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European Urology Oct 2023Differences in recovery, oncological, and quality of life (QoL) outcomes between open radical cystectomy (ORC) and robot-assisted radical cystectomy (RARC) for patients... (Meta-Analysis)
Meta-Analysis Review
Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy: A Systematic Review and Meta-analysis of Perioperative, Oncological, and Quality of Life Outcomes Using Randomized Controlled Trials.
CONTEXT
Differences in recovery, oncological, and quality of life (QoL) outcomes between open radical cystectomy (ORC) and robot-assisted radical cystectomy (RARC) for patients with bladder cancer are unclear.
OBJECTIVE
This review aims to compare these outcomes within randomized trials of ORC and RARC in this context. The primary outcome was the rate of 90-d perioperative events. The secondary outcomes included operative, pathological, survival, and health-related QoL (HRQoL) measures.
EVIDENCE ACQUISITION
Systematic literature searches of MEDLINE, Embase, Web of Science, and clinicaltrials.gov were performed up to May 31, 2022.
EVIDENCE SYNTHESIS
Eight trials, reporting 1024 participants, were included. RARC was associated with a shorter hospital length of stay (LOS; mean difference [MD] 0.21, 95% confidence interval [CI] 0.03-0.39, p = 0.02) than and similar complication rates to ORC. ORC was associated with higher thromboembolic events (odds ratio [OR] 1.84, 95% CI 1.02-3.31, p = 0.04). ORC was associated with more blood loss (MD 322 ml, 95% CI 193-450, p < 0.001) and transfusions (OR 2.35, 95% CI 1.65-3.36, p < 0.001), but shorter operative time (MD 76 min, 95% CI 39-112, p < 0.001) than RARC. No differences in lymph node yield (MD 1.07, 95% CI -1.73 to 3.86, p = 0.5) or positive surgical margin rates (OR 0.95, 95% CI 0.54-1.67, p = 0.9) were present. RARC was associated with better physical functioning or well-being (standardized MD 0.47, 95% CI 0.29-0.65, p < 0.001) and role functioning (MD 8.8, 95% CI 2.4-15.1, p = 0.007), but no improvement in overall HRQoL. No differences in progression-free survival or overall survival were seen. Limitations may include a lack of generalization given trial patients.
CONCLUSIONS
RARC offers various perioperative benefits over ORC. It may be more suitable in patients wishing to avoid blood transfusion, those wanting a shorter LOS, or those at a high risk of thromboembolic events.
PATIENT SUMMARY
This study compares robot-assisted keyhole surgery with open surgery for bladder cancer. The robot-assisted approach offered less blood loss, shorter hospital stays, and fewer blood clots. No other differences were seen.
Topics: Humans; Cystectomy; Quality of Life; Robotics; Treatment Outcome; Postoperative Complications; Randomized Controlled Trials as Topic; Urinary Bladder Neoplasms; Robotic Surgical Procedures
PubMed: 37169638
DOI: 10.1016/j.eururo.2023.04.004 -
European Urology Focus Nov 2023Radical cystectomy is considered a procedure of high complexity with a relative high complication rate. (Meta-Analysis)
Meta-Analysis Review
CONTEXT
Radical cystectomy is considered a procedure of high complexity with a relative high complication rate.
OBJECTIVE
To systematically summarize the literature regarding the complications of radical cystectomy and the factors that contribute to them.
EVIDENCE ACQUISITION
We searched MEDLINE/PubMed, ClinicalTrials.gov, and Cochrane Library, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for randomized controlled trials (RCTs) on complications related to radical cystectomy.
EVIDENCE SYNTHESIS
A total of 3766 studies were screened, and 44 studies were included in this systematic review and meta-analysis. Complications following radical cystectomy are quite common. The most common complications were gastrointestinal complications (20%), infectious complications (17%), and ileus (14%). The majority of complications occurring were Clavien I-II (45%). Specific measurable patient factors are related to certain complications and can be used to stratify risk and assist in preoperative counseling, while proper design of high-quality RCTs may better reflect real-life complication rates.
CONCLUSIONS
In our study, RCTs with a low risk of bias had higher complication rates than studies with a high risk of bias, underlining the need for further improvement on complication reporting in order to refine surgical outcomes.
PATIENT SUMMARY
Radical cystectomy is usually followed by high complication rates, which affect patients and are, in turn, strongly associated with patients' preoperative health status.
