Prospective comparative study of single dose versus 3-day administration of antimicrobial prophylaxis in minimum incision endoscopic radical prostatectomy

Objective:   From the critical stand point against the overuse of antimicrobial agents, appropriate reduction of antimicrobial prophylaxis (AMP) should be considered. We have prospectively reduced AMP and evaluated the occurrence of surgical site infection (SSI) following radical retropubic prostatectomy (RRP) by minimum incision endoscopic surgery (MIES).
Methods:   A total of 101 consecutive patients who underwent MIES-RRP for prostate carcinoma were classified into two groups according to AMP dose. The 3-day group of 52 patients received tazobactam sodium/piperacillin sodium (TAZ/PIPC) 2.5 g intravenously before the operation and continued twice daily until postoperative day 2, and the single dose group of 49 patients received TAZ/PIPC 2.5 g intravenously only once before the operation. Additional antimicrobial agents were given only when SSI occurred. The occurrence of SSI and remote infection (RI) were analyzed.
Results:   There was no significant difference in the rate of SSI occurrence between the 3-day group (3.8%) and single dose group (6.1%) ( P  = 0.6). RI did not increase in the single dose group.
Conclusion:   Antimicrobial prophylaxis dose was successfully reduced without increasing SSI or RI. A single dose of AMP is feasible to prevent SSI and RI and would be a standard regimen in MIES-RRP. Active surveillance of postoperative infection is mandatory to promptly administer antimicrobial treatment as the need arises.     

Antibiotic prophylaxis in radical prostatectomy: 1-day versus 4-day treatments

OBJECTIVE: The standard protocol of antibiotic prophylaxis in radical prostatectomy remains to be established. We retrospectively compared the occurrence of perioperative infections following radical prostatectomy between two different protocols of antibiotic prophylaxis. METHODS: This study included 106 cases of radical retropubic prostatectomy managed on the clinical pathways. Two different protocols of antibiotic prophylaxis were used in otherwise identical pathways. Between January and December 2004, 50 patients received a second generation cephem, cefotiam, for 4 days, beginning 30 min before surgery (4-day group), whilst between December 2004 and July 2005, only two doses of cefotiam were given on the day of operation in 56 patients (1-day group). The incidence of surgical site infection (SSI) and remote infection (RI) was retrospectively investigated. RESULTS: Superficial incisional SSI occurred in one (1.8%) patient in the 1-day group, whereas no patient in the 4-day group developed SSI. No RI was observed in either the 1-day or 4-day group. Intravenous antibiotics were administered besides the pathway in a patient in the 1-day group because unexplained fever more than 38 degrees C continued postoperative day (POD) 2 through POD 4 without signs of SSI or RI. Excluding this case, postoperative more than 38 degrees C was rare and transient after POD 2. CONCLUSION: The incidence of SSI and RI was low and not significantly different between the 1-day and 4-day groups. Therefore, the 1-day protocol of prophylactic antibiotic treatment seems adequate for preventing perioperative infections in radical prostatectomy.     

Antimicrobial prophylaxis in radical prostatectomy : single dose versus 1-day treatment

An adequate protocol for antimicrobial prophylaxis (AMP) in radical prostatectomy (RP) has not been established. We retrospectively compared the occurrence of perioperative infection following RP between two different AMP protocols. This study included 340 cases with prostate cancer who underwent RP at our institution between January 2005 and December 2008. The 1-day group consisting of 93 cases received a second generation cephem, cefotiam, intravenously during and after the operation on the operative day. The single dose group consisting of 247 cases received cefotiam during the operation only. The incidence of surgical site infection (SSI) and remote infection (RI) was retrospectively investigated. There was no significant difference in the rate of SSI and RI occurrence between the 1-day group (2.2, 0%) and single dose group (3.6, 0.4%) (p = 0.52). The single dose protocol of AMP seems sufficient for prevention of perioperative infection in RP.     

