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Manivasagam SS, Chandra J N. Comparison of Laparoscopic and Open Pancreaticoduodenectomy on Operative Time, Oncological Outcomes, Bleeding, Morbidity, and Mortality. Cureus 2024; 16:e53387. [PMID: 38435141 PMCID: PMC10908422 DOI: 10.7759/cureus.53387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/05/2024] Open
Abstract
Laparoscopic pancreaticoduodenectomy (LPD) has gained popularity as an alternative to open pancreaticoduodenectomy (OPD), but comparative outcomes remain debated. The objective is to perform a systematic review and meta-analysis comparing LPD and OPD on operative time, oncologic outcomes, bleeding, morbidity, and mortality. The inclusion criteria were comparative studies on LPD vs. OPD. Outcomes were pooled using random-effects meta-analysis. A total of 27 studies were included, and LPD had a substantially longer operative duration compared to the OPD procedure, with a mean increase of 56 minutes, but blood loss was reduced by an average of 123 mL in patients who underwent LPD. Morbidity, mortality, margin status, and lymph node yields were similar between LPD and OPD. This study found comparable oncologic outcomes between LPD and OPD. LPD appears safe but requires longer operative time. High-quality randomized trials are still needed.
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Affiliation(s)
| | - Nemi Chandra J
- General Surgery, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, IND
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Takemasa I, Hamabe A, Takenaka A, Kobayashi H, Mandai M, Kinugasa Y, Saika T, Shimbo M, Morizane S, Sekiyama K, Togami S, Hanaoka M, Inoue S, Nagaishi K, Sakai Y, Watanabe M. Standardization of robot-assisted pelvic lymph node dissection-Development of a common understanding of regional anatomy and surgical technique based on cross-disciplinary discussion among colorectal surgery, urology, and gynecology. Asian J Endosc Surg 2024; 17:e13274. [PMID: 38212269 DOI: 10.1111/ases.13274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/15/2023] [Accepted: 12/08/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Pelvic lymph node dissection is a procedure performed in gastroenterological surgery, urology, and gynecology. However, due to discrepancies in the understanding of pelvic anatomy among these departments, cross-disciplinary discussions have not been easy. Recently, with the rapid spread of robotic surgery, the importance of visual information in understanding pelvic anatomy has become even more significant. In this project, we attempted to clarify a shared understanding of pelvic anatomy through cross-disciplinary discussions. METHOD From May 2020 to November 2021, a total of 11 discussions were held entirely online with 5 colorectal surgery specialists, 4 urologists, and 4 gynecologists. The discussions focused on evidence from each specialty and surgical videos, aiming to create a universally understandable pelvic anatomical illustration. RESULTS The common area of dissection recognized across the three departments was identified as the obturator lymph nodes. A dynamic illustration of pelvic anatomy was created. In addition to a bird's-eye view of the pelvis, a pelvic half view was developed to enhance understanding of the deeper pelvic anatomy. The following insights were incorporated into the illustration: (1) the cardinal ligament in gynecology partly overlaps with the vesicohypogastric fascia in colorectal surgery; (2) the obturator lymph nodes continue cephalad into the fossa of Marcille in urology; and (3) the deep uterine vein in gynecology corresponds to the inferior vesical vein in colorectal surgery. CONCLUSION Based on the dynamic illustration of pelvic anatomy from cross-disciplinary discussions, we anticipate advancements in pelvic lymph node dissection aiming for curative and safe outcomes.
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Affiliation(s)
- Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Atsushi Hamabe
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Atsushi Takenaka
- Division of Urology, Faculty of Medicine, Department of Surgery, Tottori University, Yonago, Japan
| | - Hiroaki Kobayashi
- Faculty of Medicine, Department of Obstetrics and Gynecology, Kagoshima University, Kagoshima, Japan
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yusuke Kinugasa
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Saika
- Department of Urology, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Masaki Shimbo
- Department of Urology, St. Luke's International Hospital, Tokyo, Japan
| | - Shuichi Morizane
- Division of Urology, Faculty of Medicine, Department of Surgery, Tottori University, Yonago, Japan
| | - Kentaro Sekiyama
- Department of Obstetrics and Gynecology, Medical Research Institute Kitano Hospital, Osaka, Japan
| | - Shinichi Togami
- Faculty of Medicine, Department of Obstetrics and Gynecology, Kagoshima University, Kagoshima, Japan
| | - Marie Hanaoka
- Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sena Inoue
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kanna Nagaishi
- Second Department of Anatomy, Sapporo Medical University, Sapporo, Japan
| | - Yoshiharu Sakai
- Department of Surgery, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Masahiko Watanabe
- Department of Surgery, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
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Weinberg L, Aitken SAA, Kaldas P, Fletcher L, Lloyd-Donald P, Le P, Do D, Caruana CB, Walpole D, Ischia J, Ma R, Tan CO, Lee DK. Postoperative complications and hospital costs following open radical cystectomy: A retrospective study. PLoS One 2023; 18:e0282324. [PMID: 36827411 PMCID: PMC9956632 DOI: 10.1371/journal.pone.0282324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/26/2023] Open
Abstract
OBJECTIVES To evaluate primarily the relationship between postoperative complications and hospital costs, and secondarily the relationship between postoperative complications and mortality, following radical cystectomy. METHODS Postoperative complications were retrospectively examined for 147 patients undergoing radical cystectomy at a university hospital between January 2012 and July 2021. Complications were defined and graded using the Clavien-Dindo classification system. In-hospital cost was calculated using an activity-based costing methodology. Regression modelling was used to investigate the relationships among a priori selected perioperative variables, complications, and costs. The effect of complications on postoperative mortality was ascertained using time-dependent coefficients in a Cox proportional hazards regression model. RESULTS 135 (92%) patients experienced one or more postoperative complications. The medians of hospital cost for patients who experienced no complications and those who experienced complications were $42,796.3 (29,222.9-53,532.5) and $81,050.1 (49,614.8-122,533.6) respectively, p < 0.001. Hospital costs were strongly associated with complication severity: Clavien-Dindo grade II complications increased costs by 45.2% (p < 0.001, 95% CI 19.1%-76.6%), and Clavien-Dindo grade III to V complications increased costs by 107.5% (p < 0.001, 95% CI 52.4%-181.8%). Each additional count of complication and increase in Clavien-Dindo complication grade increased the risk of mortality 1.28-fold (RR = 1.28, p = 0.006, 95% CI 1.08-1.53) and 2.50-fold (RR = 2.50, p = 0.012 95% CI 1.23-5.07) respectively. CONCLUSIONS These findings demonstrate a high prevalence of complications following cystectomy and significant associated increases in hospital costs and mortality. Postoperative complications are a key target for cost-containment strategies. TRIAL REGISTRATION Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN:12622000057785.
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Affiliation(s)
- Laurence Weinberg
- Department of Anesthesia, Austin Health, Heidelberg, Australia
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
- Department of Critical Care, The University of Melbourne, Austin Health, Heidelberg, Australia
- * E-mail:
| | | | - Peter Kaldas
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
| | - Luke Fletcher
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health, Heidelberg, Australia
| | | | - Peter Le
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Daniel Do
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | | | - Dominic Walpole
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Joseph Ischia
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
| | - Ronald Ma
- Business Intelligence Unit, Austin Health, Heidelberg, Australia
| | - Chong Oon Tan
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
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Cost-utility analysis of robotic-assisted radical cystectomy for bladder cancer compared to open radical cystectomy in the United Kingdom. PLoS One 2022; 17:e0270368. [PMID: 36174057 PMCID: PMC9522012 DOI: 10.1371/journal.pone.0270368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 06/08/2022] [Indexed: 11/19/2022] Open
Abstract
Background Bladder cancer is the tenth most common cancer in the United Kingdom. Currently, open radical cystectomy (ORC) is the gold standard. Due to the risk of complications and a 2.3-8% mortality rate1, there is growing interest in the use of robot-assisted radical cystectomy (RARC). The aim of this study is to perform a cost-utility analysis, comparing RARC to ORC for bladder cancer patients from the perspective of the National Health Service England. Methods A three-stage decision tree: surgery, post-surgery transfusions and complications, in a 90-day time horizon, was produced to simulate possible pathways of patients. The incremental cost-effectiveness ratio (ICER) was calculated based on data derived from current literature. Multiple univariate sensitivity analysis was carried out to evaluate influences of varying costs of RARC and ORC on the ICER. Results The ICER for RARC compared to ORC resulted in £25,536/QALY. At the lower threshold of £20,000/QALY, RARC resulted in a negative NMB (£-4,843.32) and at the upper threshold of £30,000/QALY, a positive NMB (£624.61) compared to ORC. Threshold analysis showed that the intervention costs of £13,497 and £14,403 are met at the lower and upper threshold respectively. The univariate sensitivity analysis showed that the intervention costs of RARC or ORC, and the probabilities of complications, had the greatest impact on the ICER. Conclusion As the resultant ICER did not fall below the £20,000/QALY threshold, our study did not provide a definitive recommendation for RARC for bladder cancer. Negative values for the NMB at the lower threshold indicated the intervention was not feasible from a cost perspective. At the upper threshold of £30,000/QALY, this situation was reversed. The intervention became cost-effective. Therefore, further research is needed to justify the intervention.
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Robotic cystectomy histopathology outcomes in patients who have ‘failed’ Bacillus Calmette–Guérin: A case series. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/2051415820977993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Robot-assisted radical cystectomy (RARC) is considered the gold-standard for patients who fail Bacillus Calmette–Guérin (BCG) treatment for high-grade non-muscle-invasive bladder cancer. We reviewed our histopathological outcomes to assess whether we are proceeding to cystectomy at an appropriate time. Methods: A retrospective analysis of the RARC database (2015–2020) was performed to identify patients who received intravesical BCG before cystectomy. Data regarding demographics, number of BCG instillations and staging were collected. Histopathological stage at cystectomy was compared between patients who received an induction course of BCG only (group A), and those who had continued maintenance doses (group B). Results: A total of 73 patients (57 males and 16 females) met the final inclusion criteria, with 24 patients in group A and 49 patients in group B. At cystectomy, 19 patients had ⩾T2 disease (group A: 7; group B: 12). There was no significant difference between groups ( p=0.78). Pelvic lymph node dissection was performed in 68 patients, with six patients found to have lymph node metastases. Conclusion: RARC plays a key role in managing BCG failure, considering the number of patients with muscle-invasive disease at final staging. However, prolonged BCG treatment was not associated with more advanced disease in our case series. Thus, persistence with intravesical treatment warrants consideration for selected patients. Level of evidence: Level 4.
