Days Of Radical Cystectomy Research Articles

Cystectomy for bladder cancer in Sweden - short-term outcomes after centralization.

Radical cystectomy (RC) for bladder cancer is associated with an inherent risk of complications and even postoperative mortality. The number of hospitals performing RC has decreased in Sweden over time, and since a formal regional centralization in 2017 cystectomy care is currently provided by nine hospitals. In the Swedish National Urinary Bladder Cancer Register (SNRUBC) 90-day complications after RC have been registered with high coverage since 2012. Descriptive data and short-term outcomes were compared in relation to centralization of the cystectomy care by stratifying data before (2012-2016) and after (2017-2023). Out of all 4,638 cystectomies, 2,738 (59%) were performed after the centralization in 2017 and onwards. The median age at RC increased from 71 (Inter Quartile Range [IQR] 65-76) to 73 (IQR 67-77) years, and the proportion of patients with comorbidity (American Society of Anesthesiologists [ASA] 3 or 4) increased from 32% to 37% after the centralization (p < 0.001). The number of patients suffering from high-grade complications within 90 days of surgery corresponding to Clavien grade three were 345 (18%) and 407 (15%), and corresponding to Clavien grade four 61 (3%) and 64 (2%) before and after centralization, respectively. Reoperations within 90 days of RC decreased from 234/1,900 (12%) to 208/2,738 (8%) (p < 0.001), and 90-day mortality decreased from 84/1,900 (4%) to 85/2,738 (3%) (p = 0.023) before and after centralization, respectively. After the centralization of the cystectomy-care in Sweden, older patients and individuals with more extensive comorbidity were offered RC whereas 90-day mortality and the proportion of patients subjected to reoperations within 90 days of surgery decreased without increasing waiting times.

Acute Kidney Injury Within 90 Days of Radical Cystectomy for Bladder Cancer: Incidence and Risk Factors

To report incidence of acute kidney injury (AKI) following radical cystectomy (RC) for bladder cancer and evaluate risk factors for AKI as well as the impact of AKI on development of long-term renal insufficiency. A retrospective analysis of patients undergoing RC between 2010 and 2020 at a high-volume tertiary referral center. AKI was graded according to the Kidney Disease Improving Global Outcome (KDIGO) criteria within 90days of surgery. Long-term renal insufficiency was defined as estimated glomerular function <45 mL/min. Cumulative incidence and Cox Proportional Hazards models were used to evaluate both short- and long-term loss of renal function and investigate their association with pre- and perioperative variables. AKI occurred in 332 out of 755 patients (44%) within 90days. Preoperative chronic hypertension and obesity were independent preoperative risk factors. Robot-assisted RC was associated with a higher risk of AKI compared to open RC in multivariable analyses. The absolute risk of developing long-term renal insufficiency was 8.7% (95%CI: 5.6-12) after 5years in patients without AKI and 26% (95%CI: 16-36) in patients with KDIGO-stage ≥2. In multivariable analysis, both KDIGO-stage 1 and ≥2 were independently associated with long-term estimated glomerular filtration rate <45 mL/min. A significant number of patients experienced AKI after RC, and even patients with KDIGO-stage 1 were at increased risk of long-term renal insufficiency. Recognizing pre- and perioperative risk factors can identify patients where close surveillance and early intervention may help minimize renal function decline following RC.

Utility of Patient-Reported Symptom and Functional Outcomes to Indicate Recovery after First 90 Days of Radical Cystectomy: A Longitudinal Study.

This is a longitudinal prospective study that tracked multiple symptom burden and functioning status for bladder cancer (BLC) patients for 3 months post-radical cystectomy at The University of Texas MD Anderson Cancer Center, using a validated disease-specific patient-reported outcome measure (PROM) tool, the MD Anderson Symptom Inventory (the MDASI-PeriOp-BLC). The feasibility of collecting an objective measure for physical functioning, using "Timed Up & Go test" (TUGT) and PRO scores at baseline, discharge and end of study, was tested. Patients (n = 52) received care under an ERAS pathway. The more severe scores of fatigue, sleep disturbance, distress, drowsiness, frequent urination and urinary urgency at baseline predicted poor functional recovery postoperatively (OR = 1.661, 1.039-2.655, p = 0.034); other more severe symptoms at discharge (pain, fatigue, sleep disturbance, lack of appetite, drowsiness, bloating/abdominal tightness) predicted poor functional recovery (OR = 1.697, 1.114-2.584, p = 0.014) postoperatively. Compliance rates at preoperative, discharge and end of study were 100%, 79% and 77%, while TUGT completion rates were 88%, 54% and 13%, respectively. This prospective study found that more severe symptom burden at baseline and discharge is associated with poor functional recovery post-radical cystectomy for BLC. The collection of PROs is more feasible than using performance measures (TUGT) of function following radical cystectomy.

