Radical Cystectomy Cases Research Articles

The association between variant histology and prognostic, histomorphological and clinical aspects of bladder urothelial carcinoma

This study underscores the imperative consideration of histological subtypes and divergent differentiation in accurately estimating bladder urothelial carcinoma prognosis and guiding treatment decisions. A comparative analysis was conducted, examining clinical, histological, and prognostic factors between conventional urothelial carcinoma and urothelial carcinoma with variant histology in a clinical sample. A retrospective analysis of slides and other clinicopathologic data was conducted these cases, with an emphasis on key diagnostic elements. We examined 829 cases of urothelial carcinoma of the bladder, comprising of 744 transurethral resection (TUR) and 85 radical cystectomy (RS) specimens, an analysis that showed that 80.5 % (667 cases) were conventional urothelial carcinoma (CUC) and that 19.5 % (162 cases) exhibited variant histology (hereafter “urothelial carcinoma with subtype histology” [UCSH]). TNM classifications for the RS cases were as follows: 2 cases were stage group 0a, 11 stage group 1, 16 stage group 2, 45 stage group 3a, 2 stage group 3b, 1 stage group 4a, and 8 stage group 4b. Only 2 of the RS cases were found to be non-invasive. Among 744 TUR specimens, 387 were found to have a non-invasive tumor whereas 357 had invasive tumors. The most prevalent subtype in the UCSH group was urothelial carcinoma with squamous differentiation, accounting for 54.3 % (88 cases). Notably, 8.02 % (13 cases) exhibited more than one histological subtype. Papillary configuration, histological grade, lamina propria, muscularis mucosa and serosa invasion, lymphovascular invasion, presence of urothelial carcinoma in situ, and overall survival significantly differed between the UCSH and CUC groups (p < 0.05). However, mean age, gender, tumor size, lymphocytic response, disease-free survival, and survival status did not differ significantly (p > 0.05). Among the UCSH group, lower levels of papillary configuration, higher histological grade, higher degree of lamina propria, muscularis mucosa and serosa invasion, and the presence of carcinoma in situ corresponded to higher percentage of histological subtype morphology (p < 0.05). No significant difference in survival status was observed between the groups with and without subtype histology (p = 0.083). This study found that clinical and histopathological prognostic factors associated with a more aggressive disease were linked to the presence and percentage of histological subtypes. Recognizing histological subtype is crucial for treatment decisions and prognosis prediction in urothelial carcinoma cases with these subtypes.

Surgical outcomes and predictive value for major complications of robot-assisted radical cystectomy of real-world data in a single institution in Japan.

The objective of the study was to describe the surgical outcome of robot-assisted radical cystectomy and predictive factors for major complications in real-world clinical practice at a single institution in Japan. We retrospectively analyzed 208 consecutive patients undergoing robot-assisted radical cystectomy at our institution between 2019 and 2023. Patient and disease characteristics, intraoperative details, and perioperative outcomes were reviewed. Postoperative complications were defined as minor complications (Clavien-Dindo grades 1-2) or major complications (grades 3-5). Predictors of complications were examined using multivariable logistic analysis. Overall, 147 men and 61 women, median age 70 years (interquartile range, 62-77), were included in this study. Median operative time and estimated blood loss were 8.4 h and 185 mL, respectively; 11 patients (5%) received intraoperative blood transfusions. For urinary diversions, ileal conduit, neobladder, and cutaneous ureterostomy were performed in 153 (74%), 49 (24%), and 6 (3%) patients, respectively. Urinary diversions were primarily performed with extracorporeal urinary diversion. In total, 140 complications occurred in 111 patients (53%) within 30 days. Of these patients, 31 major complications occurred in 28 patients, and one perioperative death (0.5%) with a postoperative cardiovascular event. Multivariable analysis showed only prolonged operative time (odds ratio: 4.34, 95% confidence interval: 1.82-10.35, p < 0.01) was the independent risk factor for major complications. This study reports surgical outcomes at our single institution. Prolonged operative time was a significant prognostic factor for major complications. As far as we know, this study reports the largest number of robot-assisted radical cystectomy cases at a single center in Japan.

Surgical outcomes of robot-assisted radical cystectomy in octogenarian or older patients: A Japanese nationwide study.

