Urinary Diversion Surgery Research Articles

Carbon-ion radiotherapy for adenocarcinoma of the uterine cervix: clinical outcomes of a multicenter prospective registry-based study in Japan (2016–2020)

Prognoses are poorer in cases of adenocarcinoma of the uterine cervix (AUC) than of squamous cell carcinoma. Carbon-ion radiotherapy (CIRT) outcomes for AUC have been reported in retrospective or single institutional prospective studies but not prospective multicenter studies. We present the results of CIRT for AUC in a prospective multicenter study utilizing a nationwide hospital-based registry in Japan. Patients with locally advanced untreated AUC who received CIRT at 4 Japanese centers between June 2016 and April 2020 were included in this study. In the absence of organ dysfunction, up to 5 weekly 40 mg/m2 cisplatin courses were administered. The primary endpoints were 2-year overall survival (OS) and local control (LC) rates. The secondary endpoints were 2-year disease-free survival (DFS) rate and late adverse events (AEs). Forty-two patients were enrolled with a median age of 54 years (range, 34-76 years). Patients were diagnosed with Stage IIB (n=26), IIIB (n=12), or IVA (n=4) disease. The median follow-up period was 24 months. The 2-year OS, LC, and DFS rates were 97.5% (95% confidence interval [CI] 92.7-100.0%), 80.9% (95% CI 66.9-94.8%), and 64.3% (48.1-80.4%), respectively. Two patients developed Grade 3 rectum/sigmoid AE. One patient required urinary diversion surgery during a salvage operation for local tumor recurrence (Grade 3 genitourinary AE). No other Grade 3 or worse toxicities were reported. CIRT is an effective treatment for locally advanced AUC. Further research is required to validate the safety and efficacy of CIRT for AUC.

Efficacy and Complications of Mitrofanoff Continent Urinary Diversion in Adults with Complex Urethral Strictures: A Single-Center Experience.

The management of complicated and irreparable urethral strictures can be challenging, and continent urinary diversion has emerged as a viable option. This study aims to investigate the complications associated with continent urinary diversion using the Mitrofanoff principle in patients with complex urethral strictures that cannot be corrected through urethroplasty surgery. A total of 22 patients were included in this study, who underwent continent urinary diversion surgery using the Mitrofanoff technique. The patients were monitored for post-surgical complications over an average follow-up period of 28.36±14.26 months. Surgical failure was defined as the inability to completely and regularly empty urine from the new urinary tract. Half of the patients experienced surgical complications, with only one case resulting in surgery failure. The most common complication observed was stoma stenosis. Two patients reported slight urinary leakage from the stoma site. Notably, all patients except one, regained control over their urine after the procedure. Early therapeutic interventions were classified according to the Clavien-Dindo grading system, showed that none of the patients experienced severe complications (grade 4 or 5). The study examines the outcomes of continent urinary diversion using the Mitrofanoff technique in adults with complex urethral strictures, providing realistic expectations of complications. Overall, the study shows that this approach is a viable option with a high success rate and manageable complication for individuals with complex urethral strictures that cannot be corrected through urethroplasty surgery.

Impact of SPY Fluorescence Angiography on Incidence of Ureteroenteric Stricture After Urinary Diversion.

Ureteroenteric strictures (UESs) are a common and morbid complication of radical cystectomy and urinary diversions. UES occurs in 4% to 25% of all patients undergoing urinary diversion, and anastomotic ischemia is implicated in stricture formation. SPY fluorescence angiography is a technology that can be employed during open surgery that allows for evaluation of ureteral perfusion. We performed a prospective single-institution study of intraoperative use of SPY for ureteral assessment with a primary outcome of UES incidence compared with a cohort of historic controls prior to the use of SPY during urinary diversion at our institution. Chart abstraction was conducted to determine the presence of confirmed stricture in these patients, defined as endoscopic diagnosis or definitive imaging findings. Statistical analysis was performed using χ2 test for UES incidence. Demographics characteristics were analyzed with Wilcoxon rank sum test and χ2 test. A total of 332 patients underwent urinary diversion during the study period. UES occurred in 31 of 277 patients (11.1%) in the control group compared with 1 of 55 patients (1.8%) enrolled in the SPY arm (P = .03). The per-ureter UES rate was 6.7% (33/582) in the control group compared with 0.9% (1/107) in the SPY group. Median follow-up in the SPY group was 17.5 months and 58.6 months in the control group. Median Charlson Comorbidity Index was 5 in the SPY group and 4 in the control group. There were no other significant demographic differences between the study groups. SPY fluorescent angiography can be used during open urinary diversion to ensure perfusion to ureteroenteric anastomosis. Our single-institution study demonstrates a decreased incidence of UES when ureteral perfusion assessment is performed. NCT05022199.

