Examining the relationship between complications and perioperative mortality following radical cystectomy: a population-based analysis

Previous maximal transurethral resection of bladder tumor lead to unfavorable perioperative outcomes following radical cystectomy

PURPOSE

To evaluate the impact of maximal transurethral resection of bladder tumor (TURBT) on perioperative outcomes following radical cystectomy (RC).

METHODS

This study included 310 patients who underwent RC for the diagnosis of bladder urothelial carcinoma. Of these, 146 patients had a history of maximal TURBT (TURBT group) and 164 did not (non-TURBT group). Patients in the TURBT group were categorized into four groups according to the time interval between the last TURBT and RC: ≤ 1 month, 1-3 months, 3-6 months, and > 6 months. Additionally, the TURBT group was stratified into a single TURBT group and multiple TURBT group. Perioperative outcomes were compared between the groups.

RESULTS

The median duration of pelvic drainage tube retention was longer in the TURBT group (11 vs. 9 days, p = 0.037). The incidence of Clavien-Dindo ≥ 3 complications (15.3% vs. 7.3%, p = 0.031) and ICU admission rate(10.4% vs. 4.5%, p = 0.048) were higher in the TURBT group. Statistically significant differences were observed in the incidence of Clavien-Dindo ≥ 3 complications (p = 0.007), reoperation rates (p = 0.041), incidence of sepsis (p = 0.022), and urinary complications (p = 0.024) across the four groups stratified by the time interval between TURBT and RC, with the 1-3 to months group demonstrating the highest incidence. There was no significant difference in perioperative outcomes between patients who underwent a single TURBT and those who underwent multiple TURBT.

CONCLUSION

Patients with a history of maximal TURBT, especially those who underwent RC within 1-3 months after maximal TURBT, have an increased risk of unfavorable perioperative outcomes following RC.

Temporal patterns of major postoperative events after radical cystectomy: analysis of 90-day morbidity

AIM OF THE STUDY

To investigate the time points at which different major complications occur and their temporal distribution over the postoperative intervals.

PATIENTS AND METHODS

Patients who underwent RC between January 2003 and March 2024 at the university hospital Essen and had complete records regarding postoperative complications and their timing were included. All major complications with Clavian-Dindo (CD) grading III-V were identified and recorded according to a predefined morbidity catalog. The time to occurrence of complications, readmission and mortality, was plotted against the postoperative day over a 90-day period to illustrate the distribution of events in the postoperative period. For each complication group, the median timing and the interquartile range (IQR) as well as the incidence during the postoperative weeks were calculated.

RESULTS

Out of 757 patients, 282 (37.2%) suffered at least one major complication (CDC grade III-IV) with a total of 452 major complications. Most common complications were gastrointestinal, genitourinary and wound complications. Median (IQR) time to first major complication was 7 (4-17) days. Hospital readmission due to major complications was required in 68 (9%) patients at a median of 47 days. Most of cardiac, pulmonary, bleeding and gastrointestinal complications occurred very early in the first week, at a median of 3, 4, 4 and 5 days, respectively. Wound complications were more likely to occur within the second and third week, with a median time of 13 days. Thromboembolism developed at similar rates throughout the first 3 weeks. The other groups of complications including infectious, genitourinary and miscellaneous (mostly lymphocele) complications showed no specific pattern and occurred in a wide range over the 90 days and were considered intermediate and late events. Further analysis of the time to all complications (first major and secondary), showed an increase in median time to occurance for all complications except genitouranry and lymphocele, which occurred earlier. Deaths related to major complications were observed in 50 (6.6%) patients at a median time of 17 days.

CONCLUSION

The current study shows the temporal patterns of the major complications within the RC morbidity catalog. Physicians should be aware of these patterns to facilitate anticipation and prevent fatal outcomes.

Clinical outcomes of nephroureterectomy with bladder cuff excision or radical cystectomy for distal ureteral carcinoma invaded muscle of the ureteral orifice

PURPOSE

To present the clinical outcomes of nephroureterectomy with bladder cuff excision (NU-BCE) or radical cystectomy (NU-RC) when distal ureteral carcinoma invaded muscle of the ureteral orifice using inverse probability of treatment weighting (IPTW).

METHODS

This multicenter study retrospectively studied the demographics and perioperative outcomes of 59 patients who underwent NU-BCE or NU-RC between 2003 and 2024. Relapse-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were presented using Kaplan-Meier curves. Cox proportional hazard regression to find independent predictors.

