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Pan DL, Zhang LF, Li XJ, Zhang KP, Gao PF, Yang B, Li NC. Feasibility and safety of laparoscopic radical cystectomy for male octogenarians with muscle-invasive bladder cancer. BMC Cancer 2024; 24:159. [PMID: 38297199 PMCID: PMC10829394 DOI: 10.1186/s12885-024-11816-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/01/2024] [Indexed: 02/02/2024] Open
Abstract
This study was designed to evaluate the safety and feasibility of laparoscopic radical cystectomy (LRC) for male octogenarian patients with muscle-invasive bladder cancer (MIBC). Briefly, a total of 57 male octogenarian patients (A group) with bladder carcinoma were enrolled and underwent LRC and intracorporeal pelvic lymph node dissection with bilateral cutaneous ureterostomy from May 2016 to December 2022. Besides, 63 male patients (age < 80 years old) with bladder carcinoma undergoing LRC and 17 octogenarian male patients with bladder carcinoma undergoing open radical cystectomy (ORC) were enrolled in B and C groups as control. All perioperative clinical materials and outcomes of long-term follow-up, and complication were collected. The specific results were shown as follows. Compared with C group, the operation time and resected lymph node in A group was increased, and the estimated blood loss, the number of transfusion needed, duration of pelvic drainage and hospital stay after surgery was decreased. The death rate and ileus complication rate were higher in A group (12 cases) than in C group (15 cases). The cases of ureteral stricture in A group (13 cases) was decreased compared with that in C group. Overall, LRC and bilateral cutaneous ureterostomy are safe, feasible and better choices for the treatment of male octogenarian patients with MIBC. The octogenarian receiving cutaneous ureterostomy heals slowly and exists certain incomplete intestinal obstruction after surgery.
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Affiliation(s)
- Dong-Liang Pan
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Lu-Fang Zhang
- Department of Urology, Weifang People's Hospital, Weifang, Shandong, 261041, China.
| | - Xiao-Jian Li
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Ke-Ping Zhang
- Department of Urology, Weifang People's Hospital, Weifang, Shandong, 261041, China
| | - Peng-Fei Gao
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Bing Yang
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Ning-Chen Li
- Department of Urology, Peking University Shougang Hospital, Beijing, 100144, China
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Crettenand F, M’Baya O, Grilo N, Valerio M, Dartiguenave F, Cerantola Y, Roth B, Rouvé JD, Blanc C, Lucca I. ERAS® protocol improves survival after radical cystectomy: A single-center cohort study. Medicine (Baltimore) 2022; 101:e30258. [PMID: 36107599 PMCID: PMC9439815 DOI: 10.1097/md.0000000000030258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION To evaluate Enhanced recovery after surgery (ERAS®) protocol on oncological outcomes for patients treated with radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB). METHODS A prospectively maintained single-institutional database comprising 160 consecutive UCB patients who underwent open RC from 2012 to 2020 was analyzed. Patients receiving chemotherapy and those with a urinary diversion other than ileal conduit were excluded. Patients were divided into two groups according to the perioperative management (ERAS® and pre-ERAS®). The study aimed to evaluate the impact of the ERAS® protocol on survival at five years after surgery using a Kaplan-Meier log-rank test. A multivariable Cox proportional hazards model was used to identify prognostic factors for cancer-specific (CSS) and overall survival (OS). RESULTS Of the 107 patients considered for the final analysis, 74 (69%) were included in the ERAS® group. Median follow-up for patients alive at last follow-up was 28 months (interquartile range [IQR] 12-48). Five-years CSS rate was 74% for ERAS® patients, compared to 48% for the control population (P = 0.02), while 5-years OS was 31% higher in the ERAS® (67% vs. 36%, P = .003). In the multivariable analysis, ERAS® protocol and tumor stage were independent factors of CSS, while ERAS®, tumor stage so as total blood loss were independent factors for OS. DISCUSSION A dedicated ERAS® protocol for UCB patients treated with RC has a significant impact on survival. Reduction of stress after a major surgery and its potential improvement of perioperative patient's immunity may explain these data.
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Affiliation(s)
- François Crettenand
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
- * Correspondence: François Crettenand, Department of Urology, University Hospital CHUV, Rue du Bugnon 46, 1011 Lausanne, Switzerland (e-mail: )
| | - Olivier M’Baya
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | - Nuno Grilo
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | - Massimo Valerio
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | | | - Yannick Cerantola
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | - Beat Roth
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
| | - Jean-Daniel Rouvé
- Department of Anaesthesiology, University Hospital CHUV, Lausanne, Switzerland
| | - Catherine Blanc
- Department of Anaesthesiology, University Hospital CHUV, Lausanne, Switzerland
| | - Ilaria Lucca
- Department of Urology, University Hospital CHUV, Lausanne, Switzerland
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Bi H, Yan Y, Wang D, Qin Z, Wang G, Ma L, Huang Y, Lu J. Predictive value of preoperative lymphocyte-to-monocyte ratio on survival outcomes in bladder cancer patients after radical cystectomy. J Cancer 2021; 12:305-315. [PMID: 33391427 PMCID: PMC7738993 DOI: 10.7150/jca.50603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/25/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose: To determine the prognostic significance of the pre-operative lymphocyte-to-monocyte (LMR) in patients with bladder cancer (BCa) who underwent radical cystectomy (RC), and to assess its prognostic benefit compared to models relying solely on clinicopathological factors. Materials and Methods: A retrospective analysis of the 342 BCa patients undergoing RC at our institution from 2004 to 2017 was conducted to assess LMR prognostic significance. Overall survival (OS) and cancer-specific survival (CSS) were assessed using the Kaplan-Meier method. Cox regression models identified risk factors for survival outcomes. Two new models were developed based on basal models to predict OS and CSS at 1, 3, and 5 years after RC. The accuracy of the new models was evaluated using receiver operating characteristic curves as well as the concordance index. We also conducted decision curve analysis (DCA) to assess their net benefit. Results: An association between excellent long-term patient survival outcomes and higher LMR levels was observed. The median OS and CSS for higher LMR level in patients was 98.8 months and >120 months, respectively. Cox regression multivariate analysis showed that pre-operative LMR, as a continuous variable, was an independent survival outcome predictor (p<0.001). The utilization of LMR in the standard model resulted in significant discriminatory improvement in OS (5.6%, p<0.001) and CSS (4.9%, p=0.001) prediction. Moreover, as shown in DCA, utilization of the new model, including LMR, resulted in a net benefit compared to base models for predicting OS and CSS at 1, 3, and 5 years. Conclusions: An independent association was observed between higher pre-operative LMR in BCa patients undergoing RC and significantly better OS and CSS. In addition, a significant improvement in predictive accuracy was observed with LMR inclusion in multiparametric prediction tools. Therefore, LMR may be utilized in pre-operative patient risk stratification to assist in patient counseling and clinical decision making.
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Affiliation(s)
- Hai Bi
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, PR China
| | - Ye Yan
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, PR China
| | - Dong Wang
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, PR China
| | - Zijian Qin
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, PR China
| | - Guoliang Wang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, PR China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, PR China
| | - Yi Huang
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, PR China
| | - Jian Lu
- Department of Urology, Peking University Third Hospital, 49 North Garden Road, Haidian District, Beijing 100191, PR China
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Bada M, De Concilio B, Crocetto F, Creta M, Silvestri T, Di Mauro M, Celia A. Laparoscopic radical cystectomy with extracorporeal urinary diversion: an Italian single-center experience with 10-year outcomes. MINERVA UROL NEFROL 2020; 72:641-643. [PMID: 32550634 DOI: 10.23736/s0393-2249.20.03850-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Maida Bada
- Department of Urology, S. Bassiano Hospital, Bassano del Grappa, Vicenza, Italy
| | | | - Felice Crocetto
- Department of Neurosciences, Reproductive Sciences, and Odontostomatology, Federico II University, Naples, Italy
| | - Massimiliano Creta
- Department of Neurosciences, Reproductive Sciences, and Odontostomatology, Federico II University, Naples, Italy -
| | - Tommaso Silvestri
- Department of Urology, S. Bassiano Hospital, Bassano del Grappa, Vicenza, Italy
| | - Marina Di Mauro
- Department of Urology, Gaspare Rodolico Hospital, University of Catania, Catania, Italy
| | - Antonio Celia
- Department of Urology, S. Bassiano Hospital, Bassano del Grappa, Vicenza, Italy
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Xie W, Bi J, Wei Q, Han P, Song D, Shi L, Ye D, Shen Y, Gou X, He W, Wang S, Liu Z, Fan J, Wu K, Chen Z, Zhou X, Kong C, Liu Y, Liu C, Xu A, Jin B, Fu G, Xue W, Chen H, Pan T, Tu Z, Lin T, Huang J. Survival after radical cystectomy for bladder cancer: Multicenter comparison between minimally invasive and open approaches. Asian J Urol 2020; 7:291-300. [PMID: 32742929 PMCID: PMC7385523 DOI: 10.1016/j.ajur.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/01/2020] [Accepted: 04/26/2020] [Indexed: 02/08/2023] Open
Abstract
Objective To investigate oncological outcomes in patients with bladder cancer who underwent minimally invasive radical cystectomy (MIRC) or open radical cystectomy (ORC). Methods We identified patients with bladder cancer who underwent radical cystectomy (RC) in 13 centers of the Chinese Bladder Cancer Consortium (CBCC). Perioperative outcomes were compared between MIRC and ORC. The influence of surgical approaches on overall survival (OS) and cancer-specific survival (CSS) in the entire study group and subgroups classified according to pathologic stage or lymph node (LN) status was assessed with the log-rank test. Multivariable Cox proportional hazard models were used to evaluate the association among OS, CSS and risk factors of interest. Results Of 2 098 patients who underwent RC, 1 243 patients underwent MIRC (1 087 laparoscopic RC and 156 robotic-assisted RC, respectively), while 855 patients underwent ORC. No significant differences were noted in positive surgical margin rate and 90-day postoperative mortality rate. MIRC was associated with less estimated blood loss, more LN yield, higher rate of neobladder diversion, longer operative time, and longer length of hospital stay. There was no significant difference in OS and CSS according to surgical approaches (p=0.653, and 0.816, respectively). Subgroup analysis revealed that OS and CSS were not significantly different regardless of the status of extravesical involvement or LN involvement. Multivariable Cox regression analyses showed that the surgical approach was not a significant predictor of OS and CSS. Conclusions Our study showed that MIRC was comparable to conventional ORC in terms of OS and CSS.
