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European Urology Focus Jul 2023Patients undergoing radical cystectomy frequently suffer from infectious complications, including urinary tract infections (UTIs) and surgical site infections (SSIs)... (Review)
Review
CONTEXT
Patients undergoing radical cystectomy frequently suffer from infectious complications, including urinary tract infections (UTIs) and surgical site infections (SSIs) leading to emergency department visits, hospital readmission, and added cost.
OBJECTIVE
To summarize the literature regarding perioperative antibiotic prophylaxis, ureteric stent usage, and prevalence of infectious complications after cystectomy.
EVIDENCE ACQUISITION
A systematic review of PubMed/Medline, EMBASE, Cochrane Library, and reference lists was conducted.
EVIDENCE SYNTHESIS
We identified 20 reports including a total of 55 306 patients. The median rates of any infection, UTIs, SSIs, and bacteremia were 40%, 20%, 11%, and 6%, respectively. Perioperative antibiotic prophylaxis differed substantially between reports. Perioperative antibiotics were used only during surgery in one study but were continued over several days after surgery in all other studies. Empirical use of antibiotics for 1-3 d after surgery was described in 12 studies, 3-10 d in two studies, and >10 d in four studies. Time to stent removal ranged from 4 to 25 d after cystectomy. Prophylactic antibiotics were used before stent removal in nine of 20 studies; two of these studies used targeted antibiotics based on urine cultures from the ureteric stents, and the other seven studies used a single shot or 2 d of empirical antibiotics. Studies with any prophylactic antibiotic before stent removal found a lower median percentage of positive blood cultures after stent removal than studies without prophylactic antibiotics before stent removal (2% vs 9%).
CONCLUSIONS
We confirmed a high proportion of infectious complications after cystectomy, and a heterogeneous pattern of choice and duration of antibiotics during and after surgery or stent removal. These findings highlight a need for further studies and support quality prospective trials.
PATIENT SUMMARY
In this review, we observed wide variability in the use of antibiotics before or after surgical removal of the bladder.
Topics: Humans; Antibiotic Prophylaxis; Cystectomy; Prospective Studies; Anti-Bacterial Agents; Surgical Wound Infection; Urinary Tract Infections; Stents
PubMed: 36710211
DOI: 10.1016/j.euf.2023.01.012 -
European Urology Focus May 2022The question of the ability of frozen section analysis (FSA) to accurately detect malignant pathology intraoperatively has been discussed for many decades. (Meta-Analysis)
Meta-Analysis Review
CONTEXT
The question of the ability of frozen section analysis (FSA) to accurately detect malignant pathology intraoperatively has been discussed for many decades.
OBJECTIVE
We aimed to conduct a systematic review and meta-analysis assessing the diagnostic estimates of FSA of the urethral and ureteral margins in patients treated with radical cystectomy (RC) for bladder cancer (BCa).
EVIDENCE ACQUISITION
The MEDLINE and EMBASE databases were searched in February 2021 for studies analyzing the association between FSA and the final urethral and ureteral margin status in patients treated with RC for BCa. The primary endpoint was the value of pathologic detection of urethral and ureteral malignant involvement with FSA during RC compared with the final margin status. We included studies that provided true positive, true negative, false positive, and false negative values for FSA, which allowed us to calculate the diagnostic estimates.
EVIDENCE SYNTHESIS
Fourteen studies, comprising 8208 patients, were included in the quantitative synthesis. Forest plots revealed that the pooled sensitivity and specificity for FSA of urethral margins during RC were 0.83 (95% confidence interval [CI] 0.38-0.97) and 0.95 (95% CI 0.91-0.97), respectively. While for the FSA of ureteral margins, the pooled sensitivity and specificity were 0.77 (95% CI 0.67-0.84) and 0.97 (95% CI 0.95-0.98), respectively. Calculated diagnostic odds ratios indicated high FSA effectiveness, and patients with a positive urethral or ureteral margin at final pathology are over 100 times more likely to have positive FSA than patients without margin involvement at final pathology. Area under the curves of 96.6% and 96.7% were reached for FSA detection of urethral and ureteral tumor involvement, respectively.
