Performing Radical Cystectomy Research Articles

Radical cystectomy with extraperitoneal location of an artificial bladder

Radical cystectomy remains the “golden standard” for treatment of patients with invasive bladder cancer. The operation is a technically complex surgical intervention after which there are various complications, including gastrointestinal complications such as intestinal obstruction, peritoneal adhesive disease and others. The use of extraperitoneal access for radical cystectomy with an extraperitoneal location of the artificial bladder in carefully selected patients reduces the number of abdominal postoperative complications and improves results in the immediate postoperative period. A literature review is presented which outlines the results of using extraperitoneal approach in comparison with other options for surgical approaches when performing radical cystectomy with intestinal bladder plastic surgery. It is noted that extraperitoneal access during this operation was previously used by Russian urologists.

The impact of cardiopulmonary exercise testing (CPET) and Charlson comorbidity index (CCI) in a large contemporary cohort of patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion (RARC-ICUD).

The aim of this study was to investigate whether pre-operative comorbidity status measured by the Charlson comorbidity index (CCI) or cardiopulmonary exercise testing (CPET) is associated with postoperative complications and length of stay (LOS) in patients undergoing robot-assisted radical cystectomy and intracorporeal urinary diversion (RARC-ICUD). We conducted a retrospective study of a prospectively maintained database of 428 consecutive patients who underwent RARC-ICUD at a tertiary referral centre between 2011 and 2019. CCI was correlated with peri-operative outcomes including postoperative LOS, Clavien-Dindo (CD) complications and survival. A planned subgroup analysis was performed to evaluate the relationship between pre-operative CPET, and the same outcomes utilising the threshold of anaerobic threshold (AT) ≥ 11/ <11 ml/kg/min were analysed. Of the total cohort, 350 patients undergoing RARC-ICUD with complete data were included in the final analysis. A CCI score ≥5 was associated with a higher rate of CD III-V complications at 30-day incidence rate ratio (IRR) = 3.033, (p= 0.02) and at 90-day IRR 2.495, (p= 0.04) postsurgery. LOS was not associated with CCI; the strongest association with LOS was a CD complication of any grading. CCI did not predict readmission or mortality rates after surgery. Subanalyses of patients who underwent pre-operative CPET found that CPET <11 ml/kg/min did not predict for LOS, CD complications or death within 1year of surgery. CCI score is a simple, reliable and cost-effective way of identifying patients at increased risk of complication after RARC-ICUD. Surgeons performing radical cystectomy should consider utilising CCI to augment pre-operative patient counselling prior to RARC-ICUD.

Возможности регионарной анестезии при радикальной цистэктомии у больных мышечно-инвазивным раком мочевого пузыря

На сегодняшний день регионарная анестезия при радикальной цистэктомии у пациентов с раком мочевого пузыря выполняется в качестве компонента общей анестезии в условиях искусственной вентиляции легких. Цель работы — оценить безопасность и преимущества выполнения радикальной цистэктомии на фоне комбинированной спинально-эпидуральной анестезии при сохраненном самостоятельном дыхании c последующей оценкой течения послеоперационного периода. Материалы и методы. С 2008 по 2012 г. 96 пациентам в возрасте 67,0 ± 6,5 года произведена радикальная цистэктомия с расширенной тазовой лимфаденэктомией и различными видами деривации мочи с использованием комбинированной спинально-эпидуральной анестезии. Послеоперационная анальгезия включала продленную инфузию наропина 0,2% — 6–8 мл/ч в комбинации с системным введением нестероидных противовоспалительных средств. Оценивали характеристики вариабельности сердечного ритма в частотной области. Результаты и выводы. Развитие спинального блока сопровождалось снижением общей спектральной мощности, преимущественно спектра активности симпатического отдела (LF) — вследствие симпатической блокады, менее выраженным угнетением парасимпатического отдела вегетативной нервной системы. Плотность спектра активности подкорковых нервных центров и процессов гуморальной регуляции (VLF) достоверно не изменялась до момента седации больного. Гемодинамика характеризовалась повышением сердечного индекса на 15,9 %, снижением индекса общего периферического сосудистого сопротивления на 23,2 %.Введение гипнотиков приводило к дальнейшему уменьшению спектральной мощности в диапазоне LF и достоверному подавлению в общей спектральной мощности спектра VLF. Эти изменения вегетативного гомеостаза сопровождались снижением артериального давления, сердечного индекса на фоне недостоверного повышения индекса общего периферического сосудистого сопротивления.Применение субгипнотических доз пропофола с целью достижения медикаментозного сна обеспечивало более стабильное состояние гемодинамики и вегетативного гомеостаза по сравнению с применением бензодиазепинов. Комбинированная спектрально-эпидуральная анестезия является методом выбора анестезиологического пособия при выполнении радикальной цистэктомии. Продленная послеоперационная эпидуральная анальгезия 0,2% наропином обеспечивает максимально раннюю активизацию пациентов, сопровождается ранним восстановлением моторики желудочно-кишечного тракта и пассажа, снижает риск развития респираторных и тромбоэмболических осложнений.