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Affiliation(s)
- Weibin Xie
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Junming Bi
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qiang Wei
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Han
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Dongkui Song
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Shi
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dingwei Ye
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yijun Shen
- Department of Urology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xin Gou
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weiyang He
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shaogang Wang
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zheng Liu
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinhai Fan
- Department of Urology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Kaijie Wu
- Department of Urology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhiwen Chen
- Department of Urology, First Affiliated Hospital of Army Medical University, Urology Institute of People Liberation Army, Chongqing, China
| | - Xiaozhou Zhou
- Department of Urology, First Affiliated Hospital of Army Medical University, Urology Institute of People Liberation Army, Chongqing, China
| | - Chuize Kong
- Department of Urology, The First Hospital of China Medical University, Shenyang, China
| | - Yang Liu
- Department of Urology, The First Hospital of China Medical University, Shenyang, China
| | - Chunxiao Liu
- Department of Urology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Abai Xu
- Department of Urology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Baiye Jin
- Department of Urology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guanghou Fu
- Department of Urology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Xue
- Department of Urology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Haige Chen
- Department of Urology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tiejun Pan
- Department of Urology, General Hospital of Central Theater Command of the People's Liberation Army, Wuhan, China
| | - Zhong Tu
- Department of Urology, General Hospital of Central Theater Command of the People's Liberation Army, Wuhan, China
| | - Tianxin Lin
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jian Huang
- Department of Urology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Çelen S, Kaygısız O, Vuruşkan H, Yavaşcaoğlu İ. Laparoscopic versus open radical cystectomy in the treatment of locally advanced T3 and T4 bladder cancer: Perioperative and Mid-term oncological outcomes. Turk J Urol 2020; 46:123-128. [PMID: 32053094 DOI: 10.5152/tud.2020.19077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/25/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In this study, we aim to compare the perioperative and midterm oncological outcomes in patients with advanced bladder cancer and those who had laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC). MATERIAL AND METHODS We retrospectively reviewed medical records of patients who underwent LRC or ORC in a single center between 2008 and 2014 with a pathological diagnosis of pT3 and pT4 bladder cancer. Thirty-five and 39 patients were included in the study as part of the LRC and ORC groups, respectively. RESULTS There was no statistically significant difference between the two groups in terms of disease-free survival (LRC, 39.8±4.86 months; ORC, 45.47±8.92 months, P=0.896). Average estimated blood loss and length of hospitalization were significantly less in the LRC group. The overall survival rates of patients at 1, 2, and 3 years were 73%, 46%, and 46% in the ORC group and 78%, 65%, and 40% in the LRC group, respectively, and there was no statistically significant difference between the two groups. One patient in the ORC group experienced rectal injury in the form of a serosal tear, which was repaired primarily without any postoperative sequelae. There were no conversions in the laparoscopic group. Similarly, in 1 patient, rectal serosal tear was repaired preoperatively. CONCLUSION Our study showed that LRC provides midterm oncological outcomes similar to ORC in the treatment of locally advanced T3 and T4 bladder cancer. However, long-term oncological and functional outcomes are required.
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Affiliation(s)
- Sinan Çelen
- Department of Urology, Pamukkale University School of Medicine Hospital, Denizli, Turkey
| | - Onur Kaygısız
- Department of Urology, Uludağ University School of Medicine Hospital, Bursa, Turkey
| | - Hakan Vuruşkan
- Department of Urology, Uludağ University School of Medicine Hospital, Bursa, Turkey
| | - İsmet Yavaşcaoğlu
- Department of Urology, Uludağ University School of Medicine Hospital, Bursa, Turkey
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Kanno T, Inoue T, Ito K, Okumura K, Yamada H, Kawakita M, Fujii M, Shimizu Y, Yatsuda J, Moroi S, Shichiri Y, Akao T, Sawada A, Kobayashi T, Ogawa O. Oncological outcomes and recurrence patterns after laparoscopic radical cystectomy for bladder cancer: A Japanese multicenter cohort. Int J Urol 2020; 27:250-256. [PMID: 31944410 DOI: 10.1111/iju.14182] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/17/2019] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To investigate oncological outcomes and recurrence patterns after laparoscopic radical cystectomy for bladder cancer in a Japanese multicenter cohort, and to explore the risk factors associated with recurrences due to tumor dissemination. METHOD Laparoscopic radical cystectomies carried out at 10 institutions were included in this retrospective study. Multivariate analyses were carried out to identify the clinical parameters associated with overall recurrences together with specific recurrence types. Kaplan-Meier curves were created to elucidate time to recurrence and survival. RESULTS A total of 411 patients were included after the final analysis. Postoperative pathology was T2 or higher in 196 patients (48%), and lymph node metastasis was present in 46 patients (11%). The median follow-up period was 23 months, and the 2-year recurrence-free and cancer-specific survival rates were 71.0% and 84.7%, respectively. The recurrence sites involved distant metastasis in 75 patients (18%), local recurrence in 52 patients (13%) and urinary tract recurrence in eight patients (2%). When local recurrence at the cystectomy bed (28 patients; 7%) and abdominal recurrence including peritoneal carcinomatosis or port site recurrence (17 patients; 4%), which might be caused by tumor dissemination, were combined into a single group, prolonged surgical time was a significant risk factor, in addition to high pathological stage (T3-4 and/or positive lymph nodes), positive surgical margins, and variant histology by both univariate and multivariate analyses. CONCLUSIONS Our study findings suggest that recurrences after laparoscopic radical cystectomy might be caused by tumor dissemination, and attention should be paid to avoid prolonged surgical time in laparoscopic radical cystectomy.
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Affiliation(s)
- Toru Kanno
- Department of Urology, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Takahiro Inoue
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Katsuhiro Ito
- Department of Urology, Ijinkai Takeda General Hospital, Kyoto, Japan
| | | | - Hitoshi Yamada
- Department of Urology, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Mutsushi Kawakita
- Department of Urology, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Masato Fujii
- Department of Urology, Miyazaki University, Miyazaki, Japan
| | - Yosuke Shimizu
- Department of Urology, Nishikobe Medical Center, Hyogo, Japan
| | - Junji Yatsuda
- Department of Urology, Kumamoto University, Kumamoto, Japan
| | - Seiji Moroi
- Department of Urology, Hamamatsu Rosai Hospital, Shizuoka, Japan
| | | | - Toshiya Akao
- Department of Urology, Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Atsuro Sawada
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Kobayashi
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Osamu Ogawa
- Department of Urology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Long-term Oncological Outcomes from an Early Phase Randomised Controlled Three-arm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL). Eur Urol 2019; 77:110-118. [PMID: 31740072 DOI: 10.1016/j.eururo.2019.10.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 10/23/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The long-term oncological outcomes of laparoscopic (LRC) and robotic-assisted radical cystectomy (RARC) are still maturing compared with open radical cystectomy (ORC). OBJECTIVE To evaluate the 5-yr oncological outcomes of patients recruited into the randomised trial of Open, Laparoscopic and Robot Assisted Cystectomy (CORAL) and extracorporeal urinary diversion. DESIGN, SETTING, AND PARTICIPANTS A review of prospectively maintained database of 60 patients with muscle-invasive bladder cancer (MIBC) or high-risk nonmuscle-invasive bladder cancer (HRNMIBC) who were previously randomised in the CORAL trial to receive ORC, RARC, or LRC. This trial was designed to compare the perioperative and early oncological outcomes of these techniques. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcomes of interest included 5-yr recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). Kaplan-Meier curves were used to plot the recurrence and survival data. The curves between RFS, CSS, and OS were compared using the log-rank test. A two-sided p value <0.05 was considered significant. Results were analysed on the basis of intention to treat. RESULTS AND LIMITATIONS A total of 60 patients with either MIBC (n=38) or HRNMIBC (n=21) were randomised in the CORAL trial to receive ORC, RARC, or LRC. The 5-yr RFS was 60%, 58%, and 71%; 5-yr CSS was 64%, 68%, and 69%; and 5-yr OS was 55%, 65%, and 61% for ORC, RARC, and LRC, respectively. There was no significant difference in RFS, CSS, and OS between the three surgical arms. The principal limitation is the small sample size. CONCLUSIONS There was no difference in 5-yr RFS, CSS, and OS rates of patients who underwent ORC, RARC, and LRC for management of bladder cancer. Minimally invasive techniques achieved equivalent oncological outcomes to the gold standard of ORC. However, the study was based at a single institution with a small sample size. PATIENT SUMMARY Patients who agreed to participate in the randomised trial of either open, laparoscopic, or robotic-assisted radical cystectomy for bladder cancer did not have different cancer outcomes at 5yr.
