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JAMA Jun 2022Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with... (Comparative Study)
Comparative Study Randomized Controlled Trial
Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer: A Randomized Clinical Trial.
IMPORTANCE
Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with open radical cystectomy for bladder cancer.
OBJECTIVES
To compare recovery and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction vs open radical cystectomy.
DESIGN, SETTING, AND PARTICIPANTS
Randomized clinical trial of patients with nonmetastatic bladder cancer recruited at 9 sites in the UK, from March 2017-March 2020. Follow-up was conducted at 90 days, 6 months, and 12 months, with final follow-up on September 23, 2021.
INTERVENTIONS
Participants were randomized to receive robot-assisted radical cystectomy with intracorporeal reconstruction (n = 169) or open radical cystectomy (n = 169).
MAIN OUTCOMES AND MEASURES
The primary outcome was the number of days alive and out of the hospital within 90 days of surgery. There were 20 secondary outcomes, including complications, quality of life, disability, stamina, activity levels, and survival. Analyses were adjusted for the type of diversion and center.
RESULTS
Among 338 randomized participants, 317 underwent radical cystectomy (mean age, 69 years; 67 women [21%]; 107 [34%] received neoadjuvant chemotherapy; 282 [89%] underwent ileal conduit reconstruction); the primary outcome was analyzed in 305 (96%). The median number of days alive and out of the hospital within 90 days of surgery was 82 (IQR, 76-84) for patients undergoing robotic surgery vs 80 (IQR, 72-83) for open surgery (adjusted difference, 2.2 days [95% CI, 0.50-3.85]; P = .01). Thromboembolic complications (1.9% vs 8.3%; difference, -6.5% [95% CI, -11.4% to -1.4%]) and wound complications (5.6% vs 16.0%; difference, -11.7% [95% CI, -18.6% to -4.6%]) were less common with robotic surgery than open surgery. Participants undergoing open surgery reported worse quality of life vs robotic surgery at 5 weeks (difference in mean European Quality of Life 5-Dimension, 5-Level instrument scores, -0.07 [95% CI, -0.11 to -0.03]; P = .003) and greater disability at 5 weeks (difference in World Health Organization Disability Assessment Schedule 2.0 scores, 0.48 [95% CI, 0.15-0.73]; P = .003) and at 12 weeks (difference in WHODAS 2.0 scores, 0.38 [95% CI, 0.09-0.68]; P = .01); the differences were not significant after 12 weeks. There were no statistically significant differences in cancer recurrence (29/161 [18%] vs 25/156 [16%] after robotic and open surgery, respectively) and overall mortality (23/161 [14.3%] vs 23/156 [14.7%]), respectively) at median follow-up of 18.4 months (IQR, 12.8-21.1).
CONCLUSIONS AND RELEVANCE
Among patients with nonmetastatic bladder cancer undergoing radical cystectomy, treatment with robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy resulted in a statistically significant increase in days alive and out of the hospital over 90 days. However, the clinical importance of these findings remains uncertain.
TRIAL REGISTRATION
ISRCTN Identifier: ISRCTN13680280; ClinicalTrials.gov Identifier: NCT03049410.
Topics: Aged; Cystectomy; Female; Humans; Male; Morbidity; Neoplasm Recurrence, Local; Postoperative Complications; Quality of Life; Retrospective Studies; Robotic Surgical Procedures; Robotics; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 35569079
DOI: 10.1001/jama.2022.7393 -
International Braz J Urol : Official... 2020Standard management of muscle-invasive bladder cancer involves radical cystectomy with pelvic lymph node dissection. However, patients may be ineligible for surgery or... (Review)
Review
BACKGROUND
Standard management of muscle-invasive bladder cancer involves radical cystectomy with pelvic lymph node dissection. However, patients may be ineligible for surgery or may wish to avoid the morbidity of cystectomy due to quality of life concerns. Bladder preservation therapies have emerged as alternatives treatment options that can provide comparable oncologic outcomes while maintaining patients' quality of life.
OBJECTIVE
To review bladder preservation therapies, patient selection criteria, and functional and oncologic outcomes for BPT in muscle-invasive bladder cancer.
MATERIALS AND METHODS
We conducted a comprehensive literature review of bladder preservation therapies in Pubmed and Embase.
DISCUSSION
The ideal patient for BPT has low-volume T2 disease, absence of CIS, absence of hydronephrosis, and a maximal TURBT with regular surveillance. Technological advancements involving cancer staging, TURBT technique, and chemotherapy and radiation therapy regimens have improved BPT outcomes, with oncologic outcomes now comparable to those of radical cystectomy. Advancements in BPT also includes a heightened focus on improving quality of life for patients undergoing bladder preservation. Preservation strategies with most evidence for use include trimodality therapy and partial cystectomy with pelvic lymph node dissection.
CONCLUSIONS
This review highlights the breadth of strategies that aim to preserve a patient's bladder while still optimizing local tumor control and overall survival. Future areas for innovation include the use of predictive biomarkers and implementation of immunotherapy, moving the field towards patient-tailored care.
