Open Radical Cystectomy Patients Research Articles

A Continuous Transversus Abdominis Plane Block Decreases Hospital Length of Stay Compared to Thoracic Epidural Analgesia After Open Radical Cystectomy Surgery: A Retrospective Study

Background: Poorly managed postoperative pain can prolong hospital stays and increase the risk of complications in patients undergoing open radical cystectomy (ORC). Despite strong support from the clinical guidelines for using surgical site-specific peripheral regional anesthetic techniques and neuraxial analgesia, their effects on postoperative outcomes are unclear. Objectives: This study aims to fill the above knowledge gap by comparing thoracic epidural analgesia (TEA) and continuous transversus abdominis plane (CTAP) blocks in ORC patients. Methods: In this retrospective observational study, we conducted chart reviews at a quaternary care academic hospital in Boston, Massachusetts, between March 2015 and September 2017. Patients undergoing ORC and receiving either CTAP or TEA were included. The primary outcome was the hospital length of stay (HLOS), and secondary outcomes included time until ambulation, postoperative narcotic usage, and renal function as measured by the glomerular filtration rate (GFR). Results: We studied 146 patients, 124 of whom met our inclusion criteria. Patients receiving CTAP had a 17.4% reduction in HLOS (95% CI: 3.2, 29.4; P = 0.02) and a 13.9% reduction in time until ambulation (95% CI: 3.4, 23.3; P = 0.01) compared to those receiving TEA. This was equivalent to a relative decrease in HLOS of approximately 2.1 days in the CTAP group as compared to the TEA group. No significant differences were observed in narcotic usage or GFR between the two groups. Our sensitivity analyses using instrumental variables analysis yielded similar results. Conclusions: Continuous transversus abdominis plane was associated with a shorter HLOS and quicker time to ambulate compared to TEA, without affecting narcotic usage or renal function. These findings suggest that CTAP may be a viable alternative to TEA for perioperative analgesia in ORC patients. Further research is needed to confirm these findings.

Robotic versus open radical cystectomy for bladder cancer: evaluation of complications, survival, and opioid prescribing patterns.

We aim to compare complications, readmission, survival, and prescribing patterns of opioids for post-operative pain management for Robotic-assisted laparoscopic radical cystectomy (RARC) as compared to open radical cystectomy (ORC). Patients that underwent RARC or ORC for bladder cancer at a tertiary care center from 2005 to 2021 were included. Recurrence-free survival (RFS) and overall survival (OS) were evaluated with Kaplan-Meier curves and multivariable Cox proportional hazards regression models. Comparisons of narcotic usage were completed with oral morphine equivalents (OMEQ). Multivariable linear regression was used to assess predictors of OMEQ utilization. A total of 128 RARC and 461 ORC patients were included. There was no difference in rates of Clavien-Dindo grade ≥ 3 complications between RARC and ORC (36.7 vs 30.1%, p = 0.16). After a mean follow up of 3.4years, RFS (HR 0.96, 95%CI 0.58-1.56) and OS (HR 0.69, 95%CI 0.46-1.05) were comparable between RARC and ORC. There was no difference in the narcotic usage between patients in the RARC and ORC groups during the last 24h of hospitalization (median OMEQ: 0 vs 0, p = 0.33) and upon discharge (median OMEQ: 178 vs 210, p = 0.36). Predictors of higher OMEQ discharge prescriptions included younger age [(- )3.46, 95%CI (-)5.5-(-)0.34], no epidural during hospitalization [- 95.85, 95%CI (- )144.95-(- )107.36], and early time-period of surgery [(- )151.04, 95%CI (- )194.72-(- )107.36]. RARC has comparable 90-day complication rates and early survival outcomes to ORC and remains a viable option for bladder cancer. RARC results in comparable levels of opioid utilization for pain management as ORC.

Comparing Robotic-Assisted to Open Radical Cystectomy in the Management of Non-Muscle-Invasive Bladder Cancer: A Propensity Score Matched-Pair Analysis.

For non-muscle-invasive bladder cancer (NMIBC) requiring radical surgery, limited data are available comparing robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) to open radical cystectomy (ORC). The objective of this study was to compare the two surgical techniques. A multicentric cohort of 593 patients with NMIBC undergoing iRARC or ORC between 2015 and 2020 was prospectively gathered. Perioperative and pathologic outcomes were compared. A total of 143 patients operated on via iRARC were matched to 143 ORC patients. Operative time was longer in the iRARC group (p = 0.034). Blood loss was higher in the ORC group (p < 0.001), with a consequent increased post-operative transfusion rate in the ORC group (p = 0.003). Length of stay was longer in the ORC group (p = 0.007). Post-operative complications did not differ significantly (all p > 0.05). DFS at 60 months was 55.9% in ORC and 75.2% in iRARC with a statistically significant difference (p = 0.033) found in the univariate analysis. We found that iRARC for patients with NMIBC is safe, associated with a lower blood loss, a lower transfusion rate and a shorter hospital stay compared to ORC. Complication rates were similar. No significant differences in survival analyses emerged across the two techniques.