To evaluate the surgical outcomes of robot-assisted radical cystectomy (RARC) in octogenarian or older patients based on a Japanese nationwide database. The diagnosis procedure combination database was used to extract the data on radical cystectomy cases. Surgical outcomes of RARC in octogenarian or older patients (older group) were initially compared to those of patients younger than 80 years (younger group). Then, the surgical outcomes of RARC in the older group were compared to those of open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) in the same age group. Between 2018 and 2021, 478 RARC cases in the older group and 2257 RARC cases in the younger group were identified. In the older group, ileal conduit, neobladder, and other urinary diversions were carried out in 352 (73.6%), 22 (4.6%), and 104 (21.8%) patients, respectively. In the older group, when compared with the younger group, the complication rate (24.9%), blood transfusion rate (41.4%), and in-hospital mortality (1.4%) were equivalent, while significantly shorter anesthesia time and longer length of stay were observed in the older group (521.0 ± 140.4 min vs. 595.1 ± 141.71 min, p < 0.01, and 32.9 ± 16.8 days vs. 30.6 ± 17.8 days, p = 0.01, respectively). In the comparison of the surgical outcomes of older patients receiving RARC to those receiving ORC (n = 746) and LRC (n = 375), the RARC group had the lowest complication rate and the shortest length of stay, while the shortest anesthesia time was noted in the ORC group. The feasibility of RARC for octogenarian or older patients was demonstrated by the nationwide database study.

Partial and radical cystectomy provides equivalent oncologic outcomes in bladder cancer when combined with adequate lymph node dissection: A population-based study.

To compare the oncologic outcomes of bladder cancer (BCa) patients after partial cystectomy (PC) or radical cystectomy (RC) combined with lymph node dissection (LND). Relevant data from BCa patients who had >3 lymph nodes (LNs) removed were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Different thresholds of LN count in LND were tested to eliminate potential selection bias, and the optimal threshold was applied to screen patients who underwent adequate LND. After propensity score matching, the oncologic outcomes after PC or RC were compared in patients who underwent adequate LND. After preliminary screening, 6,785 BCa cases diagnosed between 2004 and 2015 with removal of > 3 LNs were enrolled in the analysis, including 633 (9.3%) PC cases and 6,152 (90.7%) RC cases. The PC and RC groups presented entirely different profiles in clinical parameters such as sex, T stage, number of lymph nodes (LNs) removed, and adjuvant therapy. In particular, the LN-positive rate and count were higher in the RC group, even after adjusting for other confounding factors. After comparison using different thresholds, the LN positive rate and count were similar when the LN count in LND was restricted to > 12. In patients who had > 12 LNs removed, after propensity score matching, PC and RC presented similar oncologic outcomes. Further exploration found that the prognosis of patients was associated with age, T stage, and the number of positive LNs. PC and RC could provide equivalent oncologic outcomes in BCa when combined with adequate LND. The conclusion needs further validation in future studies.

Open versus robotic-assisted radical cystectomies: A risk analysis.

4593 Background: Radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer, but it comes with significant perioperative risk with half of patients experiencing major postoperative complications. Robot-assisted radical cystectomies (RARC) have aimed to decrease patient morbidity and have become increasingly adopted in North America. Currently, both open radical cystectomies (ORC) and RARC are frequently performed. To contribute to the existing literature using newly available data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP), representing one of the most recent, largest multi-institutional studies, while uniquely accounting for a variety of factors including type of urinary diversion, cancer staging, and neoadjuvant chemotherapy. Methods: RC procedures performed between 2019-2020 were identified in NSQIP and the corresponding Cystectomy Targeted database. Cases in the ORC group were planned open procedures, and cases in the RARC group were robotic with intra- or extracorporeal diversions, including unplanned conversion to open cases for intention-to-treat. Chi-square and t-tests were performed to compare baseline demographics and operative parameters. Multivariate analysis was performed for outcomes including major complications, minor complications, and 30-day mortality, while adjusting for operative approach, medical comorbidities, functional status, age, race, sex, BMI, ASA-classification, preoperative labs, type of urinary diversion, pathological staging, prior pelvic surgery or radiation, need for preoperative transfusion, preoperative sepsis, emergent or elective surgery, and recent chemotherapy. Results: 4,022 RC cases were identified. Of these, 3,146 (78.2%) received planned ORC while 876 (21.8%) received RARC. Baseline demographics of the patients who received ORC versus RARC were largely similar, with no significant difference in age or medical comorbidities. RARC was associated with longer operative times and shorter hospital length of stay compared to ORC. On multivariate analysis, ORC was associated with a higher rate of 30-day mortality [OR 3.1; 95% CI 1.3-7.2; p=0.009], reintubation, cardiac arrest, superficial wound infection, bleeding requiring transfusion [OR 4.7; 95%CI 3.6 - 6.1; p&lt;0.001], prolonged postoperative nasogastric tube use, rectal injury, and ureteral fistula or urine leak compared to RARC. Conclusions: In the NSQIP database, ORC is associated with higher rates of 30- day mortality and operative complications, most notably bleeding, compared to RARC. This study is unique in the size of the cohorts compared, the timeliness of the data (2019-2020), and the ability to control for factors, such as type of urinary diversion, pathological bladder cancer staging, and use of neoadjuvant chemotherapy.

