Consecutive Patients Undergoing Radical Cystectomy Research Articles

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 32months, 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.

Stent-free rates in cutaneous ureterostomy urinary diversion after radical cystectomy.

Cutaneous ureterostomy (CU) urinary diversion after radical cystectomy has been relegated to highly comorbid patients due to presumed rates of stenosis and drainage tube dependence. Rates of stricture as high as 70% have been reported. Though a variety of techniques have been developed to obviate the need for prolonged stenting, CU remains uncommonly performed. Herein, we present our experience with CU diversion after radical cystectomy and stent-free rates post-operatively. We retrospectively reviewed the records of consecutive patients undergoing radical cystectomy with single-stoma cutaneous ureterostomy from June 2020 to December 2022 at our institution. Demographic and clinical data were summarized. We recorded the presence of ureteral stent, nephrostomy, or nephroureteral catheter at the last follow-up. The primary outcome was "stent-free survival" incorporating all modalities of tube-dependent urinary drainage. Kaplan-Meier analysis was performed to determine stent-free survival at 12months. We identified 28 patients meeting inclusion criteria with median age of 73years (IQR: 66-78) and median body mass index of 25 (IQR: 22-28). Of patients that underwent stent-free trial (N=23), thestent-free survival at 12months was 74%. Five of 28 patients had continued tube dependence due to locally advanced disease with hydronephrosis rather than CU stenosis. These results suggest thatsingle-stoma CU should be considereda viable option for patients undergoing radical cystectomy. Longer follow-up is needed to assess durability of stent-free rates.

MP32-02 SURGICAL TECHNIQUE OF EXTRAPERITONEALIZING ILEAL CONDUIT DECREASE PARASTOMAL HERNIA COMPLICATION: A SINGLE-CENTER, PROSPECTIVE, RANDOMIZED, CONTROLLED CLINICAL TRIAL

You have accessJournal of UrologyCME1 Apr 2023MP32-02 SURGICAL TECHNIQUE OF EXTRAPERITONEALIZING ILEAL CONDUIT DECREASE PARASTOMAL HERNIA COMPLICATION: A SINGLE-CENTER, PROSPECTIVE, RANDOMIZED, CONTROLLED CLINICAL TRIAL Zhaohui Zhou, Zhiyong Li, Zhiling Zhang, Kai Yao, Huali Ma, Shengjie Guo, Pei Dong, Yunlin Ye, Fangjian Zhou, and Zhuowei Liu Zhaohui ZhouZhaohui Zhou More articles by this author , Zhiyong LiZhiyong Li More articles by this author , Zhiling ZhangZhiling Zhang More articles by this author , Kai YaoKai Yao More articles by this author , Huali MaHuali Ma More articles by this author , Shengjie GuoShengjie Guo More articles by this author , Pei DongPei Dong More articles by this author , Yunlin YeYunlin Ye More articles by this author , Fangjian ZhouFangjian Zhou More articles by this author , and Zhuowei LiuZhuowei Liu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003265.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Parastomal hernia (PSH) is a common complication in patients receiving ileal conduit urinary diversion after radical cystectomy. To validate our previous finding that extraperitonealization of ileal conduit (modified ileal conduit) decreases incidence of PSH after ileal conduit diversion. METHODS: This is a single-center, randomized controlled clinical trial (clinicaltrials.gov, NCT03822234). Between January, 2019 and March, 2020, 104 consecutive patients undergoing radical cystectomy at Sun Yat-sen University Cancer Center were randomized 1:1 to receive either modified ileal conduit (n=52) or conventional ileal conduit (n=52). One group received extraperitonealization of ileal conduit, the other received conventional ileal conduit. Primary endpoint was incidence of radiological PSH at 24 months post surgery. Secondary endpoints were incidence of stomal complications (retraction, stenosis, and prolapse) at 24 months. Other complications related to surgery were also recorded. RESULTS: Incidence of radiological PSH was lower in modified ileal conduit patients than in conventional ileal conduit patients (11.5% [6/52] vs. 28.8% [15/52]; p=0.028) after a median follow-up of 32 months, corresponding to a hazard ratio of 0.375 (95% CI: 0.146-0.967, p=0.043) in the modified conduit group. No stomal retraction, stenosis or prolapse complications occurred. Median operating time was comparable between the groups. Early surgery-related complications were less in modified conduit patients; late complications were similar in the two groups. CONCLUSIONS: The results support our previous finding that extraperitonealization of ileal conduit is effective for reducing risk of PSH in ileal conduit diversion patients. Further multicenter controlled clinical trials on large samples (including obese patients) are needed. Source of Funding: Without source of funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e439 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zhaohui Zhou More articles by this author Zhiyong Li More articles by this author Zhiling Zhang More articles by this author Kai Yao More articles by this author Huali Ma More articles by this author Shengjie Guo More articles by this author Pei Dong More articles by this author Yunlin Ye More articles by this author Fangjian Zhou More articles by this author Zhuowei Liu More articles by this author Expand All Advertisement PDF downloadLoading ...