Comparison of long-term outcomes in a 10-year experience of robotic cystectomy vs. open cystectomy.

To compare the outcomes of robotic-assisted (RARC) vs. open radical cystectomy (ORC) at a single academic institution. We retrospectively identified patients undergoing radical cystectomy for urothelial carcinoma of the bladder at our institution from 2007 to 2017. Data collected included age, sex, Body Mass Index (BMI), Charlson Age-Adjusted Comorbidity Index (CCI), final pathologic stage, surgical margins, lymph-node yield, estimated blood loss (EBL), 90-day complication rate, and length of stay (LOS). We evaluated overall survival (OS) and recurrence-free survival (RFS). Multivariable Cox proportional hazard models were used to adjust for covariates. We identified 232 patients (73 RARC, 159 ORC) who underwent radical cystectomy. Patients who underwent RARC were older (71.8 vs. 67.5, p < 0.05) and had higher CCI scores (6.2 vs. 5.3, p < 0.05). In comparing perioperative outcomes, RARC patients had lower EBL (500 vs. 850, p < 0.01), lower blood transfusion rate (p < 0.01), and lower lymph-node yield (12 vs. 20, p < 0.01), and higher ICU admission rate (29% vs. 16% p < 0.01). There was no difference in BMI (p = 0.93), sex (p = 0.28), final pathological stage (p = 0.35), positive surgical margins (p = 0.47), complications (p = 0.58), or LOS (p = 0.34). Kaplan-Meier analysis showed no difference in OS (p = 0.26) or RFS (p = 0.86). There was no difference in restricted mean survival time for OS (53 vs. 56months, p = 0.81) or for RFS (65 vs. 64months, p = 0.90). Cox multivariate regression models showed that surgical approach does not have a significant impact on OS (p = 0.46) or RFS (p = 0.35). Our study indicates that in our 10-year experience, patients undergoing there was no difference between RARC and ORC patients with respect to OS and RFS despite being older and having more comorbidities. Our work supports the importance of patient selection to optimize outcomes.

Robot Assisted Radical Cystectomy vs Open Radical Cystectomy: Over 10 years of the Mayo Clinic Experience

ObjectivesThere is scant information about intermediate / long-term comparative outcomes between robot assisted radical cystectomy (RARC) and open radical cystectomy (ORC). The purpose of this study is to present survival and oncological outcomes between bladder cancer patients who undergo RARC vs. ORC with an overall median follow-up of over 5 years. Materials and MethodsA query of all patients who underwent radical cystectomy between January, 2007 and January, 2018 at Mayo Clinic Arizona yielded 595 patients. After excluding cystectomy performed for nonmalignant indication, cancer secondary to nonbladder primary, and cancers with grossly metastatic disease at the time of surgery, 481 patients remained. Data was collected on patient demographics, preoperative information, operative details, complications, and follow-up. Statistical analyses were generated using SPSS 22.0. ResultsIn 481 total patients, 203 (42.2%) underwent RARC and 278 (57.8%) underwent ORC. The median follow-up for the entire cohort was 66 months. The 5-year recurrence-free survival (RFS) was 70.8% vs. 64.7% and the 10-year RFS was 69.6% vs. 62.7% for the RARC vs. ORC, respectively (P = 0.135). The 5-year overall survival (OS) was 58.9% vs. 57.7% and the 10-year OS was 39.9% vs. 45.6% for RARC vs. ORC patients, respectively (P = 0.466). There were no differences in any recurrence patterns, including the incidence of atypical recurrences (1.5% vs. 1.8% [P = 0.786], respectively). A Cox-proportional hazards model was fitted that included independent predictors of RFS and OS. The results revealed no difference in RFS (HR 1.235, 95% CI: 0.832–1.833, P = 0.295) or OS (HR 0.790, 95% CI: 0.550–1.135, P = 0.202) between the respectively. ConclusionsRecurrence free survival, OS, and recurrence patterns are similar in bladder cancer patients who undergo either RARC or ORC.

Open Versus Robotic Cystectomy: A Propensity Score Matched Analysis Comparing Survival Outcomes.

Background: To assess the differential effect of robotic assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) on survival outcomes in matched analyses performed on a large multicentric cohort. Methods: The study included 9757 patients with urothelial bladder cancer (BCa) treated in a consecutive manner at each of 25 institutions. All patients underwent radical cystectomy with bilateral pelvic lymphadenectomy. To adjust for potential selection bias, propensity score matching 2:1 was performed with two ORC patients matched to one RARC patient. The propensity-matched cohort included 1374 patients. Multivariable competing risk analyses accounting for death of other causes, tested association of surgical technique with recurrence and cancer specific mortality (CSM), before and after propensity score matching. Results: Overall, 767 (7.8%) patients underwent RARC and 8990 (92.2%) ORC. The median follow-up before and after propensity matching was 81 and 102 months, respectively. In the overall population, the 3-year recurrence rates and CSM were 37% vs. 26% and 34% vs. 24% for ORC vs. RARC (all p values > 0.1), respectively. On multivariable Cox regression analyses, RARC and ORC had similar recurrence and CSM rates before and after matching (all p values > 0.1). Conclusions: Patients treated with RARC and ORC have similar survival outcomes. This data is helpful in consulting patients until long term survival outcomes of level one evidence is available.

