Radical cystectomy in patients older than 75 years: assessment of morbidity and mortality.

OBJECTIVE: We have reviewed our surgical experience to assess intra- and postoperative morbidity and mortality in 25 patients 75 years old or older with invasive bladder cancer who underwent radical cystectomy and urinary diversion or bladder substitution. METHODS: Between January 1993 and February 1999, of 190 patients who underwent radical cystectomy, 23 men and 2 women were aged from 75 to 87 (median 79) years. Urinary diversion was performed in 23 cases and bladder substitution in 2. All patients had significant comorbidity and 15 patients were ASA II and 10 ASA III. RESULTS: Median operating time was 4 h. Perioperative mortality rate was 4%. Intraoperative, early and late postoperative complications occurred in 15, 16 and 6 patients, respectively. The most common early complications were pyelonephritis (32%), disorientation (20%), additional pulmonary infection (20%) and prolonged ileus (32%). No secondary procedures were necessary. The most common late complication was ureteroileal anastomotic stricture (16%). The median hospital stay and intensive care unit stay were 24 and 14 days, respectively. With a median follow-up of 14 (5-50) months the overall mortality rate was 32%. CONCLUSIONS: Radical cystectomy can be performed in elderly patients with acceptable perioperative mortality and morbidity. However, because of the high incidence of minor medical complications, hospital stay is often prolonged.     

A multicenter study of the morbidity of radical cystectomy in select elderly patients with bladder cancer

PURPOSE: We evaluated the morbidity of radical cystectomy for invasive bladder cancer in select patients older than 75 years using recent data from 2 academic hospitals. MATERIALS AND METHODS: We analyzed 73 radical cystectomies performed from January 1995 to June 2000 in patients 75 to 89 years old (median age 79.3). Cases were categorized according to the American Society of Anesthesiologists classification with a score of 2 in 41, 3 in 30 and 4 in 2. External urinary diversion was performed in 51 cases and an ileal neobladder was constructed in 22. We evaluated the incidence and type of complications, clinical outcome, and postoperative care unit and hospital stay. Statistical analysis was done using the chi-square and Student t tests. RESULTS: Median operative time was 263 minutes (range 95 to 451). The perioperative mortality rate was 2.7%. The intraoperative, early and late postoperative complication rates were 38.4%, 46.5% and 16.4%, respectively. Three reoperations (4.1%) were necessary. The most common early complications were pyelonephritis in 12.3% of cases, disorientation in 10.9%, pneumonia in 8.2% and prolonged ileus in 12.3%. The most common late complications were ureteroileal anastomotic stenosis in 5 cases and hernia in 3. Median postoperative care unit and hospital stays were 12 and 34 days, respectively. At a median followup of 14.4 months (range 6 to 74) the overall mortality rate was 31.5%. Hospital stay was significantly higher in patients with complications. The incidence of complications was similar in the 2 groups. CONCLUSIONS: These data support the aggressive surgical management of bladder cancer in select elderly patients. A rigorous multidisciplinary team approach can provide acceptable perioperative morbidity.     

Major invasive surgery for urologic cancer in octogenarians with comorbid medical conditions

OBJECTIVES: We retrospectively reviewed the records of the octogenarian patients who underwent major surgery for urologic cancer at two institutions. The aims of our study were to assess intra- and postoperative morbidity and mortality rates, and to identify potential risk factors that can predict postoperative complications and, as a consequence, surgical outcome. METHODS: Fifty-five patients (median age: 83 yr) underwent major surgery for urologic cancer. Radical nephrectomy was performed in 27 patients, radical cystectomy with urinary diversion was done in 20 patients, and nephroureterectomy was performed in the remainder. Significant comorbidity was present in 51 patients. RESULTS: The perioperative mortality rate was 9%. The overall mortality rate was 69%; cancer-specific mortality was 28%. Intraoperative complications occurred in 11% of patients. Postoperative intensive care monitoring was required in 29% of patients. The early postoperative complication rate was 33%. Only the presence of more than two comorbidities (p<0.05) and chronic obstructive lung disease (COLD) (p=0.017) resulted in independent prognostic factors for morbidity. Sixteen percent of patients developed a late postoperative complication within the first 6 mo. Median hospital stay was 14 d (range: 6-55), and hospital stays were significantly longer among patients with complications (p<0.05). The 3-yr and 5-yr overall survival rates were 36% and 26%, respectively; these rates were significantly lower in patients with COLD (p<0.01). There was no significant difference between cancer-specific and non-cancer-specific survival rates. CONCLUSIONS: Major surgery for urologic malignancies can be safely performed in selected octogenarian patients.     

