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BJU International Apr 2024To perform a systematic review and meta-analysis of trials comparing trimodal therapy (TMT) and radical cystectomy (RC), evaluating differences in terms of oncological... (Review)
Review
OBJECTIVE
To perform a systematic review and meta-analysis of trials comparing trimodal therapy (TMT) and radical cystectomy (RC), evaluating differences in terms of oncological outcomes, quality of life, and costs.
MATERIALS AND METHODS
In July 2023, a literature search of multiple databases was conducted to identify studies analysing patients with cT2-4 N any M0 muscle-invasive bladder cancer (MIBC; Patients) receiving TMT (Intervention) compared to RC (Comparison), to evaluate survival outcomes, recurrence rates, costs, and quality of life (Outcomes). The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS) and metastasis-free survival (MFS). Hazard ratios (HRs) were used to analyse survival outcomes according to different treatment modalities and odds ratios were used to evaluate the likelihood of receiving each type of treatment according to T stage.
RESULTS
No significant difference in terms of OS was observed between RC and TMT (HR 1.07, 95% confidence interval [CI] 0.81-1.4; P = 0.6), even when analysing radiation therapy regimens ≥60 Gy (HR 1.02, 95% CI 0.69-1.52; P = 0.9). No significant difference was observed in CSS (HR 1.12, 95% CI 0.79-1.57, P = 0.5) or MFS (HR 0.88, 95% CI 0.66-1.16; P = 0.3). The mean cost of TMT was significantly higher than that of RC ($289 142 vs $148 757; P < 0.001), with greater effectiveness in terms of cost per quality-adjusted life-year. TMT ensured significantly higher general quality-of-life scores.
CONCLUSION
Trimodal therapy appeared to yield comparable oncological outcomes to RC concerning OS, CSS and MFS, while providing superior patient quality of life and cost effectiveness.
PubMed: 38622957
DOI: 10.1111/bju.16366 -
International Journal of Surgery... Apr 2024Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion (iRARC) is increasingly being used in recent years. Whether iRARC offers advantages over... (Meta-Analysis)
Meta-Analysis
Robot-assisted radical cystectomy with intracorporeal urinary diversion: an updated systematic review and meta-analysis of its differential effect on effectiveness and safety.
BACKGROUND
Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion (iRARC) is increasingly being used in recent years. Whether iRARC offers advantages over open radical cystectomy (ORC) remains controversial. This study aimed to compare the difference of perioperative outcomes, oncological outcomes and complications between iRARC and ORC.
METHODS
The PubMed, Embase, Cochrane Library, Web of Science and CNKI databases were searched in July 2023 according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement. Studies were identified to be eligible if they compared perioperative outcomes, oncological outcomes and complications in patients who underwent iRARC with ORC.
RESULTS
Twenty-two studies involving 7020 patients were included. Compared to ORC, iRARC was superior for estimated blood loss [estimated blood loss (EBL) weighted mean difference (WMD): -555.52; 95% CI, -681.64 to -429.39; P <0.001], blood transfusion rate [odds ratio (OR): 0.16; 95% CI, 0.09-0.28; P <0.001], length of hospital stay [length of hospital stay (LOS) WMD: -2.05; 95% CI, -2.93 to -1.17; P <0.001], Clavien-Dindo grades ≥III complication rate [30 days: OR: 0.57; 95% CI 0.44-0.75; P <0.001; 90 days: OR: 0.71; 95% CI 0.60-0.84; P <0.001], and positive surgical margin [positive surgical margin (PSM) OR: 0.65; 95% CI 0.49-0.85; P =0.002]. However, iRARC had a longer operative time [operative time (OT) WMD: 68.54; 95% CI 47.41-89.67; P <0.001] and a higher rate of ureteroenteric stricture [ureteroenteric stricture (UES) OR: 1.56; 95% CI 1.16-2.11; P =0.003]. Time to flatus, time to bowel, time to regular diet, readmission rate, Clavien-Dindo grades less than III complication rate for iRARC were similar to that for ORC. Interestingly, the results of subgroup analysis revealed no difference in EBL between iRARC and ORC when the diversion type was neobladder. When the ileal conduit was selected as the diversion type, the LOS was similar in both procedures.
