piloted and evaluated.Materials and methodsOne hour of massage, reflexology or a combination of both was provided twice to 38 cystectomy patients by a trained therapist in their acute post-operative phase (day one and day three). Self-reported concerns, well-being and pain were measured before and immediately after the therapy. Pain was measured once more in the early evening of each therapy day.ResultsSelf-reported concerns and pain were significantly reduced following the intervention on both days treatments were given. Pain was measured again on the evening of each of the intervention days, and this reduction was maintained on day one but not day three. Well-being scores were also significantly improved pre to post intervention on both day one and day three. Qualitative comments highlighted that this complementary therapy service was viewed both beneficial and relaxing. There were no significant differences between the different therapies used (massage, reflexology, or a combination of the two).ConclusionThe findings of this pilot evaluation very tentatively support the benefits of cancer cystectomy patients receiving massage and/or reflexology in their acute postoperative recovery period. There are many limitations to this evaluation. Further research utilising a randomised control methodology alongside medical, independent markers is warranted, and currently in development.     

Live Birth Rate after Surgical and Expectant Management of Endometriomas after In Vitro Fertilization: A Systematic Review,Meta-Analysis,and Critical Appraisal of Current Guidelines and Previous Meta-Analyses

Controversy exists regarding surgical management of endometriomas in infertile women before in vitro fertilization (IVF) because growing evidence indicates that surgery may impair the ovarian response. The objective of the present systematic review and meta-analysis was to compare surgical and expectant management of endometriomas regarding IVF outcomes. Prospective and retrospective controlled studies were found via the Cochrane Library, Embase, and MEDLINE databases. Thirteen studies (1 randomized controlled trial and 12 observational studies, N?=?2878) were pooled, and similar live birth rates were observed in the surgically and expectantly managed groups (odds ratio?=?0.83; 95% confidence interval [CI], 0.56–1.22; p?=?.98). The clinical pregnancy rates (odds ratio?=?0.83; 95% CI, 0.66–1.05; p?=?.86), the number of mature oocytes retrieved, and the miscarriage rates were not statistically different between study groups. However, the total number of oocytes retrieved was lower in the surgery group (mean difference?=??1.51; 95% CI, ?2.60 to ?0.43; p?=?.02). Findings suggest that surgical management of endometriomas before IVF therapy yields similar live birth rates as expectant management. However, future properly designed randomized controlled trials are warranted.     

The effect of length of ureteral resection on benign ureterointestinal stricture rate in ileal conduit or ileal neobladder urinary diversion following radical cystectomy

ObjectivesTo assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion.Methods and materialsWe identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis.ResultsA total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211–927). Median time to stricture formation was 235 (IQR: 134–352) and 232 days (IQR: 132–351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P = 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication≥III (hazard ratio = 2.11, 1.01–4.40) and urine leak (hazard ratio = 3.37, 1.08–10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side.ConclusionsThe etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not significantly affect stricture rate.