Predictive factors of surgical complications after pelvic exenteration for gynecological malignancies: a large single-institution experience.

To evaluate pre-operative predictors of early (<30 days) severe complications (grade Dindo 3+) in patients with gynecological malignancy submitted to pelvic exenteration (PE). We retrospectively analyzed 129 patients submitted to surgery at Fondazione Policlinico Gemelli between 2010 and 2019. We included patients affected by primary or recurrent/persistent cervical, endometrial, or vulvar/vaginal cancers. Post-operative complications were graded according to the Dindo classification. Logistic regression was used to analyze potential predictors of complications. We performed 63 anterior PE, 10 posterior PE, and 56 total PE. The incidence of early severe post-operative complications was 27.9% (n=36), and the early mortality rate was 2.3% (n=3). More frequent complications were related to the urinary diversion and intestinal surgery. In univariable analysis, hemoglobin ≤10 g/dL (odds ratio [OR]=4.2; 95% confidence interval [CI]=1.65-10.7; p=0.003), low albumin levels (OR=3.9; 95% CI=1.27-12.11; p=0.025), diabetes (OR=4.15; 95% CI=1.22-14.1; p=0.022), 2+ comorbidities at presentation (OR=5.18; 95% CI=1.49-17.93; p=0.012) were predictors of early severe complications. In multivariable analysis, only low hemoglobin and comorbidities at presentation were independent predictors of complications. Pelvic exenteration is an aggressive surgery characterized by a high rate of post-operative complications. Pre-operative assessment of comorbidities and patient health status are crucial to better select the right candidate for this type of surgery.

Opioid-Free Anaesthesia During Prolonged Orthotopic Urinary Bladder Diversion Surgery: A Prospective Randomized Comparative Study

Opioid-Free Anaesthesia During Prolonged Orthotopic Urinary Bladder Diversion Surgery: A Prospective Randomized Comparative Study

Standardized one-day evaluation before urinary reconstructive surgery for neurogenic lower urinary tract dysfunction: Feasibility and impact on surgical strategy and care pathway.

To describe a concept of standardized preoperative one-day evaluation before urinary reconstructive or diversion surgery for the treatment of neurogenic lower urinary tract (LUT) dysfunction, and to evaluate its feasibility and its impact on the care pathway. All patients who underwent a one-day standardized evaluation before a urinary reconstructive or derivation surgery for the treatment of neurogenic LUT dysfunction between January 2017 and December 2021 in our institution were included. Data were collected retrospectively from standardized reports. The main outcome was the rate of completion of the tests and consultations planned during this evaluation. Secondary outcomes included the findings from the one-day evaluation and changes in the urological surgical strategy at different time points within one year. One hundred and thirty-one patients benefited from this one-day standardized evaluation. The overall completeness rate of the data collected was 77.5%, increasing from 62.3% in 2017 to 89.3% in 2021. The urological surgical plan was modified for 19.1% of patients following this preoperative evaluation. The indication was then confirmed for 114 patients (87.0%) by the multidisciplinary meeting and was carried out unchanged during the following year for 89 patients (67.9%). An associated colostomy procedure was proposed for 18.3% of patients and was finally performed in 11.5%. A standardized multidisciplinary preoperative one-day evaluation before performing reconstructive or diversion surgery for the treatment of neurogenic LUT dysfunction seems feasible and makes it possible to optimize the surgical plan and adapt the course of care.

