Mortality Of Radical Cystectomy Research Articles

Emerging treatments for bacillus Calmette-Guérin-unresponsive non-muscle-invasive bladder cancer.

Intravesical bacillus Calmette–Guérin (BCG) immunotherapy has been the gold standard adjuvant treatment for intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC) after transurethral resection of bladder tumor (TURBT). BCG immunotherapy prevents disease recurrence and progression to muscle-invasive disease following TURBT. Although most patients initially respond well to intravesical BCG, considerable concern has been raised for patients with BCG failure who are refractory or recur in 6 months after their last BCG, which implies ‘BCG-unresponsiveness’. Based on current clinical guidelines, early radical cystectomy (RC) is recommended to treat BCG-unresponsive NMIBC. However, due to the high risk of morbidity and mortality of RC and patients' desire to preserve their own bladder, there is a critical unmet need for alternative conservative treatments as bladder-sparing strategies in BCG-unresponsive patients. Trials for effective bladder-sparing treatments are ongoing, and several novel agents have been recently tested in the NMIBC setting. The goal of this review is to introduce and summarize recently reported novel and emerging drugs and ongoing clinical trials for BCG-unresponsive NMIBC.

Bladder Sparing Protocol with Tri Modality Therapy (TMT) “A Prospective Study”

Abstract Background: To evaluate the response of the modern bladder-preservation treatment modality; trimodal therapy (TMT) in muscle-invasive bladder cancer (MIBC). Aiming at bladder preservation in MIBC, TMT was to offer a quality-of-life advantage and avoid potential morbidity and mortality of radical cystectomy (RC) without compromising oncologic outcomes.Aim of Study: To investigate the TMT as a treatment option for muscle-invasive bladder cancer confirmed by cancer specific and overall survival rates in two different institutes.Material and Methods: The study included 64 consecutive patients between 2008 and 2013, and was conducted in National Institute of Urology and Nephrology, Cairo, Egypt, Al-Azhar University, Girls Div., Urology Dept., Cairo, Egypt and National Cancer Institute, Cairo University, Cairo, Egypt. Forty nine patients were males and 15 were females. Mean age was 61±9 years (range, 34-82 years). Sixty nine percent of patients (44) were below 65 years old while 31% (20) were above 65. Sixty six percent (42 patients) were fit for surgery but refused RC as first line of treatment and 34% (22 patients) were unfit for surgery. Results: One third of patients (20) failed TMT and under went RC. Five years overall survival (OS) was 57% and disease specific survival (DSS) was 61%. There was no significant difference observed in OS or DSS between different age, sex or surgical fitness patients groups. Tumor stage showed significant statistical difference between T2 and T3 (p<0.05). Lymph nodes disease progression and distant me-tastases were recorded in 13 and 10% with TMT respectively.Conclusion: This study suggests that bladder preservation with TMT leads to acceptable outcomes comparable with RC and therefore may be considered a reasonable treatment option in well-selected patients.

Postoperative complications and 90-day mortality in radical cystectomy in high-risk patients: A monocentric retrospective observational study.

Assessing the incidence of immediate postoperative complications and 90-day mortality in high-risk patients who have undergone radical cystectomy; evaluating the correlation between preoperative conditions and surgery outcomes. This is a monocentric retrospective observational study in which data of 65 patients have been analyzed. High-risk criteria: (a) Age ≥75 years, (b) obesity, (c) age-adjusted Charlson Comorbidity Index ≥8, (d) anemic status, and (e) pT ≥3. More than 50% of patients had two or more "high-risk" indicators. Postoperative complications were assessed through Clavien-Dindo classification. Average age of patients was 70.4 years, average age-adjusted Charlson Comorbidity Index was 5.8, and average body mass index was 27.5. In 28% of patients, no complications arose, while in 46% grades I-II complications according to Clavien-Dindo occurred, in 23% grades III-IV complications occurred, and in 3% of the patients, death arose in the immediate postoperative period (grade V). Overall, 90-day mortality rate after surgery was 12.3%. The age ≥75 years and an age-adjusted Charlson Comorbidity Index score ≥8 have shown to be risk factors for the onset of severe complications (odds ratio = 3.54, p = 0.028 and odds ratio = 4.7, p = 0.026), while preoperative anemic status was a risk factor for complications in general (odds ratio = 4.1, p = 0.015). No analyzed parameter was a predictor of 90-day mortality ( p > 0.05). Immediate postoperative complications and 90-day mortality in radical cystectomy in high-risk patients remain significant, but still in line with the data in the literature on comparable populations. Some of the preoperative parameters were able to predict the outcomes of the intervention with regard to the onset of complications but not to the 90-day mortality.