SWOG S1011: A phase III surgical trial to evaluate the benefit of a standard versus an extended lymphadenectomy performed at time of radical cystectomy for muscle invasive urothelial cancer.

4508 Background: S1011 tested the hypothesis that an extended lymphadenectomy (ELND) is associated with improved disease-free and overall survival (DFS, OS) compared to standard (S) LND in patients with localized muscle invasive bladder cancer (MIBC) undergoing radical cystectomy (RC)(NCT01224665). Methods: Eligible patients with cT2-4a N0-2 were stratified by receipt and type of neoadjuvant chemotherapy (NAC), T2 vs T3-4a and PS 0-1 vs 2. Patients were randomized 1:1 after intraoperative exploration determined they did not have disease outside the pelvis. All patients then underwent a standard bilateral pelvic LND including external and internal iliac and obturator LNs. If randomized to the experimental arm additional ELND up to at least the aortic bifurcation including common iliac (CI), pre-sciatic, and pre-sacral nodes was performed. We hypothesized that patients in the ELND arm would have a 10% improvement in 3-year DFS compared to an estimated 55% for patients in the SLND arm (HR = 0.72). Assuming a 1-sided a=0.025 and 85% power, 564 eligible randomized patients were required. Final analysis was to occur at 184 DFS events in the SLND arm or after max follow-up (6 yrs) using a stratified logrank(LR) test with a=0.022 to account for interim testing. Hazard ratios from Cox model are adjusted for strat factors. Secondary endpoints included OS and safety. Results: 36 surgeons at 27 sites in US and Canada were credentialed prior to enrolling patients, 658 were registered from 8/11-2/17, and 618 eligible patients were randomized to ELND (n=292) or SLND (n=300). Median f/up was 6.1 years in both arms. Median age was 69, 21% female, and 9% non-White. Clinical stage was balanced in both arms: T2 (71%) and T3-4a (29%). NAC was given to 57% in both. Pathologic T stage was &lt;T2 in 39% in S and 37% in E and ³ T2 in 61% and 63%, respectively. Median lymph nodes removed was higher in ELND compared to SLND (41 vs 25), but there was no difference in node metastasis with 26% vs 24%, respectively. More ELND patients had N2 or N3 disease. ELND was associated with increased G3-4 AEs compared to SLND: 16% vs 8%. Deaths within 90 days of RC occurred in 26 (4.4%) patients, including 16 in ELND vs 9 in SLND. There was no difference in DFS between E vs S arms (HR 1.10; 95% CI 0.87, 1.42), 1-sided LR p=0.82. OS results were similar (HR 1.15 95% CI 0.89, 1.48), 1-sided LR p=0.87. Conclusions: Patients with MIBC undergoing RC and ELND had increased node yield and higher pathologic N stage, but no significant DFS or OS benefit compared to patients undergoing SLND. ELND was also associated with greater morbidity and higher peri-operative mortality. Clinical trial information: NCT01224665 . [Table: see text]

Intraoperative Blood Transfusion is Associated With Increased Risk of Venous Thromboembolism After Radical Cystectomy.

Our objective was to examine whether perioperative blood transfusion is associated with venous thromboembolism following radical cystectomy adjusting for both patient- and disease-related factors. Patients who underwent radical cystectomy for bladder cancer from 1980-2020 were identified in the Mayo Clinic cystectomy registry. Blood transfusion during the initial postoperative hospitalization was analyzed as a 3-tiered variable: no transfusion, postoperative transfusion alone, or intraoperative with or without postoperative transfusion. The primary outcome was venous thromboembolism within 90 days of radical cystectomy. Associations between clinicopathological variables and 90-day venous thromboembolism were assessed using multivariable logistic regression, with transfusion analyzed as both a categorical and a continuous variable. A total of 3,755 radical cystectomy patients were identified, of whom 162 (4.3%) experienced a venous thromboembolism within 90 days of radical cystectomy. Overall, 2,112 patients (56%) received a median of 1 (IQR: 0-3) unit of blood transfusion, including 811 (38%) with intraoperative transfusion only, 572 (27%) with postoperative transfusion only, and 729 (35%) with intraoperative and postoperative transfusion. On multivariable analysis, intraoperative with or without postoperative blood transfusion was associated with a significantly increased risk of venous thromboembolism (adjusted OR 1.73, 95% CI 1.17-2.56, P = .002). Moreover, when analyzed as a continuous variable, each unit of blood transfused intraoperatively was associated with 7% higher odds of venous thromboembolism (adjusted OR 1.07, 95% CI 1.01-1.13, P = .03). Intraoperative blood transfusion was significantly associated with venous thromboembolism within 90 days of radical cystectomy. To ensure optimal perioperative outcomes, continued effort to limit blood transfusion in radical cystectomy patients is warranted.

