Nomogram for predicting postoperative ileus after radical cystectomy and urinary diversion: a retrospective single-center study

OBJECTIVE

To predict the incidence of postoperative ileus in bladder cancer patients after radical cystectomy.

METHODS

We retrospectively analyzed the perioperative data of 452 bladder cancer patients who underwent radical cystectomy with urinary diversion at the Second Hospital of Tianjin Medical University between 2016 and 2021. Univariate and multivariate logistic regression were used to identify the risk factors for postoperative ileus. Finally, a nomogram model was established and verified based on the independent risk factors.

RESULTS

Our study revealed that 96 patients (21.2%) developed postoperative ileus. Using multivariate logistic regression analysis, we found that the independent risk factors for postoperative ileus after radical cystectomy included age > 65.0 years, high or low body mass index, constipation, hypoalbuminemia, and operative time. We established a nomogram prediction model based on these independent risk factors. Validation by calibration curves, concordance index, and decision curve analysis showed a strong correlation between predicted and actual probabilities of occurrence.

CONCLUSION

Our nomogram prediction model provides surgeons with a simple tool to predict the incidence of postoperative ileus in bladder cancer patients undergoing radical cystectomy.

Robot-assisted Radical Cystectomy with Totally Intracorporeal Urinary Diversion Versus Open Radical Cystectomy: 3-Year Outcomes from a Randomised Controlled Trial

BACKGROUND AND OBJECTIVE

Randomised controlled trials (RCTs) comparing open radical cystectomy (ORC) and robot-assisted RC (RARC) have involved an extracorporeal approach for urinary diversion (UD), undermining the potential benefits of a totally robotic procedure. Our objective was to compare 3-yr outcomes from a RCT comparing ORC to RARC with totally intracorporeal UD (iUD).

METHODS

Patients with cT2-4 N0 M0 or bacillus Calmette-Guérin-failed high-grade non-muscle-invasive urothelial carcinoma who were candidates for RC without absolute contraindications to robotic surgery were included. A covariate adaptive randomisation process based on body mass index, American Society of Anesthesiologists score, preoperative haemoglobin, type of UD, neoadjuvant chemotherapy, and cT stage was used. The primary endpoint was to investigate the superiority of RARC with iUD in terms of a 50% reduction in transfusion rate. Secondary outcomes included adherence to an early recovery after surgery protocol, perioperative and postoperative outcomes, readmission and complication rates, a cost analysis, and functional, oncological, and health-related quality-of-life outcomes.

KEY FINDINGS AND LIMITATIONS

Overall, 116 patients were enrolled. The primary endpoint was confirmed, as the overall perioperative transfusion rate was significantly lower in the RARC cohort, with an absolute risk reduction of 19% (95% confidence interval 2-36%; p = 0.046). No differences in perioperative and postoperative complications and 3-yr oncological outcomes were observed between the groups. Despite the superiority of ORC on quantitative analysis of night-time pad use, there were no differences in the probabilities of recovery of daytime and night-time continence. Body image was significantly better in the RARC cohort. Cost analysis confirmed that RARC is a more expensive surgical procedure.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Our findings support RARC with iUD as a safe surgical option; the transfusion rate was reduced by 50% and the complication rates and 3-yr oncological outcomes were comparable to those with ORC. The minimally invasive nature of RARC was reflected in better body image perception in this cohort. The probabilities of daytime and night-time continence recovery were comparable between the groups. Higher costs remain a drawback of robotic surgery.

PATIENT SUMMARY

This RCT demonstrated a 50% transfusions rate's reduction compared to ORC. We confirmed safety and feasibility of RARC with i-UD providing comparable peri- and postoperative complication rates, as well as, 3yr oncologic outcomes to those of ORC. Patients receiving either RARC-iUD or ORC had comparable probabilities of urinary continence recovery after surgery.

Migration of double-J ureteral stent in patients with ureteroileal anastomosis stricture undergoing radical cystectomy and orthotopic neobladder: Analysis risk factors of stent migration

The objective was to evaluate the incidence and degree of double-J ureteral stent (DJUS) migration. Additionally, we aimed to investigate the risk factors associated with stent migration in the orthotopic neobladder group. In this retrospective study, 61 consecutive patients were included; 35 patients (45 DJUS placements) underwent radical cystectomy with orthotopic neobladder and 26 patients (35 DJUS placements) underwent urinary bladder without cystectomy between July 2021 and March 2023. All the patients were treated with a DJUS for ureteric strictures. The technical success rate was 100% in each group. The DJUS migration was significantly higher in the orthotopic neobladder group, with 22 of 45 cases (48.9%), compared to the urinary bladder group, which had 4 of 35 cases (11.4%) (P ≤ .001). Among the patients in the orthotopic neobladder group who experienced DJUS migration, stent dysfunction occurred in 18 cases (81.8%), which was statistically significant (P = .003). Multivariate logistic regression analysis revealed that only the size of the DJUS was significantly and positively associated with migration (odds ratio:10.214, P = .010). DJUS migration can easily occur in patients undergoing radical cystectomy and orthotopic neobladder, and smaller stent sizes are associated with a higher incidence of migration.

Atlas of Intracorporeal Orthotopic Neobladder Techniques After Robot-assisted Radical Cystectomy and Systematic Review of Clinical Outcomes

BACKGROUND

Multiple and heterogeneous techniques have been described for orthotopic neobladder (ONB) reconstruction after robot-assisted radical cystectomy. Nonetheless, a systematic assessment of all the available options is lacking.

OBJECTIVE

To provide the first comprehensive step-by-step description of all the available techniques for robotic intracorporeal ONB together with individual intraoperative, perioperative and functional outcomes based on a systematic review of the literature.

DESIGN, SETTING, AND PARTICIPANTS

We performed a systematic review of the literature, and MEDLINE/PubMed, Embase, Scopus, and Web of Science databases were searched to identify original articles describing different robotic intracorporeal ONB techniques and reporting intra- and perioperative outcomes. Studies were categorized according to ONB type, providing a synthesis of the current evidence. Video material was provided by experts in the field to illustrate the surgical technique of each intracorporeal ONB.

SURGICAL PROCEDURE

Nine different ONB types were identified: Studer, Hautmann, Y shape, U shape, Bordeaux, Pyramid, Shell, Florence Robotic Intracorporeal Neobladder, and Padua Ileal Neobladder.

MEASUREMENTS

Continuous and categorical variables are presented as mean ± standard deviation and as frequencies and proportions, respectively.

RESULTS AND LIMITATIONS

Of 2587 studies identified, 19 met our inclusion criteria. No cohort studies or randomized control trials comparing different neobladder types are available. Available techniques for intracorporeal robotic ONB reconstruction have similar operative time, estimated blood loss, intraoperative complications, and length of stay. Major variability exists concerning postoperative complications and functional outcomes, likely related to reporting bias.

CONCLUSIONS

Several techniques are described for intracorporeal ONB during robot-assisted radical cystectomy with comparable perioperative outcomes. We provide the first step-by-step surgical atlas for robot-assisted ONB reconstruction. Further comparative studies are needed to assess any advantage of one technique over others.

PATIENT SUMMARY

Patients elected for radical cystectomy should be aware that multiple techniques for robotic orthotopic neobladder are available, but that current evidence does not favor one type over the others.

Comparison of urological outcomes and quality of life after pelvic exenteration: partial vs radical cystectomy

OBJECTIVE

To compare perioperative morbidity, functional and quality-of-life (QoL) outcomes in patients with partial cystectomy vs radical cystectomy as part of pelvic exenteration.

PATIENTS AND METHODS

Retrospective analysis of a prospectively maintained database of pelvic exenteration patients (1998-2021) was conducted in a single centre. Study outcomes included postoperative complications, quality-of-life, functional and stoma-related outcomes. The 36-item Short-Form Health Survey Physical and Mental Health Components, Functional Assessment of Cancer Therapy-Colorectal questionnaires and Distress Thermometer were available pre- and postoperatively. QoL outcomes were compared at the various time points. Stoma embarrassment and care scores were compared between patients with a colostomy, urostomy, and both.

RESULTS

Urological complications were similar between both groups, but patients with partial cystectomy experienced less wound-related complications. Overall, 34/81 (42%) partial cystectomy patients reported one or more long-term voiding complication (i.e., incontinence [17 patients], frequency [six], retention [three], high post-voiding residuals [10], permanent suprapubic catheter/indwelling catheter [14], recurrent urinary tract infection [nine], percutaneous nephrostomy [three], progression to urostomy [three]). The QoL improved following surgery in both the partial and radical cystectomy groups, differences between cohorts were not significant. Patients with two stomas reported higher embarrassment scores than patients with one stoma, although this did not result in more difficulties in stoma care.

CONCLUSIONS

Partial cystectomy patients have fewer postoperative wound-related complications than radical cystectomy patients, but often experience long-term voiding issues. The QoL outcomes are similar for both cohorts, with significant improvement following surgery.

Older versus younger patients in robot-assisted radical cystectomy with intracorporeal ileal conduit comparing safety and clinical outcomes

OBJECTIVE

To evaluate the safety and efficacy of robot-assisted radical cystectomy using an intracorporeal ileal conduit in older compared to younger patients.

METHODS

We retrospectively analyzed 122 patients who underwent robot-assisted radical cystectomy with an intracorporeal ileal conduit at Fujita Health University Hospital and Fujita Health University Okazaki Medical Center between 2012 and 2022. Patients were categorized into two groups: older (age ≥ 75 years; n = 53) and younger (age < 75 years; n = 69). Perioperative outcomes, complications, recurrence-free survival, cancer-specific survival, and overall survival were compared between the cohorts.

