Open Radical Cystectomy Group Research Articles

Use of rectus sheath catheters for pain relief in patients undergoing major pelvic urological surgery

To report on the safety and efficacy of rectus sheath blocks, 'topped-up' using bilateral rectus sheath catheters (RSCs), in patients undergoing major open urological surgery. The RSCs were inserted under ultrasound guidance into 200 patients between April 2008 and August 2011, of whom 106 patients underwent radical retropubic prostatectomy (RRP) and 94 underwent open radical cystectomy (ORC). A retrospective case-note review was undertaken. Outcomes included technical success and complication rates of the insertion and use of RSC, visual analogue pain scores, additional analgesia requirements and length of hospital stay (LOS). All RSCs were successfully placed without complication and used for a mean of 3.6 days for ORC and 2.1 days for RRP. Early removal occurred in 6.49% of patients. Low overall pain scores were reported in both groups. Patients were more likely to require a patient-controlled analgesia system in the ORC group but the overall need for additional analgesia was low in both groups, reducing significantly after the initial 24 h. In combination with an enhanced recovery programme, LOS reduced from 17.0 to 10.8 days in the ORC group and from 6.2 to 2.8 days in the RRP group. The use of RSCs appears to offer an effective and safe method of peri-operative analgesia in patients undergoing major open urological pelvic surgery.

Safety and Feasibility of Laparoscopic Radical Cystectomy for the Treatment of Bladder Cancer

Radical cystectomy is the mainstay of the management of muscle invasive bladder cancer. Numerous centers have adopted a minimally invasive approach to replace the standard open procedure. The objective of the study was to review published literature comparing laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC). A systematic review of the literature according to Cochrane guidelines was conducted (1993 to 2012) for studies comparing LRC and ORC. All studies comparing the two procedures were included. The outcome measures were the patient demographics, operative time, blood loss, transfusion rates, time to oral intake, length of hospital stay, and complications. A meta-analysis was conducted. For continuous data, a Mantel-Haenszel chi-square test was used, and for dichotomous data, an inverse variance was used, each expressed as risk ratio with 95% confidence interval. P<0.05 was considered significant. Four hundred twenty-seven patients were included-211 patients in the laparoscopic group and 216 patients in the open group (eight studies). There was no significant difference between the two groups in any of the demographic parameters except for age (age: P<0.0001; sex: P=0.1; body mass index: P=0.05). The laparoscopic group had significantly longer operative times (P<0.0001), but less blood loss (P<0.00001), less transfusion rates (P<0.0001), less time to oral intake (P<0.0001), less analgesic requirement (P=0.0009), and shorter length of hospital stay (P<0.0001). Significantly more minor complications developed in the ORC group than in the LRC group (P=0.02). There was no difference between the two groups regarding lymph node dissection yields, major complications, positive margins, pathologic results, local recurrence, or distant metastases (all P>0.05). There were significantly more positive nodes in the ORC group, however. In experienced hands, LRC is a feasible and safe alternative to ORC with less blood loss, transfusion and analgesic requirement, shorter lengths of hospital stay, and less complications. LRC does, however, have longer operative times.

Comparison of robotic-assisted and open radical cystectomy in a community-based, non-tertiary health care setting.

We examined the safety and feasibility of transitioning from open radical cystectomies to robotic-assisted laparoscopic cystectomies in a community-based, non-tertiary health care setting. A retrospective review and analysis of our most recent 14 unselected consecutive patients who underwent open cystectomy was compared to our first 14 unselected consecutive patients who underwent robotic-assisted laparoscopic cystectomy. Perioperative and pathologic outcomes were reviewed to determine the safety and oncologic equivalence of the two procedures. From 2003 to 2010, 14 consecutive patients underwent an open cystectomy and from 2010 to 2012 another 14 consecutive patients underwent a robotic-assisted laparoscopic cystectomy. The operative time was significantly longer in the robotic group (6h 23min vs. 4h 28min; p<0.05) and intraoperative blood loss was significantly lower compared with the open radical cystectomy (ORC) group (470ml vs. 942ml; p<0.05). Regarding complications, 21% of robotic-assisted radical cystectomy (RARC) patients experienced major complications versus 14% of ORC patients. Overall, there was no statistically significant difference in complication rates or length of hospital stay between the ORC and RARC groups. No pathologic differences were noted between the two groups and lymph node counts were similar in the two groups, with the median numbers being 11.9 and 9.5 in RARC and ORC, respectively. RARC can be accomplished in a community-based, non-tertiary health care setting without compromising perioperative or pathologic outcomes during the institution of this minimally invasive procedure.