MP60-05 INFECTIOUS COMPLICATION AFTER RADICAL CYSTECTOMY: TIMING AND OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023MP60-05 INFECTIOUS COMPLICATION AFTER RADICAL CYSTECTOMY: TIMING AND OUTCOMES Young Son, Mark Quiring, Benjamin Fink, Virgil Demario, Scott Serpico, Thomas Mueller, and Gordon Brown Young SonYoung Son More articles by this author , Mark QuiringMark Quiring More articles by this author , Benjamin FinkBenjamin Fink More articles by this author , Virgil DemarioVirgil Demario More articles by this author , Scott SerpicoScott Serpico More articles by this author , Thomas MuellerThomas Mueller More articles by this author , and Gordon BrownGordon Brown More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003318.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) with urinary diversion is the primary treatment option for muscle invasive bladder cancer (MIBC) and select patients for non-muscle invasive bladder cancer (NMIBC). Surgical and non-surgical Infection after RC is a devastating complication. Postoperative infection has been shown to increase admission to ICU, increase length of hospital stay, increased readmission and double the mortality rate. We aim to add to the literature of the characteristics, timing, and predilection of infection after RC. METHODS: The ACS NSQIP is a health insurance portability and accountability act (HIPAA) compliant data file containing patient cases from 706 participating hospital institutions. This retrospective study focused on radical cystectomy cases in the NSQIP data set for bladder cancer. Patients with missing data or had multiple infections were excluded. The patients were then subgrouped to surgical site infection (SSI), wound disruption, UTI, and sepsis (sepsis and septic shock). RESULTS: Among the 3955 patients, the rate of SSI, UTI, wound disruption, sepsis/septic shock was 11.9%, 8.1%, 2.1%, and 10.0% (Table). The average days from operation until infectious complications were 15.1 days for organ space SSI, 14.57 days for deep SSI, 14.2 days for superficial SSI, 14.9 days for UTI, 12.2 days for wound disruption, and 13.8 days for sepsis (figure). Multivariable analysis for all infections identified diabetes as an independent variable associated with SSI (p=0.003), UTI (p=0.039), and sepsis/septic shock (p<0.001). Prior pelvic radiation was associated with SSI (p=0.001) and sepsis/septic shock (p=0.012). Furthermore, all infectious etiologies were associated with readmission on multivariable regression. CONCLUSIONS: Infection after radical cystectomy can be an often a serious complication. We identified that the timing of wound disruption to occur earliest while organ space SSI was identified late. Diabetes was associated with all the infectious complications while prior radiation was associated with SSI and sepsis. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e844 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Young Son More articles by this author Mark Quiring More articles by this author Benjamin Fink More articles by this author Virgil Demario More articles by this author Scott Serpico More articles by this author Thomas Mueller More articles by this author Gordon Brown More articles by this author Expand All Advertisement PDF downloadLoading ...

MP46-09 ROBOT-ASSISTED RADICAL CYSTECTOMY UTILIZING THE VERSIUS SYSTEM BY CAMBRIDGE MEDICAL ROBOTICS

You have accessJournal of UrologyCME1 Apr 2023MP46-09 ROBOT-ASSISTED RADICAL CYSTECTOMY UTILIZING THE VERSIUS SYSTEM BY CAMBRIDGE MEDICAL ROBOTICS Ahmed Elsayed, Mahmoud Abdelhakim, Moustafa Abdelraouf, Farouk Algammal, and Ahmed Sharawy Ahmed ElsayedAhmed Elsayed More articles by this author , Mahmoud AbdelhakimMahmoud Abdelhakim More articles by this author , Moustafa AbdelraoufMoustafa Abdelraouf More articles by this author , Farouk AlgammalFarouk Algammal More articles by this author , and Ahmed SharawyAhmed Sharawy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003292.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy remains the most effective treatment for patients with localized, muscle invasive bladder cancer and recurrent / refractory non-muscle invasive disease. We report our experience and perioperative outcomes with 4 cases of robot-assisted radical cystectomy Utilizing the Versius System by Cambridge Medical Robotics. METHODS: Four patients (4 males) underwent robot-assisted radical cystectomy and orthotopic urinary diversion for clinically localized bladder cancer. We utilized the 4 bedside units of the Versius system, camera and two working ports and a second left side arm was used for retraction. Perioperative outcomes were assessed operative details. RESULTS: The mean age was 68 years, the mean operative time was 380 min, console time was 180 min. The mean estimated blood loss was 250 ml, and none required blood transfusion. Conversion to laparoscopy was done in one patient. The mean length of hospital stay was three days. CONCLUSIONS: We report our early experience with robot-assisted radical cystectomy for the treatment of bladder cancer, which seems to provide an acceptable surgical and pathological outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e634 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Elsayed More articles by this author Mahmoud Abdelhakim More articles by this author Moustafa Abdelraouf More articles by this author Farouk Algammal More articles by this author Ahmed Sharawy More articles by this author Expand All Advertisement PDF downloadLoading ...