RESULTS

The groups had no significant differences in perioperative outcomes, such as estimated blood loss, operative time, and blood transfusion rate. However, hospital stay was longer in the older patients than in the younger group (19 vs. 16 days; p < 0.001). The 30-day minor and major complication rates were 33.3% and 13.0%, respectively, for the younger group and 50.9% and 9.4% for the older group (p = 0.11). Urinary tract infection and bowel ileus were the most common complications in both groups. No significant differences were observed in recurrence-free survival, cancer-specific survival, and overall survival between the groups (p = 0.58, p = 0.75, and p = 0.78), and subgroup analysis in ≥cT3 revealed the older group tended to have poorer cancer-specific survival and overall survival (p = 0.07 and p = 0.01). Multivariate analysis indicated that older age was not associated with high-grade complications and cancer-specific survival.

CONCLUSIONS

Robot-assisted radical cystectomy with an intracorporeal ileal conduit is a safe and effective treatment option for older patients.

Long-term renal function following radical cystectomy and ileal conduit creation

BACKGROUND

Treatment for bladder cancer includes radical cystectomy (RC) and urinary diversion; RC is associated with long-term morbidity, kidney impairment and mortality.

AIM

To identify risk factors associated with postoperative long-term kidney function and mortality.

METHODS

Retrospective study of patients with RC and urinary diversion in Beaumont Hospital from 1996 to 2016. We included patients who had follow-up at least 2 years post-procedure. We assessed estimated glomerular filtration rate (eGFR) preoperatively and yearly post-procedure, dialysis commencement and mortality. Cox and Fine-Gray regression analyses were applied; p-value < 0.05 was considered significant.

RESULTS

We included 264 patients, median age 68.3 years, 73.7% males. The most common diagnosis was bladder cancer 93.3%, TNM stages T ≥ 2 75.9%, N ≥ 1 47.6% and M1 28%. The median eGFR preoperative was 65.8 ml/min/1.73m2 and after 2 years 58.2 ml/min/1.73m2 (p: 0.009); 5.3% required chronic dialysis and 32.8% had a decrease > 10 ml/min/1.73m2. Risk factors associated with ESKD and start dialysis included younger age (HR: 0.90, CI 95% 0.87-0.94) and lower pre-operative eGFR (HR: 0.97, CI 95% 0.94-1.00). Overall mortality was 43.2% and 54.1% at 5 and 10 years, respectively; risk factors were older age (HR: 1.04, CI 95% 1.02-1.06), tumour stage T ≥ 2 (HR: 2.22, CI 95% 1.39-3.54) and no chemotherapy (HR: 1.72, CI 95% 1.18-2.51). Limitations include retrospective design, absence of control group and single centre experience.

CONCLUSIONS

Patients with RC are at risk of progressive kidney function deterioration and elevated mortality and the main risk factors associated were age and preoperative eGFR. Regular monitoring of kidney function will permit early diagnosis and treatment.

Robotic simple cystectomy as a last resort for antibiotic-recalcitrant recurrent urinary tract infections in women

OBJECTIVE

To report a series of women with antibiotic-recalcitrant recurrent urinary tract infections (rUTI) managed with robotic simple cystectomy and ileal conduit urinary diversion.

METHODS

Following Institutional Review Board approval, all female patients who underwent robotic cystectomy for rUTI between 2011 and 2021 were identified from a prospectively-maintained internal database at a tertiary care center. Exclusion criteria included interstitial cystitis, neurogenic bladder, urinary tract neoplasm, or congenital abnormality. Electronic medical records were reviewed by an independent researcher. Patients were also administered the Quality of Life Questionnaire-C30.

RESULTS

Twenty-four patients met inclusion criteria. Median age was 75 years (range 53-87). Median rUTI duration was 6 (interquartile range [IQR] 2-10) years. Median urinary tract infections count in the 12-month preceding cystectomy was 5 (IQR 3-9). Infections with multidrug resistant organisms were found in 21 patients (88%). The 30-day postoperative complication rate was 79% (19/24), of which 11% were Clavien-Dindo grade ≥III. The main late complication was parastomal hernia, with 17% requiring repair or revision. At a median of 36 months (range 12-61) post-operatively, the median Quality of Life Questionnaire-C30 global health status score was 50 (range 33-83).

CONCLUSION

Cystectomy is a last-resort management option for women with severely symptomatic end-stage bladders in the setting of antibiotic-recalcitrant rUTI. Patients should be counseled thoroughly regarding possible acute and long-term postoperative complications. Select patients, managed in high-volume referral centers, can benefit from robotic simple cystectomy with ileal conduit urinary diversion.

Preoperative Immunonutrition Significantly Reduced Surgical Site Infection After Urinary Diversion for Invasive Bladder Cancer: A Retrospective Cohort Study

BACKGROUND

Radical cystectomy and ileal conduit have a high incidence of surgical site infection. In this study, we evaluated the effects of preoperative immunonutrition on its incidence following these procedures.

MATERIALS AND METHODS

We retrospectively enrolled 86 patients who underwent radical cystectomy and ileal conduit at our hospital between 2014 October and 2021 July. They were sequentially divided into the Immunonutrition group (n = 43) and Control group (n = 43). Patients in the Immunonutrition group drank 4 packs of IMPACT (Nestle, Japan) per day for 5 days before surgery. IMPACT contains arginine and eicosapentaenoic acid. We compared levels of plasma arginine and eicosapentaenoic acid before and after surgery and the rate of surgical site infection between the groups. Factors related to surgical site infection were analyzed using univariate and multivariable logistic regression analysis.

RESULTS

No statistically significant differences were observed in patient characteristics between the groups except for surgical operative method (P < .001) and transfusion (P = .009). Levels of plasma arginine and eicosapentaenoic acid were significantly increased the day before surgery in the immunonutrition group (P < .001). However, the levels of plasma arginine on the day after surgery did not vary significantly between the groups. The incidence of surgical site infection was significantly lower in the immunonutrition group (P = .014). Multivariate analyses showed a significant association of surgical site infection with immunonutrition (OR = 0.14, CI 0.03-0.72, P = .019) and with ASA classification (OR = 4.76, CI 1.23-18.40, P = .024).

CONCLUSIONS

Preoperative immunonutrition significantly reduced the incidence of surgical site infection following radical cystectomy and ileal conduit.

Surgical proficiency in laparoscopic radical cystectomy with extracorporeal urinary diversion and its adequacy for the execution of robot-assisted radical cystectomy with intracorporeal urinary diversion

INTRODUCTION

The number of facilities adopting intracorporeal urinary diversion (ICUD) using robots instead of extracorporeal urinary diversion (ECUD) is increasing. However, guidance on how to introduce robot-assisted radical cystectomy (RARC) + ICUD in each urological institute remains unclear. This study aimed to verify the feasibility of the transition from laparoscopic radical cystectomy (LRC) + ECUD to RARC + ICUD.

METHODS

We retrospectively analyzed 26 consecutive patients who underwent ICUD with an ileal conduit after RARC between 2018 and 2020 (RARC + ICUD early group). We then compared these patients with 26 consecutive patients who underwent ECUD with an ileal conduit after LRC between 2012 and 2019 (LRC + ECUD late group) at Yokohama City University Hospital.

RESULTS

In the RARC + ICUD early group compared with the LRC + ECUD late group, the median total operation time was 516 versus 532.5 min (P = .217); time to cystectomy, 191 versus 206.5 min (P = .234); time of urinary diversion with an ileal conduit, 198 versus 220 min (P = .016); postoperative maximum C-reactive protein levels, 6.98 versus 12.46 mg/L (P = .001); number of days to oral intake, 3 versus 5 days (P = .003); length of hospital stay, 17 versus 32 days (P < .001). The postoperative complication rates (within 90 days) were 23.1% and 42.3% in the RARC + ICUD early and LRC + ECUD late groups, respectively (P = .237). Clavien-Dindo classification ≥3 was noted in 1 and 4 patients in the RARC + ICUD early and LRC + ECUD late groups, respectively (P = .350).

CONCLUSION

Regarding perioperative outcomes, the RARC + ICUD early group was not inferior to the LRC + ECUD late group. This study suggests the feasibility of a transition from LRC + ECUD to RARC + ICUD.

Urinary function in female patients after traditional, organ-sparing and nerve-sparing radical cystectomy for bladder cancer: a systematic review and pooled analysis

OBJECTIVES

To determine and summarize the available data on urinary, sexual, and health-related quality-of-life (HRQOL) outcomes after traditional radical cystectomy (RC), reproductive organ-preserving RC (ROPRC) and nerve-sparing RC (NSRC) for bladder cancer (BCa) in female patients.

METHODS

The PubMed, SCOPUS and Web of Science databases were searched to identify studies reporting functional outcomes in female patients undergoing RC and urinary diversion for the treatment of BCa. The outcomes of interest were voiding function (for orthotopic neobladder [ONB]), sexual function and HRQOL. The following independent variables were derived and included in the meta-analysis: pooled rate of daytime and nighttime continence/incontinence, and intermittent self-catheterization (ISC) rates. Analyses were performed separately for traditional, organ- and/or nerve-sparing surgical approaches.