Variability in complications and operative mortality after radical cystectomy in Spain

BackgroundIn the literature, mortality for radical cystectomy (RC) varies between 2.3% and 7.5%. In Spain, there are no published general data on morbidity and mortality. ObjectiveTo identify the complications and mortality of RC in Spain through an analysis of all procedures performed over a 3-year period and to study the geographic variability of these results. Material and methodsWe identified patients who underwent RC in the Spanish National Health System between 2011 and 2013 based on the minimum basic data set.We analyzed the complications and mortality during hospitalization and at 30, 60 and 90 days.We compared these results in the various autonomous communities, adjusted them by age, Charlson score and sex and subsequently added the hospital size. ResultsWe studied 7999 patients who underwent RC in 197 hospitals of the Spanish National Health System. The mean age of the series was 67.2±9.8 years. The median stay was 15 days (IQR, 11–24). Some 47.2% of the patients had complications. The mean mortality in-hospital and at 30, 60 and 90 days was 4.7, 2.9, 5 and 6.2%, respectively. There was considerable variability in the mortality at 90 days among the communities (3.8–9.1%). When adjusting by the patient and hospital characteristics, there were still significant geographic variations (3.8–11.5%). ConclusionsRC mortality in Spain at 90 days is similar to the rate in the literature. There are significant geographic variations unexplained by the characteristics of the patients or by those of the hospitals in which these operations were performed.

Variabilidad en las complicaciones y la mortalidad quirúrgica tras cistectomía radical en España

BackgroundIn the literature, mortality for radical cystectomy (RC) varies between 2.3% and 7.5%. In Spain, there are no published general data on morbidity and mortality. ObjectiveTo identify the complications and mortality of RC in Spain through an analysis of all procedures performed over a 3-year period and to study the geographic variability of these results. Material and methodsWe identified patients who underwent RC in the Spanish National Health System between 2011 and 2013 based on the minimum basic data set.We analysed the complications and mortality during hospitalisation and at 30, 60 and 90 days.We compared these results in the various autonomous communities, adjusted them by age, Charlson score and sex and subsequently added the hospital size. ResultsWe studied 7999 patients who underwent RC in 197 hospitals of the Spanish National Health System. The mean age of the series was 67.2±9.8 years. The median stay was 15 days (IQR, 11-24). Some 47.2% of the patients had complications. The mean mortality in-hospital and at 30, 60 and 90 days was 4.7, 2.9, 5 and 6.2%, respectively. There was considerable variability in the mortality at 90 days among the communities (3.8-9.1%). When adjusting by the patient and hospital characteristics, there were still significant geographic variations (3.8-11.5%). ConclusionsRC mortality in Spain at 90 days is similar to the rate in the literature. There are significant geographic variations unexplained by the characteristics of the patients or by those of the hospitals in which these operations were performed.