A novel prevention bundle to reduce incisional infections after radical cystectomy

PurposeOur institution implemented a novel intervention bundle to reduce incisional surgical site infections (SSIs) for patients undergoing radical cystectomy. The primary objective of this study was to evaluate the efficacy of the bundle in reducing incisional SSIs post-cystectomy.Material and methodsA before-after cohort study was performed on all patients who underwent radical cystectomy by urologic oncologists at The Ottawa Hospital from January 2016 to March 2019. Thirty-day postoperative incisional SSIs were identified from the medical record and were compared to institutionally collected National Surgical Quality Improvement Program data. The SSI reduction strategy was implemented as of March 1st, 2018. Adjusted associations between the SSI intervention with the risk of incisional SSI were determined. Cystectomy incisional SSI rates were compared to all other National Surgical Quality Improvement Program-collected surgeries at The Ottawa Hospital during the same time period.ResultsOne hundred and thirty-two patients were included; 41 following implementation of the SSI reduction bundle. Mean age was 69 years, 104 (79%) were male, and 59 (45%) received neobladders. The risk of incisional SSI decreased from 16.5% preintervention to 2.4% post intervention (risk ratio 0.17; P = 0.004). Intraoperative transfusion and diabetes were independently associated with an increased risk of incisional SSI (P < 0.05). The SSI rate for all other surgical procedures at our institution remained stable during the same time period.ConclusionsThe risk of SSI after radical cystectomy is high. Use of an SSI reduction bundle was associated with a large reduction in incisional SSIs. Further evaluation of this intervention in other centers is warranted     

Clinical study of surgical site infection following portless endoscopic urological surgery (PLES)

We investigated the clinical risk factors and bacteriological examination for surgical site infection (SSI) in 144 portless endoscopic surgeries consisting of 66 clean and 78 clean-contaminated surgeries in urological diseases from April 2000 to December 2001. There were no cases of SSI in the clean surgeries. SSI occurred in 5 cases (3.5%) of clean-contaminated surgeries including total cystectomy and ileal conduit in 4 cases and total prostatectomy in 1 case. Multivariate statistical studies revealed that usage of ileum during operation and preoperative hypo-albuminemia were significant risk factors for SSI. Gram-negative rods and anaerobic bacteria were isolated from the operative wound in the total cystectomy and ileal conduit, suggesting that SSI in the operation with usage of the ileum was partially derived from contamination with endogenous bacteria, while, normal flora of the skin in the wound did not cause any post-operative SSI.     

Antimicrobial prophylaxis for spinal surgery

Background  The concept of antimicrobial prophylaxis (AMP) did not exist in Japan until recently. Therefore, postoperative administration of antimicrobial drugs has long been practiced under the pretext of prophylaxis against surgical site infection (SSI). In recent years, however, the concept of AMP and prophylactic countermeasures against SSI, based on evidence of the effectiveness of AMP, has gradually spread in Japan. From 2000 onward, we have undertaken prophylactic countermeasures against SSI in patients undergoing spinal surgery referring to the Guideline for Prevention of Surgical Site Infection published by the Centers for Disease Control and Prevention in 1999. The purpose of this study was to investigate the type of AMP that would be appropriate for spinal surgery and the manner in which it should be used. Methods  The subjects were 1415 patients who underwent spinal surgery at our department from January 1990 to March 2008. The patients were classified into four groups according to the method of AMP administration: group 1, AMP was employed for 7 days, only postoperatively; group 2, initial AMP dosing was administered at the time of anesthesia induction, followed by administration of AMP for 5 days, including the day of the operation; group 3, initial AMP dosing was administered at the time of anesthesia induction, and AMP was administered for 3 days, including the day of the operation; group 4, the initial dosing was administered at the time of anesthesia induction, and AMP was administered for 2 days, including the day of the operation. The frequency of SSI was assessed in the four groups. Results  The frequencies of SSI in groups 1—4 were 2.6% (14/539), 0.9% (5/536), 0% (0/257), and 0% (0/83), respectively. Thus, the frequency of SSI decreased as the duration of the AMP administration period decreased. Conclusions  As a result of thorough implementation of preventive measures against perioperative occurrence of infections, which included additional preoperative and intraoperative administration of AMP, the incidence of SSI could be decreased despite shortening the duration of AMP administration to 2 days.     