RESULTS

Fifty-three studies comprising 2740 female patients (1201 traditional RC and 1539 organ-/nerve-sparing RC, and 264 nerve-sparing-alone RC) were eligible for qualitative synthesis; 44 studies comprising 2418 female patients were included in the quantitative synthesis. In women with ONB diversion, the pooled rates of daytime continence after traditional RC, ROPRC and NSRC were 75.2%, 79.3% and 71.2%, respectively. The pooled rate of nighttime continence after traditional RC was 59.5%; this rate increased to 70.7% and 71.7% in women who underwent ROPRC and NSRC, respectively. The pooled rate of ISC after traditional RC with ONB diversion in female patients was 27.6% and decreased to 20.6% and 16.8% in patients undergoing ROPRC and NSRC, respectively. The use of different definitions and questionnaires in the assessment of postoperative sexual and HRQOL outcomes did not allow a systematic comparison.

CONCLUSIONS

Female organ- and nerve-sparing surgical approaches during RC seem to result in improved voiding function. There is a significant need for well-designed studies exploring sexual and HRQOL outcomes to establish evidence-based management strategies to support a shared decision-making process tailored towards patient expectations and satisfaction. Understanding expected functional, sexual and quality-of-life outcomes is necessary to allow individualized pre- and postoperative counselling and care delivery in female patients planned to undergo RC.

Incidence of Ureteroenteric Anastomotic Strictures After Robotic vs Open Cystectomy in Adults

To synthesise the evidence comparing the incidence rates of UAS post-RARC vs Open Radical cystectomy (ORC) in adults undergoing cystectomy and to compare differential stricture rates between Extracorporeal and Intracorporeal urinary diversion (ECUD vs ICUD). The primary outcome was incidence rate of UAS post RARC vs ORC and the secondary outcome was incidence rate of UAS in RARC post ECUD vs ICUD. Review authors conducted comprehensive search for studies comparing RARC with ORC in terms of incidence of UAS. Furthermore, we conducted a secondary search for studies which compared UAS incidence comparing ECUD and ICUD. We found that RARC may have higher incidence of UAS [OR: 1.39; 95% CI 1.11-1.75; p < 0.0001]. ECUD may result in lower rate of UAS as compared to ICUD [OR: 0.74; 95% CI 0.56 to 0.98; p= 0.04].

Magnetic Compression Anastomosis of Benign Short-Segment Ureteral Obstruction

PURPOSE

To investigate the feasibility, safety, and effectiveness of magnetic compression anastomosis of benign short-segment ureteral obstruction.

MATERIALS AND METHODS

Patients referred for failure of ureteral double-J stent placement because of impassable benign ureteral obstruction were included. Eleven patients (11 ureters) with a mean age of 57.5 years (range, 19-85 years; 8 women) underwent ureteral magnetic compression anastomosis. All patients had indwelling nephrostomy catheters. In all patients, anterograde and retrograde ureteral stent placements were unsuccessful using either interventional or cystoscopic access. Ureteral magnetic compression anastomosis was performed as a 2-step procedure. In the first step, magnets were placed. In the second step, the stricture was traversed via magnetic compression anastomosis. Successful establishment of anastomosis and ureteral double-J stent placement were considered technical success. The mean time for complete magnetic adherence and fluoroscopy time for each procedure were recorded.

RESULTS

Five patients (45%) had an ileal conduit. The technical success rate was 91% (n = 10/11). The mean time for magnetic adherence was 5.7 days (SD ± 1.3). The mean single-rotation fluoroscopy times during the first and second steps of the procedure were 9.45 minutes (SD ± 2.09) and 15.70 minutes (SD ± 2.62), respectively. Magnets were removed with the support of either balloon catheters (n = 9) or biopsy forceps (n = 2). No procedure-related adverse events occurred.

CONCLUSIONS

Magnetic compression anastomosis of benign ureteral obstruction is feasible and safe and can be performed in an interventional radiology (IR) suite without the need for endoscopy.

Identify risk factors for perioperative outcomes in Intracorporeal Urinary Diversion and Extracorporeal Urinary Diversion with Robotic Cystectomy

INTRODUCTION

The increasing adoption of robotic-assisted cystectomy with intracorporeal urinary diversion (ICUD), despite its complexity, prompts a detailed comparison with extracorporeal urinary diversion (ECUD). Our study at a single institution investigates perioperative outcomes and identifies risk factors impacting the success of these surgical approaches.

METHODS

In this retrospective analysis, 174 patients who underwent robotic-assisted cystectomy at the University of Louisville from June 2016 to August 2021 were reviewed. The cohort was divided into two groups based on the urinary diversion method: 30 patients underwent ECUD and 144 underwent ICUD. Data on demographics, complication rates, length of hospital stay, and readmission rates were meticulously collected and analyzed.

RESULTS

Operative times were comparable between the ICUD and ECUD groups. However, the ICUD group had a significantly lower intraoperative transfusion rate (0.5 vs. 1.0, p=0.02) and shorter hospital stay (7.8 vs. 12.3 days, p<0.001). Factors such as male sex, smoking history, diabetes mellitus, intravesical therapy, higher ASA, and ACCI scores were associated with increased Clavien-Dindo Grade 3 or higher complications. Age over 70 was the sole factor linked to a higher 90-day readmission rate, with no specific characteristics influencing the 30-day rate.

CONCLUSION

Robotic cystectomy with ICUD results in shorter hospitalizations and lower intraoperative transfusion rates compared to ECUD, without differences in operative time, high-grade postoperative complications, or readmission rates. These findings can inform clinical decision-making, highlighting ICUD as a potentially more favorable option in appropriate settings.

Parastomal Hernia Following Ileal Conduit: Incidence, Risk Factors, and Health-Related Quality of Life

PURPOSE

The purpose of this study was to measure the incidence of parastomal hernia (PH) after radical cystectomy and ileal conduit. Secondary aims were the identification of risk factors for PH and to compare the health-related quality of life (QOL) between patients with and without PH.

DESIGN

Retrospective review of medical records combined with cross-sectional administration of the QOL instrument and telephone follow-up.

SUBJECTS AND SETTING

The study sample comprised 219 patients who underwent radical cystectomy and ileal conduit for urothelial cancer between February 2014 and December 2018. The study setting was Peking University First Hospital (Beijing, China).

METHODS

Demographic and pertinent clinical data, including development of PH, were gathered via the retrospective review of medical records. Participants were also asked to complete the traditional Chinese language version of the City of Hope Quality of Life-Ostomy Questionnaire (C-COH). Multiple linear regression analysis was used to identify the effect of PH on C-COH scores. Logistic regression analysis was used to identify risk factors for PH development.

RESULTS

At a median follow-up of 34 months (IQR = 21-48), 43 of 219 (19.63%) patients had developed a PH. A body mass index (BMI) indicating overweight (OR = 3.548; 95% CI, 1.562-8.061; P = .002), a prior history of hernia (OR = 5.147; 95% CI, 1.195-22.159; P = .028), and chronic high abdominal pressure postdischarge (CHAP-pd) (OR = 3.197; 95% CI, 1.445-7.075; P = .004) were predictors of PH after operation. There was no significant difference between C-COH scores of patients with or without PH. No significant differences were found when participants with PH were compared to those without PH on 4 factors of the C-COH: physical scores (β= .347, P = .110), psychological scores (β= .316, P = .070), spiritual scores (β=-.125, P = .714), and social scores (β= .054, P = .833).

CONCLUSION

Parastomal hernia is prevalent in patients undergoing radical cystectomy and ileal conduit urinary diversion. Overweight, hernia history, and CHAP-pd were predictors of PH development. No significant differences in QOL were found when patients with PH were compared to those without PH.

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

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.

Impact of urinary diversion type on urethral recurrence following radical cystectomy for bladder cancer: propensity score matched and weighted analyses of retrospective cohort

BACKGROUND

The absence of randomized controlled trials and the presence of inherent selection bias in existing studies have led to ongoing uncertainty regarding the impact of urinary diversion (UD) type (orthotopic UD or nonorthotopic UD) on urethral recurrence (UR) following radical cystectomy (RC) for bladder cancer. This study aimed to assess the impact of the UD types on UR after RC and to identify predictive factors associated with UR.

MATERIALS AND METHODS

This retrospective analysis encompassed 612 male patients who underwent RC for urothelial carcinoma of the bladder. Among them, 341 patients received nonorthotopic UD [ileal conduit (IC) or ureterocutaneostomy (UC)], whereas 271 received orthotopic neobladder (NB) between January 2012 and October 2022. To mitigate potential biases, we employed 1:1 propensity score matching (PSM) and stabilized inverse probability treatment weighting (IPTW). Kaplan-Meier analysis and log-rank tests were employed to assess UR-free survival between the IC/UC and NB groups, while multivariable Cox regression analysis was conducted to determine predictive factors for UR.

RESULTS

Among the 612 patients included, 33 (5.4%) experienced UR. PSM yielded matched cohort comprising 412 patients, evenly distributed with 206 patients in each group (IC/UC and NB). Clinicopathological data demonstrated similarity between the two groups. Patients who underwent NB exhibited significantly superior UR-free survival in both PSM (log-rank P =0.033) and IPTW cohorts (log-rank P =0.009). NB reconstruction (vs. IC/UC) emerged as a substantial protective factor against UR [hazard ratio (HR) 0.283; 95% CI: 0.088-0.916; P =0.035], whereas prostatic urethral involvement was identified as a significant risk factor (HR 5.328; 95% CI: 1.298-21.868; P =0.020) in the PSM cohort. Additionally, in the IPTW cohort, NB reconstruction (vs. IC/UC) maintained its significance as a protective factor against UR (HR 0.336; 95% CI: 0.131-0.858; P =0.023) along with neoadjuvant chemotherapy (HR 0.335; 95% CI: 0.116-0.969; P =0.044), whereas prostatic urethral involvement remained a significant risk factor (HR 3.752; 95% CI: 1.484-9.488; P =0.005).

