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McNicholas DP, El-Taji O, Siddiqui Z, Hanchanale V. Systematic review comparing uretero-enteric stricture rates between open cystectomy with ileal conduit, robotic cystectomy with extra-corporeal ileal conduit and robotic cystectomy with intra corporeal ileal conduit formation. J Robot Surg 2024; 18:100. [PMID: 38413496 PMCID: PMC10899269 DOI: 10.1007/s11701-024-01850-9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/28/2024] [Indexed: 02/29/2024]
Abstract
Cystectomy is the gold standard treatment for muscle invasive bladder cancer. Robotic cystectomy has become increasingly popular owing to quicker post- operative recovery, less blood loss and less post-operative pain. Urinary diversion is increasingly being performed with an intracorporeal technique. Uretero-enteric strictures (UES) cause significant morbidity for patients. UES for open cystectomy is 3-10%, but the range is much wider (0-25%) for robotic surgery. We aim to perform systematic review for studies comparing all 3 techniques, to assess for ureteric stricture rates. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (Page et al. in BMJ 29, 2021). PubMed, Scopus and Embase databases were searched for the period January 2003 to June 2023 inclusive for relevant publications.The primary outcome was to identify ureteric stricture rates for studies comparing open cystectomy and urinary diversion, robotic cystectomy with extracorporeal urinary diversion (ECUD) and robotic cystectomy with intracorporeal urinary diversion (ICUD). Three studies were identified and included 2185 patients in total. The open operation had the lowest stricture rate (9.6%), compared to ECUD (12.4%) and ICUD (15%). ICUD had the longest time to stricture (7.55 months), ECUD (4.85 months) and the open operation (4.75 months). Open operation had the shortest operating time. The Bricker anastomoses was the most popular technique. Open surgery has the lowest rates of UES compared to both robotic operations. There is a learning curve involved with performing robotic cystectomy and urinary diversion, this may need to be considered to decide whether the technique is comparable with open cystectomy UES rates. Further research, including Randomised Control Trials (RCT), needs to be undertaken to determine the best surgical option for patients to minimise risks of UES.
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Affiliation(s)
- Daniel P McNicholas
- The Royal Liverpool University Hospital, Mount Vernon St, Liverpool, L7 8YE, UK.
- University of Salford, 43 Crescent, Salford, M5 4WT, UK.
| | - Omar El-Taji
- The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, UK
| | - Zain Siddiqui
- The Royal Liverpool University Hospital, Mount Vernon St, Liverpool, L7 8YE, UK
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Tuderti G, Mastroianni R, Chiacchio G, Anceschi U, Bove AM, Brassetti A, Ferriero M, Misuraca L, Flammia RS, Proietti F, D'Annunzio S, Leonardo C, Guaglianone S, Anselmi M, Zampa A, Galosi AB, Torregiani G, Gallucci M, Simone G. Long-term oncologic and functional outcomes following robot-assisted radical cystectomy and intracorporeal Padua ileal bladder: results from a single high-volume center. World J Urol 2023; 41:2359-2366. [PMID: 37518504 DOI: 10.1007/s00345-023-04523-8] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/04/2023] [Indexed: 08/01/2023] Open
Abstract
PURPOSE To report long-term oncologic and functional outcomes of a large consecutive single center series of Robot-assisted radical cystectomy (RARC)- intracorporeal (IC) Urinary Diversion (UD), identifying their predicting factors. METHODS A single center Bladder cancer (BC) database was queried for "RARC" and "ICUD", including patients treated between January 2012 and September 2020. Kaplan-Meier curves were assessed disease-free (DFS), cancer-specific (CSS) and overall survival (OS) probability. Univariable (UV) and multivariable (MV) analysis were adopted to identify predictors of DFS, CSS and OS. Kaplan-Meier method evaluated day- and night-time continence recovery probabilities; UV and MV analysis were adopted to identify predictors of Day-time continence. RESULTS Overall, 251 patients were included. Among them, 192 patients underwent intracorporeal ileal orthotopic neobladder (ION) (76.5%). Five-year DFS, CSS and OS rates were 66.5%, 65.4% and 61.5%; pT stage ≥ 3 and pathologic nodal involvement were identified as negative independent predictors of DFS (HR 2.39, p = 0.001, HR 4.64, p ≤ 0.001), CSS (HR 2.20, p = 0.01, HR 3.97, p < 0.001) and OS (HR 2.25, p = 0.005, HR 3.95, p < 0.001). In RARC-ION patients, Trifecta rate was 64.1%. One-year day- and night-time continence rates were 78.6% and 48.3%. Age (HR 0.98, p = 0.03), female gender (HR 0.57, p = 0.008) and complications Clavien grade ≥ 3 (HR 0.55, p = 0.03) were identified as independent predictors of day-time incontinence. CONCLUSIONS Long-term oncologic outcomes and their predicting factors seem aligned to the largest historical open series and multi-institutional robotic series data. According to the identified predicting factors undermining a proper achievement of day-time continence, this represents an objective support, in order to properly advice specific sub-group of patients.