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Zhou N, Tian F, Feng Y, Zhao K, Chen L, Fan R, Lu W, Gu C. Perioperative outcomes of intracorporeal robot-assisted radical cystectomy versus open radical cystectomy: A systematic review and meta-analysis of comparative studies. Int J Surg 2021; 94:106137. [PMID: 34600124 DOI: 10.1016/j.ijsu.2021.106137] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 08/20/2021] [Accepted: 09/28/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To systematically review studies comparing the perioperative outcomes of intracorporeal robot-assisted radical cystectomy (iRARC) and open radical cystectomy (ORC). METHODS Systematic searches of PubMed, Web of Science and the Cochrane Library were performed in June 2020. Studies with data comparing iRARC and ORC were included in our review, and a pooled meta-analysis was completed. RESULTS In total, 8 studies (7 prospective studies, 1 retrospective study) comparing 1193 patients were included for our review and meta-analysis. Compared with ORC, iRARC demonstrated lower estimated blood loss (weighted mean difference (WMD): -449.25; 95% CI -566.47 - -332.03; p < 0.01), lower blood transfusion rates (OR: 0.31; 95% CI 0.22 - 0.46; p < 0.01), and lower postoperative complication rates with Clavien-Dindo grades III-IV (30 days: OR: 0.65; 95% CI 0.47 - 0.90; p = 0.01; 90 days: OR: 0.72; 95% CI 0.53 - 0.98; p = 0.04), but a longer operative time (WMD: 78.82; 95% CI 52.77 - 104.87; P < 0.01). Furthermore, there was no significant difference between iRARC and ORC in terms of postoperative complication rates with Clavien-Dindo grades Ⅰ-Ⅱ (30 days: OR: 0.71; 95% CI 0.36 - 1.40; p = 0.32; 90 days: OR: 0.98; 95% CI 0.74 - 1.30; p = 0.89), length of stay (WMD: -1.18; 95% CI -3.33 - -2.07; p = 0.06) and positive surgical margins (OR: 0.78; 95% CI 0.0.45 - 1.36; p = 0.38). CONCLUSION iRARC was associated with a significantly lower estimated blood loss and a lower blood transfusion rate and major postoperative complication rate than ORC.
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Affiliation(s)
- Naichun Zhou
- Department of Urology, Xinyang Central Hospital, Xinyang, 464000, China Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China Department of Pediatrics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
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Zhao CC, Shakir NA, Zhao LC. The emerging role of robotics in upper and lower urinary tract reconstruction. Curr Opin Urol 2021; 31:511-515. [PMID: 34155169 DOI: 10.1097/mou.0000000000000908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Developments in robotic reconstructive urology have introduced novel treatments for complex upper and lower urinary tract disease. Short-term and mid-term data demonstrates excellent outcomes and minimal morbidity, suggesting the advanced instrumentation and visualization of robotics represent a new treatment paradigm in patients that are historically difficult to treat. Here we review recent developments in the robotically assisted surgical management of urethral and ureteral strictures. RECENT FINDINGS The minimally invasive approach, enhanced precision and reach, and near-infrared fluorescence imaging capabilities of robotic platforms have proven to be valuable additions in reconstructive urology where perfusion is often compromised, or anatomy is distorted. These benefits are leveraged heavily in recent descriptions of robotic-assisted posterior urethroplasty and ureteroplasty. Short-term to mid-term follow-up data for these procedures show excellent patency rates with low morbidity and complication rates when compared with open approaches. Long-term data for these procedures are not yet available. SUMMARY The role of robotics in reconstructive urology is being actively investigated. Initial findings demonstrate excellent results with low morbidity in the treatment of upper and lower urinary tract disease. Long-term data will ultimately determine the role of robotics in the reconstructive armamentarium.
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Affiliation(s)
- Calvin C Zhao
- Department of Urology, New York University Grossman School of Medicine, New York, New York, USA
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Adamczyk P, Pobłocki P, Kadlubowski M, Ostrowski A, Mikołajczak W, Drewa T, Juszczak K. Complication Rate after Radical Cystectomy Depends on the Surgical Technique and Patient's Clinical Status. Urol Int 2021; 106:163-170. [PMID: 34352785 DOI: 10.1159/000517787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/02/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE This study aimed to explore the complication rates of radical cystectomy in patients with muscle-invasive bladder cancer and identify potential risk factors. METHODS A total of 553 patients were included: 131 were operated on via an open approach (ORC), 242 patients via a laparoscopic method (LRC), and 180 by a robot-assisted procedure (RARC). Patient age, gender, American Society of Anesthesiologists (ASA) score, urinary diversion type, preoperative albumin level, body mass index (BMI), pathological (TNM) stage, and surgical times were collected. The severity of complications was classified according to the Clavien-Dindo scale (Grades 1-5). RESULTS The surgical technique was significantly related to the number of complications (p < 0.00005). Grade 1 complications were observed most frequently following LRC (52.5%) and RARC (51.1%), whereas mostly Grade 2 complications were detected after ORC (78.6%). Those with less severe complications had significantly higher albumin levels than those with more severe complications (p < 0.05). Patients with an elevated BMI had fewer complications if a minimally invasive approach was used rather than ORC. The patient's general condition (ASA score) did not impact the number of complications, and urinary diversion type did not affect the severity of the complications. Mean surgical time differed according to the urinary diversion type in patients with a similar TNM stage (p < 0.005); however, no difference was found in those with more locally advanced disease. Longer operation time and lower protein concentration were associated with higher probability of complication rate, that is, Clavien-Dindo score 3-5. CONCLUSIONS The risk of complications after RC is not related to the type of urinary diversion, and can be reduced by using a minimally invasive surgical technique, especially in patients with high BMI.
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Affiliation(s)
- Przemysław Adamczyk
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland
| | - Paweł Pobłocki
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland
| | - Mateusz Kadlubowski
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland
| | - Adam Ostrowski
- Clinic of General and Oncologic Urology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Witold Mikołajczak
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland
| | - Tomasz Drewa
- Department of General and Oncologic Urology, Nicolaus Copernicus Hospital, Torun, Poland.,Clinic of General and Oncologic Urology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Kajetan Juszczak
- Clinic of General and Oncologic Urology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
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Jaipuria J, Karimi AM, Singh A, Thapa BB, Gupta S, Sadasukhi N, Venkatasubramaniyan M, Pathak P, Kasaraneni P, Khanna A, Narayan TA, Sharma G, Rawal S. Pitcher pot neourethral modification of ileal orthotopic neobladder achieves satisfactory long‐term functional and quality of life outcomes with low clean intermittent self‐catheterization rate. BJUI COMPASS 2021; 2:292-299. [PMID: 35475302 PMCID: PMC8988529 DOI: 10.1002/bco2.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 12/24/2022] Open
Abstract
Objective To describe a decade of our experience with a neo‐urethral modification of ileal orthotopic neobladder (pitcher pot ONB). Multiple investigators have reported similar modifications. However, long‐term longitudinal functional and quality of life (QOL) outcomes are lacking. Methods Prospectively maintained hospital registry for 238 ONB patients comprising a mix of open and robotic surgery cohorts from 2007 to 2017, and minimum of 2 years of follow‐up was retrospectively queried. QOL was evaluated using Bladder Cancer Index (BCI). Longitudinal trends of QOL domain parameters were analysed. List of perioperative variables that have a biologically plausible association with continence, potency, and post‐operative BCI QOL sexual, urinary, and bowel domain scores was drawn. Variables included surgery type, Body Mass Index (BMI), T and N stage, neurovascular bundle (NVB) sparing, age, and related pre‐operative BCI QOL domain score. Prognostic associations were analysed using multivariable Cox proportional hazard models and multilevel mixed‐effects modeling. Results The study comprised 80 and 158 patients who underwent open and robotic sandwich technique cohorts, respectively. Open surgery was associated with significantly higher “any” complication (40% vs 27%, P‐value .050) and “major” complication rate (15% vs 11%, P‐value .048). All patients developed a bladder capacity >400 cc with negligible post‐void residual urine, and all but one patient achieved spontaneous voiding by the end of study period (<1% clean intermittent self‐catheterization [CISC] rate). By 15 months, QOL for all three domains had recovered to reach a plateau. About 45% of patients achieved potency, and the median time to achieve day and night time continence was 9 and 12 months respectively. Lower age and NVBs spared during surgery were found to be significantly associated with the earlier achievement of potency, day and night time continence, as well as better urinary and sexual summary QOL scores. Conclusions Pitcher pot neobladder achieves satisfactory long‐term functional and QOL outcomes with negligible CISC rate. Results were superior with incremental nerves spared during surgery.