Feasibility of urolithiasis management after studer neobladder urinary diversion: A multicenter center study

Background: Stones formation is a common complication after cystectomy including stones of the upper urinary tract and reservoir or conduit. Advances in instrumentation and techniques have expanded treatment options, while minimizing morbidity. Aims and Objectives: Feasibility of urolithiasis management after urinary diversion surgery. Materials and Methods: Eleven patients of diversion with stone were observed from January 01, 2015, to July 30, 2022. Operative procedures were decided on basis on stone locations and size. Perioperative parameters were observed and compared with similar studies. Percutaneous nephrolithotomy, percutaneous-based antegrade ureteroscopy with semi-rigid or flexible ureteroscope, transurethral reservoir lithotripsy, percutaneous pouch lithotripsy, and open operation were performed. The operative finding and complications were retrospectively collected and analyzed. Results: The mean age of the patients was 53.2±8.1 years and mean pre-operative stone diameter was 3.1±3.5 cm. Three patients suprapubic cystolithotomy, two patients percutaneous cystolithotripsy, two patients percutaneous nephrolithitomy, two patients extracorporeal shock wave lithotripsy, one patient per urethral cystolithotripsy/cystolitholapexy, and one patient ureteroscopy/flexible ureteroscopy were done. The male-to-female ratio was 9/2. Stone-free rate was 100% after single session of treatment. In the post-operative period, fever was observed in two patients, and urinary leakage through wound site in one patient. Conclusion: Stone surgery after urinary diversion is challenging, success of treatment depends on experience of surgical team, pre-operative preparation, and correct instrumentations.

V01-11 ROBOT-ASSISTED BILATERAL URETERAL RE-IMPLANTATION AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER FOR DISTAL URETERAL FIBROSIS

You have accessJournal of UrologyCME1 Apr 2023V01-11 ROBOT-ASSISTED BILATERAL URETERAL RE-IMPLANTATION AFTER CYSTECTOMY AND ORTHOTOPIC NEOBLADDER FOR DISTAL URETERAL FIBROSIS Gabriel Frölicher, Christoph Schregel, Yasmin Trachsel, Tutal Mustafa, and Hubert John Gabriel FrölicherGabriel Frölicher More articles by this author , Christoph SchregelChristoph Schregel More articles by this author , Yasmin TrachselYasmin Trachsel More articles by this author , Tutal MustafaTutal Mustafa More articles by this author , and Hubert JohnHubert John More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003221.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This video presents the surgical technique of robot-assisted ureteral re-implantation for distal ureteral fibrosis after open cystectomy and reconstruction with Studer orthotopic neobladder. A 59-year-old patient underwent open radical cystectomy and orthotopic urinary diversion for muscle-invasive bladder cancer. Postoperatively, left hydronephrosis and pyelonephritis occurred. Antegrade attempts to place an ureteral stent were unsuccessful. A nephrostomy drain was placed in the left side. The patient was then referred for laparoscopic robotic reconstruction. METHODS: The ports were placed in analogy to robot-assisted cystectomy. First an extended adhesiolysis was necessary. The intestinal loops were dissected guided by concomitant cystoscopy which revealed the borders between intestine and bladder wall. Finally, right ureter was identified in the proximity of the afferent loop of the Studer neobladder. After preparing and freeing, the right ureter was intubated with a Ch.8 mono-J catheter. The search for the left ureter continued. The left ureter was localised using Methylene blue applied antegrade by the nephrostomy tube. Several attempts to intubate the left ureter Ch.8 mono-J were frustrane due to the considerable long stricture. Further dissection into the retroperitoneal space was necessary. The ureter seemed totally fibrotic over several centimetres. Finally antegrade left ureteral catheterization and retrograde insertion of a Ch.8 mono-J catheter was successful. Accidental lesions of the afferent loop were closed with a 4-0 PDS suture. The ureters were re-implanted end-to-side with 4-0 Stratafix® running sutures. RESULTS: The patient was discharged on the 7th postoperative day after testing the uretero-neobladder anastomosis through a pouchography and a retrograde ureteropyelography and after removal of both mono-J stents. No perioperative complications were observed. Furthermore, the left renal function showed an increasing function 1 year postoperatively in the renal scintigraphy. CONCLUSIONS: This demanding robotic reconstructive ureteral re-implantation so far shows the feasibility and the clinical value of robotic minimal invasive approaches even in complex reconstructive surgeries after open urinary diversion. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e83 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gabriel Frölicher More articles by this author Christoph Schregel More articles by this author Yasmin Trachsel More articles by this author Tutal Mustafa More articles by this author Hubert John More articles by this author Expand All Advertisement PDF downloadLoading ...

