Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer: A Randomized Clinical Trial.

Importance: Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with open radical cystectomy for bladder cancer. Objectives: To compare recovery and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction vs open radical cystectomy. Design, Setting, and Participants: Randomized clinical trial of patients with nonmetastatic bladder cancer recruited at 9 sites in the UK, from March 2017-March 2020. Follow-up was conducted at 90 days, 6 months, and 12 months, with final follow-up on September 23, 2021. Interventions: Participants were randomized to receive robot-assisted radical cystectomy with intracorporeal reconstruction (n = 169) or open radical cystectomy (n = 169). Main Outcomes and Measures: The primary outcome was the number of days alive and out of the hospital within 90 days of surgery. There were 20 secondary outcomes, including complications, quality of life, disability, stamina, activity levels, and survival. Analyses were adjusted for the type of diversion and center. Results: Among 338 randomized participants, 317 underwent radical cystectomy (mean age, 69 years; 67 women [21%]; 107 [34%] received neoadjuvant chemotherapy; 282 [89%] underwent ileal conduit reconstruction); the primary outcome was analyzed in 305 (96%). The median number of days alive and out of the hospital within 90 days of surgery was 82 (IQR, 76-84) for patients undergoing robotic surgery vs 80 (IQR, 72-83) for open surgery (adjusted difference, 2.2 days [95% CI, 0.50-3.85]; P = .01). Thromboembolic complications (1.9% vs 8.3%; difference, -6.5% [95% CI, -11.4% to -1.4%]) and wound complications (5.6% vs 16.0%; difference, -11.7% [95% CI, -18.6% to -4.6%]) were less common with robotic surgery than open surgery. Participants undergoing open surgery reported worse quality of life vs robotic surgery at 5 weeks (difference in mean European Quality of Life 5-Dimension, 5-Level instrument scores, -0.07 [95% CI, -0.11 to -0.03]; P = .003) and greater disability at 5 weeks (difference in World Health Organization Disability Assessment Schedule 2.0 scores, 0.48 [95% CI, 0.15-0.73]; P = .003) and at 12 weeks (difference in WHODAS 2.0 scores, 0.38 [95% CI, 0.09-0.68]; P = .01); the differences were not significant after 12 weeks. There were no statistically significant differences in cancer recurrence (29/161 [18%] vs 25/156 [16%] after robotic and open surgery, respectively) and overall mortality (23/161 [14.3%] vs 23/156 [14.7%]), respectively) at median follow-up of 18.4 months (IQR, 12.8-21.1). Conclusions and Relevance: Among patients with nonmetastatic bladder cancer undergoing radical cystectomy, treatment with robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy resulted in a statistically significant increase in days alive and out of the hospital over 90 days. However, the clinical importance of these findings remains uncertain. Trial Registration: ISRCTN Identifier: ISRCTN13680280; ClinicalTrials.gov Identifier: NCT03049410.

Morbidity and mortality after robot-assisted radical cystectomy with intracorporeal urinary diversion in octogenarians: results from the European Association of Urology Robotic Urology Section Scientific Working Group.

OBJECTIVES: To evaluate the postoperative complication and mortality rate following laparoscopic radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in octogenarians. PATIENTS AND METHODS: We conducted a retrospective analysis comparing postoperative complication and mortality rates depending on age in a consecutive series of 1890 patients who underwent RARC with ICUD for bladder cancer between 2004 and 2018 in 10 European centres. Outcomes of patients aged <80 years and those aged ≥80 years were compared with regard to postoperative complications (Clavien-Dindo grading) and mortality rate. Cancer-specific mortality (CSM) and other-cause mortality (OCM) after surgery were calculated using the non-parametric Aalen-Johansen estimator. RESULTS: A total of 1726 patients aged <80 years and 164 aged ≥80 years were included in the analysis. The 30- and 90-day rate for high-grade (Clavien-Dindo grades III-V) complications were 15% and 21% for patients aged <80 years compared to 11% and 13% for patients aged ≥80 years (P = 0.2 and P = 0.03), respectively. In a multivariable logistic regression analysis adjusting for pre- and postoperative variables, age ≥80 years was not an independent predictor of high-grade complications (odds ratio 0.6, 95% confidence interval 0.3-1.1; P = 0.12). The non-cancer-related 90-day mortality was 2.3% for patients aged ≥80 years and 1.8% for those aged <80 years, respectively (P = 0.7). The estimated 12-month CSM and OCM rates for those aged <80 years were 8% and 3%, and for those aged ≥80 years, 15% and 8%, respectively (P = 0.009 and P < 0.001). CONCLUSIONS: The minimally invasive approach to RARC with ICUD for bladder cancer in well-selected elderly patients (aged ≥80 years) achieved a tolerable high-grade complication rate; the 90-day postoperative mortality rate was driven by cancer progression and the non-cancer-related rate was equivalent to that of patients aged <80 years. However, an increased OCM rate in this elderly group after the first year should be taken into account. These results will support clinicians and patients when balancing cancer-related vs treatment-related risks and benefits.