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Zhang L, Wu B, Zha Z, Qu W, Zhao H, Yuan J. Clinicopathological factors in bladder cancer for cancer-specific survival outcomes following radical cystectomy: a systematic review and meta-analysis. BMC Cancer 2019; 19:716. [PMID: 31324162 PMCID: PMC6642549 DOI: 10.1186/s12885-019-5924-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/11/2019] [Indexed: 01/10/2023] Open
Abstract
Background Assessing the prognostic significance of specific clinicopathological features plays an important role in surgical management after radical cystectomy. This study investigated the association between ten clinicopathological characteristics and cancer-specific survival (CSS) in patients with bladder cancer. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a literature search was conducted through the PubMed, EMBASE and Web of Science databases using appropriate search terms from the dates of inception until November 2018. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to evaluate the CSS. Fixed- or random-effects models were constructed according to existence of heterogeneity. Results Thirty-three articles met the eligibility criteria for this systematic review, which included 19,702 patients. The overall results revealed that CSS was associated with advanced age (old vs. young: pooled HR = 1.01; 95% CI:1.00–1.01; P < 0.001), higher tumor grade (3 vs. 1/2: pooled HR = 1.29; 95% CI:1.15–1.45; P < 0.001), higher pathological stage (3/4 vs. 1/2: pooled HR = 1.60; 95% CI:1.37–1.86; P < 0.001), lymph node metastasis (positive vs. negative: pooled HR = 1.51; 95% CI:1.37–1.67; P < 0.001), lymphovascular invasion (positive vs. negative: pooled HR = 1.36; 95% CI:1.28–1.45; P < 0.001), and soft tissue surgical margin (positive vs. negative: pooled HR = 1.42; 95% CI:1.30–1.56; P < 0.001). However, gender (male vs. female: pooled HR = 0.98; 95% CI: 0.96–1.01; P = 0.278), carcinoma in situ (positive vs. negative: pooled HR = 0.98; 95% CI: 0.88–1.10; P = 0.753), histology (transitional cell cancer vs variant: pooled HR = 0.90; 95% CI: 0.79–1.02; P = 0.089) and adjuvant chemotherapy (yes vs. no: pooled HR = 1.16; 95% CI: 1.00–1.34; P = 0.054) did not affect CSS after radical resection of bladder cancer. Conclusions Our results revealed that several clinicopathological characteristics can predict CSS risk after radical cystectomy. Prospective studies are needed to further confirm the predictive value of these variables for the prognosis of bladder cancer patients after radical cystectomy. Electronic supplementary material The online version of this article (10.1186/s12885-019-5924-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lijin Zhang
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, 214400, China.
| | - Bin Wu
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, 214400, China
| | - Zhenlei Zha
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, 214400, China
| | - Wei Qu
- Department of Pharmacy, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, 214400, China
| | - Hu Zhao
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, 214400, China
| | - Jun Yuan
- Department of Urology, Affiliated Jiang-yin Hospital of the Southeast University Medical College, Jiang-yin, 214400, China
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Influence of laparoscopic access in cancer-specific mortality of patients with pTa-2pN0R0 bladder cancer treated with radical cistectomy. Actas Urol Esp 2019; 43:241-247. [PMID: 30910257 DOI: 10.1016/j.acuro.2019.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 11/10/2018] [Accepted: 01/04/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION AND OBJECTIVE Minimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality. MATERIAL AND METHOD A retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n=191) and laparoscopic radical cystectomy (LRC) (n=74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival. RESULTS 90.9% were males with a median age of 65years and a median follow-up period of 65.5 (IQR27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P=.0001), a longer time between TUR and cystectomy (P=.04), a lower rate of intraoperative transfusion (P=.0001), a lower pT stage (P=.002) and a lower incidence of infection associated with surgical wounds (P=.04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P=.007). Open approach to cystectomy multiplied the risk of mortality by 3.27. CONCLUSIONS In our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.
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11
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Laparoscopic radical cystectomy in octogenarians: analysis of a Japanese multicenter cohort. Int J Clin Oncol 2019; 24:1081-1088. [DOI: 10.1007/s10147-019-01446-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/05/2019] [Indexed: 12/31/2022]
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12
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Moudouni SM, Latabi AF, Aarab M, Lakmichi MA, Dahami Z, Sarf I. [Oncological results of a series of 93 laparoscopic radical cystectomies: 5 years of follow-up]. Prog Urol 2018; 29:86-94. [PMID: 30584022 DOI: 10.1016/j.purol.2018.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/06/2018] [Accepted: 09/17/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report oncological results at 5 years after laparoscopic radical cystectomy (LRC) with lymph node dissection for bladder cancer (BC). PATIENTS AND METHODS This is a retrospective single-center study of all patients who underwent LRC for BC by the same surgeon from February 2007 to March 2016. Demographic, perioperative and oncologic data were collected. We reported overall survival rate (OS), cancer specific (CSS) and recurrence-free survival (SSR), as primary indicators of oncologycal outcomes. These survival rates were estimated according to the Kaplan-Meier method. Log-rank tests were used to explore overall survival according tumor stage, lymph node involvement and surgical margins status. RESULTS In all, 93 patients (82 men and 11 women) underwent LRC. Mean age was 59 years. Minor complications (Clavien I-II) occurred in 24.7%. Major complications (Clavien IIIa-V) were observed in 8.6%. No patients received neoadjuvant chemotherapy. Median lymph node (LN) yield was 15 and 26.5% patients had positive LN. The positive surgical margins (SMs) rate was 5.3%. Median follow-up for the entire patients was 50 months (19-84 months). Forty-three patients (46.2%) were followed for at least 71 months. Five year RFS, CSS and OS were 67%, 85% and 79%, respectively. Non organ confined desease, positive LN and positive SMs were associated with poorer OS (P<0.039, P<0.016 and P<0.001). CONCLUSION LRC was associated with acceptable long-term oncologic outcomes, similar to those currently reported after open cystectomy for BC. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- S M Moudouni
- Centre hospitalier universitaire de Marrakech, avenue Ibn Sina Amerchich, BP 2360, Marrakech-principal, Maroc
| | - A F Latabi
- Centre hospitalier universitaire de Marrakech, avenue Ibn Sina Amerchich, BP 2360, Marrakech-principal, Maroc.
| | - M Aarab
- Centre hospitalier universitaire de Marrakech, avenue Ibn Sina Amerchich, BP 2360, Marrakech-principal, Maroc
| | - M A Lakmichi
- Centre hospitalier universitaire de Marrakech, avenue Ibn Sina Amerchich, BP 2360, Marrakech-principal, Maroc
| | - Z Dahami
- Centre hospitalier universitaire de Marrakech, avenue Ibn Sina Amerchich, BP 2360, Marrakech-principal, Maroc
| | - I Sarf
- Centre hospitalier universitaire de Marrakech, avenue Ibn Sina Amerchich, BP 2360, Marrakech-principal, Maroc
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Okabe K, Shindo T, Maehana T, Nishiyama N, Hashimoto K, Itoh N, Takahashi A, Taguchi K, Tachiki H, Tanaka T, Masumori N. Neoadjuvant chemotherapy with gemcitabine and cisplatin for muscle-invasive bladder cancer: multicenter retrospective study. Jpn J Clin Oncol 2018; 48:934-941. [PMID: 30169681 DOI: 10.1093/jjco/hyy122] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/13/2018] [Indexed: 11/12/2022] Open
Abstract
Objectives The aim of this study was to evaluate the efficacy of neoadjuvant gemcitabine and cisplatin (GC) therapy for muscle-invasive bladder cancer (MIBC). Methods We retrospectively evaluated patients who underwent neoadjuvant GC therapy followed by radical cystectomy from April 2009 through December 2015 in the Sapporo Medical University Urologic Consortium. The efficacy of neoadjuvant chemotherapy (NAC) was assessed based on the pathological T0 (pT0) rate in radical cystectomy specimens, and the recurrence-free survival, cause-specific survival and overall survival (OS) rates. To compare the oncological benefit of NC with GC to that of the methotrexate, vinblastine, adriamycin and cisplatin (MVAC) regimen, we also utilized historical clinical data of patients who were treated with MVAC as NAC followed by radical cystectomy in our institute from 1986 through 2010. Results Fifty-eight patients receiving neoadjuvant GC therapy and 74 receiving neoadjuvant MVAC were included. The pT0 achieving rates were comparable between the two groups (20.7% vs. 18.9%, P = 0.83). Neoadjuvant GC was associated with a better 2-year OS rate than neoadjuvant MVAC for clinical T2 disease (95.2% vs. 70.8%, P = 0.036). In contrast, in patients with clinical T3 or more advanced disease, neoadjuvant MVAC provided more pT0 (20.0% vs. 5.6%, P = 0.07) and better 2-year OS than neoadjuvant GC (71.1% vs. 55.0%, P = 0.142), although the difference did not reach statistical significance. Conclusions Neoadjuvant GC had no inferiority in oncological outcomes to MVAC for MIBC.
