A comparison between limited bowel preparation and comprehensive bowel preparation in radical cystectomy with ileal urinary diversion: a systematic review and meta-analysis of randomized controlled trials

Bowel regimens before radical cystectomy: An analysis of a modern cohort

INTRODUCTION

Bowel regimens (BR) before radical cystectomy (RC) are currently not recommended by Enhanced Recovery After Surgery (ERAS) protocols, as prior studies have shown BRs lead to worsened outcomes. However, many of those studies have used historic literature before recent surgical advancements such as minimally invasive RC and have not investigated the impact BRs have by type of urinary diversion. Our goal is to determine the outcomes of preoperative BR in patients undergoing RC based on diversion type using a modern patient cohort.

METHODS

RCs performed between 2019 and 2020 with BR information available were identified in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP). Patients were grouped by type of BR received: no BR, both mechanical bowel preparation (MBP) and preoperative oral antibiotic BR (OABR), MBP only, and OABR only. We conducted propensity score matching based on factors influencing the operative approach. Baseline demographics and 30-day complication rates were compared between matched groups. We analyzed hospital length of stay (LOS) via multivariate regression with a Poisson distribution.

RESULTS

In total, 2054 RCs were identified with 2.4% receiving OABR, 21.3% receiving MBP, 5.3% receiving both, and 71.0% receiving no BR. For patients with ileal conduit diversions, outcomes with BRs appeared mixed, as OABR leads to increased LOS. For patients with neobladder diversions, BRs were not associated with any worsened outcomes and were associated with reduced length of stay.

CONCLUSIONS

BRs such as OABR may associated with improved outcomes in patients receiving RC with neobladder diversion, a finding that warrants further investigation.

Advances in Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery

Surgical site infections (SSIs) represent a major source of postoperative complications adversely impacting morbidity and mortality indices in surgical care. The discovery of antibiotics in the mid-20th century, and their ensuing use for preoperative antimicrobial bowel preparation and prophylaxis, drastically reduced the occurrence of SSIs providing a major tool to surgeons of various specialties, including urology. Because, the appropriate use of these antimicrobials is critical for their continued safety and efficacy, an understanding of the recommendations guiding their application is essential for all surgeons. Here, we comprehensively review these recommendations with a focus on open and laparoscopic urologic surgeries.

Adhesion-regulating molecule 1 (ADRM1) can be a potential biomarker and target for bladder cancer

Adhesion-regulating molecule 1 (ADRM1) has been implicated in tumor development, yet its specific role in bladder cancer (BC) remains undefined. This study aimed to elucidate the function of ADRM1 in BC through a combination of bioinformatics analysis and immunohistochemical analysis (IHC). Utilizing R version 3.6.3 and relevant packages, we analyzed online database data. Validation was conducted through IHC data, approved by the Institutional Ethics Committee (Approval No. K20220830). In both paired and unpaired comparisons, ADRM1 expression was significantly elevated in BC tissues compared to adjacent tissues, as evidenced by the results of TCGA dataset and IHC data. Patients with high ADRM1 expression had statistically worse overall survival than those with low ADRM1 expression in TCGA dataset, GSE32548 dataset, GSE32894 dataset, and IHC data. Functional analysis unveiled enrichment in immune-related pathways, and a robust positive correlation emerged between ADRM1 expression and pivotal immune checkpoints, including CD274, PDCD1, and PDCD1LG2. In tumor microenvironment, samples with the high ADRM1 expression contained statistical higher proportion of CD8 + T cells and Macrophage infiltration. Meanwhile, these high ADRM1-expressing samples displayed elevated tumor mutation burden scores and stemness indices, implying potential benefits from immunotherapy. Patients with low ADRM1 expression were sensitive to cisplatin, docetaxel, vinblastine, mitomycin C, and methotrexate. According to the findings from bioinformatics and IHC analyses, ADRM1 demonstrates prognostic significance for BC patients and holds predictive potential for both immunotherapy and chemotherapy responses. This underscores its role as a biomarker and therapeutic target in BC.

Association Between Antibiotic Prophylaxis Before Cystectomy or Stent Removal and Infection Complications: A Systematic 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.