Radical Cystectomy In Patients Research Articles

Mortality rates in radical cystectomy patients with bladder cancer after radiation therapy for prostate cancer.

To conduct a population-based study examining cancer-specific mortality (CSM) and other-cause mortality (OCM) differences in patients with radiation-induced secondary bladder cancer (RT-BCa) vs those with primary bladder cancer (pBCa) undergoing radical cystectomy (RC). Within the Surveillance, Epidemiology, and End Results database (2004-2020), we identified patients with T2-4N0-3M0 bladder cancer treated with RC, who had previously been treated with external beam radiation therapy (EBRT) or brachytherapy for prostate cancer, as well as patients with T2-4N0-3M0 pBCa treated with RC. Cumulative incidence plots and multivariable competing risks regression (CRR) models were used to assess CSM after additional adjustment for OCM. The same methodology was then repeated based on organ-confined (OC: T2N0M0) and non-organ-confined (NOC: T3-4 and/or N1-3) disease. Of 9957 RC patients, RT-BCa was identified in 347 (3%) compared with 9610 (97%) who had pBCa. In multivariable CRR models, no CSM differences were recorded in the overall comparison (P = 0.8), nor in sub-groups based on OC and NOC disease (P = 0.8 and 0.7, respectively). Conversely, multivariable CRR models identified RT-BCa as an independent predictor of 1.3-fold higher OCM in the overall cohort and of 1.5-fold higher OCM in those with NOC disease. In a sensitivity analysis of patients with NOC disease, EBRT was associated with higher OCM rates (hazard ratio 1.5). By contrast, OCM rates were not different in those with OC disease (P = 0.8). Our study showed that RC for RT-BCa was associated with similar CSM rates as RC for pBCa, regardless of disease stage. However, patients who had undergone EBRT exhibited significantly higher OCM in the NOC sub-group.

Patients´ experiences of an exercise intervention in primary care following robot-assisted radical cystectomy due to bladder cancer: a qualitative study

BackgroundPhysical activity is thought to be a key component in reducing postoperative complications following major abdominal surgery. The available literature on exercise interventions following radical cystectomy in patients with bladder cancer is scarce but suggests that physical activity and exercise might improve physical function and health-related quality of life, thus calling for further investigation. The CanMoRe-trial is a single-blinded randomised controlled trial (Clinicals Trials NCT03998579 25/06/2019), aimed at evaluating the impact of an exercise intervention in primary care following robot-assisted radical cystectomy. This study seeks to explore patients’ experiences of the exercise intervention in the CanMoRe-trial to gain a better understanding of facilitating aspects and potential barriers.MethodsA qualitative study was conducted involving 20 patients from the intervention group of the CanMoRe-trial who were interviewed individually between October 2020 and March 2023 using a semi-structured interview guide. The interviews were recorded and transcribed verbatim and reflexive thematic analysis was used to analyse the data.ResultsFour main themes were identified: Having to adapt to new circumstances, describing the challenges regarding physical activity patients face after discharge. Optimising conditions for rehabilitation, describing how practical conditions affect patients’ ability to exercise. Motivated to get back to normal, describing patients´ desire to get back to normal life and factors influencing motivation. Importance of a supportive environment, describing the impact of social support, support from physiotherapists, and how the environment where exercise takes place impacts patients’ ability to exercise.ConclusionThis study found that patients participating in the CanMoRe-trial are positive towards physical exercise in PC following radical RARC. They are motivated to get back to normal life but face major challenges when arriving home following surgery, which affect their ability to perform physical activity and engage in exercise. Conditions need to be optimised to support patients’ ability to engage in exercise by providing an accessible PC location to perform exercise in. A supportive environment is also needed, including guidance from healthcare professionals regarding which type of exercise, intensity and amount of exercise that should be performed, enabling patients gradually to develop self-efficacy regarding exercise and focusing on goals related to patients’ normal lives before surgery.

Risk factors for postoperative acute kidney injury after radical cystectomy for bladder cancer in the era of ERAS protocols: A retrospective observational study.