Alvimopan as part of the Enhanced Recovery After Surgery protocol following radical cystectomy is associated with decreased hospital stay.

To study the effect of alvimopan and the Enhanced Recovery After Surgery protocol on length of hospital stay in patients undergoing radical cystectomy. Our retrospective study involved 296 consecutive patients undergoing radical cystectomy for bladder cancer at our institution from 2010 through 2018. Patients were grouped according to three stages of the Enhanced Recovery After Surgery protocol implementation: (i) pre-Enhanced Recovery After Surgery (groupA; n=146); (ii) pre-alvimopan Enhanced Recovery After Surgery (group B; n=102); and (iii) Enhanced Recovery After Surgery plus alvimopan (groupC; n=48). The primary outcome was the length of hospital stay. Secondary outcomes were time to first bowel movement, time to tolerate a regular diet, the incidence of postoperative ileus, postoperative complications and 30-day readmission rate. GroupC showed a significantly shorter median length of hospital stay (7days, P=0.003), shorter gastrointestinal recovery time (4days, P=0.018) and a lower rate of postoperative ileus (14.6%, P=0.005). The reduction in length of hospital stay, gastrointestinal recovery time and a lower rate of postoperative ileus was significant after controlling for other confounders on multivariable regression analysis. With the open approach, groupC showed a significantly shorter length of hospital stay and gastrointestinal recovery time (P=0.005, P=0.001, respectively); however, in robotic cohorts, no significant differences were observed. There was no difference among groups in the 30-day readmission rate or postoperative complications. Patients undergoing radical cystectomy and managed by an Enhanced Recovery After Surgery protocol experience a significantly shorter length of hospital stay when receiving alvimopan as part of the protocol. Patients seem to derive the optimum benefits of alvimopan when it is used with an open approach; however, these benefits become less obvious with the robotic approach.

Alvimopan as an essential component of ERAS protocol to decrease length of hospital stay.

517 Background: Radical cystectomy for muscle invasive bladder cancer is the gold standard. However, it is frequently associated with a prolonged length of hospital stay (LOS). We study the effect of ERAS protocol implementations and Alvimopan use in patients undergoing radical cystectomy and its impact on length of hospital stay (LOS). Methods: Retrospective cohort study involving consecutive patients undergoing radical cystectomy for bladder cancer at our institution from 2010 through 2018. We evaluated Alvimopan use plus an ERAS protocol post radical cystectomy versus patients who underwent ERAS protocol alone versus those who were managed prior to ERAS protocol implementation. Primary outcome of interest was LOS, controlling for age, sex, smoking status and Charleson comorbidities index. Results: 146 patients (49.32 %) received standard care (non-ERAS) (group A), 102 patients (34.45 %) underwent ERAS protocol alone (group B) and 47 patients (15.87 %) underwent ERAS protocol plus Alvimopan (group C). There was no significant difference in length of stay between group A and group B (p=0.856). However, group C experienced a shorter LOS (16.6%) compared to group A (p=0.015). Similarly, group B was not significantly associated with the days to bowel movements compared to group A (p=0.112), however, group C demonstrated a significantly shorter time (16.3%) to bowel movements compared to group A (p=0.015). On other hand, group c wasn’t significantly associated with time tolerance to regular diet (p=0.068). Limitations include retrospective nature of some of the data, non-randomized approach and confounders such as a mix of robot and open approaches to cystectomy. Conclusions: Of all ERAS protocol components, Alvimopan appeared to be the most significant contributor in accelerating GI recovery and decrease LOS in our cohort.