This Month in Adult Urology

This Month in Adult Urology

PROGNOSTIC FACTORS TOWARD BLADDER CANCER PATIENT RECOVERY AFTER RADICAL CYSTECTOMY SURGERY

Objective: This study aimed to know independent prognostic factors to predict the recovery time of bladder cancer patients after radical cystectomy. So that it would be a consideration to determine patient feasibility before surgery and after surgery management. Material &amp; Methods: This study was an observational analytical study with a retrospective approach to examine the relationship between pre-surgery variables of the bladder cancer patients and the duration of treatment post radical cystectomy. Results: From the results of this study, it is known that the average length of postoperative care for older patients (above 65 years) was lower when compared to patients under 65 years with averages of 17.08 and 18.03 days respectively p-value of this analysis was 0.781. Patients with low hemoglobin, albumin, and HALP scores had longer postoperative hospitalization periods but with P values of 0.384, 0.276, and 0.603, the ileal conduit has the longest hospitalization treatment period between the two other procedures, with a P-value of 0.904. It was found that the average length of postoperative care for underweight patients was 16.5 days and for patients with normal BMI was 19.59 days. The difference between these averages showed a p-value of 0.396 it is known that the average length of postoperative care for older patients (above 65 years) was lower when compared to patients under 65 years with averages of 17.08 and 18.03 days respectively. The p-value of this analysis was 0.781 it was found that patients with low hemoglobin, albumin, and HALP scores had longer postoperative treatment periods, p-value 0.384, 0.276, and 0.603. The average duration of postoperative care for patients who applied the ERAS protocol tended to be faster (15.67 days) compared to patients who did not apply the ERAS protocol (18.16 days). Nevertheless, the p-value of this difference was 0.518. Conclusion: This study concludes that there is no prognostic factor that can independently predict the duration of treatment of bladder cancer patients post-radical cystectomy. Therefore in-depth assessment of various factors is required before performing radical cystectomy to achieve the best postoperative recovery rates.

Utilidad de la quimioterapia neoadyuvante en el carcinoma vesical músculo invasivo no metastásico

ObjectiveWe analyzed the profile of patients who were candidates for neoadjuvant chemotherapy (NACT) in stage pT2-4aN0M0, the tolerability and adherence of our cisplatin-based protocol and oncological outcomes. Material and methodsRetrospective observational cohort study including patients diagnosed with muscle-invasive bladder carcinoma treated with NACT. Clinical, histopathological, therapeutic and evolutionary characteristics of the patients were analyzed. The use of NACT was evaluated by the complete response in the surgical specimen (pT0). This and other pathological factors were related to overall survival and progression-free survival. ResultsWe included 90 patients with muscle-invasive bladder carcinoma (clinical stage T2a-T4aN0M0) who received a cisplatin-based NACT regimen between January 2011 and December 2018, prior to radical surgery. Forty percent of patients presented an adverse reaction, with a compliance with the NACT regimen of 92.2%. There were no deaths related to systemic treatment and no adverse reaction to treatment made radical cystectomy impracticable. After performing radical cystectomy, the presence of complete response (pT0) was observed in 20 patients (21%), lower stage in the surgical specimen (<pT2) in 36 patients (40%), positive surgical margins in 7 patients (8%), lymph node involvement (N1) in 16 patients (17.8%). A shorter time to progression was observed in the group of patients who did not achieve a complete pathological response (53 months vs. 83.1 in pT0 patients, P=0.012), in patients with lymph node involvement compared to pN0 (65.4 vs. 28, 2 months, P=0.014) and in those with positive surgical margins compared to those with tumor-free margins (63.5 vs. 8.5 months, P=0.021). ConclusionThe adequate selection of patients with muscle-invasive bladder carcinoma has shown a good tolerance to NACT, with a high compliance rate prior to RC. The improvement in the complete response rate implies a greater survival in this group of patients, with lymph node involvement and positive surgical margins being important prognostic factors.