Discarding antimicrobial prophylaxis for transurethral resection of bladder tumor: A feasibility study

Objectives:   To evaluate the feasibility of discarding antimicrobial prophylaxis (AMP) for transurethral resection of bladder tumor (TURBT).
Methods:   One-hundred and sixty-two patients undergoing TURBT, with no risk factors for infectious complications were included in this prospective study between April 2006 and April 2008. Forty-four patients received single oral dose of 200 mg levofloxacin for AMP (LVFX group), and the remaining 118 received no AMP (no AMP group). Rates of postoperative infectious complications were compared between the two groups.
Results:   There was no significant difference between the two groups in terms of baseline characteristics, including age, sex, history of TURBT, number of tumors, duration of operation and days of catheterization. Symptomatic urinary tract infections (UTIs) occurred in four patients (3.4%) in the no AMP group and one patient (2.3%) in the LVFX group ( P  = 0.61). All patients having UTIs were men, and were successfully treated by immediate administration of antibiotics. No patients developed extra-urinary tract infections.
Conclusions:   Based on our findings, AMP for TURBT in patients with no risk factors for infectious complications is not necessary. The use of antibiotics might be deferred until postoperative infections develop.     

A case of late recurrence of urothelial carcinoma in an ileal conduit after radical cystectomy and ileal conduit diversion for bladder cancer

Recurrence of urothelial cancer in an ileal conduit after radical cystectomy is rare. A 79-year-old man suffered bladder cancer (UC cTisN0M0 G2＞3) and underwent total cystectomy with ileal conduit. He had recurrence of the right renal pelvis carcinoma 6 years after the total cystectomy, and was treated by right radical nephroureterectomy (pT3 G2＝3). The patient had another episode of recurrence in the ileal conduit 13 years after the initial operation. The entire ileal conduit (UC, G3, ew (-)) was resected and left cutaneous ureterostomy was performed. This case suggests that long-term follow-up is necessary after radical cystectomy and ileal conduit for urinary diversion.     

腹腔镜保留前列腺尖部包膜根治性膀胱切除W形回肠新膀胱术尿控和勃起功能研究

目的探讨腹腔镜下保留前列腺尖部包膜根治性膀胱切除W形原位回肠新膀胱术的临床疗效。 方法回顾性分析2019年1月至2021年12月行腹腔镜根治性膀胱切除W形回肠原位新膀胱术的43例男性膀胱癌患者的临床资料。分为保留前列腺尖部包膜组20例（观察组）和非保留前列腺尖部包膜组23例（对照组）。观察组在距前列腺尖部1.0 cm处切开前列腺包膜,剜除前列腺,保留部分前列腺包膜的腹腔镜膀胱根治切除。对照组采用常规腹腔镜膀胱根治切除。两组W形回肠新膀胱制作方法相同。术后3周拔除导尿管,每３个月定期复查,收集所有患者的临床资料和完整随访信息。 结果所有患者均顺利完成手术。术后随访6~40个月无肿瘤复发。两组患者在术前人口学资料、膀胱肿瘤分期、手术时间、术中出血量、术中并发症、90 d内并发症发生率和术后6个月新膀胱残余尿量差异均无统计学意义（P>0.05）。术后6个月尿控率和勃起功能（IIEF-5评分）实验组优于对照组,日间尿控率分别为85.0%和52.2%（P<0.05）,夜间尿控率分别为65.0%和34.8%（P<0.05）,IIEF-5评分分别为[8（6,9）]分和[3（2,5）]分（P<0.05）。 结论腹腔镜下保留前列腺尖部包膜根治性膀胱切除W形原位回肠新膀胱术有利于尿控和勃起功能保护,不会影响肿瘤控制效果,值得临床推广应用。     

Incontinent urinary diversion]

We analyzed 237 patients who underwent total cystectomy with ileal conduit urinary diversion or cutaneous ureterostomy at the Center for Adult Diseases, Osaka. One-hundred and eighty-eight patients underwent ileal conduit diversion and 49 patients underwent cutaneous ureterostomy. No patient died within 30 days after the operation, but two patients who underwent ileal conduit diversion died of postoperative complications within 2 months. Early complications occurred in 94 patients (50%) in the ileal conduit group and in 18 patients (37%) in the ureterostomy group. Late complications occurred in 85 patients (45%) in the ileal conduit group and in 23 patients (47%) in the ureterostomy group. Frequent early complications in the ileal conduit group were wound infection (29%), and intestinal complications (13%) which included ileus and upper urinary tract complications (12%). The most frequent late complications were stomal complications (26%) which included peristomal dermatitis stomal stenosis, parastomal hernia, and stomal prolapse, and upper urinary tract complications which were noted in 27 patients (14%).     