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Affiliation(s)
- Ko Okabe
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tetsuya Shindo
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takeshi Maehana
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naotaka Nishiyama
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kohei Hashimoto
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoki Itoh
- Department of Urology, NTT East Corporation Sapporo Hospital, Sapporo, Japan
| | - Atsushi Takahashi
- Department of Urology, Hakodate Koseiin Hakodate Goryokaku Hospital, Hakodate, Japan
| | - Keisuke Taguchi
- Department of Urology, Oji General Hospital, Tomakomai, Japan
| | - Hitoshi Tachiki
- Department of Urology, Steel Memorial Muroran Hospital, Muroran, Japan
| | - Toshiaki Tanaka
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University School of Medicine, Sapporo, Japan
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Effectiveness of hyaluronic acid/carboxymethylcellulose in preventing adhesive bowel obstruction after laparoscopic radical cystectomy. Asian J Surg 2018; 42:394-400. [PMID: 30266466 DOI: 10.1016/j.asjsur.2018.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/22/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND/OBJECTIVE Adhesive bowel obstruction is one of the most frequent complications after radical cystectomy, prolonging hospital stay and fasting period and increasing medical expenses. This study evaluated the effectiveness of hyaluronic acid/carboxymethylcellulose (HA/CMC) in preventing adhesive bowel obstruction after laparoscopic radical cystectomy. METHODS Randomized, controlled, single-blinded study was performed. Of 76 patients who underwent laparoscopic radical cystectomy for bladder cancer, 38 received HA/CMC instillation and 38 did not. The primary endpoint was the rate of postoperative adhesive bowel obstruction. The secondary endpoint was the rate of other postoperative outcomes. RESULTS None of the patients who received HA/CMC instillation experienced postoperative adhesive bowel obstructions, compared with six (15.79%) patients in the control group (p = 0.025). Of the six patients with ileus, two underwent adhesiolysis. There were no significant differences between the two groups in other postoperative outcomes. CONCLUSION HA/CMC instillation during laparoscopic radical cystectomy may reduce the incidence of postoperative adhesive bowel obstruction without adverse effects.
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Bochner BH, Dalbagni G, Marzouk KH, Sjoberg DD, Lee J, Donat SM, Coleman JA, Vickers A, Herr HW, Laudone VP. Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: Oncologic Outcomes. Eur Urol 2018; 74:465-471. [PMID: 29784190 DOI: 10.1016/j.eururo.2018.04.030] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Open radical cystectomy (ORC) has proven to be an important component in the treatment of high-risk bladder cancer (BCa). ORC surgical morbidity remains high; therefore, minimally invasive surgical techniques have been introduced in an attempt to improve patient outcomes. OBJECTIVE To compare cancer outcomes in BCa patients managed with ORC or robotic-assisted radical cystectomy (RARC). DESIGN, SETTING, AND PARTICIPANTS A prospective, randomized trial was completed between 2010 and 2013. Patients were randomized to ORC/pelvic lymphadenectomy (PLND) or RARC/PLND, with all undergoing open/extracorporeal urinary diversion. Median follow-up was 4.9 (IQR: 3.9-5.9) yr after surgery among surviving patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Secondary outcomes to the trial included recurrence-free, cancer-specific, and overall survival. RESULTS AND LIMITATIONS The trial randomized 118 patients who underwent RC/PLND and urinary diversion. Sixty were randomized to RARC and 58 to ORC. Four RARC-assigned patients refused randomization and received ORC; however, an intention to treat analysis was performed. No differences were observed in recurrence (hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 0.69-2.36; p=0.4) or cancer-specific survival (p=0.4). No difference in overall survival was observed (p=0.8). However, the pattern of first recurrence demonstrated a nonstatistically significant increase in metastatic sites for those undergoing ORC (sub-HR [sHR]: 2.21; 95% CI: 0.96-5.12; p=0.064) and a greater number of local/abdominal sites in the RARC-treated patients (sHR: 0.34; 95% CI: 0.12-0.93; p=0.035). The major limitation to this study is that the trial was not powered to determine differences in cancer recurrences, survival outcomes, or patterns of recurrence. CONCLUSIONS The secondary outcomes from our randomized trial did not definitively demonstrate differences in cancer outcomes in patients treated with ORC or RARC. However, differences in observed patterns of first recurrence highlight the need for future studies. PATIENT SUMMARY Of 118 patients randomly assigned to undergo radical cystectomy/pelvic lymphadenectomy and urinary diversion, half were assigned to open surgery and half to robot-assisted techniques. We found no difference in risk of recurring or dying of bladder cancer between the two groups.
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Affiliation(s)
- Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA.
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Karim H Marzouk
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin Lee
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sheri M Donat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Harry W Herr
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
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Adamczyk P, Juszczak K, Poblocki P, Mikolajczak W, Drewa T. Robot-assisted radical cystectomy - first Polish clinical outcomes. Cent European J Urol 2018; 71:14-20. [PMID: 29732201 PMCID: PMC5926646 DOI: 10.5173/ceju.2018.1628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/21/2018] [Accepted: 02/14/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction Urothelial cell carcinoma is the most common neoplasm of the genito-urinary tract, which, in advanced stages, is treated with radical cystectomy with pelvic lymphadenectomy. It can be performed by an open or minimally invasive approach (laparoscopic and robot-assisted radical cystectomy). Large meta-analyses showed a significantly lower complication rate in the RARC (robot-assisted radical cystectomy) group compared to ORC (open radical cystectomy) in thirty and ninety days after surgery, with similar oncological and functional outcomes. The clinical outcomes of the first forty Polish RARC are explored in this article. Material and methods The Polish Radical Robotic Cystectomy Program (PRRC) was started in 2016 at the Nicolaus Copernicus Hospital in Toruń. Forty consecutive patients, with indications for cystectomy were included into the study. During radical robot-assisted cystectomy, obturator, external, internal, common iliac and presacral lymph nodes were dissected. Oncological outcomes, early complication rate, and the clinical variables were analyzed. Results The mean age in the study group was sixty-seven years, with the majority of patients being overweight and assessed as American Society of Anesthesiology Scale (ASA) – ASA III and ASA IV (2/3 of patients). RARC was performed, with the median time of surgery being 324 minutes (170 minutes being the shortest). Mean blood loss was 365 ml (lowest – 50 ml), and only 2 patients required intraoperative blood transfusion. Twenty patients had ileal conduit, and nineteen had other methods of urinary diversion. Only twenty-nine out of forty patients had minor complications (Clavien I and II), 11 had Clavien III and IV. Clavien V was not present. Only 3 patients required reoperation. Conclusions RARC is a reproducible oncological procedure, which can be safely performed in centers with robotic expertise, with acceptable operative time, complications, and functional and oncologic outcomes.
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Affiliation(s)
- Przemysław Adamczyk
- Nicolaus Copernicus Hospital in Toruń, Department of General and Oncologic Urology, Toruń, Poland
| | - Kajetan Juszczak
- Memorial Rydygier Hospital, Department of Urology, Cracow, Poland
| | - Pawel Poblocki
- Nicolaus Copernicus Hospital in Toruń, Department of General and Oncologic Urology, Toruń, Poland
| | - Witold Mikolajczak
- Nicolaus Copernicus Hospital in Toruń, Department of General and Oncologic Urology, Toruń, Poland
| | - Tomasz Drewa
- Nicolaus Copernicus Hospital in Toruń, Department of General and Oncologic Urology, Toruń, Poland.,Collegium Medicum of Nicolaus Copernicus University, Clinic of General and Oncologic Urology, Bydgoszcz, Poland
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Simone G, Tuderti G, Misuraca L, Anceschi U, Ferriero M, Minisola F, Guaglianone S, Gallucci M. Perioperative and mid-term oncologic outcomes of robotic assisted radical cystectomy with totally intracorporeal neobladder: Results of a propensity score matched comparison with open cohort from a single-centre series. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2018; 44:1432-1438. [PMID: 29699838 DOI: 10.1016/j.ejso.2018.04.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/29/2018] [Accepted: 04/06/2018] [Indexed: 10/17/2022]
Abstract
AIM In this study, we compared perioperative and oncologic outcomes of patients treated with either open or robot-assisted radical cystectomy and intracorporeal neobladder at a tertiary care center. METHODS The institutional prospective bladder cancer database was queried for "cystectomy with curative intent" and "neobladder". All patients underwent robot-assisted radical cystectomy and intracorporeal neobladder or open radical cystectomy and orthotopic neobladder for high-grade non-muscle invasive bladder cancer or muscle invasive bladder cancer with a follow-up length ≥2 years were included. A 1:1 propensity score matching analysis was used. Kaplan-Meier method was performed to compare oncologic outcomes of selected cohorts. Survival rates were computed at 1,2,3 and 4 years after surgery and the log rank test was applied to assess statistical significance between the matched groups. RESULTS Overall, 363 patients (299 open and 64 robotic) were included. Open radical cystectomy patients were more frequently male (p = 0.08), with higher pT stages (p = 0.003), lower incidence of urothelial histologies (p = 0.05) and lesser adoption of neoadjuvant chemotherapy (<0.001). After applying the propensity score matching, 64 robot-assisted radical cystectomy patients were matched with 46 open radical cystectomy cases (all p ≥ 0.22). Open cohort showed a higher rate of perioperative overall complications (91.3% vs 42.2%, p 0.001). At Kaplan-Meier analysis robotic and open cohorts displayed comparable disease-free survival (log-rank p = 0.746), cancer-specific survival (p = 0.753) and overall-survival rates (p = 0.909). CONCLUSIONS Robot-assisted radical cystectomy and intracorporeal neobladder provides comparable oncologic outcomes of open radical cystectomy and orthotopic neobladder at intermediate term survival analysis.