RESULTS

Of all patients, the median follow-up time for RFS was 8 months and 18 months for CSS and OS. After IPTW, the median RFS, CSS, and OS for patients who underwent NU-BCE and NU-RC was 9 vs. 27 months (p = 0.037), 18 vs. 40 months (p = 0.027), 18 vs. 30 months (p = 0.371), respectively. The mortality due to progression and complications in NU-BCE and NU-RC patients were 56.4% vs. 20.4% and 2.2% vs. 22.9% (p = 0.016). NU-BCE reduced the median operation time, blood loss, and drainage volume. Apart from NU-RC (HR, 0.18; 95%CI: 0.08-0.44; p < 0.001) (HR, 0.28; 95%CI: 0.1-0.79; p = 0.016) and tumor volume(HR, 1.17; 95%CI: 1.06-1.29; p = 0.002) (HR, 1.21; 95%CI: 1.11-1.31; p < 0.001), which are independent prognostic factors for RFS and CSS, another independent prognostic factor for CSS is the ureteral carcinoma with renal pelvic carcinoma (HR, 4.32; 95%CI: 1.28-14.511; p = 0.018).

CONCLUSIONS

Patients who underwent NU-RC had better RFS and CSS than NU-BCE, but there was little difference in OS due to the higher mortality rate of postoperative complications in the NU-RC.

The feasibility and safety of robotic-assisted salvage radical cystectomy

Objectives

To evaluate the feasibility and safety of robotic-assisted salvage radical cystectomy (RA-SRC).

Materials and Methods

We retrospectively searched the prospectively collected surgical database of two highly experienced robotic urological surgeons for cases of RA-SRC, defined as RARC performed post-previous pelvic RT for palliative or oncologic treatment purposes. Collected data included demographic and clinical information and outcome measures including operative course, hospital stay and complications.

Results

Eighteen patients were included in the current analysis. All patients had previous RT to the pelvis with 12 patients also having prior radical pelvic surgery. Indications for salvage cystectomy were either palliation (n = 12) or oncological (MIBC or high risk NMIBC, n = 6). There were no intraoperative complications and no conversions to open surgery. Ninety day postoperative complications were recorded in 11 patients (61.1%), with major complications (Clavien-Dindo grades 3 and 4) in three patients (16.6%). After a median follow-up of 43.5 months, one late postoperative complication was observed requiring surgical intervention.

Conclusion

Our data, together with the limited published data from other cohorts of RA-SRC, suggest that in experienced hands, RA-SRC is feasible, with intraoperative and perioperative complication rates that are lower than the published data for open SRC and are equivalent to open primary RC. These data will contribute to treatment decision making both in patients with post-pelvic radiation symptoms requiring palliation and patients with MIBC considering or treated with trimodal treatment.

Preoperative risk stratification models after radical cystectomy for bladder cancer: A multi-center study

OBJECTIVE

We investigated preoperative patient factors associated with prognosis in 263 bladder cancer (BC) patients undergoing radical cystectomy (RC). We also developed new risk stratification models for prognosis.

METHODS

This retrospective study included patients treated at Tottori University Hospital and affiliated hospitals between January 2010 and December 2019. The relationship between preoperative patient factors and overall recurrence-free and cancer-specific survival (CSS) was analyzed. The modified Glasgow prognosis score (mGPS) was calculated using serum albumin and C-reactive protein (CRP) levels. Statistical analyses included the log-rank test and Cox proportional hazards regression.

RESULTS

Eastern Cooperative Oncology Group performance status (ECOG-PS), mGPS, and clinical tumor stage independently predicted CSS in multivariate analysis. A new risk stratification model included ECOG-PS ≥2, clinical tumor stage ≥3, serum albumin <3.5 g/dL, and serum CRP >0.5 mg/dL. Risk groups were defined as 0 factors (low risk), 1-2 factors (intermediate risk), and 3-4 factors (high risk). High-risk patients showed significantly poorer 3-year cancer-free survival: 86.9% (low risk), 76.7% (intermediate risk), and 50.0% (high risk).

CONCLUSIONS

ECOG-PS, clinical tumor stage, and mGPS are predictive of poor cancer-free survival post-RC for BC. Our model offers the potential for prognostic prediction in these patients.