Incidence and Risk Factors of 30-Day Early and 90-Day Late Morbidity and Mortality of Radical Cystectomy During a 13-Year Follow-up: A Comparative Propensity-score Matched Analysis of Complications Between Neobladder and Ileal Conduit

We report on the short and late morbidity and mortality of ileal conduit and neobladder after radical cystectomy with their associated risk factors. We retrospectively collected data on 308 non-metastatic bladder cancer patients who underwent radical cystectomy with either ileal conduit or neobladder for a curative intent from January 1999 to December 2011. Post-operative morbidity and mortality of 30-day (early) and 90-day (late) complication with their risk factors were examined in association with different types of urinary diversion. A comparative analysis using propensity-score matching was performed with matching variables of age, sex, number of underlying diseases and pathologic T and N stages, lymph node dissection, operative time and time of surgical year for comparison of the early and late morbidities between ileal conduit and neobladder. During the median follow-up of 46.6 months, early and late morbidities were 29.5% (n=91) and 19.8% (n=61), and complication-related mortalities were 2.2 and 6.6%, respectively. The type of urinary diversion significantly affected only the late complications (early: neobladder 57 vs. ileal conduit 47, P=0.096; late: neobladder 67 vs. ileal conduit 37, P<0.001). However, after propensity-score matching, no significant differences in early and late morbidities were observed between neobladder and ileal conduit. For risk factors of morbidity, number of removed lymph node states and hypertension were independently significant for both early and late complications (P<0.05). The type of urinary diversion affected only late complication, however, results of the matching analysis showed no significant differences in early and late morbidities between neobladder and ileal conduit.

Fast‐track rehabilitation after robot‐assisted laparoscopic cystectomy accelerates postoperative recovery

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: There is evidence from large abdominal surgeries and some open cystectomy series that multifactorial fast-track regimens shorten postoperative convalescence without any effect on morbidity and mortality. Such a regimen is of particular interest in combination with minimally invasive techniques, as early patient recovery demands for more rapid nutrition and mobilisation schemes. The present study, in a single institution, reports on the design, application and results of a fast-track protocol in patients undergoing robot-assisted laparoscopic cystectomy. There was no evidence of a higher incidence of complications with the fast-track regimen and postoperative recovery was faster. To evaluate the feasibility and effectiveness of a multifactorial fast-track (FT) regimen on perioperative outcomes in patients undergoing robot-assisted laparoscopic cystectomy (RALC) with extracorporeal urinary diversion. To point out that morbidity and mortality of radical cystectomy have improved markedly over the last decades and RALC is an emerging technique showing further advances in postoperative recovery, thus demanding for more rapid nutrition and mobilisation schemes. A non-randomised cohort study of 63 patients who underwent RALC at one institution between January 2007 and March 2010. In all, 31 patients underwent RALC without FT and 31 RALC with FT. One patient required conversion to open surgery and was therefore excluded from the study. The FT regimen included early nutrition and the quickest possible mobilisation, while mechanical bowel preparation before surgery, as well as preoperative fasting and nasogastric or abdominal drains after surgery, were omitted. Demographics, perioperative and complication data (according to modified Clavien system), as well as required opioid pain medication were documented prospectively and compared between RALC patients with and without FT. Groups were comparable for demographics, risk factors and clinical stage as well as operative parameters, e.g. mean operating room time, estimated blood loss, lymph nodes removed and postoperative haemoglobin level. In the FT group, abdominal drains were mostly omitted and nasogastric tubes were removed immediately after surgery. There were significant differences in the mobilisation within the room (17.5 vs 31.2 h), the time to a regular diet (4.0 vs 6.6 days) and a remarkably lower use of postoperative morphine equivalents (57.3 vs 92.4 mg) for patients receiving FT. There were no significant differences in the overall complication rates or major complications based on Clavien classification. The informative value of the study is limited by its single-centre, non-randomised design, a relatively small sample size and a possible learning curve bias. Combining RALC with FT is feasible in the perioperative treatment of these patients. Multifactorial postoperative regimens seem to quicken postoperative recovery of RALC patients without increasing their risk of postoperative complications.