Impact of an enhanced recovery pathway on length of stay and complications in elective radical cystectomy: a before and after cohort study

BackgroundEnhanced recovery after surgery (ERAS) pathways aim to standardize and integrate perioperative care, incorporating the best available evidence-based practice throughout the perioperative period targeted at attenuating the surgical stress response while optimizing physiologic function, with the goal of facilitating recovery. Radical cystectomy is associated with significant postoperative morbidity, but comprehensive ERAS pathways have not been well studied in this population.MethodsThis is a before and after cohort study of an ERAS pathway for radical cystectomy at a large academic medical center. Following introduction of the ERAS pathway and a wash in period, we prospectively collected data from the next 100 consecutive subjects undergoing radical cystectomy with the ERAS pathway. This cohort was compared to a retrospective cohort of 100 consecutive patients undergoing radical cystectomy with traditional care. The primary outcome was hospital length of stay. Secondary outcomes included perioperative management, time to recovery milestones, complications, and costs.ResultsImplementation of an ERAS pathway for radical cystectomy was associated with reduced hospital length of stay (median LOS 10 days (IQR = 8–18) vs 7 days (IQR = 6–11); p < 0.0001), reduced time to key recovery milestones, including days to first stool (5.83 vs 3.99; p < 0.001) and days to first solid food (9.68 vs 3.2; p < 0.001), reductions in some complications, and a 26.6% reduction in overall costs (p < 0.001).ConclusionsOur data support the use of an ERAS pathway for radical cystectomy and add to the increasing body of literature supporting enhanced recovery over a wide variety of procedures.Trial registrationNot applicable.

Preoperative anemia and extensive transfusion during stay-in-hospital are critical for patient`s mortality: A retrospective multicenter cohort study of oncological patients undergoing radical cystectomy

BackgroundPreoperative anemia and allogeneic blood transfusions (ABTs) may affect outcomes in cancer surgery. The prevalence of anemia, the use of ABTs, the risks of transfusions, lengths of stay and mortality of oncological patients undergoing radical cystectomy were investigated in three University Hospitals in Germany. Patients and MethodsHospital records of 220 consecutive patients undergoing radical cystectomy from 2010 to 2012 were retrospectively analyzed for independent risk factors of ABT and unfavorable outcomes (readmission, increased length of stay (LOS) or death) using multivariate regression analysis. ResultsPreoperative anemia was present in 40%. 70% of patients received blood transfusions. Low preoperative and intraoperative nadir hemoglobin levels were associated with receipt of ABT (OR 1.33, P = 0.04 and OR 2.94, P < 0.001 respectively). Transfusion of ten or more red blood cell units (RBCs) during the entire hospital stay was a predictor of an increased LOS (P < 0.001) and death (OR 52, 95%CI [5.9, 461.3], P < 0.001), compared to non-transfused patients. Preoperative ABT and ASA scores were associated with ≥10RBCs. ConclusionAnemic patients undergoing radical cystectomy had a high risk to receive ABTs. Preoperative transfusions and transfusion of ≥10RBCs during the entire hospital stay may increase patient`s mortality.Prospective, randomized controlled studies have to follow this study.

Robot-assisted laparoscopic radical cystectomy is a safe and effective procedure for patients with bladder cancer compared to laparoscopic and open surgery: Perioperative outcomes of a single-center experience

We compared the perioperative outcomes of patients with bladder cancer according to three different procedures: robot-assisted laparoscopic radical cystectomy (RALC), laparoscopic radical cystectomy (LRC), and open radical cystectomy (ORC). From April 2008 to March 2017, 36 consecutive patients underwent radical cystectomy and ileal conduit with RALC (n=10), LRC (n=10), or ORC (n=16). All patients underwent RALC and LRC with extracorporeal urinary diversion. Perioperative data were patient demographics, perioperative laboratory data including hematocrit and creatinine, intraoperative crystalloids and colloids, estimated blood loss (EBL), allogeneic transfusion, respiratory parameters including maximum end-tidal carbon dioxide (EtCO2) and respiratory rate, arterial blood gas data including highest pH, partial pressure of CO2 (PaCO2), partial pressure of oxygen (PaO2), operative time, opiate consumption including intraoperative and postoperative anesthesia, time of hospital stay, time to oral intake and normal diet, and adverse events. EBL was less for RALC than for other procedures (p=0.0004). No blood transfusions were performed for RALC, but ORC required significant blood transfusions (p=0.003). Respiratory rate was highest and PaCO2 was lowest for RALC. Preoperative creatinine levels were significantly worse for the RALC group, but no significant differences were noted after surgery. There were no significant differences among the groups in regard to hematocrit levels. Operative time, laparoscopic time, intraoperative anesthesia, and postoperative anesthesia did not differ among the groups. High-grade adverse events were only seen for ORC. Although RALC required a steep Trendelenburg position, which might add elements of risk, RALC was safe even for this small cohort.