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Affiliation(s)
- Gabriele Tuderti
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy.
| | - Riccardo Mastroianni
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Giuseppe Chiacchio
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
- Urology Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Università Politecnica delle Marche, Ancona, Italy
| | - Umberto Anceschi
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Alfredo Maria Bove
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Aldo Brassetti
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Mariaconsiglia Ferriero
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Leonardo Misuraca
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Rocco Simone Flammia
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
- Department of Urology, "Sapienza" University of Rome, Rome, Italy
| | - Flavia Proietti
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Simone D'Annunzio
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Costantino Leonardo
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Salvatore Guaglianone
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Marianna Anselmi
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Ashanti Zampa
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Andrea Benedetto Galosi
- Urology Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Università Politecnica delle Marche, Ancona, Italy
| | - Giulia Torregiani
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Michele Gallucci
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Via Elio, Chianesi 53, Rome, Italy
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Bhanvadia RR, Khouri RK, Ashbrook C, Woldu SL, Margulis V, Raj GV, Bagrodia A. Safety, Efficacy, and Impact on Quality of Life of Palliative Robotic Cystectomy for Advanced Prostate Cancer. Clin Genitourin Cancer 2020; 19:e129-e134. [PMID: 33246846 DOI: 10.1016/j.clgc.2020.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/13/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Raj R Bhanvadia
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Roger K Khouri
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Caleb Ashbrook
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Solomon L Woldu
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Ganesh V Raj
- Department of Urology, University of Texas Southwestern, Dallas, TX
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern, Dallas, TX.
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Presicce F, Leonardo C, Tuderti G, Brassetti A, Mastroianni R, Bove A, Misuraca L, Anceschi U, Ferriero M, Gallucci M, Simone G. Late complications of robot-assisted radical cystectomy with totally intracorporeal urinary diversion. World J Urol 2020; 39:1903-1909. [PMID: 32747981 PMCID: PMC8217047 DOI: 10.1007/s00345-020-03378-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 05/27/2020] [Accepted: 07/20/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction and objectives To evaluate late complications in a large cohort of patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD). Materials and methods We prospectively enrolled patients who underwent RARC and ICUD between August 2012 and June 2019. We excluded patients with Ejection fraction < 36%, retinal vasculopathy, ventriculoperitoneal shunts, and those treated without curative intent. All complications and their onset date have been recorded, defined, and graded according to Clavien classification adapted for radical cystectomy. Results 210 patients were included, 76% of whom were men, with a mean age of 62 years. Urinary diversions used were Padua Ileal Bladder (PIB) in 80% of cases, and ileal conduit (IC) in 20% of patients (generally older and with more comorbidity). The mean follow-up was 30 ± 22 months. The stenosis rate of uretero-ileal anastomosis was 14%, while a reduction in eGFR (≥ 20%) was observed in about half of the cases. UTIs occurred in 37% of the patients, especially in the first 12 months. Only 2% of patients had bowel occlusion, whereas incisional hernia, lymphocele, and systemic events (metabolic acidosis and major cardiovascular events) occurred respectively in 20%, 10%, and 1% of cases. Conclusions Our study evaluates first late complications in a cohort of patients who underwent RARC with ICUD. These data are encouraging and in line with findings from a historical series of open radical cystectomy (ORC). This study is a further step in supporting RARC as a safe and effective surgical option for the treatment of muscle-invasive bladder cancer (MIBC) in tertiary referral centers. Electronic supplementary material The online version of this article (10.1007/s00345-020-03378-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- F Presicce
- Department of Urology, Sapienza - University of Rome, Via Alessandro Torlonia 12, Rome, Italy.
