Minimal incisions for laparoscopic radical cystectomy with extracorporeal-assisted urinary diversion

ObjectiveLaparoscopic radical cystectomy (LRC) had been used for >10 years. However, longer wound incisions for extracorporeal-assisted urinary diversion decrease the benefits of a laparoscopic approach. In this study, we describe our experience of modified LRC with extracorporeal-assisted urinary diversion using minimal wound incisions.Materials and methodsFrom January 2011 to January 2013, 22 consecutive patients underwent radical cystectomy by a single surgeon. Seven patients underwent open radical cystectomy (ORC), and 15 patients underwent LRC with four-port incisions.ResultsThe LRC group had a significantly lower estimated blood loss (p = 0.005), lower blood transfusion rate (p = 0.004), and lower ileus rate (p = 0.031) than the ORC group. No significant differences were noted in operative time, time to flatus, pain score, overall complication rate, pathological stage, positive surgical margin rate, or lymph node yield (27.6 for LRC and 29.1 for ORC). The 1-year disease free survival rate was 86.7% in the LRC group and 71.4% in the ORC group, and the 1-year overall survival rates were both 100%.ConclusionOur experience shows that LRC with extracorporeal-assisted urinary diversion using minimal incisions is a safe and feasible surgical technique with less blood loss. Further reports with a longer follow-up period and large number of cases are necessary to validate our findings.     

Risk factors for mortality and morbidity related to radical cystectomy

OBJECTIVES

To evaluate the risk factors for mortality and morbidity related to radical cystectomy (RC) in a medium‐sized academic centre, and to analyse the rate and trends of perioperative morbidity and mortality, as although complications related RC to are lower in modern than historic series, RC is still associated with marked risks.

PATIENTS AND METHODS

The study included 258 patients undergoing RC for bladder cancer in Turku University Hospital in 1986–2005. Basic patient characteristics and in‐hospital, early (from hospital discharge to 3 months) and combined morbidity and mortality were analysed. Risk analysis included 16 risk factors for complications. Trends were analysed by comparing the two study decades (1986–1995 vs 1996–2005).

RESULTS

The total complication rate was 34%, with minor and major complications in 26%, and 11% of patients, respectively. There were no significant changes in total morbidity, but the number of myocardial infarctions and atrial fibrillations decreased significantly (P = 0.045). Operative mortality was 2.7%, with an insignificant decrease (4.2% to 0.9%, P = 0.11) over time. Salvage RC, high American Society of Anesthesiologists (ASA) score (≥3), extensive blood loss (>3 L), a high number of transfusions (five or more), several comorbidities (two or more), age (≥65 vs <65 years), and extravesical tumours were significant risk factors for major complications. An ASA score of ≥3 and five or more transfusions were the only factors associated with mortality. A high ASA score (odds ration 3.25, 95% confidence interval 1.08–9.74) and high number of transfusions (2.74, 1.05–7.15) were independent risk factors for major complications.

CONCLUSION

Although RC is associated with acceptable morbidity, attention should be given to risk factors identified at the time of patient selection, and to meticulous haemostasis at the time of surgery. A predictable outcome comparable to that in high‐volume centres is also possible in a medium‐sized hospital.     

Changes in the upper urinary tract after radical cystectomy and urinary diversion: a comparison of antirefluxing and refluxing orthotopic bladder substitutes and the ileal conduit

PURPOSE: We evaluated and compared the effects of different types of urinary diversion on functional and radiographic changes in the upper urinary tract. MATERIALS AND METHODS: We analyzed data on 275 patients who underwent radical cystectomy and urinary diversion for bladder cancer and were observed at least 12 months. Of the patients 197 received an orthotopic bladder substitute, including antirefluxing ureteral anastomoses in 111 (group 1) and refluxing ureteral anastomoses in 86 (group 2). Ileal conduits were created in 78 patients (group 3). Serial serum Cr, radiographic changes in the upper urinary tract after diversion and the number of episodes of APN were compared by diversion method. Mean followup was 52 months (range 12 to 174 months) with no difference among the groups. RESULTS: Compared with group 3 patients in groups 1 and 2 demonstrated a significantly higher incidence of moderate to severe hydronephrosis (p = 0.001) but the incidence was similar between groups 1 and 2 (6.3%, 8.3% and 1.4% of the renal units in groups 1 to 3, respectively). Stabilized postoperative Cr did not differ among the groups. CRF, defined as Cr 3.0 mg/dl or greater, occurred in 2.7% of the patients in group 1 and in 3.5% of those in group 2 but in none in group 3. APN was noted in 3.3%, 4.4% and 0.4% of patients in groups 1 to 3, respectively (p = 0.012). CONCLUSIONS: An ileal conduit with a lower rate of diversion related hydronephrosis, CRF and morbidity associated with APN was superior to orthotopic bladder substitutes. Between the refluxing and antirefluxing types of orthotopic bladder substitutes no significant difference in functional or radiographic changes was noted.     

