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Uysal D, Egen L, Grilli M, Wessels F, Lenhart M, Michel MS, Kriegmair MC, Kowalewski KF. Impact of perioperative blood transfusions on oncologic outcomes after radical cystectomy: A systematic review and meta-analysis of comparative studies. Surg Oncol 2021; 38:101592. [PMID: 33979750 DOI: 10.1016/j.suronc.2021.101592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/13/2021] [Accepted: 04/18/2021] [Indexed: 01/08/2023]
Abstract
This study aimed at systematically analyzing and evaluating the impact of perioperative blood transfusions (PBT) on oncologic outcomes of patients undergoing radical cystectomy for bladder cancer. This systematic review follows the recommendations of the Cochrane Handbook for Systematic Reviews and Interventions and was conducted in line with the PRISMA statement and the AMSTAR II criteria. A comprehensive database search was performed based on the PICO criteria. Two independent reviewers performed all screening steps and quality assessment. Risk of bias and certainty in evidence were assessed with the Newcastle Ottawa Scale for non-randomized trials and the GRADE approach. Of 1123 identified studies 20 were eligible for qualitative analysis and 15 for quantitative analysis reporting on 21,915 patients. Receiving a PBT was associated with an increased risk of all-cause mortality (hazard ratio (HR) [95% confidence interval (CI)]: 1.29 [1.18, 1.40]; p < 0.001), cancer-specific mortality (HR [CI]: 1.27 [1.15; 1.41]; p < 0.001) and disease recurrence (HR [CI]: 1.22 [1.12; 1.34]; p < 0.001). Subgroup analysis of transfusion timing revealed a significantly increased risk of mortality with intraoperative or combined intra- and postoperative transfusions compared to postoperative transfusion only for all three outcomes (p < 0.001). Leukocyte-depletion was associated with increased all-cause mortality, but not cancer-specific mortality. The administration of PBT negatively impacts oncological outcomes after radical cystectomy. Therefore, careful treatment indication and strict adherence to transfusion guidelines is encouraged in order to avoid adverse effects during the perioperative course.
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Affiliation(s)
- D Uysal
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - L Egen
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M Grilli
- Library, Medical Faculty Mannheim at Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - F Wessels
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M Lenhart
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M S Michel
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - M C Kriegmair
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - K F Kowalewski
- Department of Urology and Urosurgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Kukreja JB, Li R, Narayan VM, Lim A, Seif M, Wang X, Kamat A, Dinney C, Navai N. Oncologic Equipoise Between Robotic and Open Radical Cystectomy. J Endourol 2021; 35:1168-1176. [PMID: 33619985 DOI: 10.1089/end.2020.0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Our objective was to establish the incidence of positive surgical margins, recurrence patterns, and recurrence-free (RFS) and overall survival (OS) in a large cohort of patients undergoing robotic (robot-assisted radical cystectomy [RARC]) and open radical cystectomy (ORC). Materials and Methods: We performed a large retrospective cohort study at a high-volume academic tertiary referral center. Patients were those who underwent RC for bladder cancer from 2005 to 2017. Patients were allocated to ORC or RARC by patient and surgeon choice. Propensity matching and a multivariable analysis were performed to determine factors predictive of RFS and OS after RC. All analyses were done with SAS 9.4. Results: The study included 1885 patients, 13.5% of whom underwent RARC. There was no difference in positive soft tissue surgical margins (2.4% in ORC and 1.2% in RARC). There were no differences in recurrence patterns, nor in the severity of pathology distribution between the two cohorts. Peritoneal carcinomatosis was seen in 1.1% of ORC and 0.8% in RARC. Shorter RFS was associated with younger age (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.03-1.05, p < 0.001), neoadjuvant chemotherapy (HR 1.41, 95% CI 1.14-1.75, p = 0.002), higher pathologic stage (stage ≥T2 HR 2.45, 95% CI 1.91-3.16, p < 0.001), lymph node positivity at cystectomy (HR 1.92, 95% CI 1.50-2.47, p < 0.001), and positive surgical margins (HR 1.49, 95% CI 1.09-2.05, p = 0.01). RFS and OS did not differ by surgical approach (HR 1.04, 95% CI 0.83-1.30), p = 0.75 and (HR 0.89, 95% CI 0.67-1.19), p = 0.43, respectively. Conclusion: The data from this study support continued use of RARC as a safe oncologic procedure, with similar outcomes to ORC.
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Affiliation(s)
- Janet Baack Kukreja
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Division of Urology, University of Colorado, Denver, Colorado, USA
| | - Roger Li
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Division of Urology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Vikram M Narayan
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amy Lim
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mohamed Seif
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xuemei Wang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ashish Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Colin Dinney
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Neema Navai
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Abstract
The radical cystectomy (RC) for muscle-invasive bladder cancer is one of the most morbid and complex urologic procedures performed today. To avoid these complications, the partial cystectomy (PC) has been offered as an alternative in carefully selected patients as a means of achieving equal oncologic efficacy with less morbidity. Selection criteria should include solitary tumors without concomitant carcinoma in situ (CIS) and amenable to resection with 1–2 cm margins in a normally functioning bladder. In addition to the standard work-up, random bladder and prostatic biopsies may be performed. The PC can be performed through an open, laparoscopic, or robot-assisted approach, each with acceptable outcomes. A number of techniques have been developed to identify and resect the tumor completely with negative margins, while preventing tumor spillage within the abdomen. While there are no randomized trials, single institution series have demonstrated acceptable oncologic outcomes in appropriately selected patients. Therefore, offering PC in the appropriate candidate, including those patients who do not accept or are unfit for the associated morbidity of a RC, represents an acceptable alternative.