CONCLUSIONS

Even after mitigating selection bias, NB reconstruction holds a protective effect against UR in male patients undergoing RC for bladder cancer.

Shorter Ureters Lead to Fewer Strictures Following Cystectomy and Urinary Diversion

OBJECTIVE

To identify the impact of length of distal ureteral resection on the risk of benign uretero-enteric anastomotic stricture (UEAS) formation following cystectomy and urinary diversion.

METHODS

A database of patients who underwent cystectomy and urinary diversion from 2015 to 2022 was analyzed. Distal ureteral resections were sent for final pathology. The length of resected ureter was collected from pathology reports. Benign UEAS were confirmed with renal scintigraphy, antegrade nephrostogram, or endoscopic evaluation. The relationship between stricture formation and clinical parameters were assessed using T-tests, chi-square tests, and multivariable analysis.

RESULTS

A total of 366 patients underwent cystectomy and urinary diversion. Of the cohort, 35 (9.5%) patients developed UEAS. Median time to stricture formation was 12.5months (IQR 4-30). Of the 711 uretero-enteric anastomoses, 40 (5.6%) ultimately formed a UEAS. Median distal ureteral resection was significantly longer among ureteral anastomoses which did not form a UEAS (2.3 cm vs 1.65 cm, P = .028). Multivariable logistic regression adjusting for surgical approach, prior radiation, ureteral side, and urinary diversion type demonstrated that longer distal ureteral resections were inversely associated with odds of UEAS formation (OR 0.73, 95% CI 0.58-0.92). Multivariable Cox regression analysis similarly showed that length of distal ureteral resection was inversely associated with time to stricture formation (HR 0.78, 95% CI 0.62-0.98).

CONCLUSION

The etiology of benign UIA strictures is multifactorial. Vascular compromise is a critical hypothesis. We found that longer distal ureteral resections (and thus shorter ureters) were associated with a significantly lower risk of stricture formation in cystectomy patients.

Hybrid technique has lower stricture rates than Wallace and Bricker

INTRODUCTION

A clear consensus has not yet been reached on the optimal ureteroenteric anastomosis technique for ileal conduit urinary diversion following radical cystectomy. This study aims to determine the incidence of strictures and their management associated with these anastomosis techniques.

METHODS

We conducted a retrospective, single-center study of patients who underwent radical cystectomy and urinary diversion between March 2014 and August 2022. Patients were categorized based on the ureteroenteric anastomosis technique used: Wallace, Bricker, or Hybrid. Strictures were identified through antegrade pyelography following nephrostomy placement.

RESULTS

A total of 141 patients were included in the study, with 60 patients in the Wallace group (42 %), 42 patients in the Bricker group (30 %), and 39 patients in the Hybrid group (28 %). The overall incidence of ureteroenteric strictures was 15 %, with 7 patients in the Wallace group, 11 patients in the Bricker group, and 3 patients in the Hybrid group experiencing strictures. There was no statistically significant difference in stricture rates between the Wallace and Bricker groups (11 % vs. 26 %, p = 0.09) or between the Wallace and Hybrid groups (11 % vs. 7 %, p = 0.73). However, a statistically significant difference was observed between the Bricker and Hybrid groups (26 % vs. 7 %, p = 0.03). The mean time to stricture development was 9.2 ± 3.3 months for the Wallace group, 9.5 ± 3.7 months for the Bricker group, and 12.6 ± 5 months for the Hybrid group (p = 0.407).

CONCLUSION

The Hybrid ureteroenteric anastomosis technique exhibits a lower stricture rate compared to the Bricker and Wallace techniques. It represents a safe and feasible alternative technique.

Perioperative outcomes and continence following robotic-assisted radical cystectomy with mainz pouch II urinary diversion in patients with bladder cancer

PURPOSE

To present the widely unknown perioperative outcomes and continence status of bladder cancer patients following robotic-assisted radical cystectomy (RARC) with Mainz pouch II urinary diversion (UD).

MATERIALS AND METHODS

From November 2020 to December 2023, 37 bladder cancer patients who underwent RARC with Mainz pouch II UD were retrospectively assessed (ChiCTR2300070279). The results, which included patient demographics, perioperative data, continence, and complications (early ≤ 30 days and late ≤ 30 days) were reported using the RC-pentafecta criteria. RC-pentafecta criteria included ≥ 16 lymph nodes removed, negative soft tissue surgical margins, absence of major (Grade III-IV) complication at 90 days, absence of clinical recurrence at ≤ 12 months, and absence of long-term UD-related sequelae. A numeric rating scale assessed patient satisfaction with urinary continence 30 days after surgery. The validated Patient Assessment of Constipation Symptoms (PAC-SYM) questionnaire was used to evaluate bowel function. The Kaplan-Meier curve was used to evaluate overall survival (OS).

RESULTS

Of the 37 patients evaluated over a median (range) follow-up period of 23.0 (12.0-36.5) months. The median (range) age was 65 (40-81) years. The median (range) time to urinary continence after surgery was 2.3 (1.5-6) months. Of the 37 patients, 31 (83.8%) were continent both during the day and at night, 34 (91.9%) were continent during the day, 32 (86.5%) were continent at night, 35 (94.6%) were satisfied with their urinary continence status, and 21 (56.8%) were very satisfied. The mean (range) voiding frequency was 6 (4-10) during the day and 3 (2-5.5) at night. The mean (range) PAC-SYM total score was 9.50 (4.00-15.00). In 12 (32.4%) of the patients, RC-pentafecta was achieved, and achieving RC-pentafecta was linked to better satisfaction scores (7.3 vs. 5.5, p = 0.034). There was no significant difference between RC-pentafecta and No RC-pentafecta groups in terms of OS (25.6 vs. 21.5 months, p = 0.16). 7 (19.4%) patients experienced late complications.

CONCLUSIONS

Mainz pouch II UD following RARC in bladder cancer patients results in a satisfactory continence rate. Achieving RC-pentafecta was correlated with better satisfaction scores. The intracorporeal approach to Mainz pouch II UD is beneficial for female patients due to its reduced invasiveness.

TRIAL REGISTRATION

ChiCTR2300070279; Registration: 07/04/2023, Last updated version: 01/06/2023. Retrospectively registered.

Extraperitonealization of the ileal conduit decreases the risk of parastomal hernia: A single-center, randomized clinical trial

Parastomal hernia (PSH) is a common complication in patients receiving ileal conduit urinary diversion after radical cystectomy. In this randomized controlled clinical trial, we validate our previous finding that extraperitonealization of ileal conduit decreases incidence of PSH. In total, 104 consecutive patients undergoing radical cystectomy at Sun Yat-sen University Cancer Center are randomized 1:1 to receive either modified (extraperitonealized) ileal conduit (n = 52) or conventional ileal conduit (n = 52). Primary endpoint is incidence of radiological PSH during follow-up. Incidence of radiological PSH is lower in the modified group than in the conventional group (11.5% vs. 28.8%; p = 0.028) after a median follow-up of 32 months, corresponding to a hazard ratio of 0.374 (95% confidence interval: 0.145-0.965, p = 0.034) in the modified conduit group. The results support our previous finding that extraperitonealization of the ileal conduit is effective for reducing risk of PSH in patients receiving ileal conduit diversion.

Ileal conduit obstruction secondary to tethering of the small bowel anastomosis to the pubic bone

We present the case of a late 60s male who presented to hospital 3 years postradical cystectomy and ileal conduit diversion with polyuria and acute kidney injury. CT of the kidneys, ureters and bladder (KUB) revealed mild hydronephrosis of a solitary left kidney and a 3-cm calculus in the ileal conduit. The patient subsequently underwent a laparotomy which revealed the cause of obstruction to be tethering of the small bowel anastomosis to the pubic bone. The conduit was excised with the calculus in situ and a new conduit was fashioned. The patient recovered from surgery without complication, and his kidney function improved.

Comparison of Urinary Diversion in Patients With Prostatic Fistula to Those with Localized Radiation Injury After Radiotherapy for the Treatment of Prostate Cancer

OBJECTIVE

To compare characteristics and outcomes in patients who had radiotherapy (RT) for prostate cancer (PCa) and underwent urinary diversion (UD) due to prostatic fistula (Fistula) vs localized radiation injury (Localized).

METHODS

This study was a retrospective single-institution study. Exclusion criteria included follow-up <3 months, large pelvic tumor, and surgery for cancer control. The Fistula group included fistulization outside of the urinary tract (rectal, soft tissue, thigh, pubic symphysis, and extensive necrosis surrounding the prostate). The group Localized had a multitude of problems; however, all were confined to the urinary tract. Patient characteristics, perioperative variables, and outcomes were compared between groups.

