Indiana Pouch Continent Cutaneous Urinary Diversion After Robotic-assisted Radical Cystectomy: A 16-Year Experience.

BACKGROUND: Population-based practice patterns in the United States reveal continent diversions are only performed in 8%-10.4% of patients.1-4 Ideally, for patients undergoing radical cystectomy the choice of urinary diversion should be influenced by clinical factors and patient preference, with discussions surrounding quality of life. Unfortunately, receipt of continent diversion has been shown to be influenced by a plethora of other factors such as surgeon preference/training, geography, socioeconomic status, gender, and hospital volume.1-3 Thus, by providing detailed instruction and long-term follow-up, we hope to mitigate some of these disparities by changing the perceptions regarding feasibility and complications of continent diversions. OBJECTIVE: To provide step-by-step instruction and to report long-term clinical outcomes in bladder cancer patients receiving an Indiana pouch continent cutaneous urinary diversion (CCUD) after robot-assisted radical cystectomy. DESIGN, SETTING, AND PARTICIPANTS: After Institutional Review Board approval, a prospectively maintained bladder cancer database was queried for patients with T1-T4, N0-N1, M0 bladder cancer undergoing radical cystectomy with CCUD at a tertiary referral center from 2004 to 2020. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Complications at 30- and 90-day were recorded according to the Clavien-Dindo classification. Continence rates were recorded by chart review. RESULTS AND LIMITATIONS: A total of 97 patients were included with a median follow-up of 93months. Clinically, 91.8% had ≤T2 disease and 29.9% received neoadjuvant chemotherapy. The median length of surgery was 8.0 hours, length of hospital stay was 8.3days, and urinary continence rate was 99.0%. The overall complication rate was 73.2% and 76.5% at 30- and 90-day, respectively. The major complication rate (Clavien III-V) was 17.5% at 30-day and 22.7% at 90-day. The most common major complications were abdominal infection and uretero-colonic stricture. The readmission rate was 21.4% and median overall survival was 108months. CONCLUSION: CCUD provides exceptional functional outcomes with acceptable complication rates compared to other diversion types. CCUD is a reliable reconstructive option and with this step-by-step video as a reference, we hope it will be offered to more patients.

Gemcitabine and cisplatin plus nivolumab as organ-sparing treatment for muscle-invasive bladder cancer: a phase 2 trial.

Cystectomy is a standard treatment for muscle-invasive bladder cancer (MIBC), but it is life-altering. We initiated a phase 2 study in which patients with MIBC received four cycles of gemcitabine, cisplatin, plus nivolumab followed by clinical restaging. Patients achieving a clinical complete response (cCR) could proceed without cystectomy. The co-primary objectives were to assess the cCR rate and the positive predictive value of cCR for a composite outcome: 2-year metastasis-free survival in patients forgoing immediate cystectomy or

Novel Antibiotic-Irrigating Wound Protector Reduces Infectious Complications in Robot-Assisted Radical Cystectomy with Extracorporeal Urinary Diversion.

OBJECTIVE: To determine whether use of an antibiotic-irrigating wound protector (AWP) reduces infectious complications after robotic radical cystectomy with extracorporeal urinary diversion (RCUD). METHODS: A prospectively maintained bladder cancer database was queried for patients undergoing robotic RCUD at a tertiary referral center one year prior to implementing an AWP and one year after (2018-2020). All diversions were performed extra-corporally. 92 patients total. 46 consecutive patients using a traditional wound protector (TWP) and 46 consecutive with an AWP. Infections were classified as symptomatic urinary tract infection, blood stream infection, and surgical site infection. The incidence of infectious complications at 30- and 90-days were compared. RESULTS: Baseline patient characteristics between the 2 groups showed no statistically significant differences. The overall complication rate was 65.2% in the TWP group and 26.1% in the AWP group at 30-days, and 67.4% vs 30.4% at 90-days. Focusing on infections, the 30-day complication rate was 30.4% in the TWP group compared to 6.5% in the AWP group (P =.003). This pattern persisted at 90-days with 37.0% in the TWP group compared to 6.5% in the AWP group (P =.004). Most complications were symptomatic UTI and blood stream infections, 14/24 (58%), requiring parenteral antibiotic treatment. CONCLUSION: We provide preliminary data showing use of an AWP can reduce infectious complications after RCUD. While larger prospective studies are warranted, our findings are a significant step towards decreasing morbidity of an already highly morbid procedure.