Critical analysis of complications after robotic‐assisted radical cystectomy with identification of preoperative and operative risk factors

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To better characterize short‐ and long‐term complications in patients after robotic‐assisted radical cystectomy (RRC) using standardized complications‐reporting systems, and to identify preoperative and operative risk factors predicting their occurrence.

PATIENTS AND METHODS

Data were collected for 79 consecutive patients with bladder cancer undergoing RRC with extracorporeal urinary diversion by one surgeon at our institution. Complications occurring ≤90 days after RRC were graded according to two standardized reporting methods (Memorial Sloan Kettering Cancer Center and Modified Clavien), and additionally stratified by organ system. Nineteen preoperative and operative variables were tested by univariate analysis for association with the occurrence of one or more postoperative complications. Variables with a significant (P < 0.05) or near‐significant (P < 0.20) association on univariate analysis were included in multivariate analysis to identify independent risk factors.

RESULTS

Patients were of relatively poor health, with 58% having an American Society of Anesthesiology class or Charlson Index score of ≥3. Advanced bladder disease was frequent (41% had pT3/pT4). After RRC, one or more complications occurred within 90 days of surgery for 39/79 (49%) patients. The vast majority of complications were low grade (79%), and mostly infectious (41%) or gastrointestinal (27%). Sixteen high‐grade complications occurred in 13/79 (16%) patients. Urinary obstruction, abscess, enteric fistula, gastrointestinal bleeding and thromboembolism constituted most of the high‐grade complications, nearly half (seven of 16) of which occurred 31–90 days after RRC. On multivariate analysis, only preoperative renal insufficiency and intraoperative intravenous (i.v.) fluids of >5000 mL were significantly associated with postoperative complications of any grade, with respective odds ratios (ORs) of 4.2 and 4.1. For high‐grade complications, significant independent risk factors included an age of ≥65 years, operative blood loss of ≥500 mL and intraoperative i.v. fluids of >5000 mL, with respective ORs of 12.7, 9.7 and 42.1.

CONCLUSION

Even among relatively sick patients with frequent advanced disease, the vast majority of complications after RRC are low grade. High‐grade complications are infrequent and similar in nature to high‐grade events after open RC, and a notable proportion may occur at >30 days after RRC underscoring the importance of longer reporting intervals. The surgeon’s ability to limit blood loss and i.v. fluids during RRC may provide effective risk reduction, particularly for high‐grade events.     

Contemporary trends of in-hospital complications and mortality for radical cystectomy

Study Type – Therapy (trend analysis) Level of Evidence 2b What's known on the subject? and What does the study add? Radical cystectomy (RC) carries significant risks of morbidity and mortality. Little is known whether in‐hospital outcomes are improving for RC. Using a contemporary population‐based cohort, the present study suggests minimal improvement in postoperative complications and mortality overall or by hospital‐volume category from 2001 to 2008. About 29% and 2% of patients undergoing RC will experience a postoperative complication or die during hospitalisation, respectively.

OBJECTIVE

• ? To characterise the contemporary trends of in‐hospital complications and mortality for radical cystectomy (RC) from a contemporary population‐based cohort, as patients undergoing RC for bladder cancer are at significant risk for complications and mortality and the degree to which in‐hospital outcomes have changed over time is unknown.

PATIENTS AND METHODS

• ? We identified 50 625 individuals who underwent RC for bladder cancer between 2001 and 2008 from the Nationwide Inpatient Sample.
• ? Multivariable regression models were used to identify hospital and patient covariates associated with in‐hospital complications and mortality and to estimate predicted probabilities of each outcome.
• ? Temporal trends of in‐hospital mortality and complications were assessed by Wilcoxon rank‐sum test.