Predicting the Probability of 90-Day Survival of Elderly Patients With Bladder Cancer Treated With Radical Cystectomy

Despite the increased morbidity and mortality of radical cystectomy in elderly individuals with bladder cancer numerous studies show that surgery can provide a survival benefit. We sought to better identify patients at substantial risk for postoperative mortality. We evaluated 220 consecutive patients 75 years old or older treated with radical cystectomy for bladder cancer at a single institution from 2000 to 2008. The analytical cohort comprised 169 patients with complete preoperative data available. A Cox proportional hazards model was used to determine the value of precystectomy clinical information to predict 90-day survival after radical cystectomy. Results were used to create a nomogram predicting the probability of 90-day survival after radical cystectomy. The model was then subjected to 200 bootstrap resamples for internal validation. Of the 220 patients 28 (12.7%) died within 90 days of surgery. Older age (HR 2.30, 95% CI 1.22-4.32) and lower preoperative albumin (HR 2.50, 95% CI 1.40-4.45) were significant predictors of 90-day mortality. We developed a nomogram based on patient age, clinical stage, Charlson comorbidity index and albumin to predict the likelihood of 90-day mortality with 75% accuracy. Internal validation showed a bootstrap adjusted concordance index of 71%. We developed a nomogram that provides individualized risk estimations to predict the probability of 90-day mortality, potentially enhancing preoperative counseling and providing clinicians with an added tool to individualize treatment decisions in this challenging patient population. These data suggest that albumin is a strong predictor of postoperative mortality and show the importance of assessing this variable before surgery.

Extraperitoneal radical cystectomy and ureterocutaneostomy in octogenarians

Bladder cancer is the fourth more frequent tumour in men. Radical cystectomy is considered the standard treatment for muscle invasive bladder cancer (MIBC). However, its role in elderly patients is still debate. Management of MIBC in the elderly population is considered an important issue in urological practice for the continuous ageing of the European population. Aim of our study is to evaluate the feasibility and relatively morbidity and mortality of radical cystectomy in octogenarian patients affected by MIBC. From 2005 to 2009, we performed in octogenarian patients (83-92 years), affected by MIBC, 30 radical cystectomy with mono or bilateral extraperitoneal terminal ureterocutaneostomy in regional anaesthesia (spinal anaesthesia). Pre-operative patients' characteristics were evaluated with the American Society Anaesthesiologists score (ASA); peri- and post-operative complications were also recorded. Patients were revaluated at 3-6-9 months post-operatively with physical examination, serum analysis and ultrasound kidney scan. Radical cystectomy was always performed, median surgical time was 100 min (range 80-120 min), median blood replacement was 750 ml, and the overall morbidity rate was 13%. One patient died post-operatively. Median hospital stay was 8 days (range 5-12 days). Twenty-nine patients were alive at 9 months of follow-up. Extraperitoneal radical cystectomy with ureterocutaneostomy could represent a feasible option, associated with a limited mortality and mobility, in the management of MIBC in octogenarian patients.

Radical cystectomy in patients aged ≥ 75 years: an updated review of patients treated with curative and palliative intent

To evaluate the morbidity and mortality of radical cystectomy in a group of unselected patients aged > or = 75 years who were treated with curative and palliative intent. We retrospectively analysed 53 patients aged 75-90 years (median 78.8 years) who had radical cystectomies between May 1994 and July 2002. The patients were divided into two groups: 46 were treated with curative intent (group A) and seven with palliative intent (group B). The indications for cystectomy in group A were recurrent and otherwise therapy-resistant bladder cancer, severe irritative voiding symptoms, and recurrent macrohaematuria. The indications in group B were advanced pelvic malignancy with severe irritative voiding symptoms, severe pain, and recurrent macrohaematuria requiring blood transfusions. Patients were categorized according to the American Society of Anesthesiologists classification, with a score of II in 28 patients, III in 21 and IV in four. Complications and mortality before, during and after surgery, and the duration of hospital stay and clinical outcome, were assessed. RESULTS; The early mortality rate in group A was 4% (2/46); in group B two patients died after prolonged complications. The median (range) hospital stay was 28 (6-56) days, and was significantly longer in patients with complications, at a median (range) of 36 (6-70) days. The complication rates early and late after surgery in group A were 22% and 11%, respectively, and in group B, five of seven (early). The total median survival was 2 (0.33-7) years. Elderly people undergoing radical cystectomy have a greater risk of perioperative morbidity and mortality, especially those with very advanced pelvic malignancies who have had cystectomy with palliative intent. The incidence of early and late complications in patients treated with curative intent is acceptable, but the hospital stay is prolonged.