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Affiliation(s)
- Jiten Jaipuria
- Amity Centre for Cancer Epidemiology & Cancer Research Amity Institute of Biotechnology Amity University Uttar Pradesh Noida India
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Ahmad Mamoon Karimi
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Amitabh Singh
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Bikash Bikram Thapa
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Shashikant Gupta
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Nripesh Sadasukhi
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | | | - Preeti Pathak
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Priyatham Kasaraneni
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Ashish Khanna
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Tushar Aditya Narayan
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
| | - Girish Sharma
- Centre for Medical Biotechnology, Coordinator Amity Centre for Cancer Epidemiology & Cancer Research Amity Institute of Biotechnology Amity University Uttar Pradesh Noida India
| | - Sudhir Rawal
- Department of Surgical Oncology Uro‐oncology Division Rajiv Gandhi Cancer Institute and Research Centre New Delhi India
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Gul ZG, Katims AB, Winoker JS, Wiklund P, Waingankar N, Mehrazin R. Robotic assisted radical cystectomy versus open radical cystectomy: a review of what we do and don't know. Transl Androl Urol 2021; 10:2209-2215. [PMID: 34159104 PMCID: PMC8185680 DOI: 10.21037/tau.2019.11.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Radical cystectomy (RC) is the gold standard treatment for muscle-invasive and high-risk, noninvasive bladder cancer. Since 2003, robot-assisted radical cystectomy (RARC) has been gaining popularity. Metanalyses show that the primary advantage of RARC is less blood loss and the primary advantage of open radical cystectomy (ORC) is shorter operative times. There do not appear to be significant differences in complications, cancer-related outcomes or survival between the two approaches. Cost analyses comparing RARC and ORC are complicated by the often-ill-defined distinction between the cost to the hospital versus the cost to payors. However, it is likely that for both hospitals and payors, RARC is cost effective at high-volume centers. It is feasible that in the future, increased experience with RARC will lead to improved outcomes and justify the use of RARC over ORC.
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Affiliation(s)
- Zeynep G Gul
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew B Katims
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jared S Winoker
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Pignot G, Treacy P, Walz J. Growing evidence for benefits of minimally invasive radical cystectomy. Transl Androl Urol 2021; 9:2459-2461. [PMID: 33457215 PMCID: PMC7807372 DOI: 10.21037/tau-20-873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Geraldine Pignot
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Patrick Treacy
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jochen Walz
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
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Ip KL, Javier-DesLoges JF, Leung C, Nie J, Khajir G, Nawaf CB, Syed J, Rosoff JS, Martin TV, Hesse DG. Comparison of long-term outcomes in a 10-year experience of robotic cystectomy vs. open cystectomy. J Robot Surg 2020; 15:773-780. [PMID: 33226567 DOI: 10.1007/s11701-020-01175-3] [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: 09/13/2020] [Accepted: 11/11/2020] [Indexed: 10/22/2022]
Abstract
To compare the outcomes of robotic-assisted (RARC) vs. open radical cystectomy (ORC) at a single academic institution. We retrospectively identified patients undergoing radical cystectomy for urothelial carcinoma of the bladder at our institution from 2007 to 2017. Data collected included age, sex, Body Mass Index (BMI), Charlson Age-Adjusted Comorbidity Index (CCI), final pathologic stage, surgical margins, lymph-node yield, estimated blood loss (EBL), 90-day complication rate, and length of stay (LOS). We evaluated overall survival (OS) and recurrence-free survival (RFS). Multivariable Cox proportional hazard models were used to adjust for covariates. We identified 232 patients (73 RARC, 159 ORC) who underwent radical cystectomy. Patients who underwent RARC were older (71.8 vs. 67.5, p < 0.05) and had higher CCI scores (6.2 vs. 5.3, p < 0.05). In comparing perioperative outcomes, RARC patients had lower EBL (500 vs. 850, p < 0.01), lower blood transfusion rate (p < 0.01), and lower lymph-node yield (12 vs. 20, p < 0.01), and higher ICU admission rate (29% vs. 16% p < 0.01). There was no difference in BMI (p = 0.93), sex (p = 0.28), final pathological stage (p = 0.35), positive surgical margins (p = 0.47), complications (p = 0.58), or LOS (p = 0.34). Kaplan-Meier analysis showed no difference in OS (p = 0.26) or RFS (p = 0.86). There was no difference in restricted mean survival time for OS (53 vs. 56 months, p = 0.81) or for RFS (65 vs. 64 months, p = 0.90). Cox multivariate regression models showed that surgical approach does not have a significant impact on OS (p = 0.46) or RFS (p = 0.35). Our study indicates that in our 10-year experience, patients undergoing there was no difference between RARC and ORC patients with respect to OS and RFS despite being older and having more comorbidities. Our work supports the importance of patient selection to optimize outcomes.
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Affiliation(s)
- Kevan L Ip
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Juan F Javier-DesLoges
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Cynthia Leung
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - James Nie
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Ghazal Khajir
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Cayce B Nawaf
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Jamil Syed
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - James S Rosoff
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - Thomas V Martin
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA
| | - David G Hesse
- Department of Urology, Yale University School of Medicine, P.O. Box 208058, New Haven, CT, USA.
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Clement KD, Pearce E, Gabr AH, Rai BP, Al-Ansari A, Aboumarzouk OM. Perioperative outcomes and safety of robotic vs open cystectomy: a systematic review and meta-analysis of 12,640 cases. World J Urol 2020; 39:1733-1746. [PMID: 32734460 DOI: 10.1007/s00345-020-03385-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/22/2020] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Robotic radical cystectomy (RRC) has become a commonly utilised alternative to open radical cystectomy (ORC). We performed a systematic review and meta-analysis of RRC vs ORC focusing on perioperative outcomes and safety. METHODS Medline, EMBASE and CENTRAL were searched from January 2000 to April 2020 following the Preferred Reporting Items for Systematic Review and Meta-analysis Statement for study selection. RESULTS In total, 47 studies (5 randomised controlled trials, 42 non-randomised comparative studies) comprising 12,640 patients (6572 ORC, 6068 RRC) were included. There was no difference in baseline demographics between the groups apart from males were more likely to undergo ORC (OR 0.77, 95% CI 0.69-0.85). Those with muscle-invasive disease were more likely to undergo RRC (OR 1.21, 95% CI 1.09-1.34), and those with high-risk non-muscle-invasive bladder cancer were more likely to undergo ORC (OR 0.80, 95% CI 0.72-0.89). RRC had a significantly longer operating time, less blood loss and lower transfusion rate. There was no difference in lymph node yield, rate of positive surgical margins, or Clavien-Dindo Grade I-II complications between the two groups. However, the RRC group were less likely to experience Clavien-Dindo Grade III-IV (OR 1.56, 95% CI 1.30-1.89) and overall complications (OR 1.45, 95% CI 1.26-1.68) than the ORC group. The mortality rate was higher in ORC although this did not reach statistical significance (OR 1.52, 95% CI 0.99-2.35). CONCLUSION RRC has significantly lower blood loss, transfusion rate and is associated with fewer high grade and overall complications compared to ORC.
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Affiliation(s)
- Keiran D Clement
- Department of Urology, Royal Alexandra Hospital, Castlehead, Paisley, PA2 9PJ, UK.
| | - Emily Pearce
- Department of Paediatric Surgery, Royal Hospital for Children, Glasgow, UK
| | - Ahmed H Gabr
- Department of Urology, Royal Alexandra Hospital, Castlehead, Paisley, PA2 9PJ, UK
- Department of Urology, Minia University, Minia, Egypt
| | - Bhavan P Rai
- Department of Urology, Freeman Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Abdulla Al-Ansari
- Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Omar M Aboumarzouk
- Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- University of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland, UK
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14
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Elsayed AS, Aldhaam NA, Nitsche L, Siam A, Jing Z, Hussein AA, Shigemura K, Fujisawa M, Guru KA. Robot‐assisted radical cystectomy: Review of surgical technique, and perioperative, oncological and functional outcomes. Int J Urol 2020; 27:194-205. [DOI: 10.1111/iju.14178] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/04/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Ahmed S Elsayed
- Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Naif A Aldhaam
- Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Lindsay Nitsche
- Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Alat Siam
- Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Zhe Jing
- Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Ahmed A Hussein
- Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | | | - Masato Fujisawa
- Department of Urology Kobe University Hospital Kobe Hyogo Japan
| | - Khurshid A Guru
- Roswell Park Comprehensive Cancer Center Buffalo New York USA
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15
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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: 68] [Impact Index Per Article: 13.6] [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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Miguel CM, Kosinski KE, Fazzari MJ, Kongnyuy M, Smaldone MC, Schiff JT, Katz AE, Corcoran AT. Pathologic measures of quality compare favorably in patients undergoing robot-assisted radical cystectomy to open cystectomy cohorts: a National Cancer Database analysis. J Robot Surg 2019; 14:609-614. [DOI: 10.1007/s11701-019-01031-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/23/2019] [Indexed: 10/25/2022]
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17
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Shi H, Li J, Li K, Yang X, Zhu Z, Tian D. Minimally invasive versus open radical cystectomy for bladder cancer: A systematic review and meta-analysis. J Int Med Res 2019; 47:4604-4618. [PMID: 31638461 PMCID: PMC6997785 DOI: 10.1177/0300060519864806] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background We performed a systematic review and meta-analysis to evaluate the efficacy and safety of minimally invasive radical cystectomy (MIRC) versus open radical cystectomy (ORC) for bladder cancer. Methods We searched the EMBASE and MEDLINE databases to identify randomized controlled trials (RCTs) of MIRC versus ORC in the treatment of bladder cancer. Results Eight articles describing nine RCTs (803 patients) were analyzed. No significant differences were found between MIRC and ORC in two oncologic outcomes: the recurrence rate and mortality. Additionally, no significant differences were found in three pathologic outcomes: lymph node yield, positive lymph nodes, and positive surgical margins. With respect to perioperative outcomes, however, MIRC showed a significantly longer operating time, less estimated blood loss, lower blood transfusion rate, shorter time to regular diet, and shorter length of hospital stay than ORC. The incidence of complications was similar between the two techniques. We found no statistically significant differences in the above outcomes between robot-assisted radical cystectomy and ORC or between laparoscopic radical cystectomy and ORC with the exception of the complication rate. Conclusions MIRC is an effective and safe surgical approach in the treatment of bladder cancer. However, a large-scale multicenter RCT is needed to confirm these findings.