PD10-05 PERIOPERATIVE BLOOD TRANSFUSION IS ASSOCIATED WITH INCREASED RISK OF VENOUS THROMBOEMBOLISM AFTER RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 May 2022PD10-05 PERIOPERATIVE BLOOD TRANSFUSION IS ASSOCIATED WITH INCREASED RISK OF VENOUS THROMBOEMBOLISM AFTER RADICAL CYSTECTOMY Amanda Myers, Igor Frank, Paras H. Shah, Robert F. Tarrell, Giovanni A. Gonzalez, R. Jeffrey Karnes, Houston Thompson, Matthew K. Tollefson, Stephen A. Boorjian, and Timothy D. Lyon Amanda MyersAmanda Myers More articles by this author , Igor FrankIgor Frank More articles by this author , Paras H. ShahParas H. Shah More articles by this author , Robert F. TarrellRobert F. Tarrell More articles by this author , Giovanni A. GonzalezGiovanni A. Gonzalez More articles by this author , R. Jeffrey KarnesR. Jeffrey Karnes More articles by this author , Houston ThompsonHouston Thompson More articles by this author , Matthew K. TollefsonMatthew K. Tollefson More articles by this author , Stephen A. BoorjianStephen A. Boorjian More articles by this author , and Timothy D. LyonTimothy D. Lyon More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002536.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Venous thromboembolism (VTE) is increasingly used as a quality indicator after radical cystectomy (RC). However, the role of perioperative blood transfusion (PBT) in VTE risk adjustment remains unclear. While transfusion has been associated with an increased risk of VTE in administrative datasets, these analyses are limited by inability to adjust for several risk factors for VTE including cancer stage and receipt of neoadjuvant chemotherapy which may confound the observed associations. The objective of this study was to examine whether perioperative blood transfusion is associated with VTE following RC after adjusting for both patient- and disease-related factors. METHODS: Patients who underwent RC for bladder cancer from 1980-2020 were identified in the Mayo Clinic cystectomy registry. PBT was defined as intraoperative and/or postoperative blood transfusion during the initial hospital stay. The primary outcome was VTE within 90 days of RC, inclusive of either deep venous thrombosis or pulmonary embolism. Perioperative VTE prophylaxis varied according to institutional standard at the time, but generally consisted of sequential compression devices and subcutaneous heparin while inpatient. In April 2013, we began using intraoperative tranexamic acid, and in May 2014, we began prescribing outpatient extended duration VTE prophylaxis with enoxaparin in all patients without contraindications. Associations between clinicopathologic variables and 90-day VTE were assessed using multivariable logistic regression. PBT was analyzed as both a categorical and a continuous variable. RESULTS: We identified 3958 patients with RC, of whom 162 (4%) experienced a VTE within 90 days of RC. 2244 patients (57%) received a PBT, with a median of 1 (range: 0-69, IQR: 0-3) unit transfused. Median follow up among survivors was 6.7 years (IQR 2.4-12.7). On multivariable analysis adjusting for year of surgery, BMI, robotic approach, neoadjuvant chemotherapy, diversion type, pathologic tumor stage and pathologic nodal stage, the receipt of PBT remained significantly associated with an increased risk of VTE (adjusted OR 1.46, 95% CI 1.01-2.09, p=0.04). When further analyzed as a continuous variable, each unit of blood was associated with 6% higher odds of a VTE (adjusted OR 1.06, 95% 1.01-1.10, p=0.01). CONCLUSIONS: PBT was independently associated with VTE within 90 days of RC after adjusting for disease-related factors. Each unit transfused was associated with higher odds of a VTE. Continued effort to limit blood transfusion in these patients is warranted. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e185 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda Myers More articles by this author Igor Frank More articles by this author Paras H. Shah More articles by this author Robert F. Tarrell More articles by this author Giovanni A. Gonzalez More articles by this author R. Jeffrey Karnes More articles by this author Houston Thompson More articles by this author Matthew K. Tollefson More articles by this author Stephen A. Boorjian More articles by this author Timothy D. Lyon More articles by this author Expand All Advertisement PDF DownloadLoading ...

Ability of the surgical Apgar score to predict acute kidney injury following radical cystectomy.

Acute kidney injury (AKI) is a common complication after radical cystectomy (RC). Previous literature has shown that intraoperative hemodynamic instability measured via the surgical Apgar score is an independent predictor of major complications following RC. We sought to determine whether the surgical Apgar score is predictive of postoperative AKI. We performed a retrospective review of RC patients at our institution from 2010 to 2017. Intraoperative hemodynamic instability was captured via the Apgar score based on the lowest intraoperative mean arterial blood pressure, lowest heart rate, and estimated blood loss. Patients were divided into 3 groups: high-risk (HR; Apgar ≤4), intermediate-risk (IR; Apgar score 5-6), and low-risk (LR; Apgar score ≥7). AKIs were graded according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. High grade AKIs were defined as KDIGO grade 2 or 3. Categorical variables were assessed using the Pearson Chi-Square test, quantitative with the Kruskal-Wallis test, and multivariable logistic regression to identify predictors of AKI and high grade AKIs within 30 days of RC. Eight hundred and seventy-three patients were included with a median follow-up of 35 months. AKI within 30 days was observed in 28% of patients. Predictors of AKI within 30 days on adjusted analysis included IR (OR: 1.83, P = 0.002) and HR (OR: 3.53, P < 0.001) Apgar scores. IR (OR: 2.23, P = 0.007) and HR (OR: 4.87, P < 0.001) Apgar scores were also predictors of high-grade AKIs. Intraoperative hemodynamic instability measured via the Apgar score can be predictive of AKI, which can guide individualized fluid management in the postoperative period.