RESULTS

• ? The proportion of patients with in‐hospital complications remained stable at 28.3% in 2001–2002 compared with 28.0% in 2007–2008 (P= 0.81 for trend).
• ? In‐hospital mortality was also unchanged from 2.4% in 2001–2002 compared with 2.3% in 2007–2008 (P= 0.87 for trend).
• ? While high‐volume hospitals were associated with lower odds of in‐hospital complications (odds ratio [OR] 0.77, P= 0.01) and mortality (OR 0.60, P= 0.02) compared with low‐volume hospitals, the predicted probabilities of in‐hospital complications or mortality were unchanged within each volume category between 2001 and 2008.

CONCLUSIONS

• ? In‐hospital complications and mortality for RC remain unchanged from 2001 to 2008.
• ? While high‐volume hospitals continue to have better outcomes, there is little evidence that postoperative mortality and morbidity are improving among low‐, medium‐ and high‐volume hospitals.
• ? Increased attention is needed to identify the modifiable aspects of postoperative care to improve in‐hospital outcomes and safety for patients undergoing RC.

     

Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series

IntroductionThis study seeks to evaluate the incidence and associated risk factors of Clostridium difficile infection (CDI) in patients undergoing radical cystectomy (RC) for bladder cancer.MethodsWe retrospectively reviewed a single institution׳s bladder cancer database including all patients who underwent RC between 2010 and 2013. CDI was diagnosed by detection of Clostridium difficile toxin B gene using polymerase chain reaction–based stool assay in patients with clinically significant diarrhea within 90 days of the index operation. A multivariable logistic regression model was used to identify demographics and perioperative factors associated with developing CDI.ResultsOf the 552 patients who underwent RC, postoperative CDI occurred in 49 patients (8.8%) with a median time to diagnosis after RC of 7 days (interquartile range: 5–19). Of the 122 readmissions for postoperative complications, 10% (n = 12) were related to CDI; 2 patients died of sepsis directly related to severe CDI. On multivariate logistic regression, the use of chronic antacid therapy (odds ratio = 1.9, 95% CI: 1.02–3.68, P = 0.04) and antibiotic exposure greater than 7 days (odds ratio = 2.2, 95% CI: 1.11–4.44, P = 0.02) were independently associated with developing CDI. The use of preoperative antibiotics for positive findings on urine culture within 30 days before surgery was not statistically significantly associated with development of CDI (P = 0.06).ConclusionsThe development of CDI occurs in 8.8% of patients undergoing RC. Our study demonstrates that use of chronic antacid therapy and long duration of antimicrobial exposure are associated with development of CDI. Efforts focusing on minimizing antibiotic exposure in patients undergoing RC are needed, and perioperative antimicrobial prophylaxis guidelines should be followed.     

Long-term results of orthotopic neobladder reconstruction after radical cystectomy

OBJECTIVE: To assess, in a retrospective study, the long-term results of neobladder reconstruction after radical cystectomy, as this is the standard of care for muscle-invasive bladder cancer. PATIENTS AND METHODS: Data were retrieved for all patients with muscle-invasive transitional cell carcinoma of the bladder treated by radical cystectomy and orthotopic neobladder substitution between 1988 and 1998. All perioperative and long-term complications were recorded. The voiding pattern, frequency of micturition and continence were assessed, and a complete urodynamic profile recorded. RESULTS: In all, 102 patients underwent radical cystectomy with orthotopic neobladder reconstruction in the study period; their mean (range) follow-up was 73 (36-144) months. Neobladder substitution was with an ileocaecal segment in 35 patients, sigmoid colon in 34 and ileum in 33. Early complications occurred in 32 patients (31%) although open surgical intervention was required in only nine (9%). The death rate after surgery was 3.9%. Late complications occurred in 31 patients (30%) and were primarily caused by uretero-enteric and vesico-urethral strictures (9% each). Most patients had daytime (89%) and night-time (78%) continence. The mean maximum pouch capacity (mL) and pouch pressure at capacity (cmH2O) were 562.5 and 23 (ileocaecal), 542 and 17.8 (sigmoid) and 504 and 19.1 (ileal), respectively; the mean postvoid residual was 29, 44 and 23 mL, respectively. Nine patients with ileocaecal neobladders, and 20 and seven with sigmoid and ileal neobladders, required clean intermittent catheterization. Twenty-four patients had recurrence of disease, of whom 20 died. CONCLUSIONS: Orthotopic neobladder reconstruction requires complex surgery but has an acceptable early and late complication rate in properly selected patients. It provides satisfactory continence without compromising cure rates.     