Radical cystectomy (RC) is a major surgery associated with a high morbidity rate. Perioperative fluid management according to enhanced recovery after surgery (ERAS) protocols aims to maintain patients in an optimal euvolemic state while exposing them to acute kidney injury (AKI) in the event of hypovolemia. Postoperative AKI is associated with severe morbidity and mortality. Our main objective was to determine the association between perioperative variables, including some component of ERAS protocols, and occurrence of postoperative AKI within the first 30 days following RC in patients presenting bladder cancer. Our secondary objective was to evaluate the association between a postoperative AKI and the occurrence or worsening of a chronic kidney disease (CKD) within the 2 years following RC. We conducted a retrospective observational study in a referral cancer center in France on 122 patients who underwent an elective RC for bladder cancer from 01/02/2015 to 30/09/2019. The primary endpoint was occurrence of AKI between surgery and day 30. The secondary endpoint was survival without occurrence or worsening of a postoperative CKD. AKI and CKD were defined by KDIGO (Kidney Disease: Improving Global Outcomes) classification. Logistic regression analyse was used to determine independent factors associated with postoperative AKI. Fine and Gray model was used to determine independent factors associated with postoperative CKD. The incidence of postoperative AKI was 58,2% (n = 71). Multivariate analysis showed 5 factors independently associated with postoperative AKI: intraoperative restrictive vascular filling < 5ml/kg/h (OR = 4.39, 95%CI (1.05-18.39), p = 0.043), postoperative sepsis (OR = 4.61, 95%CI (1.05-20.28), p = 0.043), female sex (OR = 0.11, 95%CI (0.02-0.73), p = 0.022), score SOFA (Sequential Organ Failure Assessment) at day 1 (OR = 2.19, 95%CI (1.15-4.19), p = 0.018) and delta serum creatinine D1 (OR = 1.06, 95%CI (1.02-1.11), p = 0.006). During the entire follow-up, occurrence or worsening of CKD was diagnosed in 36 (29.5%). A postoperative, AKI was strongly associated with occurrence or worsening of a CKD within the 2 years following RC even after adjustment for confounding factors (sHR = 2.247, 95%CI [1.051-4.806, p = 0.037]). A restrictive intraoperative vascular filling < 5ml/kg/h was strongly and independently associated with the occurrence of postoperative AKI after RC in cancer bladder patients. In this context, postoperative AKI was strongly associated with the occurrence or worsening of CKD within the 2 years following RC. A personalized perioperative fluid management strategy needs to be evaluated in these high-risk patients.

Perioperative Complications and In-Hospital Mortality in Paraplegic Radical Cystectomy Patients.

The aim of this study was to test for the association between paraplegia and perioperative complications as well as in-hospital mortality after radical cystectomy (RC) for non-metastatic bladder cancer. Perioperative complications and in-hospital mortality were tabulated in RC patients with or without paraplegia in the National Inpatient Sample (2000-2019). Of 25,527 RC patients, 185 (0.7%) were paraplegic. Paraplegic RC patients were younger (≤70years of age; 75 vs. 53%), more frequently female (28 vs. 19%), and more frequently harbored Charlson Comorbidity Index ≥3 (56 vs. 18%). Of paraplegic vs. non-paraplegic RC patients, 141 versus 15,112 (76 vs. 60%) experienced overall complications, 38 versus 2794 (21 vs. 11%) pulmonary complications, 36 versus 3525 (19 vs. 14%) genitourinary complications, 33 versus 3087 (18 vs. 12%) intraoperative complications, 21 versus 1035 (11 vs. 4%) infections, and 17 versus 1343 (9 vs. 5%) wound complications, while 62 versus 6267 (34 vs. 25%) received blood transfusions, 47 versus 3044 (25 vs. 12%) received critical care therapy (CCT), and intrahospital mortality was recorded in 13 versus 456 (7.0 vs. 1.8%) patients. In multivariable logistic regression models, paraplegic status independently predicted higher overall CCT use (odds ratio [OR] 2.1, p<0.001) as well as fourfold higher in-hospital mortality (p<0.001), higher infection rate (OR 2.5, p<0.001), higher blood transfusion rate (OR 1.45, p=0.009), and higher intraoperative (OR 1.56, p=0.02), wound (OR 1.89, p=0.01), and pulmonary (OR 1.72, p=0.004) complication rates. Paraplegic patients contemplating RC should be counseled about fourfold higher risk of in-hospital mortality and higher rates of other untoward effects.

Neoadjuvant chemotherapy before radical cystectomy in patients with organ-confined and non-organ-confined urothelial carcinoma