Topics: Combined Modality Therapy; Cystectomy; Humans; Neoplasm Invasiveness; Neoplasm Staging; Organ Sparing Treatments; Urinary Bladder Neoplasms
PubMed: 31961624
DOI: 10.1590/S1677-5538.IBJU.2020.99.01 -
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 -
International Braz J Urol : Official... 2022A systematic review of the literature with available published literature to compare ileal conduit (IC) and cutaneous ureterostomy (CU) urinary diversions (UD) in terms... (Review)
Review
PURPOSE
A systematic review of the literature with available published literature to compare ileal conduit (IC) and cutaneous ureterostomy (CU) urinary diversions (UD) in terms of perioperative, functional, and oncological outcomes of high-risk elderly patients treated with radical cystectomy (RC). Protocol Registration: PROSPERO ID CRD42020168851.
MATERIALS AND METHODS
A systematic review, according to the PRISMA Statement, was performed. Search through the Medline, Embase, Scopus, Scielo, Lilacs, and Cochrane Database until July 2020.
RESULTS
The literature search yielded 2,883 citations and were selected eight studies, including 1096 patients. A total of 707 patients underwent IC and 389 CU. Surgical procedures and outcomes, complications, mortality, and quality of life were analyzed.
CONCLUSIONS
CU seems to be a safe alternative for the elderly and more frail patients. It is associated with faster surgery, less blood loss, lower transfusion rates, a lower necessity of intensive care, and shorter hospital stay. According to most studies, complications are less frequent after CU, even though mortality rates are similar. Studies with long-term follow up are awaited.
Topics: Aged; Cystectomy; Humans; Quality of Life; Ureterostomy; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 33861058
DOI: 10.1590/S1677-5538.IBJU.2020.0892 -
Journal of Veterinary Internal Medicine Jan 2020Lower urinary tract transitional cell carcinoma (TCC) is an important but rarely described disease of cats.
BACKGROUND
Lower urinary tract transitional cell carcinoma (TCC) is an important but rarely described disease of cats.
OBJECTIVES
To report the clinical characteristics, treatments, and outcomes in a cohort of cats with lower urinary tract TCC and to test identified variables for prognostic relevance.
ANIMALS
One-hundred eighteen client-owned cats with lower urinary tract carcinoma.
METHODS
Medical records were retrospectively reviewed to obtain information regarding clinical characteristics, treatments, and outcomes. Recorded variables were analyzed statistically.
RESULTS
Median age of affected cats was 15 years (range, 5.0-20.8 years) and median duration of clinical signs was 30 days (range, 0-730 days). The trigone was the most common tumor location (32/118; 27.1%) as assessed by ultrasound examination, cystoscopy, or both. Treatment was carried out in 73 of 118 (61.9%) cats. Metastatic disease was documented in 25 of 118 (21.2%) cats. Median progression-free survival and survival time for all cats were 113 days (95% confidence interval [CI], 69-153) and 155 days (95% CI, 110-222), respectively. Survival increased significantly (P < .001) when comparing cats across the ordered treatment groups: no treatment, treatment without partial cystectomy, and treatment with partial cystectomy. Partial cystectomy (hazard ratio [HR], 0.31; 95% CI, 0.17-0.87) and treatment with nonsteroidal anti-inflammatory drugs (HR, 0.55; 95% CI, 0.33-0.93) were significantly associated with longer survival times.
CONCLUSIONS AND CLINICAL IMPORTANCE
The results support treatment using partial cystectomy and NSAIDs in cats with TCC.
Topics: Animals; Anti-Inflammatory Agents, Non-Steroidal; Carcinoma, Transitional Cell; Cat Diseases; Cats; Cohort Studies; Cystectomy; Retrospective Studies; Treatment Outcome; Urinary Bladder Neoplasms
PubMed: 31721288
DOI: 10.1111/jvim.15656 -
Archivos Espanoles de Urologia Jul 2019Bladder leiomyomas are rare benign tumors; their common presentation are irritative and obstructive urinary symptoms. The treatment is complete surgical resection.
UNLABELLED
Bladder leiomyomas are rare benign tumors; their common presentation are irritative and obstructive urinary symptoms. The treatment is complete surgical resection.
OBJECTIVE
To present our experience in the diagnosis and the treatment of bladder leiomyoma.
METHODS
A series of three clinical cases.
RESULTS
In our series, two patients were women and one was man. The mean age was 33 years. Two women presented with irritative urinary symptoms and palpation of a pelvic mass, and the man was asymptomatic. Ultrasound showed the presence of an adnexal mass with left hydronephrosis in a female patient, bladder tumor in another female patient and pelvic mass of unknown etiology in the male patient. CT scan and MRI demonstrated the bladder origin of the lesion. A biopsy confirmed a bladder leiomyoma. Surgical treatment was partial cystectomy in all patients, and in one of them, nephrectomy was performed. During follow-up, all patients were asymptomatic and without recurrence.
CONCLUSIONS
Imaging studies guide to diagnosis. Transurethral resection is recommended in lesions smaller than 3 cm. and enucleation or partial cystectomy in larger lesions. Prognosis is good.