CONCLUSION
Robot-assisted laparoscopic cystectomy with intracorporeal urinary diversion appears to be superior to open radical cystectomy in terms of effectiveness and safety. However, attention should be paid to the occurrence of ureteroenteric stricture during follow-up.
Topics: Humans; Cystectomy; Urinary Diversion; Robotic Surgical Procedures; Urinary Bladder Neoplasms; Postoperative Complications; Treatment Outcome; Length of Stay; Laparoscopy; Operative Time
PubMed: 38260944
DOI: 10.1097/JS9.0000000000001065 -
Translational Andrology and Urology Aug 2020The aim of this study was to evaluate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes in patients undergoing radical cystectomy (RC) and... (Review)
Review
Clinical efficacy and safety of enhanced recovery after surgery for patients treated with radical cystectomy and ileal urinary diversion: a systematic review and meta-analysis of randomized controlled trials.
The aim of this study was to evaluate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes in patients undergoing radical cystectomy (RC) and ileal urinary diversion (IUD). We performed a literature search of PubMed, Web of Science, EMBASE, the Cochrane Library and three main Chinese databases (WANFANG, CNKI and VIP) in December 2019 without language restrictions. Two reviewers independently selected studies, evaluated methodological quality and extracted data using Cochrane Collaboration's tools. Efficacy was assessed by the time to first flatus, first bowel movement, and hospitalization time. Safety was assessed by 30-day readmission and complications after surgery. Our searches identified 6 studies, including 628 patients. A total of 323 (51%) patients took ERAS. We observed that ERAS reduced the time to first flatus [standard mean difference (SMD): -1.65, 95% CI: -2.63 to -0.68, P=0.0009], first bowel movement (SMD: -1.14, 95% CI: -1.78 to -0.50, P=0.0005), and hospitalization time (MD: -4.09, 95% CI: -6.34 to -1.85, P=0.0004). We did not detect significant difference in terms of 30-day readmission [relative risk (RR): 1.33, 95% CI: 0.61-2.88, P=0.48] and postoperative complications (RR: 0.91, 95% CI: 0.65-1.26, P=0.56) between ERAS and conventional recovery after surgery (CRAS). Our findings indicated that ERAS protocols throughout the perioperative period of RC with IUD might reduce hospitalization expenses and contribute to higher turnover ward, more efficient utilization of medical resources and lower risk of nosocomial infection as a result of shorter length of stay. Besides, early rehabilitation of gastrointestinal function might not only facilitate wound healing and early mobilization, thereby reducing the incidence of basic complications such as cardiopulmonary disease, but also improve patients' psychological trauma and stress response, increase self-confidence and motivation in treatments, and then lead to unexpected benefits. Further large volume, multicenter randomized controlled studies are warranted before making the final clinical guidelines.
PubMed: 32944535
DOI: 10.21037/tau-19-941 -
Arab Journal of Urology Jan 2021: To compare cancer-specific mortality (CSM) and all-cause mortality (ACM) between patients with and without sarcopenia who underwent radical cystectomy for bladder... (Review)
Review
: To compare cancer-specific mortality (CSM) and all-cause mortality (ACM) between patients with and without sarcopenia who underwent radical cystectomy for bladder cancer. : We performed a systematic review and meta-analysis of original articles published from October 2010 to March 2019 evaluating the effect of sarcopenia on CSM and ACM. We extracted hazard ratios (HRs) and 95% confidence intervals (CIs) for CSM and ACM from the included studies. Heterogeneity amongst studies was measured using the -statistic and the index. Meta-analysis was performed using a random-effects model if heterogeneity was high and fixed-effects models if heterogeneity was low. : We identified 145 publications, of which five were included in the meta-analysis. These five studies represented 1447 patients of which 453 were classified as sarcopenic and 534 were non-sarcopenic. CSM and ACM were increased in sarcopenic vs non-sarcopenic patients (HR 1.64, 95% CI 1.30-2.08, < 0.01 and HR 1.41, 95% CI 1.22-1.62, < 0.01, respectively). : Sarcopenia is significantly associated with increased CSM and ACM in bladder cancer. Identifying patients with sarcopenia will augment preoperative counselling and planning. Further studies are required to evaluate targeted interventions in patients with sarcopenia to improve clinical outcomes. ACM: all-cause mortality; ASA: American Association of Anesthesiologists; BMI: body mass index; CCI: Charlson Comorbidity Index; CSM: cancer-specific mortality; CSS: cancer-specific survival; ECOG: Eastern Cooperative Oncology Group; HR: hazard ratio; NAC: neoadjuvant chemotherapy; NIH: National Institutes of Health; OS: overall survival; RC: radical cystectomy; RCT: randomised controlled trial; SMI: Skeletal Muscle Index.