IntroductionNeoadjuvant chemotherapy (NAC) before radical cystectomy (RC) is guideline-recommended in patients with cT2-T4N0M0 urothelial carcinoma of urinary bladder (UCUB). However, no population-based study validated the survival benefit of NAC recorded in clinical trials in a stage-specific fashion. We addressed this knowledge gap. MethodsWithin the Surveillance, Epidemiology, and End Results database (2007–2020), we identified patients with cT2-T4N0M0 UCUB treated with NAC before RC versus RC alone. Cumulative incidence plots and multivariable competing risks regression (CRR) models were fitted. Survival analyses were performed according to organ confined (OC: cT2N0M0) versus nonorgan confined stages (NOC: cT3-T4N0M0). ResultsOf 3,743 assessable patients, 1,020 (27%) underwent NAC versus 2,723 (73%) RC alone. NAC rates increased over time in OC stage (EAPC = 11.9%, P < 0.001) and NOC stage (EAPC = 8.6%, P < 0.001). In OC stage, cumulative incidence plots derived 5-year CSM was 15.6% in NAC and 19.9% in RC alone patients (P = 0.008). In multivariable CRR models, NAC independently predicted lower CSM (hazard ratio (HR): 0.74, P = 0.01). Similarly, in NOC stage, cumulative incidence plots derived 5-year CSM was 36.1% in NAC and 46.0% in RC alone patients (P = 0.01). In multivariable CRR models, NAC independently predicted lower CSM (HR: 0.66, P < 0.001). ConclusionNAC is associated with improved CSM compared to RC alone, both in OC and NOC stages. Specifically, the magnitude of the protective NAC effect was greater in NOC than OC patients. Thus, NAC should always be administered in all eligible patients before RC.

Outcome of perioperative immune enhancing nutrition in patients undergoing radical cystectomy

BackgroundSince radical cystectomy is associated with relatively high perioperative morbidity and mortality, this study was conducted to evaluate the efficacy of perioperative immune nutrition in radical cystectomy patients on postoperative outcomes including wound healing, postoperative complications, either infectious or non-infectious, and length of hospital stay.Patients and methodsThis prospective, randomized controlled study was conducted between June 2022 and November 2023. Forty-two patients who had undergone radical cystectomy with ileal conduit were randomized into two groups: the immune nutrition group, which received perioperative immune nutrition, and the conventional group, which did not receive immune nutrition. Patients were followed up for 30 days postoperatively to assess wound healing, infectious and non-infectious complications, and the length of hospital stay.ResultsPatients who received immune nutrition had significantly lower postoperative infectious complications (19.0 vs 61.9%; P = 0.004), shorter hospital stay (16.57 ± 3.74 vs 20.38 ± 5.97; P = 0.01) and shorter ICU stay (2.60 ± 1.07 vs 7.09 ± 7.50; P = 0.029). The proper wound healing was significantly higher in the immune nutrition group (90.5 vs 52.4%; P = 0.006). However, there was no significant difference between both groups in the rate of non-infectious complications (28.5% vs. 57.1%, P = 0.061).ConclusionPerioperative immune nutrition is associated with improved wound healing, reduced infectious complications, and reduced length of hospital stay.Trial registration clinicaltrials.gov, NCT05822518. Registered 1 April 2023—Retrospectively registered, https://clinicaltrials.gov/study/NCT05822518.

Developing and validating risk predicting models to assess venous thromboembolism risk after radical cystectomy.

Radical cystectomy (RC) patients are at significant risk for venous thromboembolism (VTE). Current predictive models, such as the Caprini risk assessment (CRA) model, have limitations. This research aimed to create a novel predictive model for forecasting the risk of VTE after RC. This single-center study involved RC patients treated between January 1, 2010 and December 31, 2019. The individuals were divided into training and testing groups in a random manner. Multivariate and stepwise logistic regression were utilized to create two novel models. The models' performance was compared to the commonly used CRA model, employing metrics including net reclassification improvement (NRI), integrated discrimination improvement (IDI), and receiver operating characteristic (ROC) curve analyses. A total of 272 patients were enrolled, among whom 36 were diagnosed with VTE after RC. Model A and Model B were then conducted. The area under ROC of Model A and Model B is 0.806 [95% confidence interval (CI): 0.748-0.856] and 0.833 (95% CI: 0.777-0.880), respectively, which were also determined in the testing cohorts. The two new Models were superior both in classification ability and prediction ability (NRI >0, IDI >0, P<0.01). Model A and Model B had a concordance index (C-index) of 0.806 and 0.833, respectively. In decision curve analysis (DCA), the two new models provided a net benefit between 0.02 and 0.84, suggesting promising clinical utility. Regarding predictive accuracy, both models surpass the existing CRA model, with Model A being advantageous due to its fewer variables. This easy-to-use model enables swift risk assessment and timely intervention for high-risk groups, yielding favorable patient outcomes.

A comparative study of survival outcomes between partial and radical cystectomy in octogenarians with muscle-invasive bladder cancer.