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Affiliation(s)
- Taylor C Peak
- Department of Urology, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Ashok Hemal
- Department of Urology, Wake Forest Baptist Health, Winston-Salem, NC, USA
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Gu Q, Xia J, Xu A, Zhang T, Wang Z. Robot-assisted radical cystectomy with totally intracorporeal neobladder diversion: perioperative, oncologic, and functional outcomes. Transl Androl Urol 2020; 9:2606-2615. [PMID: 33457233 PMCID: PMC7807315 DOI: 10.21037/tau-20-1075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Indexed: 11/17/2022] Open
Abstract
Background The use of robot-assisted radical cystectomy (RARC) has increased rapidly in the past decade. However, reports of intracorporeal neobladder diversion remain limited. This article aimed to provide the surgical steps for RARC with totally intracorporeal neobladder diversion and the present perioperative, oncologic, and functional outcomes. Methods Between June 2017 and January 2020, RARC with intracorporeal neobladder diversion was performed in 12 male patients. Perioperative variables, pathologic data, early and late complications, urinary continence, potency, and recurrence-free survival were evaluated as outcome measures. Results The surgery was successful in all cases without open conversion. The median operative time, estimated blood loss, and postoperative hospital stay were 419 min (range, 315–640 min), 400 mL (range, 250–1,200 mL), and 14.5 days (range, 9–25 days), respectively. No positive surgical margins nor lymph nodes were observed. Eleven minor (grades 1 and 2) and one major (grades 3–5) complications were found in the early (0–30 days) period and six minor and one major complications in the late (>30 days) period. The median follow-up time was 13.1 months (range, 5.4–32.0 months), and two patients died due to metastatic disease. At 6 months after surgery, the daytime continence rate was 90.0%, while the nighttime continence rate was 80.0%. Only two patients (16.7%) reported capability of potency. The study was limited by a small sample size and short follow-up. Conclusions RARC with intracorporeal neobladder is a complex procedure but technically feasible with acceptable oncologic and functional outcomes. Studies with long-term follow ups and increased number of cases and randomized trials are indispensable to assess the potential of this technique.
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Affiliation(s)
- Qi Gu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiadong Xia
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Aiming Xu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tongtong Zhang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zengjun Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Tanneru K, Jazayeri SB, Kumar J, Alam MU, Norez D, Nguyen S, Bazargani S, Ganapathi HP, Bandyk M, Marino R, Koochekpour S, Gautam S, Balaji KC, Costa J. Intracorporeal versus extracorporeal urinary diversion following robot-assisted radical cystectomy: a meta-analysis, cumulative analysis, and systematic review. J Robot Surg 2021; 15:321-33. [PMID: 33222043 DOI: 10.1007/s11701-020-01174-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/11/2020] [Indexed: 12/29/2022]
Abstract
Over the last decade, the increased utilization of robot-assisted radical cystectomy (RARC) in the surgical treatment of muscle-invasive bladder cancer has led to an uptrend in intracorporeal urinary diversions (ICUD). However, the operative results comparing ICUD to extracorporeal urinary diversion (ECUD) have varied widely. We performed a meta-analysis to analyze perioperative outcomes and complications of ICUD compared to ECUD following RARC. This study is registered at International Prospective Register of Systematic Reviews (PROSPERO) CRD42020164074. A systematic literature review was conducted using PubMed, EMBASE, and Cochrane databases in August 2019. A total of six studies comparing ICUD vs ECUD were identified and meta-analysis was conducted on these studies. In addition, a cumulative analysis was also performed on 83 studies that reported perioperative outcomes after RARC and ICUD or ECUD. The Weighed Mean Difference of operative time and blood loss between ICUD and ECUD group was (16; 95% confidence interval - 34 to 66) and (- 86; 95% confidence interval - 124 to - 48), respectively. ICUD and ECUD had comparable early (30-day) and mid-term (30-90-day) complication rate (RR 1.19; 95% confidence interval 0.71-2.0; p = 0.5) and (RR 0.91; 95% confidence interval 0.71-1.15 p = 0.4) respectively. In the 83 studies that were included in the cumulative analysis, the mean operative time for ileal conduit and neobladders by ICUD were 307 and 428 min, respectively, compared to ECUD 428 and 426 min, respectively. ICUD and ECUD have comparable short- and mid-term complication rate. The ICUD group has lower blood loss and lower rate of blood transfusion compared to ECUD.