Radical cystectomy in patients aged < 80 years versus ≥ 80 years: analysis of preoperative geriatric assessment scores in predicting postoperative morbidity and mortality

PURPOSE

Pre-operative assessment of surgical risk is essential for patient counselling in the elderly patient population. Our purpose was to compare validated geriatric assessment scores (GAS) in predicting postoperative morbidity and mortality in patients ≥ 80 years.

METHODS

Overall, eight preoperative GAS were assessed for each patient who received RC from 2016 to 2021. Postoperative morbidity was recorded according to the Clavien-Dindo classification (CDC) of surgical complications. Binary logistic regression analyses were used to determine prediction of 30-d morbidity and 90-d mortality in patients ≥ 80 years.

RESULTS

In total, 424 patients were analysed (77.4% male) with median age of 71 years (IQR: 68.82;70.69), of which 67 (15.8%) were ≥ 80 years. Patients age ≥ 80 years showed more 30-d CDC grade ≥ IIIb (41.07% vs. 27.74% compared to < 80 years, p < .001) and worse 90-d mortality (26.87% vs. 4.76%, p < .001). In patients ≥ 80 years, morbidity was predicted by simplified Frailty Index (sFI)  ≥ 2 (OR: 2.06, 95% CI: 1.27-3.34, p = .004), Eastern Cooperative Oncology Group (ECOG) performance status ≥ 2 (OR: 2.78, 95% CI: 1.18-6.54, p = .019) and severe Adult Comorbidity Evaluation (ACE)-27 score (OR: 2.07, 95% CI: 1.13-3.79, p = .019), while 90-d mortality was predicted by CDC grade ≥ IIIb (OR: 22.91, 95% CI: 8.74-60.09, p < .001) and ECOG ≥ 2 (OR: 2.87, 95% CI: 1.05-7.86, p = .04).

CONCLUSION

Even in a high-volume center of RC, 90-d mortality is significantly higher in patients age ≥ 80. Our results suggest in patient age ≥ 80, sFI ≥ 2, ECOG performance status ≥ 2 and severe ACE-27 score as clinical cut-off value to evaluate alternative bladder-sparing concepts.

Surgical outcomes and predictive value for major complications of robot-assisted radical cystectomy of real-world data in a single institution in Japan

OBJECTIVE

The objective of the study was to describe the surgical outcome of robot-assisted radical cystectomy and predictive factors for major complications in real-world clinical practice at a single institution in Japan.

METHODS

We retrospectively analyzed 208 consecutive patients undergoing robot-assisted radical cystectomy at our institution between 2019 and 2023. Patient and disease characteristics, intraoperative details, and perioperative outcomes were reviewed. Postoperative complications were defined as minor complications (Clavien-Dindo grades 1-2) or major complications (grades 3-5). Predictors of complications were examined using multivariable logistic analysis.

RESULTS

Overall, 147 men and 61 women, median age 70 years (interquartile range, 62-77), were included in this study. Median operative time and estimated blood loss were 8.4 h and 185 mL, respectively; 11 patients (5%) received intraoperative blood transfusions. For urinary diversions, ileal conduit, neobladder, and cutaneous ureterostomy were performed in 153 (74%), 49 (24%), and 6 (3%) patients, respectively. Urinary diversions were primarily performed with extracorporeal urinary diversion. In total, 140 complications occurred in 111 patients (53%) within 30 days. Of these patients, 31 major complications occurred in 28 patients, and one perioperative death (0.5%) with a postoperative cardiovascular event. Multivariable analysis showed only prolonged operative time (odds ratio: 4.34, 95% confidence interval: 1.82-10.35, p < 0.01) was the independent risk factor for major complications.

CONCLUSIONS

This study reports surgical outcomes at our single institution. Prolonged operative time was a significant prognostic factor for major complications. As far as we know, this study reports the largest number of robot-assisted radical cystectomy cases at a single center in Japan.

Maximizing efficiency and ensuring safety: Exploring the outcomes of 2 consecutive open radical cystectomies by the same team within a single surgical day

BACKGROUND

The purpose of this study was to evaluate the outcomes of performing 2 consecutive open radical cystectomies (RCs) within 1 day by the same surgical team.

PATIENTS AND METHODS

A retrospective analysis was conducted on data from patients who underwent RC at a single tertiary care center from January 2015 to February 2023. Patient characteristics, perioperative outcomes and endpoints were analyzed. Univariable and multivariable logistic regression models were created to predict major complications.

