Urethral recurrence following radical cystectomy

We reviewed the clinical courses of 86 men after radical cystoprostatectomy for transitional cell carcinoma of the bladder to determine who were at highest risk for urethral recurrence. We assessed patients for prostatic involvement as well as tumor extent in the bladder and distal ureters. Of the 30 patients with tumor in the prostate 11 (37%) suffered urethral recurrences. Of the 56 patients with all other types of tumor involvement patterns exclusive of disease in the prostate only 2 (4%) had recurrence. We recommend rigorous screening for transitional cell carcinoma of the prostate before cystectomy. Prophylactic urethrectomy is indicated for patients with prostatic involvement, while those without such involvement may be considered at low risk for urethral recurrence.     

Adjuvant chemotherapy following radical cystectomy

Summary The optimal management of invasive bladder cancer remains controversial. Combination chemotherapy regimens have been increasingly advocated in association with definitive local therapy in an attempt at eradicating micrometastases and reducing the risk of recurrence. Chemotherapy used after radical cystectomy is referred to as adjuvant therapy. The term adjuvant is occasionally used for chemotherapy following an aggressive transurethral resection (TUR). Decisions concerning individual patients must be made after careful examination of the histologic specimen and cognizance of the known relapse rates per pathologic stage. No randomized trial has reported results on patients with pT2 and pT3a tumors. Studies have not clearly proven any advantage for adjuvant therapy based on muscle infiltration alone (pT2, pT3a). For patients with minimal extravesical extension (pT3b), additional therapy may be useful. For patients with nodal metastases (pN+) and direct extension into the adjacent viscera (pT4), the data suggest a trend toward improved survival. These patients may benefit from adjuvant chemotherapy. The difficulties of clinical trials following cystectomy, conducted in an elderly patient population, done over a long period, with changing standards of effective chemotherapeutic regimens are described. Adjuvant therapy following cystectomy or an aggressive TUR remains investigational and its benefit has not yet been proven. Patients should be entered into well-designed and carefully conducted clinical trials to evaluate the role of chemotherapy in invasive bladder cancer.     

Mini-laparotomy approach to radical cystectomy

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? In the recent decade minimally invasive endoscopically approaches have been suggested as a way to reduce morbidity following radical cystectomy. The present study suggests that the same advantages found, when comparing endoscopical cystectomy to classical open cystectomy, can be achieved by reducing the wound length of the open approach.

OBJECTIVE

• ? To investigate the feasibility of performing radical cystectomy (RC) through a mini‐laparotomy and to evaluate the effect of a smaller incision on wound problems, immediate postoperative pain, bowel function and length of hospital stay (LOS).

PATIENTS AND METHODS

• ? Two consecutive cohorts of patients, one with 75 patients undergoing open RC (ORC) with lymph node dissection up to the aortic bifurcation through a conventional long midline incision and one with 75 patients undergoing RC through a mini‐laparotomy (MinilapRC) of intentionally <8–10 cm.
• ? Patient characteristics, operative duration, estimated blood loss (EBL), incidence and severity of wound problems, return of bowel function, amount of analgesics needed and LOS were analysed according to the intention‐to‐treat principle.

RESULTS

• ? The demographic characteristics of the two groups were similar.
• ? An incision of ≤10 cm was made in 65% of the patients in the MinilapRC group with a median (range) length of incision of 9 (6.5–19) cm. In the final third of patients operated on in the MinilapRC group, 76% had an incision of ≤8 cm.
• ? The operative duration and EBL were not significantly different between the groups.
• ? Wound problems were significantly fewer, bowel function was restored more quickly and the need of postoperative analgesics was less in the MinilapRC group.
• ? In the MinilapRC group LOS was reduced by a median of 3 days.

CONCLUSION

• ? MinilapRC is feasible in most patients without increasing operative duration. The reduced incision length reduces postoperative morbidity.