Propensity-matched comparison of laparoscopic and open radical cystectomy for female patients with bladder cancer

To compare the perioperative and oncologic outcomes of female patients receiving laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC). Retrospective review of 91 consecutive female patients with urothelial carcinoma of bladder undergoing radical cystectomy at a single academic institution from 2006 to 2017. Those female patients received open radical cystectomy were matched to the patients who underwent laparoscopic radical cystectomy by using propensity score matching in 1 ∶1 ratio. The matching factors included age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, pathologic stage and pathologic nodal stage. The perioperation and oncology characteristics were compared, and Kaplan-Meier method was used to analyze the overall survival (OS), cancer specific survival (CSS) and progression-free survival (PFS) estimates. Finally, we did a sensitive analysis by using multivariable COX regression of all the patients, adjusting for the matching factors. There were 65 ORC and 26 LRC patients identified in this cohort with urothelial carcinoma of bladder, the median follow-up time was 38 months (interquartile range 18-69). The age (P<0.001) and ASA scores (P=0.018) were less for LRC before being matched. There were 22 LRC and 22 ORC patients matching successfully. Before being matched, the estimate blood loss (P=0.005), transfusion rate (P<0.001) and total complications rate (P=0.015) were less for LRC, and the lymph nodes yield was greater for LRC, but there were no differences in OS (P=0.698), CSS (P=0.942) and PFS (P=0.837) between the two groups. After being matched, the estimate blood loss (P=0.009), transfusion rate (P=0.001) and total complications rate (P=0.040) were less for LRC, but there was no difference in the lymph nodes yield. Besides, there were no statistic differences in OS (P=0.432), CSS (P=0.429) and PFS (P=0.284) between the two groups. In addition, in multivariable COX regression analysis, surgical approaches (LRC/ORC) were not found to be a predictor of OS (HR 1.134, 95%CI 0.335-3.835, P=0.839), CSS (HR 1.051, 95%CI 0.234-4.719, P=0.949) and PFS (HR 0.538, 95%CI 0.138-2.095, P=0.371) of the female patients with urothelial carcinoma of bladder. It is advantageous for laparoscopic radical cystectomy in terms of estimating blood loss, transfusion rate and complication rate. But there was no evidence that laparoscopic radical cystectomy for female patients with bladder cancer had a better oncologic prognosis than open radical cystectomy from this study.

Robot-assisted radical cystectomy (RARC) versus open radical cystectomy (ORC): Oncological outcomes in 469 patients with a mean follow-up of five years.

492 Background: There is scant information about intermediate and long-term comparative outcomes between RARC and ORC, with the exception of a recent, small randomized-trial. We present our experience with RARC and ORC in managing bladder cancer patients who require cystectomy. Methods: A query of all patients who underwent radical cystectomy for a primary bladder tumor between 01/2007 and 6/2017 at our institution yield 469 patients. Data was collected on patient demographics, pre-operative information, operative details, pathology, and follow-up. Most RARCs were performed by a high-volume robotic surgeon who preferentially used the robotic approach at the start of all cases. Statistical analyses were generated using SPSS 22.0. Any open conversions were analyzed in the RARC cohort. Results: In 469 total patients, 197 (42.0%) and 272 (58.0%) underwent RARC and ORC, respectively. There were 163 (82.7%) and 224 (82.4%) males in each group and the mean ages (SD) were 71.5 (8.6) and 70.2 (10.5) years. Mean follow-up (SD) was 75 (37.7) and 61 (35.7) months, respectively. There were 130 (66.0%) and 172 (63.2%) patients who presented with T2 or greater disease (p=0.605). Soft-tissue margin rates were 4.1% for RARC and 6.7% for ORC patients (p=0.232). Neoadjuvant chemotherapy was used in 56.9% of RARC and 45.9% of ORC patients with ≥ cT2 disease (p=0.058). The 5-year overall survival was 60.0% vs 57.0% and the 10-year overall survival was 40.3% vs 44.8% for RARC vs. ORC patients, respectively (p=0.283). The 5-year recurrence-free survival was survival (RFS) was 71.7% vs 65.7% and the 10-year RFS was 70.5% vs 62.3% for the RARC vs. open groups, respectively (p=0.078). Aggressive histological variants, which were associated with greater likelihood for recurrence, were more common in the ORC group (13.7 vs. 22.4% p=0.013). Atypical recurrences (i.e. peritoneal, extrapelvic nodes) occurred in 6 (3.0%) and 14 (5.1%) RARC and ORC patients, respectively (p=0.266). Conclusions: In experienced hands, intermediate and long-term outcomes of RARC appear equivalent to ORC with regards to recurrence free survival, overall survival, and risk of atypical recurrences.