Neoadjuvant chemotherapy with radical cystectomy (RC) is the preferred first-line treatment for localized muscle-invasive bladder cancer (MIBC). Due to the concern about morbidity associated with RC, the elderly population considers bladder preservation alternatives. Guidelines suggest partial cystectomy (PC) can be considered a viable option in carefully selected individuals. We used the National Cancer Database (NCDB) to compare the overall survival (OS) among octogenarians treated with PC and RC. Using NCDB, we retrospectively evaluated individuals aged 80 years and above diagnosed with localized MIBC (cT2-4aN0M0) with tumor size less than 5 cm and urothelial histology between 2004 and 2018. Our primary cohort was divided into the RC cohort, which included patients who underwent RC with or without chemotherapy/radiotherapy, and the PC cohort, which included those who underwent PC. After propensity-matching, we compared the OS. Of 94,104 patients with MIBC, 2,528 octogenarians met our selection criteria. Among them, 313 were treated with PC, and 2,215 were treated with RC. A total of 151 (48.2%) PC patients had pelvic lymph node dissection, while 1,967 (88.8%) RC patients had lymph node dissection (P<0.001). The OS for matched PC and RC was 33.4 and 29.9 months, respectively (P=0.68). In T2 tumors, the OS for PC and RC was 37 and 33.5 months, respectively (P=0.52); for T3 tumors, the OS was 22.3 and 24.4 months, respectively (P=0.98). Our study compared PC and RC in octogenarians with localized MIBC and observed that PC is safe and not inferior to RC in carefully selected octogenarians. The role of PC needs further exploration by comparing or integrating with strategies like concurrent chemoradiation to improve the oncological and survival outcomes.

Body Image Perception and Social Support Are Important Predictors of Quality of Life in Bladder Cancer Patients after Cystectomy with Urinary Diversion

Introduction: Systematic evaluations focusing on the perception of body image and social support in relation to quality of life (QoL) outcomes in patients radical cystectomy (RC) with urinary diversion (UD) are currently lacking. This study investigated the relationship between body image perception, social support, and QoL in bladder cancer patients who underwent RC with UD. Methods: A cross-sectional survey was conducted using validated general oncology tools to assess QoL in relation to newly implemented tools assessing body image perception and social support. Body image perception was assessed with the Self-Image Scale, and social support was assessed using the Illness-Specific Social Support Scale. Logistic regression models were used to analyze factors associated with QoL and body image, respectively. Results: The survey revealed a significant association of body image perception with QoL, as well as social support with body image perception. This is the first study to systematically evaluate these psychosocial factors in the context of QoL for RC patients, highlighting their critical role in patient-reported outcomes. Conclusion: Body image perception and social support are important psychosociological factors that affect QoL of bladder cancer patients post-RC. Targeted psychosocial interventions could be promising for improving QoL patients post-RC.

The impact of double-J ureteral stenting before radical cystectomy on the development of upper tract urothelial carcinoma.

It is controversial whether the use of a double-J stent (DJ) in patients with bladder cancer before radical cystectomy (RC) increases the risk of tumour seeding in the upper tract and thus the risk of metachronous upper tract urothelial carcinoma (UTUC). The aim of our study is to investigate the risk of upper tract recurrence after RC in patients previously managed with a DJ stent. A total of 699 patients who had undergone RC between January 2003 and March 2022 with complete perioperative data and pathological outcome were included in our study. Patients treated preoperatively with a DJ stent were identified and compared for development of metachronous UTUC with those who did not receive prior internal stenting. Multivariable Cox regression analysis was used to determine predictors of UTUC occurrence among the possible pathological features; risk factors for mortality after RC were also examined. Of 699 patients, 117 (16.7%) were managed preoperatively with a DJ stent. The overall probability of metachronous UTUC was 1%, 4% and 6% at 1, 3 and 5 years, respectively. The groups with and without DJ stenting were comparable regarding their clinicopathologic features, except for the higher incidence of hydronephrosis in the DJ group. At similar follow-up periods (median follow-up 32 months), metachronous UTUC was detected in four (3.4%) patients in the DJ group and in 13 (2.2%) in the non-stented group (P=0.44). The median interval (IQR) from cystectomy to UTUC was 40.5 (20-49) months in the DJ group and 37 (24-82) in the non-stented group (P=0.7). In the multivariable analysis, only presence of CIS (HR 3.83, 95% CI 1.19-12.29, P=0.024) and positive ureteral margin (HR=5.2, 95% CI 1.38-19.57, P=0.015) were predictors of metachronous UTUC. The study is limited by the retrospective nature and relatively short follow-up. Ureteral stenting for management of hydronephrosis in patients with bladder cancer undergoing RC is a viable option, without higher risk for UTUC or mortality. Patients with positive ureteral margin and CIS are considered high-risk groups for upper tract recurrence and should receive long-term, rigorous follow-up.