RESULTS

A total of 657 patients were included in the final cohort, containing 64 paired RCs (32 RC1 and 32 RC2) and 593 single RCs. Major complications occurred in 24.7% of the entire cohort, with no significant differences between single RC vs. RC1 and RC2. Paired RCs showed significantly shorter operative time (OT; p = 0.001) and length of stay (LOS; p = 0.047) compared to single RCs. There were no significant differences in transfusion rates, 30-day readmission, 30-day mortality, or histopathological results between paired and single RCs. Multivariable analysis identified patient characteristics such as age (OR = 1.67, p = 0.03), sex (OR = 0.45, p = 0.008), BMI (OR = 1.98, p = 0.007), ASA-score (OR = 1.61, p = 0.04), and OT (OR = 1.87, p = 0.008) as independent predictors of major complications.

CONCLUSION

Performing 2 consecutive open RCs within 1 day by the same surgical team is a safe approach in experienced hands. This strategy optimizes the utilization of surgical resources and addresses the growing demand for urologic care while maintaining high-quality patient care. Preoperative planning should consider patient-specific factors to minimize risks associated with major complications.

MICRO ABSTRACT

This study evaluates the outcomes of performing 2 consecutive open radical cystectomies (RC) in a single day by the same surgical team. Data from 657 patients who underwent RC at a single tertiary medical center proved that this approach is safe, with no significant differences in major complications. Preoperative planning should consider patient-specific factors for efficient utilization of surgical resources.

Non-Surgical Bladder-Sparing Multimodal Management in Organ-Confined Urothelial Carcinoma of the Urinary Bladder: A Population-Based Analysis

BACKGROUND

Trimodal therapy is considered the most validated bladder-sparing treatment in patients with organ-confined urothelial carcinoma of the urinary bladder (T2N0M0). However, scarce evidence exists regarding cancer-specific mortality (CSM) differences between trimodal therapy and other non-extirpative multimodal treatment options such as radiotherapy alone after transurethral resection (TURBT + RT) or chemotherapy alone after transurethral resection (TURBT + CT).

METHODS

Within the Surveillance, Epidemiology, and End Results database (2004-2020), we identified T2N0M0 patients treated with either trimodal therapy, TURBT + CT, or TURBT + RT. Temporal trends described trimodal therapy vs. TUBRT + CT vs. TURBT + RT use over time. Survival analyses consisting of Kaplan-Meier plots and multivariable Cox regression (MCR) models addressed CSM according to each treatment modality.

RESULTS

3729 (40%) patients underwent TMT vs. 4030 (43%) TURBT + CT vs. 1599 (17%) TURBT + RT. Over time, trimodal therapy use (Estimating annual percent change, EAPC: +1.2%, p = 0.01) and TURBT + CT use increased (EAPC: +1.5%, p = 0.01). In MCR models, relative to trimodal therapy, TURBT + CT exhibited 1-14-fold higher CSM and TURBT + RT 1.68-fold higher CSM. In a subgroup analysis, TURBT + RT was associated with 1.42-fold higher CSM than TURBT + CT (p < 0.001).

CONCLUSIONS

Strict trimodal therapy that includes both CT and RT after TURBT offers the best cancer control. When strict trimodal therapy cannot be delivered, cancer-specific survival outcomes appear to be superior with TURBT + chemotherapy compared to TURBT + RT.

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2023 Guidelines

CONTEXT

We present an overview of the updated 2023 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).

OBJECTIVE

To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the MMIBC guidelines has been performed annually since 2017. Searches cover the Medline, EMBASE, and Cochrane Libraries databases for yearly guideline updates. A level of evidence and strength of recommendation are assigned. The evidence cutoff date for the 2023 MIBC guidelines was May 4, 2022.