Key Steps in Performing Robotic-Assisted Radical Cystectomy with Intracorporeal Urinary Diversion and the Evidence that We Have So Far

Robotic-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) has been proposed as the most minimally invasive surgical approach in performing radical cystectomy for patients with bladder cancer. However, iRARC is a highly technical and complex procedure with a steep learning curve. Without appropriate training and adequate experiences, iRARC may become a lengthy procedure and may lead to significant morbidities with a prolonged hospital stay. Essentially, the robotic approach in performing RARC is to replicate what is being done in the open approach, and the key steps in performing iRARC were described in this article. There were five randomized controlled trials (RCTs) comparing between RARC and open radical cystectomy (ORC). RARC has been shown to have a lower blood transfusion rate and short hospital stay than ORC. When compared to ORC, RARC had a similar positive surgical margin rate and time of recurrence. Given such potential benefits, a decision-analytic model has shown that RARC might be a more cost-effective treatment approach than ORC. On the other hand, previous RCTs focused mainly on RARC with extracorporeal urinary diversion; high-quality studies on the total intracorporeal approach are lacking. The iROC trial is a multicenter study comparing between iRARC and ORC. Preliminary results showed that iRARC is well tolerated by patients. The iROC trial has completed patient recruitment and the final results are eagerly awaited. By then, hopefully, we will be able to understand the true value of iRARC in managing patients with bladder cancer.

Radical cystectomy for bladder cancer: early and late postoperative complications

Background. Treatment of patients with bladder cancer remains one of the most pressing problems of oncourology. It is important to understand that the risks caused by the radical cystectomy are determined not only and even not so much by the technical difficulties of removal of the bladder, as by the somatic status of the patient who needs cystectomy. It is important to understand that radical cystectomy and urine derivation are essentially two stages of a single surgery intervetion. However, in the publications describing postoperative cystectomy complications often ignore the fact that the maximum number of complications develops and is associated with the complexity of the urinary diversion method. In a relatively recent long-term study on the results of radical cystectomy, the authors reported a 3% postoperative mortality rate and a 28% level of early postoperative complications (within 3 months after surgery). The authors paid attention to the fact that late complications was more often caused by the urinary diversion methods, whereas early complications are more often associated with radical cystectomy. In general, it is determined that morbidity and mortality are lower the more experience the clinic staff and the surgeon have in terms of patient management. The combination of these factors causes a slower recovery and a longer postoperative day. Despite the decrease in mortality, the level of complications of this procedure remains high even in the best centers of the world. Objective. Assessment of the prerequisites for the development of complications after radical cystectomy using different methods of urine diversion. Materials and methods . Oncological treatment results of 458 patients with bladder tumors were subjected to a detailed analysis. Results. The number of patients with comorbidities was significantly pronounced and noted in practically every patient (381 patients - 83.1%). At the same time, it was found that in the whole group of patients the average value of the Charlson's comorbidity index corrected for age turned out to be 2.6 ± 1.6 (from 0 to 8). Early postoperative complications were detected in 197 patients (43.0%). Early complications NOT associated with urinary diversion prevailed - 36.2%, while the frequency of early complications associated with urinary diversion was statistically significantly less on average 3 times and amounted 12.9%. The incidence of late postoperative complications (associated and NOT associated with the derivation of urine) was generally lower compared to early complications by almost 5 times (9.1%). At the same time, unlike the early postoperative period, among the late postoperative complications, mainly complications associated with the urine diversion of were recorded in 6.5% of cases. It is important that in the studied group of patients were recorded predominantly mild and moderate degrees of complication (Clavien-Dindo I-II) and amounted 41.7%. Conclusion. Obviously, radical cystectomy with urinary diversion are complex surgery with expected high rates of postoperative complications. In this regard, these indicators along with functional and oncological results should be taken into account when discussing a treatment strategy. Early postoperative complications are mainly related to technique of radical cystectomy performing, whereas late complications are more often due to used method of urinary diversion, while high indicators of the planned long-term survival indicate that it is not necessary to perform radical cystectomy. Thus, our findings unequivocally confirm the opinion of international experts and most researchers that achieving optimal optimal results in performing radical cystectomy with urinary intestinal diversion, maximizing morbidity and postoperative lethality is possible only with the accumulation of sufficient experience in this operation types.