RESULTS

Sixty-nine patients were included and had UD from 2009-2022. Median age and time from RT to UD were 73 (interquartile range (IQR) 67.9, 78.1) and 7.3 (IQR 3.2, 12.5) years. There were 29 (42%) and 40 (58%) patients in the Fistula and Localized groups. The Fistula group had a higher rate of abdominal/perineal approach (62.1% vs 12.5%, P <.001), a lower rate of right colon pouch (17.2% vs 40%, P = .043), and a longer operative time (515.7 vs 414.2 minutes, P = .017). Clavien-Dindo complications ≥3 were higher in the Fistula group (44.8% vs 20%, P = .027), including a higher rate of re-operation for recurrent pelvic abscess (37.9% vs 5%, P <.001). Survival for the cohort was 85.5% and did not differ between groups.

CONCLUSION

Patients with prostate fistula after RT for PCa undergoing UD had longer, more complex operations, and higher rates of complications, notably post-operative pelvic abscesses, compared to men with localized RT injury. Long-term survival was comparable in both groups.

Comparison of perioperative outcomes and complications between intracorporeal, extracorporeal, and hybrid ileal conduit urinary diversion during robot-assisted radical cystectomy: a comparative propensity score-matched analysis from nationwide multi-institutional study in Japan

BACKGROUND

To investigate the impact of different urinary diversion (UD) techniques on the peri- and postoperative complications of robot-assisted radical cystectomy (RARC) with ileal conduit.

METHODS

We retrospectively analyzed 373 patients undergoing RARC with ileal conduit at 11 institutions in Japan between April 2018 and December 2021. Propensity score weighting was performed to adjust for confounding factors such as age, sex, body mass index, performance status, American Society of Anesthesiologists score, previous abdominal surgery, neoadjuvant chemotherapy, and preoperative high T stage (≥ cT3) and high N stage (≥ cN1). Perioperative complications were then compared among three groups: extracorporeal, intracorporeal, and hybrid urinary diversion (ECUD, ICUD, and HUD, respectively).

RESULTS

A total of 150, 68, and 155 patients received ECUD, HUD, and ICUD, respectively. Bowel reconstruction time and UD time were significantly shorter in the ECUD group (p < 0.001), and console time was significantly longer and blood loss was significantly higher in the ICUD group (p < 0.001). For postoperative complications (Clavien-Dindo Classification grade ≥ 3), surgical site infection (p = 0.004), pelvic abscess (p = 0.013), anastomotic urine leak (p = 0.007), and pelvic organ prolapse (p = 0.011) significantly occurred in the ECUD group. For all grades, ileus was more common in the HUD group, whereas anastomotic stricture was more common in the ECUD group compared with the other groups (p < 0.05).

CONCLUSIONS

Severe complications did not increase after HUD and ICUD compared with ECUD; however, console time tended to be longer and blood loss was slightly higher during RARC.

Clinical efficacy and safety of percutaneous drainage for post-operative fluid collection in patients with bladder cancer undergoing radical cystectomy and urinary diversion

To evaluate the success rates of percutaneous drainage for fluid collection after radical cystectomy, with emphasis on factors affecting the clinical success, including lesion, patient, and procedure characteristics. In this retrospective study, 31 percutaneous drainage catheters were placed in 29 consecutive patients between January 2021 and September 2023. Most fluid collections formed near the uretero-ileal anastomosis site in the right pelvic cavity (80.6%). The technical success rate was 100%. The primary and final clinical success was 80.6% and 96.9%, respectively. Lymphoceles notably increased the primary clinical failure risk (odds ratio and 95% confidential interval: 22.667 (1.839-279.366), P = .015). Significant differences were observed between transabdominal and transgluteal approaches in terms of fluoroscopic time, dose, and location. Leakage indications on computed tomography prompted differing interventions, but all achieved final clinical success. Percutaneous drainage for post-operative fluid collection is safe and effective in patients with radical cystectomy and urinary diversion.

Ileal conduit to small intestine fistula following extensive abdominopelvic resection and radiation for metastatic colon cancer

A woman in her mid-60s presented with decreased output from urostomy, which was an opening from the neobladder (ileal conduit). Presentation was preceded by a 6-month history of alternating faecaluria and increased colostomy output. Laboratory studies were notable for normal anion gap metabolic acidosis. Creatinine level of the colostomy output was 17.7 mg/dL, a finding indicative of the presence of urine in the sample. CT enterography and X-ray loopogram confirmed neobladder to small intestine fistula.Neobladder creation is commonly performed in patients with bladder cancer requiring resection. Fistulas between the neobladder and intestine are observed in fewer than 2.7% of cases. The patient's history of extensive abdominopelvic resection, colostomy creation and radiation likely contributed to fistula development. We highlight the need for a high index of suspicion for a fistula in a patient with a neobladder experiencing recurrent urinary tract infections or a high colostomy output concurrently with low neobladder output.

Three cases of open surgical procedures on ileal conduits for the repair of benign ureteroenteric anastomotic strictures after total pelvic exenteration of rectal tumors

Ureteroenteric anastomotic strictures (UEAS) are typical complications after creating an ileal conduit for total pelvic exenteration (TPE) of rectal tumors. We report the ileal conduit for reconstruction in three patients, in the age-range of 47-73 years. Case 1 was when a left-sided UEAS had sufficient length of ureter for anastomosis, Case 2 was a right-sided UEAS with sufficient length of ureter for anastomosis, and Case 3 was a left-sided UEAS with insufficient length of ureter for anastomosis. There were no complications after operation and no recurrence of UEAS. It is important to learn the open surgical procedures for repair of a benign UEAS after TPE of rectal cancers. This has fewer complications and is safe in the long term.

What do we see when we do not see the bladder? Review of the main urinary diversion techniques and their complications

OBJECTIVE

To review the different types of urinary diversion surgeries (UDS) in order to recognize the expected findings in a postoperative study, using different imaging techniques. To recognize the main postoperative complications, both early and late.

CONCLUSION

UDS are surgical procedures whose purpose is to redirect urine flow after cystectomy, generally in an oncologic context. The imaging evaluation of urological surgeries is often a radiological challenge, with CT being the most commonly used image modality. Therefore, it is essential to know the main surgical techniques, the expected postoperative findings and the optimization of imaging techniques for early diagnosis and correct evaluation of postoperative complications.

The effect of body mass index on quality of life in modified single stoma cutaneous ureterostomy or ileal conduit after radical cystectomy

OBJECTIVE

To explore the influence of postoperative body mass index (BMI) change on postoperative quality of life (QOL) in patients undergoing radical cystectomy (RC) plus modified single stoma cutaneous ureterostomy (MSSCU) or ileal conduit (IC).

METHODS

Patients were divided into two groups according to different BMI change patterns: patients experiencing an elevated postoperative BMI level, along with a clinically significant increase in their BMI (an increase of more than 10%) were categorized as Group 1, while patients experiencing a decrease postoperative BMI level, along with a clinically significant reduction in their BMI (a decrease of more than 5%) were categorized as Group 2. Spearman correlation analysis was used to examine the correlations between quality-of-life scores and postoperative clinical parameters.

RESULTS

Spearman correlation analysis showed that postoperative BMI, late complications and catheter-free state were significantly associated with postoperative global QoL and symptom scale in MSSCU and postoperative global QoL and physical scale in IC patients. Additionally, postoperative BMI, catheter-free state and the use of adjuvant therapy were associated with bad performance in many scales of QoL like body image, future perspective, social scale, future perspective (MSSCU), and abdominal bloating (IC) (Table 2, p<0.05). Patients in Group 2 with significant weight loss had a better Global QoL, a lower rate of stomal stricture and a higher catheter-free state compared with those in Group 1 in both IC and MSSCU patients. MSSCU patients in Group 2 could achieve a comparable Global QoL as to IC patients in Group 1.

CONCLUSION

Controlling the substantial increase in body weight after surgery contributes to improving QoL, reducing the occurrence of stomal stricture, and ensuring a postoperative catheter-free state in BCa patients undergoing MSSCU.

Robot-Assisted Repair of Ureteroenteric Strictures After Cystectomy with Urinary Diversion: Technique Description and Outcomes from the European Robotic Urology Section Scientific Working Group

Background: Robot-assisted repair of benign ureteroenteric anastomotic strictures (UAS) provides an alternative to the open approach. We aimed to report short-, medium-, and long-term outcomes for robotic repair of benign UAS, and to provide a detailed video demonstration of critical operative techniques in performing this procedure robotically. Materials and Methods: Between January 2013 and September 2022, 31 patients from seven institutions who previously underwent radical cystectomy and subsequently developed UAS underwent robotic repair of UAS. Perioperative variables were prospectively collected, and postoperative outcomes were assessed. The surgery starts with a lysis of adhesions after previous surgery. Ureters are dissected, and the level of the stricture is identified. The ureter is then divided, and the stricture is resected. Finally, the ureter is spatulated and reimplanted with Nesbit technique after stenting with Double-J stents. In cases where both ureters show strictures, Wallace technique for reimplantation can be applied. Results: After robotic or open cystectomy, 31 patients had a total of 43 UAS at a median (interquartile range) follow-up of 21 (9-43) months. Median stricture length was 2.0 (1.0-3.25) cm, operative duration was 141 (121-232) minutes, estimated blood loss was 100 (50-150) mL, and length of hospital stay was 5 (3-9) days. One (3.2%) case was converted to open and one (3.2%) intraoperative complication occurred. Seven (22.6%) patients experienced postoperative complications, including four (12.9%) Clavien-Dindo grade 3 complications. No Clavien-Dindo grade 4 or 5 complications occurred. Stricture recurrence occurred in 2 (6.5%) patients. Conclusions: These results demonstrate that robotic repair of UAS is feasible and effective approach with outcomes in line with prior open series. Patient Consent Statement: Authors have received and archived patient consent for video recording and publication in advance of video recording of procedure.