Evaluation of perioperative parameters in patients undergoing radical cystectomy urinary diversion surgery for bladder cancer

Purpose: The aim of this study was to evaluate the effect of red blood cell transfusion and/or inotropic/vasopressor agent infusion during intraoperative and postoperative first 24-hour period on 30-day and one-year survival.&#x0D; Materials and Methods: In the final analysis, 133 patients who underwent radical cystectomy and urinary diversion surgery between November 2011 and January 2019 were included in this study. Perioperative anesthesia management early postoperative intensive care patient follow-ups were based on.&#x0D; Results: A statistically significant relationship was found between intraoperative red blood cell transfusion and one-year mortality rates. A statistically significant relationship was found between red blood cell transfusion in the intensive care unit and postoperative 30-day mortality rates. The relationship between vasopressor/inotrope agent infusion in intensive care unit and postoperative 30-day mortality was statistically significant.&#x0D; Conclusion: In radical cystectomy and urinary diversion, intraoperative red blood cell and/or inotrope/vasopressor drug administration, and red blood cell transfusion within first 24 postoperative hours in intensive care unit are associated with lower survival rates in both early and late periods. Future studies should focus on developing and implementing different strategies for perioperative blood management and maintenance of patient hemodynamics that may affect early and late outcomes.

V01-02 USE OF SPY FLUORESCENT ANGIOGRAPHY DURING URINARY DIVERSION

You have accessJournal of UrologyCME1 May 2022V01-02 USE OF SPY FLUORESCENT ANGIOGRAPHY DURING URINARY DIVERSION Grace Prillaman, Clinton Yeaman, Sumit Isharwal, and Tracey Krupski Grace PrillamanGrace Prillaman More articles by this author , Clinton YeamanClinton Yeaman More articles by this author , Sumit IsharwalSumit Isharwal More articles by this author , and Tracey KrupskiTracey Krupski More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002520.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroenteric strictures (UES) are a common complication of radical cystectomy and urinary diversions. UES occurs in 4-25% of all patients undergoing urinary diversion. Anastomotic ischemia is implicated in the formation of stricture. We aim to describe the method for using SPY fluorescent angiography during open urinary diversion. METHODS: Evaluation of ureteral perfusion is commonly performed during robotic-assisted intracorporeal urinary diversion using indocyanine green (ICG) and firefly technology which allow for the detection of ICG indicating perfusion but provides no information on the density of perfusion. SPY is a similar technology that can be employed during open surgery that allows for the visualization of green ICG tracer but also provide a heat map that indicates density of vascularization. ICG dye is administered via IV before the bowel work to create the conduit segment is begun. Ureteral perfusion is assessed using SPY technology to visualize the tracer and perfusion density. SPY has 3 modes of fluorescence: standard green fluorescence, black and white mode, and heatmap mode. The black and white is most sensitive for determining perfusion to tissue. The distal-most aspect of the well perfused ureter is marked with a stitch. If the ureter has poor distal perfusion, it can be resected proximally. A conduit is created, and the bowel is anastomosed accordingly. After both ureteral anastomoses are complete, ICG is again administered via IV to assess for perfusion in the post-anastomosis ureter. RESULTS: We are conducting an ongoing prospective trial to better define the role and benefit of SPY. We have enrolled 16 patients to date with median follow-up time of 4.7 months and have not detected any ureteroenteric strictures within the experimental group. Our institutional rate of UES in patients who did not have SPY fluorescent angiography is 10.3%. CONCLUSIONS: SPY fluorescent angiography can be used during open urinary diversion to ensure perfusion to ureteroenteric anastomosis. Research is ongoing to assess its role in urinary diversion and the prevention of ureteroenteric strictures. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e52 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Grace Prillaman More articles by this author Clinton Yeaman More articles by this author Sumit Isharwal More articles by this author Tracey Krupski More articles by this author Expand All Advertisement PDF DownloadLoading ...