Propensity-score-matched comparison of soft tissue surgical margins status between open and robotic-assisted radical cystectomy

IntroductionThe use of robotic-assisted radical cystectomy (RARC) is becoming more widespread. While its safety is accepted, its oncological efficacy as compared to the current standard, open radical cystectomy (ORC), remains debatable. Materials and methodsThe aim of this study is to compare the rates of positive soft tissue surgical margins (STSM), between patients treated with RARC or ORC, using a large contemporaneous collaborative database. We included 2,536 patients with urothelial carcinoma of the bladder treated at 26 institutions. A propensity-score matching 1:1 was performed with 3 ORC patients matched to 1 RARC patient. The final cohort included 1,614 patients. Uni- and multivariable logistic regression analyses tested the impact of surgical technique on STSM status, before and after propensity-score matching. ResultsOverall, 870 (34%) patients underwent RARC and 1,666 (66%) ORC. The overall STSM rate was 11%; 10% in the ORC group and 13% in the RARC group. Within the propensity-score-matched cohort, the positive STSM rate were 14% and 13% in the ORC and RARC group, respectively (P = 0.1). In multivariable analysis, after propensity match RARC approach was not associated with the risk of a positive STSM (P = 0.1). These results were confirmed in the subgroup of patients with pathologic non–organ-confined or organ-confined diseases. ConclusionsWhile treatment with RARC is associated with a higher absolute rate of STSM, the difference did not remain after adjustment for the effects of other established prognostic factors. Results from ongoing trials are awaited to assess the validity of these findings.

Comparison of 2-Year Oncological Outcome and Early Recurrence Patterns in Patients with Urothelial Bladder Carcinoma Treated with Open or Robot-Assisted Radical Cystectomy with an Extracorporeal Urinary Diversion

Background: Data on oncological follow-up after robotic-assisted radical cystectomy (RARC) have been reported only scarcely and individual studies have reported an increase in early recurrences and atypical recurrences. Patients and Methods: Clinical data of 89 patients with RARC were compared to 59 patients with open radical cystectomy (ORC) at a single institution. Two-year cancer-specific (2y-CSS) and 2-year overall survival (2y-OS) related to histopathological tumor stage of RARC patients calculated by Kaplan-Meier method were compared to ORC patients using log-rank test. Early clinical recurrence rate (eCR, progression ≤6 months post-cystectomy) and metastatic pattern of both groups were compared by chi-square test. Results: Median follow-up 32 months (RARC) and 47.5 months (ORC), both groups were balanced in baseline characteristics. For RARC pts, ­2y-OS and CSS-free survival rates were 80 and 90%, for ORC pts 65 and 71% (all p > 0.05). Margin status was not significantly different. eCR was observed in 10 out of 89 (11%) RARC pts and in 7 out of 59 (12%) ORC pts (p = 0.9). No difference in atypical metastases was seen between groups. Conclusion: Two-year oncological outcomes of RARC patients are comparable to ORC patients without differences regarding ePR or metastatic pattern.

Perioperative and mid-term oncologic outcomes of robotic assisted radical cystectomy with totally intracorporeal neobladder: Results of a propensity score matched comparison with open cohort from a single-centre series

AimIn this study, we compared perioperative and oncologic outcomes of patients treated with either open or robot-assisted radical cystectomy and intracorporeal neobladder at a tertiary care center. MethodsThe institutional prospective bladder cancer database was queried for “cystectomy with curative intent” and “neobladder”. All patients underwent robot-assisted radical cystectomy and intracorporeal neobladder or open radical cystectomy and orthotopic neobladder for high-grade non-muscle invasive bladder cancer or muscle invasive bladder cancer with a follow-up length ≥2 years were included. A 1:1 propensity score matching analysis was used. Kaplan-Meier method was performed to compare oncologic outcomes of selected cohorts. Survival rates were computed at 1,2,3 and 4 years after surgery and the log rank test was applied to assess statistical significance between the matched groups. ResultsOverall, 363 patients (299 open and 64 robotic) were included. Open radical cystectomy patients were more frequently male (p = 0.08), with higher pT stages (p = 0.003), lower incidence of urothelial histologies (p = 0.05) and lesser adoption of neoadjuvant chemotherapy (<0.001). After applying the propensity score matching, 64 robot-assisted radical cystectomy patients were matched with 46 open radical cystectomy cases (all p ≥ 0.22). Open cohort showed a higher rate of perioperative overall complications (91.3% vs 42.2%, p 0.001). At Kaplan-Meier analysis robotic and open cohorts displayed comparable disease-free survival (log-rank p = 0.746), cancer-specific survival (p = 0.753) and overall-survival rates (p = 0.909). ConclusionsRobot-assisted radical cystectomy and intracorporeal neobladder provides comparable oncologic outcomes of open radical cystectomy and orthotopic neobladder at intermediate term survival analysis.