     

Retroperitoneal hernia following radical cystectomy: case report

Retroperitoneal hernias are rare. When they occur, they most often occur in naturally occurring fossas, such as with paraduodenal hernias. Due to the anatomy of the ureterovesicular system, patients with prior urological operations may be more likely to develop retroperitoneal hernias. We report the case of a 76-year-old male who had undergone a radical cystectomy with ileal loop conduit for bladder cancer, who presented with recurrent episodes of nausea and vomiting. Upon exploratory laparotomy, he was found to have a retroperitoneal hernia. The patient underwent resection of the strangulated loop of small bowel, and recovered without complications. In our patient, ureteral dissection from his prior procedure had created a defect in the peritoneum posterior to the sigmoid mesocolon, which allowed for herniation and subsequent strangulation of a portion of small bowel. Retroperitoneal hernias may represent an under-diagnosed etiology of intestinal obstruction in post-operative urological patients. Knowledge of anatomy is crucial in patients with previous abdominal operations, and prior operative notes should be reviewed, including non general surgical operations such as urological and gynecological procedures. The surgeon must remain vigilant in such cases of small bowel obstruction, as delayed intervention may lead to bowel compromise.     

Gender-dependent cancer-specific survival following radical cystectomy

Objective

To assess the impact of detailed clinical and histopathological criteria on gender-dependent cancer-specific survival (CSS) in a large consecutive series of patients following radical cystectomy (RCE) for muscle-invasive bladder cancer (MIBC).

Patients and methods

Between 1992 and 2007, 388 men and 133 women (25.5%) underwent RCE for MIBC. A prospectively maintained database was analysed retrospectively. Uni- and multivariable Cox-regression analyses calculated the impact of detailed clinical and histopathological criteria on CSS. Median follow-up was 59?months (2–162).

Results

Among clinical and histopathological parameters, only type of urinary diversion differed between men and women. In univariable analysis, CSS did not differ between genders. In multivariable Cox-regression analysis, advanced pT-stage (HR?=?2.12; P?P?P?P?=?0.048) were related to reduced CSS. In separate multivariable Cox-models for time period of surgery between 1992 an 1999 (HR?=?1.52; P?=?0.050), age ≤55?years (HR?=?3.00; P?=?0.022), presence of LVI (HR?=?1.45; P?=?0.031) and female gender were associated with independent reduced CSS.

Conclusion

Established clinical and histopathological parameters do not differ significantly between both genders in the present series. Reduced CSS in women is present in historic cohorts possibly suggesting improvement in management over the last years. In particular, female gender has a significant negative impact on CSS in patients younger of age and with positive LVI status possibly suggesting different clinical phenotypes.     

Oncologic outcomes between open and robotic-assisted radical cystectomy: a propensity score matched analysis

Purpose

To compare oncologic outcomes between open radical cystectomy (ORC) and robotic-assisted radical cystectomy (RARC) using propensity score (PS) matching of preoperative variables.

Methods

A group of 51 consecutive patients who underwent RARC between 2009 and 2012 were matched by propensity scoring with an equal number of patients who underwent ORC. Patient demographics, clinical staging, pathologic staging, pathologic grading, histology, positive margin status, lymph node yield, duration of hospital stay, and overall survival were examined.

Results

PS-matched ORC and RARC cohorts demonstrated no significant differences with respect to preoperative variables, pathologic stage, grade, histology, metastasis at preoperative staging, and postoperative positive margin status. There were statistically significant differences in nodal status (66.7 % N0 for ORC vs. 80.4 % N0 for RARC, p = 0.039) and median lymph node yield (6 for ORC vs. 18 for RARC, p < 0.0001). No positive soft tissue margins were observed in the RARC group compared to 5.9 % in the ORC group (p = 0.332). There were no significant differences in mean duration of hospital stay or mean overall survival between ORC and RARC.

Conclusion

ORC and RARC represent effective surgical approaches for the treatment of bladder cancer. Histopathologic outcomes for RARC compare favorably to ORC with respect to soft tissue margin rates and lymph node yield. These data suggest that RARC is an acceptable surgical approach for treatment of bladder cancer that can achieve outcomes that are equal or superior to those of ORC.     

Adherence to surveillance guidelines after radical cystectomy: A population-based analysis