Transurethral Incision with Transverse Mucosal Realignment for the Management of Bladder Neck Contracture and Vesicourethral Anastomotic Stenosis.

OBJECTIVE: To assess efficacy and safety of a novel cystoscopic technique for definitive repair of bladder neck contracture (BNC) and vesicourethral anastomotic stenosis (VUAS). METHODS: A retrospective review of patients who underwent a transurethral incision with transverse mucosal realignment between July 2019 and December 2020 by a single surgeon was completed. This is novel procedure of incising a scar cystoscopically and using a laparoscopic suturing device transurethrally to bring healthy bladder mucosa across the defect, like a YV plasty. Patients were only included if they had ≥4 months follow-up. Surgical success was defined as ability to pass a 17 French flexible cystoscope through the previously stenotic segment at 4 month follow up. RESULTS: Nineteen patients with a median follow-up of 6 months were included in this analysis. Etiology of posterior urethral stenosis was 53% from VUAS and 47% from BNC, with 32% of patients having prior pelvic radiation. Success was achieved in 89% of patients after 1 procedure and 100% of patients achieved success after a second procedure. There was no de novo incontinence or major complications. CONCLUSION: Transurethral incision with transverse mucosal realignment  for VUAS and BNC has a high success rate after only 1 procedure. This is the first reported series of an endoscopic Y-V plasty type repair for BNC and VUAS. Longer term follow up to ensure durability and reporting from other institutions will be needed to establish reproducibility.

Continent cutaneous ileocecal cystoplasty in the treatment of refractory bladder neck contracture and urinary incontinence after prostate cancer treatment.

INTRODUCTION: To assess the use, complications, and outcomes of continent cutaneous ileocecal cystoplasty (CCIC) for the management of refractory bladder neck contractures and/or urinary incontinence after prostate cancer therapy. MATERIALS AND METHODS: An institutional review board approved database was reviewed for patients who underwent CCIC from January 1, 2003 to December 31, 2018. Preoperative, perioperative and postoperative factors were assessed, including complications and outcomes. RESULTS: Thirteen patients were identified. Indications for CCIC included refractory bladder neck contracture (n = 3), urinary incontinence (n = 5), or both (n = 5). Median age was 69. Median follow up was 78.1 months. Seventy-seven percent of patients (10/13) had a history of radiation. The median number of procedures between initial prostate treatment and augmentation was 3. Sixty-nine percent (9/13) of patients had a bladder neck closure along with augmentation (5 transabdominal and 4 transperineal). Median operative time was 375 minutes. Median blood loss was 175 mL. The overall complication rate was 69% (9/13), with 38% (5/13) occurring within 30 days. One patient (8%) required stomal revision. Thirty-three percent (3/9) of patients with bladder neck closure required revision due to perineal fistula. All had a history of radiation therapy. At last follow up all patients were satisfied with their urinary control. Eighty-five percent of patients (11/13) were fully continent via both urethra and stoma. One patient had urethral leakage with bladder spasms controlled with medication and one had mild stomal incontinence. CONCLUSIONS: CCIC is an effective means of treating refractory bladder neck contractures and/or urinary incontinence. While morbidity rates are high, subjective patient satisfaction is high.

Real-time indocyanine green angiography with the SPY fluorescence imaging platform decreases benign ureteroenteric strictures in urinary diversions performed during radical cystectomy.