Does previous abdominal surgery adversely affect perioperative and oncologic outcomes of laparoscopic radical cystectomy?

BackgroundLaparoscopic radical cystectomy (LRC) has been shown to have less estimated blood loss (EBL), transfusion rate, narcotic analgesic requirement, earlier return of bowel function, and shorter hospital stay. The aim of this study was to investigate the feasibility, peri-operative and oncologic outcomes of laparoscopic radical cystectomy (LRC) in patients with previous abdominal surgery (PAS).MethodsWe retrospectively reviewed 243 patients undergoing open radical cystectomy (ORC) or LRC with bilateral pelvic lymph node dissection and urinary diversion or cutaneous ureterostomy at a single center from January 2010 to December 2015. Demographic parameters, intra-operative variables, peri-operative records, pathologic outcomes, and complication rate were reviewed to assess the impact of PAS on peri-operative and oncologic outcomes.ResultsPatients in both ORC and LRC subgroups were homogeneous in terms of demography characteristics including age, gender, BMI, ASA score, and comorbidity. Estimated blood loss (EBL) was higher in patients with PAS undergoing ORC compared to those with no PAS (P = 0.008). However, there was no significant difference of EBL among patients undergoing LRC with or without PAS (P = 0.896). There was no statistical difference in peri-operative parameters and pathological outcomes. Patients with PAS undergoing ORC and ileal conduit had a higher vascular injury rate (P = 0.017). Comparing patients with PAS performed by LRC and ORC, the number of patients with the vascular injury was higher in ORC groups regardless of the type of diversion (ileal conduit, P = 0.001, cutaneous ureterostomy, P = 0.025). There is no significant difference in other complications.ConclusionThe presence of adhesions from PAS is not a contraindication to LRC. Patients with PAS may benefit from LRC with lower estimated blood loss, fewer transfusion rates, and vascular injuries. Furthermore, the overall oncologic outcomes and complication rate are similar between LRC and ORC patients with PAS.

Comparative effectiveness of robot-assisted vs. open radical cystectomy

ObjectivesOver the past decade, robot-assisted radical cystectomy (RARC) has gained traction as an alternative to the conventional open approach open radical cystectomy (ORC). However, the benefits of RARC over ORC remain unclear. Our objective was to conduct a comparative effectiveness analysis between RARC and ORC using data from the National Cancer Data Base. Materials and methodsWithin the National Cancer Data Base, we identified patients with localized muscle-invasive bladder cancer who underwent RC between 2010 and 2013. Patients were stratified according to surgical approach: ORC vs. RARC. Intraoperative endpoints included: the presence of positive surgical margins, the performance of a pelvic lymph node dissection, and number of lymph nodes (LN) removed. Postoperative endpoints included: length of stay (LOS), 30- and 90-day postoperative mortality (POM) rates, 30-day readmission rate, and overall survival (OS). To minimize selection bias, observed differences in baseline characteristics between RARC vs. ORC patients were controlled for using weighted propensity scores. Binary endpoints and OS were assessed using propensity score-adjusted logistic and Cox regression analyses, respectively. POM was assessed using propensity score weighted Kaplan-Meier survival estimates at 30 and 90 days after RC. ResultsOf 9,561 patients who underwent RC, 2,048 (21.4%) and 7,513 (78.6%) underwent RARC and ORC, respectively. The use of RARC increased over time, from 16.7% in 2010 to 25.3% in 2013. With regard to intraoperative outcomes, RARC was associated with equivalent rates of positive surgical margins (9.3% vs. 10.7%, odds ratio [OR] = 0.86, 95% CI: 0.72–1.03; P = 0.10), higher rates of pelvic lymph node dissection (96.4% vs. 92.0%, OR = 2.30, 95% CI: 1.67–3.16; P<0.001), higher median LN count (17 vs. 12, P<0.001), higher rates of LN count above the median (56.8% vs. 40.4%, OR = 1.94, 95% CI: 1.55–2.42, P<0.001). With regard to postoperative outcomes, receipt of RARC was associated with a shorter median LOS (7 vs. 8, P<0.001), and lower rates of pLOS (45.0% vs. 54.8%, OR = 0.68, 95% CI: 0.58–0.79; P<0.001). The 30- and 90-day POM rates were 2.8%, 6.7% for ORC, and 1.4%, 4.8% for RARC, respectively (hazard ratio [HR] = 0.48, 95% CI: 0.29–0.80, P = 0.005 and HR = 0.71, 95% CI: 0.54–0.93; P = 0.014). Finally, with a mean follow-up of 26.9 months, on IPTW-adjusted Cox regression analysis, RARC vs. ORC was associated with a benefit in OS (HR = 0.79, 95% CI: 0.71–0.88; P<0.001). ConclusionsOur large contemporary study found an increased adoption of RARC between 2010 and 2013, with more than 1 out of 4 patients undergoing RARC by the end of the study period. We found that RARC was associated with higher LN counts, shorter LOS, and lower POM. Our results allude to potential benefits of RARC while we wait for more definitive answers from randomized trials.

