Short- and Long-Term Evaluation of Renal Function after Radical Cystectomy and Cutaneous Ureterostomy in High-Risk Patients

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term outcomes of cutaneous ureterostomy with the aim of stent-free stoma

Objectives

We evaluated post-surgical renal function and risk factors for renal function deterioration (RFD), defined as a > 25% decrease in the estimated serum creatinine-based glomerular filtration rate (eGFR), after cutaneous ureterostomy (CU) and collected follow-up data on hydronephrosis after CU construction.

Patients and methods

CU was performed following radical cystectomy in 46 patients (90 renal units [RUs]) with a minimum follow-up period of 12 months. The median follow-up period was 102.1 months. The stoma was created using the Toyoda method. A surgical stabilization step for the abdominal tunnel of the ureters was added. Post-surgical changes in renal function and hydronephrosis were reviewed.

Results

At the end of follow-up, RFD was observed in 19 (41.3%) of 46 patients. The 5- and 10-year RFD-free survivals were 61.3% and 47.2%, respectively. Seventy-six RUs (84.4%) exhibited no hydronephrosis, whereas six RUs (6.7%) in six patients progressed to atrophic kidneys. Stent catheters were inserted in eight RUs (8.9%) in six patients. After excluding 10 patients with progression to atrophic kidneys (six patients) or ureteral obstruction attributable to retroperitoneal lymph node metastasis by cancer progression (four patients), RFD was identified in 13 (36.1%) out of 36 patients. These patients were categorized into Group 1 (without RFD, 23 patients) and Group 2 (with RFD, 13 patients). Stent insertion was identified as a significant predictor of post-surgical RFD by univariate (p = 0.001) and multivariate analyses (p = 0.001).

Conclusions

RFD was observed in 41.3% patients during follow-up. We achieved an 84.4% hydronephrosis-free rate following CU construction. Stent insertion was identified as a significant risk factor for RFD after CU construction.

Stoma Acceptance Mediates Body Image Distress and Mental Health-Related Quality of Life: A Single-Center Study on Radical Cystectomy Patients with Ureterostomy

Background: Muscle-invasive bladder cancer and subsequent radical cystectomy with ureterocutaneostomy significantly impact patients' body image and quality of life, potentially increasing the risk of adverse mental health outcomes. Acceptance may represent a psychosocial resource to buffer the effects of body image impairment on health, thereby supporting stoma adjustment and preserving quality of life. Objective: This study aimed to investigate the mediating role of stoma acceptance in the relationship between body image distress and mental health. Methods: A single-center cross-sectional survey was conducted with 73 muscle-invasive bladder cancer patients undergoing radical cystectomy with ureterocutaneostomy. Participants completed structured, anonymous self-report measures assessing body image distress, stoma acceptance, and mental health-related quality of life through validated questionnaires. Results: Statistical analyses revealed significant negative correlations between body image distress and mental health and stoma acceptance. Conversely, stoma acceptance was significantly and positively associated with mental health. Regression-based mediation modeling indicated that stoma acceptance exerted a significant mediating effect on the relationship between body image and mental health-related quality of life. Conclusions: These findings highlight the considerable and unprecedented role of stoma acceptance as a mediating factor that may promote the adjustment and enhance the quality of life of urostomy patients. Further research is warranted to explore interventions targeting stoma acceptance to prevent body image distress and promote mental health.

Colon Cancer With Bladder Invasion: A Single Center Experience

BACKGROUND/AIM

The aim of our study was to investigate the outcome of colon cancer with bladder invasion after surgical intervention.

PATIENTS AND METHODS

Between 2011 and 2022, a total of 41 patients diagnosed with colon cancer and bladder invasion underwent surgical procedures at Taichung Veterans General Hospital. The impact of various risk factors on overall survival (OS) was assessed using Kaplan-Meier analyses and Cox proportional hazards models.