Urachal Carcinoma: Insights From a National Database

IntroductionUrachal carcinoma (UrC) is a rare, nonurothelial malignancy, comprising less than 1% of all bladder cancers. It usually affects males in their fifth to sixth decade and is often diagnosed at an advanced stage with metastasis. This study examines UrC population characteristics and management. MethodsWe identified UrC patients from bladder biopsies or TURB in the PearlDiver Mariner database (2010-2022). Descriptive statistics detailed patient characteristics. Student's T-Tests compared ages for partial vs. radical cystectomy, and Fisher's exact test compared SDOH presence. Significance was set at P < .05. Analyses used R version 3.6.0 within PearlDiver's software. ResultsAmong 2475 UrC patients (mean age 69.2 ± 9.2 years, 73.1% men), most were in the south (36.5%), outpatient settings (84.5%), and privately insured (65.3%). A total of 418 (16.2%) had at least 1 SDOH. Imaging before diagnosis was used in 65.74% of patients, primarily ultrasound. Smoking was present in 54.5%, diabetes in 42.9%, and obesity in 25.2%. After diagnosis, 1246 (50.34%) had localized disease; 407 underwent radical cystectomy and 330 partial cystectomy. Patients undergoing radical cystectomy were older (66.74 ± 8.13 years) compared to those undergoing partial cystectomy (60.55 ± 12.92 years) (P < .001), with SDOH factors more prevalent in the partial cystectomy group (P = .03). ConclusionUrC is a rare, often advanced-stage cancer predominantly affecting older men. Our study shows a trend towards partial cystectomy for localized UrC. Further research is needed to personalize surgery and integrate multidisciplinary approaches for better outcomes.

Can We Go beyond Pathology? The Prognostic Role of Risk Scoring Tools for Cancer-Specific Survival of Patients with Bladder Cancer Undergoing Radical Cystectomy.

Radical cystectomy (RC) remains a mainstay surgical treatment for non-metastatic muscle-invasive and BCG-unresponsive bladder cancer. Various perioperative scoring tools assess comorbidity burden, complication risks, and cancer-specific mortality (CSM) risk. We investigated the prognostic value of these scores in patients who underwent RC between 2015 and 2021. Cox proportional hazards were used in survival analyses. Risk models' accuracy was assessed with the concordance index (C-index) and area under the curve. Among 215 included RC patients, 63 (29.3%) died, including 53 (24.7%) cancer-specific deaths, with a median follow-up of 39 months. The AJCC system, COBRA score, and Charlson comorbidity index (CCI) predicted CSM with low accuracy (C-index: 0.66, 0.65; 0.59, respectively). Multivariable Cox regression identified the AJCC system and CCI > 5 as significant CSM predictors. Additional factors included the extent of lymph node dissection, histology, smoking, presence of concomitant CIS, and neutrophil-to-lymphocyte ratio, and model accuracy was high (C-index: 0.80). The internal validation of the model with bootstrap samples revealed its slight optimism of 0.06. In conclusion, the accuracy of the AJCC staging system in the prediction of CSM is low and can be improved with the inclusion of other pathological data, CCI, smoking history and inflammatory indices.

Estimation of Physiologic Ability and Surgical Stress (E-PASS) predicts postoperative complications after radical cystectomy.

This study evaluates the effectiveness of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system in predicting postoperative complications following radical cystectomy (RC). In this single-center retrospective study, we analyzed data from patients who underwent open RC for muscle-invasive bladder cancer by a single surgeon between 2008 and 2023. Cases involving cystectomy for non-urothelial carcinoma or urinary diversion other than ileal conduit were excluded. We recorded patient demographics, body mass index (BMI), history of abdominal/retroperitoneal surgery, ASA score, performance status (PS), and pre-existing conditions, such as hypertension (HT), coronary artery disease (CAD), diabetes mellitus (DM), and chronic kidney disease (CKD). Intraoperative data included surgery duration, blood loss, and need for blood transfusion. Post-operative complications were classified using the Clavien-Dindo system. E-PASS score was calculated using the Preoperative Risk Score (PRS), Surgical Stress Score (SSS), and Comprehensive Risk Score (CRS). The study included 252 patients. Patients who experienced postoperative complications had higher age, BMI, prior surgical history, ASA score, PS, and rates of CAD, HT, DM, and CKD compared to those who did not. Surgery duration, blood loss, blood transfusion requirement, and E-PASS scores (PRS, SSS, CRS) were also higher in this group. The ROC curve for CRS revealed a predictive cutoff of 0.4911 (AUC = 0.905, p < 0.001). Independent risk factors for postoperative complications included high BMI (p = 0.031), longer surgery duration (p < 0.001), HT (p = 0.042), CKD (p = 0.017), and CRS > 0.4911 (p < 0.001). E-PASS system effectively predicts postoperative complications in RC patients.