| | - C Leonardo
- Department of Urology, Sapienza - University of Rome, Via Alessandro Torlonia 12, Rome, Italy
| | - G Tuderti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - A Brassetti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - R Mastroianni
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - A Bove
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - L Misuraca
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - U Anceschi
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - M Ferriero
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - M Gallucci
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - G Simone
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
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Narayan VM, Seif MA, Lim AH, Li R, Matulay JT, Kukreja JB, Qiao W, Hwang H, Shah JB, Pisters L, Kamat AM, Dinney C, Navai N. Radical cystectomy in women: Impact of the robot-assisted versus open approach on surgical outcomes. Urol Oncol 2020; 38:247-254. [PMID: 31953001 DOI: 10.1016/j.urolonc.2019.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 07/14/2019] [Revised: 11/10/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To perform a comparison of complications following open versus robot-assisted radical cystectomy (RC) among women who undergo the procedure. Studies comparing robotic to open RC have been mixed without a clear delineation of which patients benefit the most from one modality vs. the other, leading to continued debate. PATIENTS AND METHODS This was a retrospective study of women who underwent either open or robotic RC at the MD Anderson Cancer Center from 1/2014 to 6/2018. Co-morbidities, pathologic data, and complications were assessed with descriptive statistics, along with uni- and multivariable logistic regression. RESULTS 122 women underwent either open (n = 76) or robotic (n = 46) RC. Open RC was associated with greater intraoperative blood loss (median EBL 775 ml vs. 300 ml, P < 0.001). In both uni- and multivariable analyses, open RC was associated with a greater odds of intraoperative transfusion compared to robotic RC (odds ratio 6.49, 95% CI 2.85-14.78, P < 0.001). Women undergoing open RC were also at greater odds of receiving 4 or more units of packed red blood cells (odds ratio 5.46 (1.75-17.02), P = 0.003). Robotic RC conferred a higher median lymph node yield (27 vs. 20 nodes, P, <0.001) and operative times (median 513 min vs. 391.5 min, P < 0.001). There were no differences in margin positivity, length of stay, or readmission rates at 30 and 90 days. CONCLUSIONS Robotic RC was associated with a significantly lower risk of transfusion and EBL, and a higher median lymph node yield and operative time. Unique anatomic considerations may in part be responsible for these findings.
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Affiliation(s)
- Vikram M Narayan
- Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mohamed A Seif
- Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amy H Lim
- Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roger Li
- Department of Urology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Justin T Matulay
- Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Janet B Kukreja
- Urology Division, Department of Surgery, University of Colorado School of Medicine, Denver, CO
| | - Wei Qiao
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hyunsoo Hwang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jay B Shah
- Department of Urology, Stanford University, Stanford, CA
| | - Louis Pisters
- Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ashish M Kamat
- Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Colin Dinney
- Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Neema Navai
- Department of Urology, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX.
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Abstract
Introduction and Objective Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) has become an increasingly utilized approach to treating various bladder pathologies requiring extirpation. As surgeons have become more experienced with ICUD, especially with lesser-used diversions such as continent cutaneous reservoirs, the technique has evolved. Methods We describe our technique and recent advances in the practical creation of robotic ICUD with a continent catheterizable pouch (CCP) built upon the open principles of the previously described “Indiana Pouch, ” which uses the distal ileum and right colon. Modifications in anatomic mobilization and exposure, bowel segmentation using novel robotic bowel staplers, catheterizable channel creation, and addition of ileal chimney for uretero-enteric anastomoses are highlighted. The addition of the ileal chimney allows for ease of reconstruction in a fashion familiar to surgeons accustomed to performing intracorporeal ileal conduit and, therefore, may result in lower ureteroenteric stricture rates. Table 1 demonstrates the supplies used intraoperatively. Use of indocyanine green to assess vascularity in bowel and ureter intraoperatively is demonstrated. The port configurations are demonstrated using the DaVinci ® Xi platform. Also described are short-term outcomes of our initial experience. Results Eleven consecutive patients (5 female) who have undergone ICUD with CCP were included. Of the eleven seven had malignant indications (bladder or urethral cancer) while 4 were for benign causes (2 radiation cystitis 2 interstitial cystitis). Mean blood loss was 235cc (range 100–500cc) and mean operative time was 8.5 h (range 7–13). There were no conversions to an open procedure and no patient required a blood transfusion. Hospital stay was 7.2 days on average (range 4–18) with no 30-day post-discharge readmissions. One patient had a Clavien grade 3 or greater complication at 30 days (Table 2). No urine leaks or bowel leaks were observed and no patien experienced stomal stenosis or uretero-enteric stenosis. At three months follow up, all patients were continent and satisfied with their diversion. Conclusions RARC with CCP ICUD is a safe and effective approach to bladder removal and reconstruction. As more surgeons utilize RARC, growing attention to techniques of intracorporeal reconstruction will allow further implementation of this technique to cystectomy patients. Patients with adequate renal function (glomerular filtration rate of 40 mL/min or greater) and hepatic function, who understand the requirement for regular clean intermittent-catheterization and who possess mental acuity and manual dexterity to empty their pouch 4–6 times daily should be offered CCP ICUD as a reconstructive option following RARC.