V06-07 ROBOTIC RADICAL CYSTECTOMY IN RENAL TRANSPLANT PATIENTS: THE INDOCYANINE GREEN (ICG) TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V06-07 ROBOTIC RADICAL CYSTECTOMY IN RENAL TRANSPLANT PATIENTS: THE INDOCYANINE GREEN (ICG) TECHNIQUE Chi Hang Yee, Timothy Chang Kidd Ng, Steffi Kar Kei Yuen, Mandy Ho Man Tam, Jeremy Yuen Chun Teoh, Peter Ka Fung Chiu, Chi Kwok Chan, and Chi Fai Ng Chi Hang YeeChi Hang Yee More articles by this author , Timothy Chang Kidd NgTimothy Chang Kidd Ng More articles by this author , Steffi Kar Kei YuenSteffi Kar Kei Yuen More articles by this author , Mandy Ho Man TamMandy Ho Man Tam More articles by this author , Jeremy Yuen Chun TeohJeremy Yuen Chun Teoh More articles by this author , Peter Ka Fung ChiuPeter Ka Fung Chiu More articles by this author , Chi Kwok ChanChi Kwok Chan More articles by this author , and Chi Fai NgChi Fai Ng More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003274.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The risk of developing bladder cancer in transplant populations is higher compared with the general population. The presence of a graft kidney can be an additional challenge to surgeons when radical cystectomy is contemplated for this group of patients. The study is to review the outcome of robotic radical cystectomy in patients with a graft kidney in-situ by the use of the indocyanine green (ICG) technique. METHODS: Consecutive cases of robotic radical cystectomy in patients with history of renal transplant were reviewed. Pre-operative graft ureter catherterization was performed and robotic radical cystectomy was executed with the aide of ICG to identify the graft ureter in order to preserve its maximal length. Peri-operative and oncological outcome were assessed. RESULTS: Between 2019 to 2022, 3 renal transplant recipients underwent robotic radical cystectomy and intra-corporeal ileal conduit reconstruction, with the indication of pathologically confirmed muscle-invasive disease. One of the patients had robotic bilateral nephroureterectomy performed in the same setting. Mean patient age was 68.0±8.5 years, mean interval between renal transplant and the index cystectomy surgery was 20.0±2.6 years. All patients’ graft were located at the right lower quadrant. Operation time for the patient with additional bilateral nephroureterectomy was 543 minutes. For the other 2 patients, the operation time were 300 minutes and 227 minutes. Mean hospital stay was 7.7±1.2 days. No post-operative complication was observed 3 months after the operation. In all cases, the graft ureter could be identified with the ICG technique. CONCLUSIONS: Robotic radical cystectomy in the setting of renal transplant recipient is a safe alternative to its open surgery counterpart. The ICG technique provides an effective option to identify the graft ureter during dissection in order to gain the maximal length for subsequent reconstruction. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e510 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chi Hang Yee More articles by this author Timothy Chang Kidd Ng More articles by this author Steffi Kar Kei Yuen More articles by this author Mandy Ho Man Tam More articles by this author Jeremy Yuen Chun Teoh More articles by this author Peter Ka Fung Chiu More articles by this author Chi Kwok Chan More articles by this author Chi Fai Ng More articles by this author Expand All Advertisement PDF downloadLoading ...

Differences in overall survival of T2N0M0 bladder cancer patients vs. population-based controls according to treatment modalities.

It is unknown to what extent overall survival (OS) of organ-confined (T2N0M0) urothelial carcinoma of the urinary bladder (UCUB) patients differs from age- and sex-matched population-based controls, especially when treatment modalities such as radical cystectomy (RC), trimodal therapy (TMT), or radiotherapy (RT) are considered. Relying on the Surveillance Epidemiology and End Results database (2004-2018), we identified newly diagnosed (2004-2013) T2N0M0 UCUB patients treated with either RC, TMT or RT. For each case, we simulated an age- and sex-matched control (Monte Carlo simulation), relying on Social Security Administration Life Tables with 5years of follow-up, and compared OS with that of RC-, TMT-, and RT-treated cases. Additionally, we relied on smoothed cumulative incidence plots to display cancer-specific mortality (CSM) and other-cause mortality (OCM) rates for each treatment modality. Of 7153 T2N0M0 UCUB patients, 4336 (61%) underwent RC, 1810 (25%) TMT, and 1007 (14%) RT. At 5years, OS rate in RC cases was 65% vs. 86% in population-based controls (Δ = 21%); in TMT cases, 32% vs. 74% in population-based controls (Δ = 42%); and in RT, 13% vs. 60% in population-based control (Δ = 47%). Five-year CSM rates were highest in RT (57%), followed by TMT (46%) and RC (24%). Five-year OCM rates were the highest in RT (30%), followed by TMT (22%) and RC (12%). OS of T2N0M0 UCUB patients is substantially less than that of age- and sex-matched population-based controls. The biggest difference affects RT, followed by TMT. A modest difference was recorded in RC and population-based controls.

Risk analysis of open vs. robotic assisted radical cystectomy.