Differential Complication Rates Following Radical Cystectomy in the Irradiated and Nonirradiated Pelvis

Background

Reports suggest that cystectomy following pelvic irradiation is associated with a higher morbidity and mortality than in primary cases. However, such reports are from an era when postcystectomy complication rates were higher than are currently reported.

Objective

This study evaluates perioperative complications and mortality in primary radical and postradiation salvage cystectomy.

Design, setting, and participants

Patients treated with cystectomy for bladder cancer or advanced pelvic malignancies involving the bladder were studied.

Measurements

Perioperative complications and mortality were analysed for 426 primary and 420 salvage cystectomies performed at a single institution between 1970 and 2005.

Results and limitations

The 30- and 60-d mortality in the 2000–2005 cohort were 0% and 1.2%, respectively, in the primary group and 1.4% and 4.3%, respectively, in the salvage cystectomy group. Thirty-day mortality between 1970 and 2005 was not statistically significant in the primary and salvage groups (4.2% and 7.1%, respectively).

Conclusions

This large series from a high-volume centre demonstrates no difference in perioperative mortality in primary or postradiation salvage radical cystectomy. Similarly, there was no significant difference in the incidence of most of the surgical or medical complications in either group, although the stomal stenosis rate was higher postradiation.     

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.     

Radical cystectomy is safe in elderly patients at high risk

PURPOSE: Radical cystectomy is standard treatment for bladder cancer in healthy individuals. We determined the safety of radical cystectomy in elderly patients at high risk. MATERIALS AND METHODS: We reviewed the records of all patients who underwent radical cystectomy at our institution between January 1994 and June 2000. Of these 382 patients we identified 44 who were elderly and at high risk, as defined by age 75 years or greater and American Society of Anesthesiologists classification 3 or greater. We examined postoperative care, perioperative minor/major complications, the mortality rate and the need for rehospitalization. RESULTS: Median age of the 44 patients was 77.5 years (range 75 to 87). American Society of Anesthesiologists class was 3 in 40 patients and 4 in 4. Median hospitalization was 7 days (range 4 to 20). Postoperatively 31 of the 44 patients (70%) were transferred directly to the general urology floor, while cardiac monitoring was required postoperatively in 30%. Nine of these patients were transferred to a step-down unit and the remaining 4 required surgical intensive care unit admission. Minor and major complications developed in 10 (22.7%) and 2 (4.5%) cases, respectively. No patients died in the perioperative period and 4 patients were hospitalized within 6 months of discharge home. CONCLUSIONS: Our results support the safety of radical cystectomy in elderly patients at high risk. Acceptable perioperative morbidity and mortality may be achieved without routine intensive monitoring postoperatively.     

Orthotopic neobladder following radical cystectomy in patients with high perioperative risk and co-morbid medical conditions

PURPOSE: A significant number of patients requiring radical cystectomy for bladder cancer have substantial co-morbidity. Nonetheless, these patients often prefer orthotopic neobladder reconstruction to avoid an abdominal stoma. We performed a retrospective study to determine perioperative morbidity in this group of patients. MATERIALS AND METHODS: We used the American Society of Anesthesiologists physical status classification to assign perioperative risk. Of 250 patients undergoing orthotopic neobladder reconstruction after radical cystectomy during a 5-year period we identified 84 with an American Society of Anesthesiologists score of 3 or greater. Charts were available for review for all patients and none was lost to followup. RESULTS: Median operative time (calculated from anesthesia ready time to completion of surgery and application of a dressing) was 256 minutes. In 14 patients (16.6%) transfusion of a median of 2 units of allogeneic blood was required. A total of 79 patients (94%) were transferred directly from the recovery room to the general urology floor without a need for postoperative cardiac monitoring. Median hospital stay was 7 days. One patient (1.1%) died on postopera-tive day 9 of a presumed pulmonary embolus after having been discharged home on postoperative day 6. Minor complications occurred in 16 patients (19%). Only 1 patient required a return to the operating room for endoscopic removal of a retained stent fragment. CONCLUSIONS: In experienced hands radical cystectomy and orthotopic neobladder can be offered to patients with co-morbid conditions. Expeditious performance of the surgical procedure, minimization of blood loss, restricting the surgical incision to an infraumbilical location, and avoidance of intraoperative complications all contribute to decreasing morbidity and mortality. Although orthotopic reconstruction is more complex than performance of an ileal conduit, there is no apparent increase in perioperative morbidity or mortality. Therefore, orthotopic reconstruction can be offered to patients who want to avoid an abdominal stoma even in the face of significant co-morbid conditions.     