The Effect of Radiation Therapy on the Efficacy of Internal Urethrotomy With Intralesional Mitomycin C for Recurrent Vesicourethral Anastomotic Stenoses and Bladder Neck Contractures: A Multi-Institutional Experience

To assess the efficacy, effect of radiotherapy, and complications of direct visual internal urethrotomy (DVIU) and intralesional mitomycin C (MMC) for recurrent bladder neck contracture/vesicourethral anastomotic stenosis (BNC/VUAS). Patients who underwent DVIU with intralesional MMC for recurrent BNC/VUAS between 2007 and 2019 at 2 institutions were included. Cold knife incisions were performed in a reproducible fashion followed by injection of 0.3-0.4 mg/mL MMC at each incision site. Those with evidence of complete urethral obliteration, stenosis of the entire posterior urethra, or <3 months follow-up were excluded. Success was defined as the ability to pass a 17-French cystoscope postoperatively without the need for catheterization or additional procedures. Eighty-six patients were analyzed over a median follow-up of 21.1 months. Around 91% had at least 1 prior DVIU, 56% had at least 1 prior dilation, and 44% presented with an indwelling catheter or performed intermittent catheterization. Success was achieved in 65% after 1 procedure, an additional 18% after 2 procedures, and another 7% after 3 or more procedures (90% overall success rate). Nonradiated patients showed a higher overall success rate compared to radiated patients (94% vs 76%, P=0.04). Of the 9 cystoscopic failures, 5 were asymptomatic and pursued observation. Only 2 (5%) patients with a history of catheterization required this postoperatively. Two patients underwent subsequent urinary diversion surgery. No long-term complications were seen. DVIU with low-dose MMC remains a safe and effective BNC/VUAS treatment. A patent bladder neck was achieved in >90% of nonradiated patients and >75% of radiated patients.

Management of urethrocutaneous fistulae complicating sacral and perineal pressure ulcer in neurourological patients: A national multicenter study from the French-speaking Neuro-urology Study Group and the Neuro-urology committee of the French Association of Urology.

To describe the epidemiologic characteristics of urethrocutaneous fistulae (UCF) in sacro-perineal pressure ulcer (SPPU) in neurourological patients and to assess outcomes after surgical urinary diversion. Through the French-speaking Neurourology Study Group and Association of Urology network, a retrospective multicenter study in nine major urology and physical medicine and rehabilitation (PMR) units was conducted. All patients with SPPU associated with UCF between 2000 and 2016 were included. Data concerning: sociodemography, clinical, medical and biological comorbidities, neurological and urological history, pressure ulcer characteristics, and finally urinary diversion surgery were collected. Complications and SPPU healing/relapse were assessed. In all, 74 patients were included. The median age on diagnosis: 45.9 years (interquartile range [IQR], 38.7-53.4) and median follow-up: 15.1 months (IQR, 5.7-48.8). A psychiatric disorder was the most frequent comorbidity (44.6%). Only 59.5% and 50% had regular PMR and urologic follow-up, respectively. Seventy-one patients (95.9%) underwent urinary diversion surgery. Among those, relapse occurred in 15 (21.1%) at the end of the follow-up. The diversion was noncontinent in 85.9%. The major complications rate was 26.8%. A total of 30 late complications in 21 patients were reported. The most frequent was obstructive pyelonephritis (n = 9). All of the patients who underwent surgical diversion without cystectomy (n = 5) developed a pyocyst. Finally, the pressure ulcer healing rate when patients underwent both urinary diversion and pressure ulcer surgery was 74.4%. Our retrospective data suggest that UCF complicating SPPU is a rare and severe pathology. The combination of radical urinary diversion with cystectomy and pressure ulcer surgery should be performed as often as possible.

Robotic intracorporeal urinary diversion: state of the art.

We review historical aspects and current status of the emerging approach of robotic urinary diversion (rUD). Established surgical principles of constructing a low-pressure, large-capacity reservoir are described and the open surgical literature succinctly reviewed to establish the gold standard. Incontinent and continent rUD types [ileal conduit, orthotopic neobladder (all varieties), continent cutaneous diversion, cutaneous ureterostomy] and techniques (extra-corporeal, intra-corporeal) are discussed. Outcomes data (intra-operative, perioperative, intermediate-term, long-term), functional outcomes, complications and learning curve are presented. Outcomes data of open versus robotic urinary diversion are examined. Critiques, improvements, and pros-cons of rUD are discussed. Although the majority of centers performing rUD use the extracorporeal technique, use of intra-corporeal rUD is increasing. Although data are yet limited, intra-corporeal rUD may provide some benefits. For rUD, operative times are higher and complication rates comparable with open urinary diversion. The entire range of urinary diversion surgery has now been replicated robotically. At this writing, extracorporeal urinary diversion techniques still predominate following robotic cystectomy. However, all rUD options can now be performed intra-corporeally with success. As experience increases, the field of robotic urinary diversion is poised to grow.