RESULTS

Among the enrolled patients, 21 underwent radical cystectomy, while 20 underwent partial cystectomy. Twelve had tumors located in the rectum, 19 in the sigmoid colon, and 10 in both the rectum and sigmoid colon. The median OS was 71.8 months in stage 2, 50.8 months in stage 3, and 11.2 months in stage 4 (p=0.061). Median OS was 71.8 months in patients with negative surgical margins and 10.5 months in those with positive surgical margins (p=0.003). In multivariate regression analysis, positive surgical margins [hazard ratio (HR)=3.64, 95% confidence interval (CI)=1.28-10.34, p=0.015] and emergency operations (HR=4.57, 95%CI=1.34-15.55, p=0.015) significantly impacted OS.

CONCLUSION

Complete resection of colon cancer with bladder invasion can yield excellent oncologic outcomes. The decision between partial and radical cystectomy should balance surgical margin clearance and the preservation of quality of life. Both surgical margin involvement and emergency operations are independent risk factors for OS.

Association between early postradical cystectomy kidney injury and perioperative outcome in enhanced recovery era

OBJECTIVE

To evaluate the incidence and predictors of early postoperative acute kidney injury (EP-AKI) during index hospitalization following radical cystectomy and its association with postoperative outcomes.

METHODS

All patients with bladder cancer who underwent radical cystectomy with intent-to-cure at our center between 2012 and 2020 were reviewed. EP-AKI during index hospitalization was evaluated using the Acute Kidney Injury Network criteria. The association between EP-AKI and demographics, clinicopathologic features, and perioperative outcomes, including length of hospital stay, complication rate, and readmission rate, were examined. A logistic regression analysis was performed to evaluate the predictors of EP-AKI.

RESULTS

Overall, 435 patients met eligibility, of whom 112 (26%) experienced EP-AKI during index hospitalization (90 [21%] stage 1, 17 [4%] stage 2, and 5 [1%] stage 3). EP-AKI was associated with a longer mean operative time (6.8 vs. 6.1 hours; P < 0.001), higher mean length of hospital stay (6.3 vs. 5.6; P = 0.02), 30-day complication rate (71% vs. 51%; P < 0.001), 90-day complication rate (81% vs. 69%; P = 0.01) and 90-day readmission rate (37% vs. 33%; P = 0.04). The rate of complications increased at higher stages of AKI. On multivariable analysis, perioperative blood transfusion (OR: 1.84, P = 0.02) and continent diversion (OR: 3.29, P < 0.001) were independent predictors of EP-AKI.

CONCLUSION

A quarter of cystectomy patients experience acute kidney injury during index hospitalization, which is associated with higher length of stay, postoperative complication, and readmission rates. Perioperative blood transfusion and continent diversion are independent predictors of such injury.

Modified Tubeless Ureterocutaneostomy in High-Risk Patients After Radical Cystectomy and its Long-Term Clinical Outcomes

OBJECTIVES

This work aimed to prevent stoma stenosis and achieve tubeless cutaneous ureterostomy in elderly and high-risk patients with our modified cutaneous ureterostomy.

METHODS

We retrospectively analyzed 40 and 49 patients (176 renal units) who underwent Toyoda (group 1) and modified cutaneous ureterostomy (group 2) between 2012 and 2021. The average follow-up period was 44 months. The primary results of our study were the catheter-free rate and clinical outcomes, especially renal function and urinary diversion-related complications. Significant differences in catheter-free rate and urinary diversion-related complications were found between our modified method and the Toyoda technique.

RESULTS

A total of 56 (71.8%) of 78 renal units in group 1 and 89 (90.8%) of 98 renal units in group 2 remained catheter free. Compared with group 1, group 2 had a higher catheter-free rate (P = .001). Multivariate analysis indicated that the surgical procedure (HR = 0.268; P = .001) and body mass index (HR = 3.127; P = .002) were the predictors independently associated with catheter insertion. During follow-up, renal deterioration was observed in 32 (36.0%) patients. Patients with catheter insertion were more likely to suffer from renal deterioration (P < .001), postoperative pyelonephritis (P < .001), and urolithiasis (P < .001) than their counterparts.

CONCLUSION

Our modified cutaneous ureterostomy method may provide an effective and simple approach to tubeless cutaneous ureterostomy in elderly and high-risk patients.