Thromboembolism in Muscle-Invasive Bladder Cancer. A Population-based Nationwide Study.

Routine VTE prophylaxis within 30 days of radical cystectomy (RC) for urinary bladder cancer (UBC) is used to protect from venous thromboembolism (VTE). However, randomized studies and nationwide population-based studies are lacking. To study VTE and risk factors for VTE in muscle-invasive UBC in a nationwide population-based series, with a focus on the association with RC with and without chemotherapy. We studied all patients with clinical stage T2-T4 UBC diagnosed 1997 to 2014 in the Bladder Cancer Data Base Sweden (BladderBaSe). Previous VTE events and risk factors for VTE were registered from 1987. Cox regression analyses and Kaplan-Meier curves were performed to study risk factors for VTE and cumulative incidence of VTE. In 9720 patients (71%males) with a median age of 74 years 546 (5.6%) had VTE after diagnosis. In Cox analyses controlling for patient's and tumour characteristics, and risk factors for VTE, VTE after diagnosis and first treatment date were associated with chemotherapy with or without RC. Cumulative incidence of VTE increased during 24 months after diagnosis and first treatment date. VTE were less common in patients with previous cardiovascular disease. VTE was commonly observed after 30 days from diagnosis and from first treatment date in patients with T2-T4 UBC, particularly after chemotherapy. The findings suggest that long-term intervention studies of benefit and possible harms of VTE prophylaxis after UBC should be undertaken.

Re-operation within 30 days of radical cystectomy: Identifying high-risk patients and complications using American College of Surgeons National Surgical Quality Improvement Program database.

Radical cystectomy (RC) is a highly morbid procedure, with 30-day complication rates approaching 31%. Our objective was to determine risk factors for re-operation within 30 days following a RC for non-metastatic bladder cancer. We included all patients who underwent a RC for non-metastatic bladder cancer using The American College of Surgeons National Surgical Quality Improvement Program database between January 1, 2007 and December 31, 2014. Logistic regression analyses were used to evaluate predictors of re-operation. A total of 2608 patients were included; 5.8% of patients underwent re-operation within 30 days. On multivariable analysis, increasing body mass index (BMI) (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.07), African American race (vs. Caucasian OR 2.29, 95% CI 1.21-4.34), and history of chronic obstructive pulmonary disease (COPD) (OR 2.33, 95% CI 1.45-3.74) were significant predictors of re-operation within 30 days of RC. Urinary diversion type (ileal conduit vs. continent) and history of chemotherapy or radiotherapy within 30 days prior to RC were not. Patients who underwent re-operation within this timeframe had a significantly higher mortality rate (4.0% vs. 1.6%) and were more likely to experience cardiac (7.2% vs. 1.9%), pulmonary (23.0% vs. 3.0%), neurological (2.0% vs. 0.49%), and venous thromboembolic events (10.5% vs. 5.4%), as well as infectious complications (64.5% vs. 24.1%), with a significantly longer hospital length of stay (16.5 vs. 7.0 days). Recognizing increasing BMI, COPD, and African American race as risk factors for re-operation within 30 days of RC will allow urologists to preoperatively identify such high-risk patients and prompt them to adopt more aggressive approaches to minimize postoperative surgical complications.

Factors predicting early mortality after radical cystectomy for urothelial carcinoma in a contemporary cohort of patients.

We aimed to identify preoperatively available patient variables associated with increased mortality within 30 and 90 days of radical cystectomy (RC) for localized urothelial carcinoma (UC), and to evaluate temporal trends in early mortality rates. We reviewed the National Cancer Database to identify patients who underwent RC for UC between 2006 and 2013. Preoperatively available patient-specific demographics and mortality rates at 30 and 90 days postoperatively were analyzed. Univariable and multivariable logistic regression analyses were performed to examine factors associated with 30- and 90-day mortality. We identified 37 366 patients who underwent RC between 2006 and 2013. Overall mortality rates remained stable over time. From 2006-2013, 936 patients (2.5%) and 2554 patients (6.8%) died of any cause within 30 and 90 days post-RC, respectively. On multivariable analysis, increased age, higher clinical T and N stage, increased Charlson-Deyo comorbidity classification, African-American race, lower hospital volume, non-academic centers, lower patient income, and absence of insurance were each significantly associated with increased early mortality after RC (p<0.05). The protective effect of higher hospital volume was similar regardless of patient's age, clinical stage, or comorbidity status. Our study identified patient-specific variables that are significantly associated with increased early mortality after RC. These findings can be used in counselling to identify ideal candidates for RC to decrease patient harm. Furthermore, early mortality rates after RC have remained stable over time, indicating that ongoing quality improvement is essential to improve outcomes.