CONCLUSIONS
Intraoperative FSA demonstrated high diagnostic performance in detecting both urethral and ureteral malignant involvement at the time of RC for BCa. FSA of both urethral and ureteral margins during RC is accurate enough to be of great value in the routine management of BCa patients treated with RC. While its specificity was great to guide intraoperative decision-making, its sensitivity remains suboptimal yet.
PATIENT SUMMARY
We believe that the frozen section analysis of both urethral and ureteral margins during radical cystectomy should be considered more often in urologic practice, until quality of life-based cost-effectiveness studies can identify patients within each institution who are unlikely to benefit from it.
Topics: Cystectomy; Frozen Sections; Humans; Margins of Excision; Quality of Life; Ureter; Urinary Bladder Neoplasms
PubMed: 34127436
DOI: 10.1016/j.euf.2021.05.010 -
PloS One 2015To critically review the currently available evidence of studies comparing robot-assisted radical cystectomy (RARC) with open radical cystectomy (ORC). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To critically review the currently available evidence of studies comparing robot-assisted radical cystectomy (RARC) with open radical cystectomy (ORC).
METHODS
A comprehensive review of the literature from Pubmed, Web of Science and Scopus was performed in April 2014. All relevant studies comparing RARC with ORC were included for further screening. A pooled meta-analysis of all comparative studies was performed and publication bias was assessed by a funnel plot.
RESULTS
Nineteen studies were included for the analysis, including a total of 1779 patients (787 patients in the RARC group and 992 patients in the ORC group). Although RARC was associated with longer operative time (p <0.0001), patients in this group might benefit from significantly lower overall perioperative complication rates within 30 days and 90 days (p = 0.005 and 0.0002, respectively), more lymph node yields (p = 0.009), less estimated blood loss (p <0.00001), lower need for perioperative and intraoperative transfusions (p <0.0001 and <0.0001, respectively), and shorter postoperative length of stay (p = 0.0002). There was no difference between two groups regarding positive surgical margin rates (p = 0.19).
CONCLUSIONS
RARC appears to be an efficient alternative to ORC with advantages of less perioperative complications, more lymph node yields, less estimated blood loss, lower need for transfusions, and shorter postoperative length of stay. Further studies should be performed to compare the long-term oncologic outcomes between RARC and ORC.
Topics: Cystectomy; Female; Humans; Male; Middle Aged; Robotics
PubMed: 25825873
DOI: 10.1371/journal.pone.0121032 -
Current Urology Reports Feb 2021To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the...
PURPOSE
To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the new system will be discussed.
FINDINGS
There are currently no high-quality published studies with the SP robotic system. All studies are case series, many with 10 or fewer patients. However, all studies have found the SP system to be safe and feasible in performing most urological procedures. Renal and pelvic surgery using the SP robotic system is safe and feasible in the hands of expert robotic surgeons. Long-term, high-quality data is lacking. While the current high price and the learning curve will limit the SP systems' use in many health care systems, new updates and the release of robotic surgical systems from other developers may help drive down costs and encourage uptake.
Topics: Cystectomy; Endoscopy; Humans; Imaging, Three-Dimensional; Kidney Pelvis; Learning Curve; Nephrectomy; Prostatectomy; Plastic Surgery Procedures; Robotic Surgical Procedures; Ureter; Urinary Bladder; Urologic Diseases; Urologic Surgical Procedures
PubMed: 33554322
DOI: 10.1007/s11934-021-01040-2 -
Lower Urinary Tract Symptoms Jul 2022The purpose of this review was to summarize and compare the efficacy among surgical interventions in terms of symptomatic relief in patients with interstitial... (Review)
Review
The purpose of this review was to summarize and compare the efficacy among surgical interventions in terms of symptomatic relief in patients with interstitial cystitis/bladder pain syndrome (IC/BPS). The review protocol was published on PROSPERO. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist was followed. Following database search, a narrative synthesis was performed. Data pertaining symptom scores, pain levels, and voiding frequency following surgery were summarized by calculating percentage change in these parameters. Multiple surgical treatments were identified. These included injections of hyaluronic acid (HA), botulinum toxin A (Botox A), triamcinolone, resiniferatoxin (RTX), platelet-rich plasma, and 50% dimethyl sulfoxide (DMSO) solution, neuromodulation, hydrodistension (HD), resection/fulguration of Hunner lesions, resection of ilioinguinal and iliohypogastric nerves, reconstructive surgery, and cystectomy. This review found no evidence suggesting that HD and RTX injections can ameliorate IC/BPS symptoms. Current evidence suggests that sacral neuromodulation, cystectomy, and transurethral resection/fulguration of Hunner lesions could lead to symptomatic relief in IC/BPS. Further research into the efficacy of Botox A, triamcinolone, 50% DMSO solution, and HA instillations is required. However, the best treatment options cannot be reliably stated due to the low level of evidence of the studies identified. Further research should report outcomes for Hunner-type IC and BPS separately given their differing histopathological characteristics. Performing high-quality randomized controlled trials could be hindered by the low prevalence of the condition and a small proportion of patients progressing to surgery.