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Affiliation(s)
- Giuseppe Simone
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy.
| | - Gabriele Tuderti
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Leonardo Misuraca
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Umberto Anceschi
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | | | - Francesco Minisola
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | | | - Michele Gallucci
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
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Esquinas C, Alonso J, Mateo E, Dotor A, Martín A, Dorado J, Arance I, Angulo J. Prospective study comparing laparoscopic and open radical cystectomy: Surgical and oncological results. Actas Urol Esp 2018. [PMID: 28624175 DOI: 10.1016/j.acuro.2017.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Laparoscopic radical cystectomy with lymphadenectomy and urinary diversion is an increasingly widespread operation. Studies are needed to support the oncological effectiveness and safety of this minimally invasive approach. PATIENTS AND METHODS A nonrandomised, comparative prospective study between open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) was conducted in a university hospital. The main objective was to compare cancer-specific survival. The secondary objective was to compare the surgical results and complications according to the Clavien-Dindo scale. RESULTS We treated 156 patients with high-grade invasive bladder cancer with either ORC (n=70) or LRC (n=86). The mean follow-up was 33.5±23.8 (range 12-96) months. The mean age was 66.9+9.4 years, and the male to female ratio was 19:1. Both groups were equivalent in age, stage, positive lymph nodes, in situ carcinoma, preoperative obstructive uropathy, adjuvant chemotherapy and type of urinary diversion. There were no differences between the groups in terms of cancer-specific survival (log-rank; P=.71). The histopathology stage was the only independent variable that predicted the prognosis. The hospital stay (P=.01) and operative transfusion rates (P=.002) were less for LRC. The duration of the surgery was greater for LRC (P<.001). There were no differences in the total complications rate (p=.62) or major complications (P=.69). The risk of evisceration (P=.02), surgical wound infection (P=.005) and pneumonia (P=.017) was greater for ORC. The risk of rectal lesion (P=.017) and urethrorectal fistulae (P=.065) was greater for LRC. CONCLUSION LRC is an equivalent treatment to ORC in terms of oncological efficacy and is advantageous in terms of transfusion rates and hospital stays but not in terms of operating room time and overall safety. Studies are needed to better define the specific safety profile for each approach.
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Wei X, Lu J, Siddiqui KM, Li F, Zhuang Q, Yang W, Hu Z, Chen Z, Song X, Wang S, Ye Z. Does previous abdominal surgery adversely affect perioperative and oncologic outcomes of laparoscopic radical cystectomy? World J Surg Oncol 2018; 16:10. [PMID: 29343302 PMCID: PMC5773160 DOI: 10.1186/s12957-018-1317-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 01/10/2018] [Indexed: 12/04/2022] Open
Abstract
Background Laparoscopic radical cystectomy (LRC) has been shown to have less estimated blood loss (EBL), transfusion rate, narcotic analgesic requirement, earlier return of bowel function, and shorter hospital stay. The aim of this study was to investigate the feasibility, peri-operative and oncologic outcomes of laparoscopic radical cystectomy (LRC) in patients with previous abdominal surgery (PAS). Methods We retrospectively reviewed 243 patients undergoing open radical cystectomy (ORC) or LRC with bilateral pelvic lymph node dissection and urinary diversion or cutaneous ureterostomy at a single center from January 2010 to December 2015. Demographic parameters, intra-operative variables, peri-operative records, pathologic outcomes, and complication rate were reviewed to assess the impact of PAS on peri-operative and oncologic outcomes. Results Patients in both ORC and LRC subgroups were homogeneous in terms of demography characteristics including age, gender, BMI, ASA score, and comorbidity. Estimated blood loss (EBL) was higher in patients with PAS undergoing ORC compared to those with no PAS (P = 0.008). However, there was no significant difference of EBL among patients undergoing LRC with or without PAS (P = 0.896). There was no statistical difference in peri-operative parameters and pathological outcomes. Patients with PAS undergoing ORC and ileal conduit had a higher vascular injury rate (P = 0.017). Comparing patients with PAS performed by LRC and ORC, the number of patients with the vascular injury was higher in ORC groups regardless of the type of diversion (ileal conduit, P = 0.001, cutaneous ureterostomy, P = 0.025). There is no significant difference in other complications. Conclusion The presence of adhesions from PAS is not a contraindication to LRC. Patients with PAS may benefit from LRC with lower estimated blood loss, fewer transfusion rates, and vascular injuries. Furthermore, the overall oncologic outcomes and complication rate are similar between LRC and ORC patients with PAS.
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Affiliation(s)
- Xiaosong Wei
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China.,Department of Urology, First Affiliated Hospital of Zheng Zhou University, Zhengzhou, 450052, Henan, People's Republic of China
| | - Jinjin Lu
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China
| | - Khurram Mutahir Siddiqui
- Departments of Surgery (Urology), Western University, London Health Sciences Centre, London, ON, N6A 5W9, Canada
| | - Fan Li
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China.
| | - Qianyuan Zhuang
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China
| | - Weimin Yang
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China
| | - Zhiquan Hu
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China
| | - Zhong Chen
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China
| | - Xiaodong Song
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China
| | - Shaogang Wang
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China
| | - Zhangqun Ye
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Ave, Wuhan, 430030, Hubei, People's Republic of China
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Young MJ, Elmussareh M, Weston P, Dooldeniya M. Radical cystectomy in the elderly - Is this a safe treatment option? Arab J Urol 2017; 15:360-365. [PMID: 29234541 PMCID: PMC5717452 DOI: 10.1016/j.aju.2017.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/30/2017] [Accepted: 09/11/2017] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To determine if significant differences exist in the perioperative outcomes of patients aged >75 years treated with radical cystectomy (RC) compared to younger patients, as RC is frequently not offered to 'elderly' patients with bladder cancer because of supposed increased risks of complications. PATIENTS AND METHODS We retrospectively analysed prospectively collected data of all patients that underwent RC in our centre from May 2013 to June 2015. In all, 81 consecutive RCs were identified and included in our study. Patients were divided into two age groups: Group A, aged <75 years (51 patients) and Group B, aged ≥75 years (30). Co-morbidities and perioperative outcomes were compared between the groups. Fisher's exact test was used for statistical analysis. RESULTS In 68 patients RC was performed laparoscopically and the remaining 13 patients underwent open RC. The mean (range) age was 70.7 (36-85) years. There were 37 patients with muscle-invasive disease and 42 had non-muscle-invasive disease. The median hospital stay was not significantly different between the two age groups (10 vs 11 days). There was no significant difference in the preoperative Charlson co-morbidity index. The 30-day mortality rate was 4% for those aged <75 years and 6.6% for those aged ≥75 years, with overall perioperative complication rates of 57% vs 66%, respectively. Most complications were minor (Clavien-Dindo Grade I-II) and there was no statistically significant difference between the two cohorts. There was also no statistically significant difference in blood transfusion rates. CONCLUSION RC in patients aged ≥75 years has similar perioperative morbidity when compared with younger patients and can be offered in selected elderly patients. Thus, age should not be an absolute contraindication for RC.
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Affiliation(s)
- Matthew J Young
- Department of Urology, Pinderfields General Hospital, Mid-Yorkshire Hospitals Trust, Wakefield, West Yorkshire, UK
| | - Muhammad Elmussareh
- Department of Urology, Pinderfields General Hospital, Mid-Yorkshire Hospitals Trust, Wakefield, West Yorkshire, UK
| | - Philip Weston
- Department of Urology, Pinderfields General Hospital, Mid-Yorkshire Hospitals Trust, Wakefield, West Yorkshire, UK
| | - Mohantha Dooldeniya
- Department of Urology, Pinderfields General Hospital, Mid-Yorkshire Hospitals Trust, Wakefield, West Yorkshire, UK
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Xu K, Lang B, Fu B, Shi T, Wang B, Zhang X. Laparoendoscopic Single-Site Radical Cystectomy vs Conventional Laparoscopic Radical Cystectomy for Patient with Bladder Urothelial Carcinoma: Matched Case-Control Analysis. J Endourol 2017; 31:1259-1268. [PMID: 28967303 DOI: 10.1089/end.2017.0525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Laparoendoscopic single-site surgery (LESS) is increasingly popular in urology. However, data on LESS radical cystectomy (LESS-RC) are immature, and no adequate comparative study has assessed conventional laparoscopic radical cystectomy (CL-RC) vs LESS-RC. The primary aim of this study was to compare efficiency and safety of LESS-RC and CL-RC for patients with bladder urothelial carcinoma (BUC). MATERIALS AND METHODS A retrospective and case-matched control comparative analysis was performed of patients who underwent LESS-RC (n = 54) and CL-RC (n = 108) from January 2011 to June 2015. Oncologic, complication and perioperative outcomes were collected and evaluated. RESULTS LESS-RC vs CL-RC was associated with less estimated blood loss (EBL; median, 270 vs 337.5 mL; p = 0.014), postoperative pain (median, 4.0 vs 6.0 scores; p = 0.001), and shorter convalescence (time to ambulation and oral intake, median, 2.5 vs 3 days; p = 0.002 and 5 vs 6 days; p = 0.004, respectively). No significant differences were noted for LESS-RC and CL-RC regarding the lymph node yield (median: 18 vs 20; p = 0.101). Median follow-up time was 33.5 months (interquartile range [IQR]: 23-41.3 months) and 33 months (IQR: 23-43 months) for the LESS-RC and CL-RC groups, respectively. No significant differences were noted for LESS-RC and CL-RC regarding estimated 24-month overall survival (86.7% vs 88.1%, p = 0.703), cancer-specific survival (88.3% vs 90.9%, p = 0.539), and recurrence-free survival (80.2% vs 87.5%, p = 0.619), even when substratified according to tumor stage (pT3 or higher) and lymph node status (pN+). Early, late, and 90-day overall complication rates were similar. In multivariate analyses, LESS-RC was not associated with recurrence and worse survival rates, but was associated with 90-day overall complications. CONCLUSIONS This study demonstrated that LESS-RC and CL-RC have comparable efficiency and safety for patients with BUC. Compared to CL-RC, LESS-RC was with less postoperative pain, lower EBL, and more rapid convalescence, but was associated with 90-day overall complications.