PD41-03 VALIDATED HOSPITAL QUALITY METRICS FOR RADICAL CYSTECTOMY: DISEASE-SPECIFIC AND CORRELATED TO LONG-TERM OUTCOMES

You have accessJournal of UrologyBladder Cancer: Invasive V1 Apr 2018PD41-03 VALIDATED HOSPITAL QUALITY METRICS FOR RADICAL CYSTECTOMY: DISEASE-SPECIFIC AND CORRELATED TO LONG-TERM OUTCOMES Abhinav Khanna, Olli Saarela, Keith Lawson, Andrew Stephenson, Georges-Pascal Haber, Byron Lee, Antonio Finelli, and Robert Abouassaly Abhinav KhannaAbhinav Khanna More articles by this author , Olli SaarelaOlli Saarela More articles by this author , Keith LawsonKeith Lawson More articles by this author , Andrew StephensonAndrew Stephenson More articles by this author , Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , Byron LeeByron Lee More articles by this author , Antonio FinelliAntonio Finelli More articles by this author , and Robert AbouassalyRobert Abouassaly More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1942AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Centers for Medicare and Medicaid (CMS), private insurers, and many independent rating agencies are all measuring and publicly reporting hospital quality. However, commonly used quality metrics are not disease-specific and are rarely correlated with meaningful long term outcomes. We aim to develop and validate hospital quality metrics for radical cystectomy that are both disease-specific and correlated with meaningful outcomes. METHODS The National Cancer Database was utilized to identify hospitals performing radical cystectomy for bladder cancer from 2004-2014. A list of candidate quality indicators was developed based on literature review, and included performance of lymphadenectomy, receipt of neoadjuvant chemotherapy, receipt of continent urinary diversion, duration of time from diagnosis to cystectomy, inpatient length of stay and 30-day hospital readmission. Random effects models were used to identify quality indicators (QI's) with statistically significant between-hospital variance. Case-mix adjustment was performed by comparing observed to expected performance using the indirect standardization method. Outlier hospitals were defined as those that performed better or worse than expected based on z-test statistics. Outlier status was correlated to overall mortality using logistic and Cox regression analyses, respectively. RESULTS From 2004-2014, 48,341 patients underwent radical cystectomy at 1200 hospitals. Random effects models demonstrated significant between-hospital variance for all QI's even after adjusting for sociodemographic and clinical patient characteristics. Case-mix adjusted analyses revealed 1.7-25.4% of hospitals were categorized as outliers across the various QI's. High-performing outlier status was associated with lower overall mortality for performance of lymphadenectomy (HR 0.89, 95% confidence interval 0.83-0.95), receipt of neoadjuvant chemotherapy (HR 0.78, 0.66-0.93), receipt of continent urinary diversion (HR 0.80, 0.73-0.89), time from diagnosis to cystectomy (HR 0.90, 0.83-0.98), and 30-day hospital readmission (HR 0.84, 0.74-0.95). CONCLUSIONS Among patients undergoing radical cystectomy, there was significant variation in hospital performance across all quality indicators. High-performing outlier hospitals were associated with lower overall mortality. Our validation of these quality metrics provides support for their potential use by both policymakers and payers in efforts to measure hospital quality for high-cost surgical procedures. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e810 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Abhinav Khanna More articles by this author Olli Saarela More articles by this author Keith Lawson More articles by this author Andrew Stephenson More articles by this author Georges-Pascal Haber More articles by this author Byron Lee More articles by this author Antonio Finelli More articles by this author Robert Abouassaly More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The delivery of radical radiotherapy to the bladder and pelvis in node-positive (N1) bladder cancer: a five patient case series.