回肠代膀胱与回肠膀胱术的比较及早期并发症探讨

目的　探讨膀胱肿瘤患者膀胱全切术后行回肠代膀胱术与回肠膀胱术的临床治疗效果及术后早期并发症。方法　分析 13 5例膀胱肿瘤患者行膀胱全切术后采用回肠代膀胱术 86例与回肠膀胱术 49例的临床资料 ,就两种术式手术时间、术中出血量、术后早期并发症、平均住院日、再手术率及死亡率等指标进行比较分析。结果　除手术操作时间回肠代膀胱术组 (平均 3 46min)长于回肠膀胱术组 (平均 2 70min)外 ,回肠代膀胱与回肠膀胱术组在术中平均出血量 (660ml与 62 7ml)、术后早期并发症发生率 (18.6%与 16.3 % )、患者平均住院日 (4 7d与 41d)、再手术率 (8.1%与6.1% )及死亡率 (1.2 %与 2 .0 % )等方面差异无显著性 (P >0 .0 5 )。结论　回肠代膀胱术是膀胱全切术后膀胱替代的理想术式 ,具有手术安全 ,术后早期并发症少 ,可自主性控制排尿 ,明显提高患者的生活质量而易于接受 ,是值得推荐的膀胱替代手术方式     

Radical cystectomy in patients aged > or = 75 years: an updated review of patients treated with curative and palliative intent

OBJECTIVE

To evaluate the morbidity and mortality of radical cystectomy in a group of unselected patients aged ≥ 75 years who were treated with curative and palliative intent.

PATIENTS AND METHODS

We retrospectively analysed 53 patients aged 75–90 years (median 78.8 years) who had radical cystectomies between May 1994 and July 2002. The patients were divided into two groups: 46 were treated with curative intent (group A) and seven with palliative intent (group B). The indications for cystectomy in group A were recurrent and otherwise therapy‐resistant bladder cancer, severe irritative voiding symptoms, and recurrent macrohaematuria. The indications in group B were advanced pelvic malignancy with severe irritative voiding symptoms, severe pain, and recurrent macrohaematuria requiring blood transfusions. Patients were categorized according to the American Society of Anesthesiologists classification, with a score of II in 28 patients, III in 21 and IV in four. Complications and mortality before, during and after surgery, and the duration of hospital stay and clinical outcome, were assessed.

RESULTS

The early mortality rate in group A was 4% (2/46); in group B two patients died after prolonged complications. The median (range) hospital stay was 28 (6–56) days, and was significantly longer in patients with complications, at a median (range) of 36 (6–70) days. The complication rates early and late after surgery in group A were 22% and 11%, respectively, and in group B, five of seven (early). The total median survival was 2 (0.33–7) years.

CONCLUSIONS

Elderly people undergoing radical cystectomy have a greater risk of perioperative morbidity and mortality, especially those with very advanced pelvic malignancies who have had cystectomy with palliative intent. The incidence of early and late complications in patients treated with curative intent is acceptable, but the hospital stay is prolonged.

     

Simple cystectomy in patients requiring urinary diversion

PURPOSE: Urinary diversion is an alternative treatment for conditions such as radiation and interstitial cystitis, neurogenic bladder and severe incontinence. The subsequent complication rate may reach 60% due to the retained nonfunctional bladder. The subsequent cystectomy rate may be as high as 20% because of pyocystis, hematuria, pelvic pain and rarely bladder cancer. We describe simple cystectomy involving bladder removal without the adjacent structures, avoiding deep pelvic dissection. MATERIALS AND METHODS: Ileal conduit or continent diversion and simple cystectomy were performed for crippling bladder symptoms secondary to neurogenic bladder, pelvic radiation, hematuria and/or severe incontinence in 12 women and 7 men with a mean age of 63 years. We performed urinary diversion and simple cystectomy only when all conservative means of treatment had failed. The majority of patients had multiple co-morbidities, previous surgeries and pelvic radiation. An average of 5 conservative procedures (range 2 to 10) had been done before simple cystectomy. None of these patients had urothelial malignancy. Simple cystectomy was done concomitantly with urinary diversion in 13 cases and later as a separate procedure in 6 due to complications of a retained nonfunctional bladder. RESULTS: Mean followup was 15 months. No mortality was associated with surgery. For simple cystectomy only mean operative time was 30 minutes and mean estimated blood loss was 300 cc. Median time from symptom presentation to cystectomy was 35 months and mean hospital stay was 7 days. In all cases symptoms were dramatically alleviated. No morbidity was directly attributable to simple cystectomy. CONCLUSIONS: Simple cystectomy is well tolerated and should be performed at urinary diversion to avoid later complications of the retained bladder. Technically this procedure is not demanding and is relatively easy to perform even after previous pelvic radiation.     