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Affiliation(s)
- Hongbin Shi
- Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Jiangsong Li
- Department of Urology, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Kui Li
- Department of Urology Surgery, The People's Hospital of Yucheng, Yucheng, China
| | - Xiaobo Yang
- Department of Urology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Zaisheng Zhu
- Department of Urology, Jinhua Hospital, Zhejiang University School of Medicine, Zhejiang, China
| | - Daxue Tian
- Department of Urology, Jinhua Hospital, Zhejiang University School of Medicine, Zhejiang, China
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18
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Tzelves L, Skolarikos A, Mourmouris P, Lazarou L, Kostakopoulos N, Manatakis DK, Kural AR. Does the Use of a Robot Decrease the Complication Rate Adherent to Radical Cystectomy? A Systematic Review and Meta-Analysis of Studies Comparing Open with Robotic Counterparts. J Endourol 2019; 33:971-984. [PMID: 31161777 DOI: 10.1089/end.2019.0226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction: Radical cystectomy (RC) is the mainstay of treatment for muscle-invasive bladder cancer. In 2003, the first robot-assisted radical cystectomy (RARC) was performed and since then many studies, mainly observational, were conducted to compare robotic and open methods. This study aims to assess perioperative outcomes between the two methods based on pooled data from existing literature. Methods: A literature search of articles in English and French languages was performed in three databases (Medline, Embase, and Cochrane) until 30th of June 2018, as well as in urology conference programs and reference lists of included studies. The study protocol was registered at PROSPERO (CRD42018103063). Terms such as "robotic," "open," and "radical cystectomy" and synonyms were used for the searching algorithm. The primary outcome was the number of minor and major postoperative complications (Clavien grading system). Risk of bias was assessed with the Cochrane tool and Newcastle-Ottawa scale. Comparison of continuous outcomes was performed with weighted mean differences, while for dichotomous outcomes, odds ratios (ORs) were used. Review Manager 5.3 was used. Results: Fifty-four studies (5 randomized trials and 49 observational) were eligible, including 29,697 patients (6500 in the RARC group and 23,197 in the open radical cystectomy group). Minor complications (grade 1-2) in pooled data of 29 studies were fewer in the RARC group (OR = 0.54, 95% confidence interval [CI]: 0.38-0.76, p < 0.001), a difference persisting after sensitivity analysis for 30 and 90 days. Major complications (grade 3-5) in 31 studies were fewer in the RARC group (OR = 0.78, 95% CI: 0.65-0.94, p = 0.009), but this difference disappeared in the 30-day subanalysis. RARC was associated with lower blood transfusion rates (p < 0.001), lower length of stay (p < 0.001), faster return to regular diet (p < 0.001), and lower postoperative mortality rates (p < 0.001), but longer operating time. Conclusions: RARC appears to be associated with fewer complications and favoring perioperative outcomes in comparison with the open method. Due to the observational nature of most studies, larger randomized trials are needed to confirm these findings.
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Affiliation(s)
- Lazaros Tzelves
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas Skolarikos
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Mourmouris
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Lazaros Lazarou
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Kostakopoulos
- 2nd Department of Urology, Sismanoglio General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ali Riza Kural
- Department of Urology, School of Medicine, Acibadem Maslak Hospital, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
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19
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Tyritzis SI, Gaya JM, Wallestedt-Lantz A, Pini G, Everaerts W, de Naeyer G, Palou J, Kelly J, Wiklund NP. Current role of robotic bladder cancer surgery. MINERVA UROL NEFROL 2019; 71:301-308. [PMID: 31086134 DOI: 10.23736/s0393-2249.19.03435-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in urology, that is not devoid of postoperative complications. Minimally invasive surgery, and especially robot-assisted RC (RARC) has emerged as an alternative to open RC (ORC) in an attempt to minimize surgical morbidity and facilitate the surgical approach. The aim of this paper was to present the current knowledge on the oncological efficacy and complication outcomes of RARC. EVIDENCE ACQUISITION A non-systematic review on all relevant studies with the keywords "Radical cystectomy," "Open," "Robot-assisted," "Complications," "Recurrence," "Survival," "Neobladder," "Potency," "Continence" and "Intracorporeal" was performed using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) Guidelines. EVIDENCE SYNTHESIS RARC shows similar lymph node yields and positive surgical margin rates as well as perioperative complication outcomes compared with ORC. RARC exhibits significantly less blood loss and less intra- and postoperative blood transfusion. Moreover, survival and recurrence rates are not related to the surgical approach. Finally, RARC seems to be more expensive and has a longer operating time compared to the open technique. CONCLUSIONS As current evidence shows, RARC seems as a technically feasible and safe procedure, providing equivalent perioperative and oncological results compared to ORC. More prospective, randomized-controlled trials are necessary to draw definitive conclusions on all comparative aspects.
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Affiliation(s)
- Stavros I Tyritzis
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden - .,Department of Urology, HYGEIA Hospital, Athens, Greece -
| | - Josep M Gaya
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - Anna Wallestedt-Lantz
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden
| | - Giovannalberto Pini
- Department of Urology, San Raffaele Turro Hospital, San Raffaele University, Milan, Italy
| | - Wouter Everaerts
- Department of Urology, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Joan Palou
- Department of Urology, Puigvert Foundation, Autonomous University of Barcelona, Barcelona, Spain
| | - John Kelly
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Urology, University College London Hospital, London, UK
| | - Nils P Wiklund
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm Sweden.,ICAHN School of Medicine, Mount Sinai Hospital, New York, NY, USA
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20
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Shen JK, Jamnagerwalla J, Yuh BE, Bassett MR, Chenam A, Warner JN, Zhumkhawala A, Yamzon JL, Whelan C, Ruel NH, Lau CS, Chan KG. Real-time indocyanine green angiography with the SPY fluorescence imaging platform decreases benign ureteroenteric strictures in urinary diversions performed during radical cystectomy. Ther Adv Urol 2019; 11:1756287219839631. [PMID: 31057669 PMCID: PMC6452578 DOI: 10.1177/1756287219839631] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 03/04/2019] [Indexed: 01/09/2023] Open
Abstract
Background Ischemia is thought to contribute to benign ureteroenteric stricture (UES) after radical cystectomy with urinary diversion (RCUD). Our institution adopted the use of ureteral perfusion assessment during all RCUDs using real-time indocyanine green angiography using the SPY fluorescence imaging platform (Stryker Corp., Kalamazoo, MI, USA). This guides the location of ureteral transection prior to ureteroenteric anastomosis. We sought to compare UES rates before and after adoption of SPY. Methods A retrospective chart review was undertaken for the first 47 consecutive cases of RCUD using SPY as well as the previous 47 consecutive cases, which were performed without SPY. Fisher's exact and Wilcoxon rank-sum tests were used to compare benign UES rates and the length of ureter excised during anastomosis. A p < 0.05 indicated statistical significance. Results Median follow up was 12.0 months for SPY cases and 24.3 months for non-SPY cases. The UES rate for SPY RCUDs was 0% (0/93 ureters) compared with 7.5% (7/93 ureters) for non-SPY RCUDs (p = 0.01). Amongst SPY RCUDs, 86 ureters had no hydronephrosis and 7 had mild hydronephrosis with reflux on loopogram. A total of 34.4% of ureters (32/93) had poor distal perfusion, requiring a more proximal anastomosis. The median length excised for ureters with poor distal perfusion was 3.8 cm, compared with 2.2 cm for ureters with good distal perfusion (p < 0.0001). No complications attributable to the use of SPY were noted. Conclusion Use of SPY to assess ureteral perfusion was associated with a decrease in the UES rate after RCUD. A total of 34.4% of ureters demonstrated poor distal perfusion, requiring a significantly more proximal ureteroenteric anastomosis.
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Affiliation(s)
- Jim K Shen
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Juzar Jamnagerwalla
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Bertram E Yuh
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Mitchell R Bassett
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Avinash Chenam
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Jonathan N Warner
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Ali Zhumkhawala
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Jonathan L Yamzon
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Christopher Whelan
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Nora H Ruel
- Department of Biostatistics, City of Hope National Medical Center, Duarte, CA, USA
| | - Clayton S Lau
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Kevin G Chan
- Department of Surgery, Division of Urology and Urologic Oncology, City of Hope National Medical Center, 1500 East Duarte Road, MOB L002H, Duarte, CA 91010, USA
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Chinder PS, Hindiskere S, Doddarangappa S, Sk R, Mascarenhas A, Pal U. Robotic Surgery Assisted Staged En-Bloc Sacrectomy for Sacral Chordoma: A Case Report. JBJS Case Connect 2019; 9:e0240. [PMID: 31140987 DOI: 10.2106/jbjs.cc.18.00240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
CASE Two male patients aged 37 years and 39 years, diagnosed with sacral chordoma, underwent robotic-assisted preparatory adhesiolysis from the anterior aspect of the tumor, followed by posterior en-bloc partial sacrectomy. The average total operative time was 360 minutes (anterior docking + anterior console + posterior excision), and mean blood loss was 930 mL. Both patients were mobilized early, had no postoperative complications, and were free of local recurrence at 18 month of follow-up. CONCLUSIONS Robotic-assisted surgery is a novel, valid, safe, and minimally invasive technique which drastically reduces the associated surgical complications of single-staged posterior sacrectomy, resulting in excellent functional and oncological outcome.