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Khan MS, Omar K, Ahmed K, Gan C, Van Hemelrijck M, Nair R, Thurairaja R, Rimington P, Dasgupta P. Long-term Oncological Outcomes from an Early Phase Randomised Controlled Three-arm Trial of Open, Robotic, and Laparoscopic Radical Cystectomy (CORAL). Eur Urol 2020; 77:110-8. [PMID: 31740072 DOI: 10.1016/j.eururo.2019.10.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Brassetti A, Cacciamani G, Anceschi U, Ferriero M, Tuderti G, Miranda G, Mastroianni R, Desai M, Aron M, Gill I, Gallucci M, Simone G. Long-term oncologic outcomes of robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD): a multi-center study. World J Urol 2019; 38:837-843. [PMID: 31190152 DOI: 10.1007/s00345-019-02842-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/03/2019] [Indexed: 01/16/2023] Open
Abstract
PURPOSE To report survival outcomes after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) for recurrent/muscle-invasive non-metastatic bladder cancer. METHODS Prospectively maintained databases were queried for "robotic cystectomy AND ICUD". Patients treated after October 2013 and those treated without curative intent were excluded. Kaplan-Meier method was used to plot stage-specific survival outcomes, computed at 1, 2, and 5 years after surgery. Univariable and multivariable Cox analyses assessed predictors of recurrence-free (RFS), cancer-specific (CSS) and overall (OS) survival. RESULTS 113 consecutive patients were included, mostly men (82%). Neoadjuvant chemotherapy was performed in 23% of cases, median lymph node (LN) yield was 36 (IQR 28-45) and the rate of positive surgical margins (PSM) was 8%. Orthotopic ileal neobladder was the preferred ICUD type (57%). An organ-confined disease was observed in 51% of cases and 21% were pT0 on final histology. Overall, 5-year RFS, CSS and OS probabilities were 58 ± 5%, 61 ± 5% and 54 ± 5%, respectively. At Kaplan-Meier method, tumor stage group was a significant predictor of survival probabilities (all p < 0.001) and this was confirmed at multivariable Cox regression analysis (RFS-OR 2.29; 95% CI 1.58-3.32; p < 0.001) (CSS-OR 1.82; 95% CI 1.3-2.53; p < 0.001) (OS-OR 2.14; 95% CI 1.46-3.14; p < 0.001). PSM status was associated to CSS (OR 2.54; 95% CI 1.13-5.69; p = 0.024) and OS (OR 2.82; 95% CI 1.17-6.77; p = 0.021), but did not predict RFS (p = 0.062). CONCLUSIONS Long-term oncologic outcomes after RARC with ICUD appear similar to recent robotic series with extracorporeal diversion and historical open experiences.
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Affiliation(s)
- Aldo Brassetti
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy.
| | - Giovanni Cacciamani
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Umberto Anceschi
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | | | - Gabriele Tuderti
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Gus Miranda
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Riccardo Mastroianni
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Mihir Desai
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Monish Aron
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Inderbir Gill
- Department of Urology, University of Southern California, Los Angeles, CA, USA
| | - Michele Gallucci
- Department of Urology, "Sapienza" University of Rome, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
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Lee CU, Kang M, Kim TJ, Na JP, Sung HH, Jeon HG, Seo SI, Jeon SS, Lee HM, Jeong BC. Predictors of postoperative complications after robot-assisted radical cystectomy with extracorporeal urinary diversion. Cancer Manag Res 2019; 11:5055-5063. [PMID: 31213917 PMCID: PMC6549423 DOI: 10.2147/cmar.s199432] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 03/26/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose: Robot-assisted radical cystectomy (RARC) is known to have less postoperative morbidity and complications than open radical cystectomy. However, various complications not yet have been reported after RARC. In this study, we aimed to identify the predictors of complications following RARC. Patients and methods: From August 2008 to November 2017, we retrospectively reviewed 126 patients who underwent RARC with extracorporeal urinary diversion. Overall perioperative complications were examined, and factors that may affect complications were analyzed using a logistic regression model. Complications were classified according to the Clavien-Dindo system. Results: Overall postoperative complications occurred in 78 (61.9%) of 126 patients. Whereas the rate of minor complications was 58.0% (grade I=15.9% (n=20), grade II=42.1% (n=53)), the rate of major complications was very low (grade IIIa=1.6% (n=2), grade IIIb =2.4% (n=3)). No fatal complications more than grade IV were developed. Notably, transfusions (27.0%), urinary tract infection (15.9%), anastomosis site leakage (14.3%), and ileus (10.3%) were the most common complications after RARC. In the multivariate regression model, previous intravesical instillation (odds ration [OR]=3.374), preoperative hemoglobin (OR=0.751), and estimated blood loss (EBL) (OR=3.949) were identified as the predictors of postoperative complications. Conclusion: In sum, our data showed the rates of major complications were comparable after RARC with extracorporeal urinary diversion compared as reported in previous studies and lower major than minor complications following RARC. Moreover, we identified the independent predictors of postoperative complications, such as preoperative hemoglobin, intravesical instillation, and EBL.