Topics: Botulinum Toxins, Type A; Cystitis, Interstitial; Dimethyl Sulfoxide; Humans; Hyaluronic Acid; Triamcinolone
PubMed: 35393778
DOI: 10.1111/luts.12441 -
Canadian Urological Association Journal... Jan 2021We aimed to perform a systematic review and meta-analysis on the long-term durability, incidence of complications, and patient satisfaction outcomes in ileal conduit... (Review)
Review
INTRODUCTION
We aimed to perform a systematic review and meta-analysis on the long-term durability, incidence of complications, and patient satisfaction outcomes in ileal conduit (IC) and orthotopic neobladder (ONB).
METHODS
A systematic electronic literature search was performed in Medline, Embase, Cochrane Library, and Scopus using MeSH and free-text search terms "Urinary diversion" AND "Ileal conduit" AND "Neobladder." The search concluded June 19, 2018. Inclusion criteria were those patients who had a cystectomy and required urinary diversion by either IC or neobladder.
RESULTS
In total, 32 publications met the inclusion criteria. Data were available on 46 787 patients (n=36 719 for IC and n=10 068 for ONB). Meta-analyses showed that IC urinary diversions performed less favorably than ONB in terms of re-operation rates, Clavien-Dindo complications, and mortality rates; odds ratios (ORs) and 95% confidence intervals (CIs) were 1.76 (1.24, 2.50), p<0.01; 1.16 (1.09, 1.22), p<0.01; and 6.29 (5.30, 7.48), p<0.01, respectively. IC urinary diversion performed better than ONB in relation to urinary tract infection rates and ureteric stricture rates, OR and 95% CI 0.67 (0.58, 0.77), p<0.01; and 0.70 (0.55, 0.89), p<0.01, respectively.
CONCLUSIONS
Our results show that there is no significantly increased morbidity with ONB compared to IC. Selection of either urinary diversion technique should be based on factors such as tumor stage, comorbidities, surgical experience, and patient acceptance of postoperative sequalae.
PubMed: 32701445
DOI: 10.5489/cuaj.6466 -
Frontiers in Surgery 2023Bladder cancer is the ninth most common malignant tumor worldwide. As an effective evidence-based multidisciplinary protocol, the enhanced recovery after surgery (ERAS)... (Review)
Review
BACKGROUND
Bladder cancer is the ninth most common malignant tumor worldwide. As an effective evidence-based multidisciplinary protocol, the enhanced recovery after surgery (ERAS) program is practiced in many surgical disciplines. However, the function of ERAS after radical cystectomy remains controversial. This systematic review and meta-analysis aims to research the impact of ERAS on radical cystectomy.
METHODS
A systematic literature search on PubMed, EMBASE, SCOPUS, and the Cochrane Library databases was conducted in April 2022 to identify the studies that performed the ERAS program in radical cystectomy. Studies were selected, data extraction was performed independently by two reviewers, and quality was assessed using a random effects model to calculate the overall effect size. The odds ratio and standardized mean difference (SMD) with a 95% confidence interval (CI) served as the summary statistics for the meta-analysis. A sensitivity analysis was subsequently performed.