EVIDENCE SYNTHESIS

Patients should be counselled regarding risk factors for bladder cancer. Pathologists should describe tumour and lymph nodes in detail, including the presence of histological subtypes. The importance of the presence or absence of urothelial carcinoma (UC) in the prostatic urethra is emphasised. Magnetic resonance imaging (MRI) of the bladder is superior to computed tomography (CT) for disease staging, specifically in differentiating T1 from T2 disease, and may lead to a change in treatment approach in patients at high risk of an invasive tumour. Imaging of the upper urinary tract, lymph nodes, and distant metastasis is performed with CT or MRI; the additional value of flurodeoxyglucose positron emission tomography/CT still needs to be determined. Frail and comorbid patients should be evaluated by a multidisciplinary team. Postoperative histology remains the most important prognostic variable, while circulating tumour DNA appears to be an interesting predictive marker. Neoadjuvant systemic therapy remains cisplatin-based. In motivated and selected women and men, sexual organ-preserving cystectomy results in better functional outcomes without compromising oncological outcomes. Robotic and open cystectomy have comparable outcomes and should be combined with (extended) lymph node dissection. The diversion type is an individual choice after taking patient and tumour characteristics into account. Radical cystectomy remains a highly complex procedure with considerable morbidity and risk of mortality, although lower rates are observed for higher hospital volumes (>20 cases/yr). With proper patient selection, trimodal therapy (chemoradiation) has comparable outcomes to radical cystectomy. Adjuvant chemotherapy after surgery improves disease-specific survival and overall survival (OS) in patients with high-risk disease who did not receive neoadjuvant treatment, and is strongly recommended. There is a weak recommendation for adjuvant nivolumab, as OS data are not yet available. Health-related quality of life should be assessed using validated questionnaires at baseline and after treatment. Surveillance is needed to monitor for recurrent cancer and functional outcomes. Recurrences detected on follow-up seem to have better prognosis than symptomatic recurrences.

CONCLUSIONS

This summary of the 2023 EAU guidelines provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology guidelines panel on muscle-invasive and metastatic bladder cancer has released an updated version of the guideline containing information on diagnosis and treatment of this disease. Recommendations are based on studies published up to May 4, 2022. Surgical removal of the bladder and bladder preservation are discussed, as well as updates on the use of chemotherapy and immunotherapy in localised and metastatic disease.

Impact of Medicaid Expansion on Abdominal Surgery Morbidity, Mortality, and Hospital Readmission

INTRODUCTION

Medicaid expansion's (ME) impact on postoperative outcomes after abdominal surgery remains poorly defined. We aimed to evaluate ME's effect on surgical morbidity, mortality, and readmissions in a state that expanded Medicaid (Virginia) compared to a state that did not (Tennessee) over the same time period.

METHODS

Virginia Surgical Quality Collaborative (VSQC) American College of Surgeons National Surgical Quality Improvement Program data for Medicaid, uninsured, and private insurance patients undergoing abdominal procedures before Virginia's ME (3/22/18-12/31/18) were compared with post-ME (1/1/19-12/31/19), as were corresponding non-ME state Tennessee Surgical Quality Collaborative (TSQC) data for the same 2018 and 2019 time periods. Postexpansion odds ratios for 30-d morbidity, 30-d mortality, and 30-d unplanned readmission were estimated using propensity score-adjusted logistic regression models.

RESULTS

In Virginia, 4753 abdominal procedures, 2097 pre-ME were compared to 2656 post-ME. In Tennessee, 5956 procedures, 2484 in 2018 were compared to 3472 in 2019. VSQC's proportion of Medicaid population increased following ME (8.9% versus 18.8%, P < 0.001) while uninsured patients decreased (20.4% versus 6.4%, P < 0.001). Post-ME VSQC had fewer 30-d readmissions (12.2% versus 6.0%, P = 0.013). Post-ME VSQC Medicaid patients had significantly lower probability of morbidity (-8.18, 95% confidence interval: -15.52 ∼ -0.84, P = 0.029) and readmission (-6.92, 95% confidence interval: -12.56 ∼ -1.27, P = 0.016) compared to pre-ME. There were no differences in probability of morbidity or readmission in the TSQC Medicaid population between study periods (both P > 0.05); there were no differences in mortality between study periods in VSQC and TSQC patient populations (both P > 0.05).

CONCLUSIONS

ME was associated with decreased 30-d morbidity and unplanned readmissions in the VSQC. Data-driven policies accounting for ME benefits should be considered.