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Affiliation(s)
- Chung Un Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Minyong Kang
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Jin Kim
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jun Phil Na
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Hwan Sung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hwang Gyun Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seong Il Seo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seong Soo Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyun Moo Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Furrer MA, Huesler J, Fellmann A, Burkhard FC, Thalmann GN, Wuethrich PY. The Comprehensive Complication Index CCI: A proposed modification to optimize short-term complication reporting after cystectomy and urinary diversion. Urol Oncol 2019; 37:291.e9-291.e18. [PMID: 30638668 DOI: 10.1016/j.urolonc.2018.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/05/2018] [Accepted: 12/16/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To optimize complication reporting in patients undergoing cystectomy and urinary diversion (UD) using the Comprehensive Complication Index (CCI). The original CCI ranging from 0 (no complications) to 100 (death) integrates all complications weighted by severity over time in a single formula. However, due to the large number of complications after cystectomy and UD, the CCI may exceed the upper limit. METHODS In an observational single-center cohort, 90-day postoperative complications in 1,313 consecutive patients undergoing cystectomy and UD from 2000 to 2017 were evaluated. Prospectively collected complications were graded according to the Clavien-Dindo classification (CDC). A modified Berne CCI was developed using an exponential function, which transforms the sum of the weights into a value between 0 and 100. The correlation between the Berne and original CCI values was depicted graphically. Finally, original CCI and Berne CCI values for each patient were extracted and compared. Predictive values of CCI scores for mortality or severe complications (CDC ≥IV) within 1 year postoperatively were investigated by use of multiple logistic regression analyses. RESULTS Overall complication rate was 82%, with CDC grade I to II in 56% and CDC grade IIIa to V in 27% respectively. Applying the original CCI, the upper limit was exceeded in 8 patients, with a maximal value of 119.1 (median 25.7 [interquartile range: 20.9-37.2]). The maximal value of the Berne CCI was 99.4 (21.2 [14.6-39.3]) for nondeath cases. The Berne CCI predicted the onset of death and severe complications between postoperative day 91 and 365 (both P <0.0001), whereas the original CCI was only predictive in interaction with other variables but not alone (P = 0.2772 and P = 0.0862, respectively). CONCLUSION The optimized Berne CCI depicts postoperative morbidity and burden within 90 days after cystectomy and UD without exceeding the upper index limit. It is specifically suited for longitudinal assessment of complications after cystectomy and UD taking into consideration every single complication and corresponding treatment. As the Berne CCI well predicted the onset of mortality and severe complications within 1 year postoperatively, this may allow a better preoperative patient counselling. It therefore warrants consideration for standardized reporting of complications after cystectomy and UD.
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Affiliation(s)
- Marc A Furrer
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Juerg Huesler
- Institute of Mathematical Statistics and Actuarial Science, University of Bern, Bern, Switzerland
| | - Adrian Fellmann
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fiona C Burkhard
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - George N Thalmann
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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11
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Peak T, Chapple A, Coon G, Hemal A. Semi-competing risk model to predict perioperative and oncologic outcomes after radical cystectomy. Ther Adv Urol 2018; 10:317-326. [PMID: 30344643 DOI: 10.1177/1756287218791412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/18/2018] [Indexed: 11/16/2022] Open
Abstract
Background To utilize a semi-competing risk model to predict perioperative and oncologic outcomes after radical cystectomy and to compare the findings with the univariate Cox regression model. Methods We reviewed the Institutional Review Board approved database of radical cystectomy of 316 patients who had undergone robot-assisted radical cystectomy (RARC) or open radical cystectomy between 2006 and 2016. Demographic data, perioperative outcomes, complications, metastasis, and survival were analyzed. The Bayesian variable selection method was utilized to obtain models for each hazard function in the semi-competing risks. Results Of 316 patients treated, 48% and 18% experienced any or major complication respectively within 30 days. Intracorporeal RARC was associated with decreased metastasis risk. Extracorporeal RARC was associated with marginally decreased risks of overall complications or major complications. Patients with advanced cancer had an increased risk of metastasis, death after metastasis and death after complication. Positive nodes were associated with an increased risk of death without overall or major complications and increased risk of death after metastasis occurs. When a serious complication was taken into account there was no significant difference in mortality, irrespective of disease stage. Conclusions A semi-competing risk model provides relatively more accurate information in comparison to Cox regression analysis in predicting risk factors for complications and metastasis in patients undergoing radical cystectomy.
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Affiliation(s)
- Taylor Peak
- Urology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Andrew Chapple
- Statistics, Rice University Wiess School of Natural Sciences, Houston, TX, USA
| | - Grayson Coon
- Urology, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Ashok Hemal
- Department of Urology, Wake Forest Baptist Medical Center, 1 Medical Center Blvd, Winston-Salem, NC, USA
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12
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Sargos P, Baumann BC, Eapen L, Christodouleas J, Bahl A, Murthy V, Efstathiou J, Fonteyne V, Ballas L, Zaghloul M, Roubaud G, Orré M, Larré S. Risk factors for loco-regional recurrence after radical cystectomy of muscle-invasive bladder cancer: A systematic-review and framework for adjuvant radiotherapy. Cancer Treat Rev 2018; 70:88-97. [PMID: 30125800 DOI: 10.1016/j.ctrv.2018.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Radical cystectomy (RC) associated with pelvic lymph node dissection (PLND) is the most common local therapy in the management of non-metastatic muscle invasive bladder cancer (MIBC). Loco-regional recurrence (LRR), however, remains a common and important therapeutic challenge associated with poor oncologic outcomes. We aimed to systematically review evidence regarding factors associated with LRR and to propose a framework for adjuvant radiotherapy (RT) in patients with MIBC. METHODS We performed this systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We searched the PubMed database for articles related to MIBC and associated treatments, published between January 1980 and June 2015. Articles identified by searching references from candidate articles were also included. We retrieved 1383 publications from PubMed and 34 from other sources. After an initial screening, a review of titles and abstracts, and a final comprehensive full text analysis of papers assessed for eligibility, a final consensus on 32 studies was obtained. RESULTS LRR is associated with specific patient-, tumor-, center- or treatment-related variables. LRR varies widely, occurring in as many as 43% of the cases and is strongly related to survival outcomes. While perioperative treatment does not impact on LRR, pathological factors such as pT, pN, positive margins status, extent of PLND, number of lymph nodes removed and/or invaded are correlated with LRR. Patients with pT3-T4a and/or positive lymph-nodes and/or limited pelvic lymph-node dissection and/or positive surgical margins have been distributed in LRR risk groups with accuracy. CONCLUSIONS LRR patterns are well-known and for selected patients, adjuvant treatments could target this event. Intrinsic tumor subtype may guide future criteria to define a personalized treatment strategy. Prospective trials evaluating safety and efficacy of adjuvant RT are ongoing in several countries.