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Affiliation(s)
- Kai Xu
- 1 Department of Urology, Zhujiang Hospital of Southern Medical University , Guangzhou, People's Republic of China
| | - Bin Lang
- 2 School of Health Sciences, Macao Polytechnic Institute , Macao, People's Republic of China
| | - Bin Fu
- 3 Department of Urology, First Affiliated Hospital of Nanchang University , Nanchang, People's Republic of China
| | - Taoping Shi
- 4 Department of Urology, Clinical Division of Surgery, Chinese PLA General Hospital , Beijing, People's Republic of China
| | - Baojun Wang
- 4 Department of Urology, Clinical Division of Surgery, Chinese PLA General Hospital , Beijing, People's Republic of China
| | - Xu Zhang
- 4 Department of Urology, Clinical Division of Surgery, Chinese PLA General Hospital , Beijing, People's Republic of China
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22
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Ding X, Yang D, Ke C, Gong L, Zhan H, Yan R, Chen Y, Li H, Wang J. Value of evaluating procalcitonin kinetics in diagnosis of infections in patients undergoing laparoscopic radical cystectomy. Medicine (Baltimore) 2017; 96:e8152. [PMID: 29049197 PMCID: PMC5662363 DOI: 10.1097/md.0000000000008152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Postsurgery infection is a common complication after laparoscopic radical cystectomy (LRC) followed by urinary diversion. White blood cell (WBC) values and C-reactive protein (CRP) are routinely used as markers for infection, but lack of specificity and their elevation is often delayed in clinically significant events. In this study, we aimed to investigate the value of procalcitonin (PCT) kinetics in assisting early diagnosis of infection in patients undergoing LRC.The patients' medical records between May 2013 and May 2016 were reviewed retrospectively. WBC, CRP, and PCT plasma levels as well as clinical symptoms were registered in 306 patients preoperatively (day 0), and 5 consecutive days postoperatively. Based on microbiological and clinical data, patients were grouped into noninfection- (NI-) and infection- (I-) groups. The day of new onset infection was observed were defined as day t0 and the day after that as day t1. For the NI-group, the day on which PCT was at the peak was defined as day t1 and the previous day as day t0.Of the 306 patients, 46 (15.03%) have proven infection. PCT levels were analogous at day t0:NI-group [median (interquartile range)]: 0.69(1.99) vs I-group [median (interquartile range)]: 1.0[0.75], P = .1. PCT levels were significantly increased at day t1 in the I-group[median (interquartile range)]:2.9(1.3) vs NI-group[median (interquartile range)]: 1.3(1.5), P < .01. The area under the curve for the prediction of infection was 0.72 [95% confidence interval (CI) = 0.63-0.81] for the absolute value of PCT; and for delta PCT:0.88 (95% CI = 0.81-0.94), P < .01. The optimal cut-off value was 0.79 ng/mL with the highest Youden index of 0.80 for delta-PCT to indicate infection. Neither absolute values nor changes in CRP, or WBC could predict infection better. The "delta" was considered as the changes in the absolute values (subtracting day t0 from day t1) of PCT, CRP, and WBC.This study suggest that early elevation of PCT within the first 24 hours of new onset infection, interpreted with clinical results, appears to be a promising indicator for the diagnosis of infections following LRC.
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Affiliation(s)
- Xiangli Ding
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
| | - Delin Yang
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
| | - Changxing Ke
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
| | - Long Gong
- Department of Orthopedics, 252 Hospital of Chinese PLA, Baoding, Hebei
| | - Hui Zhan
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
| | - Ruping Yan
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
| | - Yan Chen
- Department of Obstetrical, The Second Affiliated Hospital of Kunming Medical University
| | - Haiyuan Li
- Department of Urology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Jiansong Wang
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan
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23
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Palazzetti A, Sanchez-Salas R, Capogrosso P, Barret E, Cathala N, Mombet A, Prapotnich D, Galiano M, Rozet F, Cathelineau X. Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy. Actas Urol Esp 2017; 41:416-425. [PMID: 27908634 DOI: 10.1016/j.acuro.2016.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/12/2016] [Indexed: 11/30/2022]
Abstract
Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.
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Affiliation(s)
- A Palazzetti
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - R Sanchez-Salas
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia.
| | - P Capogrosso
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - E Barret
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - N Cathala
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - A Mombet
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - D Prapotnich
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - M Galiano
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - F Rozet
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
| | - X Cathelineau
- Departamento de Urología, L'Institute Mutualiste Montsouris, París, Francia
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24
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Hong X, Li T, Ling F, Yang D, Hou L, Li F, Tan W. Impact of surgical margin status on the outcome of bladder cancer treated by radical cystectomy: a meta-analysis. Oncotarget 2017; 8:17258-17269. [PMID: 27791991 PMCID: PMC5370038 DOI: 10.18632/oncotarget.12907] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 10/14/2016] [Indexed: 01/24/2023] Open
Abstract
Data regarding the association between surgical margin status and the outcome of bladder cancer treated by radical cystectomy (RC) are conflicting. Therefore, the present meta-analysis was performed to assess the associations between the outcomes of bladder cancer, in terms of recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS), and the presence of positive surgical margins versus negative surgical margins following treatment with RC. Research articles published prior to April 2016 were identified from Pubmed, Embase and the Cochrane Library databases. A total of 36 articles were included, with a sample size of 38,384 bladder cancer patients. Of these, 4,354 patients were reported to have positive surgical margins. Significant associations were detected between positive surgical margins following RC and unfavorable RFS [summary relative risk estimate (SRRE), 1.63; 95% confidence interval (CI), 1.46-1.83; P = 0.105], CSS (SRRE, 1.82; 95% CI, 1.63-2.04; P = 0.001) and OS (SRRE, 1.68; 95% CI, 1.58-1.80; P = 0.805), by fixed or random effects models. The findings were consistent independently of age, sample size, publication year, follow-up duration, study type and geographical region. In summary, the present findings demonstrate that the presence of positive surgical margins is associated with poor survival outcomes in bladder cancer following RC, indicating that avoidance of positive surgical margins during surgery is helpful to improve the prognosis of patients with bladder cancer.
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Affiliation(s)
- Xuwei Hong
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Tieqiu Li
- Department of Urology, The People's Hospital of Hunan Province, First Affiliated Hospital of Hunan Normal University, Changsha, P. R. China
| | - Fengsheng Ling
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Dashan Yang
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Lina Hou
- Department of Healthy Management, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Fei Li
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Wanlong Tan
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
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25
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Hermans TJN, Fossion LMCL, Verhoeven R, Horenblas S. Laparoscopic Radical Cystectomy in the Elderly - Results of a Single Center LRC only Series. Int Braz J Urol 2017; 42:1099-1108. [PMID: 27532116 PMCID: PMC5117965 DOI: 10.1590/s1677-5538.ibju.2015.0419] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 03/07/2016] [Indexed: 12/25/2022] Open
Abstract
Objective: To compare outcome of laparoscopic radical cystectomy (LRC) with ileal conduit in 22 elderly (≥75 years) versus 51 younger (<75 years) patients. Materials and Methods: Analysis of prospectively gathered data of a single institution LRC only series was performed. Selection bias for LRC versus non-surgical treatments was assessed with data retrieved from the Netherlands Cancer Registry. Results: Median age difference between LRC groups was 9.0 years. (77.0 versus 68.0 years). Both groups had similar surgical indications, body mass index and gender distribution. Charlson Comorbidity Index score was 3 versus 4 in ≥50% of younger and elderly patients. Median operative time (340 versus 341 min) and estimated blood loss (<500 versus >500mL) did not differ between groups. Median total hospital stay was 12.0 versus 14.0 days for younger and elderly patients. Grade I-II 90-d complication rate was higher for elderly patients (68 versus 43%, p=0.05). Grade III-V 90-d complication rate was equal for both groups (23 versus 29%, p=0.557). 90-d mortality rate was higher for elderly patients (14 versus 4%, p=0.157). Median follow-up was 40.0 months for younger and 57.0 months for elderly patients. Estimated overall and cancer-specific survival at 5years. was 46% versus 35% and 64% versus 64% for younger and elderly patients respectively. Conclusions: Our results suggest that LRC is feasible in elderly patients, where a non-surgical treatment is usually favoured.