576 Background: Radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer, but it comes with significant perioperative risk with half of patients experiencing major postoperative complications. Robot-assisted radical cystectomies (RARC) have aimed to decrease patient morbidity and have become increasingly adopted in North America. Currently, both open radical cystectomies (ORC) and RARC are frequently performed. To contribute to the existing literature using newly available data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP), representing one of the most recent, largest multi-institutional studies, while uniquely accounting for a variety of factors including type of urinary diversion, cancer staging, and neoadjuvant chemotherapy. Methods: RC procedures performed between 2019-2020 were identified in NSQIP and the corresponding Cystectomy Targeted database. Cases in the ORC group were planned open procedures, and cases in the RARC group were robotic with intra- or extracorporeal diversions, including unplanned conversion to open cases for intention-to-treat. Chi-square and t-tests were performed to compare baseline demographics and operative parameters. Multivariate analysis was performed for outcomes including major complications, minor complications, and 30-day mortality, while adjusting for operative approach, medical comorbidities, functional status, age, race, sex, BMI, ASA-classification, preoperative labs, type of urinary diversion, pathological staging, prior pelvic surgery or radiation, need for preoperative transfusion, preoperative sepsis, emergent or elective surgery, and recent chemotherapy. Results: 4,022 RC cases were identified. Of these, 3,146 (78.2%) received planned ORC while 876 (21.8%) received RARC. Baseline demographics of the patients who received ORC versus RARC were largely similar, with no significant difference in age or medical comorbidities. RARC was associated with longer operative times and shorter hospital length of stay compared to ORC. On multivariate analysis, ORC was associated with a higher rate of 30-day mortality [OR 3.1; 95% CI 1.3-7.2; p=0.009], reintubation, cardiac arrest, superficial wound infection, bleeding requiring transfusion [OR 4.7; 95%CI 3.6 - 6.1; p&lt;0.001], prolonged postoperative nasogastric tube use, rectal injury, and ureteral fistula or urine leak compared to RARC. Conclusions: In the NSQIP database, ORC is associated with higher rates of 30-day mortality and operative complications, most notably bleeding, compared to RARC. This study is unique in the size of the cohorts compared, the timeliness of the data (2019-2020), and the ability to control for factors, such as type of urinary diversion, pathological bladder cancer staging, and use of neoadjuvant chemotherapy.

Trends of radical cystectomy and comparisons of surgical outcomes among surgical approaches focusing on robot-assisted radical cystectomy: A Japanese nationwide database study.

To clarify the trends in radical cystectomy and to compare surgical outcomes among surgical approaches focusing on robot-assisted radical cystectomy based on a Japanese nationwide database. The Diagnosis Procedure Combination database was used to extract data on radical cystectomy cases. Trends in open radical cystectomy, laparoscopic radical cystectomy, minimum incision endoscopic radical cystectomy, and robot-assisted radical cystectomy between April 2012 and March 2021 were evaluated. Basic characteristics and peri-operative indicators were compared among the four groups. Propensity score matching was applied to assess the differences between open radical cystectomy and robot-assisted radical cystectomy. During the study period, a decreasing number of open radical cystectomies and an increasing number of minimally invasive radical cystectomies were shown in the total cohort of 28 345 cases. The number of robot-assisted radical cystectomies rapidly increased after government approval in 2018. Minimally invasive radical cystectomies, including robot-assisted radical cystectomies, had a significantly lower complication rate, a shorter length of stay, and a lower blood transfusion rate, but a longer anesthesia time than open radical cystectomies. In the propensity score matching analysis comparing the surgical outcomes of robot-assisted radical cystectomy and open radical cystectomy, similar results were demonstrated, and blood transfusion rates were equivalent. For the past decade, the number of minimally invasive radical cystectomies has steadily increased without compromised surgical outcomes, except for anesthesia time. Robot-assisted radical cystectomies in particular rapidly became widespread in Japan after government approval in 2018 and became a standard surgery within the first 3 years.

Venous thromboembolism risk in patients receiving neoadjuvant chemotherapy for bladder cancer.