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Affiliation(s)
- Richard S Matulewicz
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gregory T Chesnut
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Chun C Huang
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alvin C Goh
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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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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Flamiatos JF, Chen Y, Lambert WE, Martinez Acevedo A, Becker TM, Bash JC, Amling CL. Open versus robot-assisted radical cystectomy: 30-day perioperative comparison and predictors for cost-to-patient, complication, and readmission. J Robot Surg 2019; 13:129-40. [PMID: 29948875 DOI: 10.1007/s11701-018-0832-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/03/2018] [Indexed: 12/29/2022]
Abstract
The objectives of this study are to evaluate if robotic cystectomy demonstrates reduced complications, readmissions, and cost-to-patient compared to open approach 30-day post-operatively, and to identify predictors of complication, readmission, and cost-to-patient. This retrospective cohort study analyzed 249 patients who underwent open (n = 149) or robotic (n = 100) cystectomy from 2009 to 2015 at our institution. Outcomes included 30-day post-operative complication, readmission, and cost-to-patient charges. We used modified Clavien-Dindo/MSKCC classifications. Multivariable logistic and linear regression models were used to evaluate associations to outcomes and to build predictive models. Patient, clinical, and surgical characteristics differed by open and robotic groups, respectively, only for estimated blood loss (median: 600 versus 150 cc, p < 0.01), operative time (mean: 6.19 versus 6.85 h, p < 0.01), and length of stay (median: 7 versus 5 days, p < 0.01). Complication: frequency of patients with at least one 30-day complication was 85% compared to 66% (p < 0.01). Minor gastrointestinal and bleeding complications were increased in the open group (50% versus 41%, p = 0.01; 52% versus 11%, p < 0.01, respectively). Fifty percent of patients required blood transfusion in open compared to 11% (p < 0.01). Patients in the open group experienced more major complications (19% versus 10%, p = 0.04). Robotic approach was a predictor for fewer complications (OR 0.44, 95% CI 0.20-0.99, p = 0.049). Readmission: no significant difference in number of patients readmitted was found. Cost-to-patient: Robotic approach predicted an 18% reduction in total cost-to-patient compared to open approach (p < 0.01). Robotic cystectomy demonstrated reduced total cost-to-patient when taking into account all 30-day post-operative services with fewer complications compared to open cystectomy.
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Khetrapal P, Tan WS, Lamb B, Tan M, Baker H, Thompson J, Sridhar A, Kelly JD, Briggs T. The Role of Robotics in the Invasive Management of Bladder Cancer. Curr Urol Rep 2017. [PMID: 28634646 DOI: 10.1007/s11934-017-0706-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Robot-assisted radical cystectomy (RARC) has been adopted widely in many centres, owed largely to the success of robot-assisted laparoscopic prostatectomy (RALP). It aims to replicate the oncological outcomes of open radical cystectomy (ORC), while providing a shorter recovery period. Despite this, previous RCTs have failed to show a benefit for RARC over ORC. These trials have compared extracorporeal RARC (eRARC) with ORC, which requires a further incision to mobilise the bowel for urinary reconstruction with an open technique. For intracorporeal RARC (iRARC), this urinary reconstruction is performed robotically without further incisions. There are theoretical benefits to this approach such as reduced recovery time for the bowel and reduced ileus rates, but no level 1 evidence currently exists to support this. While there has been an improvement in patient outcomes since the adoption of RARC, various other factors, such as enhanced recovery programmes and surgical learning curve, have made it difficult to attribute this solely to the robotic approach as many centres performing ORC have also shown similar improvements. In this review, we will discuss implementation of RARC as well as perioperative measures that have helped improve outcomes, offer a comparison of outcomes between ORC and RARC and highlight upcoming RCTs that may offer new evidence for or against a paradigm shift in the future of bladder cancer surgery.
