Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes

Contemporary outcomes for robotic radical cystectomy and intracorporeal neobladder urinary diversion

INTRODUCTION

Widespread adoption of robotic-assisted radical cystectomy (RARC) with totally intracorporeal neobladder urinary diversion (UD) has not been achieved, and there is a dearth of literature exploring its short-term and long-term safety. We aim to present perioperative, complications, and oncologic outcomes for this procedure.

MATERIALS AND METHODS

Data from patients who underwent RARC with intracorporeal neobladder UD for bladder cancer between 2003 and 2022 from our multi-institutional cohort was prospectively collected. A retrospective review of this data was performed. The primary outcome was the number of days the patient was alive and outside of the hospital within 90 days postoperatively. Secondary outcomes were recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) at 24-months estimated by Kaplan-Meier plots, and 30-day and 90-day overall and major (Clavien ≥III) complication rates.

RESULTS

Of 410 patients (370 [90%] male), median (IQR) age was 64.2 (58.0, 69.4) and BMI was 26.8 (23.9, 29.1) kg/m2. The cohort included 2 (0.5%) cT0, 46 (11%) cTa or cTis, 109 (7%) cT1, 202 (49%) cT2, 47 (11%) cT3, and 4 (1.0%) cT4 tumors preoperatively. Median (IQR) follow-up was 37.6 (11.1, 81.0) months. Surgical margins were positive in 8 (2.0%) patients. Median number of days alive and outside hospital within 90 days postoperatively was 82 (77,85). Clavien III-IV complications occurred in 63 (15%) and 88 (21%) patients within 30 and 90 days, respectively. Clavien V complications occurred in 1 (0.2%) and 2 (0.5%) patients within 30 and 90 days, respectively. Kaplan-Meier estimates for RFS, CSS, and OS at 24-months were 78%, 88%, and 86%, respectively.

DISCUSSION

RARC with intracorporeal neobladder UD led to favorable recovery with increased days alive and out of the hospital within 90-days of surgery compared to open RC series, and major complication rates and oncologic outcomes were in line with prior open RC series.

A Novel Scoring System to Assess Continence Quality Outcomes of Orthotopic Ileal Neobladders After Open and Robot-Assisted Radical Cystectomy: The Urodynamic Trifecta

INTRODUCTION

A comprehensive scoring system for standardizing quality of functional outcomes of orthotopic ileal neobladders (OINs) is still unavailable. In this study we propose a novel trifecta for both open and robot-assisted radical cystectomy conceived on urodynamic parameters that summarize OINs functional outcomes regardless of the surgical technique used and predicts continence status.

MATERIALS & METHODS

Between June 2017 and May 2023 two prospective, institutional review board approved, radical cystectomy datasets were matched and queried for "OINs" "and "urodynamic evaluation" (n = 149). Urodynamic assessment was performed between 6 and 9 months after surgery. Baseline data and complete urodynamic profile including uroflowmetry, cystometry, compliance, presence of residual peristaltic activity, abdominal leak point pressures (ALPP) and daytime and night-time continence were reported. Descriptive analyses were used. Frequencies and proportions were reported for categorical variables while medians and interquartile ranges (IQRs) were reported for continuously coded variables. Trifecta was defined as the coexistence of: cystometric capacity ≥ 250 cc; neobladder compliance ≥ 35 cmH20; negative Valsalva and abdominal leak point pressure testing. Simultaneous achievement of only two of the presented criteria was considered a suboptimal result. Logistic regression analyses were built to identify predictors of daytime and night-time urinary continence. For all analyses, a two-sided p < 0.05 was considered significant.

RESULTS

Overall, at a median follow-up of 25 months (IQR 16-37), 149 patients achieved a complete urodynamic evaluation. In the current series, the complete trifecta rate was 40.2% while a suboptimal trifecta achievement was observed in 35.6% of patients. On multivariable analysis, complete trifecta achievement was the only independent predictor of daytime (OR 7.29, 95% CI 2.05-25.9) and night-time (OR 8.13; 95% CI 2.94-22.4) urinary continence, respectively (each p < 0.003). A complete UDM-T at urodynamic testing was associated with a day-time continence, night-time continence, and complete dry status rates of 93.2%, 83.1%, and 79.7%, respectively.

CONCLUSION

This novel urodynamic trifecta for OINs is based on standardized parameters and seems to be predictor of either daytime or night-time urinary continence at a midterm follow-up. Satisfactory continence outcomes may be also expected when a suboptimal trifecta rate is achieved.

CLINICAL TRIAL REGISTRATION

Not applicable.

Robot-assisted radical cystectomy with the clinical application of "Y-shaped" end-to-side ureteral anastomosis in elderly and obese patients

OBJECTIVE

To investigate the clinical effect and safety of "Y-shaped" end-to-side ureteral anastomosis with robotic endoscopic technique in radical cystectomy (RC) and urinary diversion (UD) in elderly and obese patients with bladder cancer.

MATERIALS AND METHODS

We retrospectively reviewed the records of 10 patients with bladder cancer who underwent robot-assisted laparoscopic radical cystectomy and "Y-shaped" end-to-side ureteral anastomosis under general anesthesia at Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China, 310014) from October 2018 to January 2021. Demographic and clinical data are summarized. The incidence of postoperative complications such as papillary retraction, ureteral stricture, anastomotic stenosis, anastomotic fistula and ureteral calculi were observed and analyzed.

RESULTS

A total of 10 elderly and obese patients successfully underwent RC with "Y-shaped" end-to-side ureteral anastomosis in this research. Median age was (80.6 ± 5.7) y and BMI was (25.12 ± 3.83) kg/m2. The operation time was (95 ± 26) min and the estimated intraoperative blood loss was (100.5 ± 35.6) ml, with no perioperative blood transfusion and no readmission 30 days after operation. No serious complications above Clavien-Dindo grade 4 occurred in the early (≤ 30 d) and late (> 30 d) after surgery. 1 patient developed fever three days after operation and was cured by strengthening anti-infection. 1 patient had a small amount of urine leakage at the anastomotic site after operation, and recovered after strengthening nutrition and maintaining the patency of abdominal drainage tube and single J tube. Postoperatively, the patients replaced the single J tube regularly and were followed up for 3-28 months (average 15 months) until April 10, 2021. In two cases, the ureterostomy nipple was slightly retracted and collapsed without special treatment. one case formed ureteral calculi and was treated conservatively. No ureteral stenosis, necrosis, anastomotic stenosis or severe anastomotic fistula, hernia around the stoma occurred. No visceral metastases or new lesions of urothelial carcinoma were observed. All patients were satisfied with the postoperative quality of life.

CONCLUSIONS

The robot-assisted "Y-shaped" end-to-side ureteral anastomosis technique performed intracorporeally seems to be a straightforward, secure, and viable approach. It is considered suitable for radical resection of bladder cancer and urinary diversion in elderly and obese patients.

Health-related quality of life after radical cystectomy for bladder cancer in elderly patients with ileal orthotopic neobladder, ureterocutaneostomy or ileal conduit: cross-sectional study using validated questionnaires

PURPOSE

The most appropriate form of urinary diversion (UD) after radical cystectomy remains controversial. In this study, we aimed to compare the health-related quality of life questionnaire results of patients who underwent orthotopic neobladder (ONB), ureterocutaneostomy (UC) and ileal conduit (IC) diversion.

MATERIALS

A total of 92 patients, including 42 out of 65 IC patients, 11 out of 15 ONB patients, and 39 out of 59 UC patients, completed the SF-36 and Barthel index quality of life questionnaires.

RESULTS

The mean follow-up periods were 11.7 ± 13.5 months for UC patients, 24.2 ± 20.8 months for IC patients, and 34.3 ± 25 months for ONB patients. The drain removal times were 5.7 ± 2.3 days in the UC group, 7 ± 2.8 days in the IC group, and 10.9 ± 9.2 days in the ONB group, with both the follow-up and drain removal periods being shorter in the UC group (P < 0.001; P = 0.002). Significant differences were noted in quality of life scores, particularly for emotional function (P = 0.016) and fatigue (P = 0.001), with the ONB group having higher emotional function scores and the UC group having higher fatigue scores than the other groups did.

CONCLUSION

Although there was no significant difference in terms of quality of life among the three methods, according to our results, we concluded that ONB should be performed in healthy, young, fit patients, especially those with body image expectations, and that UC should be performed in high-risk elderly patients. Although the selection of UD is based on individual considerations and the experience of the physician, quality of life questionnaires and patient counseling have critical importance.

The effect of chronic kidney disease on adverse in-hospital outcomes after radical cystectomy with ileal conduit urinary diversion

PURPOSE

Chronic kidney disease (CKD) is frequent in bladder cancer patients undergoing radical cystectomy (RC) with ileal conduit. However, the effect of CKD on adverse in-hospital outcomes after ileal conduit RC is not well known.

METHODS

Descriptive analyses, propensity score matching (PSM), and multivariable logistic and Poisson regression models were used to address National Inpatient Sample patients treated with ileal conduit RC between 2006 and 2019. CKD severity was stratified as mild (stage II) vs. moderate (stage III) vs. severe (stage IV/V).

RESULTS

Of 13,359 patients treated with RC with ileal conduit, 1973 (14.8%) had CKD. Of those, 956 (48.5%), 802 (40.6%), and 215 (10.9%) were classified as mild, moderate, or severe CKD, respectively. CKD rate increased from 4.1 to 21.9% (2006-2019, EAPC: +8.9%, p < 0.001). CKD RC patients exhibited higher rates of adverse in-hospital outcomes in 11 of 15 categories. The absolute differences were largest for overall complications (+ 13.2%), prolonged length of stay (+ 7.0%), blood transfusions (+ 6.0%, all p < 0.001). After detailed multivariable adjustment, CKD was an independent predictor of 11 of 15 adverse in-hospital outcomes' categories. The detrimental effect of CKD was most pronounced for dialysis (OR 7.09), overall complications (OR 1.84), and neurological complications (OR 1.61, all p < 0.001). Finally, a dose-response effect according to CKD severity on adverse in-hospital outcomes was observed in eight of 15 categories.