There is limited evidence to inform thromboprophylaxis use for patients receiving neoadjuvant chemotherapy prior to surgery in bladder cancer. We sought to determine the incidence of venous thromboembolism (VTE) in patients receiving neoadjuvant chemotherapy and cystectomy. We also assessed if the Khorana score was associated with VTE risk. A retrospective cohort study was performed on consecutive patients who received a radical cystectomy for bladder cancer at The Ottawa Hospital between January 2016 and August 2020. Demographic information, chemotherapy data, operative characteristics, VTE and bleeding outcomes were collected from the start of treatment to 90 days postoperative. A Khorana score was calculated for each patient who received neoadjuvant chemotherapy. The primary outcome for this study was the incidence of VTE from the time the patient started treatment with neoadjuvant chemotherapy until 90 days post-cystectomy. Secondary outcomes included risk factors for VTE during neoadjuvant chemotherapy. Among 181 radical cystectomy cases during the study period, 123 had muscle-invasive disease and 72 (39.8%) received neoadjuvant chemotherapy. Eighteen (25.0%) patients who received neoadjuvant chemotherapy and radical cystectomy developed a VTE from the start of chemotherapy to 90 days postoperative. Thirteen of the 18 VTEs (72%) occurred while the patient was receiving chemotherapy. In multivariable analysis, the only factor associated with a significantly increased risk of VTE was treatment with neoadjuvant chemotherapy (Relative risk (RR) 3.05, 95% confidence interval [CI] 1.16-8.02; P = 0.02). A higher Khorana score was not associated with an increased risk of VTE in patients who received neoadjuvant chemotherapy (RR = 0.33, 95% CI 0.08-1.28, P = 0.11). One (1.4%) patient had a major bleeding event during neoadjuvant chemotherapy. Patients receiving neoadjuvant chemotherapy and radical cystectomy are at very high-risk of VTE. Prospective studies that assess the benefits and harms of pharmacologic thromboprophylaxis in this population are needed.

MP56-14 UTILIZING THE MODIFIED FRAILTY INDEX TO PREDICT OUTCOMES AFTER RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022MP56-14 UTILIZING THE MODIFIED FRAILTY INDEX TO PREDICT OUTCOMES AFTER RADICAL CYSTECTOMY Hannah Jarvis, and Andrew Harris Hannah JarvisHannah Jarvis More articles by this author , and Andrew HarrisAndrew Harris More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002639.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: For patients with muscle invasive bladder cancer radical cystectomy remains the gold standard. There is significant risk associated with this procedure and we aim to evaluate patient characteristics that may predict outcomes following surgery. The modified frailty index (MFI) is used as a tool for predicting morbidity. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) public use files (PUF) between 2012 and 2018 were reviewed for cases of radical cystectomy, with 10,338 total observations. Morbidity was defined by the following 30-day complications: mortality, superficial incisional surgical site infection (SSI), deep incisional SSI, organ/space SSI, wound dehiscence, pneumonia, bleeding requiring transfusion, urinary tract infection (UTI), unplanned intubation, ventilator for more than 48 hours, sepsis, acute renal failure, progressive renal insufficiency, pulmonary embolism, deep vein thrombosis (DVT) or thrombophlebitis, cardiac arrest requiring CPR, myocardial infarction, and stroke with neurological deficit or cerebrovascular accident (CVA). The modified frailty index score is defined on a scale of 1 to 5, with each patient receiving one point per each of their existing comorbidities: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes mellitus, hypertension that requires medication, or a functional status that was not dependent. RESULTS: Variables found to have significant differences when compared to MFI scores include patient age, gender, race, BMI, ASA class, and smoking history. Post-operative variables with statistical significance in relation to MFI scores include LOS, surgical site infection, sepsis, pneumonia, unplanned intubations, need for transfusion, readmission, and returns to the operating room. Under multivariate analysis of morbidity by frailty score, adjusting for all significant patient characteristics and operation duration, significance was found for MFI >2, age >80, male sex, minority race, smoking history, disseminated cancer, and operation duration greater than 320 minutes. CONCLUSIONS: We believe mFI score is an effective pre-operative tool for evaluating potential morbidity in patients with MIBC who are under consideration for radical cystectomy. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e978 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hannah Jarvis More articles by this author Andrew Harris More articles by this author Expand All Advertisement PDF DownloadLoading ...

Treatment trends for muscle-invasive bladder cancer in Germany from 2006 to 2019

PurposeTo examine national treatment trends of muscle-invasive bladder cancer (MIBC) in Germany with a special focus on radical cystectomy (RC).Patients and methodsPopulation-based data were derived from the nationwide hospital billing database of the German Federal Statistical Office and institution-related information from the reimbursement.INFO tool based on hospitals’ quality reports from 2006 to 2019. Additionally, we used the German National Center for Cancer Registry data to analyze all cases of bladder cancer with stage ≥ T2 who received RC, chemotherapy, radiation therapy or a combination from 2006 to 2017.ResultsThe annual number of RC cases in Germany increased by 28% from 5627 cases in 2006 to 7292 cases in 2019 (p = 0.001). The proportion of patients undergoing RC remained constant at about 75% in all age groups between 2006 and 2017 (p = 0.3). Relative to all performed RC, the proportion of patients > 75 years increased from 25% in 2006 to 38% in 2019 (p = 0.03). The proportion of patients receiving a combination of RC and chemotherapy increased from 9% in 2006 to 13% in 2017 (p = 0.005). In 2006, 8 of 299 urology departments (2.7%) performed more than 50 RCs per year, which increased to 17 of 360 (4.7%) in 2019. In 2019, 107 departments (29%) performed 25–49 RCs and 236 (66%) departments performed < 25 RCs.ConclusionIn Germany, three out of four patients with MIBC receive RC and the proportion of patients > 75 years is increasing. The combination of surgery and chemotherapy is increasingly used. With overall increasing case numbers, there is a slight tendency towards centralization.