Impact of a Potassium-enriched, Chloride-depleted 5% Glucose Solution on Gastrointestinal Function after Major Abdominopelvic Surgery: Results of a Randomized Controlled Trial.

Gastrointestinal (GI) complications often delay recovery after radical cystectomy with urinary diversion. The authors investigated if perioperative administration of a potassium-enriched, chloride-depleted 5% glucose solution (G5K) accelerates recovery of GI function. This randomized, parallel-group, single-center double-blind trial included 44 consecutive patients undergoing radical cystectomy and pelvic lymph node dissection with urinary diversion. Patients were randomized to receive either a G5K (G5K group) solution or a Ringer's maleate solution (control group). Fluid management aimed for a zero fluid balance. Primary endpoint was time to first defecation. Secondary endpoints were time to normal GI function, need for electrolyte substitution, and renal dysfunction. Time to first defecation was not significantly different between groups (G5K group, 93 h [19 to 168 h] and control group, 120 h [43 to 241 h]); estimator of the group difference, -16 (95% CI, -38 to 6); P = 0.173. Return of normal GI function occurred faster in the G5K group than in the control group (median, 138 h [range, 54 to 262 h] vs. 169 h [108 to 318 h]); estimator of the group difference, -38 (95% CI, -74 to -12); P = 0.004. Potassium and magnesium were less frequently substituted in the G5K group (13.6 vs. 54.5% [P = 0.010] and 18.2 vs. 77.3% [P < 0.001]), respectively. The incidence of renal dysfunction (Risk, Injury, Failure, Loss and End-stage kidney disease stage "risk") at discharge was 9.1% in the G5K group and 4.5% in the control group; P = 1.000. Perioperative administration of a G5K did not enhance first defecation, but may accelerate recovery of normal GI function, and reduces potassium and magnesium substitution after radical cystectomy and urinary diversion.

A retrospective evaluation of preoperative anemia in patients undergoing radical cystectomy for muscle-invasive urothelial urinary bladder cancer, with or without neoadjuvant chemotherapy.

Background and objectiveNeoadjuvant chemotherapy (NAC) can be associated with anemia, which can lead to more perioperative blood transfusions (PBT). Usage of PBT is associated with worse oncological outcomes. We evaluated the prevalence of preoperative anemia (PA) and the effect on hemoglobin levels depending on surgery timing after NAC.MethodsA retrospective single-center study with 240 consecutive patients undergoing radical cystectomy (RC) between 2001 and 2014 for muscle-invasive urothelial carcinoma (MIBC). Anemia was defined according to the WHO classification (male ≤ 130 g/L, female ≤ 120 g/L). Multivariable logistical regression was used to identify factors associated with PA and Pearson correlation for evaluating the change in hemoglobin levels depending on surgery timing.ResultsOverall, 128 (53.3 %) patients were anemic pre-RC and 87 (36.3 %) patients received NAC. In a multivariable analysis, age, receipt of NAC, female gender, and low BMI were independent predictors of PA. In patients receiving NAC, the time to surgery from the last NAC cycle was correlated with the change in hemoglobin levels between the initiation of NAC and surgery.ConclusionsPA was common in patients undergoing RC for MIBC. Receipt of NAC was found to be a strong predictor of PA.Clinical messageThe emerging treatment of cisplatin based neoadjuvant chemotherapy for muscle-invasive bladder cancer, confers an increased risk for preoperative anemia. In the management of this malignancy, preoperative anemia renders further attention and focus.

Enumerating pelvic recurrence following radical cystectomy for bladder cancer: A Canadian multi-institutional study.

We aimed to enumerate the rate of pelvic recurrence following radical cystectomy at university-affiliated hospitals in Canada. Canadian, university-affiliated hospitals were invited to participate. They were asked to identify the first 10 consecutive patients undergoing radical cystectomy starting January 1, 2005, who had urothelial carcinoma stages pT3/T4 N0-2 M0. The first 10 consecutive cases starting January 1, 2005 who met these criteria were the patients submitted by that institution with information regarding tumour stage, age, number of nodes removed, and last known clinical status in regard to recurrence and patterns of failure. Of the 111 patients, 80% had pT3 and 20% pT4 disease, with 62% being node-negative, 14% pN1, and 27% pN2; 57% had 10 or more nodes removed. Cumulative incidence of pelvic relapse was 40% among the entire group. This review demonstrates a high rate of pelvic tumour recurrence following radical cystectomy for pT3/T4 urothelial cancer.