CONCLUSIONS

CKD RC patients invariably exhibited higher rates of adverse in-hospital outcomes after RC with ileal conduit. In consequence this patient group should receive particularly strong consideration for preoperative optimization.

Long-term outcomes of bladder-sparing therapy vs radical cystectomy in BCG-unresponsive non-muscle-invasive bladder cancer

OBJECTIVE

To quantify the oncological risks of bladder-sparing therapy (BST) in patients with Bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) compared to upfront radical cystectomy (RC).

PATIENTS AND METHODS

Pre-specified data elements were collected from retrospective cohorts of patients with BCG-unresponsive NMIBC from 10 international sites. After Institutional Review Board approval, patients were included if they had BCG-unresponsive NMIBC meeting United States Food and Drug Administration criteria. Oncological outcomes were collected following upfront RC or BST. BST regimens included re-resection or surveillance only, repeat BCG, intravesical chemotherapy, systemic immunotherapy, and clinical trials.

RESULTS

Among 578 patients, 28% underwent upfront RC and 72% received BST. The median (interquartile range) follow-up was 50 (20-69) months. There were no statistically significant differences in metastasis-free survival, cancer-specific survival, or overall survival between treatment groups. In the BST group, high-grade recurrence rates were 37% and 52% at 12 and 24 months and progression to MIBC was observed in 7% and 13% at 12 and 24 months, respectively. RC was performed in 31.7% in the BST group and nodal disease was found in 13% compared with 4% in upfront RC (P = 0.030).

CONCLUSION

In a selected cohort of patients, initial BST offers comparable survival outcomes to upfront RC in the intermediate term. Rates of recurrence and progression increase over time especially in patients treated with additional lines of BST.

Integrated enhanced recovery after surgery protocol in radical cystectomy for bladder tumour-A retroprospective study

Introduction

Enhanced recovery after surgery (ERAS) is a patient-centerd, evidence-based approach to improve postoperative outcomes. The protocol involves multidisciplinary collaboration and standardisation of perioperative interventions. ERAS has shown positive results in reducing hospitalisation and complications.

Methods

The study conducted in the Department of Urology was a retro-prospective study. It included an ERAS cohort group of 47 patients, studied prospectively from May 2021 to May 2023. These patients were compared to a historical cohort of 47 consecutive patients who underwent radical cystectomy with traditional care before the ERAS pathway was implemented. The primary outcome was hospital length of stay (LOS). Secondary outcomes included perioperative management, time to recovery milestones and complications.

Results

Implementation of ERAS pathway for radical cystectomy was associated with reduced hospital LOS (mean LOS 16.19 ± 2.53 days vs. 10.26 ± 3.33 days 7 days; p < 0.0001), reduced time to key recovery milestones, including days to first flatus (3.17 vs. 2.68; p = 0.013) and days to first solid food (5.19 vs. 3.45 p value < 0.0001), first stool (5.53 vs. 4.23; p < 0.0001), reductions in some complications like postoperative ileus (p value = 0.021) and need for total parental nutrition (p value = 0.023).

Conclusion

In conclusion, the implementation of the integrated approach facilitates a more efficient recovery process, potentially reducing healthcare costs and enhancing patient comfort.

Temporal Trends in Urinary Diversion among Patients Undergoing Radical Cystectomy Between 1986 and 2022: Experience at the University Medical Center Mainz with 2224 Cases

BACKGROUND

Analysis of temporal trends of urinary diversion (UD) and identification of predictive factors for continent urinary diversion (CUD) in patients with bladder cancer (BC) is scarce and data on large cohorts are missing. We aimed to describe longitudinal temporal trends and predictive factors for UD among patients with BC receiving radical cystectomy (RC).

PATIENTS AND METHODS

We retrospectively analysed institutional data collected from patients undergoing RC from 1986 to 2022 to describe changes in patients' characteristics and UD. Primary end points were patients' characteristics associated with type of UD. Logistic regression analysis was used to determine predictive factors for CUD.

RESULTS

In total, 2224 patients (77.16% male, 22.84% female) with a mean age of 66 years [standard deviation (SD), 10.64 years] were included. We observed an increase in mean age from 59.86 (10.8) years (1986-1990) to 69.85 (9.99) years (2016-2022) (p < 0.001). The proportion of CUD gradually declined from 43.72% (94/215; 1986-1990) to 18.38% (86/468; 2016-2022). Patients who were male [odds ratio (OR): 1.92, 95% confidence interval (CI): 1.43-2.57, p < 0.001), younger (OR: 0.88, 95% CI: 0.87-0.89, p < 0.001) and had no hydronephrosis prior to RC (OR: 2.2, 95% CI: 1.66-2.92, p < 0.001) were more likely to receive CUD.

CONCLUSIONS

We report the largest European single-center cohort of UD after RC, demonstrating a significant shift from CUD to IUD, accompanied by an increasing age. Finally, our data mirrors the development and extensive experience with the Mainz Pouch-I in the 1980's and 1990's together with other colon pouches.

New clinical insights into the treatment of benign uretero-ileal anastomotic stricture following radical cystectomy and urinary diversion

BACKGROUND

Benign uretero-ileal anastomotic stricture (UIAS) is a potentially serious complication that can arise after radical cystectomy (RC) and subsequent urinary diversion. To preserve residual renal function and improve prognosis, it is crucial to derive insights from experience and tailor individualized treatment strategies for different patients.

PATIENTS AND METHODS

From October 2014 to June 2021, a total of 47 patients with benign UIAS underwent endoscopic management (n = 19) or reimplantation surgery (n = 28). The basic data, perioperative conditions, and postoperative outcomes of the two groups were compared and analyzed to evaluate efficacy.

RESULTS

Comparing preoperative and postoperative clinical efficacy within the same group, the endoscopic group showed no significant differences in creatinine and blood urea nitrogen (BUN) levels before surgery or after extubation (p > 0.05). However, significant differences were observed in glomerular filtration rate (GFR) levels on the affected side before surgery and after extubation (p < 0.05). In contrast, the laparoscopic reimplantation group did not exhibit significant differences in creatinine, BUN, or GFR levels of affected side before surgery and after extubation (p > 0.05). Postoperative clinical efficacy showed no significant difference in creatinine and BUN levels between the two groups (p > 0.05). However, GFR values of affected side in the endoscopic treatment group decreased more than those in the laparoscopic reimplantation group (p < 0.05). Additionally, the laparoscopic reimplantation group was able to remove the single-J tube earlier than the endoscopic treatment group (p < 0.05), had a lower recurrence rate of hydronephrosis after extubation (p < 0.05), and experienced a later onset of hydronephrosis compared to the endoscopic treatment group (p < 0.05).

CONCLUSIONS

Based on our experience in treating UIAS following RC combined with urinary diversion, laparoscopic reimplantation effectively addresses the issue of UIAS, allowing for the removal of the ureteral stent relatively soon after surgery. This approach maintains long-term ureteral patency, preserves residual renal function, reduces the risk of ureteral restenosis and hydronephrosis, and has demonstrated superior therapeutic outcomes in this study.

A Propensity Score-Based Comparison regarding Renal, Functional, and Surgical Outcome of Continent Cutaneous Urinary Diversions in Patients with Benign Chronic Bladder Diseases and Patients with Bladder Cancer

INTRODUCTION

Continent cutaneous urinary diversion post-cystectomy is an established approach addressing both oncological and functional indications. However, there is a noticeable gap of evidence when it comes to comparing outcomes between these indications, especially concerning the technique of Mainz pouch I (MPI). This study aimed to close the gap by analyzing the long-term functional and renal outcomes of patients with MPI after cystectomy due to both benign and malign bladder pathologies.

METHODS

In this retrospective study, we examined 173 patients, who underwent MPI surgery between 2000 and 2022. Patients were categorized into a study group (benign conditions, n = 26) and a control group (bladder cancer, n = 52) using propensity score matching. Clinical demographics, surgical outcomes, and functional/renal parameters were analyzed using unpaired t tests and χ2 tests.

RESULTS

Patients undergoing cystectomy with MPI due to benign bladder pathologies were significantly younger and had a lower comorbidity burden compared to those with bladder cancer. In contrast to a significantly higher incidence of chemotherapy in the oncological cohort, the long-term renal function was comparable between both populations. Surgical outcomes, revisions, and postoperative complications did not differ significantly between both groups. Nearly 90% of patients in both groups showed full continence.

CONCLUSION

This study demonstrates the efficacy and safety of MPI surgery in both benign and malignant conditions, proving favorable long-term renal and functional outcomes.

Perioperative and extended outcomes of patients undergoing parastomal hernia repair following cystectomy and ileal conduit

PURPOSE

To report perioperative and long-term postoperative outcomes of cystectomy patients with ileal conduit (IC) urinary diversion undergoing parastomal hernia (PSH) repair.

METHOD

We reviewed patients who underwent cystectomy and IC diversion between 2003 and 2022 in our center. Baseline variables, including surgical approach of PSH repair and repair technique, were captured. Multivariable Cox regressionanalysis was performed to test for the associations between different variables and PSH recurrence.

RESULTS

Thirty-six patients with a median (IQR) age of 79 (73-82) years were included. The median time between cystectomy and PSH repair was 30 (14-49) months. Most PSH repairs (32/36, 89%) were performed electively, while 4 were due to small bowel obstruction. Hernia repairs were performed through open (n=25), robotic (10), and laparoscopic approaches (1). Surgical techniques included direct repair with mesh (20), direct repair without mesh (4), stoma relocation with mesh (5), and stomarelocation without mesh (7). The 90-day complication rate was 28%. In a median follow-up of 24 (7-47) months, 17 patients (47%) had a recurrence. The median time to recurrence was 9 (7-24) months. On multivariable analysis, 90-day complication following PSH repair was associated with an increased risk of recurrence.

