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Ellis JL, Dalimov Z, Chew L, Quek ML. Preoperative optimization of the radical cystectomy patient: Current state and future directions. J Surg Oncol 2024; 129:138-144. [PMID: 38037317 DOI: 10.1002/jso.27546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
Radical cystectomy (RC) is associated with high rates of morbidity and mortality despite adoption of robotics and implementation of enhanced recovery after surgery protocols. There have been increased efforts to investigate preoperative optimization through comprehensive nutritional evaluation, preoperative supplementation, and prehabilitation outside of previously described enhanced recovery after surgery protocols to reduce mortality and morbidity from RC. In this review, we summarize and evaluate the current literature on preoperative assessment and optimization in RC.
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Affiliation(s)
- Jeffrey L Ellis
- Department of Urology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Zafardjan Dalimov
- Department of Urology, Einstein Healthcare Network-Jefferson Health, Philadelphia, Pennsylvania, USA
| | - Lauren Chew
- Department of Urology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Marcus L Quek
- Department of Urology, Loyola University Medical Center, Maywood, Illinois, USA
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Cohen S, Gal J, Freifeld Y, Khoury S, Dekel Y, Hofman A, Malshi K, Amiel G, Sagi I, Leibovici I, Golan S, Baniel J, Rozenzweig B, Dotan Z, Haifler M. Nutritional Status Impairment Due to Neoadjuvant Chemotherapy Predicts Post-Radical Cystectomy Complications. Nutrients 2021; 13:4471. [PMID: 34960023 PMCID: PMC8708207 DOI: 10.3390/nu13124471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Radical cystectomy (RC) is the standard treatment for muscle invasive bladder cancer (MIBC). Neoadjuvant chemotherapy (NAC) is associated with improved patient survival. The impact of NAC on nutritional status is understudied, while the association between malnutrition and poor surgical outcomes is well known. This study aims to examine the association between NAC, nutritional status impairment, and post-operative morbidity. MATERIALS AND METHODS We included MIBC patients who underwent RC and received NAC from multiple academic centers in Israel. Cross-sectional imaging was used to measure the psoas muscle area and normalized it by height (smooth muscle index, SMI). Pre- and post-NAC SMI difference was calculated (represents nutritional status change). The primary outcomes were post-RC ileus, infection, and a composite outcome of any complication. Logistic regression models were fit to identify independent predictors of the outcomes. RESULTS Ninety-one patients were included in the study. The median SMI change was -0.71 (-1.58, -0.06) cm2/m2. SMI decline was significantly higher in patients with post-RC complications (-18 vs. -203, p < 0.001). SMI change was an independent predictor of all complications, ileus, infection, and other complications. The accuracy of SMI change for predicting all complications, ileus, infection, and other complications was 0.85, 0.87, 0.75, and 0.86, respectively. CONCLUSIONS NAC-related nutritional deterioration is associated with increased risk of complications after RC. Our results hint towards the need for nutritional intervention during NAC prior to RC.
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Affiliation(s)
- Sharon Cohen
- Department of Urology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 5266202, Israel; (S.C.); (B.R.); (Z.D.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (J.G.); (I.S.); (I.L.); (S.G.); (J.B.)
| | - Jonathan Gal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (J.G.); (I.S.); (I.L.); (S.G.); (J.B.)
- Department of Urology, Shamir Medical Center, Tzrifin 7073001, Israel
| | - Yuval Freifeld
- Department of Urology, Carmel Medical Center, Haifa 3436212, Israel; (Y.F.); (S.K.); (Y.D.)
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3109601, Israel; (A.H.); (K.M.); (G.A.)
| | - Sobhi Khoury
- Department of Urology, Carmel Medical Center, Haifa 3436212, Israel; (Y.F.); (S.K.); (Y.D.)
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3109601, Israel; (A.H.); (K.M.); (G.A.)
| | - Yoram Dekel
- Department of Urology, Carmel Medical Center, Haifa 3436212, Israel; (Y.F.); (S.K.); (Y.D.)
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3109601, Israel; (A.H.); (K.M.); (G.A.)
| | - Azik Hofman
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3109601, Israel; (A.H.); (K.M.); (G.A.)
- Department of Urology, Rambam Medical Center, Haifa 3109601, Israel
- Israel Urologic Oncology Collaboration, Petah-Tikva 4941492, Israel
| | - Kamil Malshi
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3109601, Israel; (A.H.); (K.M.); (G.A.)