Emerging Roles of Circulating Tumor DNA for Increased Precision and Personalization in Radiation Oncology

Recent breakthroughs in circulating tumor DNA (ctDNA) technologies present a compelling opportunity to combine this emerging liquid biopsy approach with the field of radiogenomics, the study of how tumor genomics correlate with radiotherapy response and radiotoxicity. Canonically, ctDNA levels reflect metastatic tumor burden, although newer ultrasensitive technologies can be used after curative-intent radiotherapy of localized disease to assess ctDNA for minimal residual disease (MRD) detection or for post-treatment surveillance. Furthermore, several studies have demonstrated the potential utility of ctDNA analysis across various cancer types managed with radiotherapy or chemoradiotherapy, including sarcoma and cancers of the head and neck, lung, colon, rectum, bladder, and prostate . Additionally, because peripheral blood mononuclear cells are routinely collected alongside ctDNA to filter out mutations associated with clonal hematopoiesis, these cells are also available for single nucleotide polymorphism analysis and could potentially be used to detect patients at high risk for radiotoxicity. Lastly, future ctDNA assays will be utilized to better assess locoregional MRD in order to more precisely guide adjuvant radiotherapy after surgery in cases of localized disease, and guide ablative radiotherapy in cases of oligometastatic disease.

Risk factors for wound dehiscence following radical cystectomy: a prediction model

Objectives:

Radical cystectomy (RC) is a complex urologic procedure performed for the treatment of bladder cancer and causes significant morbidity. Wound dehiscence (WD) is a major complication associated with RC and is associated with multiple risk factors. The objectives of this study are to identify clinical risk factors for incidence of WD and develop a risk-prediction model to aid in patient risk-stratification and improvement of perioperative care.

Materials and Methods:

The American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) database was used to derive the study cohort. A univariate analysis provided nine variables eligible for multivariate model entry. A stepwise logistic regression analysis was conducted and refined considering clinical relevance of the variables, and then bootstrapped with 1000 samples, resulting in a five-factor model. Model performance and calibration were assessed by a receiver operated curve (ROC) analysis and the Hosmer–Lemeshow test for goodness of fit, respectively.

Results:

A cohort of 11,703 patients was identified from years 2005 to 2017, with 342 (2.8%) incidences of WD within 30 days of operation. The final five-factor model included male gender [odds ratio (OR) = 2.5, p < 0.001], surgical site infection (OR = 6.3, p < 0.001), smoking (OR = 1.8, p < 0.001), chronic obstructive pulmonary disease (COPD) (OR = 1.9, p < 0.001), and weight class; morbidly obese patients had triple the odds of WD (OR = 2.9, p < 0.001). The ROC analysis provided a C-statistic of 0.76 and calibration R² was 0.99.

Conclusion:

The study yields a statistically robust and clinically beneficial five-factor model for estimation of WD incidence risk following RC, with good performance and excellent calibration. These factors may assist in identifying high-risk patients, providing preoperative counseling and thus leading to improvement in perioperative care.

Urine tumor DNA detection of minimal residual disease in muscle-invasive bladder cancer treated with curative-intent radical cystectomy: A cohort study

BACKGROUND

The standard of care treatment for muscle-invasive bladder cancer (MIBC) is radical cystectomy, which is typically preceded by neoadjuvant chemotherapy. However, the inability to assess minimal residual disease (MRD) noninvasively limits our ability to offer bladder-sparing treatment. Here, we sought to develop a liquid biopsy solution via urine tumor DNA (utDNA) analysis.

METHODS AND FINDINGS

We applied urine Cancer Personalized Profiling by Deep Sequencing (uCAPP-Seq), a targeted next-generation sequencing (NGS) method for detecting utDNA, to urine cell-free DNA (cfDNA) samples acquired between April 2019 and November 2020 on the day of curative-intent radical cystectomy from 42 patients with localized bladder cancer. The average age of patients was 69 years (range: 50 to 86), of whom 76% (32/42) were male, 64% (27/42) were smokers, and 76% (32/42) had a confirmed diagnosis of MIBC. Among MIBC patients, 59% (19/32) received neoadjuvant chemotherapy. utDNA variant calling was performed noninvasively without prior sequencing of tumor tissue. The overall utDNA level for each patient was represented by the non-silent mutation with the highest variant allele fraction after removing germline variants. Urine was similarly analyzed from 15 healthy adults. utDNA analysis revealed a median utDNA level of 0% in healthy adults and 2.4% in bladder cancer patients. When patients were classified as those who had residual disease detected in their surgical sample (n = 16) compared to those who achieved a pathologic complete response (pCR; n = 26), median utDNA levels were 4.3% vs. 0%, respectively (p = 0.002). Using an optimal utDNA threshold to define MRD detection, positive utDNA MRD detection was highly correlated with the absence of pCR (p < 0.001) with a sensitivity of 81% and specificity of 81%. Leave-one-out cross-validation applied to the prediction of pathologic response based on utDNA MRD detection in our cohort yielded a highly significant accuracy of 81% (p = 0.007). Moreover, utDNA MRD-positive patients exhibited significantly worse progression-free survival (PFS; HR = 7.4; 95% CI: 1.4-38.9; p = 0.02) compared to utDNA MRD-negative patients. Concordance between urine- and tumor-derived mutations, determined in 5 MIBC patients, was 85%. Tumor mutational burden (TMB) in utDNA MRD-positive patients was inferred from the number of non-silent mutations detected in urine cfDNA by applying a linear relationship derived from The Cancer Genome Atlas (TCGA) whole exome sequencing of 409 MIBC tumors. We suggest that about 58% of these patients with high inferred TMB might have been candidates for treatment with early immune checkpoint blockade. Study limitations included an analysis restricted only to single-nucleotide variants (SNVs), survival differences diminished by surgery, and a low number of DNA damage response (DRR) mutations detected after neoadjuvant chemotherapy at the MRD time point.