PubMed: 33763255
DOI: 10.1080/2090598X.2021.1876289 -
Cancer Treatment Reviews Oct 2013Robot-assisted radical cystectomy (RARC) is increasingly being used in the management of bladder cancer. Studies comparing RARC and open radical cystectomy (ORC) have... (Meta-Analysis)
Meta-Analysis Randomized Controlled Trial Review
BACKGROUND
Robot-assisted radical cystectomy (RARC) is increasingly being used in the management of bladder cancer. Studies comparing RARC and open radical cystectomy (ORC) have reported conflicting results. We conducted a systematic review and meta-analysis of the literature on the efficacy and advantages of RARC compared with ORC.
METHODS
An electronic database search of PubMed, Scopus, and the Cochrane Library was performed up to July 8, 2012. This systematic review and meta-analysis was performed based on all randomized controlled trials (RCTs) and observational comparative studies assessing the two techniques.
RESULTS
One RCT, eight studies with prospectively collected data, and four retrospective studies were identified, including 962 cases. Although RARC was associated with longer operative time (p<0.001), patients in this group might benefit from less overall perioperative complications (p=0.04), more lymph node yield (p=0.009), less estimated blood loss (p<0.001), a lower need for perioperative transfusion (p<0.001), and shorter length of hospital stay (p<0.001). Positive surgical margins did not differ significantly between techniques. Sensitivity analysis with prospective studies showed similar results to the original analysis, but no significant difference of lymph node yield and length of stay between two techniques.
CONCLUSIONS
RARC is a mini-invasive alternative to ORC with less overall perioperative complications, more lymph node yields, less estimated blood loss, less need for a perioperative transfusion, and shorter length of stay.
Topics: Cystectomy; Humans; Prospective Studies; Robotics; Treatment Outcome; Urinary Bladder Neoplasms
PubMed: 23273846
DOI: 10.1016/j.ctrv.2012.11.007 -
Journal of Endourology Oct 2014Robotic radical cystectomy (RRC) has been growing in popularity across the world as a treatment option for bladder cancer. (Comparative Study)
Comparative Study Meta-Analysis Review
UNLABELLED
Robotic radical cystectomy (RRC) has been growing in popularity across the world as a treatment option for bladder cancer.
OBJECTIVES
To compare early surgical outcomes for RRC and open radical cystectomy (ORC) with an emphasis on complications and postoperative mortality rates.
EVIDENCE ACQUISITION
A literature review was conducted from 2000 to 2013, including studies comparing RRC and ORC. The main outcome measures analyzed were the complications and mortality rates, in addition to patient demographics, pathological parameters, operating time, estimated blood loss (EBL), transfusion rates, and type of urinary diversion. A meta-analysis was conducted. For continuous data, the Mantel-Haenszel chi-square test was used, and for dichotomous data, inverse variance was used and each expressed as risk ratio with 95% CI.
RESULTS
In total, 748 patients were included, 461 patients in the robotic group and 287 patients in the open group (seven studies). There were no significant differences in the demographic parameters of the two groups, except for age (age: p=0.03). There was no difference in the number of muscle-invasive diseases: p=0.47. No difference in positive surgical margin rates (p=0.21).
PRIMARY OUTCOMES
The overall (p=0.32) and lower grade (Clavien I-II) (p=0.10) complication rates between the two cohorts did not achieve statistical significance. The high-grade (Clavien III-IV) (p=0.007) complication rates in the ORC group were significantly higher. The mortality rate (Clavien V) was higher in the ORC group (2.2%) compared with the RRC group (0.35%) and this did achieve statistical significance on a meta-analysis (p=0.04).
SECONDARY OUTCOMES
The EBL and transfusion rates were statistically significantly lower in the RRC cohort (p<0.00001). The operating time was statistically significantly higher in the RRC cohort (p<0.00001). There was no statistically significant difference in the margin positivity between the two cohorts (p=0.08).