Influence of post-cystectomy complications on cost and subsequent outcome

PURPOSE: Of commonly performed urological cancer procedures radical cystectomy is associated with the highest morbidity and mortality. The impact of each individual type of complication or a combination of them on various outcome measures, such as mortality, charges and length of stay, is unclear. We quantified the impact of specific post-cystectomy complications and combinations thereof in terms of mortality, charges and length of stay. MATERIALS AND METHODS: All 6,577 patients undergoing radical cystectomy for bladder cancer were identified from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (1998 to 2002). The prevalence of different International Classification of Diseases, 9th Revision, Clinical Modification coded complications following cystectomy were determined. Outcome variables of interest were in-hospital mortality, total charges and length of stay. The association between types of complications and measured outcomes were examined using univariate and multivariate regression models. The cumulative impact of multiple complications and various combinations of complications on outcomes was also examined. RESULTS: The overall complication rate was 28.4% in 1,869 cases and the mortality rate was 2.6%. Median total charges was 41,905 dollars and median length of stay was 9 days. Overall 20.7% of patients had 1, 6.1% had 2, 1.2% had 3 and 0.42% had greater than 3 complications. At least 1 complication almost doubled the odds of mortality and increased median total charges and length of stay by 15,000 dollars and 4 days, respectively. We defined expected levels of increase in the various outcome measures with increasing numbers of complications. The combination of postoperative infection and respiratory complication had the greatest impact on mortality, while the combination of wound and urinary tract infection had the greatest impact on length of stay and total charges. CONCLUSIONS: Although most patients undergoing cystectomy are older and have multiple comorbidities, the postoperative complications with the most significant impact were those directly related to surgery (primary complications). Secondary complications (cardiac, respiratory, vascular, etc) appear to have less of an impact on most common outcome measures. Hence, the greatest gains can be achieved by limiting primary complications. These data could be used to develop benchmarks of expected levels of primary and secondary complications after cystectomy.     

Analysis of early complications after radical cystectomy: results of a collaborative care pathway

PURPOSE: We examined our recent series of patients who underwent radical cystectomy to determine and analyze the early perioperative morbidity of the procedure in a contemporary series treated with the guidance of a clinical pathway. MATERIALS AND METHODS: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. We specifically evaluated complications that developed within 30 days of the procedure. Potential variables predictive of early morbidity were analyzed, including patient age, gender, race, American Society of Anesthesiologists score, type of urinary diversion, smoking history, estimated blood loss, transfusion requirement, pathological stage and operative time. RESULTS: The overall minor complication rate was 30.9% (94 of 304 patients). Postoperative ileus was the most common minor complication, affecting 54 patients (18%). Increased blood loss and major complications predicted a significantly higher likelihood of ileus on multivariate analysis (p = 0.02 and 0.001, respectively). Major complications in 15 patients (4.9%) correlated with higher American Society of Anesthesiologists score, surgical intensive care unit admission and transfusion requirement (p = 0.01, <0.001 and 0.001, respectively). The early mortality rate was 0.3% (1 patient). CONCLUSIONS: Within the framework of a clinical pathway, radical cystectomy can be performed safely with an acceptable rate of early minor and major complications. Delay in the return of bowel function is the most common minor complication. Increased estimated blood loss, transfusion requirement and a major complication predicted a higher likelihood of postoperative ileus. The acceptable rate of early morbidity in this series in a 5-year period validates its use in patients undergoing radical cystectomy.     