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Affiliation(s)
- Pramod S Chinder
- Department of Musculoskeletal Oncology, HCG Hospital, Bangalore, India
| | - Suraj Hindiskere
- Department of Musculoskeletal Oncology, HCG Hospital, Bangalore, India
| | | | - Raghunath Sk
- Department of Uro Oncology. HCG Hospital, Bangalore, India
| | | | - Utkarsh Pal
- Department of Musculoskeletal Oncology, HCG Hospital, Bangalore, India
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22
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Borghesi M, Schiavina R, Antonelli A, Buizza C, Celia A, Parma P, De Concilio B, Mengoni F, Romagnoli D, Saraceni G, Brunocilla E, Porreca A. Peri-Operative Outcomes after Open and Robot-Assisted Radical Cystectomy by Using an Advanced Bipolar Seal and Cut Technology (Caiman®): A Prospective, Comparative, and Multi-Institutional Study. Curr Urol 2019; 12:64-69. [PMID: 31114462 DOI: 10.1159/000489421] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To report and compare the peri-operative outcomes of patients undergoing open (ORC) and robotic-assisted radical cystectomy (RARC) for bladder cancer performed with a radiofrequency seal and cut device (Caiman®). Materials and Methods Data of patients undergoing ORC or RARC between January 2015 and March 2016 at 6 Italian institutions were prospectively recorded and analyzed. Thirty-and 90-day complications were stratified according to the Martin's criteria and graded according to the Clavien-Dindo classification. Data on operative time, blood loss, transfusion rate, complications, and length of stay were evaluated and compared between the ORC and RARC groups. Results Thirty-three (66%) and 17 (34%) patients were treated with ORC and RARC, respectively. The median age was 72 (64-78) years. Overall operative time was longer in RARC compared to ORC (389 ± 80.1 vs. 242 ± 62.2 min, p < 0.001), while the estimated blood loss during cystectomy was higher after ORC (370 ± 126.8 vs. 243.3 ± 201.6 ml, p = 0.03). The transfusion rate was significantly higher in the ORC compared to RARC (24.2 vs. 5.9%, p = 0.04). Eight (19%) and 7 (16.7%) patients experienced 30- and 90-day post-operative complications, with no significant difference between ORC and RARC. Length of stay was significantly shorter in RARC group (median 7 vs. 14 days, p < 0.001). Conclusion Open and robot-assisted procedures were safely performed by using a new advanced bipolar seal and cut technology (Caiman®). RARC demonstrated to be superior to ORC in terms of bleeding, transfusion rates and length of hospital stay, despite longer operative time.
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Affiliation(s)
- Marco Borghesi
- Department of Urology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Riccardo Schiavina
- Department of Urology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | | | - Carlo Buizza
- Department of Urology, Ospedale di Circolo, Busto Arsizio
| | - Antonio Celia
- Department of Urology, San Bassiano Hospital, Bassano del Grappa
| | - Paolo Parma
- Department of Urology, Carlo Poma Hospital, Mantova
| | | | - Francesco Mengoni
- Department of Urology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Daniele Romagnoli
- Department of Urology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Giacomo Saraceni
- Department of Urology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Eugenio Brunocilla
- Department of Urology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Angelo Porreca
- Department of Urology, Policlinino Abano Terme, Abano Terme, Italy
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23
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Maj M, Kokocha A, Bajek A, Drewa T. The interplay between adipose-derived stem cells and bladder cancer cells. Sci Rep 2018; 8:15118. [PMID: 30310111 PMCID: PMC6181926 DOI: 10.1038/s41598-018-33397-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/26/2018] [Indexed: 12/13/2022] Open
Abstract
Tissue engineering approaches offer alternative strategies for urinary diversion after radical cystectomy. Possible triggering of cancer recurrence remains, however, a significant concern in the application of stem-cell based therapies for oncological patients. Soluble mediators secreted by stem cells induce tissue remodelling effects, but may also promote cancer cells growth and metastasis. We observed a substantial increase in the concentration of IL-6 and IL-8 in the secretome of adipose-derived stem cells (ASCs) co-cultured with bladder cancer cells. Concentrations of GM-CSF, MCP-1 and RANTES were also elevated. Bioactive molecules produced by ASCs increased the viability of 5637 and HT-1376 cells by respectively 15.4% and 10.4% (p < 0.0001). A trend in reduction of adhesion to ECM components was also noted, even though no differences in β-catenin expression were detected. When HT-1376 cells were co-cultured with ASCs their migration and invasion increased by 24.5% (p < 0.0002) and 18.2% (p < 0.002). Expression of p-ERK1/2 increased in 5637 cells (2.2-fold; p < 0.001) and p-AKT in HB-CLS-1 cells (2.0-fold; p < 0.001). Our results confirm that ASCs crosstalk with bladder cancer cells in vitro what influences their proliferation and invasive properties. Since ASCs tropism to tumour microenvironment is well documented their application towards post-oncologic reconstruction should be approached with caution.
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Affiliation(s)
- Malgorzata Maj
- Chair of Urology, Department of Tissue Engineering, Collegium Medicum, Nicolaus Copernicus University, Karlowicza 24, 85-092, Bydgoszcz, Poland.
| | - Anna Kokocha
- Chair of Urology, Department of Tissue Engineering, Collegium Medicum, Nicolaus Copernicus University, Karlowicza 24, 85-092, Bydgoszcz, Poland
| | - Anna Bajek
- Chair of Urology, Department of Tissue Engineering, Collegium Medicum, Nicolaus Copernicus University, Karlowicza 24, 85-092, Bydgoszcz, Poland
| | - Tomasz Drewa
- Chair of Urology, Department of Tissue Engineering, Collegium Medicum, Nicolaus Copernicus University, Karlowicza 24, 85-092, Bydgoszcz, Poland
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24
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Koç E, Atmaca AF, Asil E, Gok B, Canda AE, Balbay MD. Management of ureteric duplications identified during robotic cystectomy and intracorporeal urinary diversion. MINERVA UROL NEFROL 2018; 70:534-537. [PMID: 29969001 DOI: 10.23736/s0393-2249.18.03136-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ureteral duplication is rarely seen malformation that could be diagnosed during radiological imaging. Herein, we present 5 patients with ureteral duplication who underwent robotic radical cystectomy with intracorporeal urinary diversion for bladder cancer. Preoperative computerized tomography did not show presence of a ureteral duplication in any patient and all were identified intraoperatively. A Wallace type uretero-ureteral anastomosis was performed in all patients. During the follow-up period, we did not detect any ureterointestinal anastomotic strictures or complication related to the presence of a ureteral duplication following robotic cystectomy. We conclude that ureteral duplication might be missed during preoperative radiological imaging, might be a surprising and challenging issue for the robotic surgeon that could be safely managed intraoperatively.
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Affiliation(s)
- Erdem Koç
- Department of Urology, Ankara Atatürk Training and Research Hospital, Ankara, Turkey -
| | - Ali F Atmaca
- Department of Urology, Ankara Yıldırım Beyazıt University, School of Medicine affiliated with Ankara Atatürk Training and Research Hospital, Ankara, Turkey
| | - Erem Asil
- Department of Urology, Ankara Atatürk Training and Research Hospital, Ankara, Turkey
| | - Bahri Gok
- Department of Urology, Ankara Yıldırım Beyazıt University, School of Medicine affiliated with Ankara Atatürk Training and Research Hospital, Ankara, Turkey
| | - Abdullah E Canda
- Department of Urology, Koc University, School of Medicine, İstanbul, Turkey
| | - Mevlana D Balbay
- Department of Urology, Koc University, School of Medicine, İstanbul, Turkey
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25
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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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26
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Banerjee S, Banerjee S. Robot-assisted laparoscopic implantation of brachytherapy catheters in bladder cancer recent interests and prospective. Transl Androl Urol 2018; 7:S114-S117. [PMID: 29644176 PMCID: PMC5881195 DOI: 10.21037/tau.2017.11.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Susovan Banerjee
- Division of Radiation Oncology, Medanta the Medicity, Gurgaon, NCR-Delhi, India
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Abstract
AIM To scrutinize the rapid development of robotic versus traditional laparoscopic technique in pelvic urologic surgery. INTRODUCTION In the last few decades, advances in research and development have led to tremendous progress in medical diagnostics and treatment of disease. Minimally invasive surgery has moved from experimental to becoming the dominant form of surgical management across the surgical specialties. Laparoscopy is nowadays used widely in abdominal surgery, from simple diagnostic laparoscopy to complex colorectal and gynecologic cancer procedures. METHODS A literature search of electronic databases (PubMed, Medscape, Embase) using the key words: "pelvic laparoscopy, urologic oncology, robotic surgery, minimally invasive access" was performed for all relevant articles in the English language. Data were extrapolated from the abstracts alone to avoid subjective bias in drawing conclusions. RESULTS Telemedicine and telesurgery, the diagnostic and operative process is conducted from a distance. The surgeon uses computer-assisted surgery away from the bedside via a robotic system and performs the surgical task at hand. In pelvic urological cancer surgery the use of robotic technique expands to female and reconstructive procedures as well. The leap forward is so massive, that traditional laparoscopic surgery is starting to be considered less, with a growing number of organizations being now more interested in developing a robotic service. Minimally invasive surgical techniques aim to improve surgical outcome in conjunction with delivery of high-quality patient care. Quality studies demonstrating superiority and cost effectiveness are lacking, however. CONCLUSIONS Although tremendous accomplishments took place over a few years, there is still a lot of ground to be covered in standardizing the learning process and evaluating the outcome from the application of new technologies in the field of robotic pelvic surgery.
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28
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Joseph JR, Smith BW, Liu X, Park P. Current applications of robotics in spine surgery: a systematic review of the literature. Neurosurg Focus 2018; 42:E2. [PMID: 28463618 DOI: 10.3171/2017.2.focus16544] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical robotics has demonstrated utility across the spectrum of surgery. Robotics in spine surgery, however, remains in its infancy. Here, the authors systematically review the evidence behind robotic applications in spinal instrumentation. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Relevant studies (through October 2016) that reported the use of robotics in spinal instrumentation were identified from a search of the PubMed database. Data regarding the accuracy of screw placement, surgeon learning curve, radiation exposure, and reasons for robotic failure were extracted. RESULTS Twenty-five studies describing 2 unique robots met inclusion criteria. Of these, 22 studies evaluated accuracy of spinal instrumentation. Although grading of pedicle screw accuracy was variable, the most commonly used method was the Gertzbein and Robbins system of classification. In the studies using the Gertzbein and Robbins system, accuracy (Grades A and B) ranged from 85% to 100%. Ten studies evaluated radiation exposure during the procedure. In studies that detailed fluoroscopy usage, overall fluoroscopy times ranged from 1.3 to 34 seconds per screw. Nine studies examined the learning curve for the surgeon, and 12 studies described causes of robotic failure, which included registration failure, soft-tissue hindrance, and lateral skiving of the drill guide. CONCLUSIONS Robotics in spine surgery is an emerging technology that holds promise for future applications. Surgical accuracy in instrumentation implanted using robotics appears to be high. However, the impact of robotics on radiation exposure is not clear and seems to be dependent on technique and robot type.