CONCLUSION
In early experience, RRC appears to be feasible and a safe alternative to the ORC. RRC appears to have lower high-grade complications and mortality rates compared with the open approach. Although these results are promising, the authors would suggest caution while interpreting these results due to concerns with methodological flaws in the included studies in this review.
Topics: Aged; Blood Loss, Surgical; Blood Transfusion; Carcinoma, Transitional Cell; Cystectomy; Female; Humans; Male; Middle Aged; Operative Time; Postoperative Complications; Robotic Surgical Procedures; Safety; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion
PubMed: 25000311
DOI: 10.1089/end.2014.0033 -
International Journal of Surgery... Jan 2016The aim of the study was to evaluate the efficacy of alvimopan on accelerates gastrointestinal recovery after radical cystectomy. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The aim of the study was to evaluate the efficacy of alvimopan on accelerates gastrointestinal recovery after radical cystectomy.
METHODS
We searched for all studies investigating alvimopan for bladder cancer patients undergoing radical cystectomy in Pubmed, Web of Knowledge, and the Cochrane Central Search Library. A systematic review and meta-analysis were performed. All studies that compared alvimopan with control group for patients undergoing radical cystectomy were included. Studies with overlapping or insufficient data were excluded. No language restrictions were made. Efficacy was assessed by the time to first toleration of clear liquids, first toleration of solid food, first bowel movement and length of stay.
RESULTS
Our searches identified 5 studies, including 613 patients. A total of 294 (47%) patients took alvimopan. On meta-analysis, alvimopan reduced time to first toleration of clear liquids (HR 1.34, 95% CI 1.19 to 1.51, p < 0.001), first toleration of solid food (HR 1.22, 95% CI 1.11 to 1.34, p < 0.001), first bowel movement (HR 1.27, 95% CI 1.12 to 1.43, p < 0.001) and length of stay (HR 1.17, 95% CI 1.10 to 1.25, p < 0.001).
CONCLUSIONS
This meta-analysis has shown that alvimopan significantly accelerates recovery of gastrointestinal function and reduces the length of stay in patients performed radical cystectomy. More large scale, multicenter randomized controlled studies are needed before final clinical recommendations can be made.
Topics: Cystectomy; Gastrointestinal Agents; Gastrointestinal Tract; Humans; Length of Stay; Piperidines; Postoperative Complications
PubMed: 26596716
DOI: 10.1016/j.ijsu.2015.11.013 -
Progres En Urologie : Journal de... Apr 2018Orthotopic neobladder (ONB) and ileal conduit (IC) are the most commonly practiced techniques of urinary diversion (UD) after radical cystectomy (RC) in bladder cancer... (Meta-Analysis)
Meta-Analysis Review
Ileal conduit vs orthotopic neobladder: Which one offers the best health-related quality of life in patients undergoing radical cystectomy? A systematic review of literature and meta-analysis.
INTRODUCTION
Orthotopic neobladder (ONB) and ileal conduit (IC) are the most commonly practiced techniques of urinary diversion (UD) after radical cystectomy (RC) in bladder cancer patients. Data in the literature is still discordant regarding which UD technique offers the best HR-QoL.
OBJECTIVE
The objective was to compare HR-QoL in patients undergoing ONB and IC after RC, through a systematic review of the literature and meta-analysis.
MATERIAL AND METHODS
We performed a literature search of PubMed, ScienceDirect, CochraneLibrary and ClinicalTrials.Gov in September 2017 according to the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes. The studies were evaluated according to the "Oxford Center for Evidence-Based Medicine" criteria. The outcome measures evaluated were subdomains' scores of Bladder Cancer Index BCI: urinary function (UF), urinary bother (UB), bowel function (BF), bowel bother (BB), sexual function (SF) and sexual bother (SB). Continuous outcomes were compared using weighted means differences, with 95% confidence intervals. The presence of publication bias was examined by funnel plots.
RESULTS
Four studies met the inclusion criteria. The pooled results demonstrated better UF and UB scores in IC patients: differences were -18.17 (95% CI: -27.49, -8.84, P=0.0001) and -3.72 (95% CI: -6.66, -0.79, P=0.01) respectively. There was no significant difference between IC and ONB patients in terms of BF and BB. SF was significantly better in ONB patients: the difference was 12.7 (95% CI, 6.32, 19.08, P<0.0001). However no significant difference was observed regarding SB.
