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.

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.

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.

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.

In vitro comparison of changes in effective patient weight between purely laparoscopic and hand-assisted laparoscopic surgery.

BACKGROUND AND PURPOSE: Subclinical rhabdomyolysis (RM) has been reported to occur at a high frequency in patients who are undergoing hand-assisted laparoscopic (HAL) surgery. Compressive forces of the surgeon's hand pushing the patient down onto the operating table may increase the patient's effective weight, a factor that is correlated with risk of RM. The purpose of this study was to evaluate the changes in effective patient weight during pure laparoscopic (PL) and HAL surgery. MATERIALS AND METHODS: Using an in vitro model, 10 subjects performed translocation and knot tying tasks with both PL and HAL techniques. Changes in weight were monitored using a dynamic industrial scale with real-time digital recording. The means of the average changes in effective weight during the different tasks were compared using the Wilcoxon signed rank test with a P value of <0.05 considered significant. RESULTS: The mean of the average weight increases during translocation was 2.99 kg with HAL compared with 0.06 kg with PL (Z=4.3, P<0.05). The mean average weight increase during knot tying was 1.28 kg in HAL compared with 0.02 kg (Z=2.6, P<0.05) in PL. The mean maximum weight increase was 8.70 kg and 8.01 kg in HAL compared with 0.43 kg and 0.59 kg in PL during translocation and knot tying tasks, respectively (P<0.05 for each). CONCLUSIONS: HAL surgery results in a significant increase in effective patient weight compared with PL surgery. This increased effective weight during HAL surgery may increase the risk for subsequent RM.