BACKGROUND: Ischemia is thought to contribute to benign ureteroenteric stricture (UES) after radical cystectomy with urinary diversion (RCUD). Our institution adopted the use of ureteral perfusion assessment during all RCUDs using real-time indocyanine green angiography using the SPY fluorescence imaging platform (Stryker Corp., Kalamazoo, MI, USA). This guides the location of ureteral transection prior to ureteroenteric anastomosis. We sought to compare UES rates before and after adoption of SPY. METHODS: A retrospective chart review was undertaken for the first 47 consecutive cases of RCUD using SPY as well as the previous 47 consecutive cases, which were performed without SPY. Fisher's exact and Wilcoxon rank-sum tests were used to compare benign UES rates and the length of ureter excised during anastomosis. A p < 0.05 indicated statistical significance. RESULTS: Median follow up was 12.0 months for SPY cases and 24.3 months for non-SPY cases. The UES rate for SPY RCUDs was 0% (0/93 ureters) compared with 7.5% (7/93 ureters) for non-SPY RCUDs (p = 0.01). Amongst SPY RCUDs, 86 ureters had no hydronephrosis and 7 had mild hydronephrosis with reflux on loopogram. A total of 34.4% of ureters (32/93) had poor distal perfusion, requiring a more proximal anastomosis. The median length excised for ureters with poor distal perfusion was 3.8 cm, compared with 2.2 cm for ureters with good distal perfusion (p < 0.0001). No complications attributable to the use of SPY were noted. CONCLUSION: Use of SPY to assess ureteral perfusion was associated with a decrease in the UES rate after RCUD. A total of 34.4% of ureters demonstrated poor distal perfusion, requiring a significantly more proximal ureteroenteric anastomosis.

Enhanced Recovery After Surgery for Radical Cystectomy.

Even with advances in perioperative medical care, anesthetic management, and surgical techniques, radical cystectomy (RC) continues to be associated with a high morbidity rate as well as a prolonged length of hospital stay. In recent years, there has been great interest in identifying multimodal and interdisciplinary strategies that help accelerate postoperative convalescence by reducing variation in perioperative care of patients undergoing complex surgeries. Enhanced recovery after surgery (ERAS) attempts to evaluate and incorporate scientific evidence for modifying as many of the factors contributing to the morbidity of RC as possible, and optimize how patients are cared for before and after surgery. In this chapter, we review the preoperative, intraoperative and postoperative elements of using an ERAS protocol for RC.

Direct inversion algorithm for focal plane scanning optical projection tomography.

To achieve approximately parallel projection geometry, traditional optical projection tomography (OPT) requires the use of low numerical aperture (NA) objectives, which have a long depth-of-field at the expense of poor lateral resolution. Particularly promising methods to improve spatial resolution include ad-hoc post-processing filters that limit the effect of the system's MTF and focal-plane-scanning OPT (FPS-OPT), an alternative acquisition procedure that allows the use of higher NA objectives by limiting the effect of their shallow depth of field yet still assumes parallel projection rays during reconstruction. Here, we provide a detailed derivation that establishes the existence of a direct inversion formula for FPS-OPT. Based on this formula, we propose a point spread function-aware algorithm that is similar in form and complexity to traditional filtered backprojection (FBP). With simulations, we demonstrate that our point-spread-function aware FBP for FPS-OPT leads to more accurate images than both traditional OPT with deconvolution and FPS-OPT with naive FBP reconstruction. We further illustrate the technique on experimental zebrafish data, which shows that our approach reduces out-of-focus blur compared to a direct FBP reconstruction with FPS-OPT.

Ureteroenteric anastomotic revision as initial management of stricture after urinary diversion.