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Affiliation(s)
- Jacob R Joseph
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Brandon W Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Xilin Liu
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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29
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Open Techniques and Extent (Including Pelvic Lymphadenectomy). Bladder Cancer 2018. [DOI: 10.1016/b978-0-12-809939-1.00024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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Abstract
Robot-assistance is being increasingly used for radical cystectomy (RC). Fifteen years of surgical evolution might be considered a short period for a radical procedure to be established as the treatment of choice, but robot assisted radical cystectomy (RARC) is showing promising results when compared with the current gold standard, open RC (ORC). In this review, we describe the current status of RARC and continue the discussion on the on-going RARC versus ORC debate.
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Affiliation(s)
- Stavros Ioannis Tyritzis
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Justin W Collins
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - Nils Peter Wiklund
- Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
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31
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Moschini M. The impact of perioperative blood transfusion on survival outcomes in radical cystectomy patients. Transl Androl Urol 2017; 6:1205-1207. [PMID: 29354514 PMCID: PMC5760388 DOI: 10.21037/tau.2017.11.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Marco Moschini
- Klinik für Urologie, Luzerner Kantonsspital, Lucerne, Switzerland
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32
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Flavin K, Prasad V, Gowrie-Mohan S, Vasdev N. Renal Physiology and Robotic Urological Surgery. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10313685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The use of robotic-assisted laparoscopic techniques has transformed the face of urological surgery in the last decade, with demonstrable benefits over both unassisted laparoscopic and traditional open approaches. For example, robotic-assisted partial nephrectomy is associated with lower morbidity, improved convalescence, reduced postoperative pain, shorter length of hospital stay, and a superior cosmetic result when compared to an open procedure. This review discusses the various perioperative influences on the renal physiology of patients undergoing robotic-assisted urological procedures.
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Affiliation(s)
- Kate Flavin
- Department of Anaesthetics, Lister Hospital, Hertfordshire, UK
| | - Venkat Prasad
- Department of Anaesthetics, Lister Hospital, Hertfordshire, UK
| | | | - Nikhil Vasdev
- Hertfordshire and Bedfordshire Urological Cancer Centre, Department of Urology, Lister Hospital, Hertfordshire, UK; School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
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33
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Tyritzis SI, Wiklund NP. Is the open cystectomy era over? An update on the available evidence. Int J Urol 2017; 25:187-195. [PMID: 29178344 DOI: 10.1111/iju.13497] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/18/2017] [Indexed: 12/24/2022]
Abstract
In 2018, robot-assisted radical cystectomy will enter its 15th year. In an era where an effort is being made to standardize complication reporting and videos of the procedure are readily available, it is inevitable and justified that like everything novel, robot-assisted radical cystectomy should be scrutinized against the gold standard, open radical cystectomy. The present comparison is focused on several parameters: oncological, functional and complication outcomes, and direct and indirect costs. Meta-analysis and prospective randomized trials comparing robot-assisted radical cystectomy versus open radical cystectomy have been published, showing an oncological equivalence and in some cases an advantage of robot-assisted radical cystectomy in terms of postoperative morbidity. In the present review, we attempt to update the available knowledge on this debate and discuss the limitations of the current evidence that prevent us from drawing safe conclusions.
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Affiliation(s)
- Stavros I Tyritzis
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.,Center for Minimally Invasive Urological Surgery, Athens Medical Center, Athens, Greece
| | - N Peter Wiklund
- Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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34
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Aro T, Mullerad M, Amiel GE. Expanding the Utilization of Robotic Procedures in Urologic Surgery. Rambam Maimonides Med J 2017; 8:RMMJ.10320. [PMID: 29059044 PMCID: PMC5652935 DOI: 10.5041/rmmj.10320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Although the word "robot" was coined in 1921, only close to 70 years later were robotic devices developed to assist during surgery. Urology has always been at the forefront of endoscopic, minimally invasive, and robotic developments in medicine. Robotic prostatectomy signaled the emerging role of robotic surgery in urology, but since then it has been applied to every urologic laparoscopic procedure.
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Affiliation(s)
- Tareq Aro
- Urology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Michael Mullerad
- Urology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gilad E Amiel
- Urology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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35
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Tang JQ, Zhao Z, Liang Y, Liao G. Robotic-assisted versus open radical cystectomy in bladder cancer: A meta-analysis of four randomized controlled trails. Int J Med Robot 2017; 14. [PMID: 29027351 DOI: 10.1002/rcs.1867] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 08/19/2017] [Accepted: 09/01/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Robot-assisted radical cystectomy (RARC) is increasing annually for treatment of bladder cancer. The objective of this meta-analysis was to compare the safety and efficacy of RARC and open radical cystectomy (ORC) for bladder cancer. METHODS Our meta-analysis searches were conducted using PubMed, Web of Science, and Cochrane Library databases to identify randomized controlled trials (RCT) assessing the two techniques. RESULTS Four RCT studies were identified, including 239 cases. Our studies indicated that RARC was associated with longer operative time (WMD: 69.69, 95% CI:17.25 to122.12; P= 0.009), lower estimated blood loss (WMD: -299.83, 95% CI:-414.66to -184.99; P<0.00001). The two groups had no significant difference in overall perioperative complications, length of hospital stay, lymph node yield and positive surgical margins. CONCLUSIONS RARC is mini-invasive alternative to ORC for bladder cancer. The advantage of RARC was reduced estimated blood loss. More studies are needed to compare the two techniques.
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Affiliation(s)
- Jin-Qiu Tang
- Department of nephrology and urology, Guangzhou Hospital of traditional Chinese medicine, Guangzhou, China
| | - Zhihong Zhao
- Department of Nephrology, Shenzhen People's Hospital, Second Clinical Medicine Centre, Jinan University, China
| | - Yiwen Liang
- Department of Urology People's Hospital of Guigang, Guigang, Guangxi, China
| | - Guixiang Liao
- Department of Oncology, Shenzhen People's Hospital, Second Clinical Medicine Centre, Jinan University, China
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36
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Enhanced recovery after urologic surgery-Current applications and future directions. J Surg Oncol 2017; 116:630-637. [DOI: 10.1002/jso.24821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/07/2017] [Indexed: 12/20/2022]
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37
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Khetrapal P, Tan WS, Lamb B, Tan M, Baker H, Thompson J, Sridhar A, Kelly JD, Briggs T. The Role of Robotics in the Invasive Management of Bladder Cancer. Curr Urol Rep 2017. [PMID: 28634646 DOI: 10.1007/s11934-017-0706-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Robot-assisted radical cystectomy (RARC) has been adopted widely in many centres, owed largely to the success of robot-assisted laparoscopic prostatectomy (RALP). It aims to replicate the oncological outcomes of open radical cystectomy (ORC), while providing a shorter recovery period. Despite this, previous RCTs have failed to show a benefit for RARC over ORC. These trials have compared extracorporeal RARC (eRARC) with ORC, which requires a further incision to mobilise the bowel for urinary reconstruction with an open technique. For intracorporeal RARC (iRARC), this urinary reconstruction is performed robotically without further incisions. There are theoretical benefits to this approach such as reduced recovery time for the bowel and reduced ileus rates, but no level 1 evidence currently exists to support this. While there has been an improvement in patient outcomes since the adoption of RARC, various other factors, such as enhanced recovery programmes and surgical learning curve, have made it difficult to attribute this solely to the robotic approach as many centres performing ORC have also shown similar improvements. In this review, we will discuss implementation of RARC as well as perioperative measures that have helped improve outcomes, offer a comparison of outcomes between ORC and RARC and highlight upcoming RCTs that may offer new evidence for or against a paradigm shift in the future of bladder cancer surgery.
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Affiliation(s)
- Pramit Khetrapal
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK. .,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK.
| | - Wei Shen Tan
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK.,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK
| | - Benjamin Lamb
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Melanie Tan
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Hilary Baker
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - James Thompson
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Ashwin Sridhar
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - John D Kelly
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK.,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK
| | - Tim Briggs
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
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38
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DiLizia EM, Sadeghi F. Surgical and pathological outcomes of robotic-assisted radical cystectomy for bladder cancer in the community setting. J Robot Surg 2017; 12:337-341. [DOI: 10.1007/s11701-017-0740-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/18/2017] [Indexed: 10/19/2022]
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39
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Lauridsen SV, Tønnesen H, Jensen BT, Neuner B, Thind P, Thomsen T. Complications and health-related quality of life after robot-assisted versus open radical cystectomy: a systematic review and meta-analysis of four RCTs. Syst Rev 2017; 6:150. [PMID: 28768530 PMCID: PMC5541663 DOI: 10.1186/s13643-017-0547-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 07/20/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Radical cystectomy is associated with high rates of perioperative morbidity. Robotic-assisted radical cystectomy (RARC) is widely used today despite limited evidence for clinical superiority. The aim of this review was to evaluate the effect of RARC compared to open radical cystectomy (ORC) on complications and secondary on length of stay, time back to work and health-related quality of life (HRQoL). METHODS The databases PubMed, The Cochrane Library, Embase and CINAHL were searched. A systematic review according to the PRISMA guidelines and cumulative analysis was conducted. Randomized controlled trials (RCTs) that examined RARC compared to ORC were included in this review. We assessed the quality of evidence using the Cochrane Collaboration's 'Risk of bias' tool and Grading of Recommendations Assessment, Development and Evaluation approach. Data were extracted and analysed. RESULTS The search retrieved 273 articles. Four RCTs were included involving overall 239 patients. The quality of the evidence was of low to moderate quality. There was no significant difference between RARC and ORC in the number of patients developing complications within 30 or 90 days postoperatively or in overall grade 3-5 complications within 30 or 90 days postoperatively. Types of complications differed between the RARC and the ORC group. Likewise, length of stay and HRQoL at 3 and 6 months did not differ. CONCLUSION Our review presents evidence for RARC not being superior to ORC regarding complications, LOS and HRQoL. High-quality studies with consistent registration of complications and patient-related outcomes are warranted. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016038232.
