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Japanese Journal of Clinical Oncology Oct 2023To determine the impact of postoperative complications on long-term survival outcomes in patients with bladder cancer undergoing radical cystectomy.
OBJECTIVE
To determine the impact of postoperative complications on long-term survival outcomes in patients with bladder cancer undergoing radical cystectomy.
METHODS
This retrospective multi-institutional study included 766 bladder cancer patients who underwent radical cystectomy between 2011 and 2017. Patient characteristics, perioperative outcomes, all complications within 90 days after surgery and survival outcomes were collected. Each complication was graded based on the Clavien-Dindo system, and grouped using a standardized grouping method. The Comprehensive Complication Index, which incorporates all complications into a single formula weighted by their severity, was utilized. Overall survival and recurrence-free survival (local, distant or urothelial recurrences) were stratified by Comprehensive Complication Index (high: ≥26.2; low: <26.2). A multivariate model was utilized to identify independent prognostic factors.
RESULTS
The incidence of any and major complications (≥Clavien-Dindo grade III) was 70 and 24%, respectively. In terms of Comprehensive Complication Index, 34% (261/766) of the patients had ≥26.2. Patients with Comprehensive Complication Index ≥ 26.2 had shorter overall survival (4-year, 59.5 vs. 69.8%, respectively, log-rank test, P = 0.0037) and recurrence free survival (51.9 vs. 60.1%, respectively, P = 0.0234), than those with Comprehensive Complication Index < 26.2. The Cox multivariate model identified the age, performance status, pT-stage, pN-stage and higher CCI (overall survival: HR = 1.35, P = 0.0174, recurrence-free survival: HR = 1.26, P = 0.0443) as independent predictors of both overall survivial and recurrence-free survival.
CONCLUSIONS
Postoperative complications assessed by Comprehensive Complication Index had adverse effects on long-term survival outcomes. Physicians should be aware that major postoperative complications can adversely affect long-term disease control.
Topics: Humans; Cystectomy; Incidence; Postoperative Complications; Retrospective Studies; Treatment Outcome; Urinary Bladder Neoplasms; Cancer Survivors
PubMed: 37461191
DOI: 10.1093/jjco/hyad079 -
World Journal of Urology Jun 2020The aim of this review is to present an anesthesiological overview on surgical safety for radical cystectomy implementing the cornerstones of today's rapidly evolving... (Review)
Review
PURPOSE
The aim of this review is to present an anesthesiological overview on surgical safety for radical cystectomy implementing the cornerstones of today's rapidly evolving field of perioperative medicine.
METHODS
This is a narrative review of current perioperative medicine and surgical safety concepts for major surgery in general with special focus on radical cystectomy.
RESULTS
The tendency for perioperative care and surgical safety is to consider it a continuous proactive pathway rather than a single surgical intervention. It starts at indication for surgery and lasts until full functional recovery. Preoperative optimization leads to superior outcome by mobilizing and/or increasing physiological reserve. Multidisciplinary teamwork involving all the relevant parties from the beginning of the pathway is crucial for outcome rather than an isolated specialist approach. This fact has gained importance in times of an ageing frail population and rising health care cost. We also present our 2019 Cystectomy Enhanced Recovery Approach for optimization of perioperative care for open radical cystectomy in a high caseload center.
CONCLUSIONS
With the implementation of in itself simple but crucial steps in perioperative medicine such as multimodal prehabilitation, safety checks, better perioperative monitoring and enhanced recovery concepts, even complex surgical procedures such as radical cystectomy can be performed safer. Emphasis has to be laid on a more global view of the patients' path through the perioperative process than on the surgical procedure alone.
Topics: Anesthesiology; Attitude of Health Personnel; Clinical Protocols; Cystectomy; Humans; Patient Safety; Perioperative Care; Postoperative Complications
PubMed: 31201522
DOI: 10.1007/s00345-019-02839-y -
European Urology Focus Nov 2023Given the morbidity associated with radical cystectomy (RC) and the significant survival benefit for patients who experience tumor downstaging after neoadjuvant... (Review)
Review
Given the morbidity associated with radical cystectomy (RC) and the significant survival benefit for patients who experience tumor downstaging after neoadjuvant chemotherapy (NAC), there is growing interest in bladder preservation strategies for select patients who have a complete response (CR) to NAC. In this mini-review we discuss the concept of avoiding RC as an alternative option for patients who experience a clinical CR following NAC. Several studies support this concept, with comparable long-term survival outcomes observed for patients with cT0 disease after NAC and patients undergoing RC. However, the definitive approach and the optimal surveillance strategy for patients with a clinical CR who choose bladder preservation are lacking. A dynamic response-driven bladder preservation strategy is a highly anticipated option for patients and is needed to avoid debilitating overtreatment. PATIENT SUMMARY: For selected patients with bladder cancer who experience a complete response to chemotherapy before any surgery, close follow-up might be an alternative option to surgical removal of the bladder without compromising cancer control.