CONCLUSIONS

utDNA MRD detection prior to curative-intent radical cystectomy for bladder cancer correlated significantly with pathologic response, which may help select patients for bladder-sparing treatment. utDNA MRD detection also correlated significantly with PFS. Furthermore, utDNA can be used to noninvasively infer TMB, which could facilitate personalized immunotherapy for bladder cancer in the future.

Fibrinogen prophylaxis for reducing perioperative bleeding in patients undergoing radical cystectomy: A double-blind placebo-controlled randomized trial

OBJECTIVE

Excessive bleeding is an important complication of radical cystectomy. We aimed to assess whether preoperative administration of fibrinogen decreases perioperative bleeding and improves the outcome of radical cystectomy.

DESIGN

Double-blinded randomized trial with two parallel arms.

SETTING

The study was conducted in the department of surgery at a teaching hospital affiliated with a University of Medical Sciences.

PATIENTS

In total, 70 men undergoing radical cystectomy were randomized to fibrinogen (n = 35) and placebo-control groups. Mean (SD) age was 64.7 (7.4) years.

INTERVENTIONS

The intervention group received 2 g fibrinogen concentrate diluted in 100 ml distilled water, and the control group received 100 ml normal saline; both intravenously 15 ̶ 30 min before the start of the surgery.

OUTCOME MEASURES

The primary outcome was the amount of perioperative blood loss. The secondary outcomes were hemodynamic features and vital signs.

MAIN RESULTS

Fibrinogen significantly decreased the volume of blood loss (p < 0.001) and the total number of transfused packed-cell units per group (38 vs. 115 units); and compensated the decrease of HCO3 (p = 0.030), the mean arterial pressure (p < 0.001), hemoglobin O2 saturation (p = 0.001), heart rate (p < 0.001), and temperature (p < 0.001) throughout the surgery compared with the placebo. Patients in the fibrinogen group had shorter Intensive Care Unit (p = 0.001) and hospital (p < 0.001) stay. We did not find any adverse reaction in our patients receiving fibrinogen concentrate.

CONCLUSION

Fibrinogen concentrate reduces perioperative bleeding and the need for blood transfusion in radical cystectomy. It improves the outcomes of the surgery and decreases patients' length of stay in the healthcare system following radical cystectomy.

REGISTRATION

Iranian Registry of Clinical Trials (IRCT) http://www.irct.ir/, reference number: IRCT20191013045091N1.

ETHICS CODE

Shahid Beheshti University of Medical Sciences, reference number: IR.SBMU.RETECH.REC.1398.033.

Major Urological Cancer Surgery for Patients is Safe and Surgical Training Should Be Encouraged During the COVID-19 Pandemic: A Multicentre Analysis of 30-day Outcomes

COVID-19 has resulted in the deferral of major surgery for genitourinary (GU) cancers with the exception of cancers with a high risk of progression. We report outcomes for major GU cancer operations, namely radical prostatectomy (RP), radical cystectomy (RC), radical nephrectomy (RN), partial nephrectomy (PN), and nephroureterectomy performed at 13 major GU cancer centres across the UK between March 1 and May 5, 2020. A total of 598 such operations were performed. Four patients (0.7%) developed COVID-19 postoperatively. There was no COVID-19–related mortality at 30 d. A minimally invasive approach was used in 499 cases (83.4%). A total of 228 cases (38.1%) were described as training procedures. Training case status was not associated with a higher American Society of Anesthesiologists (ASA) score (p =  0.194) or hospital length of stay (LOS; p >  0.05 for all operation types). The risk of contracting COVID-19 was not associated with longer hospital LOS (p =  0.146), training case status (p =  0.588), higher ASA score (p =  0.295), or type of hospital site (p =  0.303). Our results suggest that major surgery for urological cancers remains safe and training should be encouraged during the ongoing COVID-19 pandemic provided appropriate countermeasures are taken. These real-life data are important for policy-makers and clinicians when counselling patients during the current pandemic.

