The morbidity of laparoscopic radical cystectomy: analysis of postoperative complications in a multicenter cohort by the European Association of Urology (EAU)-Section of Uro-Technology

Purpose

To analyze postoperative complications after laparoscopic radical cystectomy (LRC) and evaluate its risk factors in a large prospective cohort built by the ESUT across European centers involved in minimally invasive urology in the last decade.

Methods

Patients were prospectively enrolled, and data were retrospectively analyzed. Only oncologic cases were included. There were no formal contraindications for LRC: Also patients with locally advanced tumors (pT4a), serious comorbidities, and previous major abdominal surgery were enrolled. All procedures were performed via a standard laparoscopic approach, with no robotic assistance. Early and late postoperative complications were graded according to the modified Clavien–Dindo classification. Multivariate logistic regression was performed to explore possible risk factors for developing complications.

Results

A total of 548 patients were available for final analysis, of which 258 (47 %) experienced early complications during the first 90 days after LRC. Infectious, gastrointestinal, and genitourinary were, respectively, the most frequent systems involved. Postoperative ileus occurred in 51/548 (9.3 %) patients. A total of 65/548 (12 %) patients underwent surgical re-operation, and 10/548 (2 %) patients died in the early postoperative period. Increased BMI (p = 0.024), blood loss (p = 0.021), and neoadjuvant treatment (p = 0.016) were significantly associated with a greater overall risk of experiencing complications on multivariate logistic regression. Long-term complications were documented in 64/548 (12 %), and involved mainly stenosis of the uretero-ileal anastomosis or incisional hernias.

Conclusions

In this multicenter, prospective, large database, LRC appears to be a safe but morbid procedure. Standardized complication reporting should be encouraged to evaluate objectively a surgical procedure and permit comparison across studies.

     

Long-term evaluation of postoperative acromegalic patients in remission with previous and newly proposed criteria

Criteria to define remission of acromegaly have changed over years. Since 2000, criteria for cure are normal IGF-I levels and a nadir GH after oral glucose tolerance test (OGTT) of less than 1 microg/liter, although recent studies have suggested to lower this cutoff value. This study reevaluated long-term disease activity of acromegalic patients, who were previously considered in remission, using these criteria. The study included 70 of 146 patients operated on between 1984 and 1996 who were considered cured based on normal IGF-I levels, GH values less than 2.5 microg/liter, and/or disappearance of abnormal GH response to TRH/GnRH. Among these 70 patients, 16 were lost to follow-up, three died, and 11 (one of whom had disease recurrence) only gave a phone interview. Forty patients participated in the study and were reevaluated for IGF-I levels and post-OGTT GH nadir after 14.3 +/- 4.2 (mean +/- sd) yr from surgery. In all patients, normal IGF-I levels and a post-OGTT GH nadir of less than 1 microg/liter were found. In particular, 19 patients had a GH nadir of less than 0.19 microg/liter, i.e. the upper limit (mean + 2 sd) found in 30 controls, whereas 21 patients had a nadir between 0.19 and 0.77 microg/liter. No significant differences in hormonal parameters and comorbidities between the two subgroups were observed. These data showed that lowering the post-OGTT GH cutoff value within the normal range does not seem to better discriminate patients with different disease activity or long-term recurrence risk.     

Lingual mucosal graft urethroplasty for anterior urethral reconstruction

OBJECTIVE: Evaluate the use of lingual mucosal graft (LMG) in anterior urethral strictures. METHODS: From January 2001 to December 2006, 29 men (mean age, 48.5 yr) with anterior urethral strictures underwent graft urethroplasty with LMG. The mean length of stricture was 3.6cm. Patients with bulbar, penile, or bulbopenile strictures received one-stage dorsal free graft urethroplasties. In patients with failed hypospadias repair we performed a two-stage urethroplasty. Criteria for successful reconstruction were spontaneous voiding with no postvoid residual urine and no postoperative instrumentation of any kind. Clinical assessment included the donor site morbidity. RESULTS: Mean follow-up was 17.7 mo. One-stage bulbar and penile urethroplasties without meatal involvement had an 81.8-100% success rate. Bulbopenile urethroplasties were successful in 60% of the cases, whereas one-stage urethral reconstructions in patients with meatal involvement were successful in 66.6%. The two cases of two-stage urethral reconstruction with LMG and buccal mucosal graft after failed multiple hypospadias repairs were unsuccessful. The overall early recurrence rate was 20.7%. Patients with the graft harvested from the tongue reported only slight oral discomfort at the donor site and difficulty in talking for 1 or 2 d. CONCLUSIONS: The mucosa of the tongue, which is identical to the mucosa of the rest of the oral cavity, is a safe and effective graft material in the armamentarium for urethral reconstruction with potential minor risks of donor site complications. LMG may be used alone for short strictures (<5cm) or in combination with buccal mucosa when longer grafts are needed.     