Topics: Humans; Urinary Bladder; Neoadjuvant Therapy; Urinary Bladder Neoplasms; Cystectomy; Pathologic Complete Response
PubMed: 37150628
DOI: 10.1016/j.euf.2023.04.009 -
Clinical Nutrition ESPEN Jun 2023Enhanced recovery after surgery (ERAS®) pathways aim to improve patient outcomes by applying multimodal practices before, during, and after operative procedures....
Impact of nutritional compliance within ERAS protocols for hepatopancreatobiliary, radical cystectomy, and head and neck procedures: A case-matched analysis adjusted for major complications.
BACKGROUND
Enhanced recovery after surgery (ERAS®) pathways aim to improve patient outcomes by applying multimodal practices before, during, and after operative procedures. Compared with standard care before ERAS, we investigated whether compliance to ERAS guidelines for nutritional care, preoperative oral carbohydrate loading and postoperative oral nutrition, was associated with a decrease in hospital length of stay (LOS) after pancreaticoduodenectomy, distal pancreatectomy, hepatectomy, radical cystectomy, and head and neck tumor resection with reconstruction.
METHODS
Compliance to ERAS nutrition recommendations was evaluated. Post-ERAS cohort was retrospectively analyzed. Pre-ERAS cohort consisted of case matched patients one year before ERAS: age more than or less than 65 years, body mass index (BMI) more than greater than or less than 30 kg/m, diabetes mellitus, sex, and procedure. Each cohort consisted of 297 patients. Binary linear regressions evaluated the incremental effect of postoperative nutrition timing and preoperative carbohydrate loading on LOS. Multivariate regressions adjusted for postoperative complications.
RESULTS
Compliance with preoperative carbohydrate loading for the post-ERAS cohort was 81.7%. Mean hospital LOS was significantly shorter for the post-ERAS cohort compared with pre-ERAS cohort (8.3 vs 10.0 days, p < 0.001). By procedure, LOS was significantly shorter for patients undergoing pancreaticoduodenectomy (p = 0.003), distal pancreatectomy (p = 0.014), and head and neck procedures (p = 0.024). Early postoperative oral nutrition was associated with a 3.75-day shorter LOS (p < 0.001); no nutrition was associated with a 3.29-day longer LOS (p < 0.001).
CONCLUSION
Compliance with ERAS protocols for specific nutritional care practices was associated with a statistically significant decrease in LOS without subsequent increases in 30-day readmission rates and positive financial impact. These findings suggest that ERAS guidelines for perioperative nutrition are a strategic pathway to improved patient recovery and value-based care in surgery.
Topics: Humans; Aged; Cystectomy; Retrospective Studies; Postoperative Complications; Pancreaticoduodenectomy; Nutritional Status
PubMed: 37202034
DOI: 10.1016/j.clnesp.2023.03.001 -
The Journal of Urology Mar 2020The RAZOR (Randomized Open versus Robotic Cystectomy) trial revealed noninferior 2-year progression-free survival for robotic radical cystectomy. This update was... (Randomized Controlled Trial)
Randomized Controlled Trial
Predictors of Recurrence, and Progression-Free and Overall Survival following Open versus Robotic Radical Cystectomy: Analysis from the RAZOR Trial with a 3-Year Followup.
PURPOSE
The RAZOR (Randomized Open versus Robotic Cystectomy) trial revealed noninferior 2-year progression-free survival for robotic radical cystectomy. This update was performed with extended followup for 3 years to determine potential differences between the approaches. We also report 3-year overall survival and sought to identify factors predicting recurrence, and progression-free and overall survival.
MATERIALS AND METHODS
We analyzed the per protocol population of 302 patients from the RAZOR study. Cumulative recurrence was estimated using nonbladder cancer death as the competing risk event and the Gray test was applied to assess significance in differences. Progression-free survival and overall survival were estimated by the Kaplan-Meier method and compared with the log rank test. Predictors of outcomes were determined by Cox proportional hazard analysis.