CONCLUSION
This meta-analysis of non-randomized studies demonstrated a better HR-QoL in urinary outcomes in IC patients compared with ONB patients.
Topics: Cystectomy; Humans; Quality of Life; Randomized Controlled Trials as Topic; Treatment Outcome; Urinary Bladder Neoplasms; Urinary Diversion; Urinary Reservoirs, Continent
PubMed: 29571902
DOI: 10.1016/j.purol.2018.02.001 -
Urologic Oncology May 2016The existing guidance on bladder cancer surveillance following radical cystectomy is limited and variable. Additionally, the effect of surveillance on mortality is... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The existing guidance on bladder cancer surveillance following radical cystectomy is limited and variable. Additionally, the effect of surveillance on mortality is debatable. Herein, we perform a systematic review to evaluate the characteristics of alternative oncologic surveillance protocols and determine the association of detection of asymptomatic vs. symptomatic recurrences on mortality.
METHODS
An electronic search of PubMed, MEDLINE, EMBASE, and Cochrane Library databases was performed from 1970 to 2015. In all, 3 reviewers independently assessed the 1,729 candidate studies for eligibility and abstracted data based on an a priori established protocol. Outcomes were pooled using random effects meta-analysis.
RESULTS
We identified 7 studies for inclusion that were uncontrolled and thereby represented a body of evidence at high risk of bias; 5 studies developed surveillance protocols using a methodology similar to that of established guidelines. The majority proposed a pathologic stage-stratified approach, but ended surveillance for all patients at 5 years. Detection of asymptomatic recurrences was associated with a nonsignificant reduction in mortality (relative risk = 0.78; 95% CI: 0.58-1.04). This effect became statistically significant when upper and lower urinary tract recurrences were included in the analyses (relative risk = 0.69; 95% CI: 0.59-0.79).
CONCLUSIONS
Only sparse evidence supports alternative oncologic surveillance protocols for bladder cancer following radical cystectomy. The majority of existing protocols proposed similar strategies to those recommended by published guidelines. Detecting asymptomatic recurrences may lead to a reduction in overall mortality, which could provide a rationale for surveillance.
Topics: Cystectomy; Follow-Up Studies; Guidelines as Topic; Humans; Neoplasm Recurrence, Local; Outcome Assessment, Health Care; Urinary Bladder Neoplasms
PubMed: 26873028
DOI: 10.1016/j.urolonc.2015.11.025 -
Climacteric : the Journal of the... Dec 2016To evaluate the impact of radical cystectomy and urinary diversion on female sexual function. (Review)
Review
OBJECTIVES
To evaluate the impact of radical cystectomy and urinary diversion on female sexual function.
MATERIALS AND METHODS
A Medline search was conducted according to the PRISMA statement for all English full-text articles published between 1980 and 2016 and assessing female sexual function post radical cystectomy and urinary diversion. Eligible studies were subjected to critical analysis and revision. The primary outcomes were the reporting methods for female sexual dysfunction (FSD), manifestations of FSD, and factors associated with FSD, postoperative recoverability of FSD, and awareness level regarding FSD.
RESULTS
From the resulting 117 articles, 11 studies were finally included in our systematic review, with a total of 361 women. Loss of sexual desire and orgasm disorders were the most frequently reported (49% and 39%). Dyspareunia and vaginal lubrication disorders were reported in 25% and 9.5%, respectively. The incidence of sexual dysfunction was 10% in 30 patients receiving genital- or nerve-sparing cystectomy vs. 59% receiving conventional cystectomy.
CONCLUSION
Although female sexual function is an important predictor of health-related quality of life post radical cystectomy and urinary diversion, the available literature is not enough to provide proper information for surgeons and patients.
Topics: Adult; Aged; Cystectomy; Dyspareunia; Female; Humans; MEDLINE; Middle Aged; Postoperative Complications; Quality of Life; Sexual Dysfunction, Physiological; Sexual Dysfunctions, Psychological; Urinary Diversion
PubMed: 27649461
DOI: 10.1080/13697137.2016.1225714