Incidence and predictors of deep incisional and organ/space surgical site infection following radical cystectomy

OBJECTIVE

To investigate clinical risk factors associated with postoperative deep incisional or organ/space surgical site infections (SSI) following radical cystectomy (RC) in a well characterized and large contemporary cohort.

METHODS

We used the American College of Surgeons National Surgical Quality Improvement Program database to identify adult patients who underwent RC for bladder cancer between 2015 and 2020 (n = 13,081). We conducted multivariable-adjusted logistic regression and Cox adjusted proportional hazards regression analysis to identify clinical predictors of deep incisional or organ/space SSI in the 30-day postoperative-period following RC.

RESULTS

Deep incisional or organ/space SSI risk increased with continent urinary diversion (HR = 1.61, 95% CI: 1.38-1.88; P < 0.001), obesity (HR = 1.60, 95% CI: 1.35-1.90; P < 0.001), diabetes mellitus (HR = 1.30, 95% CI: 1.13-1.51; P < 0.001), and being functionally dependent before surgery (HR = 2.09, 95% CI: 1.44-3.03; P < 0.001).

CONCLUSIONS

Postoperative deep incisional or organ/space SSIs following RC occur more frequently in patients who were obese, diabetic, functionally dependent before surgery, and those who underwent continent urinary diversion. These findings may assist urologists in preoperative counseling, medical optimization, and choice of urinary diversion approach, as well as improved patient monitoring and identification of candidates for intervention postoperatively.

Self-esteem and quality of life in patients with neurogenic dysfunction and continent urinary diversion and/or procedures for anterograde enemas

INTRODUCTION AND OBJECTIVE

The importance of evaluating the self-esteem and quality of life of patients with a chronic disease has become increasingly relevant. The study describes self-esteem and quality of life outcomes in patients with neurogenic dysfunction and continent urinary diversions and/or antegrade enema procedures.

MATERIALS AND METHODS

Cross-sectional observational study, including patients with neurogenic dysfunction who required a continent urinary diversion and/or an antegrade enema conduit during their treatment. The self-esteem evaluation was done with the Rosenberg scale and the quality of life with the KIDSCREEN-27 questionnaire.

VARIABLES MEASURED

socio-demographic, clinical and economic characteristics. Descriptive statistics were applied.

RESULTS

The mean age of the 9 patients was 15.6 years, the mean time elapsed from surgery to application of the questionnaires was 60.9 ± 37.1 months. With a perception of improvement in 8 of the 9 patients and a normal or higher self-esteem score in all cases. In the description of physical activity and health, it was found that 7 of the 9 young people presented a perception of good health in general. A considerable reduction in the use of diapers was achieved after the intervention, going from consuming 6.2 ± 1.4 diapers per day to only 1.7 ± 1.3 diapers per day.

CONCLUSIONS

Despite the sequelae, comorbidities and procedures, the results of self-esteem and quality of life in patients with neurogenic dysfunction are high.

Robot-assisted radical cystectomy with intracorporeal urinary diversion: a Danish 11-year series

OBJECTIVES

To evaluate the oncological and perioperative outcomes from a large, single-centre, robot-assisted radical cystectomy (RARC) cohort performed with intracorporeal urinary diversion (ICUD).

PATIENTS AND METHODS

Patients who underwent RARC because of bladder cancer or recurrent carcinoma in situ from June 2009 until August 2020 at Herlev and Gentofte Hospital were prospectively and consecutively included. Kaplan-Meier survival analysis was used to estimate recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). A Cox proportional hazards model was used to identify individual predictors of outcomes. Multiple logistic regression analysis was used to identify predictors of high-grade complications (Clavien-Dindo Grade ≥III).

RESULTS

A total of 542 patients were included. The median (interquartile range) follow-up was 5.3 (2.73-8.06) years. In all, 78 patients (14%) were converted to open surgery; 15 (3%) during cystectomy and 63 patients (12%) were converted from ICUD to extracorporeal urinary diversion. The 5-year RFS, CSS and OS rates were 63% (95% confidence interval [CI] 59%-68%), 75% (95% CI 72%-80%) and 67% (95% CI 63%-72%), respectively. Pathological non-organ-confined disease (tumour stage >T2 or positive lymph nodes) predicted poorer RFS, CSS and OS. Reconstruction with a neobladder (20% of cases) compared to an ileal conduit was the only predictor of high-grade complications (odds ratio 2.54, 95% CI 1.46-4.43; P < 0.001).

CONCLUSION

A RARC with ICUD is feasible as a standard surgical procedure for bladder cancer with only a few patients converted to open surgery. In our hands reconstruction with a neobladder was a strong predictor for high-grade complications.

Mini-percutaneous nephrolithotomy versus retrograde intrarenal surgery for the treatment of 10-20-mm kidney stones in patients with ileal conduit: a comparative study

BACKGROUND

Both mini-percutaneous nephrolithotomy (mPNL) and retrograde intrarenal surgery (RIRS) are two major strategies for the endourological management of kidney stones. In the current study, we aimed to compare the efficacy and safety of mPNL and RIRS for the treatment of 10-20 mm kidney stones in patients with ileal conduit.

METHODS

Patients with a history of bladder cancer and ileal conduit who had undergone mPNL or RIRS for unilateral kidney stones 10-20 mm in size between January 2015 and June 2022 were retrospectively included. Baseline characteristics and perioperative outcomes were analyzed and compared between mPNL and RIRS.

RESULTS

The failure rate of the initial surgery was 2.5% and 18.9% for mPNL and RIRS, respectively (P=0.025). In total, 39 and 30 patients were finally included in the mPNL and RIRS groups. One-session stone-free rate (SFR) was higher in the mPNL group than the RIRS group (97.4% vs. 66.7%, P=0.002). However, there was no statistically significant difference between the two groups with regard to operation time, postoperative hospitalization, complications according to Clavien-Dindo classification, as well as the change in hemoglobin, creatinine, procalcitonin, and pain Visual Analogue Scale Score before and after the surgery. Moreover, Results were consistent across subgroup analyses in patients stratified by years (2015-2018 and 2019-2022).

CONCLUSIONS

Both mPNL and RIRS were feasible and safe for the treatment of 10-20 mm kidney stones in patients with ileal conduit. However, mPNL achieved superior SFR outcomes with a similar incidence of complications, and it might be a sensible alternative for selected patients.

Management of urinary incontinence after radical cystectomy and orthotopic neobladder: A scoping review of international practices

OBJECTIVES

To identify and describe international practice in incontinence management after radical cystectomy and orthotopic neobladder.

MATERIALS AND METHODS

A systematic scoping review following the methodology of the Joanne Briggs Institute was conducted in which the application searched 15 data sources to identify papers published in English, from 1979 to 2022.

RESULTS

Of the 16 papers that met the eligibility criteria, articles in Eastern countries mainly focus on the effect of conservative treatment, while in Western countries, more attention is paid to the effect of surgical treatment. Clinical characteristics of patients included conservative treatment failure, duration of post-operative intervention and unique differential treatment of male and female patients. Reported factors influencing the achievement of urinary incontinence (UI) include lack of evidence to guide management practice, limited value of conservative treatment, high risk of surgical treatment and uncertainty of efficacy; currently, early behavioural research and multimodal rehabilitation training have good results.

CONCLUSIONS

UI in neobladder patients is a distressing condition that is difficult to treat and often requires high-quality rehabilitation guidance and surgical intervention. Further research to address current knowledge gaps is important to inform practice.

Postsurgery Opiate Use Is Significantly Lower in Patients With Interstitial Cystitis/Bladder Pain Syndrome Following Cystectomy With Urinary Diversion

OBJECTIVE

To compare pre-and post-operative opiate use in a large cohort of interstitial cystitis/bladder pain syndrome (IC/BPS) patients who underwent cystectomy with urinary diversion (CWUD).

METHODS

A retrospective analysis was completed using a database of IC/BPS patients who underwent CWUD at a single institution from 2014 to 2022. In addition to demographic information, bladder capacity and Hunner lesion status were documented for each patient. Opiate use (milligram morphine equivalents [MME]) was calculated for each patient and change in MME (ΔMME) was calculated by subtracting pre-CWUD MME from post-CWUD MME. Paired t test was used to compare ΔMME for all parameters except age, where a Pearson's correlation was used.

RESULTS

The analysis included 82 patients (17 M; 65 F) that underwent CWUD as follows: 53 ileal conduit diversions, 11 neobladders, and 18 Indiana Pouches. Mean pre-CWUD MME use was 4509.57 and mean post-CWUD MME was 1788.48 with a ΔMME of - 2721.09 (P < .001). ΔMME was not significantly different based on gender (P = .597), bladder capacity (P = .754), age (P = .561), or Hunner lesion status (P = .085).

CONCLUSION

IC/BPS patients using opiates primarily for relief of pain directly related to their condition show a significant decrease in opiate use following CWUD, which likely represents significant pain reduction and implicates the bladder as the primary source of that pain.