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Affiliation(s)
- Tom J N Hermans
- Department of Urology, Maxima Medical Center Veldhoven, Veldhoven, The Netherlands
| | | | - Rob Verhoeven
- Eindhoven Cancer Registry/Comprehensive Cancer Centre South, Eindhoven, The Netherlands
| | - Simon Horenblas
- Department of Urology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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26
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Autorino R, Porpiglia F, Dasgupta P, Rassweiler J, Catto JW, Hampton LJ, Lima E, Mirone V, Derweesh IH, Debruyne FMJ. Precision surgery and genitourinary cancers. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2017; 43:893-908. [PMID: 28254473 DOI: 10.1016/j.ejso.2017.02.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/08/2017] [Indexed: 02/06/2023]
Abstract
The landscape of the surgical management of urologic malignancies has dramatically changed over the past 20 years. On one side, better diagnostic and prognostic tools allowed better patient selection and more reliable surgical planning. On the other hand, the implementation of minimally invasive techniques and technologies, such as robot-assisted laparoscopy surgery and image-guided surgery, allowed minimizing surgical morbidity. Ultimately, these advances have translated into a more tailored approach to the management of urologic cancer patients. Following the paradigm of "precision medicine", contemporary urologic surgery has entered a technology-driven era of "precision surgery", which entails a range of surgical procedures tailored to combine maximal treatment efficacy with minimal impact on patient function and health related quality of life. Aim of this non-systematic review is to provide a critical analysis of the most recent advances in the field of surgical uro-oncology, and to define the current and future role of "precision surgery" in the management of genitourinary cancers.
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Affiliation(s)
- R Autorino
- Urology Institute, University Hospitals, Case Western Reserve University, Cleveland, OH, USA.
| | - F Porpiglia
- Division of Urology, University of Turin, San Luigi Hospital, Orbassano, Italy.
| | - P Dasgupta
- King's College London, Guy's Hospital, London, UK.
| | - J Rassweiler
- Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heidelberg, Germany.
| | - J W Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK.
| | - L J Hampton
- Division of Urology, Virginia Commonwealth University, Richmond, VA, USA.
| | - E Lima
- Life and Health Sciences Research Institute, The Clinic Academic Center, University of Minho, and Department of CUF Urology, Braga, Portugal.
| | - V Mirone
- Department of Urology, Federico II University, Naples, Italy.
| | - I H Derweesh
- Department of Urology, UC San Diego Health System, La Jolla, CA, USA.
| | - F M J Debruyne
- Andros Men's Health Institutes, Arnhem, The Netherlands.
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27
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Krajewski W, Zdrojowy R, Tupikowski K, Małkiewicz B, Kołodziej A. How to lower postoperative complications after radical cystectomy - a review. Cent European J Urol 2016; 69:370-376. [PMID: 28127453 PMCID: PMC5260457 DOI: 10.5173/ceju.2016.880] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/16/2016] [Accepted: 10/13/2016] [Indexed: 11/22/2022] Open
Abstract
Introduction Lowering morbidity and mortality after RC is subject of considerable interest. Lately, many evidence-based data on improvements in operative technique, anesthetic management, and patient care have been published. In this article, we present a review of literature on how to lower postoperative complications after RC. Material and methods The Medline, and Web of Science databases were searched without a time limit on February 2016 using the terms ‘cystectomy’ in conjunction with ‘radical’, ‘bladder cancer’, ‘complications’ or ‘management’. Boolean operators (NOT, AND, OR) were also used in succession to narrow and broaden the search. The search was limited to the English, Polish and Spanish literature. Results Many complications may be avoided by appropriate patient selection and meticulous introduction of care protocols. Conclusions RC as treatment free of complications, even in the hands of an experienced urologist, does not exist. A large number of complications are acceptable in the name of good long-term results. Optimum results are possible with proper surgical technique, good patients and urinary diversion selection and proper patient management in the pre-, peri, and postoperative period.
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Affiliation(s)
- Wojciech Krajewski
- Urology and Urologic Oncology Department, Wrocław Medical University, Wrocław, Poland
| | - Romuald Zdrojowy
- Urology and Urologic Oncology Department, Wrocław Medical University, Wrocław, Poland
| | - Krzysztof Tupikowski
- Urology and Urologic Oncology Department, Wrocław Medical University, Wrocław, Poland
| | - Bartosz Małkiewicz
- Urology and Urologic Oncology Department, Wrocław Medical University, Wrocław, Poland
| | - Anna Kołodziej
- Urology and Urologic Oncology Department, Wrocław Medical University, Wrocław, Poland
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28
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Development and Validation of a Quality Assurance Score for Robot-assisted Radical Cystectomy: A 10-year Analysis. Urology 2016; 97:124-129. [DOI: 10.1016/j.urology.2016.06.063] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 06/13/2016] [Accepted: 06/14/2016] [Indexed: 11/22/2022]
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29
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Lucca I, Hofbauer SL, Leitner CV, de Martino M, Özsoy M, Susani M, Shariat SF, Klatte T. Development of a Preoperative Nomogram Incorporating Biomarkers of Systemic Inflammatory Response to Predict Nonorgan-confined Urothelial Carcinoma of the Bladder at Radical Cystectomy. Urology 2016; 95:132-8. [DOI: 10.1016/j.urology.2016.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/31/2016] [Accepted: 06/08/2016] [Indexed: 11/29/2022]
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30
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Albisinni S, Fossion L, Oderda M, Aboumarzouk OM, Aoun F, Tokas T, Varca V, Sanchez-Salas R, Cathelineau X, Chlosta P, Gaboardi F, Nagele U, Piechaud T, Rassweiler J, Rimington P, Salomon L, van Velthoven R. Critical Analysis of Early Recurrence after Laparoscopic Radical Cystectomy in a Large Cohort by the ESUT. J Urol 2016; 195:1710-7. [DOI: 10.1016/j.juro.2016.01.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Simone Albisinni
- Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Laurent Fossion
- Department of Urology, Maxima Medisch Centrum, Eindhoven, The Netherlands
| | - Marco Oderda
- Department of Urology, Clinique Saint Augustin, Bordeaux
| | | | - Fouad Aoun
- Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Virginia Varca
- Department of Urology, San Raffaele – Turro Hospital, Vita Salute San Raffaele University, Milan, Italy
| | | | | | - Piotr Chlosta
- Department of Urology, Jagiellonian University, Krakow, Poland
| | - Franco Gaboardi
- Department of Urology, San Raffaele – Turro Hospital, Vita Salute San Raffaele University, Milan, Italy
| | - Udo Nagele
- Department of Urology, Tirol Kliniken, Innsbruck, Austria
| | | | | | - Peter Rimington
- Department of Urology, East Sussex Healthcare NHS Trust, Eastbourne, United Kingdom
| | | | - Roland van Velthoven
- Department of Urology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
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Abstract
In the past 10 years, laparoscopy has been challenged by robotic surgery; nevertheless, laparoscopic techniques are subject to continuous change. Ultrahigh definition is the next development in video technology, it delivers fourfold more detail than full high definition resulting in improved fine detail, increased texture, and an almost photographic emulsion of smoothness of the image. New 4K ultrahigh-definition technology might remove the current need for the use of polarized glasses. New devices for laparoscopy include advanced sealing devices, instruments with six degrees of freedom, ergonomic platforms with armrests and a chest support, and camera holders. A manually manipulated robot-like device is still at the experimental stage. Robot-assisted surgery has substantially revolutionized laparoscopy, increasing its distribution; however, robot-assisted surgery is associated with considerable costs. All technical improvements of laparoscopic surgery are extremely valuable to further simplify the use of classical laparoscopy.
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32
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Kanno T, Kubota M, Otsuka K, Sakamoto H, Nishiyama R, Oida T, Okada T, Akao T, Higashi Y, Yamada H. [MID-TERM ONCOLOGICAL OUTCOME AND TECHNICAL MODIFICATIONS FOR LAPAROSCOPIC RADICAL CYSTECTOMY AT OUR INSTITUTION: 60 CASES ANALYSIS]. Nihon Hinyokika Gakkai Zasshi 2016; 107:220-226. [PMID: 29070734 DOI: 10.5980/jpnjurol.107.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
(Objective) Although laparoscopic radical cystectomy (LRC) is becoming a standard care for invasive and high-risk non-invasive bladder cancer in Japan, the data about mid-and long-term oncological outcome is still lacking. We previously reported our initial experience of LRC compared to open radical cystectomy. In this study, we evaluated mid-term oncological outcome for LRC by updating our clinical data. In addition, we evaluated the effect of technical modifications for LRC. (Patients and methods) From March 2005 to September 2015, 60 patients underwent LRC at our institution. Treatment outcomes including surgical and oncological outcomes were analyzed. We also assessed the effect of technical modifications between first 30 cases and second 30 cases as to blood loss, operating time and complication rate. (Results) The overall complication rate was 47%, including 18% serious complications (Clavien score 3 or greater). The 5-year recurrence-free survival, cancer-specific survival, and overall survival were 56.2%, 74.4%, and 63.6%, respectively. The recurrence occurred in 19 (32%) cases, including distant metastasis in 12 (20%) cases, local recurrence in 6 (10%) cases, and both in 1 (2%) cases. As for the effect of technical modifications for LRC, the blood loss decreased and postoperative recovery was faster in second 30 cases. (Conclusion) These results indicate that LRC could be performed safely with acceptable oncological outcomes.