Timing of adjuvant chemotherapy and overall survival following radical cystectomy

BackgroundWe investigated the relationship between timing of adjuvant chemotherapy on overall survival following radical cystectomy. MethodsWe retrospectively reviewed the National Cancer Data Base for patients with newly diagnosed pT2-T4, N0, M0 urothelial cell carcinoma who received no treatment prior to radical cystectomy. Patients who received no adjuvant chemotherapy or who received adjuvant chemotherapy more than 45 days after radical cystectomy were propensity matched to patients receiving adjuvant chemotherapy within 45 days of radical cystectomy. Selection bias was assessed by comparing the length of stay, readmission rate, and surgical approach between groups. Median survival was calculated using Kaplan-Meier analysis. Adjusted hazard ratios and 95% confidence intervals were calculated from a multivariable Cox regression model to examine factors affecting overall survival. ResultsFrom 2004 to 2014, 284 patients with muscle-invasive bladder cancer met inclusion criteria. Patients receiving chemotherapy within 45 days had the best 5-year overall survival (47.0%, 95%CI: 40.6%–53.2%) compared to those receiving chemotherapy after 45 days (37.5%, 95%CI: 31.4%–43.7%). Chemotherapy after 45 days and no adjuvant chemotherapy were significant predictors of worse overall survival compared to chemotherapy within 45 days (1.27, 1.02–1.59, P = 0.033 and 1.41, 1.12–1.78, P = 0.003). Receiving no adjuvant chemotherapy was not significantly different than chemotherapy after 45 days (1.11, 0.89–1.38, P = 0.348). Significant predictors of poorer overall survival were female sex (1.37, 1.04–1.81, P = 0.028), Medicare (1.37, 1.06–1.76, P = 0.016), pT3 stage (1.79, 1.35–2.38, P < 0.001), and pT4 stage (3.00, 2.20–4.01, P < 0.001). Significantly more patients with length of stay ≤7 days following RC received chemotherapy within 45 days (53.2%) compared to those who received adjuvant chemotherapy after 45 days after RC (44.0%) or no adjuvant chemotherapy (43.0%; P = 0.0369). ConclusionsInitiation of adjuvant chemotherapy within 45 days of radical cystectomy for patients with pT2-4 bladder cancer was associated with an overall survival benefit compared to patients who received adjuvant chemotherapy after 45 days or no adjuvant chemotherapy.

Comprehensive characterization of perioperative reoperation following radical cystectomy

IntroductionTo examine the nature, timing, and risk factors underlying return to the operating room (ROR) following radical cystectomy (RC). ROR has been proposed as a surgical quality metric based on data from the general surgery literature, but ROR has not been comprehensively characterized following RC. Patients and methodsWe queried our institutional Cystectomy Registry from 2000 to 2016 to identify patients with ROR within 90 days of RC. Multivariable logistic regression was used to examine associations between patient features and ROR. Survival outcomes were studied based on whether ROR was necessary. ResultsOf 1968 patients treated with RC, 112 (5.7%) underwent 125 reoperations within 90 days of RC, of which 93% were unanticipated and due to postsurgical complications. The most common reasons for ROR were facial dehiscence (29%), bowel obstruction (21%), and enteric anastomotic leak (8%). On multivariable analysis, increasing body mass index (odds ratio 1.04, 95% confidence interval (CI) 1.01–1.08, P = 0.045) and albumin <3.5 g/dl (odds ratio 2.15, 95% CI 1.28–3.59, P = 0.004) were associated with greater odds of ROR. Patients with a ROR had significantly decreased 5-year overall survival compared to patients who did not undergo ROR (43% vs. 55%; P = 0.003), and ROR was associated with increased all-cause mortality after multivariable adjustment (hazard ratio 1.33, 95% CI 1.01–1.74, P = 0.04). ConclusionROR principally occurred due to unanticipated complications and was associated with increased mortality after RC. These data suggest ROR may be a useful metric by which urological programs can track the efficacy of interventions aimed at improving perioperative care for RC patients.