CONCLUSIONS

In this report of one of the largest series of PSH repair in the Urology literature, 47% of patients had a recurrence following hernia repair with a median follow-up time of 2 years. There was no significant difference in recurrence rates when comparing repair technique or the use of open or minimally invasive approaches.

Caregiver Burden in Bladder Cancer Patients with Urinary Diversion Post-Radical Cystectomy and the Need for Comprehensive Nursing Education: A Narrative Literature

Background

Bladder cancer ranks seventh in global cancer prevalence. Radical cystectomy and urinary diversion are standard for muscle-invasive bladder cancer. Family caregivers shoulder a substantial care burden, affecting their own quality of life, with repercussions extending to patients' health-related quality of life (HRQOL).

Objective

This narrative review aims to highlight the major concerns perceived by the caregivers and efficacy of nurse-led interventions in alleviating their concerns and improving HRQOL.

Methods

A systematic search of the PubMed, CINAHL, and Science Direct databases was carried out to identify studies published in the last 5 years (from Jan 2018 to Aug 2023) that have evaluated the concerns and problems of caregivers attending bladder cancer patients with urinary diversion. Additionally, studies evaluating the efficacy of nurse-led interventions in alleviating these concerns were also searched.

Results

Overall, 6 studies involving 933 BC patients with UD and 1042 caregivers were identified as suitable for inclusion in this narrative literature review. Major concerns identified included psychological well-being, medical assistance needs, and peer support. Significant psychological impact was evident in the caregivers which operated in a dyadic manner. Nurse-led stoma education programs have demonstrated potential in enhancing caregivers' quality of life, although they remain restricted.

Conclusion

Emphasizing caregivers' role and program effectiveness is critical. Our review addresses these gaps, focusing on caregivers' concerns and the impact of nursing education for improved patient outcomes.

Implications for Practice

Holistic and collaborative approach could enhance the overall well-being and quality of life of bladder cancer patients and their caregivers.

Early and late post-procedural complications in different orthotopic neobladder surgical approaches: A systematic review

Bladder cancer (BCa) represents the second most common malignancy of the genitourinary tract. The major risk factors include age, gender, smoking attitude, and occupational exposure, while the exact etiopathogenesis is still uncertain. Patients diagnosed with a BCa showing invasion of the muscle layer below the submucosa must undergo radical cystectomy (RC) with urinary diversion (UD). Many different surgical approaches to UD have been developed. Packaging an orthotopic neobladder (ON) with a bowel tract represents the gold standard when certain patient selection criteria are satisfied. Using PRISMA guidelines, we performed a systematic review assessing early (within 90 days) and late (beyond 90 days) post-procedural complications of different ON surgical approaches. A comprehensive systematic search was conducted in PubMed, Scopus, and Google Scholar databases to identify papers starting from 2012 using dedicated keywords ("neobladder", "orthotopic neobladder", "complications'' and "outcomes"). A total of 27 articles were found to satisfy the inclusion criteria and selected. Although the ON is a safe procedure that guarantees the patient the best quality of life (QoL), it is not free from risks. Many complications could occur during and after the surgical time which imposes the necessity of strict follow-up and careful checks over time, which should be properly discussed with patients before.

[Urinary diversion in old patients (80+ years)]

With increasing life expectancy there is also an increased need for the management of older (≥ 80 years) patients with the diagnosis of muscle-invasive bladder cancer. Radical cystectomy with urinary diversion is the state of the art treatment (with neoadjuvant chemotherapy, as long as the patient is fit enough). Choosing the best urinary diversion with respect to morbidity compared to functionality and quality of life remains a challenge in these patients. Physical age alone is not decisive for making a decision. A thorough preoperative assessment of medical features, physical and cognitive impairments is more important. Older patients are generally provided with an ileal conduit as an incontinent urinary diversion, as the intervention involves reduced operating times and complexity compared to continent urinary diversions; however, in the case of good health status with an adequate life expectancy and sufficient compliance, continent diversions may be considered even in aged candidates. In the case of multimorbid patients with a high perioperative risk, ureterostomy with permanent ureteric stents is an important alternative. Most importantly, a thorough preoperative counselling enables patients to reach an informed decision.

Quality of life following pelvic exenteration in neoplasms

BACKGROUND

Pelvic exenteration (PE) is an extensive surgical treatment reserved for advanced or recurrent pelvic neoplasms, with potential impacts on patients' quality of life (QoL) poorly referenced in the literature.

OBJECTIVES

This study aimed to evaluate QoL outcomes among three types of PE.

METHODS

A cross-sectional study assessed 106 patients divided into anterior PE (APE), posterior PE (PPE), or total PE (TPE) groups. QoL was measured using e short form 36 version 2 (SF-36) and the European Organization for Research and Treatment of Cancer QoL Quality of Life Questionnaire Core 30 (QLQ-C30) QoL questionnaires. Descriptive and inferential analyses compared questionnaire scores.

RESULTS

The findings unveiled a balance among the three groups concerning demographic variables and comorbidities, with the exception of a male predominance in the APE and TPE cohorts. Notably, the APE group exhibited elevated scores in overall health (assessed via SF-36) and social functioning and diarrhea domains (assessed via QLQ-C30). Moreover, in terms of the fatigue and nausea/vomiting domains (assessed via QLQ-C30), the APE group demonstrated superior QoL compared to the PPE group. Conversely, the PPE group manifested a notably lower QoL in the constipation domain (assessed via QLQ-C30) compared to the other two groups. Additionally, disease recurrence was significantly associated with diminished QoL across multiple domains.

CONCLUSION

APE patients exhibited better QoL than PPE and TPE groups, with disease recurrence adversely affecting QoL.

Very long-term follow-up of Indiana Pouches proves durability

INTRODUCTION

An Indiana Pouch (IP) is a heterotopic, continent, urinary diversion from an ileocolonic segment. Numerous studies have investigated its long-term outcomes, albeit none extending beyond a 5-year follow-up period. IPs can be used as urinary diversion for benign indications and as such are constructed in typically young patients. As a consequence of their extended lifespan, there is a need for very long-term (>5 years) IP outcome data and comprehensive complication analysis.

MATERIALS AND METHODS

In this retrospective cohort study, the data of all patients attending our academic functional urology tertiary referral center for surveillance between 2015 and 2022 after an earlier IP procedure without uro-oncological indication were analyzed. The primary objective was to identify the prevalence of complications associated with IP, including stomal stenosis, ureter-pouch stenosis, pouch calculi, stomal leakage, pouch perforation, and parastomal herniation, and to determine the time span between creation of the IP and occurrence of complications.

RESULTS

A cohort of 33 patients (23 female) was analyzed. Median age at IP creation was 38 (range 5-62) years. Median follow-up was 258 (range 24-452) months. During follow-up, 22 (67%) patients underwent at least one surgical revision. In total, 45 revision procedures were performed. The estimated mean revision-free survival was 198 (95%-CI 144-242) months.

CONCLUSION

Two-thirds of our IP patients required surgical revision during very long-term follow-up. However, the mean revision-free survival was 198 months. This establishes the IP as a durable and resilient option for urinary diversion, yet underlines the need for lifelong follow-up as some of these complications and indication were subclinical. These results contribute significantly to patient counseling when discussing different options for urinary diversion, especially at a younger age.

Does radical cystectomy have a better prognosis than bladder conservative treatment in the real world?

PURPOSE

To compare the prognosis and quality of life between radical cystectomy and bladder conservative treatment for muscle invasive bladder cancer in the real world.

MATERIALS AND METHODS

Patients treated for muscle invasive bladder cancer without metastases were retrospectively evaluated for overall survival, progression-free survival, and rehospitalization.

RESULTS

Of the 141 patients, 62 underwent bladder conservative treatment and 79 underwent radical cystectomy. Patients who underwent radical cystectomy had significantly better progression-free survival (HR: 1.83, 95% CI: 1.12-3.00; p < 0.01) and overall survival (HR: 1.82, 95% CI: 0.99-3.34; p = 0.03) than those who underwent conservative treatment. However, there was no significant difference in prognosis between patients who refused to undergo radical cystectomy and those who underwent. In addition, rehospitalization rates for complications and additional treatment were significantly higher in patients who received conservative treatment (69.3% vs. 34.2%; p < 0.01), and the length of hospital stay was also prolonged compared to patients who received radical cystectomy (26 vs. 9 days; p = 0.03).

CONCLUSIONS

Overall, conservative treatment had a significantly poorer prognosis than radical cystectomy, but there was no significant difference in prognosis when comparing patients who refused radical cystectomy and received conservative treatment with those who received radical cystectomy. However, hospitalization rates and length of stay were significantly worse for patients who chose conservative treatment, which may lead to a decline in quality of life.

Continent cutaneous diversion: Unveiling the interplay of neuro-urology and oncological challenges

OBJECTIVES

The objective of our study is to demonstrate the practical application of continent cutaneous urinary diversion (CCUD) in oncological patients, with a focus on various aspects of the procedure: surgical challenges, functional outcomes, and quality of life.

MATERIALS AND METHODS

We studied the perioperative and follow-up data of patients who underwent cystectomy for cancer associated with CCUD (Mitrofanoff, Monti or Casale). We retrospectively analyzed complications within 30days and beyond 30days post-surgery. We evaluated oncological outcomes. Patients' quality of life was assessed using the Bladder Cancer Index (BCI) questionnaire. Results are given on an intention-to-treat basis.

RESULTS

A total of 24 patients were included in the study (July 2001 and May 2022), with a median follow-up of 62.5months. We report three deaths due to neoplasic recurrence. Forty-six percent had an early postoperative complication, two of whom required revision surgery. Overall, the medium-term complication rate was 70% and the reoperation rate was 62%. There were 8 stomal cutaneous stenoses (33%) and 3 uretero-ileal stenoses (12.5%). Overall satisfaction was rated at 9.2/10 on average, and body image was unaltered or slightly altered in 62.5% of patients. Of the patients who responded to the BCI, 75% had complete continence.