Laparoscopic versus Open Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Single Institute Comparative Analysis

Background: Open radical cystectomy (ORC) is the gold standard of treatment for muscle-invasive bladder cancer. Laparoscopic radical cystectomy (LRC) has emerged to provide an alternative. Methods: Between 2006 and 2012, 155 patients who underwent LRC or ORC were compared (mean follow-up 53 months). Results: The ORC group had shorter operative times (p < 0.0001), more blood loss (p < 0.00001), more transfusion requirement (p < 0.00001), longer postoperative length of hospital stay (p < 0.00001) and more morphine requirement (p = 0.02). No difference was found regarding lymph node yield (p = 0.07), positive margins (p = 0.11), cystectomy pathology results (p > 0.05) and positive lymph nodes (p = 0.02). The ORC group had less intraoperative complications (p = 0.03). No difference was found between the two groups regarding 5-year overall survival (p = 0.93), cancer-specific survival (p = 0.7) and recurrence-free survival (p = 0.62). Conclusion: LRC can be considered as an alternative to ORC with good operative and postoperative results in addition to comparable 5-year survival results.

当院における腹腔鏡下膀胱全摘除術の治療成績

The standard care for invasive bladder cancer is radical cystectomy with urinary diversion, but laparoscopic radical cystectomy (LRC) is still being evaluated. We describe our initial experience of laparoscopic radical cystectomy compared to open radical cystectomy (ORC). From January 2000 to June 2012, 84 patients underwent radical cystectomy by ORC (n = 54) or LRC (n = 30). Treatment outcomes including surgical and oncological outcomes between LRC and ORC were compared. We also assessed learning curve during LRC as to blood loss, operating time and complication rate. The patients' characteristics were similar in LRC and ORC groups except for ASA score. Importantly, Operating time during LRC was longer but complication rate of LRC was lower than that of ORC (586 min vs 424 min and 40% vs 69%, respectively). In addition, pathological stage or outcomes were similar in both groups and there were no significant difference between LRC and ORC groups in terms of overall and recurrence free survival rate. As for learning curve of LRC, operating time and blood loss tended to decrease with increased experience. These results indicate that LRC could be performed safely with decreased complication rate and similar oncological outcomes compared to ORC.

Is Robot-Assisted Radical Cystectomy Justified in the Elderly? A Comparison of Robotic Versus Open Radical Cystectomy for Bladder Cancer in Elderly ≥75 Years Old