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Affiliation(s)
- Susanne Vahr Lauridsen
- Department of Urology, Copenhagen University Hospital, 2112, Rigshospitalet, 2100, Copenhagen, Denmark.
| | - Hanne Tønnesen
- Clinical Health Promotion Centre, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospitals, Copenhagen, Denmark.,Clinical Health Promotion Centre, Health Sciences, Lund University, Lund, Sweden.,Health Science, University of Southern Denmark, Odense, Denmark
| | - Bente Thoft Jensen
- Department of Urology, Aarhus University Hospital and Centre of Research in Rehabilitation, Aarhus University, Aarhus, Denmark
| | - Bruno Neuner
- Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Thind
- Department of Urology, Copenhagen University Hospital, 2112, Rigshospitalet, 2100, Copenhagen, Denmark
| | - Thordis Thomsen
- Abdominal Centre, University Hospital of Copenhagen, Health and Medical Sciences, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
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40
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Kingo PS, Nørregaard R, Borre M, Jensen JB. Postoperative C-reactive protein concentration and clinical outcome: comparison of open cystectomy to robot-assisted laparoscopic cystectomy with extracorporeal or intracorporeal urinary diversion in a prospective study. Scand J Urol 2017; 51:381-387. [PMID: 28678652 DOI: 10.1080/21681805.2017.1334698] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to compare clinical outcome and postoperative systemic inflammatory response using C-reactive protein (CRP) levels, to quantify the degree of tissue injury in open mini-laparotomy cystectomy (OMC) versus robot-assisted laparoscopic cystectomy with extracorporeal (RALC-EUD) or intracorporeal urinary diversion (RALC-IUD). MATERIALS AND METHODS From September 2012 to September 2015, 309 patients diagnosed with bladder cancer underwent radical cystectomy with urinary diversion. Of these, 175 patients were eligible for the study and underwent OMC (n = 125), RALC-EUD (n = 12) or RALC-IUD (n = 38). Blood samples were obtained preoperatively and postoperatively on days 1-7. Clinical and perioperative parameters, including demographics, comorbidity, tumour stage and postoperative outcomes, were collected from medical records. RESULTS Age, American Society of Anesthesiologists score and Charlson score were significantly higher in OMC than in the robotic groups (p = 0.020, 0.012 and 0.008, respectively). Other demographic data showed no significant group differences. Estimated blood loss and blood transfusion volume were higher in OMC (p < 0.001) and operative time was longer in the robotic groups (p < 0.001); no difference was found between RALC groups. Postoperative CRP levels changed over time (p < 0.001) and RALC-IUD appeared to have significantly higher CRP levels on postoperative days 3-7 compared to OMC and RALC-EUD (p < 0.031), but OMC CRP levels were higher than RALC-EUD. CONCLUSIONS In this study, robotic techniques seem less traumatic overall than open surgery, as OMC had higher postoperative CRP levels than RALC-EUD. The higher CRP levels in RALC-IUD may be more reflective of the urinary diversion technique than the true tissue trauma.
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Affiliation(s)
- Pernille Skjold Kingo
- a Department of Urology/Department of Clinical Medicine , Aarhus University Hospital , Aarhus N , Denmark
| | - Rikke Nørregaard
- b Department of Clinical Medicine , Aarhus University , Aarhus N , Denmark
| | - Michael Borre
- a Department of Urology/Department of Clinical Medicine , Aarhus University Hospital , Aarhus N , Denmark
| | - Jørgen Bjerggaard Jensen
- a Department of Urology/Department of Clinical Medicine , Aarhus University Hospital , Aarhus N , Denmark
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Attalla K, Kent M, Waingankar N, Mehrazin R. Robotic-assisted radical cystectomy versus open radical cystectomy for management of bladder cancer: review of literature and randomized trials. Future Oncol 2017. [PMID: 28650267 DOI: 10.2217/fon-2017-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Among the many milestones in the last several decades in the management of muscle-invasive bladder cancer and high-risk nonmuscle-invasive bladder cancer including the extension of the standard lymph node dissection and the use of neoadjuvant chemotherapy, minimally invasive techniques have gained traction as an attractive option for radical cystectomy. Open radical cystectomy is plagued with high rates of perioperative and postoperative morbidity and mortality, and as robotic assistance has demonstrated benefits in other arenas of surgery and urology, the evolution of the approach to radical cystectomy has likewise incorporated robotic assistance. We thus sought to critically review the literature comparing open radical cystectomy with robotic-assisted radical cystectomy. Perioperative and oncologic outcomes as well as cost analyses and health-related quality of life were compared between the two approaches, and identified manuscripts were categorized according to level of evidence.
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Affiliation(s)
- Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Marissa Kent
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY 10029, USA
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Covotta M, Claroni C, Torregiani G, Naccarato A, Tribuzi S, Zinilli A, Forastiere E. A Prospective, Randomized, Clinical Trial on the Effects of a Valveless Trocar on Respiratory Mechanics During Robotic Radical Cystectomy. Anesth Analg 2017; 124:1794-1801. [DOI: 10.1213/ane.0000000000002027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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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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Son SK, Lee NR, Kang SH, Lee SH. Safety and Effectiveness of Robot-Assisted Versus Open Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2017; 27:1109-1120. [PMID: 28350238 DOI: 10.1089/lap.2016.0437] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES To evaluate the safety and effectiveness of robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC) in bladder cancer. METHODS A literature search for the systematic review was conducted using international databases as well as domestic databases up to April 2015. Outcomes of interest included baseline characteristics, complication rates, perioperative, and oncologic outcomes. RESULTS Twenty-four articles were finally selected for inclusion in the meta-analysis. Complication rates of RARC were similar to those of ORC, except for 90-day overall complication rate, wound dehiscence, abscess, pneumonia, respiratory failure, and sepsis, which was lower after RARC. RARC was also associated with a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield, whereas ORC was associated with a shorter operation time and lower rate of stricture. Considering oncologic outcomes, there were no differences between RARC and ORC. CONCLUSIONS RARC seems to be associated with equivalent complication rates, a smaller amount of estimated blood loss, lower transfusion rate, shorter length of hospital stay, shorter time to flatus, and more lymph node yield. Randomized controlled trials with a large sample size and comparative studies with long-term follow-up data are warranted to assess our findings and the oncologic effectiveness of RARC.
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Affiliation(s)
- Soo Kyung Son
- 1 Division for Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,2 Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University , Seoul, Korea
| | - Na Rae Lee
- 1 Division for Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.,2 Department of Health Policy and Hospital Management, Graduate School of Public Health, Korea University , Seoul, Korea
| | - Seok Ho Kang
- 3 Department of Urology, College of Medicine, Korea University , Seoul, Korea
| | - Seon Heui Lee
- 4 Department of Nursing Science, College of Nursing, Gachon University , Incheon, Korea
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Ahmed YE, Hussein AA, May PR, Ahmad B, Ali T, Durrani A, Khan S, Kumar P, Guru KA. Natural History, Predictors and Management of Ureteroenteric Strictures after Robot Assisted Radical Cystectomy. J Urol 2017; 198:567-574. [PMID: 28257782 DOI: 10.1016/j.juro.2017.02.3339] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Ureteroenteric strictures represent the most common complication requiring reoperation after radical cystectomy. We investigated the prevalence, outcomes, predictors and management of ureteroenteric strictures. MATERIALS AND METHODS We retrospectively reviewed our quality assurance, robot assisted radical cystectomy database to identify patients in whom ureteroenteric strictures developed. Data were reviewed for demographics, perioperative outcomes and ureteroenteric stricture characteristics. The Kaplan-Meier method was used to calculate time to ureteroenteric stricture and multivariable stepwise regression was done to evaluate predictors of ureteroenteric strictures. RESULTS Ureteroenteric strictures developed in 12%, 16% and 19% of 51 patients (13%) at 1, 3 and 5 years after robot assisted radical cystectomy, respectively. All patients were initially treated endoscopically or percutaneously, including 57% treated only endoscopically or percutaneously and 43% who required surgery, which was open repair in 6 and robot assisted repair in 16. At a median followup of 23 months 33 patients (65%) were free of disease, including 13 after endoscopic or percutaneous treatment, 15 after robot assisted repair and 5 after open revision. Open and robot assisted revisions showed comparable perioperative outcomes. On multivariable analysis the predictors of ureteroenteric anastomotic strictures were body mass index (OR 1.07, 95% CI 1.01-1.13, p = 0.02), intracorporeal urinary diversion (OR 3.28, 95% CI 1.41-7.61, p = 0.006), length of the right resected ureter (OR 0.66, 95% CI 0.50-0.88, p = 0.004), estimated glomerular filtration rate 30 days after assisted radical cystectomy (OR 0.85, 95% CI 0.74-0.98, p = 0.03), urinary tract infection (OR 2.68, 95% CI 1.31-5.49, p = 0.007) and leakage (OR 3.85, 95% CI 1.05-14.1, p = 0.04). Male gender (OR 0.19, 95% CI 0.04-0.96, p = 0.04) and higher body mass index (OR 0.85, 95% CI 0.72-0.996, p = 0.05) were associated with lower odds of successful endoscopic management. CONCLUSIONS Multiple modifiable factors were associated with ureteroenteric anastomotic strictures following robot assisted radical cystectomy. Surgical revision can provide a definitive management with comparable outcomes for open and robotic repairs.
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Affiliation(s)
- Youssef E Ahmed
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | | | - Paul R May
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | - Basim Ahmad
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | - Taimoor Ali
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | - Ayesha Durrani
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | - Saira Khan
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York
| | - Prasanna Kumar
- Department of Radiology, Roswell Park Cancer Institute, Buffalo, New York
| | - Khurshid A Guru
- Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.