In the UK over 10,000 new cases of bladder cancer were diagnosed in 2012, making it the seventh most common cancer in the UK. For those with advanced disease at presentation, prognosis is poor. Disease presenting with one pathological node (N1) is considered to be Stage 4 and is therefore considered the same as disease with widespread metastases. Pelvic lymph node dissection is considered standard when performing radical cystectomy; however, owing to potential toxicity, pelvic radiotherapy is not routine even when attempting radical treatment. We present five cases where radical treatment has been delivered to patients with node-positive bladder cancer. Treatment volumes included the whole bladder and bilateral pelvic nodes, and where it was felt appropriate, chemotherapy was delivered concurrently. Data has been collected by reviewing hospital notes including radiotherapy, volumes and dose distributions. Treatment was tolerated well with only minimal gastrointestinal and urinary symptoms reported. Three of the five patients had thrombocytopenia. This complication may be explained by the larger volume of radiation exposure. Local control appears to be good with all the patients having no pelvic relapse at the time of reporting. Two patients have relapsed with distant metastatic disease. No long-term side effects of therapy have been reported. Intensity-modulated radiotherapy techniques allow larger volumes to be treated owing to improved conformality and the resulting reduced toxicity. Treatment may be appropriate with both radical and adjuvant doses of radiation. More work is necessary to assess which patients would benefit and are most suitable for such treatment.

PD39-06 COST DASHBOARDS FOR RADICAL CYSTECTOMY: ACCOUNTING FOR SURGEON COST VARIATION

INTRODUCTION AND OBJECTIVES: In addition to promoting quality, new payment models are emerging with a mandate to control healthcare costs. On a national level, there is significant variation in the cost of major index cancer operations. Accurate cost accounting, clinician-defined metrics, risk-adjustment, and feedback of data are essential steps in using cost data for quality improvement. We sought to account for institutional direct costs incurred during radical cystectomy, identify the main cost drivers in the index hospitalization, and examine surgeon variability in the main cost drivers within the context of patient characteristics. METHODS: Direct itemized institutional cost data for 321 consecutive radical cystectomies performed by 5 de-identified surgeons was obtained. Costs were adjusted using a multiplier equal to the ratio of normalized Medicare reimbursement over institutional reported cost. Interactive web-based dashboards were created to feedback patient characteristics, outcomes, cost components, and anonymized surgeon cost comparisons. Analysis of variance was used to compare patient characteristics and cost components across surgeons. Multivariable logistic regression was used to model above average costs on surgeon and patient specific factors. RESULTS: The median adjusted total cost per case was $13009.57 (interquartile range $11254.82, $15730.53). Inpatient, anesthesia, disposable device, operating room, and physician costs accounted for the majority of the total costs incurred. Inpatient costs were not significantly different across surgeons, however maximum differences between cost means for anesthesia ($93.62, p1⁄40.0039), disposable device (energy devices, $279.48, p<0.0001; staplers, $494.73, p<0.0001), operating room ($1168.55, p<0.0001), and physician costs ($1362.20, p<0.0001) did differ significantly across surgeons. Adjusting for patient factors including gender, American Society of Anesthesiologists status, diversion type, and total lymph node count, these significant differences in cost across surgeons persisted. CONCLUSIONS: Cost accounting using dashboards identified significant cost differences across surgeons performing radical cystectomy at our institution independent of differences in patient characteristics. Additional longitudinal cost data is needed to determine if such anonymized, interactive cost feedback through dashboards can improve the value of surgical care by reducing cost without sacrificing quality.

Panniculectomy and Cystectomy: An Approach to the Morbidly Obese Patient.

The obese patient undergoing radical cystectomy faces a unique set of challenges. We present the case of a 68-year-old gentleman who presented to our institution with Bacillus Calmette-Guerin refractory disease, a body mass index of 38.5, and a large pannus. The present paper describes our technique for performing radical cystectomy with ileal conduit urinary diversion and concomitant panniculectomy. We discuss the impact of obesity on patients undergoing radical cystectomy and how this may be mitigated by panniculectomy.