Radical cystectomy for primary bladder malignancy: a 10 year review

BACKGROUND: Radical cystectomy is universally accepted as the definitive treatment for muscle invasive bladder cancer and preventing stage progression in high-risk groups. There are few recent reviews outside of major international centres. We compared our institution's results with published literature. METHODS: Records of 50 consecutive patients treated with radical cystectomy for biopsy-proven bladder carcinoma between 1995 and 2005 were reviewed. RESULTS: The mean age was 70 years and 76% were male. Median follow up was 38 months (1-111 months). Twenty-three patients (46%) had known history of superficial transitional cell carcinoma and 12 patients (24%) had undergone previously intravesical therapy. Transitional cell carcinomas accounted for 94% of cases and most (76%) were poorly differentiated. Twenty-four (48%) had disease at pT3 stage or higher. Regional lymph nodes were involved in 35%. Twenty-three patients (46%) developed recurrence and over half (12 patients) recurred within 12 months. Both lymph node involvement and recurrence were associated with higher pT stage (P < 0.001). All patients with recurrent disease were dead within a year (median 103 days). Median hospital stay was 19 days and there was one postoperative death (2%). Five-year disease-free and overall survival were 42 and 34% respectively. CONCLUSION: Survival following curative resection for primary bladder malignancy is at best modest. Our overall proportion of higher stage disease contributed to earlier recurrence and lower survival rates. Our postoperative morbidity and mortality rates as well as length of stay are acceptable compared with major international units.     

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.     

RADICAL CYSTECTOMY IN THE OCTOGENARIAN

Purpose

We evaluated the morbidity and outcome of cystectomy and urinary diversion in patients 80 years old or older with invasive bladder cancer.

Materials and Methods

We reviewed the records of all patients older than 80 years who underwent cystectomy during the last 15 years. Of 1,186 cystectomies 44 patients (4%) were identified. Patients were evaluated for complications, mortality and functional status after surgery.

Results

The 44 patients had a median age of 81 years (range 80 to 87). Of the patients 78% had significant co-morbidity, including 41% with 2 or more medical problems. Median hospital stay was 14 days, with 20% of the patients requiring intensive care for 24 hours. There was a 51% complication rate including 25% due to surgical complications and 26% from underlying medical illness. Operative mortality was 4.5%. Within 6 months of surgery 66% were rehospitalized for medical or surgical reasons. Median survival time was 25 months. Median performance status before and after surgery decreased slightly from 70 to 65.

Conclusions

The results of this study support the use of cystectomy in octogenarians with invasive bladder cancer. Surgery can be accomplished with acceptable morbidity and mortality. Radical cystectomy in this population offers the best opportunity for sustained disease-free quality survival.     

Radical cystectomy and perioperative chemotherapy in octogenarians with bladder cancer

IntroductionWe aimed to compare the treatment patterns and oncological outcomes, including postoperative morbidity and chemotherapy use, between octogenarians and patients <80 years of age who underwent radical cystectomy for bladder cancer.MethodsWe conducted a retrospective analysis of 119 patients who underwent radical cystectomy for bladder cancer at our center between January 2013 and April 2019. Comorbidities, clinical and pathological data, 30-day postoperative morbidity, and perioperative chemotherapy use were compared between octogenarians (n=31) and younger patients (n=88). Cancer-specific and overall survival rates were estimated with the Kaplan-Meier method and compared between the groups.ResultsNo significant differences were found between the age groups in the clinical and pathological findings, including Charlson comorbidity index, modified frailty index, albumin level, renal function, and TNM stage. The median followup for survivors was 19 months (interquartile range [IQR] 11–30). Major complications (Clavien-Dindo grade ≥3) and 30-day postoperative mortality rates did not differ between the age groups (p=0.3 and p=0.18, respectively). Despite no difference in baseline glomerular filtration rates, perioperative chemotherapy utilization rate was lower among octogenarians compared to younger patients (13% vs. 34%, p=0.03). Estimated two-year cancer-specific survival rates for octo-generians and younger patients were 40% and 75%, respectively. Similarly, estimated two-year overall survival rates were 30% and 69%, respectively. Both cancer-specific and overall survival rates were significantly lower in octogenarians (p=0.007 and p=0.001, respectively).ConclusionsRadical cystectomy in octogenarians results in comparable short-term outcomes as in younger patients. However, in the elderly population, perioperative chemotherapy utilization rates are lower and survival is inferior.     