RESULTS
A total of 25 studies with 4,083 patients were enrolled. The meta-analysis showed that the complications (OR = 0.76; 95% CI: 0.63-0.90), transfusion rate (OR = 0.59; 95% CI: 0.39-0.90), readmission rate (OR = 0.79; 95% CI: 0.64-0.96), length of stay (SMD = -0.79; 95% CI: -1.41 to -0.17), and time to first flatus (SMD = -1.16; 95% CI: -1.58 to -0.74) were significantly reduced in the ERAS group. However, no significance was found in 90-day mortality and urine leakage.
CONCLUSION
The ERAS program for radical cystectomy can effectively decrease the risk of overall complications, postoperative ileus, readmission rate, transfusion rate, length of stay, and time to first flatus in patients who underwent radical cystectomy with relative safety.
SYSTEMATIC REVIEW REGISTRATION
https://inplasy.com/, identifier INPLASY202250075.
PubMed: 37273829
DOI: 10.3389/fsurg.2023.1101098 -
Canadian Urological Association Journal... Feb 2022This systematic review summarizes the urinary continence, male sexual function, and female sexual function outcomes after robotic-assisted radical cystectomy (RARC).... (Review)
Review
This systematic review summarizes the urinary continence, male sexual function, and female sexual function outcomes after robotic-assisted radical cystectomy (RARC). Greater intracorporeal diversion use, longer followup, and clearly stated urinary continence definitions have revealed RARC urinary continence rates for orthotopic ileal neobladders that are similar to those after open radical cystectomy (ORC) when using the strictest continence definitions. Nerve-sparing technique appears to be well-used in most studies, with short-term and long-term RARC potency rates similar those after ORC when using the strictest potency definitions. Level 1 evidence using validated questionnaires suggests that quality of life outcomes are also similar.
PubMed: 34582337
DOI: 10.5489/cuaj.7313 -
Actas Urologicas Espanolas Sep 2017Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and... (Review)
Review
Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.
Topics: Cystectomy; Humans; Laparoscopy; Postoperative Complications; Robotic Surgical Procedures; Treatment Outcome
PubMed: 27908634
DOI: 10.1016/j.acuro.2016.05.009 -
Surgical Oncology Sep 2016Radical cystectomy and urinary diversion is the treatment of choice for invasive bladder cancer. Quality of life (QOL) is an important outcome of surgery. This review... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Radical cystectomy and urinary diversion is the treatment of choice for invasive bladder cancer. Quality of life (QOL) is an important outcome of surgery. This review compares the QOL after continent and incontinent urinary diversion in radical cystectomy for patients with primary invasive bladder cancer.
METHODS
A systematic review and meta-analysis of clinical studies published after January 2000 was performed according to the PRISMA guidelines. Quality appraisal and data tabulation were performed using pre-determined forms. Data were synthesised by narrative review and random-effects meta-analysis using standardized response means. Heterogeneity and bias was assessed by Tau(2) and I(2) values and Funnel plots.
RESULTS
Twenty-nine studies (3754 patients) were included for review. Pooled post-operative FACT and SF-36 scores showed no difference in overall QOL between continent and incontinent diversion (p = 0.31). Subgroup analysis demonstrated greater improvement in physical health for incontinent (p = 0.002) compared to continent diversions, but no differences in mental health (p = 0.35) and social health (p = 0.81). Qualitative analysis showed patients with neobladder had superior emotional function and body image compared to cutaneous diversion. QOL may improve to similar or better levels compared to baseline after 1 year, but data remains scarce. Patients report poor urinary and sexual function after surgery compared the general population. Long-term QOL is unclear. Levels of heterogeneity and bias were low.
CONCLUSIONS
QOL after radical cystectomy is comparable after either continent or incontinent urinary diversion. Post-operative QOL may improve, but urinary and sexual dysfunction remains inferior to the general population. Patient choice is key to selection of reconstruction method.
Topics: Cystectomy; Humans; Prognosis; Quality of Life; Urinary Bladder Neoplasms
PubMed: 27566035
DOI: 10.1016/j.suronc.2016.05.027