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Affiliation(s)
- Pramit Khetrapal
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK. .,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK.
| | - Wei Shen Tan
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK.,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK
| | - Benjamin Lamb
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Melanie Tan
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Hilary Baker
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - James Thompson
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - Ashwin Sridhar
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
| | - John D Kelly
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK.,Division of Surgical and Interventional Sciences, University College London, 4th Floor, UCL Medical School Building, 21 University Street, London, WC1E 6AU, UK
| | - Tim Briggs
- Department of Urology, University College London Hospital at Westmoreland Street, 16-18 Westmoreland St, Marylebone, London, W1G 8PH, UK
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Whelan P, Tan WP, Papagiannopoulos D, Omotosho P, Deane L. Robotic assisted laparoscopic radical cystectomy with stentless intracorporeal modified Ves.Pa neobladder: early experience. J Robot Surg 2017; 11:423-431. [PMID: 28070738 DOI: 10.1007/s11701-017-0673-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 12/02/2016] [Accepted: 01/02/2017] [Indexed: 10/20/2022]
Abstract
This study aimed at demonstrating the feasibility of robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder with stentless ureteroileal anastomosis. Pure intracorporeal robotic assisted laparoscopic technique has been recently developed with a select number of high-volume centers utilizing various operative and neobladder techniques. We reviewed the patient characteristics, operative details and perioperative courses in the two patients who have undergone robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder and one who has undergone the Hautmann W neobladder. These results were compared to other contemporary robotic neobladder series. We demonstrate technical success with similar operative and perioperative results with the modified Ves.Pa neobladder. The robotic pure intracorporeal modified Ves.Pa neobladder is a technically feasible operation and may be easier to perform compared to other neobladders. Initial experience suggests operative time and perioperative outcomes are similar to other robotic techniques.
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Affiliation(s)
| | - Wei Phin Tan
- Rush University Medical Center, Chicago, IL, USA
| | | | | | - Leslie Deane
- Rush University Medical Center, Chicago, IL, USA
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Almassi N, Zargar H, Ganesan V, Fergany A, Haber GP. Management of Challenging Urethro-ileal Anastomosis During Robotic Assisted Radical Cystectomy with Intracorporeal Neobladder Formation. Eur Urol 2016; 69:704-9. [PMID: 26463317 DOI: 10.1016/j.eururo.2015.09.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/23/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Robotic assisted radical cystectomy (RARC) is increasingly being adopted, but intracorporeal neobladder formation remains a challenging procedure limited to selected centers. Common challenges with intracorporeal neobladder formation relate to fashioning a tension-free urethro-ileal anastomosis. In this paper, we describe a series of maneuvers to overcome these challenges that we believe will be of great utility to surgeons performing intracorporeal neobladder. OBJECTIVE To describe maneuvers to overcome challenges during intracorporeal urethro-ileal anastomosis formation and to report postoperative outcomes for patients in whom these maneuvers were used. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of medical records of patients who underwent RARC with intracorporeal neobladder performed by one surgeon (G.-P.H.) at our tertiary center from January 2012 to February 2015 in which at least one additional maneuver was required beyond preservation of urethral length, removal of the sigmoid colon from the pelvis, and careful ileal loop selection. The primary end point was 90-d complications. Follow-up ranged from 6 to 36 mo, and 16 patients had at least 1-yr follow-up. SURGICAL PROCEDURE RARC with intracorporeal neobladder formation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES Clinical and operative data collected from a prospectively maintained, institutional review board-approved database. Maneuvers used during intracorporeal urethro-ileal anastomosis were recorded. Descriptive statistics were used to evaluate postoperative outcomes. RESULTS AND LIMITATIONS Nineteen patients met the inclusion criteria. Mean operative time was 486 min (standard deviation: 112 min) with median hospitalization of 7 d (interquartile range: 7-9 d). Seven patients (36.8%) experienced a complication, with one (5.3%) major complication thought to be unrelated to surgery. No open conversions were required. There was no 90-d mortality. CONCLUSIONS Our stepwise approach can help overcome challenges of urethro-ileal anastomosis during intracorporeal neobladder formation. PATIENT SUMMARY When performing intracorporeal neobladder formation, challenges are often encountered in fashioning the urethro-ileal anastomosis. We describe a series of maneuvers that, when used in a stepwise manner, help overcome these challenges.