- Department of Urology, Rambam Medical Center, Haifa 3109601, Israel
| | - Gilad Amiel
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 3109601, Israel; (A.H.); (K.M.); (G.A.)
- Department of Urology, Rambam Medical Center, Haifa 3109601, Israel
- Israel Urologic Oncology Collaboration, Petah-Tikva 4941492, Israel
| | - Itay Sagi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (J.G.); (I.S.); (I.L.); (S.G.); (J.B.)
- Israel Urologic Oncology Collaboration, Petah-Tikva 4941492, Israel
- Department of Urology, Meir Medical Center, Kfar Sab 4428164, Israel
| | - Ilan Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (J.G.); (I.S.); (I.L.); (S.G.); (J.B.)
- Department of Urology, Meir Medical Center, Kfar Sab 4428164, Israel
| | - Shay Golan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (J.G.); (I.S.); (I.L.); (S.G.); (J.B.)
- Israel Urologic Oncology Collaboration, Petah-Tikva 4941492, Israel
- Department of Urology, Rabin Medical Center, Petah-Tikva 4941492, Israel
| | - Jack Baniel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (J.G.); (I.S.); (I.L.); (S.G.); (J.B.)
- Department of Urology, Rabin Medical Center, Petah-Tikva 4941492, Israel
| | - Barak Rozenzweig
- Department of Urology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 5266202, Israel; (S.C.); (B.R.); (Z.D.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (J.G.); (I.S.); (I.L.); (S.G.); (J.B.)
- Israel Urologic Oncology Collaboration, Petah-Tikva 4941492, Israel
| | - Zohar Dotan
- Department of Urology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 5266202, Israel; (S.C.); (B.R.); (Z.D.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (J.G.); (I.S.); (I.L.); (S.G.); (J.B.)
| | - Miki Haifler
- Department of Urology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 5266202, Israel; (S.C.); (B.R.); (Z.D.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (J.G.); (I.S.); (I.L.); (S.G.); (J.B.)
- Israel Urologic Oncology Collaboration, Petah-Tikva 4941492, Israel
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Torbahn G, Strauss T, Sieber CC, Kiesswetter E, Volkert D. Nutritional status according to the mini nutritional assessment (MNA)® as potential prognostic factor for health and treatment outcomes in patients with cancer - a systematic review. BMC Cancer 2020; 20:594. [PMID: 32586289 PMCID: PMC7318491 DOI: 10.1186/s12885-020-07052-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 06/08/2020] [Indexed: 02/08/2023] Open
Abstract
Background Patients with cancer have an increased risk of malnutrition which is associated with poor outcome. The Mini Nutritional Assessment (MNA®) is often used in older patients with cancer but its relation to outcome is not known. Methods Four databases were systematically searched for studies relating MNA-results with any reported outcome. Two reviewers screened titles/abstracts and full-texts, extracted data and rated the risk of bias (RoB) independently. Results We included 56 studies which varied widely in patient and study characteristics. In multivariable analyses, (risk of) malnutrition assessed by MNA significantly predicts a higher chance for mortality/poor overall survival (22/27 studies), shorter progression-free survival/time to progression (3/5 studies), treatment maintenance (5/8 studies) and (health-related) quality of life (2/2 studies), but not treatment toxicity/complications (1/7 studies) or functional status/decline in (1/3 studies). For other outcomes – length of hospital stay (2 studies), falls, fatigue and unplanned (hospital) admissions (1 study each) – no adjusted results were reported. RoB was rated as moderate to high. Conclusions MNA®-result predicts mortality/survival, cancer progression, treatment maintenance and (health-related) quality of life and did not predict adverse treatment outcomes and functional status/ decline in patients with cancer. For other outcomes results are less clear. The moderate to high RoB calls for studies with better control of potential confounders.
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Affiliation(s)
- G Torbahn
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany.