Postoperative complications and short-term oncological outcomes of patients aged ≥80 years undergoing robot-assisted radical cystectomy.

To assess complication rates and early oncological outcomes of patients aged ≥80 years who underwent robot-assisted radical cystectomy (RARC). A total of 368 consecutive patients underwent radical cystectomy from April 2001 to September 2013 in a tertiary referral center. Sixty-one patients aged ≥80 years underwent RARC and constitute the cohort of interest. Complications arising within 30 and 90 days of surgery were graded using the modified Clavien classification and were additionally categorized by organ system using a standardized complication reporting system. Recurrence-free survival, disease-specific survival and overall survival were calculated using Kaplan-Meier curves. Median age was 83 years (range 80-94). Twenty-nine (48 %) of all tumor specimens were stage ≥pT3. The median number of nodes removed was 19 (range 6-67). The soft tissue positive margin rate was 10 %. A total of 27 (44 %) patients had complications within 90 days, of which 9 had major complications. Two patients (3 %) died from surgical complications within 90 days. At a median follow-up of 13 months, 12 (20 %) patients had developed recurrent cancer and subsequently died from disease. An additional 13 (21 %) patients died from non-cancer-related causes. The median overall survival time was 36.0 months. At 2 years, recurrence-free, cancer-specific and overall survival rates were 73, 74 and 61 %, respectively. In patients aged ≥80 years, RARC is feasible with acceptable perioperative morbidity and favorable short-term oncological outcomes. Therefore, RARC should be considered a valid option for carefully selected patients aged ≥80 years with bladder cancer.

Minimal incisions for laparoscopic radical cystectomy with extracorporeal-assisted urinary diversion

ObjectiveLaparoscopic radical cystectomy (LRC) had been used for >10 years. However, longer wound incisions for extracorporeal-assisted urinary diversion decrease the benefits of a laparoscopic approach. In this study, we describe our experience of modified LRC with extracorporeal-assisted urinary diversion using minimal wound incisions. Materials and methodsFrom January 2011 to January 2013, 22 consecutive patients underwent radical cystectomy by a single surgeon. Seven patients underwent open radical cystectomy (ORC), and 15 patients underwent LRC with four-port incisions. ResultsThe LRC group had a significantly lower estimated blood loss (p = 0.005), lower blood transfusion rate (p = 0.004), and lower ileus rate (p = 0.031) than the ORC group. No significant differences were noted in operative time, time to flatus, pain score, overall complication rate, pathological stage, positive surgical margin rate, or lymph node yield (27.6 for LRC and 29.1 for ORC). The 1-year disease free survival rate was 86.7% in the LRC group and 71.4% in the ORC group, and the 1-year overall survival rates were both 100%. ConclusionOur experience shows that LRC with extracorporeal-assisted urinary diversion using minimal incisions is a safe and feasible surgical technique with less blood loss. Further reports with a longer follow-up period and large number of cases are necessary to validate our findings.

Anterior Fascial Fixation Does Not Reduce the Parastomal Hernia Rate After Radical Cystectomy and Ileal Conduit

To compare the rate of parastomal hernia in patients undergoing anterior fascial fixation of the ileal conduit with that in patients without fascial fixation. Limited data exist on whether anterior fascial fixation of the ileal conduit impacts the rate of parastomal hernia. A total of 496 consecutive patients undergoing radical cystectomy and ileal conduit reconstruction from 1995 to 2012 were retrospectively evaluated for parastomal hernia. All patients had a 2-fingerbreadth aperture and the ileal conduit brought through the rectus muscle and sheath. Patients were divided into 1 of 3 groups based on stoma fixation and/or reinforcement: anterior fascial fixation, posterior reinforcement, or no fascial fixation. A parastomal hernia was defined as a palpable bulge at the stoma site. Multivariate logistic regression was conducted for the primary end point of parastomal hernia, controlling for other patient- and treatment-related factors that might affect the rate of parastomal hernia. Median follow-up was 16 months (range, 1-189 months). The parastomal hernia rate was significantly greater in the anterior fascial suture group (43 of 281; 15.3%) than the no fascial suture group (12 of 164; 7.3%; P=.02). Multivariate logistic regression analysis modeled for the occurrence of a parastomal hernia demonstrated that anterior fascial fixation was an independent predictor of the development of parastomal hernia (odds ratio, 2.3; 95% confidence interval, 1.03-5.14; P=.04). Anterior fascial fixation of the ileal conduit does not reduce the risk of parastomal hernia formation compared with the patients treated without fascial fixation. Surgeons should consider avoiding anterior suture fixation during ileal conduit creation.