ObjectivesSurveillance after radical cystectomy is recommended to detect tumor recurrence and treatment complications. We evaluated adherence to National Comprehensive Cancer Network (NCCN) guidelines using a large population-based database.Methods and materialsThe Surveillance, Epidemiology, and End Results–Medicare database was used to identify patients aged ≥66 years diagnosed with nonmetastatic bladder cancer who had undergone radical cystectomy between 2000 and 2007. Medicare claims information identified recommended surveillance tests for 2 years after cystectomy as outlined in the NCCN guidelines. Adherence was defined as receipt of urine cytology and imaging of the chest, abdomen, and pelvis in each year. We evaluated the effect of patient and provider characteristics on adherence, controlling for demographic and disease characteristics.ResultsOf 3,757 patients who had undergone radical cystectomy, 2,990 (80%) were alive after 2 years. Adherence to all recommended investigations was 17% for the first and the second years following surgery. Among patients surviving 2 years, only 9% had complete surveillance in both years. In either year, adherence was less likely in patients with advanced pathologic stage (III/IV) (adjusted odds ratio [AOR] = 0.74, 95% CI: 0.60–0.91) and unmarried patients (AOR = 0.82, 95% CI: 0.68–0.99). Adherence was more likely in patients treated by high-volume surgeons (AOR = 2.00, 95% CI: 1.70–2.36) and those who saw a medical oncologist (AOR = 1.52, 95% CI: 1.27–1.82). We also observed significant geographic variability in adherence.ConclusionPatterns of surveillance after radical cystectomy deviate considerably from NCCN recommendations. Despite increased utilization of radiographic imaging investigations, the omission of urine cytology significantly contributed to the low rate of overall adherence to surveillance guidelines. Uniform adherence to surveillance guidelines was observed in patients treated by high-volume surgeons. This suggests an important opportunity for quality improvement in bladder cancer care.     

Laparoscopic radical cystectomy: an Italian survey

Background Radical cystectomy with urinary diversion is the current gold standard procedure for muscle-invasive bladder cancer. However, laparoscopic radical cystectomy (LRC) has evolved rapidly worldwide during the past decade, despite its complexity due to both the demolitive step with management of a highly aggressive cancer and the reconstructive step. The authors performed a survey to assess the Italian experience with LRC and urinary diversion in an effort to point out the volume of the procedure in their country, providing some surgical details. Methods A total of 10 Italian urologic departments with experts in laparoscopic urologic surgery were contacted and asked to participate in a two-page survey concerning indications for cystectomy, laparoscopic technique, intra- and postoperative complications, and follow-up evaluation of the procedure when available. Results Five sites elected to participate, and a total of 83 LRCs were collected. All centers used five trocar ports. The mean operative time was 8 h and 40 min, and the estimated blood loss was 376 ml. In two cases, the procedure was converted to open surgery. Postoperative complications consisted of one urinary leakage, one fistula, and one atrium rupture. A retrieval sac was used in all cases. Urinary diversions consisted of 43 ileal conduits, 26 orthotopic diversions, and 14 other techniques. The mean follow-up period was 9 months (range, 1–36 months). No tumor seeding was recorded. Conclusions The LRC procedure is feasible although technically demanding. The morbidity of this procedure is evident, but may be reduced with further experience. Bowel management and reconstruction remain the most challenging part of the procedure.     

Bladder replacement by ileocystoplasty following radical cystectomy

Summary Between 1958 and 1985, over 402 patients underwent a radical cystoprostatectomy for bladder cancer. In 150, the bladder was replaced by a U-shape segment of ileum anastomosed midway to the urethral stump; the ureters were anastomosed to each end of the loop via an antireflux technique. Continence was achieved by an external sphincter mechanism and voiding accomplished by voluntary sphincter relaxation and abdominal straining. In the past 10 years, daytime continence has been achieved in 95% of cases. Nighttime continence was obtained in 50% by means of rehabilitation. Antireflux implantation, checked by retrograde cystogram, was proven effective in 85% of cases. The residual volume is generally moderate and 70% of patients maintain sterile urine, which is an essential factor in protecting renal function. This procedure can be performed only in patients at low risk of urethral recurrence. They must be able to undergo major surgery and be well informed and motivated. The surgical team must adhere to the rules of this long and difficult procedure.     

Ureter and bladder replacement following radical cystectomy

During the course of Hautmann-type bladder replacement, left sided ureter damage necessitated ureter replacement as well, modifying the removal of the ileum-bladder. The proximal 20 cm length of the 70 cm long isolated ileum portion was not detubularized; instead it was slipped through the mesosigma and mesocolon to the left side of the colon and the left ureter stub was anastomized without tautness to the ileum according to Le Duc. The implantation of the right ureter was accomplished according to Hautmann. For similar cases authors recomment this procedure, since neither stricture, nor reflux could be detected at later examinations.     

Oncologic outcomes following radical prostatectomy with intraoperative cell salvage

Purpose

To evaluate oncologic outcomes following the use of intraoperative cell salvage (IOCS) as a blood loss management strategy during open radical prostatectomy (RP).

Methods

We retrospectively reviewed all open retropubic RP cases performed by a single surgeon. Patients were identified who received IOCS blood and evaluated for an increased risk of biochemical recurrence (BCR) and overall mortality.