Open radical cystectomy (ORC) or minimally invasive radical cystectomy with pelvic lymph node (LN) dissection carries significant morbidity to the elderly because they often have several medical comorbidities that make a surgical approach more challenging. The objective of this study is to compare robot-assisted radical cystectomy (RARC) and ORC in elderly patients. A prospective bladder cancer cystectomy database was queried to identify all patients age ≥75 years. A total of 20 patients were identified for each of the RARC and ORC cohorts. A retrospective analysis was performed on these 40 patients undergoing radical cystectomy for curative intent. Patients in both groups had comparable preoperative characteristics and demographics. Patients had significant medical comorbidities with 80% in each cohort having American Society of anesthesiologists classification of 3 and 50% having had previous abdominal surgery. Complete median operative times for RARC was 461 (interquartile range [IQR] 331, 554) vs 370 minutes for ORC (IQR 294, 460) (P=0.056); however, median blood loss for RARC was 275 mL (IQR 150, 450) vs 600 mL for ORC (IQR 500, 1925). The median hospital stay for RARC was 7 days (IQR 5, 8) vs 14.5 days for ORC (IQR 8, 22) (P<0.001). The major complication (Clavien≥III) rate for RARC was 10% compared with 35% for ORC (P=0.024). There were two positive margins in the ORC group compared with one in the RARC group with median LN yields of 15 nodes (IQR 11, 22) and 17 nodes (IQR 10, 25) (P=0.560) respectively. In a comparable cohort of elderly patients, RARC can achieve similar perioperative outcomes without compromising pathologic outcomes, with less blood loss and shorter hospital stays. For an experienced robotic team, RARC should be considered in elderly patients because it may offer significant advantage with respect to perioperative morbidity over ORC.

Preliminary results of perioperative outcomes and oncologic efficacy from a single-institution randomized controlled trial of open versus robotic-assisted radical cystectomy.

305 Background: In the past decade minimally invasive robotic assisted approaches have emerged as a viable option for the treatment of many urologic malignancies. Robotic-assisted radical cystectomy (RARC) for bladder cancer has been reported with the potential for lower blood loss, less transfusion requirement, and shorter hospital stay in prior studies. We present preliminary data from a single institution prospective randomized clinical trial of open radical cystectomy (ORC) versus RARC. Methods: Prospective randomized single institution series evaluating the feasibility of ORC versus RARC for consecutive patients was performed from July 2009 to June 2011. Oncologic efficacy was assessed based on the surrogates of total number of lymph nodes removed and positive surgical margins. Perioperative morbidity was assessed evaluating for estimated blood loss, transfusion requirements, length of stay and perioperative morbidity. Results: To date 46 patients have been randomized with data available on 39 patients for analysis. Each group was similar with regards to age, sex, race, BMI, comorbidities, and previous abdominal procedures, operative time, and final pathologic stage. We observed no significant difference between oncologic outcomes of positive surgical margins (5% vs 5.263%, p 0.48) or number of LN removed (11 vs 23, p 0.40) for the RARC versus ORC groups respectively. The RARC group was noted to have decreased estimated blood loss (400 mL vs 800 mL, p 0.008) and a trend towards decreased rate of excessive length of stay (&gt;5 days) (65% vs 84%, p 0.17) for the RARC versus ORC groups. The robotic group had a trend towards decreased rate of transfusion however this was not statistically significant (40% versus 53%, p 0.26). Conclusions: Our preliminary findings from a single institution randomized trial of RARC versus ORC indicates that RARC has equivalent oncologic outcomes as measured by positive surgical margins and total number of lymph node removed. RARC demonstrates Perioperative benefits of decreased blood loss, fewer excessive hospital stays, and a trend toward fewer transfusions that was not significant.

A Comparison of Early Complications Between Open and Robot-Assisted Radical Cystectomy

The aim of our study was to compare early complication rates between the robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) using a standardized reporting system. From September 2008 to March 2011, 35 and 104 patients underwent ORC and RARC, respectively. Demographics and perioperative and complication data on all patients were reviewed retrospectively and compared between the two groups. All complications were categorized using a modified Clavien reporting system. We also sought to identify independent predictive factors of grade II or greater complications. There were no significant differences between the ORC and RARC groups with regard to age, body mass index, American Society of Anesthesiologists score, clinical stage, surgical procedure history, or sex. The RARC group had more cases of ileal neobladder urinary diversion (P<0.001). We did not find any differences in terms of pathologic stage or length of stay. The ORC group had more grade II or greater complications (P=0.001), wound problems (P=0.043), multiple complications (P=0.014), greater estimated blood loss (EBL) (P<0.001), and needed more transfusions (P<0.001). A longer operative time was needed in the RARC group, however. Multivariate logistic regression analysis demonstrated that the ORC (P=0.045, odds ratio [95% confidence interval]=2.44 [1.02-5.85]), EBL (>500 mL, P=0.013, 2.75 [1.24-6.10]), and female sex (P=0.028, 4.06 [1.12-14.11]) were independent predictors of grade II or greater complications. Our results showed that the RARC group was comparable to the ORC group with respect to complications using the Clavien reporting system. Further long-term and randomized trials are needed, however, because RARC is still not considered the standard therapy for bladder cancer.