OBJECTIVE: To report our experience with ureteroenteric anastomotic revision as initial treatment of stricture after urinary diversion. METHODS: An institutional review board-approved retrospective study was carried out. A total of 41 patients who underwent primary ureteroenteric anastamotic revision were identified between 2007 and 2015. Data analyzed included patient characteristics, type of diversion, estimated blood loss, operative time, change in renal function, length of stay, postoperative complications and time with nephrostomy/stent. Success of revision was defined as an improvement in hydronephrosis on radiographic imaging and/or reflux during pouchogram. Predictors of length of stay and complications were analyzed using analysis of covariance. RESULTS: A total of 50 renal units were revised with a success rate of 100%. The median length of stay was 6 days (2-16 days). There were a total of 15 complications (one major, 14 minor) in 14 patients (33% 30-day complication rate). The most common were wound infection (n = 4) and arrhythmia (n = 4). Robotic revision (n = 5) had a median length of stay of 3 days (2-4) with no complications. CONCLUSIONS: Primary ureteroenteric anastomotic revisions have an excellent success rate at an experienced center and might obviate the need for multiple interventions. Open revision is associated with mostly minor complications. Robotic revision might reduce the morbidity of open revision in select cases.

Penile inversion through a penoscrotal incision for the treatment of penile urethral strictures.

PURPOSE: This article describes a novel technique for the repair of penile urethral strictures and establishes the safety, feasibility, and efficacy of this innovative surgical approach. MATERIALS AND METHODS: Patients with urethral strictures underwent a one-sided anterior dorsal oral mucosal graft urethroplasty through a penoscrotal inversion technique. The clinical outcome was considered a failure when any instrumentation was needed postoperatively, including dilatation. RESULTS: Five patients underwent the novel procedure. The patients' mean age was 58 years. The cause of stricture was instrumentation in 2 cases (40%), lichen sclerosis in 1 case (20%), and failed hypospadias repair in 2 cases (40%). The mean stricture length was 3 cm. The overall mean (range) follow-up was 6 months (range, 3-9 months). Of the 5 patients, 4 (80%) had a successful outcome and 1 (20%) had a failed outcome. The failure was successfully treated by use of a meatotomy. CONCLUSIONS: The penile inversion technique through a penoscrotal incision is a viable option for the management of penile urethral strictures with several advantages to other techniques: namely, no penile skin incision, a single-stage operation, and supine positioning.

Best practices in robot-assisted radical cystectomy and urinary reconstruction: recommendations of the Pasadena Consensus Panel.

CONTEXT: Robot-assisted surgery is increasingly used for radical cystectomy (RC) and urinary reconstruction. Sufficient data have accumulated to allow evidence-based consensus on key issues such as perioperative management, comparative effectiveness on surgical complications, and oncologic short- to midterm outcomes. OBJECTIVE: A 2-d conference of experts on RC and urinary reconstruction was organized in Pasadena, California, and the City of Hope Cancer Center in Duarte, California, to systematically review existing peer-reviewed literature on robot-assisted RC (RARC), extended lymphadenectomy, and urinary reconstruction. No commercial support was obtained for the conference. EVIDENCE ACQUISITION: A systematic review of the literature was performed in agreement with the PRISMA statement. EVIDENCE SYNTHESIS: Systematic literature reviews and individual presentations were discussed, and consensus on all key issues was obtained. Most operative, intermediate-term oncologic, functional, and complication outcomes are similar between open RC (ORC) and RARC. RARC consistently results in less blood loss and a reduced need for transfusion during surgery. RARC generally requires longer operative time than ORC, particularly with intracorporeal reconstruction. Robotic assistance provides ergonomic value for surgeons. Surgeon experience and institutional volume strongly predict favorable outcomes for either open or robotic techniques. CONCLUSIONS: RARC appears to be similar to ORC in terms of operative, pathologic, intermediate-term oncologic, complication, and most functional outcomes. RARC consistently results in less blood loss and a reduced need for transfusion during surgery. RARC can be more expensive than ORC, although high procedural volume may attenuate this difference. PATIENT SUMMARY: Robot-assisted radical cystectomy (RARC) is an alternative to open surgery for patients with bladder cancer who require removal of their bladder and reconstruction of their urinary tract. RARC appears to be similar to open surgery for most important outcomes such as the rate of complications and intermediate-term cancer-specific survival. Although RARC has some ergonomic advantages for surgeons and may result in less blood loss during surgery, it is more time consuming and may be more expensive than open surgery.