Topics: Adult; Cystectomy; Female; Humans; Leiomyoma; Male; Neoplasm Recurrence, Local; Urinary Bladder Neoplasms
PubMed: 31274128
DOI: No ID Found -
Ugeskrift For Laeger Dec 2022In this case report, a 58-year-old male with comorbidities of BMI 41 kg/m2, hypertension and diabetes type 2 underwent radical cystectomy. The operation was performed in...
In this case report, a 58-year-old male with comorbidities of BMI 41 kg/m2, hypertension and diabetes type 2 underwent radical cystectomy. The operation was performed in 30-degree Trendelenburg and lasted > 7 hours with a total blood loss of 850 ml. The patient presented with painless bilateral vision loss upon awakening. MRI, CT and CT angiography of the cerebrum was performed and revealed arteriosclerosis and hypophysis adenoma. Neurological and ophthalmic consults were performed. Three weeks post-operatively, bilateral papillary atrophy was present, and posterior ischaemic optic neuropathy was confirmed.
Topics: Male; Humans; Middle Aged; Gynecomastia; Cystectomy; Optic Neuropathy, Ischemic; Breast; Mammography
PubMed: 36621877
DOI: No ID Found -
Journal of Endourology Sep 2021Radical cystectomy is the standard of care for patients with nonmetastatic high-risk bladder cancer. Robotic approach to radical cystectomy has been developed to reduce...
Radical cystectomy is the standard of care for patients with nonmetastatic high-risk bladder cancer. Robotic approach to radical cystectomy has been developed to reduce perioperative morbidities and enhance postoperative recovery while maintaining oncologic control. Classically, radical cystectomy in female patient entails anterior pelvic exenteration with removal of the bladder, uterus, fallopian tubes, ovaries, anterior vaginal wall, and urethra. Pelvic organ-sparing radical cystectomy has been adopted in carefully selected patients to optimize postoperative sexual and urinary function, especially in those undergoing orthotopic urinary diversion. In this article, we describe our techniques of both classical and organ-sparing robot-assisted laparoscopic radical cystectomy in female patients. We also review patient selection criteria, perioperative management, and alternative approaches to improve operative outcomes in female patients.
Topics: Cystectomy; Female; Humans; Robotic Surgical Procedures; Robotics; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 34499552
DOI: 10.1089/end.2020.1190 -
Ugeskrift For Laeger Apr 2023Bladder cancer is the fifth most frequently diagnosed cancer in Europe, with major healthcare costs. For patients with non-muscle invasive bladder cancer, recurrences,... (Review)
Review
Bladder cancer is the fifth most frequently diagnosed cancer in Europe, with major healthcare costs. For patients with non-muscle invasive bladder cancer, recurrences, treatment and surveillance regimes with multiple invasive procedures are a significant burden. Muscle invasive or metastatic disease is treated with radical surgery, radiation therapy and/or systemic chemo- or immunotherapy, with a five-year overall survival of around 50% and long-term quality of life issues for survivors. We present a brief overview of bladder cancer in various stages and give examples of new developments.
Topics: Humans; Cystectomy; Europe; Quality of Life; Urinary Bladder Neoplasms
PubMed: 37057696
DOI: No ID Found -
Investigative and Clinical Urology Mar 2023Open radical cystectomy (ORC) is associated with high rates of perioperative morbidity and mortality, owing to its extensive surgical nature and the high frequency of... (Review)
Review
Open radical cystectomy (ORC) is associated with high rates of perioperative morbidity and mortality, owing to its extensive surgical nature and the high frequency of multiple co-morbidities among patients. As an alternative, robot-assisted radical cystectomy (RARC) has been increasingly adopted worldwide, being a reliable treatment option that utilizes minimally invasive surgery. Seventeen years have passed since the advent of the RARC, and comprehensive long-term follow-up data are now becoming available. The present review focuses on the current knowledge of RARC in 2023, and analyzes various aspects, including oncological outcomes, peri/post-operative complications, post-operative quality of life (QoL) change, and cost-effectiveness. Oncologically, RARC showed comparable oncological outcomes to ORC. With regard to complications, RARC was associated with lower estimated blood loss, lower intraoperative transfusion rates, shorter length of stay, lower risk of Clavien-Dindo grade III-V complications, and lower 90-day rehospitalization rates than ORC. In particular, RARC with intracorporeal urinary diversion (ICUD) performed by high-volume centers significantly reduced the risk of post-operative major complications. In terms of post-operative QoL, RARC with extracorporeal urinary diversion (ECUD) showed comparable results to ORC, while RARC with ICUD was superior in some respects. As the RARC implementation rate increases and the learning curve is overcome, more prospective studies and randomized controlled trials with large-scale patients are expected to be conducted in the future. Accordingly, sub-group analysis in various groups such as ECUD, ICUD, continent and non-continent urinary diversion, etc. is considered to be possible.
Topics: Humans; Cystectomy; Quality of Life; Prospective Studies; Robotics; Learning Curve; Postoperative Complications; Randomized Controlled Trials as Topic
PubMed: 36882169
DOI: 10.4111/icu.20220384