Routine postoperative intensive care monitoring is not necessary after radical cystectomy

PURPOSE: Patients undergoing radical cystectomy have historically required intensive care monitoring in the perioperative period. We examined the postoperative care of these patients since the institution of a clinical care pathway with special attention to the need for intensive care unit admission. MATERIALS AND METHODS: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. Variables examined were the location and nature of postoperative care, American Society of Anesthesiologists score, estimated blood loss, transfusion requirement, hospital stay, perioperative minor complications, major complications, the mortality rate and urinary diversion type. RESULTS: Of the 304 patients 20 (6.5%) required intensive care unit monitoring during postoperative recovery and 18 were admitted directly to the intensive care unit postoperatively. Compared with the total population those admitted to the intensive care unit had increased hospital stay (p = 0.002), higher American Society of Anesthesiologists score (p <0.001), higher transfusion requirement (p = 0.001) and shorter operative time (p = 0.02). Patients who received blood transfusion and those with major complications were more likely to need intensive care unit care (p = 0.019 and <0.001, respectively). A single patient died who did not receive intensive care unit care. CONCLUSIONS: Our clinical care pathway outlines postoperative care on the regular urology floor for patients who undergo radical cystectomy. This policy has been safe and efficacious. We believe that admission to the intensive care unit should only be done in select cases.     

机器人辅助全膀胱切除术的研究进展

机器人辅助全膀胱切除术是近年新发展起来的微创手术方式。为总结机器人辅助全膀胱切除术的疗效,本文回顾近年来机器人辅助全膀胱切除术的文献,总结和比较了机器人辅助全膀胱切除术与开放手术在围手术期结果、早期手术并发症、肿瘤转归和盆腔淋巴结清扫术的情况,初步评估该微创手术与开放全膀胱切除术相比具有的优势和不足。文献统计发现与开放全膀胱切除术相比,机器人手术具有术中出血量少、平均住院时间短、肠道功能恢复时间快、围手术期并发症发生率低等优点,而且,机器人手术在短期肿瘤控制和盆腔淋巴结清扫术中也具有一定的优势。但是,仍需要长期随访和多中心随机对照研究对机器人辅助全膀胱手术作进一步的评价。     

Radical cystectomy for carcinoma of the bladder in the elderly patient

Between 1979 and 1984, 136 patients underwent radical cystectomy and urinary diversion for the treatment of invasive carcinoma of the bladder. Of the patients 38 were 70 years old or more and they were considered elderly. The mortality rates for those less than 70 compared to those more than 70 years old were 1 and 5 per cent, respectively, and the morbidity rates were 39 and 34 per cent, respectively, with wound separation being the most common complication. There was no statistically significant difference with respect to age in the morbidity or mortality rates. The median hospital stay was 14 days but if a complication occurred the hospital stay was significantly longer. For elderly patients in general good health, radical cystectomy and urinary diversion should not be withheld on the basis of age alone.     

Is robot-assisted radical cystectomy justified in the elderly? A comparison of robotic versus open radical cystectomy for bladder cancer in elderly ≥75 years old

Abstract Background and Purpose: Open radical cystectomy (ORC) or minimally invasive radical cystectomy with pelvic lymph node (LN) dissection carries significant morbidity to the elderly because they often have several medical comorbidities that make a surgical approach more challenging. The objective of this study is to compare robot-assisted radical cystectomy (RARC) and ORC in elderly patients. Patients and Methods: A prospective bladder cancer cystectomy database was queried to identify all patients age ≥75 years. A total of 20 patients were identified for each of the RARC and ORC cohorts. A retrospective analysis was performed on these 40 patients undergoing radical cystectomy for curative intent. Results: Patients in both groups had comparable preoperative characteristics and demographics. Patients had significant medical comorbidities with 80% in each cohort having American Society of anesthesiologists classification of 3 and 50% having had previous abdominal surgery. Complete median operative times for RARC was 461 (interquartile range [IQR] 331, 554) vs 370 minutes for ORC (IQR 294, 460) (P=0.056); however, median blood loss for RARC was 275?mL (IQR 150, 450) vs 600?mL for ORC (IQR 500, 1925). The median hospital stay for RARC was 7 days (IQR 5, 8) vs 14.5 days for ORC (IQR 8, 22) (P<0.001). The major complication (Clavien≥III) rate for RARC was 10% compared with 35% for ORC (P=0.024). There were two positive margins in the ORC group compared with one in the RARC group with median LN yields of 15 nodes (IQR 11, 22) and 17 nodes (IQR 10, 25) (P=0.560) respectively. Conclusions: In a comparable cohort of elderly patients, RARC can achieve similar perioperative outcomes without compromising pathologic outcomes, with less blood loss and shorter hospital stays. For an experienced robotic team, RARC should be considered in elderly patients because it may offer significant advantage with respect to perioperative morbidity over ORC.