Topics: Humans; Cystectomy; Urinary Bladder Neoplasms; Robotic Surgical Procedures; Postoperative Complications; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 37246124
DOI: 10.1016/j.euf.2023.05.002 -
Current Opinion in Obstetrics &... Oct 2023The use of hormonally suppressive medication to reduce levels of reproductive hormones around the time of surgery is widely used in the management of endometriosis. This...
PURPOSE OF REVIEW
The use of hormonally suppressive medication to reduce levels of reproductive hormones around the time of surgery is widely used in the management of endometriosis. This review summarizes the current evidence concerning the perioperative use of hormonal treatment in the management of endometriosis.
RECENT FINDINGS
European Society of Human Reproduction and Embryology (ESHRE) guidanceSurgical Outcomes and Complications of Laparoscopic Hysterectomy for Endometriosis: A Multicentre Cohort StudyPre and postsurgical medical therapy for endometriosis surgery. Cochrane 2020Postoperative hormonal treatment for prevention of endometrioma recurrence after ovarian cystectomy: a systematic review and network meta-analysis. BJOG 2021.
SUMMARY
The literature highlights the importance of hormonal treatment for symptom relief, reduced surgical complications and postoperative benefits, including a reduction in pain, disease recurrence and improved pregnancy rates. The treatment of endometriosis can be broadly categorized into medical, commonly using hormonal suppression medications and surgical, in which endometriosis tissue is excised or ablated. This review aims to outline current management strategies and examines the relationship between the two treatment modalities.
Topics: Female; Humans; Pregnancy; Endometriosis; Hysterectomy; Ovariectomy; Pain; Postoperative Period
PubMed: 37610988
DOI: 10.1097/GCO.0000000000000902 -
Animals : An Open Access Journal From... Sep 2023This review provides a summary of the literature encompassing partial and total cystectomy procedures in dogs and subsequent conclusions that can be drawn. Surgical... (Review)
Review
This review provides a summary of the literature encompassing partial and total cystectomy procedures in dogs and subsequent conclusions that can be drawn. Surgical excision as a component of treatment for lower urinary tract neoplasia in dogs may enhance survival time and result in acceptable quality of life, though risk for surgical complications is substantial, particularly following total cystectomy procedures. However, for dogs with urothelial carcinoma, cystectomy is generally not considered curative and disease progression is common. Appropriate case selection and thorough preoperative discussion with owners regarding potential risks and benefits of cystectomy are imperative for successful outcomes.
PubMed: 37760296
DOI: 10.3390/ani13182896 -
Annals of Surgical Oncology Sep 2023This study aimed to compare perioperative and oncologic outcomes of extraperitoneal radical cystectomy (EPRC) and transperitoneal radical cystectomy (TPRC). (Meta-Analysis)
Meta-Analysis
BACKGROUND
This study aimed to compare perioperative and oncologic outcomes of extraperitoneal radical cystectomy (EPRC) and transperitoneal radical cystectomy (TPRC).
METHODS
A systematical search of multiple scientific databases was performed in September 2022. The systematic review and cumulative meta-analysis of the primary outcomes of interest were performed according to the PRISMA and AMSTAR guidelines and registered in the PROSPERO database (PROSPERO [CRD42022359322]).
RESULTS
The review and analysis included eight studies with 989 participants. No significant differences were found between EPRC and TPRC in terms of operation time, estimated blood loss (EBL), hospital length of stay (LOS), or transfusion. A shorter exhaust time (standardized mean difference [SMD] - 0.59; 95 % confidence interval [CI] - 0.97 to 0.21; p = 0.002) and time to liquid intake (SMD, - 0.56; 95 % CI - 1.07 to 0.04; p = 0.03) were associated with EPRC. No clinically meaningful difference was observed in terms of postoperative infection, wound complications, postoperative genitourinary complications, late postoperative complications, early major complications, or late major complications. However, EPRC was related to lower incidences of early postoperative complications (odds ratio [OR], 0.66; 95 % CI 0.51-0.86; p = 0.002), gastrointestinal complications (OR 0.28; 95 % CI 0 0.17-0.46; p < 0.00001), and postoperative ileus (OR 0.38; 95 % CI 0.25-0.59; p < 0.0001). A higher incidence of postoperative lymphocele was associated with EPRC (OR 3.05; 95 % CI 1.13-8.25; p = 0.03). No clinically meaningful difference was found in terms of positive surgical margin (PSM), local recurrence, distant metastasis, or OS.