PD14-12 COMPARISON OF INITIAL AND FOLLOW-UP HOSPITAL COSTS FOR MINIMALLY INVASIVE VS. OPEN RADICAL CYSTECTOMY IN A NATIONALLY REPRESENTATIVE SAMPLE

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Value of Care: Cost and Outcomes Measures I1 Apr 2017PD14-12 COMPARISON OF INITIAL AND FOLLOW-UP HOSPITAL COSTS FOR MINIMALLY INVASIVE VS. OPEN RADICAL CYSTECTOMY IN A NATIONALLY REPRESENTATIVE SAMPLE Meera Chappidi, Max Kates, Trinity Bivalacqua, and Phillip Pierorazio Meera ChappidiMeera Chappidi More articles by this author , Max KatesMax Kates More articles by this author , Trinity BivalacquaTrinity Bivalacqua More articles by this author , and Phillip PierorazioPhillip Pierorazio More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.713AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Previous studies demonstrated higher initial hospitalization and 90-day hospital costs for minimally-invasive (MIRC) vs. open radical cystectomy (ORC). These studies were limited in that they were conducted with Medicare databases (>65 years-old) or private payer databases (<65 years-old). Therefore, our objective was to compare initial, 30-day, and 90-day follow-up hospital costs for patients undergoing MIRC vs. ORC in a nationally representative sample containing both Medicare and non-Medicare beneficiaries. METHODS We queried the 2013 Nationwide Readmissions Database for bladder cancer patients undergoing RC. ICD-9 codes were used to determine surgical approach. Initial, 30-day, and 90-day hospital costs, length of stay (LOS), and complication rates were compared between MIRC and ORC patients. Multivariable linear regression was performed to determine if surgical approach was a significant predictor of 30-day and 90-day hospital costs after controlling for patient and hospital characteristics. Multivariable logistic regression was performed to compare the odds of 30-day and 90-day readmission between MIRC vs. ORC. RESULTS In the cohort, 4918 ORCs and 1608 MIRCs were performed. The initial hospital costs were significantly higher for MIRC vs. ORC ($36970 vs. $32111, p=0.005). However, MIRC patients had a shorter LOS (8.9 vs. 10.6 days, p<0.001) and lower perioperative complication rate (37.3% vs. 43.2%, p=0.01) than ORC patients, respectively. Both 30-day ($4403 vs. $4571, p=0.8) and 90-day ($8013 vs. $8432, p=0.7) follow-up hospital costs were comparable for MIRC vs. ORC, respectively. After adjustment, there was still no significant difference in 30-day (βmirc=$-45 [95%CI: -1377,1287]) and 90-day (βmirc=$-222 [95%CI: -2441, 1997]) follow-up hospital costs between surgical approaches. In multivariable models, when comparing MIRC vs. ORC the odds of 30-day (OR=0.93 95%CI [0.63, 1.18]) and 90-day readmission (OR=1.01 95%CI [0.79, 1.29]) were comparable. CONCLUSIONS In this nationally representative study that includes both Medicare and non-Medicare patients, higher perioperative hospital costs for MIRC vs. ORC were driven by higher initial hospital costs as 30 and 90-day follow-up hospital costs were comparable. This higher initial cost of MIRC cannot be explained by LOS or complication rates, which are significantly lower for MIRC. As use of MIRC continues to expand, future studies are needed to identify potential areas to decrease costs associated with MIRC during the initial hospitalization. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e281-e282 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Meera Chappidi More articles by this author Max Kates More articles by this author Trinity Bivalacqua More articles by this author Phillip Pierorazio More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD36-11 COMPARISON OF TOTAL 90 DAY COSTS FOR OPEN VERSUS ROBOTIC CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Invasive III1 Apr 2017PD36-11 COMPARISON OF TOTAL 90 DAY COSTS FOR OPEN VERSUS ROBOTIC CYSTECTOMY Michael Metcalfe, Zachary Compton, Roger Li, James Ferguson, Debashish Sundi, Justin Nguyen, Ashish Kamat, Jay Shah, Colin Dinney, and Neema Navai Michael MetcalfeMichael Metcalfe More articles by this author , Zachary ComptonZachary Compton More articles by this author , Roger LiRoger Li More articles by this author , James FergusonJames Ferguson More articles by this author , Debashish SundiDebashish Sundi More articles by this author , Justin NguyenJustin Nguyen More articles by this author , Ashish KamatAshish Kamat More articles by this author , Jay ShahJay Shah More articles by this author , Colin DinneyColin Dinney More articles by this author , and Neema NavaiNeema Navai More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1560AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Gold standard therapy for muscle invasive bladder cancer (BC) and high risk recurrent non-muscle invasive BC is radical cystectomy (RC) with pelvic node dissection. Traditionally this has been an open approach, however recent data demonstrates that robotic RC is a safe and viable option with good oncologic outcomes. A concern is the cost differential between open RC (ORC) and robotic RC (RRC). We perform a single center matched study comparing the total 90 day cost between open and radical cystectomy. METHODS With IRB approval, we assessed a single center prospectively collected RRC database for patients between 2007 and 2015. We matched RRC cases 1:1 by age and year of surgery with a retrospective ORC database. All patients who underwent adjunct procedures and procedures with two or more surgeons were excluded from the study. We then performed a comparison of clinical and pathological variables as well as 90 day technical, professional and total costs, including hospital readmissions and complication related costs. Costs are represented as a fraction of RRC over the ORC. Student′s unpaired t-test and Fisher′s exact tests were used to analyze data between the two cohorts. RESULTS We identified 126 RRC patients and matched the with 106 ORC patients. 83% of the RRC was male (104/126) vs. 78% (83/126) of the ORC group (P=0.501). Median age of RRC was 66.50 (61-73 IQR), and for ORC was 67 (61-74 IQR) (p=0.501). 33% of RRC vs. 37% of ORC were clinical stage < T2, 49% of RRC vs. 45% of ORC were cT2, and 18% RRC vs. 18% of ORC were > cT2 (p=0.491). Mean Charleston Comorbidity score was 1.3 (1.05 std. dev.) for RRC and 1.99 (1.89 std. dev) for ORC (p=0.006). 21% (26/126) of RRC and 13% (14/104) of ORC had a continent diversion. Of the RRC cases, 52% (65/126) of the diversions were done robotically. Median length of hospital stay was 6.5 days (5-9 IQR) for RRC and 7 days (5-9 IQR) for ORC (p=0.385). The 90 day total cost for RRC was 1.15 times greater than for the ORC cohort (p=0.084). Professional Fees for the RRC were 1.05 times greater than the ORC (p=0.3454) and the technical fees of RRC were 1.18 times that of the ORC (p=0.074). 82% of the cost for the RRC, and 81% of the ORC costs were technical. CONCLUSIONS In a matched cohort, the total 90 day post-operative costs for robotic approach was not statistically significantly more than the open. This was primarily related to technical costs, and the initial capital required for either approach was not included. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e672-e673 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Michael Metcalfe More articles by this author Zachary Compton More articles by this author Roger Li More articles by this author James Ferguson More articles by this author Debashish Sundi More articles by this author Justin Nguyen More articles by this author Ashish Kamat More articles by this author Jay Shah More articles by this author Colin Dinney More articles by this author Neema Navai More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Recurrence Patterns After Open and Robot-assisted Radical Cystectomy for Bladder Cancer