PA-MSHA improves prognosis of patients undergoing radical cystectomy: a retrospective cohort study using inverse probability of treatment weighting.

To observe the effect of Pseudomonas aeruginosa mannose-sensitive hemagglutinin (PA-MSHA) on the prognosis and the incidence of lymphatic leakage in patients undergoing radical cystectomy (RC). A total of 129 patients who underwent RC in Lanzhou University Second Hospital from 2013 to 2022 were enrolled in this study. They were divided into 43 patients treated with PA-MSHA and 86 patients in the control group. Inverse probability of treatment weighting (IPTW) was applied to reduce potential selection bias. Kaplan-Meier method and Cox regression analysis were used to analyze the effect of PA-MSHA on the survival of patients and the incidence of postoperative lymphatic leakage. The PA-MSHA group exhibited improved overall survival (OS) and cancer-specific survival (CSS) rates compared to the control group. The 3-year and 5-year overall survival (OS) rates for the PA-MSHA group were 69.1% and 53.2%, respectively, compared to 55.6% and 45.3% for the control group (Log-rank=3.218, P=0.072). The 3-year and 5-year cancer-specific survival (CSS) rates for the PA-MSHA group were 73.3% and 56.5%, respectively, compared to 58.0% and 47.3% for the control group (Log-rank=3.218, P=0.072). Additionally, the 3-year and 5-year progression-free survival (PFS) rates for the PA-MSHA group were 74.4% and 56.8%, respectively, compared to 57.1% and 52.2% for the control group (Log-rank=2.016, P=0.156). Multivariate Cox regression analysis indicates that lymph node metastasis and distant metastasis are poor prognostic factors for patients, while the use of PA-MSHA can improve patients' OS (HR: 0.547, 95%CI: 0.304-0.983, P=0.044), PFS (HR: 0.469, 95%CI: 0.229-0.959, P=0.038) and CSS (HR: 0.484, 95%CI: 0.257-0.908, P=0.024). The same trend was observed in the cohort After IPTW adjustment. Although there was no significant difference in the incidence of postoperative lymphatic leakage [18.6% (8/35) vs. 15.1% (84.9%), P=0.613] and pelvic drainage volume [470 (440) ml vs. 462.5 (430) ml, P=0.814] between PA-MSHA group and control group, PA-MSHA could shorten the median retention time of drainage tube (7.0 d vs 9.0 d) (P=0.021). PA-MSHA may improve radical cystectomy in patients with OS, PFS, and CSS, shorten the pelvic drainage tube retention time.

Critical care therapy use after radical cystectomy in patients with non-metastatic bladder cancer

PurposeTo assess critical care therapy use in patients with non-metastatic bladder cancer undergoing radical cystectomy. MethodsUsing the National Inpatient Sample (2000-2019), we identified non-metastatic bladder cancer patients undergoing radical cystectomy. Study endpoints consisted of critical care therapy use, defined as total parenteral nutrition, invasive mechanical ventilation, dialysis, percutaneous endoscopic gastrostomy tube insertion, tracheostomy, and in-hospital mortality. Estimated annual percentage changes (EAPC) and multivariable logistic regression models were used. ResultsOf 25,535 patients, 3,091 (12.1%) received critical care therapy. Critical care therapy use decreased from 13.1 in 2000 to 5.9% in 2019 (EAPC -2.4; p=0.005), and in-hospital mortality also decreased from 3.4 to 0.7% (EAPC -4.2%; p<0.001). Older (≥80 years: odds ratio [OR] 1.91; p<0.001, and 60-79 years OR 1.41; p<0.001) and sicker patients (Charlson comorbidity index [CCI] ≥3: OR 3.16; p<0.001; CCI 1-2 OR 1.89; p<0.001) were more likely to receive critical care therapy. Conversely, minimally-invasive surgical approach (OR 0.66; p=0.01) and teaching hospital status (OR 0.70; p=0.008) independently predicted lower critical care therapy use. The same risk factors were identified for in-hospital mortality. ConclusionsCritical care therapy use in radical cystectomy patients decreased from 13.1 in 2000 to 5.9% in 2019 and so did in-hospital mortality (3.4 to 0.7%). Of all critical care therapy determinants, CCI ≥3 (OR 3.2) represented the strongest followed by octogenarian age (OR 1.9). Even after adjustment for patient age and comorbidities, minimally-invasive surgical approach and teaching hospital status were associated with lower critical care therapy use, and lower in-hospital mortality.