NLR is predictive of upstaging at the time of radical cystectomy for patients with urothelial carcinoma of the bladder

ObjectiveTo evaluate the ability of preoperative neutrophil-lymphocyte ratio (NLR) to predict pathologic upstaging and nonorgan-confined (NOC) (≥pT3) disease. Methods and materialsAfter institutional review board approval, the records of consecutive patients undergoing radical cystectomy (RC) for urothelial carcinoma from 2002 to 2012 at the University of Wisconsin Hospital were reviewed. A total of 102 patients with NLR within 100 days of surgery were eligible for analysis. The primary outcome was difference in stage from preoperative assessment to time of RC. Differences in preoperative NLR between groups were evaluated with an unequal variance t test. A univariate analysis assessed whether NLR, preoperative stage, grade, associated lymphovascular invasion, preoperative hydronephrosis, gender, previous pelvic radiotherapy, previous intravesical bladder cancer treatments, or nodal stage were related to upstaging. Multivariate analyses were performed to evaluate the relationship of NLR to upstaging and relative organ-confined (≤pT2) and NOC disease. ResultsOf 390 consecutive patients undergoing RC, 102 patients met study criteria. Overall, 55 (53.9%) patients were upstaged, 25 (25.5%) were unchanged, and 21 (20.6%) were downstaged. Fifty-one patients (50%) were upstaged to more advanced disease (≥pT3). NLR and preoperative hydronephrosis were significantly related to pathologic tumor staging. NLR, preoperative hydronephrosis, and preoperative tumor stage were significantly related to upstaging to NOC disease. Patients who were upstaged to≥pT3 demonstrated statistically significant greater NLRs (4.33±0.87) compared with patients who remained at≤pT2 stage (2.66±0.29) (P<0.001). ConclusionsPreoperative NLR is a simple measurement that can be used to identify high-risk patients who may be upstaged at the time of RC and may benefit from neoadjuvant chemotherapy.

Occult lymph node metastases in patients with carcinoma invading bladder muscle: incidence after neoadjuvant chemotherapy and cystectomy vs after cystectomy alone

To investigate the effect of neoadjuvant chemotherapy (NAC) on the incidence of lymph node (LN) metastases in clinically node-negative (cN0) patients with carcinoma invading the bladder muscle (MIBC). Between 1990 and 2012, 828 consecutive patients underwent radical cystectomy (RC) with extended pelvic LN dissection (ePLND), of whom 441 had cT2-4N0M0 stage disease. A total of 83 patients received NAC then underwent RC and 358 patients underwent RC only. The ePLND template and the indication for NAC remained the same during the study period. The incidence of occult LN metastases was compared between the groups. Unadjusted and adjusted odds ratios (ORs) were calculated to investigate the influence of NAC, cT stage, gender and the preoperative staging technique used (computed tomography [CT] or positron emission tomography/CT) on the occurrence of LN metastases. Overall survival (OS) and disease-specific survival were analysed using the Kaplan-Meier method. Patients in the NAC group more often had locally advanced MIBC than patients in the non-NAC group (cT3-4: 88.0 vs 30.2%). In the NAC group, 19.3% of patients had LN metastases vs 28.5% of the patients in the non-NAC group (P = 0.099). In the patients with cT3-4 disease, the occurrence of LN metastases was significantly lower in the NAC group than in the non-NAC group (21.9 vs 40.7%, respectively, P = 0.002). In multivariable analysis, adjusting for cT stage, gender and staging method, NAC was independently associated with a lower likelihood of LN metastases (OR: 0.41, 95% CI 0.21-0.79; P = 0.008). Among the patients with cT3-4 disease, the median OS was significantly longer in the NAC group than in the non-NAC group (68.0 vs 23.0 months, P = 0.047) CONCLUSION: These data suggest that, along with a downstaging effect on the primary bladder tumour, NAC is associated with a lower incidence of occult LN metastases at the time of RC.

1416 ARE WE EVALUATING PROPERLY THE RENAL FUNCTION WITH THE MODIFICATION OF DIET IN RENAL DISEASE (MDRD) IN PATIENTS WITH ORTHOTOPIC ILEAL NEOBLADDER?