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Affiliation(s)
- Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, F-33076 Bordeaux Cedex, France.
| | - Brian C Baumann
- Department of Radiation Oncology, Washington University, St. Louis, Washington, MO 63110, United States
| | - Libni Eapen
- Department of Radiation Oncology, Ottawa Hospital, K1H 8L6 Ottawa, ON, Canada
| | - John Christodouleas
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, 19104-6021 Philadelphia, PA, United States
| | - Amhit Bahl
- Department of Radiation Oncology, University Hospitals Bristol, Bristol BS2 8HW, United Kingdom
| | - Vedang Murthy
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra 400012, India
| | - Jason Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Valérie Fonteyne
- Department of Radiotherapy, Ghent University Hospital, 9000 Ghent, Belgium
| | - Leslie Ballas
- Department of Radiation Oncology, USC Norris Comprehensive Cancer Center, Keck School of Medicine, Los Angeles, CA 90033, United States
| | - Mohamed Zaghloul
- Children's Cancer Hospital Egypt, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Guilhem Roubaud
- Department of Medical Oncology, Institut Bergonié, F-33076 Bordeaux Cedex, France
| | - Mathieu Orré
- Department of Radiation Oncology, Institut Bergonié, F-33076 Bordeaux Cedex, France
| | - Stéphane Larré
- Department of Urology, Centre Hospitalier Universitaire de Reims, F-51092 Reims, France
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13
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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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14
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Abstract
Robot-assisted radical cystectomy (RARC) has seen remarkable growth in the last decade. Despite a low level of evidence, numerous publications reporting on outcomes after RARC are now available. While definitive data on the long-term oncologic safety and efficacy of this technique are still lacking, similar oncological and functional outcomes compared to open radical cystectomy (ORC) have been reported. Several studies have also reported on atypical recurrences after RARC, including peritoneal carcinomatosis, extra-pelvic lymph node metastasis and port-site metastasis. While distant metastases overall do not appear to be affected by technique, it is possible that RARC may be associated with an increased risk of some atypical recurrences and this should be prospectively studied in RARC. However, atypical recurrences are rare events and are infrequent in their description. To date, there is no convincing evidence that, in the hands of equally experienced surgeons who treat bladder cancer routinely, a skillfully performed RARC is less oncologically efficacious than a skillfully performed ORC.
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Affiliation(s)
- François Audenet
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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15
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Hong X, Li T, Ling F, Yang D, Hou L, Li F, Tan W. Impact of surgical margin status on the outcome of bladder cancer treated by radical cystectomy: a meta-analysis. Oncotarget 2017; 8:17258-17269. [PMID: 27791991 PMCID: PMC5370038 DOI: 10.18632/oncotarget.12907] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [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: 04/29/2016] [Accepted: 10/14/2016] [Indexed: 01/24/2023] Open
Abstract
Data regarding the association between surgical margin status and the outcome of bladder cancer treated by radical cystectomy (RC) are conflicting. Therefore, the present meta-analysis was performed to assess the associations between the outcomes of bladder cancer, in terms of recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS), and the presence of positive surgical margins versus negative surgical margins following treatment with RC. Research articles published prior to April 2016 were identified from Pubmed, Embase and the Cochrane Library databases. A total of 36 articles were included, with a sample size of 38,384 bladder cancer patients. Of these, 4,354 patients were reported to have positive surgical margins. Significant associations were detected between positive surgical margins following RC and unfavorable RFS [summary relative risk estimate (SRRE), 1.63; 95% confidence interval (CI), 1.46-1.83; P = 0.105], CSS (SRRE, 1.82; 95% CI, 1.63-2.04; P = 0.001) and OS (SRRE, 1.68; 95% CI, 1.58-1.80; P = 0.805), by fixed or random effects models. The findings were consistent independently of age, sample size, publication year, follow-up duration, study type and geographical region. In summary, the present findings demonstrate that the presence of positive surgical margins is associated with poor survival outcomes in bladder cancer following RC, indicating that avoidance of positive surgical margins during surgery is helpful to improve the prognosis of patients with bladder cancer.
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Affiliation(s)
- Xuwei Hong
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Tieqiu Li
- Department of Urology, The People's Hospital of Hunan Province, First Affiliated Hospital of Hunan Normal University, Changsha, P. R. China
| | - Fengsheng Ling
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Dashan Yang
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Lina Hou
- Department of Healthy Management, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Fei Li
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
| | - Wanlong Tan
- Department of Urology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P. R. China
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16
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Gandaglia G, Karl A, Novara G, de Groote R, Buchner A, D'Hondt F, Montorsi F, Stief C, Mottrie A, Gratzke C. Perioperative and oncologic outcomes of robot-assisted vs. open radical cystectomy in bladder cancer patients: A comparison of two high-volume referral centers. Eur J Surg Oncol 2016; 42:1736-1743. [DOI: 10.1016/j.ejso.2016.02.254] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/13/2016] [Accepted: 02/24/2016] [Indexed: 01/19/2023] Open
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17
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Abstract
The first urologic robotic program in the world was built at the Vattikuti Urology Institute, Henry Ford Hospital Detroit, Michigan, in 2000 under the vision of surgical innovator, Dr. Mani Menon for the radical prostatectomy. The robot-assisted radical prostatectomy continues being modified with techniques to improve perioperative and surgical outcomes. The application of robotic surgical technique has since been expanded to the bladder and upper urinary tract surgery. The evolution of surgical technique and its expansion of application will continue to improve quality, outcome parameters and experience for the patients.