Population-Based Assessment of Determining Predictors for Discharge Disposition in Patients with Bladder Cancer Undergoing Radical Cystectomy

Objective: To assess predictors of discharge disposition—either home or to a CRF—after undergoing RC for bladder cancer in the United States. Methods: In this retrospective, cohort study, patients were divided into two cohorts: those discharged home and those discharged to CRF. We examined patient, surgical, and hospital characteristics. Multivariable logistic regression models were used to control for selected variables. All statistical tests were two-sided. Patients were derived from the Premier Healthcare Database. International classification of disease (ICD)-9 (<2014), ICD-10 (≥2015), and Current Procedural Terminology (CPT) codes were used to identify patient diagnoses and encounters. The population consisted of 138,151 patients who underwent RC for bladder cancer between 1 January 2000 and 31 December 2019. Results: Of 138,151 patients, 24,922 (18.0%) were admitted to CRFs. Multivariate analysis revealed that older age, single/widowed marital status, female gender, increased Charlson Comorbidity Index, Medicaid, and Medicare insurance are associated with CRF discharge. Rural hospital location, self-pay status, increased annual surgeon case, and robotic surgical approach are associated with home discharge. Conclusions: Several specific patient, surgical, and facility characteristics were identified that may significantly impact discharge disposition after RC for bladder cancer.

Metastasis-Directed Radiation Therapy with Consolidative Intent for Oligometastatic Urothelial Carcinoma: A Systematic Review and Meta-Analysis

The management of patients with oligometastatic urothelial carcinoma (UC) represents an evolving field in uro-oncology, and the role of metastasis-directed therapies, including metastasectomy and metastasis-directed radiation therapy (MDRT), is gaining increasing attention. Herein, we summarize available evidence about the role of MDRT with consolidative intent in oligometastatic UC patients. A systematic review was performed in December 2021. Six studies involving 158 patients were identified. Most patients (n = 120, 90.2%) had a history of bladder cancer and the most frequent sites of metastases were lymph nodes (n = 61, 52.1%) followed by the lungs (n = 34, 29%). Overall, 144 metastases were treated with MDRT. Median follow-up ranged from 17.2 to 25 months. Local control rates ranged from 57% to 100%. Median Overall Survival (OS) ranged from 14.9 to 51.0 months and median progression-free survival ranged from 2.9 to 10.1 months. Rates of OS at one and two years ranged from 78.9% to 96% and from 26% to 63%, respectively. Treatment-related toxicity was recorded in few patients and in most cases a low-grade toxicity was evident. MDRT with consolidative intent represents a potential treatment option for selected patients with oligometastatic UC.

Impact of early postoperative creatinine increase on mid-term renal function after cystectomy

OBJECTIVES

To determine whether early acute kidney injury affects mid-term renal function, to identify risk factors for impaired mid-term renal function, and to highlight the evolution of plasma creatinine and estimated glomerular filtration rate in the first 12 months after cystectomy and urinary diversion.

METHODS

We conducted a single-center retrospective observational cohort study from 2000 to 2019. We included 900 consecutive patients undergoing cystectomy and urinary diversion. Patients with incomplete data and preoperative hemodialysis were excluded. Early acute kidney injury was defined as an increase in plasma creatinine of >50% or >26.5 μmol/L within 24 h after surgery. Multiple linear regression analysis was performed to model the association between risk factors and change in plasma creatinine and estimated glomerular filtration rate at 12 months.

RESULTS

Early acute kidney injury was diagnosed in 183/900 patients (20.3%) and was associated with significant mid-term plasma creatinine increase compared to preoperative value (+10.0 μmol/L [95% confidence interval -1.5, 25.0] vs +4.0 μmol/L [-7.0, 13.0]; P < 0.001). Similarly, a significant estimated glomerular filtration rate change was found (-11.2 mL/min [95% confidence interval -19.8, 0.6] vs -4.9 mL/min [-15.6, 5.3]; P < 0.001). In the linear regression model, early acute kidney injury increased creatinine at 12 months by 9.8% (estimated glomerular filtration rate: decrease by 6.2 mL/min), male sex by 12.0%. Limitations include retrospective analysis from prospectively assessed data.

CONCLUSIONS

Early acute kidney injury resulted in elevated plasma creatinine and decreased estimated glomerular filtration rate values 12 months postoperatively, albeit the clinical relevance remains questionable.