DISCUSSION

The experience gained with continent stomas in neuro-urology has allowed, in carefully selected cases, to offer patients an alternative that can improve their quality of life in a context already burdened by the shadow of cancer. CCUD can be proposed as an alternative to Bricker diversion in cases of urethral invasion or a high risk of neobladder incontinence, in selected patients.

LEVEL OF EVIDENCE: 4

Role performance and factors affecting quality of life in bladder cancer survivors with ileal orthotopic neobladder

Objective

Bladder cancer survivors with neobladder experience changes in role performance and quality of life (QoL) due to various symptoms and problems, but related studies are limited. Therefore, this study attempted to explore the QoL and factors influencing it in bladder cancer survivors with neobladder.

Methods

A cross-sectional descriptive design was used. Data were collected from 100 bladder cancer survivors with a neobladder using the European Organisation for Research and Treatment of Cancer QLQ-C30 and Muscle-Invasive Bladder Cancer Module, the Patient Activation Measure 13, the Enforced Social Dependency Scale, and the Multidimensional Scale of Perceived Social Support. Factors affecting the QoL were identified using multiple regression analysis.

Results

QoL significantly differed by daily pad usage, need for clean intermittent catheterization, and role performance. QoL was correlated with urinary symptoms and problems, future perspective, abdominal bloating and flatulence, body image, role performance, and social support. Role performance, body image, and the need for clean intermittent catheterization were identified as the factors affecting QoL.

Conclusions

The study highlights the importance of bladder cancer survivors continuing their roles at home, at work, and in society after neobladder reconstruction. Specifically, continuing recreational and social activity positively affects QoL, even if the activity range is modified. To help with their role performance, institutional support and changes in social perception are needed. Additionally, education and interventions, including body image enhancement, symptom management, and self-care, should be developed and applied to improve their QoL.

Comparison of different urinary diversions after radical cystectomy in Iran: Assessment of health-related quality of life and financial burden in a Middle Eastern country

OBJECTIVES

To compare health-related quality of life (HRQOL), cost-effectiveness, and survival among different types of urinary diversion (UD) utilized after radical cystectomy (RC) for bladder cancer with consideration of the unique economic and cultural context in Iran.

PATIENTS AND METHODS

In this retrospective study, we examined all patients who underwent RC from May 2017 to December 2021 at two specialized centers by the same surgical team. Patients were grouped based on their UD. Post-surgical HRQOL (obtained from EORTC QLQ-C30 and QLQBLM-30), financial burden, surgical complications, and survival were compared. Kruskal-Wallis H test, One-way ANOVA, and Kaplan-Meier analyses were utilized; accordingly.

RESULTS AND LIMITATIONS

In total 187 patients were identified-orthotopic neobladder (ONB) (N = 75), ileal conduit (IC) (N = 57), and cutaneous ureterostomy (CU) (N = 55)-and were followed for a median 17.5 (Interquartile range: 7.0, 47.0) months. ONB was associated with better HRQOL, especially in the domains addressing physical, role and social functioning (p = 0.003, 0.011, 0.045) as well as better body image (p < 0.001), lower short- and long-term financial burden (p = 0.034 and <0.001, respectively), marginally lower complication rate (p = 0.049), and better 5-year overall survival (p < 0.001), in comparison with other UDs. Patients who underwent CU had the lowest HRQOL and worst survival. Limitations were retrospective design and possibility of selection bias.

CONCLUSIONS

In this first study that assesses a Middle Eastern collective; ONB seems to be the UD of choice with regard to HRQOL and economic burden when there is no contraindication.

Lymphadenectomy before and after radical cystectomy: does this affect the radicality? A prospective randomized comparative study

PURPOSE

To compare the oncological outcome of performing ePLND before or after RC in 200 patients in a prospective randomized manner.

MATERIALS AND METHODS

From January 2014 to December 2019, 200 patients with T2-T3b N0M0 BCa were included in the current study after signing an informed consent. Patients were divided into two groups, 100 in each one. Group I underwent ePLND before RC, whereas group II underwent ePLND after RC. Postoperative evaluation included clinical, laboratory, and radiographic studies.

RESULTS

Patients' characteristics were comparable between both groups. The mean operative time excluding that of urinary diversion was significantly shorter in group II than in group I (p = 0.01). The mean number of LNs removed was 25 ± 6 in group I and 32 ± 8 in group II (p = 0.141). Intraoperative complications occurred in four patients in the form of external iliac artery and vein injury [two in each group (p = 0. 245)]. Postoperative complications were comparable between both groups with no statistically significant difference (p = 0.375). Oncological failure occurred in 28 patients [16 (17.6%) in group I and 12 (22%) in group II (p = 0.389)].

CONCLUSIONS

EPLND before and after RC has comparable oncological outcomes. The stage of the disease, the time since the first diagnosis till RC and the surgeon experience in performing meticulous ePLND are more important. In absence of oncological superiority, the timing of ePLND should be judged according to the patient-related factors to facilitate safe RC with minimal morbidity.

Parastomal Hernia Following Ileal Conduit: Incidence, Risk Factors, and Health-Related Quality of Life

PURPOSE

The purpose of this study was to measure the incidence of parastomal hernia (PH) after radical cystectomy and ileal conduit. Secondary aims were the identification of risk factors for PH and to compare the health-related quality of life (QOL) between patients with and without PH.

DESIGN

Retrospective review of medical records combined with cross-sectional administration of the QOL instrument and telephone follow-up.

SUBJECTS AND SETTING

The study sample comprised 219 patients who underwent radical cystectomy and ileal conduit for urothelial cancer between February 2014 and December 2018. The study setting was Peking University First Hospital (Beijing, China).

METHODS

Demographic and pertinent clinical data, including development of PH, were gathered via the retrospective review of medical records. Participants were also asked to complete the traditional Chinese language version of the City of Hope Quality of Life-Ostomy Questionnaire (C-COH). Multiple linear regression analysis was used to identify the effect of PH on C-COH scores. Logistic regression analysis was used to identify risk factors for PH development.

RESULTS

At a median follow-up of 34 months (IQR = 21-48), 43 of 219 (19.63%) patients had developed a PH. A body mass index (BMI) indicating overweight (OR = 3.548; 95% CI, 1.562-8.061; P = .002), a prior history of hernia (OR = 5.147; 95% CI, 1.195-22.159; P = .028), and chronic high abdominal pressure postdischarge (CHAP-pd) (OR = 3.197; 95% CI, 1.445-7.075; P = .004) were predictors of PH after operation. There was no significant difference between C-COH scores of patients with or without PH. No significant differences were found when participants with PH were compared to those without PH on 4 factors of the C-COH: physical scores (β= .347, P = .110), psychological scores (β= .316, P = .070), spiritual scores (β=-.125, P = .714), and social scores (β= .054, P = .833).

CONCLUSION

Parastomal hernia is prevalent in patients undergoing radical cystectomy and ileal conduit urinary diversion. Overweight, hernia history, and CHAP-pd were predictors of PH development. No significant differences in QOL were found when patients with PH were compared to those without PH.

Status and Influencing Factors of Body Image Disturbance in Patients With Hemifacial Spasm: A Quantitative and Qualitative Study

OBJECTIVE

Patients diagnosed with hemifacial spasm (HFS) often experience significant facial changes that affect their body image and potentially have a negative impact on their physical and psychological well-being. This study therefore seeks to identify the current state of body image of Chinese patients with HFS, analyze the factors that influence it, and further explore their experiences based on their level of body image disturbance (BID) using a mixed methods approach.

METHODS

A mixed-methods study was conducted between January 2021 and June 2023. Phase I encompassed the completion of questionnaires by 124 participants. Subsequently, in Phase II, in-depth interviews were conducted with 15 individuals selected from Phase I to gain deeper insights into their specific experiences with BID.

RESULTS

Patients afflicted with HFS achieved Body Image Scale scores 9.00 (0.00, 12.00). Age, anxiety, depression, and fear of negative evaluation were identified as predictors of exacerbated BID (P < 0.05). Qualitative research predominantly centered on 2 primary themes: the experiences and outward manifestations of BID in HFS patients. These individuals expressed dissatisfaction with their appearance, apprehensions about being the focus of attention, and instances of social avoidance.

CONCLUSIONS

Owing to varying degrees of anxiety, depression, and apprehension about external evaluation, individuals grappling with HFS are susceptible to experiencing BID. Consequently, when devising interventions, it is imperative to conduct a comprehensive assessment of the patient's condition and implement targeted measures aimed at ameliorating body image, ultimately enhancing the overall quality of life for the patient.

Bladder sparing by short-course radiotherapy combined with toripalimab in high-risk/extremely high-risk non-muscle invasive bladder cancer (HOPE-04): study protocol for a single-arm, prospective, phase II trial

INTRODUCTION

Radical cystectomy remains the standard treatment for intravesical Bacille Calmette-Guerin (BCG) unresponsive non-muscle invasive bladder cancer (NMIBC) because potential bladder-preserving therapies are not well established. Combination of radiotherapy with programmed death-1 (PD-1) antibody may offer an optional bladder preservation treatment for high-risk/extremely high risk NMIBC. Hence, the current study aims to investigate the safety and efficacy of short-course radiotherapy (5×5 Gy) and toripalimab (PD-1 antibody) as a novel bladder sparing treatment in this population.

METHODS AND ANALYSIS

HOPE-04 is an open-label, single-arm, phase II study, designed to evaluate the safety and efficacy of short-course radiotherapy and toripalimab in patients with high-risk/extremely high risk NMIBC. Fifty-five patients with pathological and imaging diagnosed NMIBC with or without BCG treatment will be recruited. Radiotherapy of 5×5 Gy will be given to the whole bladder followed by a focal tumour bed boost and concomitant administration of toripalimab of 240 mg intravenous infusion every 21 days for 12 cycles (about 1 year). The primary endpoints are disease-free survival and safety. The secondary endpoint is overall survival. Additional indicators include implementation rate of salvage surgery and quality of life.