Upper Tract Urinary Cancer Recurrence after Radical Cystectomy: Risk Assessment of Intraoperative Frozen Section

Introduction: Upper tract urinary cancer recurrence (UTUCR) after radical cystectomy (RC) is outcome-limiting. Surgical recommendations on intraoperative performance of frozen section analysis (FSA) and management of positive ureteral margin (PUM) are lacking. Methods: 634 RC cases were identified (2010–2018). In patients with PUM, sequential ureteral resections up to a negative margin were performed. We investigated the accuracy of FSA, significance of PUM, and identified risk factors (RFs) to stratify patients for UTUCR. Results: FSA was performed in 355 patients, including a total of 693 ureters. FSA sensitivity was 0.93 and specificity 0.99. PUM conversion was possible in 52 (91.2%) cases. UTUCR occurred in 17 (4.8%) patients. Identified UTUCR RFs are non-muscle invasive bladder carcinoma (NMIBC) (OR 3.8, 95% confidence intervals [CI] 1.4–10.2, p = 0.008), multifocal bladder cancer in cystectomy specimen (OR 4.7, CI 1.1–20.8, p = 0.042), and recurrent NMIBC (OR 4.1, CI 1.5–10.9, p = 0.006). Risk-group stratification showed a six-fold increase in UTUCR risk (low-to high-risk). Conclusion: FSA is a sensitive and specific method to identify PUM. UTUCR occurs significantly more often in patients with recurrent, multifocal NMIBC at the time of RC. Patients can be risk stratified for UTUCR. In case of NMIBC-PUM, surgeons can safely opt for a kidney preserving strategy.

Robot-assisted radical cystectomy for bladder cancer: single-center experience

Abstract Objective Radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. Recently some surgeons have begun to describe outcomes associated with less invasive surgical approaches to this disease, such as laparoscopic or robotic assisted techniques. We report our maturing experience with 100 consecutive cases of robotic assisted laparoscopic radical cystectomy regarding perioperative results, pathological outcomes, and surgical complications. Methods A total of 100 consecutive patients (73 male and 27 female) underwent robotic radical cystectomy with intracorporeal urinary diversion at our institution from February 2018 to February 2021 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes, and complication rate. Results The mean age of this cohort was 60.4 years (range 38 to 82). Ninety-five patients underwent ileal conduit diversion, 5 received a neobladder). The mean operating room time for all patients was 184 min (min time was 160 min) and mean surgical blood loss was 286 ml. On surgical pathology, 2% of the cases were pT1, 35% were pT2, 51+12% were pT3/T4 disease and 17% were node positive. The mean number of lymph nodes removed was 16 (range 10 to 40). In no case was there a positive surgical margin. The mean days to flatus were 2.6, bowel movement 2.8 and discharge home 8.2. There were 21 postoperative complications in 20 patients with 4% having a major complication (Clavien grade 3 or higher) and 15% being readmitted within 30 days after surgery. At a mean follow-up of 12 months 3 patients had disease recurrence and died 4 of disease. Conclusions We report a relatively large cohort and maturing experience with robotic radical cystectomy for the treatment of bladder cancer, providing acceptable surgical and pathological outcomes. These results support continued efforts to refine the surgical management of muscle-invasive bladder cancer.

Prognostic significance of EZH2 and ARID1A expression in urothelial carcinoma: an immunohistochemical study

ABSTRACT Enhancer of zeste homolog 2 (EZH2) and AT-rich interactive domain 1A (ARID1A) expression in urothelial carcinoma (UC) has not been well studied. ARID1A is a novel tumor suppressor gene coding for a chromatin remodeling protein that is mutated in urinary bladder cancer. The enhancer of zeste homolog 2 (EZH2) is a transcriptional repressor involved in gene silencing. Amplification of EZH2 has been reported in several malignancies. This study analyzed the immunohistochemical expression of EZH2 and ARID1A in 56 cases of UC that included (n = 21) cases of radical cystectomy and (n = 35) cases of transurethral resections of bladder tumor (TURBT) with muscle fibers and immunotherapy with adjuvant intravesical bacillus Calmette-Guerin (BCG). The predicting role of both markers for tumor recurrence and recurrence-free survival (RFS) was also analyzed. High EZH2 marker expression was observed in 75% of cases while 78.6% of cases had low ARID1A marker expression. There was a significant negative correlation between the two markers where high EZH2 and low ARID1A expression was significantly associated with higher tumor grade, stage, presence of muscle invasion, lymph node metastasis, presence of concomitant carcinoma in situ (CIS) and higher incidence of recurrence with shorter RFS rate. It was concluded that EZH2 and ARID1A play a role in tumor carcinogenesis and differentiation and could be considered as independent prognostic factors in UC and for use as a potential therapeutic target.