Robot-assisted radical cystectomy and urinary diversion: technical recommendations from the Pasadena Consensus Panel.

BACKGROUND: The technique of robot-assisted radical cystectomy (RARC) has evolved significantly since its inception >10 yr ago. Several high-volume centers have reported standardized techniques with refinements and subsequent outcomes. OBJECTIVE: To review all existing literature on RARC and urinary diversion techniques and summarize key points that may affect oncologic, surgical, and functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: The Pasadena Consensus Panel on RARC and urinary reconstruction convened May 3-4, 2014, to review the existing peer-reviewed literature and create recommendations for best practice. The panel consisted of experts in open radical cystectomy and RARC. No commercial support was received. SURGICAL PROCEDURE: The consensus panel extensively reviewed the surgical technique of RARC in men and women, extended pelvic lymph node dissection, extracorporeal urinary diversion, and intracorporeal urinary diversion. Critical aspects of the technique are described. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Preoperative, operative, and postoperative parameters from the largest and most contemporary RARC series, stratified by urinary diversion technique, are presented. RESULTS AND LIMITATIONS: Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery. CONCLUSIONS: Refinement of techniques for RARC and urinary diversion over the past 10 yr has made it safe, reproducible, and oncologically sound. PATIENT SUMMARY: We summarize the critical aspects of surgical techniques reviewed at the Pasadena international consensus meeting on RARC and urinary reconstruction. Preoperative, operative, and postoperative measures of RARC technique adhere closely to the standards established in open surgery.

The effect of nerve-sparing robot-assisted radical cystoprostatectomy on erectile function in a preoperatively potent population.

OBJECTIVE: To evaluate the effects on the potency of a bilateral cavernosal nerve-sparing approach to robot-assisted radical cystectomy (RARC) in a preoperatively potent population. PATIENTS AND METHODS: We conducted a retrospective review of 254 patients who underwent RARC between 2003 and 2012 at our single institution. We identified 33 men who were younger than 65 years and had evidence of preoperative erections on chart review. Twenty-nine of them underwent a bilateral nerve-sparing procedure, with 28 (97%) having concomitant creation of a continent urinary diversion. RESULTS: Median follow-up was 32.9 months. Postoperatively, 13 (45%) patients had documented erections sufficient for penetration with or without the use of phosphodiesterase 5 inhibitors. Additional 6 (21%) were potent with intracavernosal injections (ICI), and the remaining 10 (34%) failed ICI usage, had on-going medical issues, or lost interest in sexual activity. With univariate analysis, no significant difference was found between those who recovered erections and those who did not on a wide range of demographic, operative, and perioperative factors, including age, comorbidities, operative time, or pathologic stage. Despite neurovascular bundle preservation, there was no local cancer recurrence and no positive soft tissue margins. CONCLUSION: A cavernosal nerve-sparing robot-assisted approach to radical cystectomy allows for recovery of potency without sacrificing oncologic outcomes even with higher risk disease as compared to historical open or laparoscopic series. Further studies are required to help elucidate why some men have better recovery in this setting than others.

Intermediate-term oncologic outcomes of robot-assisted radical cystectomy for urothelial carcinoma.