机器人辅助全腹腔镜下"紫砂壶型"原位回肠新膀胱的临床疗效分析

目的探讨机器人辅助全腹腔镜下"紫砂壶型"原位回肠新膀胱患者的尿控和肿瘤学预后。 方法以2017年5月至2019年6月连续进行的10例机器人辅助根治性膀胱切除+回肠原位新膀胱术患者为研究对象，男9例，女1例，年龄（63±11）岁，极高危非肌层浸润膀胱癌5例，肌层浸润性膀胱癌5例；术后随访时间为12～37个月。记录手术视频、术后90 d内并发症、随访期间患者的尿控恢复、分肾功能、上尿路影像学结构改变以及肿瘤学预后。 结果10例患者均顺利完成全腹腔镜下机器人辅助根治性膀胱切除回肠原位新膀胱手术，手术时间（584±56）min，出血量（655±275）ml，术后进食时间1～3 d；1例患者术后6个月行切口疝修复术，其余无Ⅲ级以上并发症。5例（50%）患者术后6～12个月尿流动力学检查提示最大尿流率及平均尿流率分别为（6.3±4.5）ml/s、1.80（0.30）ml/s，术后新膀胱充盈尿量及残余尿量分别为（525±273）ml、161（227）ml，患者日间完全控尿9例（90%），夜间完全控尿8例（80%）。随访期间，发现4侧肾盂轻度扩张，监测分肾功能正常。1例患者术后18个月出现肺转移，其余患者未发现局部复发及转移。 结论"紫砂壶型"回肠原位新膀胱是在Studer型、VIP型回肠新膀胱基础上的储尿囊成型技术改进，术后新膀胱功能良好，能有效保护上尿路形态，恢复排尿功能。     

Ileal conduit in era of systemic chemotherapy

The records of 62 patients with invasive transitional cell carcinoma of the bladder whose planned treatment was radical cystectomy with ileal conduit urinary diversion and postoperative systemic chemotherapy were reviewed. Seven of the patients received radical cystectomy but not postoperative chemotherapy as planned, 3 of them (5%) for reasons directly related to complications from the urinary diversion. Fifty-five patients received the planned postoperative chemotherapy. Complications during chemotherapy that were related to the ileal conduit were urinary tract infection in 37 percent and stenosis at the ureteroileal anastomosis requiring percutaneous nephrostomy in 3.6 percent. Chemotherapy was not discontinued in any patient, however, because of complications specifically related to the urinary diversion. We conclude that the ileal conduit is well tolerated by patients who require systemic chemotherapy and is, today, the simplest, safest, and best diversion method when systemic chemotherapy is to follow radical cystoprostatectomy.     

Does body mass index impact the performance of robot-assisted intracorporeal ileal conduit?

BACKGROUND AND PURPOSE: Body mass index (BMI) has been shown to influence perioperative outcomes for patients undergoing open radical cystectomy and urinary diversion. The impact of BMI on robot-assisted intracorporeal ileal conduit has not been studied. PATIENTS AND METHODS: All patients undergoing robot-assisted radical cystectomy (RARC) with ileal conduit at our institution were offered intracorporeal ileal conduit beginning May 2009. Fifty-six consecutive patients underwent robot-assisted radical cystectomy with intracorporeal ileal conduit from May of 2009 to July 2010. Patients were categorized into three groups based on BMI: Normal (BMI < 25 kg/m(2)), overweight (BMI=25-29 kg/m(2)), and obese (BMI ≥ 30 kg/m(2)). The effect of BMI on intraoperative and postoperative outcomes was assessed by retrospective review of a comprehensive RARC quality assurance database. Results: Median age at cystectomy was 72 (range 42-87 y), and 75% of patients were male. Median follow-up for the entire cohort was 5 months (range 12 d-16 mos). Median BMI was 27 kg/m(2) (range 19-47 kg/m(2)), and 75% of patients were overweight or obese. Age, ASA score, and overall operative time were not significantly different among the normal, overweight, and obese patients. Median urinary diversion times were 95, 151, and 124 minutes for normal, overweight, and obese patients, respectively (P=0.13). Conclusions: Robot-assisted intracorporeal ileal conduit can be safely performed in all body mass indices. Further studies are needed to assess long-term conduit function and stomal complications.     