膀胱肿瘤膀胱切除及尿流改道13年总结(附56例报告)

目的 评价膀胱切除治疗膀胱癌的疗效及四种不同方式尿流改道的远期效果。方法 回顾分析1992年至2004年膀胱癌行膀胱切除及尿流改道术56例临床资料。结果 随访1—10年，5年生存率58．8％，生存超过10年者1例，大部分患者对正位可控肠代膀胱控尿满意。结论 膀胱切除并不能提高5年生存率，对部分浸润性膀胱癌可选择地采用保留膀胱手术；正位可控回肠膀胱术是最理想的尿流改道方式。     

Hand‐assisted laparoscopic radical cystectomy and extracorporeal urinary diversion: Experience with 31 cases

Objectives: To report our techniques and experience with hand‐assisted laparoscopic radical cystectomy and extracorporeal urinary diversion for bladder cancer. Methods: Between May 2004 and November 2007, 31 patients (mean age 61.3 years, range 40–79) underwent hand‐assisted laparoscopic radical cystectomy with extracorporeal urinary diversion for bladder cancer. Five patients had previously undergone abdominal surgeries. Data were collected with respect to patient demographics, perioperative outcomes and short‐term oncological follow up. Results: Twenty‐four patients underwent an ileal conduit and seven patients underwent an orthotopic neobladder. Mean operative time was 365.7 min (range 245 to 530). Estimated blood loss was 250.9 cc (range 100 to 500), with a transfusion rate of 9.7%. Oral liquids were resumed at 4.3 days and the mean hospital stay was 19.7 days. There were no intraoperative complications. Postoperative early complications (within 30 days of surgery) occurred in six patients (19.4%). Two wound infections, one urinary leak, one wound dehiscence, one bowel obstruction and one alimentary tract hemorrhage were all treated conservatively. Late complications occurred in three patients (two parastomal hernias and one ureteroenteric stricture). With a mean follow up of 18 months, 27 patients had no evidence of disease. One patient died because of cancer and one died for unrelated causes. One was alive with local recurrences and one with lung metastasis. Conclusions: Hand‐assisted laparoscopic radical cystectomy is a safe, reproducible and minimally invasive option for bladder cancer patients.     

Laparoscopic radical cystectomy with extracorporeal urinary diversion: Preliminary experience

AIM: We present our experience with the fi rst eight patients who underwent laparoscopic radical cystectomy with bilateral pelvic lymphadenectomy and extracorporeal urinary diversion. Patients, operative data and the surgical techniques are presented. METHODS: Between June 2003 and April 2004, seven men and one woman with organ-con fi ned muscle-invasive transitional cell carcinoma of the bladder underwent laparoscopic radical cystectomy with urinary diversion. The age range was 41-73 years. Laparoscopic radical cystectomy and bilateral pelvic lymphadenectomy were performed using fi ve ports by a transperitoneal approach. An ileal conduit diversion or ileal W-neobladder was constructed through the site of specimen retrieval. RESULTS: We performed eight radical cystectomies with ileal conduits (six cases) or orthotopic ileal W-neobladders (two cases). Conversion to open surgery was necessary in one due to technical dif fi culty in urethroneobladder anastomosis. Mean operating time was 560 min (range 455-680). Mean estimated blood loss was 675 mL (range 400-1050). Two of the eight patients needed blood transfusion (800 mL each). Mean days to oral intake and ambulation was 4.4 (range 2-6) and 4.1 (range 3-5), respectively. Mean hospital stay was 12.8 days (range 7-28). Mean follow up was 6.1 months (range 4-14). Histopathological examination of the specimens revealed stage T2N0M0 in fi ve cases, T3aN0M0 in one, T3aN1M0 in one and T3bN1M0 in one. No metastases have been detected and all are alive and free of disease. CONCLUSION: Laparoscopic radical cystectomy is feasible, although dif fi cult and technically demanding, and our results are promising. With more experience and improvement of the surgical technique, laparoscopic radical cystectomy with urinary diversion may become an alternative surgical method for treating the selected patients with localized muscle invasive bladder cancer.     