Discriminatory ability of perioperative heart rate variability in predicting postoperative complications in major urologic surgery: a prospective cohort study

We aimed to determine if continuous perioperative heart rate variability (HRV) monitoring could improve risk stratification compared to a short preoperative measurement in radical cystectomy patients. Electrocardiography (ECG) recordings were collected continuously preoperatively to discharge in 83 patients. Two, 5-min ECG signal segments (preoperative and at 24-h post ECG placement) were analyzed offline to extract HRV metrics. HRV metric discriminatory ability to identify patients with 30-day postoperative complications were analyzed using receiver operating characteristics curves. Sixty participants were included for analysis of which 27 (45%) developed a complication within 30 days postoperative. HRV was reduced in patients with complications. Postoperative standard deviation NN intervals and root mean square of successive differences had area under the curves (AUC) of 0.67 (95% CI 0.54 to 0.81) and 0.68 (95% CI 0.54 to 0.82), respectively. Significant discriminatory abilities were also reported for postoperative frequency metrics of absolute low frequency (LF) [AUC = 0.65 (95% CI 0.51 to 0.79)] and high frequency (HF) powers [AUC = 0.69 (95% CI 0.55 to 0.83)] and total power [AUC = 0.66 (95% CI 0.53 to 0.80)]. Postoperative acquired HRV metrics demonstrated improved discriminatory ability. Our findings suggest that longer-term perioperative HRV monitoring presents with superior ability to stratify complication risk.

Abstract A001: Urine-based liquid biopsy test for the detection of residual bladder cancer in radical cystectomy patients

Abstract One commonly employed management strategy for muscle-invasive bladder cancer (MIBC) is neoadjuvant chemotherapy followed by radical cystectomy (RC) and urinary diversion. Approximately 35% of patients achieve a pathologic complete response (pCR) when evaluated from RC specimens. RC with urinary diversion is a life-altering operation with high complication rates and therefore determining who are complete responders would improve quality of life and could decrease costs and still achieve a high cure rate via RC avoidance. Unfortunately, current methods cannot accurately identify complete responders. Our lab has developed a urine-based liquid biopsy test in which DNA isolated from urine and germline is isolated and subjected to panel exome sequencing for enumeration of somatic variants. This occurs under the premise that tumor DNA identified (as mutant alleles) is a marker of residual disease while the absence of tumor DNA (meaning the absence of mutant alleles) can indicate a pCR. A 60 gene panel was designed to be used for exonic sequencing of urinary DNA (uDNA) to identify mutations indicative of bladder cancer or therapeutic targets. We have shown that most mutations in tumor tissue (Mt) are detectable as mutations in urine (Mu). We also showed that the presence or absence of residual Mu after completion of chemotherapy strongly associates with residual disease or pCR at the time of RC, respectively. Therefore, this test could be used after neoadjuvant therapy to better identify patients for RC avoidance. We optimized this test by studying pre-analytical factors affecting the yield, purity, and integrity of uDNA and the quality of sequencing data using prospectively collected samples from patients with MIBC. We are also in the process of testing commercial and novel preservatives to optimize DNA integrity, yield, and mutation detection accuracy to enable temporary ambient temperature storage without compromising mutation detection, permitting shipping/centralized testing. Lastly, we are comparing two library preparation approaches. Study of these preanalytical factors has increased the number of Mu that can be detected and were applied to a cohort of patients who underwent bladder sparing curative-intent treatment in a prospective clinical trial. Studies described herein will enable liquid biopsy tests to accurately identify patients with pCR after neoadjuvant therapy and might safely avoid radical cystectomy. Citation Format: Philip H. Abbosh, Henkel Valentine, Rhea Arya. Urine-based liquid biopsy test for the detection of residual bladder cancer in radical cystectomy patients [abstract]. In: Proceedings of the AACR Special Conference on Bladder Cancer: Transforming the Field; 2024 May 17-20; Charlotte, NC. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(10_Suppl):Abstract nr A001.

It's complicated: The relationship of non-narcotic medications and postoperative opioid use in radical cystectomy patients