RESULTS
Estimated progression-free survival at 36 months was 68.4% (95% CI 60.1-75.3) and 65.4% (95% CI 56.8-72.7) in the robotic and open groups, respectively (p=0.600). At 36 months overall survival was 73.9% (95% CI 65.5-80.5) and 68.5% (95% CI 59.8-75.7) in the robotic and open groups, respectively (p=0.334). There was no significant difference in the cumulative incidence rates of recurrence (p=0.802). Patient age greater than 70 years, poor performance status and major complications were significant predictors of 36-month progression-free survival. Stage and positive margins were significant predictors of recurrence, and progression-free and overall survival. Surgical approach was not a significant predictor of any outcome.
CONCLUSIONS
This analysis showed no difference in recurrence, 3-year progression-free survival or 3-year overall survival for robotic vs open radical cystectomy. It provides important prospective data on the oncologic efficacy of robotic radical cystectomy and high level data for patient counseling.
Topics: Aged; Cystectomy; Disease Progression; Female; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Robotic Surgical Procedures; Survival Rate; United States; Urinary Bladder Neoplasms
PubMed: 31549935
DOI: 10.1097/JU.0000000000000565 -
International Journal of Surgery... Jul 2022Although radical cystectomy is considered as the first choice for muscle-invasive bladder cancer (MIBC), there are also concerns regarding the cost of long-term...
INTRODUCTION
Although radical cystectomy is considered as the first choice for muscle-invasive bladder cancer (MIBC), there are also concerns regarding the cost of long-term morbidity, loss of body image, and compromised quality of life. Transurethral resection of bladder tumor (TURBT) is a candidate for bladder sparing treatments, but its viability as a substitute for radical cystectomy is questionable. Therefore, we conducted this population-based study to investigate the prevalence of TURBT in the treatments of T2-stage MIBC in the United States, and to compare its therapeutic efficiency with that of radical cystectomy.
METHODS
Information on patients with T2-stage bladder cancer (BC) between 2000 and 2017 was extracted from the Surveillance, Epidemiology, and End Results program. The overall survival (OS) and disease-specific survival (DSS) of patients with different interventions were fitted.
RESULTS
A total of 22,074 patients with T2-stage MIBC were enrolled, of whom 14,021 reached the main endpoint. Only 28% of the patients with T2-stage MIBC chose radical cystectomy as the initial surgical treatment, while TURBT was applied as the primary surgical treatment in 66.6% of the patients. The TURBT rate increased significantly with age at cancer diagnosis (40-44 years, 45.5% to > 85 years, 90.9%). The survival rate of patients undergoing TURBT was significantly lower than for those undergoing radical cystectomy (median OS: 1.5 versus 9.7 years; median DSS: 2.7 years versus not reached). Upon multivariable Cox analyses, the OS (HR: 2.34; p < 0.001) and DSS (HR: 2.68; p < 0.001) of TURBT were found to be significantly worse than those of radical cystectomy.
CONCLUSION
Two-thirds of the patients with T2-stage MIBC were treated by TURBT in the United States. However, the long-term follow-up data indicate that the therapeutic efficiency of current TURBT techniques is far less effective than that of radical cystectomy. Further studies are urgently needed to devise the best management strategy for T2 stage bladder cancer.
Topics: Adult; Aged; Aged, 80 and over; Cohort Studies; Cystectomy; Female; Humans; Male; Middle Aged; Muscles; Neoplasm Invasiveness; Prevalence; Quality of Life; Retrospective Studies; Treatment Outcome; United States; Urinary Bladder; Urinary Bladder Neoplasms
PubMed: 35690361
DOI: 10.1016/j.ijsu.2022.106693 -
Acta Chirurgica Belgica Dec 2021Radical cystectomy (RC) with ileal conduit urinary diversion has become a common surgical procedure. Stomal complications and particularly parastomal hernia (PH) are the... (Review)
Review
Radical cystectomy (RC) with ileal conduit urinary diversion has become a common surgical procedure. Stomal complications and particularly parastomal hernia (PH) are the most frequent complications and causes of reintervention after RC with ileal conduit urinary diversion. PH is usually asymptomatic. When PH increases in size and becomes symptomatic, it clearly impairs patients' quality of life in terms of physical limitation, mental distress and social interaction. The aim of this article was to review the current knowledge on PH after RC with ileal conduit urinary diversion, regarding its natural history, risk factors, prevention and surgical management. There is no strong recommendation on the ideal surgical technique for repair of PH after RC, but laparoscopic Sugarbaker or Sandwich techniques with non-absorbable meshes are emerging as the preferred modern means of PH repair. Techniques for prevention and repair of PH after RC need to be specifically evaluated in future prospective studies.
Topics: Cystectomy; Humans; Incisional Hernia; Quality of Life; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 34581648
DOI: 10.1080/00015458.2021.1987617 -
Wounds : a Compendium of Clinical... Jun 2021Malnourishment of surgical patients has long been recognized as contributing to postoperative morbidity and mortality.1,2 Early protocols calling for lengthy...