Characteristics of Certifying Urologists Performing Cystectomies in the United States

IntroductionThe surgical volume and training of the surgeon performing radical cystectomy can have a significant impact on bladder cancer outcomes. We hypothesize significant variability in the training and volume of surgeons performing radical cystectomy in the United States. MethodsThe 6-month case log data of urologists certifying between 2003 and 2013 were obtained from the American Board of Urology. Cases specifying an ICD-9 code for bladder cancer and a CPT code for radical cystectomy were analyzed for surgeon specific variables. ResultsA total of 5,335 radical cystectomies in the case log system were performed by 2,102 urologists, with 289 (5.4%) performed laparoscopically or robotically. Median urologist age was 42 years (range 36 to 50). Median number of cystectomies performed was 2 (IQR 1–3) with the top 10% of urologists performing 5 or more cystectomies. Half of cystectomies were performed by a urologist who performed only 1 during the certification period. On multivariable analysis stated specialty of oncology and nonprivate practice type were associated with top 10% cystectomy volume. For minimally invasive cystectomy 54% of surgeons logged only a single minimally invasive cystectomy. Factors predictive of performing minimally invasive cystectomy on multivariable analysis were male gender, more recent certifying year and original certification year, endourology and urolithiasis specialization, and Northeast practice region. ConclusionsDespite the high level of complexity associated with the surgical management of bladder cancer with radical cystectomy, the majority of cystectomies seem to be performed by low volume surgeons who have most often applied for their first certification with the American Board of Urology.

Risk Assessment of Stone Formation in Stapled Orthotopic Ileal Neobladder

The increasing trend of performing radical cystectomy with a minimally invasive approach has made stapled neobladders an attractive alternative to hand-sewn pouches. To date, data on the incidence and clinical impact of stone formation in long surviving neobladder cases are scarce. We report a long-term, single-center experience of stapled orthotopic ileal neobladder and identify predictors of stone formation. From May 2001 to October 2012, 445 consecutive patients (388 male, 57 female) underwent radical cystectomy and stapled orthotopic ileal neobladder. Univariable and multivariable analyses were performed to identify independent predictors of an increased risk of stone formation. At a median followup of 41 months (IQR 16-58) neobladder stone formation occurred in 41 patients (9.2%). All of these patients successfully underwent endoscopic stone lithotripsy with 34 as outpatient procedures. On univariable Cox analysis only female gender (p = 0.001, HR 3.29, 95% CI 1.59-6.83) and intermittent self-catheterization (p <0.001, HR 15.2, 95% CI 5.87-39.5) were associated with an increased risk of stone formation. On multivariable analysis the only independent predictor of stone formation was intermittent self-catheterization (p = 0.001, HR 8.98, 95% CI 2.59-31.1). In our series of stapled orthotopic ileal neobladders the rate of stone formation was comparable to that reported in the literature for completely hand-sewn ileal reservoirs. The only variable independently predictive of stone formation was intermittent self-catheterization.

Performing Radical Cystectomy and Urinary Diversion in Regional Anesthesia: Potential Risk Reduction in the Treatment of Bladder Cancer

Objective: To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA), avoiding the adverse effects of general anesthesia. Materials and Methods: In our hospital, radical cystectomy with extended pelvic and iliac lymphadenectomy and urinary diversion was performed on 28 patients using CSTEA without applying general anesthesia, in 2011 and 2012. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Outcome measurements included operative time, blood loss, start of oral nutrition, start of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), postoperative complications according to the Clavien-Dindo classification and length of hospital stay. Results: All surgical procedures were performed without any complications and caused no anesthesiologically or surgically untoward effects. We observed no more severe complications than grade 1 according to the Clavien-Dindo classification. Conclusions: Our data show that CSTEA is an effective and safe technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks, especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes and complications of CSTEA.

Feasibility of radical cystectomy in exclusive spinal and/or epidural anaesthesia