Is mechanical bowel preparation necessary in patients undergoing cystectomy and urinary diversion?

OBJECTIVE: To compare the surgical outcome in patients with or with no bowel preparation before cystectomy and ileal conduit urinary diversion, specifically assessing local and systemic complications. PATIENTS AND METHODS: All patients undergoing cystectomy and ileal conduit urinary diversion between January 1991 and December 1999 were assessed retrospectively. Twenty-two receive no bowel preparation (group 1) and were compared with 64 who had (group 2). Patients had similar demographic characteristics, stage and grade of tumour. Patients in group 2 received a standard 4-day bowel preparation and group 1 received no lavage or enemas. All patients underwent a standard iliac and obturator lymph node dissection, and cystoprostatectomy or anterior exenteration and ileal conduit urinary diversion. All patients received intraoperative metronidazole and gentamicin intravenously, and two further doses after surgery. RESULTS: Deaths after surgery were comparable in the two groups (two in group 1 and four in group 2) and the incidence of wound infection was similar (three and seven, respectively). There were no significant differences between the respective groups for fistula and anastomotic dehiscence (two and six) or sepsis (three and six). Group 2 had a higher incidence of wound dehiscence (one) than in group 1 (none). The incidence of prolonged postoperative ileus was lower in group 1 (one vs 12), as was the length of hospital stay (31.6 days vs 22.8 days). CONCLUSIONS: Bowel preparation had no advantage for the surgical outcome but it increased the length of hospital stay.     

Hand-assisted versus pure laparoscopic radical cystectomy: A clinical outcome comparison

Objectives:   To compare hand-assisted laparoscopic radical cystectomy (HALRC) with the standard laparoscopic radical cystectomy (LRC) in an attempt to delineate their role in bladder cancer treatment.
Methods:   We retrospectively analyzed 51 patients who underwent HALRC (HALRC group, 31 cases) or LRC (LRC group, 20 cases). Urinary diversion was performed extracorporeally through the hand port or the incision for specimen retrieval, respectively, in the two groups. Baseline patient characteristics, intraoperative parameters, and postoperative outcomes were evaluated.
Results:   There was no statistically significant difference in age, sex, body mass index, previous abdominal surgeries, or tumor stage between the two groups. Although the LRC group yielded a significantly smaller incision for urinary diversion than the HALRC group (7.3 cm vs 6.2 cm, P  < 0.05), mean operative time, mean estimated blood loss, blood transfusion rate, time to oral intake and complications were similar in the two groups. Hernia formation was observed with increased frequency in the HALRC group. No patients in the HALRC group and only one patient (5%) in the LRC group presented a positive margin.
Conclusions:   The HALRC group yielded the same outcomes as the LRC group, except with a larger incision. The hand-assisted approach might be preferred for obese patients or those having multiple previous abdominal surgeries.     

全膀胱切除直肠代膀胱与回肠膀胱术疗效观察

目的:探讨膀胱全切直肠代膀胱与回肠膀胱术的效果。方法:回顾性分析全膀胱切除直肠代膀胱130例,回肠膀胱16例临床资料。结果:143例膀胱肿瘤病例,浸润性肿瘤132例。手术均顺利,术后3个月未发现上尿路梗阻积水,电解质、肾功正常范围。发生近期并发症12例,远期并发症11例。87例随访1～10年,5年生存率63%。结论:膀胱全切是浸润性膀胱癌首选治疗方法之一,直肠代膀胱和回肠膀胱都是尿流改道的较好选择,长期随访其并发症少。     

Continent urinary reconstruction versus ileal conduit: a contemporary single-institution comparison of perioperative morbidity and mortality

OBJECTIVES: To compare postoperative morbidity and mortality in a concurrent and contemporary series of patients who underwent radical cystectomy with ileal conduit versus orthotopic neobladder. METHODS: The data of 198 patients were reviewed, 117 with orthotopic reconstruction and 81 with ileal conduit during a 5-year time frame. Thirty-day morbidity, mortality, reoperative rates, and parameters associated with the surgical procedures were obtained from chart review. RESULTS: No perioperative or postoperative deaths occurred in either group. The median operative time for the ileal conduit was 201 minutes (range 140 to 373), and for the orthotopic neobladder, it was 270 minutes (range 230 to 425). The median blood loss was 389 and 474 mL, respectively. The median length of hospitalization was 8 days for the ileal conduit group and 7 days for the orthotopic neobladder group. Diversion-related complications recognized within 30 days that ultimately required a return to the operating room occurred in 3.4% of those with a neobladder and 1.2% of those with an ileal conduit. CONCLUSIONS: The orthotopic neobladder is a longer and technically more complex procedure than the ileal conduit procedure. However, no demonstrable difference in morbidity or perioperative complications were found between the two procedures in our review.     