Malnourishment of surgical patients has long been recognized as contributing to postoperative morbidity and mortality.1,2 Early protocols calling for lengthy perioperative patient fasting have been replaced by interventions aimed at diagnosing and addressing each patient's nutritional and metabolic needs; maintaining fluid and electrolyte balance, energy, and protein stores; and preserving muscle strength and gut microbiome by restoring oral feeding as soon as possible postoperatively.3 Interventions to achieve this physiologic balance have been the subject of considerable research, yet neither comprehensive preoperative programs4 nor early postoperative oral feeding5 have been reported to result in consistently improved clinical outcomes following abdominal surgery. This installment of Evidence Corner explores 2 systematic reviews, one of which presents clinical outcomes of early resumption of enteral food intake within 24 hours after gastrointestinal (GI) surgery,6 and the other presents clinical outcomes of perioperatively enhanced nutrition for those undergoing radical cystectomy (RC) for bladder cancer.7.
Topics: Cystectomy; Digestive System Surgical Procedures; Humans; Malnutrition; Nutritional Status; Postoperative Complications
PubMed: 34356033
DOI: No ID Found -
World Journal of Urology Jun 2021To evaluate late complications in a large cohort of patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD).
INTRODUCTION AND OBJECTIVES
To evaluate late complications in a large cohort of patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD).
MATERIALS AND METHODS
We prospectively enrolled patients who underwent RARC and ICUD between August 2012 and June 2019. We excluded patients with Ejection fraction < 36%, retinal vasculopathy, ventriculoperitoneal shunts, and those treated without curative intent. All complications and their onset date have been recorded, defined, and graded according to Clavien classification adapted for radical cystectomy.
RESULTS
210 patients were included, 76% of whom were men, with a mean age of 62 years. Urinary diversions used were Padua Ileal Bladder (PIB) in 80% of cases, and ileal conduit (IC) in 20% of patients (generally older and with more comorbidity). The mean follow-up was 30 ± 22 months. The stenosis rate of uretero-ileal anastomosis was 14%, while a reduction in eGFR (≥ 20%) was observed in about half of the cases. UTIs occurred in 37% of the patients, especially in the first 12 months. Only 2% of patients had bowel occlusion, whereas incisional hernia, lymphocele, and systemic events (metabolic acidosis and major cardiovascular events) occurred respectively in 20%, 10%, and 1% of cases.
CONCLUSIONS
Our study evaluates first late complications in a cohort of patients who underwent RARC with ICUD. These data are encouraging and in line with findings from a historical series of open radical cystectomy (ORC). This study is a further step in supporting RARC as a safe and effective surgical option for the treatment of muscle-invasive bladder cancer (MIBC) in tertiary referral centers.
Topics: Aged; Cystectomy; Female; Humans; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Robotic Surgical Procedures; Time Factors; Urinary Diversion
PubMed: 32747981
DOI: 10.1007/s00345-020-03378-7 -
Urologic Oncology Jun 2023To develop a specific supportive care needs scale for patients who have undergone radical cystectomy, and to assess its reliability and validity.
OBJECTIVE
To develop a specific supportive care needs scale for patients who have undergone radical cystectomy, and to assess its reliability and validity.
METHODS
The clinical test version of the scale was developed based on literature review, qualitative interviews, Delphi method, and a pretest. The reliability and validity of the scale were assessed in a cohort of 603 patients who had undergone radical cystectomy at 5 Grade A hospitals in Chongqing, China.
RESULTS
The final scale included 26 items across the following 7 dimensions: health information needs, social needs, family support needs, physiological needs, sexual needs, daily activities needs, and psychological needs. The content validity index was 0.991 and the content validity indices of each item ranged from 0.889 to 1.00. Seven factors were extracted by exploratory factor analysis and the cumulative contribution of variance accounted for 70.762%. Confirmatory factor analysis revealed a good fit of the model (X/df = 1.595, GFI = 0.904, IFI = 0.943, TLI = 0.932, CFI = 0.942, RMSEA = 0.044, and RMR = 0.026). The Cronbach's ɑ coefficient and retest reliability were 0.807 and 0.810, respectively.
CONCLUSION
The specific supportive care needs scale for radical cystectomy patients developed in this study showed the good reliability and validity. The tool can be invaluable for comprehensive assessment of the specific supportive care needs of these patients.
Topics: Humans; Cystectomy; Surveys and Questionnaires; Reproducibility of Results; Psychometrics; China
PubMed: 36581514
DOI: 10.1016/j.urolonc.2022.11.002