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Leow JJ, Catto JWF, Efstathiou JA, Gore JL, Hussein AA, Shariat SF, Smith AB, Weizer AZ, Wirth M, Witjes JA, Trinh QD. Quality Indicators for Bladder Cancer Services: A Collaborative Review. Eur Urol 2020; 78:43-59. [PMID: 31563501 DOI: 10.1016/j.eururo.2019.09.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/03/2019] [Indexed: 12/14/2022]
Abstract
CONTEXT There is a lack of accepted consensus on what should constitute appropriate quality-of-care indicators for bladder cancer. OBJECTIVE To evaluate the optimal management of bladder cancer and propose quality indicators (QIs). EVIDENCE ACQUISITION A systematic review was performed to identify literature on current optimal management and potential quality indicators for both non-muscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer. A panel of experts was convened to select a recommended list of QIs. EVIDENCE SYNTHESIS For NMIBC, preoperative QIs include tobacco cessation counselling and appropriate imaging before initial transurethral resection of bladder tumour (TURBT). Intraoperative QIs include administration of antibiotics, proper safe conduct of TURBT using a checklist, and performing restaging TURBT with biopsy of the prostatic urethra in appropriate cases. Postoperative QIs include appropriate receipt of perioperative adjuvant therapy, risk-stratified surveillance, and appropriate decision to change therapy when indicated (eg, bacillus Calmette-Guerin [BCG] unresponsive). For MIBC, preoperative QIs include multidisciplinary care, selection for candidates for continent urinary diversion, receipt of neoadjuvant cisplatin-based chemotherapy, time to commencing radical treatment, consideration of trimodal therapy as a bladder-sparing alternative in select patients, preoperative counselling with stoma marking, surgical volume of radical cystectomy, and enhanced recovery after surgery protocols. Intraoperative QIs include adequacy of lymphadenectomy, blood loss, and operative time. Postoperative QIs include prospective standardised monitoring of morbidity and mortality, negative surgical margins for pT2 disease, appropriate surveillance after primary treatment, and adjuvant cisplatin-based chemotherapy in appropriate cases. Participation in clinical trials was highlighted as an important component indicating high quality of care. CONCLUSIONS We propose a set of QIs for both NMIBC and MIBC based on established clinical guidelines and the available literature. Although there is currently a lack of level 1 evidence for the benefit of implementing these QIs, we believe that the measurement of these QIs could aid in the improvement and benchmarking of optimal care for bladder cancer. PATIENT SUMMARY After a systematic review of existing guidelines and literature, a panel of experts has recommended a set of quality indicators that can help providers and patients measure and strive towards optimal outcomes for bladder cancer care.
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Affiliation(s)
- Jeffrey J Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James W F Catto
- Academic Urology Unit, The University of Sheffield, Sheffield, UK
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John L Gore
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
| | - Ahmed A Hussein
- Department of Urology, Cairo University, Cairo, Egypt; Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Departments of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Angela B Smith
- Department of Urology, Lineberger Comprehensive Cancer Center, UNC-Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Alon Z Weizer
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Manfred Wirth
- Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - J Alfred Witjes
- Department of Urology, Radboud University, Nijmegen, The Netherlands
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Kolwijck E, Seegers AEM, Tops SCM, van der Heijden AG, Sedelaar JPM, Ten Oever J. Incidence and microbiology of post-operative infections after radical cystectomy and ureteral stent removal; a retrospective cohort study. BMC Infect Dis 2019; 19:303. [PMID: 30943902 PMCID: PMC6448312 DOI: 10.1186/s12879-019-3932-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-operative infections are frequent after radical cystectomy with urinary diversion surgery (UDS). Reduction of post-operative infections necessitates appropriate peri-operative antimicrobial prophylaxis targeting causative bacteria. We assessed the incidence and microbiology of infections in the 30-day post-operative period after UDS and investigated effectiveness of the currently used peri-operative antibacterial prophylaxis. METHODS Retrospective cohort study of all patients undergoing UDS in a tertiary university medical center from January 2014 until September 2016. Antibiotic prophylaxis consisted of cefazolin plus metronidazol according to the Dutch national guideline. Primary outcome was the incidence of post-operative infections within 30 days. Risk factors for post-operative infections and antimicrobial susceptibility profiles of cultured bacteria were also assessed. RESULTS 147 patients were included. 