Factors associated with urinary diversion and fatality of hospitalised acute pyelonephritis patients in France: a national cross-sectional study (FUrTIHF-2)

Acute pyelonephritis (AP) epidemiology has been sparsely described. This study aimed to describe the evolution of AP patients hospitalised in France and identify the factors associated with urinary diversion and fatality, in a cross-sectional study over the 2014-2019 period. Adult patients hospitalised for AP were selected by algorithms of ICD-10 codes (PPV 90.1%) and urinary diversion procedure codes (PPV 100%). 527,671 AP patients were included (76.5% female: mean age 66.1, 48.0% Escherichia coli), with 5.9% of hospital deaths. In 2019, the AP incidence was 19.2/10,000, slightly increasing over the period (17.3/10,000 in 2014). 69,313 urinary diversions (13.1%) were performed (fatality rate 6.7%), mainly in males, increasing over the period (11.7% to 14.9%). Urolithiasis (OR [95% CI] =33.1 [32.3-34.0]), sepsis (1.73 [1.69-1.77]) and a Charlson index ≥3 (1.32 [1.29-1.35]) were significantly associated with urinary diversion, whereas E. coli (0.75 [0.74-0.77]) was less likely associated. The same factors were significantly associated with fatality, plus old age and cancer (2.38 [2.32-2.45]). This nationwide study showed an increase in urolithiasis and identified, for the first time, factors associated with urinary diversion in AP along with death risk factors, which may aid urologists in clinical decision-making.

Negative Pressure Wound Therapy for Patients With Complicated Mucocutaneous Separation Following Ileal Conduit Urinary Diversion: A Case Series

BACKGROUND

Mucocutaneous separation (MCS) is one of the early stomal complications of ileal conduit diversion after radical cystectomy. It can result in abdominal infection and sepsis, prolonging patient recovery. Negative pressure wound therapy (NPWT) has been widely used for abdominal wounds after orthopedic and burn surgery. This case series describes its use in complicated MCS and ostomy retraction after ileal conduit diversion.

CASES

We describe a case series of 3 patients with moderate to severe MCS with and without infection after robot-assisted radical cystectomy with ileal conduit diversion. Our patients were treated with NPWT to avoid infection and create a satisfactory environment for healing MCS. After 2 to 4 weeks of NPWT, all 3 patients had normal micturition function with no additional peristomal wounds or complications.

CONCLUSION

Negative pressure wound therapy may be used in the management of complicated MCS after ileal conduit diversion.

Voiding and renal function 10 years after radical cystectomy and orthotopic neobladder in women

OBJECTIVES

To assess long-term voiding and renal function (RF) changes after radical cystectomy (RC) and orthotopic neobladder (ONB) surgery in women without disease recurrence.

MATERIAL AND METHODS

Women who underwent RC and ONB reconstruction between 1995 and 2011 were included in this study. Patients who developed disease failure or were lost to follow-up were excluded. The study outcomes were long-term voiding function and the incidence and predictors of RF deterioration (defined as >20% decline of baseline). Analysis was performed using the log-rank test and Cox regression analysis.

RESULTS

The study included 195 patients with a median (interquartile range) follow-up of 98 (53-151) months, of whom 95 had >10 years of follow-up. Daytime continence, night-time continence and chronic urine retention (CUR) were identified in 170 (87%), 134 (69%) and 52 patients (27%), respectively. Among patients with >10 years of follow-up, 82 (86%), 66 (70%) and 31 (33%) had daytime continence, night-time continence and CUR at the last follow-up visit, respectively. RF deterioration events occurred in 74 patients throughout the follow-up and chronic kidney disease (CKD) stage III-V developed in 80 patients. Patients' age (hazard ratio [HR] 1.41, 95% confidence interval [CI]1.06-1.89; P = 0.02) and serous-lined extramural tunnel diversion (HR 0.43, 95% CI 0.19-0.86; P = 0.02) were the independent predictors of RF deterioration. Among patients with >10 years of follow-up, RF deteriorated in 46 patients (49%) and CKD stage III-V developed in 40 (42%).

CONCLUSION

Women surviving more than 10 years after RC and ONB maintained acceptable continence status, apart from having a higher CUR rate, compared to those followed for <10 years. However, RF deterioration developed in nearly half of them.

Long-term oncologic and functional outcomes following robot-assisted radical cystectomy and intracorporeal Padua ileal bladder: results from a single high-volume center

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.

Renal function change after radical cystectomy for urothelial carcinoma patients with a solitary kidney may be independent of urinary diversion type

PURPOSE

To compare renal function change by urinary diversion (UD) type (ileal conduit [IC] vs. neobladder [NB]) in patients with a single kidney who underwent radical cystectomy (RC) due to bladder cancer.

MATERIALS AND METHODS

We evaluated the renal function change in 86 patients with a single kidney who underwent RC between January 1999 and August 2022. Renal function was assessed using serum creatinine, serum estimated glomerular filtration rate (eGFR), eGFR difference value (preoperative and follow-up values), and eGFR difference proportion (eGFR difference value/preoperative eGFR) at 1, 3, 6, 12, 24, 36, 48, and 60 months. In addition, multiple definitions of eGFR decline were evaluated: 10 points, 10%, and 20% decline in eGFR. Cox regression models were used to identify risk factors of eGFR decline-free, recurrence-free, overall, and cancer-specific survival rates.

RESULTS

A total of 54 patients (62.8%) underwent IC, whereas 32 (37.2%) underwent NB. Baseline characteristics were similar between the two groups except for age and body mass index. Renal functions over time by various methods did not differ significantly between the IC and NB groups. Furthermore, eGFR decline-free survival rate using different definitions was similar between the IC and NB groups. Overall survival, recurrence-free survival, and cancer-specific-free survival rates were not different between the IC and NB groups.

CONCLUSIONS

UD type (IC vs. NB) did not impact the renal function change of patients with a single kidney who underwent RC. Therefore, patients with a single kidney might be considered to be an indication of NB.

Prospective evaluation of functional outcomes in 395 patients with an ileal neobladder 1 year after radical cystectomy

PURPOSE

This study aims to report on functional outcomes in a large cohort of patients who underwent inpatient rehabilitation (IR) in a highly specialized, high-volume German urologic rehabilitation center after radical cystectomy (RC) and creation of an ileal neobladder (INB).

METHODS

Data for 842 patients, who underwent three weeks of IR after RC and urinary diversion between April 2018 and December 2019 were prospectively collected. INB patients were surveyed on continence and sexual function. Data were collected at 4 weeks (T1), 6 months (T2), and 12 months (T3) after RC. Multivariate logistic regressions were performed to identify predictors of better functional outcomes.

RESULTS

INB was chosen as urinary diversion in 395 patients (357 male, 38 female). Social continence (maximum of one safety pad/24 h) was reported by 78.3% of men and 64.0% of women at T3. Severe incontinence was reported by 27.3% of men and 44.0% of women. Male sex was identified as an independent predictor for the use of no pads at T3 (OR 4.110; 95% CI 1.153-14.655; p = 0.029). Nerve-sparing surgery was identified as an independent predictor both for the use of only a safety pad (OR 1.918; 95% CI 1.031-3.569; p = 0.040) and good erectile function at T3 (OR 4.377; 95% CI 1.582-12.110; p = 0.004).

CONCLUSION

Urologists should aspire for nerve-sparing surgery. When advising patients before RC, functional outcomes (continence, sexual function) should be given special attention. Women should be counseled on potentially prolonged urinary incontinence.

Annual trends of cystectomy complications: A contemporary analysis of the NSQIP database

INTRODUCTION

Despite significant morbidity, radical cystectomy (RC) is standard of care for muscle invasive bladder cancer, certain high-risk nonmuscle invasive tumors and after failure of intravesical or trimodal therapy. Modern efforts have hastened the recovery after this surgery without impact on overall complication rates. Our primary aim was to examine changes in complication rates of RC over time.

METHODS

The National Surgical Quality Improvement Program database included 11,351 RC from 2006 to 2018 for nondisseminated bladder cancer. Baseline characteristics and complication rates were studied across time periods: 2006 to 2011, 2012 to 2014, and 2015 to 2018. Thirty-day complications, readmissions, and mortality were identified.

RESULTS

Overall complication rates decreased over time (56.5%, 57.4%, 50.6%, P < 0.01). Infectious complications were stable, including UTIs (10.1%, 8.8%, 8.3% respectively, P = 0.11) and sepsis (10.4%, 8.8%, 8.7% respectively, P = 0.20). On multivariable analysis, ASA≥3 (OR 1.399, 95% CI 1.279-1.530) was associated with increased complications, while procedures in 2015 to 2018 (OR 0.825, 95% CI 0.722-0.942), laparoscopic/robotic approach (OR 0.555, 95%CI 0.494-0.622), and ileal conduit (OR 0.796, 95% CI 0.719-0.882) were associated with decreased complication rates. Other outcomes of interest included mean length of stay (LOS), which decreased over time (10.5, 9.8, 8.6 days, respectively, P < 0.01) and readmission (20.0%, 21.3%, 21.0%, respectively, P = 0.84) and mortality rates were stable (2.7%, 1.7%, 2.0%, respectively, P = 0.13).

CONCLUSION

Decreased early complications and LOS after RC over time may reflect beneficial effects of recent advances in bladder cancer treatment such as enhanced recovery after surgery protocols and minimally invasive techniques. Further opportunities to improve long term outcomes, readmissions and infection rates are needed.

[Long-term results of ureteral replacement using small bowel in patients with long strictures: 9-years single-center experience]

INTRODUCTION

When reconstructing long ureteral strictures, the optimal substitution material is reconfigured pelvis or bladder flaps. However, it is not always possible to use them due to involvement in the pathological process or insufficient length to replace the defect. In such cases, substitution of the ureter by ileal segment is successfully used.