Temporal trends in venous thromboembolism after radical cystectomy

PurposeTo determine whether the rate of venous thromboembolism (VTE) following radical cystectomy (RC) is changing overtime. Materials and methodsThe American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent RC for bladder cancer from 2011 to 2016. VTE was defined as pulmonary embolism or deep vein thrombosis within 30 days of RC. VTE rate by year was assessed using the Cochran-Armitage test for trend. Associations between patient features and VTE were evaluated with multivariable logistic regression. ResultsA total of 8,241 patients undergoing RC were identified, of whom 348 (4.2%) were diagnosed with VTE. VTE was diagnosed at a median of 13 days (IQR: 7–19) after RC, with 171 (49%) occurring after hospital discharge. Notably, the rate of VTE after RC was found to significantly decrease over time, from 5.1% in 2011 to 2.8% in 2016 (P = 0.001). On multivariable analysis, clinical factors significantly associated with increased odds of VTE included congestive heart failure (odds ratio [OR] = 2.83, P = 0.01), prolonged operative time (OR: 1.48–1.56, P = 0.02–0.01), and receipt of a perioperative blood transfusion (OR = 1.27; P = 0.04). When postoperative complications were adjusted for, sepsis/septic shock (OR = 2.37, P<0.001) and perioperative infection (OR = 1.74, P<0.001) were likewise found to be associated with VTE. ConclusionsThe rate of VTE after RC significantly decreased in recent years, potentially reflecting improvements in perioperative care. The specific casual factors underlying this trend, in addition to efforts to address identified risk factors for VTE, warrant continued study.

Post-Operative Infections among Patients Undergoing Radical Cystectomy at a Tertiary Center.

Post-operative infection after radical cystectomy is a common complication. It is essential to identify modifiable risk factors that can predict post-operative infection to reduce the incidence of infection after radical cystectomy. We investigated the incidence of post-operative infection, associated pathogens, and risk factors for post-operative infection after radical cystectomy. Patients who underwent radical cystectomy for bladder cancer in a single urologic department from 2014 to 2016 were included. Age, gender, length of stay, body mass index (BMI), diabetes mellitus, hypertension, pre-operative estimated glomerular filtration rate, hydronephrosis, smoking status, neoadjuvant chemotherapy, pathologic tumor stage, pathologic nodal stage, types of urinary diversion, laparoscopic approach, operative time, and receipt of peri-operative blood transfusion were assessed to determine the association of these factors with the risk of infection within 30 days of radical cystectomy. Risk factors were assessed for correlation with any kind of infection and separately for urinary tract infection (UTI), blood infection/septic shock (BI), and surgical site infection (SSI). Pathogens were identified in all cases of infection. A total of 134 patients were included in the analysis. Post-operative infection was diagnosed in 10.45%. Urinary tract infection, BI, and SSI were diagnosed in 3.73%, 4.48%, and 7.46%, respectively. Co-infections and mixed infection were diagnosed in 50% of patients with infection. Enterococcus was the most common pathogen. On multivariable analysis, age, BMI ≥30 kg/m2, and laparoscopic approach were associated with the risk of infection; odds ratios (ORs) were 1.27 (95% confidence interval [CI] 1.01-1.59), 13.07 (1.39-122.88), and 0.07 (0.01-0.78), respectively. One-tenth of patients undergoing radical cystectomy developed an infection within 30 days of surgery. Fifty percent of patients had co-infection with UTI, SSI, and/or BI and 50% of infections were polymicrobial. Increased BMI is the strongest factor associated independently with all types of infection. Therefore, obese patients should be encouraged to lose weight pre-operatively.

PD15-06 TIMING OF ADJUVANT CHEMOTHERAPY AND SURVIVAL FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Invasive II1 Apr 2018PD15-06 TIMING OF ADJUVANT CHEMOTHERAPY AND SURVIVAL FOLLOWING RADICAL CYSTECTOMY Joshua Jue, Zachary Kroeger, Tulay Koru-Sengul, Feng Miao, Kevin Moore, Mahmoud Alameddine, Chad Ritch, and Mark Gonzalgo Joshua JueJoshua Jue More articles by this author , Zachary KroegerZachary Kroeger More articles by this author , Tulay Koru-SengulTulay Koru-Sengul More articles by this author , Feng MiaoFeng Miao More articles by this author , Kevin MooreKevin Moore More articles by this author , Mahmoud AlameddineMahmoud Alameddine More articles by this author , Chad RitchChad Ritch More articles by this author , and Mark GonzalgoMark Gonzalgo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.805AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Radical cystectomy (RC) is the standard of care for surgical management of patients with muscle-invasive bladder cancer (MIBC). The use of perioperative chemotherapy is also important for achieving optimal outcomes. We investigated the impact of timing of adjuvant chemotherapy (AC) on survival following radical cystectomy. METHODS Patients with newly diagnosed pT2-T4, N0, M0 urothelial cell carcinoma who received no chemotherapy prior to RC were identified in the National Cancer Data Base (NCDB). Patients who underwent RC and received no AC or patients who received AC > 45 days following RC were propensity matched to patients receiving AC = 45 days following RC. Median survival was calculated using Kaplan-Meier analysis. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated from a multivariable Cox regression model to examine factors affecting overall survival (OS). RESULTS A total of 284 patients with MIBC treated with AC within 45 days of RC were identified from 2004-2014. Patients who received AC = 45 days following RC had better 5 year OS (47.0%, 95% CI: 40.6%-53.2%) compared to patients who received AC > 45 days following RC (37.5%, 95% CI: 31.4%-43.7%) or no AC (41.2%, 95% CI: 35.0%-47.2%). There was no significant difference in OS between patients who received AC > 45 days and no AC (1.11, 0.89-1.38, p=0.348). AC > 45 days and no AC were significant predictors of worse OS compared to AC = 45 days (1.27, 1.02-1.59, p=0.033 and 1.41, 1.12-1.78, p=0.003). CONCLUSIONS Patients who received AC = 45 days following RC had better overall survival compared to patients who received AC > 45 days or no AC following RC. These data highlight the importance of appropriate timing of AC following RC. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e312 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Joshua Jue More articles by this author Zachary Kroeger More articles by this author Tulay Koru-Sengul More articles by this author Feng Miao More articles by this author Kevin Moore More articles by this author Mahmoud Alameddine More articles by this author Chad Ritch More articles by this author Mark Gonzalgo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Evolution of cystectomy care over an 11-year period in a high-volume tertiary referral centre.