PURPOSE: To evaluate intermediate-term oncologic outcomes in a large series of patients who were treated with robot-assisted radical cystectomy (RARC) for urothelial carcinoma of the bladder (UCB). PATIENTS AND METHODS: Between 2004 and 2010, 162 patients underwent RARC at City of Hope Cancer Center for UCB and were analyzed with respect to overall (OS), disease-specific (DSS), and disease-free survival (DFS). Descriptive statistics were used to summarize demographics and perioperative variables. The Kaplan-Meier method was used to estimate survival and recurrence. Univariable and multivariable Cox proportional hazards regression models were used to determine predictors of survival. RESULTS: Median follow-up was 52 months. Thirty-eight (23.4%) patients received neoadjuvant chemotherapy before RARC; 28% of patients were pT2 and 33% had final pathology status of pT3 or pT4. Median lymph node count was 28, and positive surgical margin rate was 4.3%. Local recurrence occurred in 11 (6.8%) patients. OS, DFS, and DSS at 3 years were 61%, 76%, and 83%, respectively. OS, DFS, and DSS at 5 years were 54%, 74%, and 80%, respectively. Predictors of OS and DFS on multivariable analysis were lymph node density, pathologic stage, and age-adjusted Charlson Comorbidity Index, while receipt of transfusion was also a negative predictor of OS. CONCLUSIONS: RARC provides an effective means of treatment of UCB in a minimally invasive fashion with comparable oncologic outcomes to that reported in the literature of open procedures.

Early and late complications of robot-assisted radical cystectomy: a standardized analysis by urinary diversion type.

PURPOSE: Minimally invasive surgical treatment for bladder cancer has gained popularity but standardized data on complications are lacking. Urinary diversion type contributes to complications and to our knowledge diversion types after minimally invasive cystectomy have not yet been compared. We evaluated perioperative complications stratified by urinary diversion type in patients treated with robot-assisted radical cystectomy. MATERIALS AND METHODS: We analyzed the records of 209 consecutive patients who underwent robot-assisted radical cystectomy at our institution from 2003 to 2012 with respect to perioperative complications, including severity, time period (early and late) and diversion type. All complications were reviewed by academic urologists. Urinary diversion was also done. As outcome measurements and statistical analysis, univariate and multivariate logistic regression models were used to determine predictors of various complications. RESULTS: The American Society of Anesthesiologists(®) (ASA) score was 3 or greater in 80% of patients and continent diversion was performed in 68%. Median followup was 35 months. Within 90 days 77.5% of patients experienced any complication and 32% experienced a major complication. The 90-day mortality rate was 5.3%. Most complications were gastrointestinal, infectious and hematological. On multivariate analysis patients with ileal conduit diversion had a decreased likelihood of complications compared to patients with Indiana pouch and orthotopic bladder substitute diversion despite the selection of a more comorbid population for conduit diversion. Continent diversion was associated with a higher likelihood of urinary tract infection. Our results are comparable to those of previously reported open and minimally invasive cystectomy series. CONCLUSIONS: Open or minimally invasive cystectomy is a complex, morbid procedure. Urinary diversion is a significant contributor to complications, as is patient comorbidity. Although patients with an ileal conduit had more comorbidities, they experienced fewer complications than those with an orthotopic bladder substitute or Indiana pouch diversion.

Standardized analysis of frequency and severity of complications after robot-assisted radical cystectomy.

BACKGROUND: Comprehensive and standardized reporting of adverse events after robot-assisted radical cystectomy (RARC) and urinary diversion for bladder cancer is necessary to evaluate the magnitude of morbidity for this complex operation. OBJECTIVE: To accurately identify and assess postoperative morbidity after RARC using a standardized reporting system. DESIGN, SETTING, AND PARTICIPANTS: A total of 241 consecutive patients underwent RARC, extended pelvic lymph node dissection, and urinary diversion between 2003 and 2011. In all, 196 patients consented to a prospective database, and they are the subject of this report. Continent diversions were performed in 68% of cases. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: All complications within 90 d of surgery were defined and categorized by a five-grade and 10-domain modification of the Clavien system. Univariable and multivariable logistic regression analyses were used to identify predictors of complications. Grade 1-2 complications were categorized as minor, and grade 3-5 complications were categorized as major. All blood transfusions were recorded as grade ≥2. RESULTS AND LIMITATIONS: Eighty percent of patients (156 of 196 patients) experienced a complication of any grade ≤90 d after surgery. A total of 475 adverse events (113 major) were recorded, with 365 adverse events (77%) occurring ≤30 d after surgery. Sixty-eight patients (35%) experienced a major complication within the first 90 d. Other than blood transfusions given (86 patients [43.9%]), infectious, gastrointestinal, and procedural complications were the most common, at 16.2%, 14.1%, and 10.3%, respectively. Age, comorbidity, preoperative hematocrit, estimated blood loss, and length of surgery were predictive of a complication of any grade, while comorbidity, preoperative hematocrit, and orthotopic diversion were predictive of major complications. The 90-d mortality rate was 4.1%. The main limitation is lack of a control group. CONCLUSIONS: Analysis of postoperative morbidity following RARC demonstrates a considerable complication rate, though the rate is comparable to contemporary open series that followed similar reporting guidelines. This finding reinforces the need for complete and standardized reporting when evaluating surgical techniques and comparing published series.