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Bachman AG, Parker AA, Shaw MD, Cross BW, Stratton KL, Cookson MS, Patel SG. Minimally Invasive Versus Open Approach for Cystectomy: Trends in the Utilization and Demographic or Clinical Predictors Using the National Cancer Database. Urology 2017; 103:99-105. [PMID: 28214574 DOI: 10.1016/j.urology.2017.02.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/11/2017] [Accepted: 02/09/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To examine temporal national trends of operative approach for cystectomy and identify demographic or clinical predictive factors that influence choice of approach. METHODS We performed a retrospective cohort study of patients who underwent cystectomy for bladder cancer between 2010 and 2013 using the National Cancer Database. Approach was stratified by open vs minimally invasive (robotic or laparoscopic). Univariate Pearson chi-square and multivariate logistic regression analysis were used to assess the relationships between demographic and hospital factors and the receipt of minimally invasive or open surgical approach. RESULTS A total of 9439 patients met our inclusion criteria, of which 34.1% received a minimally invasive approach (MIA). Frequency of MIA increased from 26.3% in 2010 to 39.4% in 2013 (P < .0001). Univariate analysis identified statistically significant associations between year of diagnosis, sex, age, race, clinical T stage, insurance status, income, education, distance from hospital, facility type, geographic location, and facility cystectomy volume, and the choice of approach (all P < .01). On multivariate analysis, independent predictors of MIA included increasing year of diagnosis, male gender, lower clinical T stage, private insurance vs Medicaid, nonacademic vs academic program, northeastern geographic region, receipt of neoadjuvant chemotherapy, and lower cystectomy volume. CONCLUSION Utilization of MIA for cystectomy has increased nationally over the last several years likely due to increased surgeon familiarity with robotic laparoscopic pelvic surgery. Factors associated with MIA included male sex, locally confined disease, receipt of neoadjuvant chemotherapy, lower cystectomy volume centers, and nonacademic centers.
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Affiliation(s)
- Andrew G Bachman
- University of Oklahoma Health Science Center, Oklahoma City, OK.
| | | | - Marshall D Shaw
- University of Oklahoma Health Science Center, Oklahoma City, OK
| | - Brian W Cross
- University of Oklahoma Health Science Center, Oklahoma City, OK
| | | | | | - Sanjay G Patel
- University of Oklahoma Health Science Center, Oklahoma City, OK
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Tan WS, Khetrapal P, Tan WP, Rodney S, Chau M, Kelly JD. Robotic Assisted Radical Cystectomy with Extracorporeal Urinary Diversion Does Not Show a Benefit over Open Radical Cystectomy: A Systematic Review and Meta-Analysis of Randomised Controlled Trials. PLoS One 2016; 11:e0166221. [PMID: 27820855 PMCID: PMC5098822 DOI: 10.1371/journal.pone.0166221] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/25/2016] [Indexed: 11/18/2022] Open
Abstract
Background The number of robotic assisted radical cystectomy (RARC) procedures is increasing despite the lack of Level I evidence showing any advantages over open radical cystectomy (ORC). However, several systematic reviews with meta-analyses including non-randomised studies, suggest an overall benefit for RARC compared to ORC. We performed a systematic review with meta-analysis of randomised controlled trials (RCTs) to evaluate the perioperative morbidity and efficacy of RARC compared to ORC in patients with bladder cancer. Methods Literature searches of Medline/Pubmed, Embase, Web of Science and clinicaltrials.gov databases up to 10th March 2016 were performed. The inclusion criteria for eligible studies were RCTs which compared perioperative outcomes of ORC and RARC for bladder cancer. Primary objective was perioperative and histopathological outcomes of RARC versus ORC while the secondary objective was quality of life assessment (QoL), oncological outcomes and cost analysis. Results Four RCTs (from 5 articles) met the inclusion criteria, with a total of 239 patients all with extracorporeal urinary diversion. Patient demographics and clinical characteristics of RARC and ORC patients were evenly matched. There was no significant difference between groups in perioperative morbidity, length of stay, positive surgical margin, lymph node yield and positive lymph node status. RARC group had significantly lower estimated blood loss (p<0.001) and wound complications (p = 0.03) but required significantly longer operating time (p<0.001). QoL was not measured uniformly across trials and cost analysis was reported in one RCTs. A test for heterogeneity did highlight differences across operating time of trials suggesting that surgeon experience may influence outcomes. Conclusions This study does not provide evidence to support a benefit for RARC compared to ORC. These results may not have inference for RARC with intracorporeal urinary diversion. Well-designed trials with appropriate endpoints conducted by equally experienced ORC and RARC surgeons will be needed to address this.
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Affiliation(s)
- Wei Shen Tan
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, University College London Hospital, London, United Kingdom
- * E-mail:
| | - Pramit Khetrapal
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, University College London Hospital, London, United Kingdom
| | - Wei Phin Tan
- Department of Urology, Rush University Medical Center, Chicago, Illinois, United States of America
| | - Simon Rodney
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, University College London Hospital, London, United Kingdom
| | - Marisa Chau
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - John D. Kelly
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
- Department of Urology, University College London Hospital, London, United Kingdom
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Systematic review and meta-analysis of randomised trials of perioperative outcomes comparing robot-assisted versus open radical cystectomy. BMC Urol 2016; 16:59. [PMID: 27664079 PMCID: PMC5034537 DOI: 10.1186/s12894-016-0177-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/14/2016] [Indexed: 12/29/2022] Open
Abstract
Background With the introduction of robotic surgery, whether the robot-assisted radical cystectomy (RARC) could reduce the perioperative morbidity compared with Open radical cystectomy (ORC) was unknown. Methods Studies reported RARC were reviewed based on all randomized controlled trials (RCTs), which focused on the efficacy of RARC versus ORC. Results Of the 201 studies from preliminary screening, four RCTs were included. By pooling these studies, there were significant differences in comparison of operative time (p = 0.007), estimated blood loss (EBL) (p < 0.001) and time to diet (p < 0.001) between the RARC group and ORC groups. There was no significant difference regarding perioperative complications (Clavien 2–5, Clavien 3–5), length of stay (LOS), positive surgical margins (PSM) and lymph node positive. Conclusion This meta-analysis presented evidence for a benefit of EBL, time to diet, similar perioperative complications and oncological outcomes, but a longer operative time in RARC. It is noted that RARC was considered as a comparable surgical procedure to ORC.
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Surgical control and margin status after robotic and open cystectomy in high-risk cases: Caution or equivalence? World J Urol 2016; 35:657-663. [PMID: 27495912 DOI: 10.1007/s00345-016-1915-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/29/2016] [Indexed: 01/16/2023] Open
Abstract
PURPOSE The benefits of robotic-assisted radical cystectomy (RARC) are unclear, especially in patients with high-risk disease (pT3/T4). We evaluated pathological and postoperative outcomes of RARC versus open radical cystectomy (ORC) in these patients. METHODS We identified bladder cancer patients treated with RARC or ORC from January 2010-August 2014. Clinicodemographic factors were examined for potential confounding. Our primary outcome of interest was positive soft-tissue surgical margins (STSMs). Secondary outcomes included post-operative complications and length of stay (LOS). We used logistic regression to define the association between clinical factors with outcomes of interest, focusing on patients with locally advanced disease. RESULTS We identified 472 patients treated with ORC (407, 86.2 %) or RARC (65, 13.8 %) of which 215 (45.6 %) were high-risk cases based on advanced pathologic stage (pT3/4). RARC patients were more commonly men (96.9 vs. 73.2 %, p < 0.01), had better performance status (ECOG 0, 78.5 vs. 59.7 %, p = 0.031), and received less neoadjuvant chemotherapy (21.5 vs. 39.3 %, p = 0.006). Total (52.3 vs. 59.7 %, p = 0.26) and high-grade complication rates (13.8 vs. 19.7 %, p = 0.27) were similar, but median LOS was shorter after RARC (6 vs. 7 days, p < 0.01). On multivariate analysis, prior pelvic radiation (OR: 4.78, 95 % CI: 2.16-10.57), and advanced tumor stage (OR: 3.06, 95 % CI: 1.56-6.03) were independently associated with positive STSMs in high-risk patients but robotic surgical approach was not (OR: 0.81, 95 % CI: 0.29-2.30; p = 0.69). CONCLUSION RARC had similar short-term postoperative outcomes compared to ORC and did not compromise oncological control in patients with extravesical disease.
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50
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Erlich A, Zlotta AR. Treatment of bladder cancer in the elderly. Investig Clin Urol 2016; 57 Suppl 1:S26-35. [PMID: 27326404 PMCID: PMC4910758 DOI: 10.4111/icu.2016.57.s1.s26] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/12/2016] [Indexed: 12/16/2022] Open
Abstract
As the population ages and life expectancy increases in the human population, more individuals will be diagnosed with bladder cancer (BC). The definition of who is elderly is likely to change in the future from the commonly used cut-off of ≥75 years of age. Physiological rather than chronological age is key. BC care in the elderly is likely to become a very common problem in daily practice. Concerns have been raised that senior BC patients are not given treatments that could cure their disease. Clinicians lack quantitative and reliable estimates of competing mortality risks when considering treatments for BC. Majority of patients diagnosed with BC are elderly, making treatment decisions complex with their increasing number of comorbidities. A multidisciplinary approach to these patients may be a way to incorporate discussion from various disciplines regarding treatment options available. Here we review various treatment options for elderly patients with muscle invasive BC and nonmuscle invasive BC. We include differences in treatments from robotic versus open radical cystectomy, various urinary diversion techniques, chemotherapy, radiation therapy and combination treatments. In clinical practice, treatment decisions for elderly patients should be done on a case-by-case basis, tailored to each patient with their specific histories and comorbidities considered. Some healthy elderly patients may be better candidates for extensive curative treatments than their younger counterparts. This implies that these important, life-altering decisions cannot be solely based on age as many other factors can affect patient survival outcomes.
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Affiliation(s)
- Annette Erlich
- Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Alexandre R Zlotta
- Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.; Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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