Laparoscopic versus open radical cystectomy for the management of bladder cancer: Mid-term oncological outcome

Objective:   To compare the mid-term oncological outcome of laparoscopic radical cystectomy (LRC) with those of open radical cystectomy (ORC).
Methods:   From June 2003 to February 2008, 36 LRCs were carried out at our institute for the treatment of bladder cancer. Clinical and oncological data were retrospectively analyzed. A match-pair comparison with an historical series of 34 patients who were submitted to ORC between 1996 and 2003 was carried out.
Results:   Median follow-up of the LRC group was 21 months (3–56 months). Pathological stage or grade was similar in the two groups. There was no significant difference between the LRC and ORC groups in terms of 3-year overall (64.2% vs 72.6%, respectively; P  = 0.682), cancer-specific (73.0% vs 75.3%, respectively; P  = 0.951), and recurrence-free survival (70.5% vs 72.5%, respectively; P  = 0.715) rates. In a subgroup analysis according to stage, there was also no significant difference in the 3-year disease-specific survival after LRC or ORC for organ-confined (pT1 and pT2; 85.7% vs 83.9%, respectively; P  = 0.256) or extravesical disease (pT3 and pT4; 73.3% vs 63.8%, respectively; P  = 0.825).
Conclusion:   These findings suggest that LRC provides mid-term oncological outcomes similar to those of ORC in the management of bladder cancer.     

Surgical site infection by bacillus Calmette-Guerin (BCG) after radical cystectomy, occurring after intravesical bcg therapy: a case report

A 51-year-old man received 2 courses of intravesical bacillus Calmette-Guerin (BCG) therapy for carcinoma in situ of the bladder. Two years after the therapy, he underwent left radical nephroureterectomy, cystectomy, urethrectomy and construction of an ileal conduit because of left renal pelvic cancer and severe atrophic bladder. The histopathological diagnosis was carcinoma in situ of the left pelvis and ureter, and epithelioid cell granuloma of left kidney, prostate and bladder. After the operation, he developed extensive surgical site infection (SSI) by BCG, the diagnosis of which was delayed. He recovered from the SSI soon after anti-tuberculosis chemotherapy was begun. We discuss the requirements for more prompt diagnosis of SSI by BCG by analysis of this case.     

腹腔镜膀胱根治性切除术联合吡柔比星治疗膀胱肿瘤的效果及对血清CA125、α-FR水平的影响

目的 分析腹腔镜膀胱根治性切除术联合术后吡柔比星治疗膀胱肿瘤的效果及对血清CA125、α-FR水平的影响。方法 将本院2016年12月至2019年10月间收治的80例膀胱癌患者随机分为观察组和对照组,每组40例。对照组采用腹腔镜膀胱根治性切除术治疗,观察组采用腹腔镜膀胱根治性切除术联合术后吡柔比星治疗;记录两组患者的术后排气时间、术后住院时间、引流管拔除时间及术后3个月不良反应发生情况;随访1年以上,记录患者的术后复发情况及术前、术后半年、术后1年时检测患者的血清α-FR和CA125水平。结果 观察组的术后排气时间、术后住院时间和引流管拔除时间均明显低于对照组（均P<0.01）;两组的治疗并发症比较,差异无统计学意义（5% vs. 10%,P>0.05）;观察组治疗1年内的复发率明显低于对照组（P=0.007）;术后半年和术后1年时观察组的血清α-FR和CA125水平均明显低于对照组,差异有统计学意义（均P<0.001）。结论 腹腔镜膀胱根治性切除术联合术后吡柔比星治疗膀胱肿瘤可有效改善患者的预后质量,降低血清CA125、α-FR水平。