Lymph node dissection during laparoscopic (LRC) and open (ORC) radical cystectomy due to muscle invasive bladder urothelial cancer (pT2-3, TCC).

AimThe aim of the study was to compare the number of nodes dissected during laparoscopic and open radical cystoprostatectomy in men or anterior exenteration in women due to muscle invasive bladder urothelial cancer (IBC).Material and methodsFifty-one patients treated with laparoscopic radical cystectomy (LRC) and 63 with open radical cystectomy (ORC) were compared. The LRC group consisted of 47 pT2 tumours and 4 pT3, while the ORC group was composed of 27 pT2 tumours and 36 pT3. During ORC external, internal, common iliac and obturator lymph nodes were removed separately, but were added and analysed together for each side. Nodes dissected from one side during ORC were compared to en bloc dissected nodes in the LRC group.ResultsThere were no complications associated with extended pelvic lymph node dissection during LRC or ORC. There were significant differences in the mean number of resected lymph nodes between LRC and ORC for pT2 tumours. The laparoscopic approach allowed about 8-9 more lymph nodes to be removed than open surgery in the pT2 group. In 15% of patients with pT2 disease treated with open radical cystectomy node metastases were observed. Active disease was detected in 18% of nodes resected laparoscopically due to pT2 disease. Fourty-seven percentage of patients with pT3 disease treated with open surgery were diagnosed as harbouring metastatic lymph nodes. The laparoscopic group with pT3 disease was too small to analyse.ConclusionsWe have found that laparoscopic radical cystectomy can be performed without any compromise in lymph node dissection. The technique of lymph node dissection (LND) during laparoscopic cystectomy (LRC) resulted in sufficient resected lymphatic tissue, especially in patients with bladder-confined tumours with a low volume of lymph nodes.

Robot Assisted Laparoscopic Pelvic Lymphadenectomy at the Time of Radical Cystectomy Rivals That of Open Surgery: Single Institution Report

The purpose of this study was to analyze the pelvic lymph node dissection (PLND) and margin status using a standard technique in the first 35 patients undergoing robot-assisted radical cystectomy (RARC) at our institution while establishing a robotics program, and then to compare the results to the past 35 open radical cystectomy (ORC) performed at our institution. After obtaining institutional review board approval, we reviewed the clinical and pathologic data from 70 consecutive patients with clinically localized bladder cancer who underwent radical cystectomy with PLND from April 2007 to June 2009. Thirty-five operations were performed open and 35 used the da Vinci robotic system. The PLND was performed in all patients using the same template. There was no significant difference between the ORC and RARC group in regards to patient characteristics, tumor stage (43% ORC and 40% RARC having pT3/pT4 disease), and node status (29% N+ in each group). The median total lymph node yield was similar, with 15 (interquartile range [IQR] 11, 22) in the ORC group and 16 (IQR 11, 24) in the RARC group (P = 0.5). One patient who underwent RARC had a positive margin compared with 3 patients in the ORC group. The initial 35 RARC with PLND performed at our institution compared with the last 35 ORC resulted in equivalent lymph node yield and similar rates of positive margins. RARC with PLND is feasible, safe, and effective when performed at a high-volume center by an experienced team.