Patient summary

We collected outcome data for major operations for prostate, bladder, and kidney cancers during the COVID-19 pandemic. These surgeries remain safe and training should be encouraged during the ongoing pandemic provided appropriate countermeasures are taken. Our real-life results are important for policy-makers and clinicians when counselling patients during the COVID-19 pandemic.

Intensified and Standardized Digital Communication with Cystectomy Patients as a Potentially Simple and Effective Modality for Early Detection of Postoperative Complications: Results from a Pilot Study

BACKGROUND

Postoperative readmission rates following radical cystectomy remain significant. Early identification of emerging complications could potentially allow for immediate institution of therapy.

OBJECTIVE

To intensify postoperative patient-physician communication via a cellphone-based health care application (CHA) and to evaluate its potential for early detection of complications.

DESIGN SETTING AND PARTICIPANTS

This was a pilot study involving 18 radical cystectomy patients. During the first 30 d, patients received a push cellphone notification twice a week requesting data input into the CHA. This was reduced to once a week from day 31 to day 90. De-identified recorded data were reviewed by the surgeon involved. If deemed necessary, patients were contacted by the surgeon via telephone to obtain more detailed clinical information.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Descriptive statistics were used.

RESULTS AND LIMITATIONS

Of the 18 patients enrolled, all completed the 90-d reporting period. On two occasions, interventions were necessary on the basis of data recorded on the CHA. One neobladder patient was given antibiotic therapy for pyelonephritis. Another patient reported weight loss and nausea with clinical suspicion of metabolic acidosis, and his sodium bicarbonate and fluid intake were increased. Limitations include the small number of cases from a single low-volume center.

CONCLUSIONS

CHA-based monitoring of clinical parameters within the crucial 90-d postoperative period following radical cystectomy provides meaningful information. In this pilot study, two potential readmissions were possibly avoided on the basis of recorded basic vital signs and early intervention.

PATIENT SUMMARY

Besides regular clinic follow-up visits after radical cystectomy, additional aids such as a cellphone-based health care application can provide treating physicians with relevant clinical information and may help to identify imminent deviations from normal postoperative recovery at an early stage.

Impact of inflammatory bowel disease on radical prostatectomy outcomes and costs of care

Background

Recent studies suggest an association between prostate cancer and inflammatory bowel disease (IBD). Our objectives were to investigate clinical and financial impacts of IBD on radical prostatectomy (RP) and to determine the impact of surgical approach on our findings.

Methods

The Premier Hospital Database was queried for patients who underwent RP from 2003 to 2017. Multivariable logistic regression models were used to determine the independent impact of IBD on complications and readmission rates. We determined 90-day readmissions and examined 90-day hospital costs adjusted to 2019 US dollars with multivariable quantile regression models.

Results

Our study population included 262,189 men with prostate cancer, including 3,408 (1.3%) with IBD. There were higher odds for any complication for IBD patients compared with non-IBD controls for RP (15.64% vs. 10.66%). Patients with IBD had overall complication rates of 14.1% (P < 0.05) for open surgery and 17.2% for minimally invasive surgery (MIS) (P < 0.01). Between 2013 and 2017, the IBD cohort had significantly more complications (odds ratios (ORs): 2; 95% confidence interval (CI): 1.5 to 2.67; P < 0.0001), was more likely to have surgical costs in the top quartile (OR: 1.6; 95% CI: 1.23 to 2.1; P < 0.01), and had higher readmission rates (OR: 1.51; 95% CI: 1.1 to 2.06; P = 0.01).

Conclusions

The IBD cohort who underwent MIS had the highest complication rates. Hospital readmissions and surgical costs were significantly higher for the IBD cohort who underwent RP between 2013 and 2017, when a minimally invasive approach was more prevalent than an open approach. These findings may be important when deciding which surgical approach to take when performing RP on men with IBD.