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Abstract
Bladder cancer is the most expensive cancer to treat from diagnosis to death. Frequent disease recurrence, intense follow-up, and expensive, invasive techniques for diagnosis and treatment drive these costs for non-muscle invasive bladder cancer. Fluorescence cystoscopy increases the detection of superficial bladder cancer and reduces costs by improving the quality of resection and reducing recurrences. Radical cystectomy with intestinal diversion is the mainstay of treatment of invasive disease; however it is associated with substantial cost and morbidity. Increased efforts to improve the surgical management of bladder cancer while reducing the cost of treatment are increasingly necessary.
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Affiliation(s)
- David C Johnson
- Department of Urology, University of North Carolina, School of Medicine, 2113 Physician's Office Building, 170 Manning Drive, CB 7235, Chapel Hill, NC 27599, USA.
| | - Peter S Greene
- Department of Urology, University of North Carolina, School of Medicine, 2113 Physician's Office Building, 170 Manning Drive, CB 7235, Chapel Hill, NC 27599, USA
| | - Matthew E Nielsen
- Department of Urology, University of North Carolina, School of Medicine, 2113 Physician's Office Building, 170 Manning Drive, CB 7235, Chapel Hill, NC 27599, USA
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Oksar M, Akbulut Z, Ocal H, Balbay MD, Kanbak O. Anesthetic considerations for robotic cystectomy: a prospective study. Braz J Anesthesiol 2013; 64:109-15. [PMID: 24794453 DOI: 10.1016/j.bjane.2013.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [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: 07/30/2013] [Accepted: 09/02/2013] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Robotic cystectomy is rapidly becoming a part of the standard surgical repertoire for the treatment of prostate cancer. Our aim was to describe respiratory and hemodynamic challenges and the complications observed in robotic cystectomy patients. PATIENTS Sixteen patients who underwent robotic surgery between December 2009 and January 2011 were prospectively enrolled. Main outcome measures were non-invasive monitoring, invasive monitoring and blood gas analysis performed at supine (T0), Trendelenburg (T1), Trendelenburg+pneumoperitoneum (T2), Trendelenburg-before desufflation (T3), Trendelenburg (after desufflation) (T4), and supine (T5) positions. RESULTS There were significant differences between T0-T1 and T0-T2 with lower heart rates. The mean arterial pressure value at T1 was significantly lower than T0. The central venous pressure value was significantly higher at T1, T2, T3, and T4 than at T0. There was no significant difference in the PET-CO2 value at any time point compared with T0. There were no significant differences in respiratory rate at any time point compared with T0. The mean f values at T3, T4, and T5 were significantly higher than T0. The mean minute ventilation at T4 and T5 were significantly higher than at T0. The mean plateau pressures and peak pressures at T1, T2, T3, T4, and T5 were significantly higher than the mean value at T0. CONCLUSIONS Although the majority of patients generally tolerate robotic cystectomy well and appreciate the benefits, anesthesiologists must consider the changes in the cardiopulmonary system that occur when patients are placed in Trendelenburg position, and when pneumoperitoneum is created.
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Affiliation(s)
- Menekse Oksar
- Department of Anesthesiology and Reanimation, Ankara Ataturk Training and Research Hospital, Ankara, Turkey.
| | - Ziya Akbulut
- Department of Urology, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
| | - Hakan Ocal
- Department of Anesthesiology and Reanimation, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
| | - Mevlana Derya Balbay
- Department of Urology, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
| | - Orhan Kanbak
- Department of Anesthesiology and Reanimation, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
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