Comparison of Hand-Assisted Laparoscopic and Open Radical Cystectomy for Bladder Cancer

Purpose: To present our experience of hand-assisted laparoscopic radical cystectomy (HALRC) and compare it with open radical cystectomy (ORC). Patients and Methods: During the period between May 2004 and November 2007, 31 patients underwent HALRC and 39 patients underwent ORC for bladder cancer. The patient demographics, intraoperative variables and postoperative outcomes were compared retrospectively. Results: There was no statistically significant difference with regard to age, sex, body mass index, and urinary diversion in the 2 groups. In the HALRC group, 20 patients had stage pT2 or less, 7 had pT3 disease, and 4 had stage pT4 disease. In the ORC group, 29 patients had stage pT2 or less, 5 had pT3 disease, and 5 had stage pT4 disease. All margins in both groups were negative. The HALRC group had decreased blood loss (250.9 vs. 812.8 ml, p < 0.001) and a lower rate of transfusion (9.7 vs. 76.9%, p < 0.001), but similar mean operative time (365.7 vs. 362.6 min, p = 0.862). Time to liquid diet was significantly less in the HALRC group versus the ORC group (4.3 vs. 6.3 days, p < 0.001). The median number of lymph nodes were similar between the HALRC and ORC groups (14 vs. 15, p = 0.377). Six patients developed perioperative complications in the HALRC group and 12 patients had complications in the ORC group (19.4 vs. 30.8%, p = 0.278). Late complications occurred in 3 patients (2 parastomal hernias and 1 ureteroenteral stricture) in the HALRC group. Conclusions: Compared with ORC, HALRC patients had decreased blood loss, less transfusion requirements, and quicker intestinal recovery. Long-term follow-up in a larger cohort of patients is needed to assess the long-term oncological and functional outcomes.

Laparoscopic versus open radical cystectomy for the management of bladder cancer: Mid‐term oncological outcome

To compare the mid-term oncological outcome of laparoscopic radical cystectomy (LRC) with those of open radical cystectomy (ORC). From June 2003 to February 2008, 36 LRCs were carried out at our institute for the treatment of bladder cancer. Clinical and oncological data were retrospectively analyzed. A match-pair comparison with an historical series of 34 patients who were submitted to ORC between 1996 and 2003 was carried out. Median follow-up of the LRC group was 21 months (3-56 months). Pathological stage or grade was similar in the two groups. There was no significant difference between the LRC and ORC groups in terms of 3-year overall (64.2% vs 72.6%, respectively; P = 0.682), cancer-specific (73.0% vs 75.3%, respectively; P = 0.951), and recurrence-free survival (70.5% vs 72.5%, respectively; P = 0.715) rates. In a subgroup analysis according to stage, there was also no significant difference in the 3-year disease-specific survival after LRC or ORC for organ-confined (pT1 and pT2; 85.7% vs 83.9%, respectively; P = 0.256) or extravesical disease (pT3 and pT4; 73.3% vs 63.8%, respectively; P = 0.825). These findings suggest that LRC provides mid-term oncological outcomes similar to those of ORC in the management of bladder cancer.

DOES THE CLOSURE OF THE DORSAL PERITONEAL LAYER AFTER CYSTECTOMY AND EXTENDED PELVIC LYMPHADENECTOMY (PLND) HAVE A SIGNIFICANT BENEFICIAL IMPACT ON EARLY POSTOPERATIVE RECOVERY AND COMPLICATIONS?

The purpose of this study was to analyze the pelvic lymph node dissection (PLND) and margin status using a standard technique in the first 35 patients undergoing robot-assisted radical cystectomy (RARC) at our institution while establishing a robotics program, and then to compare the results to the past 35 open radical cystectomy (ORC) performed at our institution.After obtaining institutional review board approval, we reviewed the clinical and pathologic data from 70 consecutive patients with clinically localized bladder cancer who underwent radical cystectomy with PLND from April 2007 to June 2009. Thirty-five operations were performed open and 35 used the da Vinci robotic system. The PLND was performed in all patients using the same template.There was no significant difference between the ORC and RARC group in regards to patient characteristics, tumor stage (43% ORC and 40% RARC having pT3/pT4 disease), and node status (29% N+ in each group). The median total lymph node yield was similar, with 15 (interquartile range [IQR] 11, 22) in the ORC group and 16 (IQR 11, 24) in the RARC group (P = 0.5). One patient who underwent RARC had a positive margin compared with 3 patients in the ORC group.The initial 35 RARC with PLND performed at our institution compared with the last 35 ORC resulted in equivalent lymph node yield and similar rates of positive margins. RARC with PLND is feasible, safe, and effective when performed at a high-volume center by an experienced team.