The changing pattern of mortality and morbidity from radical cystectomy.

To examine the morbidity and mortality of radical cystectomy as currently practised, and to compare the findings with historical data. The operative mortality and early and late complications were recorded in 101 consecutive patients (median age 65 years, range 38-81; 33 aged >70 years) undergoing radical cystectomy between April 1992 and October 1997. Fifteen patients had relapsed after previous radical radiotherapy. The median postoperative stay was 14 days (range 8-44). There were two deaths within 60 days of surgery (of patients aged 46 and 59 years) from respiratory failure and sepsis, respectively. The mortality in the elderly was not more than in other age groups. The early morbidity included two cases of lower limb insufficiency, both in the salvage cystectomy group, where the morbidity was significantly higher than in those undergoing primary cystectomy (chi-squared, P<0.01). Three patients underwent early re-exploration. There were four clinically significant episodes of deep vein thrombosis and two pulmonary emboli that were not fatal. As currently practised, radical cystectomy is associated with a lower mortality (<2%) and morbidity than described previously. The added morbidity of salvage cystectomy and the acceptable mortality of primary cystectomy suggests that the treatment of choice for muscle-invasive disease is primary cystectomy, with external beam radiotherapy reserved for those patients unfit for major surgical intervention. Age alone should no longer be considered a contraindication to cystectomy.

Morbidity and Mortality of Radical Cystectomy (1971???78 and 1978???85)

The mortality after radical cystectomy with urinary diversion has been reduced from 11% in 53 patients operated on during 1971-78, to 2.5% in a similar group of 120 patients operated on during 1978-85. Amongst the latter, mortality varied from 0 amongst 32 non-irradiated patients, to 1 (3%) of 33 after planned preoperative radiotherapy and 2 (3.6%) of 55 after previous radical radiotherapy. The improvement in results appears to be due to a number of factors including routine intensive care in the early postoperative phase, with epidural analgesia, and meticulous attention to haemostasis and the technical details of construction of the ileal conduit.

Morbidity and Mortality of Radical Cystectomy (1971–78 and 1978–85)

The mortality after radical cystectomy with urinary diversion has been reduced from 11% in 53 patients operated on during 1971-78, to 2.5% in a similar group of 120 patients operated on during 1978-85. Amongst the latter, mortality varied from 0 amongst 32 non-irradiated patients, to 1 (3%) of 33 after planned preoperative radiotherapy and 2 (3.6%) of 55 after previous radical radiotherapy. The improvement in results appears to be due to a number of factors including routine intensive care in the early postoperative phase, with epidural analgesia, and meticulous attention to haemostasis and the technical details of construction of the ileal conduit.

Morbidity and mortality of radical cystectomy (1971-78 and 1978-85).

The mortality after radical cystectomy with urinary diversion has been reduced from 11% in 53 patients operated on during 1971-78, to 2.5% in a similar group of 120 patients operated on during 1978-85. Amongst the latter, mortality varied from 0 amongst 32 non-irradiated patients, to 1 (3%) of 33 after planned preoperative radiotherapy and 2 (3.6%) of 55 after previous radical radiotherapy. The improvement in results appears to be due to a number of factors including routine intensive care in the early postoperative phase, with epidural analgesia, and meticulous attention to haemostasis and the technical details of construction of the ileal conduit.