Incidence and microbiology of post-operative infections after radical cystectomy and ureteral stent removal; a retrospective cohort study

BackgroundPost-operative infections are frequent after radical cystectomy with urinary diversion surgery (UDS). Reduction of post-operative infections necessitates appropriate peri-operative antimicrobial prophylaxis targeting causative bacteria. We assessed the incidence and microbiology of infections in the 30-day post-operative period after UDS and investigated effectiveness of the currently used peri-operative antibacterial prophylaxis.MethodsRetrospective cohort study of all patients undergoing UDS in a tertiary university medical center from January 2014 until September 2016. Antibiotic prophylaxis consisted of cefazolin plus metronidazol according to the Dutch national guideline. Primary outcome was the incidence of post-operative infections within 30 days. Risk factors for post-operative infections and antimicrobial susceptibility profiles of cultured bacteria were also assessed.Results147 patients were included. 69 patients (46.9%) had 82 post-operative infections, 27 of which were patients with bacteremia (18.4%). Highest incidence of infections was on day 4–5 and on day 8–10 postoperatively. The second peak was associated with ureteral stent removal. 4.8% of 147 study patients developed bacteremia 24 h after stent removal, which counted for 25.9% of all bacteremia episodes found in this study. Enterobacteriaceae were cultured in 67.9% of blood cultures and were only highly susceptible to ciprofloxacine, piperacillin-tazobactam (90%), meropenem and gentamicin (100%). Multivariate logistic regression analysis showed orthotopic Hautmann neobladder to be associated with increased infections complications: odds ratio 4.1 (95% confidence interval 1.6–10.5), p = 0.03.ConclusionsThe incidence of infections after radical cystectomy is high and particularly ureteral stent removal was associated with both bacteremia and complicated urinary tract infections. Based on the results of this study, antibiotic prophylaxis might need to be broadened for patients undergoing radical cystectomy. Further research is required to investigate whether current guidelines need to be altered concerning administration of antibiotic prophylaxis just before stent removal.

Comparison of health-related quality of life (HRQoL) between ileal conduit diversion and orthotopic neobladder based on validated questionnaires: a systematic review and meta-analysis.

The question of whether orthotopic neobladder (ONB) reconstruction is superior to ileal conduit diversion (ICD) with respect to health-related quality of life (HRQoL) remains controversial. The goal of this study is to perform a meta-analysis to compare post-ICD and post-ONB HRQoL in patients with bladder cancer. A systematic search of Medline, Embase, the Cochrane Central Register of Controlled Trials, and the annual congress abstracts of the European Association of Urology (EAU), the American Urological Association (AUA) and the Société Internationale d'Urologie (SIU) up to June 2017 was conducted to identify all relevant clinical trials using validated questionnaires to assess HRQoL. A systematic review and meta-analysis were then performed. A total of 2507 patients from 26 eligible studies were included. Meta-analyses showed significant differences favouring ONB patients in global health status (WMD + 9.13, p = 0.004), physical functioning (WMD + 11.57, p = 0.0001), role functioning (WMD + 9.64, p = 0.002), and social functioning (WMD + 6.81, p = 0.03) based on the EORTC-QLQ-C30 questionnaire and in the total score of FACT questionnaire (WMD + 6.80, p = 0.001). However, ONB patients were more likely to have postoperative urinary symptoms than ICD patients (WMD - 22.19, p = 0.0001). ONB patients are more likely to have a better global health status than ICD patients. Regardless of the type of urinary diversion (UD) surgery, a gradual improvement in HRQoL over preoperative status tended to stabilise after 12months postoperatively.

Severe hyperkalemia following ureteroileostomy: A case report and literature review

Metabolic complications, including hyponatremia and metabolic acidosis have been reported following urinary diversion operations, occasionally together with hyper- or hypokalemia, depending on the bowel segment used. While Hypokalemia often accompanies ureterosigmoidostomy and may develop following ileal conduits, we report a rare case of recurrent life threatening hyperkalemia following this procedure, associated with hyponatremia and acidosis. Reviewing the English literature (1973 to 2016) we found 25 cases of hyperkalemia complicating ureteral diversion procedures, mostly after jejunal conduits. Only five cases of hyperkalemia were described after ileal conduit surgeries, including the current report. We discuss the nature of the metabolic and electrolyte disturbances following urinary diversion and debate possible reasons for the rare cases of hyperkalemia complicating ileal conduits.