69 patients (46.9%) had 82 post-operative infections, 27 of which were patients with bacteremia (18.4%). Highest incidence of infections was on day 4-5 and on day 8-10 postoperatively. The second peak was associated with ureteral stent removal. 4.8% of 147 study patients developed bacteremia 24 h after stent removal, which counted for 25.9% of all bacteremia episodes found in this study. Enterobacteriaceae were cultured in 67.9% of blood cultures and were only highly susceptible to ciprofloxacine, piperacillin-tazobactam (90%), meropenem and gentamicin (100%). Multivariate logistic regression analysis showed orthotopic Hautmann neobladder to be associated with increased infections complications: odds ratio 4.1 (95% confidence interval 1.6-10.5), p = 0.03. CONCLUSIONS The incidence of infections after radical cystectomy is high and particularly ureteral stent removal was associated with both bacteremia and complicated urinary tract infections. Based on the results of this study, antibiotic prophylaxis might need to be broadened for patients undergoing radical cystectomy. Further research is required to investigate whether current guidelines need to be altered concerning administration of antibiotic prophylaxis just before stent removal.
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Affiliation(s)
- E Kolwijck
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands. .,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - A E M Seegers
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - S C M Tops
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - A G van der Heijden
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J P M Sedelaar
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J Ten Oever
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
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Kolwijck E, Seegers AEM, Tops SCM, van der Heijden AG, Sedelaar JPM, Ten Oever J. Incidence and microbiology of post-operative infections after radical cystectomy and ureteral stent removal; a retrospective cohort study. BMC Infect Dis 2019. [PMID: 30943902 DOI: 10.1186/s12879.019-3932-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-operative infections are frequent after radical cystectomy with urinary diversion surgery (UDS). Reduction of post-operative infections necessitates appropriate peri-operative antimicrobial prophylaxis targeting causative bacteria. We assessed the incidence and microbiology of infections in the 30-day post-operative period after UDS and investigated effectiveness of the currently used peri-operative antibacterial prophylaxis. METHODS Retrospective cohort study of all patients undergoing UDS in a tertiary university medical center from January 2014 until September 2016. Antibiotic prophylaxis consisted of cefazolin plus metronidazol according to the Dutch national guideline. Primary outcome was the incidence of post-operative infections within 30 days. Risk factors for post-operative infections and antimicrobial susceptibility profiles of cultured bacteria were also assessed. RESULTS 147 patients were included. 69 patients (46.9%) had 82 post-operative infections, 27 of which were patients with bacteremia (18.4%). Highest incidence of infections was on day 4-5 and on day 8-10 postoperatively. The second peak was associated with ureteral stent removal. 4.8% of 147 study patients developed bacteremia 24 h after stent removal, which counted for 25.9% of all bacteremia episodes found in this study. Enterobacteriaceae were cultured in 67.9% of blood cultures and were only highly susceptible to ciprofloxacine, piperacillin-tazobactam (90%), meropenem and gentamicin (100%). Multivariate logistic regression analysis showed orthotopic Hautmann neobladder to be associated with increased infections complications: odds ratio 4.1 (95% confidence interval 1.6-10.5), p = 0.03. CONCLUSIONS The incidence of infections after radical cystectomy is high and particularly ureteral stent removal was associated with both bacteremia and complicated urinary tract infections. Based on the results of this study, antibiotic prophylaxis might need to be broadened for patients undergoing radical cystectomy. Further research is required to investigate whether current guidelines need to be altered concerning administration of antibiotic prophylaxis just before stent removal.
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Affiliation(s)
- E Kolwijck
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands. .,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - A E M Seegers
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - S C M Tops
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of medical microbiology, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
| | - A G van der Heijden
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J P M Sedelaar
- Department of urology, Radboud university medical center, Nijmegen, the Netherlands
| | - J Ten Oever
- Radboud center for infectious diseases, Radboud university medical center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.,Department of internal medicine, Radboud university medical center, Nijmegen, the Netherlands
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