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Affiliation(s)
- Wooju Jeong
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Ramesh Kumar
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Mani Menon
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
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18
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Adding C, Collins JW, Laurin O, Hosseini A, Wiklund NP. Enhanced recovery protocols (ERP) in robotic cystectomy surgery. Review of current status and trends. Curr Urol Rep 2015; 16:32. [PMID: 25850413 DOI: 10.1007/s11934-015-0497-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Open radical cystectomy with pelvic lymphadenectomy and urinary diversion is associated with a high complication rate. Robotic-assisted laparoscopic radical cystectomy is increasingly performed in many urologic surgical departments in an effort to reduce surgical stress and decrease perioperative morbidity. Robotic cystectomy survival studies demonstrate similar oncologic outcomes compared to the open procedure. Enhanced recovery protocols (ERP) after major surgery are multimodal perioperative interventions to reduce surgical stress, complications, and patient convalescence. Evidence for different ERP interventions are currently mainly from colorectal surgery and recently adapted to major urologic operations including cystectomy. Guidelines for perioperative care after open radical cystectomy for bladder cancer were recently published, but these recommendations may differ when considering a robotic approach. Therefore, we look at the current evidence for ERP in both open and robotic radical cystectomy and the potential for improving ERPs in robotic cystectomy by utilizing a totally intracorporeal robotic cystectomy approach. We also present the Karolinska ERP currently utilized in totally intracorporeal robotic cystectomy.
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19
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Gandaglia G, De Groote R, Geurts N, D'Hondt F, Montorsi F, Novara G, Mottrie A. Oncologic Outcomes of Robot-Assisted Radical Cystectomy: Results of a High-Volume Robotic Center. J Endourol 2015; 30:75-82. [PMID: 26401724 DOI: 10.1089/end.2015.0482] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE The aim of our study was to assess the oncologic outcomes of robot-assisted radical cystectomy (RARC) in patients with bladder cancer (BCa) treated in a high-volume robotic center. MATERIALS AND METHODS We retrospectively collected data of 155 consecutive patients who received RARC for urothelial BCa from January 2004 to May 2014. Kaplan-Meier analyses were used to assess time to recurrence, cancer-specific mortality (CSM) rate, and overall mortality rate. Uni- and multivariable Cox regression models addressed the predictors of recurrence and CSM. RESULTS Median follow-up for survivors was 42 months. Overall, 43%, 34%, 55%, and 18% of the patients had pT ≤1, pT2, pT3/4, and pN1-3 disease, respectively. Overall, 76% of the patients had high-grade disease at final pathology. The positive surgical margin rate was 9%. The 5-year recurrence-free, CSM-free, and overall survival estimates were 53.7%, 73.5%, and 65.2%, respectively. Among patients who experienced recurrence, 12.0%, 4.0%, and 84.0% had local, peritoneal, and distant recurrence, respectively. In multivariable Cox regression analyses, pathologic stage and nodal status represented independent predictors of recurrence and CSM (all p ≤ 0.04). CONCLUSIONS In a high-volume robotic center, RARC provides acceptable oncologic outcomes in patients with urothelial BCa. Tumor stage and nodal status represent independent predictors of recurrence and CSM in this setting.
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Affiliation(s)
- Giorgio Gandaglia
- 1 OLV Vattikuti Robotic Surgery Institute , Melle, Belgium .,2 Unit of Urology, Division of Oncology, URI, IRCCS Ospedale San Raffaele , Milan, Italy .,3 Department of Urology, Onze-Lieve-Vrouw Hospital , Aalst, Belgium
| | - Ruben De Groote
- 3 Department of Urology, Onze-Lieve-Vrouw Hospital , Aalst, Belgium
| | - Nicolas Geurts
- 3 Department of Urology, Onze-Lieve-Vrouw Hospital , Aalst, Belgium
| | | | - Francesco Montorsi
- 2 Unit of Urology, Division of Oncology, URI, IRCCS Ospedale San Raffaele , Milan, Italy
| | - Giacomo Novara
- 1 OLV Vattikuti Robotic Surgery Institute , Melle, Belgium .,4 Urology Clinic, Department of Surgery, Oncology, and Gastroenterology, University of Padua , Padua, Italy
| | - Alexandre Mottrie
- 1 OLV Vattikuti Robotic Surgery Institute , Melle, Belgium .,3 Department of Urology, Onze-Lieve-Vrouw Hospital , Aalst, Belgium
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20