Quality of life among women in Bangladesh following ileal conduit urinary diversion operations for irreparable vesicovaginal fistula and bladder exstrophy: observational study.

To determine the quality of life (QOL) of fistula patients in Bangladesh who have undergone ileal conduit (IC) urinary diversion operations, and to assess whether the risks and ethical challenges involved, outweigh the reality of leaving a woman with urinary incontinence for the rest of her life. Observational study. LAMB Hospital, Bangladesh. Seventeen women who had undergone IC between February 2012 and March 2016: 14 women previously had irreparable obstetric fistulas and three had bladder exstrophy. Demographic, obstetric, IC-related, stigma and discrimination information were collected by questionnaire. Univariate analysis was done using the two-sided t-test for comparison of differences before and after IC surgery. Change in stigma and discrimination scores. Health-related QOL assessed using the 36-item Short Form Health Survey. Of the 17 women, 14 (82.3%) felt they were cured of their fistula disease. Three complained of occasional leakage due to insufficient seal of the bag, mainly at night, and all but one experienced no limits to their daily activities. Stigma and discrimination scores were significantly lower after having the IC surgery. The mean difference from when the woman had a fistula to when she had an IC for stigma score was 3.17 (1.12-4.16, P < 0.001), and for discrimination score was 3 (1.9-4.1, P < 0.001). Overall, there has been improved QOL following IC among the women in this study and all would recommend IC to women in the same situation. They remain chronic patients with some physical symptoms, but are well re-integrated back into their communities. Improved QOL following ileal conduit in women with persistent fistula related disorder in Bangladesh.

Radical cystectomy for bladder cancer: сomparison of early surgical complications during laparoscopic, open-access, and video-assisted surgery

Objectives. To evaluate peri- and postoperative morbidity and functional results of LRC in a single-site cohort of patients, comparing it with standard open approach (ORC) and laparoscopic cystectomy with open urinary diversion (HALRC). Subjects and methods. A prospective analysis was performed in 51 muscle-invasive and locally advanced BCa patients who underwent RC between February 2012 and March 2014 in N. N. Petrov Research Institute of Oncology, Saint-Petersburg. The final cohort included 21 ORC, 21 LRC and 9 HALRC patients. Mean patients age was 64 (38–81) years old and did not differ in all groups. Pathological stage were similar in all groups. Multivariable logistic and median regression was performed to evaluate operating time, perioperative and postoperative complications (30-d and 90-d), readmission rates, length of stay (LOS) – totally and in ICU. Results. Operating time during LRC and HALRC was longer than that of ORC (398 min vs 468 min vs 243 min, respectively). Despite that, there was no statistically significant influence of type of surgery on intraoperative complications – 14.3 % in ORC group, 11.1 % in HALRC and 4.7 % in LRC patients. Major complication rates (Clavien grade  3; 23.8 % vs 33.3 % vs 19.4 %) were similar between all groups. However, LRC had 4,0 times lower rate of minor complications (Clavien grade 1–2) compared to ORC (4.7 % vs 19.0 %). LRC had a significantly shorter LOS (27.8 d vs 32.6 d vs 22.6 d in ORC, HALRC and LRC groups, respectively), but no significant differences in ICU stay existed (5.1 d vs 3.1 d vs 2.1 d). Morbidity were present by one patient in each group (medium rate 5,8 %). The common transfusion rate during and after surgical intervention was 19.6 % and was higher in ORC group (33.3 % vs 4.7 % in LRC); as well, intraoperative bleeding was lower in minimally invasive techniques – the average volume of blood loss was 285 ml in LRC and did not differ between HALRC and ORC groups – 468 and 577 ml, respectively. Depending on the timing of complications, there were 30-d complications in 19 patients (37,2 %) and 90-d in 27 (52,9 %). The greatest difference was observed between any grade gastrointectinal complications (foremost, ileus) with significantly better outcomes in LRC patients – 14.2 %, compared with 47.6 % and 55 % in ORC and HALRC, respectively. Conclusions. We found that LRC is safe and associated with lower blood loss, decreased postoperative ileus and lower LOS compared with ORC. Using a population-based cohort, we found that laparoscopic surgery for bladder cancer decreased minor complications (mainly due to lower bleeding and gastrointestinal complication rate) and had no impact on major complications.