Short Term Comparative Analysis of Laparoscopic and Open Radical Cystectomy with Extracorporeal Urinary Diversion

Purpose: We analyzed the efficacy and safety of laparoscopic radical cystectomy (LRC) compared with open radical cystectomy (ORC). Materials and Methods: Between November 2007 and April 2009, we performed LRC to treat bladder cancer in 23 patients and ORC in 64 patients. Data including the patients’ clinical characteristics, peri-operative parameters, clinical outcomes, and oncologic outcomes were collected retrospectively and analyzed by use of the Mann-Whitney U test and chi-square test. Results: There were no significant differences in demographic data between the two groups. Operative time was longer (595.2 min vs. 453.1 min; p<0.01) in the LRC group but blood loss was less (634.8 ml vs. 1,415.9 ml; p<0.01) and fewer transfusions were required (13.0% vs. 50.0%; p=0.002) in the LRC group. Days to oral intake (5.7 days vs. 7.3 days; p<0.01), days to drain removal (10.9 days vs. 13.9 days; p=0.014), and length of hospital stay (15.2 days vs. 22.3 days; p<0.01) were shorter in the LRC group. Postoperative complications occurred in 4 cases in the LRC group and 28 cases in the ORC group (17.4% vs. 43.8%, p<0.01). There were no cases with a positive surgical margin in the LRC group and 3 cases in the ORC group. There was no significant difference in the number of lymph nodes excised (17.4 vs. 19.6; p=0.132) between groups. Conclusions: These short-term clinical and oncological results suggest that LRC is a safe and effective method for the treatment of invasive bladder cancer. (Korean J Urol 2009;50:1083-1088) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Short Term Outcomes of Laparoscopic Radical Cystectomy with an Extracorporeal Ileal Conduit: Comparative Analysis with the Open Method

Purpose: We analyzed the perioperative and early oncological outcomes following radical cystectomy with using the laparoscopic method, and we compared these findings with those of the conventional open method. Materials and Methods: Between January 2003 and December 2006, we performed laparoscopic radical cystectomy (LRC) with an extracorporeal ileal conduit for treating bladder cancer in 22 patients, and the results of the LRC were compared with those of open radical cystectomy (ORC) in 20 cases. The surgical results such as the operation time, the estimated blood loss (EBL), the transfusion rate, the hospital stay, the complications and the oncological results were reviewed retrospectively and then analyzed via the Mann-Whitney U test. Results: There were no significant differences of demographic data between the two groups. The pathologic reports showed a transitional cell type in all cases. For the LRC and ORC groups, the mean operation time for cystectomy was 186.5 min (150-240) vs 192.4 min (150-240), respectively (p=0.276), the EBL was 228.18ml (150-380) vs 995.0ml (400-1,200), respectively (p<0.01), the transfusion rate was 15.7% vs 85.0%, respectively, the hospital stay was 11.2 days vs 12.4 days, respectively (p=0.67), the intraoperative complications was 3/22 cases (13.6%) vs 9/20 cases (45.0%), respectively. The pathologic surgical margins were all negative. The surgical and pathologic parameters of the LRC group showed no significant differences compared to those of the ORC group, except for the EBL and transfusion rate. Conclusions: LRC resulted in less blood loss, a lower transfusion rate and earlier, more rapid recovery than did ORC. In our opinion, lararoscopic surgery is a feasible treatment for bladder cancer. (Korean J Urol 2007; 48:938-944)