ETHICS AND DISSEMINATION

This trial has been approved by the Ethics Committee of West China Hospital, Sichuan University. Trial findings will be disseminated via peer reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Chinese Ethics Committee of Registering Clinical Trials (ChiCTR2200059970).

Outcome of small versus big capacity Hautmann neobladder reconstruction: A prospective randomized study - a 5-year follow up

BACKGROUND

Orthotopic urinary diversion is the preferred diversion after cystectomy. Neobladder reconstruction with a longer ileum segment (60 cm) is advantageous for obtaining a large capacity and continence at the beginning; however, the long-term risk of residual urine, chronic infection, and the need for intermittent catheterization is more pronounced with the neobladder constructed with a longer ileal segment compared to the neobladder tailored from the shorter ileal segment.

OBJECTIVE

To establish the differences in the functional outcome of a shorter (< 45 cm) and longer (⩾ 45 cm) ileal segment usage in the reconstruction of the Hautmann ileal neobladder following the radical cystectomy.

METHODS

Between July 2013 and September 2015, 121 patients with muscle-invasive bladder cancer underwent radical cystectomy and Hautmann ileal neobladder reconstruction. Patients were divided into two groups, depending on the length of the ileum used for the diversion creation: < 45 cm of the ileum was used in the first group and ⩾ 45 cm in the second group. Five-year follow-up was performed at 1, 3, 6, and 9 months and 1 and 5 years. The main measured outcomes were functional outcomes and the quality of life. The evaluation included clinical, laboratory, and QLQ-C30 questionnaires. Statistical analysis was performed using descriptive statistics, Mann-Whitney U test, Kolmogorov-Smirnov test, ANOVA, and chi-squared tests.

RESULTS

Patients with a smaller neobladder had a better quality of life, and higher global health status scale score. Thirteen early and 21 late complications developed in 10 and 17 patients, respectively. There were significant differences in the need for clean intermittent self-catheterization (CIC) between the two groups: smaller-volume pouch patients had statistically decreased need for CIC in 5 year follow-up compared to larger-volume pouch patients (χ2 test = 8.245; df = 1; P= 0.004). Eighteen percent of patients with smaller neobladders had urinary tract infections in 5 years, compared to 35% with larger neobladders (χ2 test = 4.447; df = 1; P= 0.034).

CONCLUSION

Minimizing the length of the ileal segment needed for Hautmann neobladder reconstruction is feasible and provides better long-term results than larger-volume neobladders.

Cutaneous Ureterostomy Following Radical Cystectomy for Bladder Cancer: A Contemporary Series

OBJECTIVE

To report peri-operative outcomes of a contemporary series of bladder cancer patients undergoing radical cystectomy (RC) with cutaneous ureterostomy (CU) urinary diversion at a tertiary referral center.

METHODS

We retrospectively identified patients who underwent RC with CU at Mayo Clinic between 2016 and 2021. Clinicopathologic and perioperative characteristics were analyzed using standard descriptive statistics.

RESULTS

A total of 31 patients underwent RC with CU at our institution. Median age was 72years and 21 were male. This was highly comorbid cohort (83% had an American Society of Anesthesiologists [ASA] Physical Status Classification System ≥3; median Charlson Comorbidity index= 8). Median time to flatus, tolerating regular diet, and length of stay were 3 (interquartile range [IQR] 3-3), 3 (IQR 3-4), and 4days (IQR 4-7), respectively. A total of 14 patients experienced a high-grade complication (Clavien-Dindo ≥3) within 30days of surgery, and 8 were readmitted. The most common 30-day complication was sepsis, which affected 13% (4/31) of patients. At 90days postsurgery, the readmission rate was 32% (10/31), most commonly for sepsis. Three patients required reoperation within 90days, including one patient who required CU revision due to stomal ischemia. One patient died within this time frame from causes unrelated to bladder cancer.

CONCLUSION

In a comorbid, relatively elderly bladder cancer cohort undergoing RC, the use of CU was associated with expeditious surgery and postoperative recovery. CU represents an option for urinary diversion in high-risk patients undergoing RC. Higher rate of postoperative ureteral obstruction can be pre-emptively addressed with chronic stent placement.

The effect of body mass index on quality of life in modified single stoma cutaneous ureterostomy or ileal conduit after radical cystectomy

OBJECTIVE

To explore the influence of postoperative body mass index (BMI) change on postoperative quality of life (QOL) in patients undergoing radical cystectomy (RC) plus modified single stoma cutaneous ureterostomy (MSSCU) or ileal conduit (IC).

METHODS

Patients were divided into two groups according to different BMI change patterns: patients experiencing an elevated postoperative BMI level, along with a clinically significant increase in their BMI (an increase of more than 10%) were categorized as Group 1, while patients experiencing a decrease postoperative BMI level, along with a clinically significant reduction in their BMI (a decrease of more than 5%) were categorized as Group 2. Spearman correlation analysis was used to examine the correlations between quality-of-life scores and postoperative clinical parameters.

RESULTS

Spearman correlation analysis showed that postoperative BMI, late complications and catheter-free state were significantly associated with postoperative global QoL and symptom scale in MSSCU and postoperative global QoL and physical scale in IC patients. Additionally, postoperative BMI, catheter-free state and the use of adjuvant therapy were associated with bad performance in many scales of QoL like body image, future perspective, social scale, future perspective (MSSCU), and abdominal bloating (IC) (Table 2, p<0.05). Patients in Group 2 with significant weight loss had a better Global QoL, a lower rate of stomal stricture and a higher catheter-free state compared with those in Group 1 in both IC and MSSCU patients. MSSCU patients in Group 2 could achieve a comparable Global QoL as to IC patients in Group 1.

CONCLUSION

Controlling the substantial increase in body weight after surgery contributes to improving QoL, reducing the occurrence of stomal stricture, and ensuring a postoperative catheter-free state in BCa patients undergoing MSSCU.

Surgical outcomes of robot-assisted radical cystectomy in octogenarian or older patients: A Japanese nationwide study

OBJECTIVE

To evaluate the surgical outcomes of robot-assisted radical cystectomy (RARC) in octogenarian or older patients based on a Japanese nationwide database.

METHODS

The diagnosis procedure combination database was used to extract the data on radical cystectomy cases. Surgical outcomes of RARC in octogenarian or older patients (older group) were initially compared to those of patients younger than 80 years (younger group). Then, the surgical outcomes of RARC in the older group were compared to those of open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) in the same age group.

RESULTS

Between 2018 and 2021, 478 RARC cases in the older group and 2257 RARC cases in the younger group were identified. In the older group, ileal conduit, neobladder, and other urinary diversions were carried out in 352 (73.6%), 22 (4.6%), and 104 (21.8%) patients, respectively. In the older group, when compared with the younger group, the complication rate (24.9%), blood transfusion rate (41.4%), and in-hospital mortality (1.4%) were equivalent, while significantly shorter anesthesia time and longer length of stay were observed in the older group (521.0 ± 140.4 min vs. 595.1 ± 141.71 min, p < 0.01, and 32.9 ± 16.8 days vs. 30.6 ± 17.8 days, p = 0.01, respectively). In the comparison of the surgical outcomes of older patients receiving RARC to those receiving ORC (n = 746) and LRC (n = 375), the RARC group had the lowest complication rate and the shortest length of stay, while the shortest anesthesia time was noted in the ORC group.

CONCLUSION

The feasibility of RARC for octogenarian or older patients was demonstrated by the nationwide database study.

Bladder cancer

Bladder cancer is a global health issue with sex differences in incidence and prognosis. Bladder cancer has distinct molecular subtypes with multiple pathogenic pathways depending on whether the disease is non-muscle invasive or muscle invasive. The mutational burden is higher in muscle-invasive than in non-muscle-invasive disease. Commonly mutated genes include TERT, FGFR3, TP53, PIK3CA, STAG2 and genes involved in chromatin modification. Subtyping of both forms of bladder cancer is likely to change considerably with the advent of single-cell analysis methods. Early detection signifies a better disease prognosis; thus, minimally invasive diagnostic options are needed to improve patient outcomes. Urine-based tests are available for disease diagnosis and surveillance, and analysis of blood-based cell-free DNA is a promising tool for the detection of minimal residual disease and metastatic relapse. Transurethral resection is the cornerstone treatment for non-muscle-invasive bladder cancer and intravesical therapy can further improve oncological outcomes. For muscle-invasive bladder cancer, radical cystectomy with neoadjuvant chemotherapy is the standard of care with evidence supporting trimodality therapy. Immune-checkpoint inhibitors have demonstrated benefit in non-muscle-invasive, muscle-invasive and metastatic bladder cancer. Effective management requires a multidisciplinary approach that considers patient characteristics and molecular disease characteristics.

Prevalence of metabolic acidosis in ileal diversions more than one year after radical cystectomy and associated secondary metabolic effects

INTRODUCTION AND OBJECTIVE

Metabolic acidosis (MA) is a well-known complication in patients with ileal urinary diversions. It is common in the early postoperative stages and decreases over time. Our objective is to investigate the prevalence of MA after more than one year of follow-up, identify the associated risk factors, and analyze its secondary metabolic consequences.

MATERIALS AND METHODS

We conducted an observational study between January 2018 and September 2022 following the STROBE guidelines. MA was defined as a serum bicarbonate level ​​<22mEq/L. Finally, we analyzed 133 patients with a mean follow-up of 55.24 ± 42.36 months.

RESULTS

MA was observed in 16 (12%) patients. Patients with and without MA were comparable in age, sex, and follow-up time. The group with MA presented a higher rate of anemia (68,75% vs 19,65%, p < 0.001) and renal failure (100% vs 45,29%, p < 0.001), statistically significant higher levels of serum creatinine, chloride, potassium, parathyroid hormone, and phosphorus but lower serum values ​​of hemoglobin, renal glomerular filtration rate, total cholesterol, vitamin D, calcium, and albumin (all p < 0.05). Renal glomerular filtration rate was the only independent risk factor related to the development of MA (OR 0.914; 95% CI 0.878-0.95; p < 0.0001), proving a close correlation with venous bicarbonate values ​​(r = 0.387, p < 0.001).