To describe the evolution in radical cystectomy (RC) care over 11 years at a referral centre. The clinical data of patients undergoing either open RC (ORC) or robot-assisted RC (RARC) for cT1-4aN0M0 bladder cancer (BCa) at our centre between January 2006 and December 2016 were retrospectively evaluated. Crude and propensity score-weighted log-binomial regression analyses were conducted to assess the association between pre- and peri-operative variables and the risk of reoperation, intensive care unit (ICU) admission and death <90 days after RC. A total of 814 patients were considered. The percentage of RARCs performed increased (from 10% to 100%) between 2006 and 2013. Overall, 29% of the patients received neoadjuvant chemotherapy (12-37% from 2006 to 2016). Despite no differences in terms of operating time, pelvic lymph node dissection (PLND) was more commonly attempted during RARC and extended PLND was more frequently performed in the RARC group (72% vs 19%; P < 0.001). Ileal conduit was the preferred urinary diversion in both groups, and more patients in the RARC group underwent neobladder construction (34% vs 14%; P < 0.001). The overall rates of re-intervention, ICU admission and death within 90 days of RC were 8.9%, 5.4% and 2.9%, respectively. On crude analysis, RARC was associated with a reduced risk of ICU admission (relative risk [RR] 0.42, 95% confidence interval [CI] 0.23-0.77; P = 0.005), reintervention (RR 0.58, 95% CI 0.37-0.90; P = 0.015) and death (RR 0.37, 95% CI 0.16-0.85; P = 0.020); however, these risk reductions were not statistically significant on weighted analyses. The introduction of RARC has coincided with a reduction in the rate of ICU admission, reoperation and death within 90 days of surgery, without compromising operating time, PLND extent or neobladder utilization.

Characteristics and Associated Factors of Postoperative Pulmonary Complications in Patients Undergoing Radical Cystectomy for Bladder Cancer: A National Surgical Quality Improvement Program Study.

The purpose of this study was to summarize the characteristics and identify associated factors of postoperative pulmonary complications (PPCs) in patients undergoing radical cystectomy (RC). The National Surgical Quality Improvement Project (NSQIP) database (2005-2014) was used to identify patients who underwent RC for bladder cancer. PPCs were defined as pneumonia, unplanned reintubation, and ventilator support > 48 hours within 30 days of RC. Incidence, timing, and outcomes of PPCs were described and analyzed. Multivariable logistic regression was used to evaluate associated factors of PPCs. Among 3790 patients included, 213 (5.6%) had at least 1 PPC. Patients with PPCs had a significantly higher 30-day mortality (17.4% vs. 0.7%; P< .001) and longer hospital stay (13 vs. 8 days; P< .001). Logistic regression showed that age≥ 75 years (odds ratio [OR], 2.07; P= .001), body mass index< 18.5 kg/m2 (OR, 2.48; P= .017), body mass index≥ 30 kg/m2 (OR, 1.71; P= .009), dependent functional status (OR, 2.77; P= .006), current smoker (OR, 1.57; P= .011), chronic obstructive pulmonary disease (OR, 1.70; P= .018), insulin-treated diabetes (OR, 1.70; P= .042), and albumin< 3.5 g/dL (OR, 1.72; P= .015) were associated with increased risk of overall PPCs. Approximately 5.6% of patients have at least one PPC within 30 days of RC. Several preoperative associated factors for PPCs were identified, which should be helpful for risk stratification, patient counseling, and perioperative care.

Association of perioperative venous thromboembolism with long-term oncologic outcomes following radical cystectomy.