BackgroundConcerns remain whether robot-assisted radical cystectomy (RARC) compromises survival because of inadequate oncologic resection or alteration of recurrence patterns. ObjectiveTo describe recurrence patterns following open radical cystectomy (ORC) and RARC. Design, setting, and participantsRetrospective review of 383 consecutive patients who underwent ORC (n=120) or RARC (n=263) at an academic institution from July 2001 to February 2014. InterventionORC and RARC. Outcome measurements and statistical analysisRecurrence-free survival estimates were illustrated using the Kaplan-Meier method. Recurrence patterns (local vs distant and anatomic locations) within 2 yr of surgery were tabulated. Cox regression models were built to evaluate the effect of surgical technique on the risk of recurrence. Results and limitationsThe median follow-up time for patients without recurrence was 30 mo (interquartile range [IQR] 5–72) for ORC and 23 mo (IQR 9–48) for RARC (p=0.6). Within 2 yr of surgery, there was no large difference in the number of local recurrences between ORC and RARC patients (15/65 [23%] vs 24/136 [18%]), and the distribution of local recurrences was similar between the two groups. Similarly, the number of distant recurrences did not differ between the groups (26/73 [36%] vs 43/147 [29%]). However, there were distinct patterns of distant recurrence. Extrapelvic lymph node locations were more frequent for RARC than ORC (10/43 [23%] vs 4/26 [15%]). Furthermore, peritoneal carcinomatosis was found in 9/43 (21%) RARC patients compared to 2/26 (8%) ORC patients. In multivariable analyses, RARC was not a predictor of recurrence. Limitations of the study include selection bias and a limited sample size. ConclusionsWithin limitations, we found that RARC is not an independent predictor of recurrence after surgery. Interestingly, extrapelvic lymph node locations and peritoneal carcinomatosis were more frequent in RARC than in ORC patients. Further validation is warranted to better understand the oncologic implications of RARC. Patient summaryIn this study, the locations of bladder cancer recurrences following conventional and robotic techniques for removal of the bladder are described. Although the numbers are small, the results show that the distribution of distant recurrences differs between the two techniques.