Disease progression in bladder cancer: which developments since 1994

Objectives The introduction of PSA in clinical practice has resulted in decreasing the death rate form prostate cancer and in a downward shift of the pathological stage in radical prostatectomy specimens. This seems not to be the case for bladder cancer. In order to verify this assumption, we have reviewed the charts of the patients operated on of radical prostatectomy and radical cystectomy between 1994 and 2006. METHODS 456 and 491 consecutive patients, respectively, underwent radical cystectomy and radical prostatectomy with bilateral lymph nodes dissection. We excluded all the patients who had received neoadjuvant treatment or did not undergo node dissection. The patients were divided into two consecutive groups according to the year of treatment: group 1 included pts treated from 1994 to 2000, and group 2 pts from 2001 to 2006. The histopathological findings of the two groups of pts were compared. The difference among TNM systems has been balanced evaluating histopathological reports critically and converting them to the 2002 edition. RESULTS. For patients with prostate cancer, those in group 2 had a decrease in the incidence of extracapsular extension and lymph nodes invasion. The bladder cancer patients belonging to group 2 had a greater number of T2, but there was an increased number of pN+ in this group. CONCLUSIONS Even if there is a decline in locally advanced disease in patients with bladder cancer, our retrospective analysis did not show a comparable success in early diagnosis as it did for prostate cancer. There is undoubtedly an increase in the lymph node dissemination, whether this is due to a more extended lymph node dissection or to a premature dissemination remains questionable. Public awareness regarding bladder cancer and its risk factors is limited, but several studies have reported that a delay in diagnosis of invasive bladder cancer is an adverse prognostic factor. A higher care in the development of new diagnostic markers for bladder tumors and especially in the screening protocols together with an earlier radical therapy could hopefully improve the management of such a pathology, as it happened for prostate cancer.     

Early vs delayed radical cystectomy compared in highgrade superficial bladder tumors

Objectives. The treatment of aggressive superficial TCC of the bladder remains controversial. In fact, although still classified as 'superficial', it has been shown that the biological characteristics of T1G3 bladder tumors are the same as those of the muscle-invasive group (T2 and above). Even with close monitoring and intensive intravesical therapy, the reported risk of muscle invasion in these patients is 53% and 1/3 die from this disease in the long-term. The aim of this study is to determine whether the timing of radical cystectomy affects the survival of patients with aggressive superficial bladder tumor. Methods. We consider 74 patients who underwent radical cystectomy between November 1994 and October 2006 before a diagnosis of T1G3 bladder tumor. These patients were divided in 2 subgroups: group A (n=27, 25 M and 2 F) who underwent immediate radical cystectomy, and group B (n=47, 40 M and 7 F) who underwent other conservative treatments before radical cystectomy. Results. The two subgroups were similar concerning age (66.29±8.37 yrs vs 66.87±8.6 yrs, respectively, p NS) and the timing of follow-up (respectively 77±45 vs 60±35 mths, p NS). Moreover, the progression-free survival was significantly higher in subgroup A (53.73±48.54 vs 31.94±35.19 mths, log-rank p<0.05) as well as the overall survival (59.73±45.37 vs 36.45±33.96 mths respectively, log-rank p<0.05). Comparing the histological examinations, the two subgroups were significantly different concerning the T stage (superficial tumors 14/27 vs 16/47, respectively, p<0.05; invasive tumors 13/27 vs 31/47, respectively, p<0.00005) and the lymphonodal dissemination (2N+/27 vs 11N+/47, respectively, p<0.0005). . Delaying radical cystectomy for aggressive superficial bladder tumors leads to a worse progression-free survival; the overall survival is likely to be due also to an early lymphonodal dissemination, which occurs extending the timing between diagnosis and radical treatment.     

Antibacterial resin-based composite containing chlorhexidine for dental applications

ObjeticveThe aim of this study was to develop a composite material with antibacterial activity using MMT loaded with clorhexidine (CHX). For that it was used a BisGMA/TEGDMA matrix and added low concentration of MMT/CHX. The aim was to evaluate the drug release capacity of MMT, and not to provide reinforcement.MethodsSix experimental composites were made with organic matrix of BisGMA/TEGDMA in equal proportions by weight. The composites received organophlizated montmorillonite with or without CHX. The concentrations were 2,5; 5 or 10% by weight. Degree of conversion (DC) was evaluated using FTIR (peak 6165 cm-1; n = 5). Specimens for flexural properties (10×2×1 mm) were immediate tested (24h). Elastic modulus(E) and flexural strength (FS) was measured using the three point bending test (n = 10). Inibition halo was used to test the antibacterial activity against Staphylococcus aureus, Streptococcus mutans, and Porphyromonas gingivalis (n = 5 for each bacteria). The inhibition of biofilm formation (BF) was evaluated by inserting polymerized disc of composite in to a culture media colonized with Streptococcus mutans (n = 10). The release of CHX was measured using ultraviolet (255 nm) for 10 days (n = 5). The data of degree of conversion was analysed using Kruskal–Wallis/ Mann–Whitney, and the other variables using two-way ANOVA/Tukey, always considering a global level of significance of 5%.ResultsDC ranged from 71% to 74%. E ranged from 5.7 to 8.1 GPa. FS ranged from 61.4 to 74.7 MPa. There were no statistical differences among the groups for all the variables. For the three bacteria tested the composites with CHX loaded presented inhibition of growth for all concentration, except for 2,5% that did not inihibited the growth of P. gingivalis. BF was lower for the groups with 10% MMT/CHX, all groups presented BF, even those without CHX loaded. All concentrations presented release off CHX during all the 28 days analyzed.ConclusionsWithin the limitation of this study it can be concluded that: all concentrations tested presented release of CHX and reduced BF. All concentration presented antibacterial activity for the three bacteria tested, except for 2,5% that did not inhibit the growth of P. gingivalis. The presence of MMT with CHX loaded did not interfere in the properties evaluated.