Research in length of stay, early complications and treatment cost in radical cystectomy patients with different Charlson Comorbidity Index score

Objective To assess the length of stay, early complication and cost of treatment in radical cystectomy (RC) patients with different Charlson Comorbidity Index Score (CCI). Methods A prospective study of a total of 102 patients who underwent RC between March 2012 and August 2014 in Center for Research of Urology in Yunnan Province, China. They were divided into three groups: 69 cases in CCI=0 or 1 group, 19 cases in CCI=2 group, 14 cases in CCI≥3 group. Comorbidities were graded according to CCI, and each patient was followed-up for 3 months after RC. Length of stay, early complications and treatment cost were analyzed by statistics. Results A total of 102 patients were analyzed. There were obvious differences with respect to length of stay, early complication and cost of treatment comparing patients in each CCI group,H=20.722, 6.025, and 7.047,P 0.05. Conclusions Patients with different CCI showed difference in the length of stay, early complication and cost of treatment in RC patients with different CCI. CCI≥3 might help to identify patients at risk for early complications after RC, especially in the orthotopic urinary diversion operation. Patients' complication should be evaluated standardized before operation and these should be included in patients' consideration. Key words: Cystectomy; Length of stay; Comorbidity; Early complication; Cost of treatment

Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial

BackgroundOpen radical cystectomy (ORC) and urinary diversion in patients with bladder cancer (BCa) are associated with significant perioperative complication risk. ObjectiveTo compare perioperative complications between robot-assisted radical cystectomy (RARC) and ORC techniques. Design, setting, and participantsA prospective randomized controlled trial was conducted during 2010 and 2013 in BCa patients scheduled for definitive treatment by radical cystectomy (RC), pelvic lymph node dissection (PLND), and urinary diversion. Patients were randomized to ORC/PLND or RARC/PLND, both with open urinary diversion. Patients were followed for 90 d postoperatively. InterventionStandard ORC or RARC with PLND; all urinary diversions were performed via an open approach. Outcome measurements and statistical analysisPrimary outcomes were overall 90-d grade 2–5 complications defined by a modified Clavien system. Secondary outcomes included comparison of high-grade complications, estimated blood loss, operative time, pathologic outcomes, 3- and 6-mo patient-reported quality-of-life (QOL) outcomes, and total operative room and inpatient costs. Differences in binary outcomes were assessed with the chi-square test, with differences in continuous outcomes assessed by analysis of covariance with randomization group as covariate and, for QOL end points, baseline score. Results and limitationsThe trial enrolled 124 patients, of whom 118 were randomized and underwent RC/PLND. Sixty were randomized to RARC and 58 to ORC. At 90 d, grade 2–5 complications were observed in 62% and 66% of RARC and ORC patients, respectively (95% confidence interval for difference, −21% to −13%; p=0.7). The similar rates of grade 2–5 complications at our mandated interim analysis met futility criteria; thus, early closure of the trial occurred. The RARC group had lower mean intraoperative blood loss (p=0.027) but significantly longer operative time than the ORC group (p<0.001). Pathologic variables including positive surgical margins and lymph node yields were similar. Mean hospital stay was 8 d in both arms (standard deviation, 3 and 5 d, respectively; p=0.5). Three- and 6-mo QOL outcomes were similar between arms. Cost analysis demonstrated an advantage to ORC compared with RARC. A limitation is the setting at a single high-volume, referral center; our findings may not be generalizable to all settings. ConclusionsThis trial failed to identify a large advantage for robot-assisted techniques over standard open surgery for patients undergoing RC/PLND and urinary diversion. Similar 90-d complication rates, hospital stay, pathologic outcomes, and 3- and 6-mo QOL outcomes were observed regardless of surgical technique. Patient summaryOf 118 patients with bladder cancer who underwent radical cystectomy, pelvic lymph node dissection, and urinary diversion, half were randomized to open surgery and half to robot-assisted laparoscopic surgery. We compared the rate of complications within 90 d after surgery for the open group versus the robotic group and found no significant difference between the two groups. Trial RegistrationClinicalTrials.gov identifier NCT01076387, www.clinicaltrials.gov.