CONCLUSIONS

MA is a little prevalent disorder in ileal urinary diversions more than one year after radical cystectomy is performed but it has secondary consequences on hematologic, renal, protein, lipid, and bone metabolism. We recommend to a close follow-up in patients with renal failure for early diagnosis and treatment.

Contemporary outcomes of patients undergoing robotic-assisted radical cystectomy: A comparative analysis between intracorporeal ileal conduit and neobladder urinary diversions

Objective

We aimed to compare perioperative and oncologic outcomes for patients undergoing robotic-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IC) and neobladder (NB) urinary diversion.

Methods

Patients undergoing RARC with intracorporeal urinary diversion between January 2017 and January 2022 at the Icahn School of Medicine at Mount Sinai, New York, NY, USA were indexed. Baseline demographics, clinical characteristics, perioperative, and oncologic outcomes were analyzed. Survival was estimated with Kaplan-Meier plots.

Results

Of 261 patients (206 [78.9%] male), 190 (72.8%) received IC while 71 (27.2%) received NB diversion. Median age was greater in the IC group (71 [interquartile range, IQR 65-78] years vs. 64 [IQR 59-67] years, p<0.001) and BMI was 26.6 (IQR 23.2-30.4) kg/m2. IC group was more likely to have prior abdominal or pelvic radiation (15.8% vs. 2.8%, p=0.014). American Association of Anesthesiologists scores were comparable between groups. The IC group had a higher proportion of patients with pathological tumor stage 2 (pT2) tumors (34 [17.9%] vs. 10 [14.1%], p=0.008) and pathological node stages pN2-N3 (28 [14.7%] vs. 3 [4.2%], p<0.001). The IC group had less median operative time (272 [IQR 246-306] min vs. 341 [IQR 303-378] min, p<0.001) and estimated blood loss (250 [150-500] mL vs. 325 [200-575] mL, p=0.002). Thirty- and 90-day complication rates were 44.4% and 50.2%, respectively, and comparable between groups. Clavien-Dindo grades 3-5 complications occurred in 27 (10.3%) and 34 (13.0%) patients within 30 and 90 days, respectively, with comparable rates between groups. Median follow-up was 324 (IQR 167-552) days, and comparable between groups. Kaplan-Meier estimate for overall survival at 24 months was 89% for the IC cohort and 93% for the NB cohort (hazard ratio 1.23, 95% confidence interval 1.05-2.42, p=0.02). Kaplan-Meier estimate for recurrence-free survival at 24 months was 74% for IC and 87% for NB (hazard ratio 1.81, 95% confidence interval 0.82-4.04, p=0.10).

Conclusion

Patients undergoing intracorporeal IC urinary diversion had higher postoperative cancer stage, increased nodal involvement, similar complications outcomes, decreased overall survival, and similar recurrence-free survival compared to patients undergoing RARC with intracorporeal NB urinary diversion.

Analysis of the efficacy of a single subumbilical stoma for bilateral cutaneous ureterostomy after radical cystectomy

BACKGROUND

Radical cystectomy and urinary diversion are the standard surgical treatments for patients with muscle-invasive or high-risk, or recurrent non-muscle-invasive bladder cancer. Although this approach significantly prolongs patient survival, it can lead to postoperative complications. This study aims to compare the efficacy and complications of bilateral cutaneous ureterostomy with a single subumbilical stoma to those of cutaneous ureterostomy with two stomas and an ileal conduit as a means of urinary diversion after radical cystectomy. The findings of this study will provide valuable information for healthcare providers in selecting the appropriate urinary diversion method for their patients.

METHODS

The clinical data for 108 patients who received bilateral cutaneous ureterostomy with a single subumbilical stoma (ureterostomy with a single stoma group), cutaneous ureterostomy with two stomas (ureterostomy with two stomas group), or an ileal conduit (ileal conduit group) after radical cystectomy were retrospectively analysed. The operative time, pathological stage, survival status, perioperative complication rate, rate of successful first extubation, rehospitalization rate at 6 months after surgery,ostomy-related medical costs,and postoperative quality of life were compared between the three groups of patients.

RESULTS

A significant difference in the operative time was found between the three groups (P = 0.001). No significant differences in pathological stage, survival status, perioperative complication rate, rehospitalization rate at 6 months after surgery, or bladder cancer index (BCI) score were identified among the three groups. The difference in the successful first extubation rate between the three groups of patients was significant (P = 0.001). Significant differences in ostomy-related medical costs were observed among the three groups of patients (P = 0.006).

CONCLUSION

A single subumbilical stoma for bilateral cutaneous ureterostomy after radical cystectomy may result in shorter surgery time, increased success rates for initial catheter removal, and lower medical expenses. However, to confirm these findings, further prospective randomized clinical trials are necessary.

Three-port approach vs conventional laparoscopic radical cystectomy with orthotopic neobladder: a single-center retrospective study

BACKGROUND

This study aimed to compare the clinical outcomes of patients who underwent three-port laparoscopic radical cystectomy (LRC) with orthotopic neobladder (ONB) and traditional five-port method.

METHODS

From January 2017 to November 2020, 100 patients underwent LRC + ONB at a third-level grade A hospital.

RESULTS

Our study included 55 patients who underwent three-port LRC and 45 patients who underwent the five-port method. There were no significant differences in perioperative data such as operation time (253.00 ± 43.89 vs. 259.07 ± 52.31 min, P = 0.530), estimated blood loss (EBL)(97.64 ± 59.44 vs. 106.67 ± 55.35 min, P = 0.438), day to flatus (2.25 ± 1.49 vs. 2.76 ± 1.77 days, P = 0.128), day to regular diet (7.07 ± 2.99 vs. 7.96 ± 3.32 days, P = 0.165), day to pelvic drain removal (9.58 ± 3.25 vs. 10.53 ± 3.80 days, P = 0.180), and hospital stay after operation (11.62 ± 3.72 vs. 11.84 ± 4.37 days, P = 0.780) between the two groups. The only significant difference was in the treatment cost (P = 0.035). Similarly, postoperative complications, quality of life, and tumor outcomes were not significantly different between the two groups (P > 0.05).

CONCLUSIONS

The three-port method is safe and feasible for patients suitable for traditional five-port LRC with an orthotopic neobladder.

Robot-assisted low anterior resection for a rectal cancer patient with ileal conduit: A case report

Surgery for rectal cancer patients with an ileal conduit after total cystectomy is difficult because adhesions in the pelvis and around the ileal conduit are expected. In the present case, we performed robot-assisted low anterior resection of the rectum in a 69-year-old male patient with rectal cancer who underwent ileal conduit diversion after total cystectomy. In this procedure, the port was inserted into the left upper abdomen as a first step, and two additional ports were added on the left side. Low anterior resection was performed using two left hands to create more space in the abdominal cavity for the ileal conduit. We present this minimally invasive robotic procedure that is extremely useful for dissection of adhesions in a narrow pelvic cavity.

Ileal conduit versus single stoma uretero-cutanoustomy after radical cystectomy in patients ≥ 75 years; which technique is better? a prospective randomized comparative study

PURPOSE

To compare the clinical results and patients' health-related quality of life (HR-QoL) of ileal conduit (IC) versus single stoma uretero-cutanoustomy (SSUC) after radical cystectomy in two groups of randomly selected patients ≥ 75 years.

METHODS

From January 2013 to March 2018, 100 patients ≥ 75 years with muscle invasive BCa underwent RCX and cutaneous diversion. Patients were divided in two groups; group I underwent IC (50 patients) and group II underwent SSUC (50 patients). Postoperative evaluation included clinical, laboratory, radiographic and HR-QoL. The latter was performed using the Functional Assessment of Cancer Therapy-Bladder Cancer (FACT-BL) after 12 months postoperatively.

RESULTS

Patients' characteristics were comparable between both groups. No intraoperative complications occurred. Early postoperative complications occurred in 27 patients [16 (35.5%) in group I and 11 (23.9%) in group II (p = 0.02)]. Delayed postoperative complications occurred in 26 patients [6 (13.3%) in group I and 20 (43.4%) in group II, (P = 0.002)]. No significant differences between both groups regarding the physical, social/family, emotional, functional and additional concerns scales of FACT-BL questionnaire were reported.

CONCLUSION

SSUC is a good alternative to IC in elderly frail patients  ≥ 75 years and those with multiple comorbidities who require rapid surgery in terms of perioperative complications and HR-QoL. However, the stomal complications and the possibility of a frequent stent exchange are considered its drawbacks.

Ileal Conduit Versus Orthotopic Neobladder Urinary Diversion in Robot-assisted Radical Cystectomy: Results from a Multi-institutional Series

Background

Head-to-head comparisons between ileal conduit (IC) and orthotopic neobladder (ONB) in terms of peri- and postoperative outcomes and complications, in the specific setting of robot-assisted radical cystectomy (RARC), are not available.

Objective

To address the impact of the type of urinary diversion (UD, IC vs ONB) on RARC morbidity, as well as operative time (OT), length of stay (LOS), and readmissions.

Design setting and participants

Urothelial bladder cancer patients treated with RARC at nine high-volume European institutions between 2008 and 2020 were identified.

Intervention

RARC with either IC or ONB.

Outcome measurements and statistical analysis

Intra- and postoperative complications were collected and reported according to the Intraoperative Complications Assessment and Reporting with Universal Standards recommendations and European Association of Urology guidelines, respectively. Multivariable logistic regression models tested the impact of UD on outcomes, after adjustment for clustering at single hospital level.