CONCLUSIONS
Although EPRC had a higher incidence of lymphoceles than TPRC, it was found to have similar oncologic outcomes and fewer early complications, particularly in terms of postoperative gastrointestinal complications and ileus. These results suggest that EPRC is a safe option both functionally and oncologically.
Topics: Humans; Cystectomy; Urinary Bladder; Urinary Bladder Neoplasms; Ileus; Postoperative Complications; Robotic Surgical Procedures; Treatment Outcome
PubMed: 37344747
DOI: 10.1245/s10434-023-13744-5 -
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 -
Medicina (Kaunas, Lithuania) Sep 2023: The most common sites of implantation of endometriotic tissue are the ovaries. Endometriomas are present in most cases of endometriosis (up to 45%). Although... (Meta-Analysis)
Meta-Analysis Review
: The most common sites of implantation of endometriotic tissue are the ovaries. Endometriomas are present in most cases of endometriosis (up to 45%). Although laparoscopic cystectomy is the standard of care in endometrioma, new strategies have been set up to minimize iatrogenic injuries to ovarian tissue. Sclerotherapy consists of injecting alcohol into the endometrioma to denature the amino acidic components of its pseudocapsule. The aim of this systematic review and meta-analysis is to compare clinical and pregnancy outcomes in surgery and sclerotherapy. : Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched PubMed, EMBASE, Scopus, Google Scholar, Clinical-trials.gov, and the Cochrane Central Register of Controlled Trials databases in January 2023, adopting the string "Endometriosis and sclerotherapy". We made no limitations on the country and year of publication. We included the studies containing Success Rate (SR), Recurrence Rate (RR), Pregnancy Rate (PR) before and after the procedure. We used comparative studies for meta-analysis. : A total of 29 studies fulfilled inclusion criteria, 7 retrospective observational studies and 22 prospective studies. Eight comparative studies were enrolled in meta-analysis. Patients were analyzed concerning the number of recurrences and pregnancies in surgery, and compared with sclerotherapy. Four studies showed SR > 80.0%, and only two had SR < 80.0%, of which one consisted of tetracycline instillation. Only 1 study had 100% PR, the other 14 reported PR > 30.0%, whereas six had PR < 30.0%, of which one showed 0.0% PR with ethanol injection at two-thirds of the cyst fluid volume. Meta-analysis highlighted a non-significant lower incidence of recurrence in the surgery group compared to the sclerotherapy group ( = 0.87). In parallel, the surgery group showed a non-significant better PR than the sclerotherapy group ( = 0.08). : Despite sclerotherapy having a minor incidence of postoperative complications compared to surgery, the latter is associated with a lower RR and better PR. However, those data assert the importance of a targeted therapy according to preoperative conditions and reproductive potential.
Topics: Female; Pregnancy; Humans; Sclerotherapy; Endometriosis; Prospective Studies; Retrospective Studies; Fertility
PubMed: 37763762
DOI: 10.3390/medicina59091643 -
Urology Aug 2023To collate available data via systematic review considering etiology, presentation, and treatment of Uro-Symphyseal Fistula (USF) in order to inform a contemporary... (Review)
Review
OBJECTIVE
To collate available data via systematic review considering etiology, presentation, and treatment of Uro-Symphyseal Fistula (USF) in order to inform a contemporary management framework.
MATERIALS AND METHODS
A systematic review was performed according to the Cochrane Handbook and registered in PROSPERO (CRD42021232954). MEDLINE and CENTRAL databases were searched for manuscripts considering USF published between 2000 and 2022. Full text manuscripts were reviewed for clinical data. Univariate statistical analysis was performed where possible.
RESULTS
A total of 31 manuscripts, comprising 248 USF cases, met inclusion criteria. Suprapubic pain and difficulty ambulating were common symptoms. MRI confirmed the diagnosis in 95% of cases. Radiotherapy for prostate cancer was the most common predisposing factor (93%). Among these patients, prior endoscopic bladder outlet surgery was common (83%; bladder neck incision/urethral dilatation n = 59, TURP/GLL PVP n = 34). In those with prior prostatic radiation, conservative management failed in 96% of cases. Cystectomy with urinary diversion (86% n = 184) was favored over bladder-sparing techniques (14% (n = 30) after prior radiation. In radiation naïve patients, conservative management failed in 72% of patients, resulting in either open fistula repair with flap (62%) or radical prostatectomy (28%).