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion (II)1 Apr 20131416 ARE WE EVALUATING PROPERLY THE RENAL FUNCTION WITH THE MODIFICATION OF DIET IN RENAL DISEASE (MDRD) IN PATIENTS WITH ORTHOTOPIC ILEAL NEOBLADDER? Mathieu Rouanne, Yann Neuzillet, Dominique Eladari, Thierry Lebret, and Henry Botto Mathieu RouanneMathieu Rouanne Suresnes, France More articles by this author , Yann NeuzilletYann Neuzillet Suresnes, France More articles by this author , Dominique EladariDominique Eladari Paris, France More articles by this author , Thierry LebretThierry Lebret Suresnes, France More articles by this author , and Henry BottoHenry Botto Suresnes, France More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2770AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Few studies assessing prospectively the renal function changes after orthotopic ileal bladder substitution are available.The aim was to evaluate the accuracy of Modification of Diet in Renal Disease (MDRD) formulae as a substitute for the gold standard measure of glomerular filtration rate (GFR) using chromium 51 EDTA. METHODS Seventeen consecutive patients underwent radical cystectomy (RC) from July 2011 to December 2011 for muscle-invasive bladder cancer were included in this prospective protocol. Exclusion criteria were chronic kidney disease (CKD) and neoadjuvant chemotherapy. Bias and precision of estimated GFR (eGFR) were compared with isotopic GFR (iGFR). Chromium-51 ethylenediamine tetra-acetic acid (51 Cr-EDTA) was used to measure the glomerular filtration rate of both kidneys. 51Cr-EDTA GFR was performed preoperatively and 6 mo postoperatively. In addition, technetiumTc99m-diethylenetriaminepentaaceticacid (Tc99m-DTPA) renal scintigraphy was used to determine the glomerular filtration rate (GFR) of each kidney individually. RESULTS Mean preoperative GFR values were 84 ml/min per 1.73 m2 (range to 61-116) and 75 ml/min per 1.73 m2 (range to 60-117) using eGFR and 51 Cr-EDTA GFR respectively. At 6 mo, the mean GFR values were 77 ml/min per 1.73 m2 (range to 60-117) and 68 ml/min per 1.73 m2 (range to 60-102) using eGFR and iGFR respectively. At 6 mo, the difference between 51 Cr-EDTA GFR and eGFR was statistically different (p = 0.035). In addition, 51 Cr-EDTA GFR values were statistically different between preoperative time and at 6 mo ((p=0.025) whereas no statistical significant difference was found using eGFR (p > 0.05). CONCLUSIONS There is poor correlation between eGFR and 51Cr-EDTA GFR in patients with ileal neobladder reconstruction. eGFR should be used with caution as a surrogate marker for isotope GFR in these patients. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byRouanne M, Lebret T and Courbebaisse M (2018) Re: Long-Term Renal Function Outcomes after Radical CystectomyJournal of Urology, VOL. 193, NO. 3, (1066-1067), Online publication date: 1-Mar-2015. Volume 189Issue 4SApril 2013Page: e580 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mathieu Rouanne Suresnes, France More articles by this author Yann Neuzillet Suresnes, France More articles by this author Dominique Eladari Paris, France More articles by this author Thierry Lebret Suresnes, France More articles by this author Henry Botto Suresnes, France More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urodynamic analysis of W shape orthotopic ileal neobladder following radical cystectomy

Objective To evaluate the urodynamic parameters of shape orthotopic ileal neobladder during a 36-month follow-up post-operatively.Methods Forty-five consecutive patients underwent radical cystectomy and W shape ileal neobladder substitution for muscle-invasive bladder cancer were recruited.Follow-up and urodynamic evaluation were performed at 12 and 36 months after surgery.Cystourethrography,ultrasonography,IVU and renal function test were performed during the follow-up.Results Of the 45 patients,3 were dead during the follow-up because of cancer-related causes.When comparing to the 12-and 36-month urodynamic parameters,Qmax,MCC,compliance,end-filling pressure,peak flow pressure and PVR respectively were 15.6 ± 2.3 ml/s and 14.9 ± 1.9 ml/s,588.0 ± 264.6 ml and 561.0 ±197.4 ml,27.6±8.4 ml/cm H2O and 29.5 ±1.7 ml/cm H2O,24.4 ±5.2 cm H2O and 33.0 ±6.8 cmH2O,60.7 ±18.0 cm H2O and 79.9 ±28.2 cm H2O,83.5±24.4 ml and 80.4 ±26.8 ml.At early and late evaluation,daytime continence rate was 90％ and 94％,night continence rate was 48％ and 74％.Conclusions Orthotopic shape ileal neobladder was proven to maintain an adequate capacity and low pressure during a 36-month period of follow-up.The urodynamic results support this urinary diversion as a valid treatment option for muscle-invasive bladder cancer. Key words: Urodynamic; Bladder neoplasmas; Ileal neobladder