Muscle invasive bladder cancer can be found predominantly in elderly people with a high likelihood of suffering from concomitant diseases; especially in these patients, the risks associated with general anaesthesia during radical cystectomy can be the limiting factor of performing an otherwise indicated radical operation. To overcome this limitation, we analysed the feasibility of performing radical cystectomy in exclusive spinal and/or epidural anaesthesia. Between March and June 2010, nine patients underwent radical cystectomy in exclusive spinal and/or epidural anaesthesia. These patients were either not willing or unfit to undergo radical cystectomy in general anaesthesia. A continent urinary diversion (ileum neobladder) and an ileum-conduit were performed in five patients and four patients, respectively. The feasibility of radical cystectomy in regional anaesthesia was tested using a variety of parameters. All nine procedures could be performed under strict regional anaesthesia. Mean operation time was 206 min (range 146-265 min), mean intraoperative blood loss was 622 ml (range 200-1,500 ml), mean postoperative time at intermediate care was 1 day (range 0-3 days) and mean length of hospital stay was 21.8 days (range 17-26 days). Analgesics of the WHO class I, II and III were applied for 5.7, 1.2 and 2.8 days mean, respectively. Performance of radical cystectomy in exclusive spinal and/or epidural anaesthesia is feasible and can be considered particularly in those patients who would be otherwise unfit to undergo radical cystectomy in general anaesthesia. This new operative and anaesthesiological concept could also play an important role in new fast track regimens.

Mini‐laparotomy approach to radical cystectomy

• To investigate the feasibility of performing radical cystectomy (RC) through a mini-laparotomy and to evaluate the effect of a smaller incision on wound problems, immediate postoperative pain, bowel function and length of hospital stay (LOS). • Two consecutive cohorts of patients, one with 75 patients undergoing open RC (ORC) with lymph node dissection up to the aortic bifurcation through a conventional long midline incision and one with 75 patients undergoing RC through a mini-laparotomy (MinilapRC) of intentionally <8-10 cm. • Patient characteristics, operative duration, estimated blood loss (EBL), incidence and severity of wound problems, return of bowel function, amount of analgesics needed and LOS were analysed according to the intention-to-treat principle. • The demographic characteristics of the two groups were similar. • An incision of ≤10 cm was made in 65% of the patients in the MinilapRC group with a median (range) length of incision of 9 (6.5-19) cm. In the final third of patients operated on in the MinilapRC group, 76% had an incision of ≤8 cm. • The operative duration and EBL were not significantly different between the groups. • Wound problems were significantly fewer, bowel function was restored more quickly and the need of postoperative analgesics was less in the MinilapRC group. • In the MinilapRC group LOS was reduced by a median of 3 days. • MinilapRC is feasible in most patients without increasing operative duration. The reduced incision length reduces postoperative morbidity.

Radical cystectomy for BCG failure: has the timing improved in recent years?

• To analyse if there is a trend in recent years towards performing radical cystectomy (RC) before muscle invasion or extravesical spread after failure of bacille Calmette-Guérin (BCG) for high grade Ta/T1 bladder cancer. Although BCG is indicated for prophylaxis after endoscopic tumour resection there is still a risk of progression. • A retrospective analysis of our RC database (1992-2008) was performed to identify patients who underwent RC after receiving BCG. • Relevant clinical and pathological data for the patients with clinical stage Ta, T1 and/or Tis at initial transurethral resection of bladder tumour were analysed. • Pathological stage and survival for patients undergoing RC from 2003 to 2007 (group 2) were compared with those for patients operated between 1992 and 2002 (group 1). • A total of 152 patients were included (75 in group 2 and 77 in group 1). Both groups were similar in T-stage before BCG initiation, number of BCG cycles received and time interval to RC. • There was no change in the proportion of patients undergoing RC with ≥ pT2 bladder cancer in recent years (P= 0.5). • Fifty-two percent of group 2 and 43% of group 1 had ≥ pT2 BC. The 5-year survival was similar. • Despite concerns about delay in performing RC for patients failing one or more courses of BCG we have not observed a trend towards a lower pathological stage for patients undergoing RC after BCG. • A high proportion of patients have muscle-invasive bladder cancer; more than 10% have lymph node metastasis.

Delayed Spontaneous Rupture of an Orthotopic Ileal Neobladder

Chang Yell Lee, Suk Gun Jung, Sung Woo Park, Wan Lee, Moon Kee Chung From the Department of Urology, Pusan National University College of Medicine, Busan, Korea Orthotopic bladder replacement using detubularized ileum has become a popular form of continent urinary diversion after performing radical cystectomy for treating invasive bladder cancer. Delayed spontaneous rupture of an orthotopic ileal bladder has rarely been reported in the English literature and it has never been reported in Korea. We describe here a case of delayed spontaneous rupture of an ileal orthotopic neobladder secondary to overdistension, and this was successfully managed nonoperatively. (Korean J Urol 2007;48:1186-1189) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