CONCLUSION
Prior radiotherapy is a significant risk factor for USF and almost always requires definitive major surgery (debridement, cystectomy, and urinary diversion). On the basis of the findings within this systematic review, we present management principles that may assist clinicians with these complex cases. Further research into pathogenesis, prevention, and optimal treatment approach is required.
Topics: Male; Humans; Fistula; Cystectomy; Urinary Bladder; Urologic Surgical Procedures; Urinary Diversion; Urinary Fistula
PubMed: 37182647
DOI: 10.1016/j.urology.2023.05.002 -
Cureus Dec 2023Muscle-invasive bladder cancer poses a significant clinical challenge that necessitates effective therapeutic interventions. Radical cystectomy is a primary treatment... (Review)
Review
Muscle-invasive bladder cancer poses a significant clinical challenge that necessitates effective therapeutic interventions. Radical cystectomy is a primary treatment option, but a comprehensive understanding of its outcomes is crucial for informed clinical decision-making. This systematic review and meta-analysis aimed to investigate and summarize the outcomes associated with radical cystectomy as a primary treatment for muscle-invasive bladder cancer with a focus on survival rates, complications, and quality of life. A systematic search across databases-PubMed, Google Scholar, and others-covered studies from 2017 onwards. Included were studies reporting survival rates, complications, and quality of life post-radical cystectomy in muscle-invasive bladder cancer patients, including randomized controlled trials, cohort, and observational studies. Multidimensional analysis revealed promising findings regarding the efficacy of radical cystectomy in muscle-invasive bladder cancer. Survival outcomes, including overall survival and disease-specific mortality, have demonstrated significant improvements, particularly in recent randomized controlled trials and cohort studies. Complications associated with the surgical procedure, such as positive surgical margins and lymph node yields, were generally acceptable. Quality of life outcomes post-radical cystectomy exhibited positive trends, although variations were noted in the emotional and social domains. This review underscores radical cystectomy's role in enhancing overall survival and reducing disease-specific mortality in muscle-invasive bladder cancer. Despite reported complications, recent studies support its acceptable risk profile. Detailed examination of various factors contributes to a comprehensive understanding of the procedure. These findings emphasize the importance of individualized treatment approaches in the management of muscle-invasive bladder cancer, considering both oncological efficacy and perioperative outcomes. Radical cystectomy remains fundamental in urological oncology, with ongoing advancements refining its significance.
PubMed: 38229790
DOI: 10.7759/cureus.50646 -
PloS One 2023One of the most complex surgeries including radical cystectomy (RC) has a high rate of morbidity. The standard approach for the muscle-invasive bladder is conventional... (Meta-Analysis)
Meta-Analysis
BACKGROUND
One of the most complex surgeries including radical cystectomy (RC) has a high rate of morbidity. The standard approach for the muscle-invasive bladder is conventional transperitoneal radical cystectomy. However, the procedure is associated with significant morbidities like ileus, urinary leak, bleeding, and infection. The aim of this study is to compare the transperitoneal RC approach with the extraperitoneal RC approach in the treatment of bladder cancer patients. The outcomes of this study are Operative time, Estimated Blood Loss, Hospital Stay, Post-Operative Ileus, Infection, and Major Complication (Clavien-Dindo Grade 3-5).
METHODS
PubMed, Cochrane Library, and Science Direct were systematically searched for different publications related to the meta-analysis. Keywords used for searching were Radical Cystectomy AND Extraperitoneal AND Transperitoneal up until 31st August 2022. The studies were screened for our eligibility criteria. Demographic parameters, perioperative variables, and postoperative complications were recorded and analyzed. The Newcastle-Ottawa Scale was used to evaluate the risk of bias in each study. The Review Manager (RevMan) software version 5.4.1 was used for statistical analysis.
RESULTS
Eight studies (3 laparoscopic and 5 open methods) involving 1207 subjects (588 patients using the extraperitoneal approach and 619 using the transperitoneal approach) were included. The incidence of postoperative ileus is significantly lower after the extraperitoneal approach compared to the transperitoneal approach (p < 0.00001). The two techniques did not differ in operative time, estimated blood loss, duration of hospital stay, total infection, and major complication events.
CONCLUSION
This meta-analysis shows that extraperitoneal radical cystectomy benefits in terms of reduced postoperative ileus.
Topics: Humans; Cystectomy; Urinary Bladder; Treatment Outcome; Urinary Bladder Neoplasms; Postoperative Complications; Ileus
PubMed: 38032964
DOI: 10.1371/journal.pone.0294809