Results and limitations

Overall, 555 nonmetastatic RARC patients were identified. In 280 (51%) and 275 (49%) patients, an IC and an ONB were performed, respectively. Eighteen intraoperative complications were recorded. The rates of intraoperative complications were 4% in IC patients and 3% in ONB patients (p = 0.4). The median LOS and readmission rates were 10 versus 12 d (p < 0.001) and 20% versus 21% (p = 0.8) in IC versus ONB patients, respectively. At a multivariable logistic regression analyses, the type of UD (IC vs ONB) reached the independent predictor status for prolonged OT (odds ratio [OR]: 0.61, p = 0.03) and prolonged LOS (OR: 0.34, p < 0.001), but not for readmission (OR: 0.92, p = 0.7). Overall, 513 postoperative complications were experienced by 324 patients (58%). At least one postoperative complication was experienced by 160 (57%) IC patients versus 164 (60%) ONB patients (p = 0.6). The type of UD reached the status of an independent predictor of UD-related complications (OR: 0.64, p = 0.03).

Conclusions

Compared with RARC with ONB, RARC with IC is less prone to UD-related postoperative complications, prolonged OT, and prolonged LOS.

Patient summary

To date, the impact of the type of urinary diversion, namely, ileal conduit versus orthotopic neobladder, on peri- and postoperative outcomes of robot-assisted radical cystectomy is unknown. Based on a rigorous data accrual, which relied on established complication reporting systems (Intraoperative Complications Assessment and Reporting with Universal Standards and European Association of Urology recommended systems), we reported intra- and postoperative complications according to urinary diversion type. Moreover, we found that ileal conduit was associated with lower operative time and length of stay, and yielded a protective effect in terms of urinary diversion-related complications.

Prediction of immune infiltration and prognosis for patients with urothelial bladder cancer based on the DNA damage repair-related genes signature

Objectives

To analyze the correlations between the expression and effect of DNA damage repair genes and the immune status and clinical outcomes of urothelial bladder cancer (BLCA) patients. In addition, we evaluate the efficacy and value of utilizing the DNA damage repair genes signature as a prognosis model for BLCA.

Methods

Two subtype groups (C1 and C2) were produced based on the varied expression of DNA damage repair genes. Significantly differentiated genes and predicted enriched gene pathways were obtained between the two subtypes. Seven key genes were obtained from the DNA damage repair-related genes and a 7-gene signature prognosis model was established based on the key genes. The efficacy and accuracy of this model in prognosis prediction was evaluated and verified in two independent databases. Also, the difference in biological functions, drug sensitivity, immune infiltration and affinity between the high-risk group and low-risk group was analyzed.

Results

The DNA damage repair gene signature could significantly differentiate the BLCA into two molecular subgroups with varied genetic expression and enriched gene pathways. Seven key genes were screened out from the 232 candidate genes for prognosis prediction and a 7-gene signature prognosis model was established based on them. Two independent patient cohorts (TCGA cohort and GEO cohort) were utilized to validate the efficacy of the prognosis model, which demonstrated an effective capability to differentiate and predict the overall survival of BLCA patients. Also, the high-risk group and low-risk group derived from the 7-gene model exhibited significantly differences in drug sensitivity, immune infiltration status and biological pathways enrichment.

Conclusions

Our established 7-gene signature model based on the DNA damage repair genes could serve as a novel prognosis predictive tool for BLCA. The differentiation of BLCA patients based on the 7-gene signature model may be of great value for the appropriate selection of specific chemotherapy agents and immune-checkpoint blockade therapy administration.

Impact of early self-clean intermittent catheterization in orthotopic ileal neobladder: prospective randomized study to evaluate functional outcomes, continence status and urinary tract infections

BACKGROUND

Urinary diversions after radical cystectomy (RC) have a significant impact on quality of life and body image. Particularly for orthotopic neobladder (ONB), the rate of continence, urinary retention and urinary tract infections can impact on patient's quality of life. The aim of this study was to investigate whether early clean intermittent catheterization (CIC) might improve functional outcomes, continence status, and reduce the incidence of UTIs in patients with ONB.

METHODS

In this prospective randomized study patients were divided in two groups. Patients were on a standard postoperative care (group A) or started CIC within the first postoperative month (group B). All patients were evaluated postoperatively at 1, 3, 6, and 9 months after ONB. The CIC was executed 4 times/daily after each voluntary micturition. The postoperative evaluation included: post-void residual volume (PVR), urine analysis and culture, number of pads/day and the self-administrated questionnaire International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF).

RESULTS

Thirty-nine male and 8 female patients underwent laparoscopic or robotic RC with intracorporeal ONB (37 U shaped and 10 Padua reconstructions). At the first follow up, mean PVR was in group A and B, 136.5 mL and 125.7 mL (P value: 0.105), respectively. The ICIQ-UI SF mean score was 16.2 and 17.1 (P value: 0.243) respectively and the mean no. of pads/day was 3 in both groups. 15 patients in group A and 10 in group B reported episodes of symptomatic UTIs. At 3, 6 and 9 months follow up after surgery the PVR and the ICIQ-UI SF scores were significantly improved (P value <0.0001). The number of pads decreased to 2 pads/day in group A and 1 in group B at 9 months. The episodes of UTIs significantly decreased over the time (P value <0.0001).

CONCLUSIONS

Our data support the early introduction of self CIC in patients with ONB after RC. The CIC was significantly associated a reduced risk of incontinence, urinary retention, and UTI with significant improvement in QoL. These encouraging data need to be confirmed by further investigations with a larger number of patients.

Learning Curve of a Novel Three-Port Laparoscopic Radical Cystectomy with Urinary Diversion: A Single-Center Retrospective Analysis

Objective: Three-port laparoscopic radical cystectomy (LRC) is a novel method of radical cystectomy, which is being spread by our team in primary hospitals in our country. The purpose of this study was to evaluate the learning curve of urologists using this technique for bladder cancer patients. Methods: We retrospectively evaluated clinical data from patients with bladder cancer who received three-port LRC with urinary diversion at our medical center between January 2018 and December 2021. Consecutive cases were grouped according to different surgical years, and perioperative parameters among groups were assessed as variables for the learning curve, including operative time, estimated blood loss (EBL), lymph nodes (LN) yield, and postoperative hospital stay. Results: We assessed 154 patients who were divided into three groups, all of which were comparable in terms of preoperative characteristics. With the increase in surgical experience, the operation time of urologists is obviously reduced (P < .05), especially after 100 surgeries, whereas no statistically significant difference was observed in terms of EBL, LN yield, and postoperative hospital stay in the different surgical experience groups (P > .05). Conclusions: Our early learning curve experience indicates that the three-port LRC with urinary diversion is a safe and feasible technique that can be mastered by urologists after learning from a large sample. Given its advantages in cost and significantly improved learning curve, we recommend this technique to surgeons with extensive laparoscopic experience.

Decision regret related to urinary diversion choices after cystectomy among Chinese bladder cancer patients

AIM

To explore factors associated with decision regret after cystectomy among Chinese bladder cancer patients.

METHODS

This cross-sectional study involved 112 patients, who had received radical bladder cancer resection. Participants were recruited from August 2021 until January 2022. The decision regret scale (DRS), decision conflict scale (DCS), and the Functional Assessment of Cancer Therapy-Bladder cancer (FACT-BL) form were used to measure decision regret, decision conflict, and quality of life. Investigator-designed items further explored perceptions involved in decision-making participation and outcomes.

RESULTS

The average score for decision regret was 26.21 (SD 15.886), while decision conflict was 20.27 (SD 13.375) and quality of life was 94.74 (SD 20.873). 57.1% of our participants had a little knowledge about the quality of life of patients who chose an alternate urinary diversion method; however, only 13.4% reported having a clear understanding. In addition, 8.9%, 26.8%, and 36.6% thought that quality of life related to alternate decisions was poor, average, or good, respectively. Multiple regression analysis suggested that decision regret is associated with decision conflict, quality of life, and the perceptions that others (who took alternate urinary diversion decisions) had a better quality of life.

CONCLUSION

Decision regret is common among Chinese bladder cancer patients, after cystectomy. The prevalence of regret appears to be much higher in Chinese bladder cancer patients compared to similar studies from other regions. Decisions in mainland China are often made by the treating physician or by family members which may cause more profound regret. However, education and economic status are positively related to higher levels of regret which creates questions around knowing, participation, and expectations, which must be explored.

Enhanced Nursing Care for Improving the Self-Efficacy & Health-Related Quality of Life in Patients with a Urostomy

Background

Bladder cancer is the most predominant cancer of the lower urinary tract and is the most common cause for urostomy or urinary diversion. Urostomy immensely affect the patient's everyday life from minor physical activity to social relations. Nurse-led interventions have been evaluated for improvement in quality of life in patients with urostomy.

Objective

The main objective of this study was to review the medical literature in a systematic way to evaluate the nursing role in improving the health-related quality of life of patients undergoing urostomy.

Methods

A systematic search of the PubMed, CINAHL, Embase, and Science Direct databases was carried out to identify studies that have evaluated the effect of nurse-led intervention on the self-efficacy and health-related quality of life in patients with urostomy. In addition, studies for factor affecting the quality of life were also investigated.

Results

Overall, 10 studies were identified as suitable for inclusion in this review. Health-related quality of life was lower in these patients as compared to population norms and several factors such as age, employment, and living status were identified as the contributing factors. Preoperative education was critical in meeting the psychological needs while postoperative intervention was instrumental in improving the self-efficacy and health-related quality of life particularly when a continued nursing-patient interaction was existent.

Conclusion

A comprehensive nurse-led intervention consisting of preoperative and postoperative components aimed at ostomy-related education, psychological counseling and compliant with patient factors is feasible and may result in greater improvement in self-efficacy and health-related quality of life in patients with urostomy. Larger clinical trials are warranted to validate these results.