Functional outcomes and complications in patients with bladder cancer undergoing robotic-assisted radical cystectomy with extracorporeal Indiana pouch continent cutaneous urinary diversion.

OBJECTIVE: To evaluate the functional outcomes and complications for patients with bladder cancer undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion. METHODS: From February 2004 to March 2010, 34 patients underwent robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction. After surgery, the complications were identified, categorized, and graded using an established 5-grade modification of the original Clavien grading system, and continence was assessed. Descriptive statistics were used in evaluating the outcomes. Fischer's exact test was used in the comparison of early and late Clavien grade III complications. RESULTS: Overall, 175 (123 early and 52 late) complications after surgery were reported in 32 (94%) of 34 patients. Within 90 days of surgery, 31 (91%) of 34 patients experienced ≥ 1 early complication. Of 34 patients, 15 (44%) reported ≥ 1 late complications (>90 days). Most (85% and 69%, respectively) early and late complications were graded as minor (grade II or less). Fewer patients with early complications required an additional intervention (grade III) compared with patients with late complications (14% vs 31%; P = .116). The most common complication in both intervals was infection, reported in 22% and 37% of patients with early and late complications, respectively. The continence data for 31 patients at a mean follow-up of 20.1 months (median 12.0) showed that all but 1 patient (97%) had daytime and nighttime continence. CONCLUSION: Patients undergoing robotic-assisted laparoscopic radical cystectomy with Indiana pouch continent cutaneous urinary diversion reconstruction have comparable complication rates and functional outcomes compared with patients in the open series.

Robotic-assisted laparoscopic radical cystectomy in the octogenarian.

BACKGROUND: The advanced age and comorbidities often associated with bladder cancer patients creates a difficult scenario regarding further management. Robotic-assisted laparoscopic radical cystectomy (RALRC) has had favorable results as a minimally invasive treatment option. We studied perioperative outcomes of RALRC in octogenarians to discern if there is any added benefit in this patient population. METHODS: One hundred and sixty robotic cystectomies have been performed between October 2003 and June 2010. We identified 24 octogenarians who underwent RALRC and form the cohort of the study. RESULTS: Mean patient age was 84.7 years and mean BMI was 24 kg/m². Most of the patients in the study had serious medical comorbidities, as 82.6% of them had an ASA classification ≥ 3 and 95.6% had Charlson scores ≥ 3. There was one open conversion and two patients had positive surgical margins. There were a total of 45 complications in the study, with 14 major complications observed in the 90-day period after surgery. There were five patients who had no complications, and two patients expired as a result of multiple organ failure. At 24 months the overall, disease-free and disease-specific survivals were 51.1%, 64.3%, and 79%, respectively. The 90-day mortality rate was 8.7%. CONCLUSIONS: Octogenarians undergoing RALRC have a significant risk of morbidity and mortality. The relationship between advanced age and oncologic outcomes or complications needs to be discerned further as it relates to the octogenarian. Further study is needed to delineate the safety and efficacy of this approach.