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Wittig K, Chan K, Kawachi M, Wilson TG. Laparoscopic/robotic radical cystectomy and urinary diversion. Bladder Cancer 2015. [DOI: 10.1002/9781118674826.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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21
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Raza SJ, Wilson T, Peabody JO, Wiklund P, Scherr DS, Al-Daghmin A, Dibaj S, Khan MS, Dasgupta P, Mottrie A, Menon M, Yuh B, Richstone L, Saar M, Stoeckle M, Hosseini A, Kaouk J, Mohler JL, Rha KH, Wilding G, Guru KA. Long-term oncologic outcomes following robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol 2015; 68:721-8. [PMID: 25985883 DOI: 10.1016/j.eururo.2015.04.021] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 04/14/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Long-term oncologic data on patients undergoing robot-assisted radical cystectomy (RARC) are limited and based largely on single-institution series. OBJECTIVE Report survival outcomes of patients who underwent RARC ≥5 yr ago. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of the prospectively populated International Robotic Cystectomy Consortium multi-institutional database identified 743 patients with RARC performed ≥5 yr ago. Clinical, pathologic, and survival data at the latest follow-up were collected. Patients with palliative RARC were excluded. Final analysis was performed on 702 patients from 11 institutions in 6 countries. INTERVENTION RARC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Outcomes of interest, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were plotted using Kaplan-Meier survival curves. A Cox proportional hazards model was used to identify factors that predicted outcomes. RESULTS AND LIMITATIONS Pathologic organ-confined (OC) disease was found in 62% of patients. Soft tissue surgical margins (SMs) were positive in 8%. Median lymph node (LN) yield was 16, and 21% of patients had positive LNs. Median follow-up was 67 mo (interquartile range: 18-84 mo). Five-year RFS, CSS, and OS were 67%, 75%, and 50%, respectively. Non-OC disease and SMs were associated with poorer RFS, CSS, and OS on multivariable analysis. Age predicted poorer CSS and OS. Adjuvant chemotherapy and positive SMs were predictors of RFS (hazard ratio: 3.20 and 2.16; p<0.001 and p<0.005, respectively). Stratified survival curves demonstrated poorer outcomes for positive SM, LN, and non-OC disease. Retrospective interrogation and lack of contemporaneous comparison groups that underwent open radical cystectomy were major limitations. CONCLUSIONS The largest multi-institutional series to date reported long-term survival outcomes after RARC. PATIENT SUMMARY Patients who underwent robot-assisted radical cystectomy for bladder cancer have acceptable long-term survival.
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Affiliation(s)
| | - Timothy Wilson
- City of Hope and Beckman Research Institute, Duarte, CA, USA
| | | | | | | | | | - Shiva Dibaj
- Roswell Park Cancer Institute, Buffalo, NY, USA
| | | | | | | | - Mani Menon
- Henry Ford Health System, Detroit, MI, USA
| | - Bertram Yuh
- City of Hope and Beckman Research Institute, Duarte, CA, USA
| | - Lee Richstone
- Arthur Smith Institute for Urology, New Hyde Park, NY, USA
| | | | | | | | - Jihad Kaouk
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Koon-Ho Rha
- Yonsei University Health Systems Severance Hospital, Seoul, Korea
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Janda GM, Woods ME, Pruthi RS. Practical tips for safe and efficient robotic cystectomy. Curr Urol Rep 2015; 16:37. [PMID: 25917231 DOI: 10.1007/s11934-015-0514-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Robotic-assisted radical cystectomy (RARC) is a challenging procedure that potentially offers the patient decreased perioperative morbidity. With careful patient selection and attention to surgical detail, one can learn to efficiently and safely perform RARC with extracorporeal diversion. As one develops further expertise with RARC, patient selection criteria can be liberalized and intracorporeal diversion can be performed. The accumulated experience of our institution and other high-volume institutions are reviewed with attention to the technical details that yield a safe and efficient robotic cystectomy.
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Affiliation(s)
- Gregory M Janda
- Department of Urology, University of North Carolina at Chapel Hill, 170 Manning Drive, 2113 Physicians Office Building, CB#7235, Chapel Hill, NC, 27599-7235, USA,
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Yuh B, Chan K, Lau C, Wilson T. Variable recurrence patterns after cystectomy in bladder cancer: can the robot be blamed? Eur Urol 2015; 68:406-7. [PMID: 25900783 DOI: 10.1016/j.eururo.2015.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/03/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Bertram Yuh
- Division of Urologic Oncology, City of Hope National Cancer Center, Duarte, CA, USA.