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Affiliation(s)
- Toru Kanno
- The Department of Urology, Ijinkai Takeda General Hospital
| | - Masashi Kubota
- The Department of Urology, Ijinkai Takeda General Hospital
| | - Kazuo Otsuka
- The Department of Surgery, Ijinkai Takeda General Hospital
| | - Hiromasa Sakamoto
- The Department of Urology, Graduate School of Medicine, Kyoto University
| | | | - Tomoyuki Oida
- The Department of Urology, Koseikai Takeda General Hospital
| | - Takashi Okada
- The Department of Urology, Ijinkai Takeda General Hospital
| | - Toshiya Akao
- The Department of Urology, Rakuwakai Otowa Hospital
| | | | - Hitoshi Yamada
- The Department of Urology, Ijinkai Takeda General Hospital
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A Single-centre Early Phase Randomised Controlled Three-arm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL). Eur Urol 2015; 69:613-621. [PMID: 26272237 DOI: 10.1016/j.eururo.2015.07.038] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 07/16/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) are increasingly popular, but high-level evidence for these techniques remains lacking. OBJECTIVE To compare the outcomes of patients undergoing open radical cystectomy (ORC), RARC, and LRC. DESIGN, SETTING, AND PARTICIPANTS From March 2009 to July 2012, 164 patients requiring radical cystectomy for muscle-invasive bladder cancer or high-risk non-muscle-invasive bladder cancer were invited to participate, with an aim of recruiting 47 patients into each arm. Overall, 93 were suitable for trial inclusion; 60 (65%) agreed and 33 (35%) declined. INTERVENTION ORC, RARC, or LRC with extracorporeal urinary diversion. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary end points were 30- and 90-d complication rates. Secondary end points were perioperative clinical, pathologic, and oncologic outcomes, and quality of life (QoL). The Fisher exact test and analysis of variance were used for statistical analyses. RESULTS AND LIMITATIONS The 30-d complication rates (classified by the Clavien-Dindo system) varied significantly between the three arms (ORC: 70%; RARC: 55%; LRC: 26%; p=0.024). ORC complication rates were significantly higher than LRC (p<0.01). The 90-d complication rates did not differ significantly between the three arms (ORC: 70%; RARC: 55%; LRC 32%; p=0.068). Mean operative time was significantly longer in RARC compared with ORC or LRC. ORC resulted in a slower return to oral solids than RARC or LRC. There were no significant differences in QoL measures. Major limitations are the small sample size and potential surgeon bias. CONCLUSIONS The 30-d complication rates varied by type of surgery and were significantly higher in the ORC arm than the LRC arm. There was no significant difference in 90-d Clavien-graded complication rates between the three arms. PATIENT SUMMARY We compared patients having open, robotic, or laparoscopic bladder removal surgery for bladder cancer and found no difference in Clavien-graded complication rates at 90 d.
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Albisinni S, Oderda M, Fossion L, Varca V, Rassweiler J, Cathelineau X, Chlosta P, De la Taille A, Gaboardi F, Piechaud T, Rimington P, Salomon L, Sanchez-Salas R, Stolzenburg JU, Teber D, Van Velthoven R. The morbidity of laparoscopic radical cystectomy: analysis of postoperative complications in a multicenter cohort by the European Association of Urology (EAU)-Section of Uro-Technology. World J Urol 2015; 34:149-56. [PMID: 26135307 DOI: 10.1007/s00345-015-1633-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/24/2015] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To analyze postoperative complications after laparoscopic radical cystectomy (LRC) and evaluate its risk factors in a large prospective cohort built by the ESUT across European centers involved in minimally invasive urology in the last decade. METHODS Patients were prospectively enrolled, and data were retrospectively analyzed. Only oncologic cases were included. There were no formal contraindications for LRC: Also patients with locally advanced tumors (pT4a), serious comorbidities, and previous major abdominal surgery were enrolled. All procedures were performed via a standard laparoscopic approach, with no robotic assistance. Early and late postoperative complications were graded according to the modified Clavien-Dindo classification. Multivariate logistic regression was performed to explore possible risk factors for developing complications. RESULTS A total of 548 patients were available for final analysis, of which 258 (47%) experienced early complications during the first 90 days after LRC. Infectious, gastrointestinal, and genitourinary were, respectively, the most frequent systems involved. Postoperative ileus occurred in 51/548 (9.3%) patients. A total of 65/548 (12%) patients underwent surgical re-operation, and 10/548 (2%) patients died in the early postoperative period. Increased BMI (p = 0.024), blood loss (p = 0.021), and neoadjuvant treatment (p = 0.016) were significantly associated with a greater overall risk of experiencing complications on multivariate logistic regression. Long-term complications were documented in 64/548 (12%), and involved mainly stenosis of the uretero-ileal anastomosis or incisional hernias. CONCLUSIONS In this multicenter, prospective, large database, LRC appears to be a safe but morbid procedure. Standardized complication reporting should be encouraged to evaluate objectively a surgical procedure and permit comparison across studies.
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Affiliation(s)
- Simone Albisinni
- Department of Urology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium. .,Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Boulevard de Waterloo 121, Brussels, Belgium.
| | - Marco Oderda
- Department of Urology, Clinique Saint Augustin, Bordeaux, France
| | - Laurent Fossion
- Department of Urology, Maxima Medisch Centrum, Eindhoven, The Netherlands
| | - Virginia Varca
- Department of Urology, Ospedale Luigi Sacco, Milan, Italy
| | | | | | - Piotr Chlosta
- Department of Urology, Jagiellonian University, Kraków, Poland
| | | | | | - Thierry Piechaud
- Department of Urology, Clinique Saint Augustin, Bordeaux, France
| | - Peter Rimington
- Department of Urology, East Sussex Healthcare NHS Trust, Eastbourne, UK
| | | | | | | | - Dogu Teber
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Roland Van Velthoven
- Department of Urology, Jules Bordet Institute, Université Libre de Bruxelles, Boulevard de Waterloo 121, Brussels, Belgium
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Raza SJ, Wilson T, Peabody JO, Wiklund P, Scherr DS, Al-Daghmin A, Dibaj S, Khan MS, Dasgupta P, Mottrie A, Menon M, Yuh B, Richstone L, Saar M, Stoeckle M, Hosseini A, Kaouk J, Mohler JL, Rha KH, Wilding G, Guru KA. Long-term oncologic outcomes following robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol 2015; 68:721-8. [PMID: 25985883 DOI: 10.1016/j.eururo.2015.04.021] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 04/14/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Long-term oncologic data on patients undergoing robot-assisted radical cystectomy (RARC) are limited and based largely on single-institution series. OBJECTIVE Report survival outcomes of patients who underwent RARC ≥5 yr ago. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of the prospectively populated International Robotic Cystectomy Consortium multi-institutional database identified 743 patients with RARC performed ≥5 yr ago. Clinical, pathologic, and survival data at the latest follow-up were collected. Patients with palliative RARC were excluded. Final analysis was performed on 702 patients from 11 institutions in 6 countries. INTERVENTION RARC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Outcomes of interest, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were plotted using Kaplan-Meier survival curves. A Cox proportional hazards model was used to identify factors that predicted outcomes. RESULTS AND LIMITATIONS Pathologic organ-confined (OC) disease was found in 62% of patients. Soft tissue surgical margins (SMs) were positive in 8%. Median lymph node (LN) yield was 16, and 21% of patients had positive LNs. Median follow-up was 67 mo (interquartile range: 18-84 mo). Five-year RFS, CSS, and OS were 67%, 75%, and 50%, respectively. Non-OC disease and SMs were associated with poorer RFS, CSS, and OS on multivariable analysis. Age predicted poorer CSS and OS. Adjuvant chemotherapy and positive SMs were predictors of RFS (hazard ratio: 3.20 and 2.16; p<0.001 and p<0.005, respectively). Stratified survival curves demonstrated poorer outcomes for positive SM, LN, and non-OC disease. Retrospective interrogation and lack of contemporaneous comparison groups that underwent open radical cystectomy were major limitations. CONCLUSIONS The largest multi-institutional series to date reported long-term survival outcomes after RARC. PATIENT SUMMARY Patients who underwent robot-assisted radical cystectomy for bladder cancer have acceptable long-term survival.
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Affiliation(s)
| | - Timothy Wilson
- City of Hope and Beckman Research Institute, Duarte, CA, USA
| | | | | | | | | | - Shiva Dibaj
- Roswell Park Cancer Institute, Buffalo, NY, USA
| | | | | | | | - Mani Menon
- Henry Ford Health System, Detroit, MI, USA
| | - Bertram Yuh
- City of Hope and Beckman Research Institute, Duarte, CA, USA
| | - Lee Richstone
- Arthur Smith Institute for Urology, New Hyde Park, NY, USA
| | | | | | | | - Jihad Kaouk
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Koon-Ho Rha
- Yonsei University Health Systems Severance Hospital, Seoul, Korea
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