MATERIALS AND METHODS

A total of 25 patients, 10 men (40%) and 15 women (60%), who undergone to reconstructive procedure during the period from 2012 to 2021 with a follow-up period of at least 6 months (mean 51.26 months) were included in the retrospective analysis. Additionally, a comparative analysis was carried out between the laparoscopic and open access according to a set of criteria. The endpoints in the study were the functional state of the kidneys, repeated procedures and development of metabolic disorders.

RESULTS

The average length of the stricture was 10.7 cm (5-20 cm). Eleven patients underwent open approach (44%), while in 14 cases laparoscopic approach was used (56%). Primary procedure was performed in 16 (64%) patients, repeated intervention due to stricture recurrence was performed in 7 (28%) cases, and two patients (8%) underwent bowel substitution of the ureter, implanted into the ileal conduit after radical cystectomy. The average duration of the procedure was 240 min (Q1-186 min, Q3-307 min). For laparoscopic access it was 230 min (Q1-186 min, Q3-292 min) compared to 240 min (Q1-202 min, Q3- 312 min) for open access. Complications of the Clavien I grade developed in 5 cases (20%). With a minimally invasive approach, the length of stay in hospital was 6 days (5-6), including 0.7 days (0-1) in the intensive care unit. The average number of drains after laparoscopic procedure was 1.3 (0-2), and the drains were removed in average after 4.4 days (3-5). With open access, the median length of stay was 8 (5-11), including 2 days (1-5) in the intensive care unit. The number of drains was 1.6 (1-2), and the drains were removed in average after 4 days (3-5). Thirteen patients were undergone to follow-up examination until discharge. Regression of dilatation of the pelvicaliceal system was noted in 12 patients (92.3%). Among them, renal function stabilized in 8 (61.5%), improved in 4 (30.8%) and deteriorated in 1 case (7.7%). Clinically significant metabolic acidosis was detected in 1 patient (7.7%).

CONCLUSION

Substitution of the ureter by ileal segment showed satisfactory results in long-term follow-up.

[A Study of Retrograde Ureteroscopic Lithotripsy with Ureteral Access Sheath for Urinary Calculus After Ileal Conduit Construction]

We retrospectively evaluated the safety and effectiveness of retrograde ureteroscopy via ileal conduit construction. Between January 2014 and December 2021, 5 patients (8 procedures) with ileal conduit construction received retrograde ureteroscopic lithotripsy with a 11/13 Fr ureteral access sheath. At postoperative 1 month, a plain computed tomography (CT) and kidney, ureter, and bladder X-ray (KUB) were performed to assess stone fragmentation and hydronephrosis. According to postoperative imaging, stone-free was defined as residual fragments of 4 mm or less on KUB and 2 mm or less on CT. The mean stone size was 11 mm (6-13 mm). The mean stone volume was 1. 51 ml (0.33-2.56 ml). The mean operative time was 91 min (60-133 min). SFR was 100% on KUB and 87.5% on CT. One procedure (12.5%) resulted in a postoperative fever greater than 38.5℃. There were no complications of grade III or higher according to the modified Clavien-Dindo classification. No exacerbation of hydronephrosis was observed on CT. Retrograde ureteroscopy with a ureteral access sheath was found to be effective for urolithiasis in patients with ileal conduit.

Surgical management of parastomal hernia following radical cystectomy and ileal conduit: A french multi-institutional experience

BACKGROUND

Parastomal incisional hernia (PH) is a frequent complication following the creation of an ileal conduit (IC), and it can be a significant detriment to quality of life. The aim of this study was to evaluate outcomes of PH repair following IC for urinary diversion.

METHOD

A multicenter retrospective study was conducted of 6 academic hospitals in France. The study's population included patients who underwent surgical treatment for parastomal hernia following IC creation from 2013 to 2021.

RESULTS

Fifty-one patients were included in the study. Median follow up was 15.3 months. Eighteen patients presented with a recurrence (35%), with a median time to recurrence of 11.1 months. The vast majority of PH repair was performed through an open approach (88%). With regard to technique, Keyhole was the most reported technique (46%) followed by Sugarbaker (22%) and suture only (20%). The Keyhole technique was associated with a higher risk of recurrence compared to the Sugarbaker technique (52% vs 10%, p = 0.046). Overall, there was a 7.8% rate of major complications without a statistical difference between PH repair techniques for major complications.

CONCLUSION

Surgical treatment of parastomal hernia following IC was associated with a high risk of recurrence. Novel surgical approaches to PH repair should be considered.

Ileal Ureter Utilization in Patients With Previous Urinary Diversions

OBJECTIVE

To evaluate a subset of patients who develop strictures requiring Ileal Ureter (IU) in the setting of prior urinary diversion or augmentation (ileal conduits, neobladders, continent urinary diversions). To our knowledge, there are no prior studies on patients with IU substitution into established lower urinary tract reconstructions.

METHODS

A retrospective review of patients (18 years) undergoing IU creation from 1989 to 2021 was performed. A total of 160 patients were identified. In total, 19 (12%) patients had IUs into diversions. We examined demographics, stricture cause, diversion type, renal function, and postoperative complications.

RESULTS

Nineteen patients were identified. Sixteen were male. Mean age was 57.7(SD 17.0) years. Diversions included continent urinary reservoirs (4), neobladders (5), ileal conduits (7), and bladder augmentations with Monti channels (3). Fifteen had unilateral surgery, and 4 had bilateral "reverse 7" IU creation. Average length of stay was 7.6 days (SD 2.9). Average follow-up was 32.9 months (SD 27). Mean preoperative creatinine was 1.5 (SD 0.4); mean postoperative creatinine at most recent follow-up was 1.6 (SD 0.7). There was no significant difference between pre- and postoperative creatinine (P = .18). One patient had a ventriculoperitoneal Shunt infection resulting ventriculoperitoneal shunt externalization, 1 had Clostridium difficile infection potentially causing an entero-neobladder fistula, 2 with ileus, 1 urine leak, and 1 wound infection. None required renal replacement therapy.

CONCLUSION

Patients with urinary diversions and prior bowel reconstructive surgeries with subsequent ureteral strictures are a challenging cohort of patients. In properly selected patients, ureteral reconstruction with ileum is feasible and preserves renal function with minimal long-term complications.

Prevention and management of urinary tract infections after cystectomy

PURPOSE OF REVIEW

To give an overview of the most relevant recent literature about urinary tract infections (UTI) after radical cystectomy and to discuss them in the context of new individualized therapy approaches and possible preventive measures.

RECENT FINDINGS

UTI following radical cystectomy is a common complication associated with significant morbidity and readmission risk. Recent literature focuses on the identification of risk factors and the optimization of management. The risk factors most commonly associated with increased risk for UTI were perioperative blood transfusions and orthotopic neobladder (ONB). Furthermore, the effect of perioperative antibiotic regimens on rates of postoperative infections has been studied, but no consistent significant changes in UTI rates have yet been identified. Guidelines should be based on urologic studies and, wherever appropriate, should be uniform in design to encourage more frequent adherence. Furthermore, understanding the pathomechanisms leading to the development of UTI after radical cystectomy needs to be more central to discussions.

SUMMARY

Uniform definition of UTI, characteristics of bacterial pathogens involved, and type and duration of antibiotics used and identification of clinical risk factors must be the focus of well designed prospective studies to enable reduction of the most common complication after radical cystectomy.

Rapid geriatric screening tools predict inability to manage stoma by oneself after urinary diversion: G8 and IADL-modified G8

INTRODUCTION

This study aimed to evaluate whether functional screening, as assessed by the Geriatric-8 (G8) and the instrumental activities of daily living (IADL)-modified G8, are associated with the inability to manage a stoma by themselves in patients with bladder cancer who underwent robot-assisted radical cystectomy.

MATERIALS AND METHODS

We analyzed a total of 110 consecutive patients with bladder cancer who underwent robot-assisted radical cystectomy and were screened preoperatively using the G8 and the IADL-modified G8 at our institution between January 2020 and December 2022. Patients who could not undergo geriatric screening at the preoperative clinic before surgery and patients who underwent orthotopic neobladder construction were excluded. We evaluated the association between clinical factors, including scores of G8 and IADL-modified G8, and the inability to manage a stoma by oneself. For both G8 and IADL-modified G8, a cutoff value of ≤14 was set.

RESULTS

Of the 110 patients, the median age was 77 years, 92 (84%) patients were male and 47 (43%) patients were unable to manage a stoma by themselves. The geriatric assessment indicated that 64 patients (58%) were classified in the low G8 (≤14) group and 66 patients (60%) were classified in the low IADL-modified G8 (≤14) group. The values of area under the receiver operating characteristic curve for predicting inability to manage stoma by oneself were 0.725 for the G8 and 0.734 for the IADL-modified G8, respectively. Multivariate analysis including the G8 revealed that age ≥ 80, Charlson comorbidity index of ≥3, and G8 ≤ 14 (odds ratio [OR] = 4.9; 95% confidence interval [CI] = 1.8-13.0; P = 0.002) were independent risk factors for inability to manage a stoma by oneself. Likewise, multivariate analysis including the IADL-modified G8 revealed that age ≥ 80, Charlson comorbidity index of ≥3, and IADL-modified G8 ≤ 14 (OR = 5.4; 95% CI = 1.9-14.0; P = 0.001) were independent risk factors for inability to manage a stoma by oneself.

DISCUSSION

Screening using G8 and IADL-modified G8 may predict patients who have difficulty self-managing their stomas.