| | - Kevin Chan
- Division of Urologic Oncology, City of Hope National Cancer Center, Duarte, CA, USA
| | - Clayton Lau
- Division of Urologic Oncology, City of Hope National Cancer Center, Duarte, CA, USA
| | - Timothy Wilson
- Division of Urologic Oncology, City of Hope National Cancer Center, Duarte, CA, USA
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Yuh B, Wilson T, Bochner B, Chan K, Palou J, Stenzl A, Montorsi F, Thalmann G, Guru K, Catto JW, Wiklund PN, Novara G. Systematic Review and Cumulative Analysis of Oncologic and Functional Outcomes After Robot-assisted Radical Cystectomy. Eur Urol 2015; 67:402-22. [DOI: 10.1016/j.eururo.2014.12.008] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 11/20/2022]
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25
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Wilson TG, Guru K, Rosen RC, Wiklund P, Annerstedt M, Bochner BH, Chan KG, Montorsi F, Mottrie A, Murphy D, Novara G, Peabody JO, Palou Redorta J, Skinner EC, Thalmann G, Stenzl A, Yuh B, Catto J; Pasadena Consensus Panel. Best practices in robot-assisted radical cystectomy and urinary reconstruction: recommendations of the Pasadena Consensus Panel. Eur Urol 2015; 67:363-75. [PMID: 25582930 DOI: 10.1016/j.eururo.2014.12.009] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 12/03/2014] [Indexed: 12/20/2022]
Abstract
CONTEXT Robot-assisted surgery is increasingly used for radical cystectomy (RC) and urinary reconstruction. Sufficient data have accumulated to allow evidence-based consensus on key issues such as perioperative management, comparative effectiveness on surgical complications, and oncologic short- to midterm outcomes. OBJECTIVE A 2-d conference of experts on RC and urinary reconstruction was organized in Pasadena, California, and the City of Hope Cancer Center in Duarte, California, to systematically review existing peer-reviewed literature on robot-assisted RC (RARC), extended lymphadenectomy, and urinary reconstruction. No commercial support was obtained for the conference. EVIDENCE ACQUISITION A systematic review of the literature was performed in agreement with the PRISMA statement. EVIDENCE SYNTHESIS Systematic literature reviews and individual presentations were discussed, and consensus on all key issues was obtained. Most operative, intermediate-term oncologic, functional, and complication outcomes are similar between open RC (ORC) and RARC. RARC consistently results in less blood loss and a reduced need for transfusion during surgery. RARC generally requires longer operative time than ORC, particularly with intracorporeal reconstruction. Robotic assistance provides ergonomic value for surgeons. Surgeon experience and institutional volume strongly predict favorable outcomes for either open or robotic techniques. CONCLUSIONS RARC appears to be similar to ORC in terms of operative, pathologic, intermediate-term oncologic, complication, and most functional outcomes. RARC consistently results in less blood loss and a reduced need for transfusion during surgery. RARC can be more expensive than ORC, although high procedural volume may attenuate this difference. PATIENT SUMMARY Robot-assisted radical cystectomy (RARC) is an alternative to open surgery for patients with bladder cancer who require removal of their bladder and reconstruction of their urinary tract. RARC appears to be similar to open surgery for most important outcomes such as the rate of complications and intermediate-term cancer-specific survival. Although RARC has some ergonomic advantages for surgeons and may result in less blood loss during surgery, it is more time consuming and may be more expensive than open surgery.
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Novara G, Catto JWF, Wilson T, Annerstedt M, Chan K, Murphy DG, Motttrie A, Peabody JO, Skinner EC, Wiklund PN, Guru KA, Yuh B. Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 2015; 67:376-401. [PMID: 25560798 DOI: 10.1016/j.eururo.2014.12.007] [Citation(s) in RCA: 301] [Impact Index Per Article: 33.4] [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: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 12/21/2022]
Abstract
CONTEXT Although open radical cystectomy (ORC) is still the standard approach, laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) have gained popularity. OBJECTIVE To report a systematic literature review and cumulative analysis of perioperative outcomes and complications of RARC in comparison with ORC and LRC. EVIDENCE ACQUISITION Medline, Scopus, and Web of Science databases were searched using a free-text protocol including the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy. RARC case series and studies comparing RARC with either ORC or LRC were collected. Cumulative analysis was conducted. EVIDENCE SYNTHESIS The searches retrieved 105 papers. According to the different diversion type, overall mean operative time ranged from 360 to 420 min. Similarly, mean blood loss ranged from 260 to 480 ml. Mean in-hospital stay was about 9 d for all diversion types, with consistently high readmission rates. In series reporting on RARC with either extracorporeal or intracorporeal conduit diversion, overall 90-d complication rates were 59% (high-grade complication: 15%). In series reporting RARC with intracorporeal continent diversion, the overall 30-d complication rate was 45.7% (high-grade complication: 28%). Reported mortality rates were ≤3% for all diversion types. Comparing RARC and ORC, cumulative analyses demonstrated shorter operative time for ORC, whereas blood loss and in-hospital stay were better with RARC (all p values <0.003). Moreover, 90-d complication rates of any-grade and 90-d grade 3 complication rates were lower for RARC (all p values <0.04), whereas high-grade complication and mortality rates were similar. CONCLUSIONS RARC can be performed safely with acceptable perioperative outcome, although complications are common. Cumulative analyses demonstrated that operative time was shorter with ORC, whereas RARC may provide some advantages in terms of blood loss and transfusion rates and, more limitedly, for postoperative complication rates over ORC and LRC. PATIENT SUMMARY Although open radical cystectomy (RC) is still regarded as a standard treatment for muscle-invasive bladder cancer, laparoscopic and robot-assisted RC are becoming more popular. Robotic RC can be safely performed with acceptably low risk of blood loss, transfusion, and intraoperative complications; however, as for open RC, the risk of postoperative complications is high, including a substantial risk of major complication and reoperation.
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Affiliation(s)
- Giacomo Novara
- Department of Surgery, Oncology, and Gastroenterology - Urology Clinic, University of Padua, Italy.
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | | | | | - Kevin Chan
- City of Hope National Cancer Center Duarte, CA, USA
| | - Declan G Murphy
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, St. Andrews Place, East Melbourne, Victoria, Australia
| | | | - James O Peabody
- Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA
| | - Eila C Skinner
- Department of Urology, Stanford University, Stanford, CA, USA
| | | | - Khurshid A Guru
- Department of Urology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Bertram Yuh
- City of Hope National Cancer Center Duarte, CA, USA
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Affiliation(s)
- Clayton Stephen Lau
- Division of Urologic Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Robert H Blackwell
- Department of Urology, Loyola University Medical Center, Maywood, Illinois
| | - Marcus L Quek
- Department of Urology, Loyola University Medical Center, Maywood, Illinois
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