IntroductionThe effect of individual non-narcotic analgesics in cystectomy enhanced recovery after surgery (ERAS) is unknown. Additionally, many non-narcotic medications are associated with side effects pertinent to the cystectomy population. To better understand the actual use and utility of these medications, we sought to characterize the association between non-narcotic medications and milligram morphine equivalent (MME) narcotic score during the postoperative inpatient stay. MethodsWe reviewed 260 consecutive ERAS cystectomy patients. The MME impact of non-narcotic compliance and cumulative dose of medication received was evaluated separately with general linear models. We also assessed relationship of non-narcotic compliance to patient reported pain score, length of stay (LOS), and time to return of bowel function (ROBF) and performed manual review of postoperative documentation to identify reasons for medication noncompliance. ResultsCompliance with postoperative acetaminophen, gabapentin, and ketorolac was low. There was an inverse relationship between ketorolac dose and MME on postoperative day 1 (−0.026 MME/mg; P = 0.004) and postoperative day 2 (−0.33 MME/mg; P < 0.001). Compliance with ketorolac was associated with lower MME on postoperative day 1 (26.1 MME v. 33.6 MME; P = 0.023). There were no such associations identified with gabapentin or acetaminophen. Gabapentin compliance was associated with earlier ROBF (3.7 days v. 4.3 days; P = 0.006). Ketorolac compliance was associated with lower pain score on POD1 (3.25 VAS v. 4.07 VAS; P = 0.019) and POD2 (3.05 VAS v. 3.85 VAS; P = 0.040) There was no association between medication compliance and LOS. The most common reasons identified for non-compliance with gabapentin and ketorolac were renal function concerns (38% and 40% respectively), bleeding concerns with ketorolac (20%) and concerns for neurologic adverse effect with gabapentin (16%). ConclusionCompliance with non-narcotic medications in our ERAS cystectomy protocol was poor. There was a modest association with ketorolac and postoperative MME but no association with gabapentin or acetaminophen. Further study will clarify the role of these medications for cystectomy patients. Component specific analysis of protocolized care is valuable and may alter care pathways.

Trimodal therapy vs radical cystectomy in patients with muscle-invasive bladder cancer: a systematic review and meta-analysis of comparative studies.

To perform a systematic review and meta-analysis of trials comparing trimodal therapy (TMT) and radical cystectomy (RC), evaluating differences in terms of oncological outcomes, quality of life, and costs. In July 2023, a literature search of multiple databases was conducted to identify studies analysing patients with cT2-4 N any M0 muscle-invasive bladder cancer (MIBC; Patients) receiving TMT (Intervention) compared to RC (Comparison), to evaluate survival outcomes, recurrence rates, costs, and quality of life (Outcomes). The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS) and metastasis-free survival (MFS). Hazard ratios (HRs) were used to analyse survival outcomes according to different treatment modalities and odds ratios were used to evaluate the likelihood of receiving each type of treatment according to T stage. No significant difference in terms of OS was observed between RC and TMT (HR 1.07, 95% confidence interval [CI] 0.81-1.4; P = 0.6), even when analysing radiation therapy regimens ≥60 Gy (HR 1.02, 95% CI 0.69-1.52; P = 0.9). No significant difference was observed in CSS (HR 1.12, 95% CI 0.79-1.57, P = 0.5) or MFS (HR 0.88, 95% CI 0.66-1.16; P = 0.3). The mean cost of TMT was significantly higher than that of RC ($289 142 vs $148 757; P < 0.001), with greater effectiveness in terms of cost per quality-adjusted life-year. TMT ensured significantly higher general quality-of-life scores. Trimodal therapy appeared to yield comparable oncological outcomes to RC concerning OS, CSS and MFS, while providing superior patient quality of life and cost effectiveness.

Hyperthermic Intravesical Chemotherapy (HIVEC) Using Epirubicin in an Optimized Setting in Patients with NMIBC Recurrence after Failed BCG Therapy.

To evaluate hyperthermic intravesical chemotherapy (HIVEC) using conductive heating and epirubicin in an optimized setting as an alternative to radical cystectomy in patients with recurrent non-muscle invasive bladder cancer (NMIBC) who have failed bacillus Calmette-Guérin (BCG) therapy. We retrospectively analyzed our prospectively recorded database of patients who underwent HIVEC between 11/2017 and 11/2022 at two Swiss University Centers. Cox regression analysis was used for univariate/multivariate analysis, and the Kaplan-Meier method for survival analysis. Of the 39 patients with NMIBC recurrence after failed BCG therapy, 25 (64%) did not recur within the bladder after a median follow-up of 28 months. The 12- and 24-month intravesical RFS were 94.8% and 80%, respectively. Extravesical recurrence developed in 14/39 (36%) of patients. Only 7/39 (18%) patients had to undergo radical cystectomy. Seven patients (18%) progressed to metastatic disease, with five of these (71%) having previously developed extravesical disease. No adverse events > grade 2 occurred during HIVEC. Device-assisted HIVEC using epirubicin in an optimized setting achieved excellent RFS rates in this recurrent NMIBC population at highest risk for recurrence after previously failed intravesical BCG therapy. Extravesical disease during or after HIVEC, however, was frequent and associated with metastatic disease and consecutively poor outcomes.