| | - T Strauss
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany
| | - C C Sieber
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany.,Kantonsspital Winterthur, Brauerstrasse 15, 8400, Winterthur, Switzerland
| | - E Kiesswetter
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany
| | - D Volkert
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany
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The impact of preoperative nutritional status on post-surgical complication and mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review of the literature. World J Urol 2020; 39:1045-1081. [PMID: 32519225 DOI: 10.1007/s00345-020-03291-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/29/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To investigate the impact of preoperative nutritional factors [body mass index (BMI)], hypoalbuminemia (< 3.5 g/dL, sarcopenia) on complication and mortality rates after radical cystectomy (RC) for bladder cancer. METHODS The PubMed database was systematically searched for studies investigating the effect of nutritional status on postoperative outcomes after RC. English-language articles published between March 2010 and March 2020 were reviewed. For statistical analyses odds ratios (ORs) and hazard ratios (HRs) weighted mean was applied. RESULTS Overall, 81 studies were included. Twenty-nine studies were enrolled in the final analyses. Patients with a 25-29.9 kg/m2 BMI (OR 1.55, 95% confidence interval [CI] 1.14-2.07) and those with a BMI ≥ 30 kg/m2 (OR 1.73, 95% CI 1.29-2.40) had a significantly increased risk of 30 day complications after RC. Preoperative hypoalbuminemia increased the risk of 30 day complications (OR 1.56, 95% CI 1.07-2.35); it was a predictor of worse 3 year overall survival (OS) (HR 1.86, 95% CI 1.32-2.66). Sarcopenic patients had a higher risk of 90 day complications than non-sarcopenic ones (OR 2.49, 95% CI 1.22-5.04). Sarcopenia was significantly associated with unfavorable 5 year cancer-specific survival (CSS) (HR 1.73, 95% CI 1.07-2.80), and OS (HR 1.60, 95% CI 1.13-2.25). CONCLUSION High BMI, hypoalbuminemia, and sarcopenia significantly increased the complication rate after RC. Hypoalbuminemia predicted worse 3 year OS and sarcopenia predicted unfavorable 5 year CSS and OS. Preoperative assessment of RC patients' nutritional status is a useful tool to predict perioperative and survival outcomes.
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Khalil MI, Tourchi A, Langford BT, Bhandari NR, Payakachat N, Davis R, Safaan A, Raheem OA, Kamel MH. Early Postoperative Morbidity of Robotic Versus Open Radical Cystectomy in Obese Patients. J Endourol 2020; 34:461-468. [PMID: 31964189 DOI: 10.1089/end.2019.0560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims: To compare the 30-day postoperative complications of robotic radical cystectomy (RRC) vs open radical cystectomy (ORC) in obese patients (body mass index ≥30) with bladder cancer (BC). Methods: The National Surgical Quality Improvement Program database was queried to identify obese BC patients who underwent RRC or ORC between 2005 and 2016. Patient demographics, postoperative mortality rate, morbidity, operating time (OPTIME), length of stay (LOS), readmission, and reoperation rates were recorded and compared between the two groups. Each RRC patient was matched with three ORC patients using a propensity score approach. Results: Four hundred forty-two RRC patients were matched with 1326 ORC patients. No difference in early postoperative mortality rate between RRC and ORC (0.7% vs 1.3%, relative risk, RR [95% confidence interval CI]: 0.27 [0.07-1.02]). Compared with ORC, the RRC group showed shorter mean OPTIME (364.7 [standard deviation, SD = 133.4] vs 387.8 [SD = 129.7] minutes, p = 0.001) and mean LOS (7.1 [SD = 5.6] vs 10.6 [SD = 6.6] days, p < 0.001). Compared with ORC, the RR of developing the following events in RRC group was lower: 30-day postoperative any complication (45%), any wound occurrence (64%), blood transfusion (70%), superficial surgical-site infection (78%), and wound disruption (77%). There was no difference in the RR of any-cause readmission (RR [95% CI]: 0.77 [0.57-1.05]) and reoperation (RR [95% CI]: 0.48 [0.22-1.04]) between the two groups. Conclusions: The study revealed that RRC for obese BC patients is associated with shorter OPTIME, shorter LOS, and lower risk of early postoperative complications when compared with a matched group of patients who received ORC. In addition, no difference in early postoperative mortality rate between RRC and ORC was observed.
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Affiliation(s)
- Mahmoud I Khalil
- Department of Urology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Department of Urology, Ain Shams University, Cairo, Egypt
| | - Ali Tourchi
- Department of Urology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Brian T Langford
- Department of Urology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Naleen Raj Bhandari
- Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Nalin Payakachat
- Division of Pharmaceutical Evaluation and Policy, Department of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Rodney Davis
- Department of Urology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Ahmed Safaan
- Department of Urology, Ain Shams University, Cairo, Egypt
| | - Omer A Raheem
- Department of Urology, Tulane University, New Orleans, Louisiana, USA
| | - Mohamed H Kamel
- Department of Urology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Department of Urology, Ain Shams University, Cairo, Egypt
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