Comparative outcomes of open and robotic-assisted radical cystectomy in an enhanced recovery programme era

Aim: The aim of this study was to determine the added value of robotic surgery for radical cystectomy in the context of an established enhanced recovery programme (ERP). Background: We have previously reported on ERP in open radical cystectomy (ORC) and shown that it is safe and not associated with an increase in complications or readmissions. Further, it is associated with reductions in ICU stay, length of hospital stay and duration of postoperative ileus. The recent introduction of robotic-assisted radical cystectomy (RARC), with its perceived benefit of minimal invasiveness, has led to the question of whether patients who have their radical cystectomy in the environment of ERP would experience an added benefit if the surgery were performed robotically. We implemented the ERP for all patients undergoing radical cystectomy in 2008. In 2010 we started to offer RARC as the first line treatment for all bladder cancer patients with an indication for bladder extirpation. In this study we compare the perioperative results of the last 50 RARC patients with the last 50 ORC. The same ERP protocol was implemented in all patients. Patients and methods: We used our prospectively kept electronic database to identify the last 50 ORC and 50 RARC patients (we excluded the first 10 RARC in our series to reduce learning curve effect). We compared preoperative (age, sex, comorbidity), intraoperative (diversion type, fluid loss, blood transfusion, conversion and number of lymph node dissections (LND)) and post-operative (length of stay LOS, nodal yield and pathological T stage) variables. We also reported on the 30 day complications according to Clavien–Dindo classification. Results: The two groups did not differ significantly in their preoperative variables, number of LND performed and pathological T and N stage. Patients in the RARC arm were more likely to have continent diversion and had significantly less intraoperative fluid loss. LOS and lymph nodal yield was no worse in the RARC cohort in comparison to the ORC patients. The RARC patients had significantly lower transfusion rates and overall 30-day complication rates. Conclusions: We have shown that robotic surgery offers an added value to patients undergoing radical cystectomy for bladder cancer in addition to the benefits gained from enrolling in an ERP. This is likely due to the minimally invasive nature of robotic surgery, and thus an attenuation of its physiological insult, which is the cornerstone of ERP theory.

MP60-10 PREDICTORS OF EARLY POST-OPERATIVE READMISSION AFTER OPEN AND ROBOTIC RADICAL CYSTECTOMY FOR PATIENTS WITH BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Invasive III1 Apr 2014MP60-10 PREDICTORS OF EARLY POST-OPERATIVE READMISSION AFTER OPEN AND ROBOTIC RADICAL CYSTECTOMY FOR PATIENTS WITH BLADDER CANCER Jordan Allen, Ahmed Sarhan, and Ahmad Shabsigh Jordan AllenJordan Allen More articles by this author , Ahmed SarhanAhmed Sarhan More articles by this author , and Ahmad ShabsighAhmad Shabsigh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1764AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Robotic radical cystectomy (RRC) is a minimally-invasive technique with reported lower low grade complications rate compared to the Open radical cystectomy (ORC). Regardless of surgical technique; cystectomy remains a complex procedure with many potential complications and high readmission rate. We analyze the incidence, cause and predictors of readmission after ORC and RRC. Methods We retrospectively reviewed a total of 337 patients who underwent radical cystectomy at our institution from April 2008 through April 2013. Pre-operative patient characteristics and perioperative outcomes were analyzed. All perioperative complications within 30 days of surgery were analyzed and graded according to the Clavien complication grading system and correlated to post-operative readmission. Univariate and multivariate regression models were used to identify the predictors of post-operative readmission. Results A total of 115 and 225 patients underwent robotic and open radical cystectomy with urinary diversion for bladder cancer, respectively. The groups had similar pre-operative characteristics including age, BMI, Charlson-Romano scores, prior abdominal surgery or pelvic radiation, renal function, presence of hydronephrosis, and ASA scores. Significantly more patients undergoing an ORC had a continent urinary diversion. Overall, 26 (23.2%) RRC patients and 57 (25.3%) ORC patients had at least one readmission within 30 days of surgery (p = 0.7). Infections and gastrointestinal complications were the most common causes 27% and 25% respectively. On multivariate regression analysis weight, was the only significant predictor of readmission (p<0.05). Both history of active smoking and chemotherapy were strong predictors (p=0.09) but not significant. Factors such as prior history of dyspnea, pelvic radiation therapy, ability to walk, diabetes, renal function, surgical technique, and urinary diversions were not significant predictors of post-operative readmission. Conclusions Whether performed open or robotically, radical cystectomy is a complex procedure with a high readmission rate. The minimally-invasive approach did reduce the number of readmission, predicting readmission is a difficult task, and obesity is a major risk factor. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e636 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Jordan Allen More articles by this author Ahmed Sarhan More articles by this author Ahmad Shabsigh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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.

1764 COMPARATIVE ONCOLOGIC EFFECTIVENESS BETWEEN ROBOT-ASSISTED AND OPEN RADICAL CYSTECTOMY

1764 COMPARATIVE ONCOLOGIC EFFECTIVENESS BETWEEN ROBOT-ASSISTED AND OPEN RADICAL CYSTECTOMY