Health-related quality of life after curative treatment for muscle-invasive bladder cancer

Muscle-invasive bladder cancer (MIBC) is an aggressive disease for which the gold-standard treatment is radical cystectomy (RC) in combination with cisplatin-based neoadjuvant chemotherapy. Bladder-sparing strategies such as trimodal therapy (TMT) have also emerged to improve health-related quality of life (HRQoL) of patients. However, an improved understanding of the effect of all these treatment modalities on HRQoL is essential to provide personalized patient care. Different combinations of generic, cancer-specific and bladder cancer-specific questionnaires can be used as instruments for HRQoL evaluation in patients with MIBC before and after curative treatments, which can largely affect multiple domains of HRQoL including general health as well as physical, functional, social and emotional well-being. However, diagnosis of MIBC per se is also likely to affect HRQoL, and the perspective of cure after RC or TMT could induce a return to baseline HRQoL values for most of these domains. A considerable amount of data on HRQoL after RC is available, but conflicting results have been reported regarding the effect of urinary diversion (ileal conduit or orthotopic neobladder) and surgical approach (open or robotic surgery) on patient quality of life. Data on HRQoL after TMT are scarce, and additional comparative studies including patients receiving RC (especially using ileal orthotopic neobladder) are needed.

Evaluation of silk fibroin-based urinary conduits in a porcine model of urinary diversion

Background: The primary strategy for urinary diversion in radical cystectomy patients involves incorporation of autologous gastrointestinal conduits into the urinary tract which leads to deleterious consequences including chronic infections and metabolic abnormalities. This report investigates the efficacy of an acellular, tubular bi-layer silk fibroin (BLSF) graft to function as an alternative urinary conduit in a porcine model of urinary diversion. Materials and methods: Unilateral urinary diversion with stented BLSF conduits was executed in five adult female, Yucatan mini-swine over a 3 month period. Longitudinal imaging analyses including ultrasonography, retrograde ureteropyelography and video-endoscopy were carried out monthly. Histological, immunohistochemical (IHC), and histomorphometric assessments were performed on neoconduits at harvest. Results: All animals survived until scheduled euthanasia and displayed moderate hydronephrosis (Grades 1-3) in reconstructed collecting systems over the course of the study period. Stented BLSF constructs supported formation of vascularized, retroperitoneal tubes capable of facilitating external urinary drainage. By 3 months post-operative, neoconduits contained α-smooth muscle actin+ and SM22α+ smooth muscle as well as uroplakin 3A+ and pan-cytokeratin + urothelium. However, the degree of tissue regeneration in neotissues was significantly lower in comparison to ureteral controls as determined by histomorphometry. In addition, neoconduit stenting was necessary to prevent stomal occlusion. Conclusion: BLSF biomaterials represent emerging platforms for urinary conduit construction and may offer a functional replacement for conventional urinary diversion techniques following further optimization of mechanical properties and regenerative responses.

Systemic therapy issues: Immunotherapy in nonmetastatic urothelial cancer

Non-muscle-invasive bladder cancer is one of the most common malignancies. Patients with intermediate-risk or high-risk disease can be treated with intravesical Bacillus Calmette-Guerin, a vaccine against tuberculosis. However, many of these patients will experience tumor recurrence, despite appropriate treatment. 1 The standard of care in these patients is radical cystectomy (RC) with urinary diversion. 2 Patients diagnosed with muscle-invasive bladder cancer (MIBC) have traditionally faced 2 main treatment options: RC and urinary diversion, as in Bacillus Calmette-Guerin-unresponsive Non-muscle-invasive bladder cancer, or alternatively, trimodal therapy comprising maximal transurethral resection of bladder tumor plus chemoradiation. 3 For patients with MIBC and clinical (c)T2-T4a, neoadjuvant chemotherapy (NAC) preceding RC is supported by Level 1 evidence with a modest 5-year overall survival benefit of 5% with cisplatin-based regimens. 4-9 A number of factors preclude MIBC patients from standard treatment options. For example, patients with serious comorbidities might be unable to tolerate general anesthesia, while others might be unwilling to adapt to the lifestyle changes after RC. 10-12 Likewise, patients with extensive carcinoma in situ or poor bladder function might not be optimal candidates for trimodal therapy or be prepared for the ongoing risk that salvage RC might be ultimately required. Reasons for the underuse of NAC range from the fear of delaying potentially curative surgery in nonresponders to patient ineligibility to cisplatin-based NAC. 13,14 Despite best efforts, in both surgical and bladder-sparing approaches, the 5-year overall survival in treated patients with MIBC is only 35% to 50%. 3,15 Strategies to improve overall prognosis as well as to reduce the indications of RC are desperately needed. Trial results have demonstrated the unprecedented ability of immune-checkpoint inhibitors to induce durable remissions in some patients with metastatic urothelial carcinoma. 16-20 Furthermore, immune-checkpoint inhibitors have shown to be better tolerated than traditional chemotherapy. 16 These successful results have spearheaded the research on these agents in earlier curative settings, with the shared goal of improving overall outcomes, and potentially avoid surgery in patients who show complete response (pT0). Strategies to enhance the immune response by combining immunotherapy with immune sensitizers such as chemotherapy, immunotherapy, targeted therapy or radiation are on the rise.

Factors Influencing Quality of Life and Functional Outcomes in Patients With Bladder Cancer

Here, we review the quality of life and functional outcomes of patients with bladder cancer after treatment and assess potential contributing factors. For current scoring systems, we highlighted the most commonly used specificity scores. In addition, we discuss the impact and bias on the quality of life of patients undergoing urinary diversion modalities, robotic surgery, perioperative rehabilitation, and bladder-preserving radiochemotherapy. Through this review, clinicians will gain better insights regarding the importance of improving patients' quality of life with the goal of restoring their patients' normal function and participating in social activities.

Radical cystectomy and urinary diversion outcomes in patients with single vs. double renal unit: A 2:1 matched-pair analysis

OBJECTIVE

To evaluate perioperative and functional outcomes of radical cystectomy (RC) and urinary diversion (UD) in patients with a single kidney (SK) vs. double kidneys (DK).

METHODS

We reviewed records of patients who underwent RC for bladder cancer with a history of prior or concurrent nephrectomy at USC between 2004 and 2020. Patients with chronic kidney disease who were already on dialysis were excluded. UD, perioperative complications, and postoperative glomerular filtration rate (GFR) of the SK group were compared with a group of patients who underwent RC with DK using 2:1 matching with respect to age, sex, preop GFR, and tumor stage.

RESULTS

We included 186 patients (SK = 62 and DK = 124). Half of the SK patients underwent continent UD. SK patients had a higher length of hospital stay compared to the DK group; however, 90-day complications, readmission, and mortality rates were similar. In patients with continent diversion, SK vs. DK showed similar 90-day complications (71% vs. 69%, P = 1.0). SK patients had significantly lower GFRs at discharge, 3-, and 12-month following RC compared to the DK group. Postoperative GFRs of the SK patients with continent vs. incontinent UD were statistically similar. On multivariable analysis, UD (i.e. continent vs. incontinent) was not associated with post-op GFR decline at discharge, 3- and 12-month following RC.

CONCLUSIONS

Perioperative outcomes of radical cystectomy patients with single kidney are similar to double kidney patients, except for more GFR decline in single kidney cases. Continent urinary diversion in single kidney is as safe as double kidney patients.

Oncological and functional outcomes of female reproductive organ-sparing radical cystectomy and ileal neobladder construction

OBJECTIVES

To examine the oncological and urinary functional outcomes of reproductive organ-sparing radical cystectomy (ROS-RC) and U-shaped ileal neobladder construction in females compared with male patients.

METHODS

We retrospectively examined 357 patients (281 male and 76 female) with muscle-invasive bladder cancer who were treated with RC plus U-shaped ileal neobladder construction between May 1996 and July 2021. All female patients were treated with ROS-RC. We compared disease-free survival (DFS), cancer-specific survival (CSS), overall survival (OS), and urinary functional outcomes between male and female patients. We evaluated the effect of gender on DFS, CSS, and OS. Furthermore, urinary functional outcomes were evaluated in 140 males and 48 females using a pressure-flow study at 3, 6, 9, and 12 months postoperatively.

RESULTS

Female patients were considerably older than male patients at the time of radical cystectomy. No significant difference was noted in the tumor stage preoperatively. The multivariable Cox regression analysis with an inverse probability treatment weighted model revealed that the female gender was not significantly related to DFS, CSS, and OS. Moreover, urinary functions at 12 months were not markedly different between males and females, except for the capacity of the neobladder, detrusor pressure, and maximum urethral closure pressure.

CONCLUSIONS

This study demonstrates that female patients with ROS-RC and U-shaped ileal neobladder construction did not significantly correlate with worse oncological outcomes. The combination of ROS-RC and U-shaped ileal neobladder construction might attain adequate urinary function without sacrificing oncologic outcomes.

Impact of internet plus health education on urinary stoma caregivers in coping with care burden and stress in the era of COVID-19

OBJECTIVE

To explore the impact of "Internet Plus Health Education" on coping with care burden and pressure in urinary stoma caregivers in the era of COVID-19.

MATERIALS AND METHODS

Eighty caregivers of patients with urinary ostomy were equally randomized to experimental and control groups. Caregivers in the experimental group received digital nursing education intervention, which involved nursing intervention of Internet Plus Health Education (IPHE), and those in the control group received conventional care instructions. Six months later, care burden and emotional pressure were assessed in all caregivers using the Zarit Caregiver Burden Interview (ZBI) and the Simplified Coping Style Questionnaire (SCSQ).

RESULTS

Before the intervention, the ZBI and SCSQ scores were comparable between both groups (p > 0.05). After the intervention, the ZBI scores in the experimental group were significantly higher than in the control group and vice versa for SCSQ scores (p < 0.01). Furthermore, after the intervention, the family care satisfaction scale (FCSS) of the experimental group was significantly higher than the control group.

CONCLUSION

Providing "Internet Plus Health Education" to urinary stoma caregivers can reduce their care burden and enhance their pressure-coping ability in the COVID-19 era.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.