364 Background: Venous thromboembolism (VTE) has been reported to occur in 2-5% of patients undergoing radical cystectomy (RC). While VTE is an important cause of perioperative morbidity, the association of these events with long-term cancer prognosis has not been established. Herein, we evaluated the association of perioperative VTE with patients’ risk of subsequent disease recurrence and mortality. Methods: We reviewed 2889 patients undergoing RC between 1980−2009 at the Mayo Clinic to identify patients diagnosed with a VTE within 90 days of RC. These cases were then matched in a 1:2 fashion to control patients undergoing RC who did not develop VTE. Matching was performed on the basis of age, BMI, receipt of neoadjuvant chemotherapy, and pathologic T and N stages. Recurrence-free (RFS), cancer-specific (CSS), and overall survival (OS) were estimated utilizing the Kaplan-Meier method and compared with the log-rank test. Results: A total of 132 patients with a VTE within 90 days of RC were identified, accounting for 4.6% of all patients analyzed. These cases were matched to 257 controls per criteria noted above, and were overall well-matched. Of the 389 patients in this study, median follow-up after RC was 9.2 years, during which time 152 (39%) patients experienced recurrence and 306 (78%) died, including 157 (40%) who died of bladder cancer. We found no significant difference in 5-year RFS (59% versus 61%; p = 0.75); CSS (57% versus 64%; p = 0.13); or OS (45% versus 50%; p = 0.15) between patients with versus without perioperative VTE, respectively. Conclusions: We found that VTE within 90 days of RC did not significantly impact long-term cancer outcomes. While these events represent an important cause of perioperative morbidity, no interaction with oncologic control was noted, and patients may be counseled accordingly.

Safety and Efficacy of Extended Duration of Thromboembolic Prophylaxis Following Radical Cystectomy: An Initial Institutional Experience

IntroductionWe evaluated the safety and efficacy of extended duration of pharmacological prophylaxis for preventing symptomatic venous thromboembolism following radical cystectomy. MethodsWe recorded symptomatic venous thromboembolism and lymphocele events within 30 days of radical cystectomy among patients treated with extended duration of pharmacological prophylaxis (enoxaparin 40 mg subcutaneously daily for 30 days). We compared these outcomes to those in the cohort of patients who underwent radical cystectomy at our institution in the year prior to extended prophylaxis implementation. Unadjusted descriptive statistics and univariate analyses were performed using the Pearson test or the Fisher chi-square test for categorical variables and the Wilcoxon rank sum test for continuous variables. ResultsWe analyzed the records of 52 patients who did and 82 who did not receive extended duration of pharmacological prophylaxis after radical cystectomy. Only 1 patient (1.9%) discharged home on extended prophylaxis was diagnosed with venous thromboembolism within 30 days of RC compared to 5 (6.1%) who had not received extended prophylaxis. In 3 patients symptomatic lymphocele developed within 30 days of radical cystectomy, including 1 (1.9%) who had received extended prophylaxis and 2 (2.4%) who had not. No patient in either cohort was rehospitalized for bleeding complications. ConclusionsOur initial experience suggests that extended duration of pharmacological prophylaxis is associated with a lower rate of venous thromboembolism following radical cystectomy and it does not increase the risk of bleeding or symptomatic lymphocele. These data warrant validation in larger patient cohorts, ideally in the prospective clinical trial setting.

Characterization of perioperative infection risk among patients undergoing radical cystectomy: Results from the national surgical quality improvement program

ObjectivesTo evaluate the incidence, risk factors, and timing of infections following radical cystectomy (RC). MethodsThe American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patients undergoing RC for bladder cancer from 2006 to 2013. Characteristics including year of surgery, age, sex body mass index, diabetes, smoking, renal function, steroid usage, preoperative albumin, preoperative hematocrit, perioperative blood transfusion (PBT), and operative time were assessed for association with the risk of infection within 30 days of RC using multivariable logistic regression. ResultsA total of 3,187 patients who had undergone RC were identified, of whom 766 (24.0%) were diagnosed with a postoperative infection, at a median of 13 days (interquartile ranges 8-19) after RC. Infections included surgical site infection (SSI) (404; 12.7%), sepsis/septic shock (405; 12.7%), and urinary tract infection (UTI) (309; 9.7%). On multivariable analysis, body mass index≥30kg/m2 (odds ratios [OR] = 1.52; P<0.01), receipt of a PBT (OR = 1.27; P<0.01), and operative time≥480 minutes (OR = 1.72; P<0.01) were significantly associated with the risk of infection. When the outcomes of UTI, SSI, and sepsis were analyzed separately, operative time≥480 minutes remained independently associated with increased infection risk in each model (OR = 2.11 for UTI, OR = 1.63 for SSI, and OR = 1.80 for sepsis/septic shock; all P<0.05), whereas PBT was associated with SSI and sepsis/septic shock (OR = 1.33 and OR = 1.29, respectively; both P< 0.05). ConclusionsApproximately 25% of patients undergoing RC experience an infection within 30 days of surgery. Several potentially modifiable risk factors for infection were identified, specifically PBT and prolonged operative time, which may represent opportunities for future care improvement.