A modified ileal conduit technique in patients undergoing radical cystectomy: Single-centre experience

Objective: We aimed to evaluate perioperative outcomes and complications of a modified technique of ileal conduit diversion. Methods: Forty-seven cases of radical cystectomy with modified ileal conduit diversion were performed at our institution from January 2015 to January 2020. After radical cystectomy, a segment of ileum was used to pack the conduit and was placed below the digestive anastomosis. Then, the mesentery window of the ileo-ileal anastomosis was sutured. The ureters were anastomosed on their native side on single loop ureteral stents. All procedures were performed by a single surgical team. Intra- and postoperative complications were classified and reported according to the Satava and Clavien–Dindo grading systems. Results: The mean age of population was 66.40±10.14 years, and 76.6% were male. Concomitant diabetes was found in 31.9% of patients. About three quarters of patients had T2G3 bladder cancer. Mean blood loss was 449.36±246.50 ml, and hospitalization was 10.32±5 days. With a mean follow-up of 17.36±12.63 months, the recurrence rate was 17%, and 14.9% of patients died of bladder cancer. Out of the 47 patients, three (4.3%) experienced intraoperative complications, while 15 (31.9%) had postoperative complications. Of these, only three patients experienced Clavien–Dindo complications ⩾grade 3. Multivariate logistic regression model showed that diabetes ( p=0.023) and higher blood loss ( p=0.010) were significantly associated with an increased risk of postoperative complications. We reported one case of ureterointestinal anastomosis stenosis on the left side and none on the right side. Despite our results being promising, larger randomized trials with longer follow-up are needed to explore further the feasibility of this technique on a larger scale. Conclusion: We describe a safe and simple surgical technique with a similar postoperative complications rate and a lower incidence of ureteroileal anastomosis stenosis compared to the standard technique. Level of evidence 4.

Pathological reporting of cystectomy lymph nodes: a retrospective analysis of experience in Paris

PurposePathological evaluation of pelvic lymph node (LN) dissection (PLND) is important for management of cystectomy patients. However, challenges such as unclear interobserver variability of LN counting remain. Here, we assess interobserver variability of LN measures and their clinical utility, with a focus on variant histology.MethodsWe retrieved radical cystectomy cases with PLND between 2010 and 2016 and reevaluated pathological parameters; number of total and metastatic LN, LN density (LND), length of metastatic LN and metastases, extranodal extension (ENE).ResultsWe report 96 patients: median age of 71a, 34 cases pN+, 36 cases with any extent of variant histology, median follow-up 10 months. Perivesical LN were only rarely identified, but frequently metastatic (4/9). Variant histology (34 cases) frequently exhibited LN metastasis (53% of pN+ cases). Interobserver variance was poor for total LN (kappa = 0.167), excellent for positive LN (0.85) and pN staging (0.96), and mediocre for LND (0.53). ROC analysis suggests that both LND and the sum of LN metastasis length may predict outcome (AUC 0.83 and 0.75, respectively).ConclusionOur study confirms the notion of LND as a prognostic measure, but cautions due to strong interobserver variance of LN counts. The sum length of LN metastases could be a measure that is independent of LN counts. We find that microscopically identified perivesical LN merit particular attention. In summary, our study highlights current challenges in pathological reporting of PLND, confirms previous observations and forms a basis for further studies.

Radical Cystectomy With Urinary Diversion in the Form of Ileal Conduit : Outcome Analysis in 15 Cases Done by Single Surgeon

Objective: To analyse the outcome of 15 cases of radical cystectomy with urinarydiversion in the form of ileal conduit done by single surgeon. Methods: This retrospective study included 15 cases of radical cystectomy with urinarydiversion in the form of ileal conduit between 2014 and 2018 done by single surgeon indifferent hospitals. Follow up of these patients continued up to June 2018.Data werecollected through follow up visits at every 3 months interval in the first year, and then forevery 6 months from the second year. Results: In this study, the mean age was 67.67 years. Early complications like wounddehiscence, wound infection, bowel obstruction and GIT bleeding occurred in 47%patients and maximum were wound dehiscence (20%) and wound infection (13.3%).High incidence of early complications in this study may have multiple reasons likepreoperative co-morbidity, small sample size study and lastly surgeons learning curvebecause in early phase, complications occurred in 63% cases but only 29% cases inlate phase.Seven patients (46.7%) developed ED postoperatively. Recurrent UTI was recorded in33.3% cases. During mean 2.4 years follow up time, there was no local recurrence. Conclusions: Radical cystectomy for the muscle invasive urothelial bladder cancer isthe elective treatment and urinary diversion in the form of ileal conduit is a safe andconvenient option with less post operative complications and with good oncologicaloutcome. But for better evaluation of post operative outcomes, large sample size andlong term follow up are recommended. Bangladesh Journal of Urology, Vol. 22, No. 1, January 2019 p.63-68