Towards bloodless cystectomy: a 10‐year experience of intra‐operative cell salvage during radical cystectomy

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Guidance from the UK National Institute for Health and Clinical Excellence (NICE) on the use of intraoperative cell savage (ICS) has been in place for over 3 years and recommends its routine usage in all patients undergoing radical pelvic urological surgery. The current series describes the contribution of ICS to contemporary blood conservation strategies and the goal of 'bloodless' cystectomy. • To describe a 10-year experience of intra-operative cell salvage (ICS) during radical cystectomy at a regional cancer centre. • Between 1(st) January 2001 and 31(st) December 2010, 213 consecutive patients underwent radical cystectomy and pelvic lymphadenectomy for bladder cancer, with an ICS suction device used in theatre. • Surgery was performed by one of three consultant surgeons using an open technique with lymph node clearance to the iliac bifurcation. Orthotopic bladder substitution was performed in 25% of patients overall. • ICS data were collected prospectively on an electronic database and the institutional database was then cross-referenced with a complete review of patients' medical records, laboratory results and radiological investigations retrospectively. • Data collected included patient demographics, haemoglobin levels before and after surgery, the volume of ICS blood collected and re-infused, complications related to ICS usage, the volume of allogeneic red blood cells (RBCs) transfused, length of stay and overall patient survival at 3 and 5 years after surgery. • In all 213 cases described, ICS was used without complication, with no recorded episodes of device failure and no complications related to the use of cell salvage. • Overall, 91% of patients received ICS blood and 28% of patients avoided any further transfusion products. • The median (range) follow-up for the cohort was 24 (9-119) months. • Seventy percent of the transfusion requirement for patients who underwent surgery in 2001 was met using allogeneic RBC transfusion but by 2010, as blood loss markedly reduced, ICS blood was able to provide ∼70% of overall transfusion requirements. As a consequence, the percentage of patients avoiding an allogeneic RBC transfusion significantly increased during the 10-year period, such that 70% of patients avoided allogeneic RBC transfusion in 2010 compared with only 10-20% in the period 2001-2003 • The overall survival rate at 3 and 5 years was 58% and 49%, respectively. • In conclusion, the use of ICS during radical cystectomy is safe; it is capable of meeting the majority of or, in some cases, the total blood product requirement for individual patients. As a result, it decreases the need for allogeneic RBC transfusion and hence the associated risks. Current follow-up shows no apparent risk of decreased long-term survival from an oncological perspective. • The authors advocate routine availability of ICS for all major urological oncology cases.

Upper urinary tract and urethral recurrences following radical cystectomy: review of risk factors and outcomes between centres with different follow-up protocols

To examine which patient-related and tumour-related characteristics predict upper urinary tract recurrence (UUTR) and urethral recurrence (UR) of bladder cancer post-radical cystectomy (RC). Secondary objective is to evaluate whether or not recurrence patterns are similar between two centres with different post-RC follow-up (F/U) protocols. A retrospective cohort study of 574 consecutive patients undergoing radical cystectomy for urothelial carcinoma of the bladder at two tertiary centres was performed. Clinicopathological factors associated with bladder cancer recurrence and patient-related outcomes, including time to recurrence and death, were collected. Risk factors for recurrences were examined using univariate and multivariable regression analyses. Likelihood of recurrence, time to recurrence, and survival were compared. There was a 3.7% risk of UUTR (21/574) and a 3.6% risk of UR (18/503) for the combined cohort at a median F/U of 45months. When controlling for the effects of all variables modelled, female gender was a significant risk factor for UUT recurrence (OR 3.2, 95% CI 1.0-9.5, p=0.03) and prostatic urethral involvement was a significant risk factor for urethral recurrence (OR 7.8, 95% CI 2.2-27.6, p=0.001). UUTR were similar (p=0.82) between Turku (8/205) and Toronto (12/369). Urethral recurrences trended (p=0.06) towards being more common in Turku (9/151, 6.0%) versus Toronto (9/352, 2.6%), but no difference in overall survival was demonstrated between sites. The frequency of UUT and urethral recurrences post-cystectomy is relatively low and remained stable for the past 15years. The ideal F/U protocol to maximize patient-survival remains unknown.