Upper urinary tract recurrence after radical cystectomy for bladder cancer: incidence and risk factors

Objectives: To examine the incidence of and the risk factors for upper urinary tract recurrence in patients undergoing a radical cystectomy for bladder cancer, and to examine the clinical course of patients harboring upper urinary tract recurrence. Methods: This retrospective study included 362 patients who underwent radical cystectomy for bladder cancer. Patients with a history of upper urinary tract recurrence and concomitant upper urinary tract recurrence at cystectomy were excluded. Results: After a median follow up of 48 months (range 0–214) after radical cystectomy, 11 patients (3.0%) developed upper urinary tract recurrence. The median time to upper urinary tract recurrence was 48.4 months (range 11.6–78.6). The overall probability of upper urinary tract recurrence was 3.3% at 5 years. The median overall survival period after upper urinary tract recurrence was 23.5 months (range 4.3–53.9), with a better overall survival for patients who received a radical operation than for those who did not (38.6 months vs 11.9 months, respectively; P = 0.03). At multivariable analysis, the presence of carcinoma in situ (P < 0.01) and invasion of the urethra (P = 0.02) were independent risk factors for upper urinary tract recurrence. The 5‐year upper urinary tract recurrence was significantly higher for patients positive for either of these risk factors than for those without risk factors (12.0% vs 0.9%, respectively; P < 0.001). Conclusions: This study shows that the presence of carcinoma in situ and cancer invading the urethra are risk factors for upper urinary tract recurrence. Close follow up is needed for early detection of upper urinary tract recurrence in patients at higher risk.     

Causes of increased hospital stay after radical cystectomy in a clinical pathway setting.

PURPOSE: Our institution targets postoperative days 6 to 8 for discharge home after radical cystectomy. We examined this population to determine the causes of increased hospital stay and risk factors that may predict prolonged hospitalization. MATERIALS AND METHODS: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from October 1995 to July 2000. The variables examined included age, gender, race, American Society of Anesthesiologists score, urinary diversion type, smoking history, estimated blood loss, transfusion requirement, operative time, hospital stay, perioperative minor and major complications, and the mortality rate. RESULTS: Of the 304 patients 144 (47.4%) underwent ileal conduit diversion and 145 (47.7%) underwent orthotopic bladder substitution. Median hospital stay was 7 days (range 4 to 48). Of 302 patients 225 (74%) were discharged home by postoperative day 8, while 52 of the remaining 77 (67.5%) with increased hospital stay were discharged home by day 12. Postoperative ileus was the most common cause of increased hospitalization (53 of 77 cases or 68.8%). Major complications developed in 15 patients (4.9%), of whom 66% required a hospital stay of greater than 12 days. There was a single perioperative death (0.3%). No preoperative variables other than race predicted increased hospitalization. Of the clinical variables increased estimated blood loss, transfusion and minor or major complications correlated with an increased stay (p <0.05). However, on multivariate analysis only complications were associated with prolonged hospitalization. CONCLUSIONS: Our cystectomy clinical care pathway targets a hospital discharge date that is safely achieved in the majority of patients. Postoperative ileus is the most common cause of prolonged hospitalization. Age, gender, American Society of Anesthesiologists score, urinary diversion type and pathological stage did not correlate with increased hospital stay.     

Identification of risk factors and clinical model construction of abdominal distension after radical cystectomy

BackgroundThe occurrence of abdominal distention after radical cystectomy (RC) is common. We sought to determine risk factors of abdominal distention after RC, and to establish a simple and reliable nomogram for clinical risk assessment.MethodsClinical information on 139 patients who underwent RC from January 2020 to August 2021 was collected. The chi-square test, hypergeometric test, and univariate/multivariate logistic regression were utilized to explore the relationship between variables and abdominal distention after RC. A nomogram was then used to predict the probability of abdominal distension for the patients who underwent RC. Calibration and receiver operating characteristic (ROC) curves were used to evaluate the accuracy of the model.ResultsWe found that 35 patients (25%) occurred in abdominal distention after RC. Among the patients, 7 of them developed intestinal obstruction. Postoperative water fasting time and abdominal surgery history were independent risk factors for abdominal distension after surgery. Finally, we constructed a risk model to predict the probability of abdominal distension after surgery. This model showed good fitting and calibration and excellent diagnostic performance with an area under the curve (AUC) of 0.804.ConclusionsPostoperative water fasting time and abdominal surgery history were independent risk factors for abdominal distension after surgery. There was no significant difference in the incidence of postoperative abdominal distention between robot-assisted cystectomy and laparoscopic cystectomy.     

Prospective implementation of a nonopioid protocol for patients undergoing robot-assisted radical cystectomy with extracorporeal urinary diversion

Objectives

To evaluate the feasibility and outcomes of a nonopioid (NOP) perioperative pain management protocol for patients undergoing robot-assisted radical cystectomy (RARC).