Results

The study cohort consisted of 1,862 men, 395 (21.2%) of whom received IOCS blood. At a median follow-up of 47.0?months, men who received IOCS blood were not at an increased risk of BCR (P?=?0.323) or all-cause mortality (P?=?0.892). IOCS use did not confer an increased risk of BCR within any D??Amico preoperative risk category (low risk, P?=?0.592; intermediate risk, P?=?0.107; and high risk, P?=?0.697).

Conclusions

IOCS is safe for the management of blood loss during RP. At long-term follow-up, IOCS use was not associated with an increased risk of BCR or death. While it remains preferable to avoid any form of blood transfusion, we advocate for the use of IOCS in place of allogeneic blood. These conclusions are drawn from our study of the largest and longest followed cohort patients who received IOCS blood during RP.     

Age and bupivacaine plasma concentrations following radical cystectomy

Purpose

Continuous epidural analgesia with bupivacaine for postoperative analgesia can increase its plasma concentrations. Whether this effect can be aggravated with increasing age is unknown. Therefore, bupivacaine concentrations were prospectively monitored in patients undergoing radical cystectomies.

Methods

We analyzed plasma concentrations of bupivacaine in 38 consecutive patients scheduled for radical cystectomy. All patients received general and epidural anesthesia (10 ml bupivacaine 0.5 % followed by bupivacaine 0.375 % every 90 min) and postoperative continuous epidural analgesia (bupivacaine 0.25 % with sufentanil 0.5 μg/ml). For 4 subsequent days, bupivacaine plasma concentrations were measured and the correlation of bupivacaine plasma concentrations with the patient’s age were analyzed. Data (mean ± SD) were analyzed by 2-way ANOVA with post hoc analysis or regression analysis.

Results

The median age of the patients was 70 years (range 41–86). Postoperatively, bupivacaine plasma concentrations increased significantly. No correlation of plasma concentrations and age could be found. Maximal bupivacaine concentrations of the younger patients were not different from the older patients. No neurological or cardiovascular symptoms of bupivacaine intoxication were found.

Conclusion

In conclusion, continuous epidural administration of bupivacaine leads to increasing plasma concentrations. No age dependent differences in bupivacaine plasma concentrations could be found. Therefore, in our patients with intact liver function, we did not find a reason for an age-related restriction in the use of continuous epidural analgesia.     

Early and late treatment-related morbidity following radical cystectomy

OBJECTIVE: To evaluate treatment-related morbidity following cystectomy in a cohort of consecutive bladder cancer patients. The impact of age, comorbid condition, previous pelvic radiotherapy and type of urinary diversion was analysed. MATERIAL AND METHODS: Between 1992 and 1998 the treatment-related early (<30 days after cystectomy) and late morbidity was recorded in 268 consecutive bladder cancer patients (median age 65 years) undergoing cystectomy and the following types of urinary diversion: ileal conduit, n = 195; orthotopic neobladder, n = 36; continent reservoir, n = 33; and ureterocutaneous diversion, n = 4. Twenty-four patients had received previous pelvic radiotherapy and 79 had pre-existing morbidity. The median follow-up period was 5.4 years. RESULTS: The postoperative mortality rate was 2%. Age >70 years and pre-existing morbidity (especially cardiovascular disease) significantly increased the mortality rate. No relationship was found between early complication (57%) and re-exploration rates (17%) and either age, previous radiotherapy, pre-existing morbidity or type of urinary diversion. Patients undergoing orthotopic neobladder or continent reservoir had a significantly increased risk of calculus formation as well as cystectomy-related surgical procedures compared to patients undergoing ileal conduit. Age had a significant impact on vitamin B12 deficiency and renal deterioration, whereas previous pelvic irradiation significantly increased the probability of ureteroenteric stricture and lost renal function. Age and urinary diversion had no impact on hernia, ureteroenteric stricture or pyelonephritis. CONCLUSION: The risk of treatment-related morbidity was high and careful patient selection before cystectomy seems important. The lack of standard criteria regarding how to report morbidity makes comparison with other studies difficult.     

Comprehensive characterization of perioperative reoperation following radical cystectomy

Introduction

To examine the nature, timing, and risk factors underlying return to the operating room (ROR) following radical cystectomy (RC). ROR has been proposed as a surgical quality metric based on data from the general surgery literature, but ROR has not been comprehensively characterized following RC.