Open radical cystectomy in England: the current standard of care - an analysis of the British Association of Urological Surgeons (BAUS) cystectomy audit and Hospital Episodes Statistics (HES) data.

OBJECTIVE: To establish the current standard for open radical cystectomy (ORC) in England, as data entry by surgeons performing RC to the British Association of Urological Surgeons (BAUS) database was mandated in 2013 and combining this with Hospital Episodes Statistics (HES) data has allowed comprehensive outcome analysis for the first time. PATIENTS AND METHODS: All patients were included in this analysis if they were uploaded to the BAUS data registry and reported to have been performed in the 2 years between 1 January 2014 and 31 December 2015 in England (from mandate onwards) and had been documented as being performed in an open fashion (not laparoscopic, robot assisted or the technique field left blank). The HES data were accessed via the HES website. Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures version 4 (OPCS-4) Code M34 was searched during the same 2-year time frame (not including M34.4 for simple cystectomy or with additional minimal access codes Y75.1-9 documenting a laparoscopic or robotic approach was used) to assess data capture. RESULTS: A total of 2 537 ORCs were recorded in the BAUS registry and 3 043 in the HES data. This indicates a capture rate of 83.4% of all cases. The median operative time was 5 h, harvesting a median of 11-20 lymph nodes, with a median blood loss of 500-1 000 mL, and a transfusion rate of 21.8%. The median length of stay was 11 days, with a 30-day mortality rate of 1.58%. CONCLUSIONS: This is the largest, contemporary cohort of ORCs in England, encompassing >80% of all performed operations. We now know the current standard for ORC in England. This provides the basis for individual surgeons and units to compare their outcomes and a standard with which future techniques and modifications can be compared.

Comparison of 2-Year Oncological Outcome and Early Recurrence Patterns in Patients with Urothelial Bladder Carcinoma Treated with Open or Robot-Assisted Radical Cystectomy with an Extracorporeal Urinary Diversion.

BACKGROUND: Data on oncological follow-up after robotic-assisted radical cystectomy (RARC) have been reported only scarcely and individual studies have reported an increase in early recurrences and atypical recurrences. PATIENTS AND METHODS: Clinical data of 89 patients with RARC were compared to 59 patients with open radical cystectomy (ORC) at a single institution. Two-year cancer-specific (2y-CSS) and 2-year overall survival (2y-OS) related to histopathological tumor stage of RARC patients calculated by Kaplan-Meier method were compared to ORC patients using log-rank test. Early clinical recurrence rate (eCR, progression ≤6 months post-cystectomy) and metastatic pattern of both groups were compared by chi-square test. RESULTS: Median follow-up 32 months (RARC) and 47.5 months (ORC), both groups were balanced in baseline characteristics. For RARC pts, -2y-OS and CSS-free survival rates were 80 and 90%, for ORC pts 65 and 71% (all p > 0.05). Margin status was not significantly different. eCR was observed in 10 out of 89 (11%) RARC pts and in 7 out of 59 (12%) ORC pts (p = 0.9). No difference in atypical metastases was seen between groups. CONCLUSION: Two-year oncological outcomes of RARC patients are comparable to ORC patients without differences regarding ePR or metastatic pattern.

A prognostic model for survival after palliative urinary diversion for malignant ureteric obstruction: a prospective study of 208 patients.

OBJECTIVE: To identify factors associated with survival after palliative urinary diversion (UD) for patients with malignant ureteric obstruction (MUO) and create a risk-stratification model for treatment decisions. PATIENTS AND METHODS: We prospectively collected clinical and laboratory data for patients who underwent palliative UD by ureteric stenting or percutaneous nephrostomy (PCN) between 1 January 2009 and 1 November 2011 in two tertiary care university hospitals, with a minimum 6-month follow-up. Inclusion criteria were age >18 years and MUO confirmed by computed tomography, ultrasonography or magnetic resonance imaging. Factors related to poor prognosis were identified by Cox univariable and multivariable regression analyses, and a risk stratification model was created by Kaplan-Meier survival estimates at 1, 6 and 12 months, and log-rank tests. RESULTS: The median (range) survival was 144 (0-1084) days for the 208 patients included after UD (58 ureteric stenting, 150 PCN); 164 patients died, 44 (21.2%) during hospitalisation. Overall survival did not differ by UD type (P = 0.216). The number of events related to malignancy (≥4) and Eastern Cooperative Oncology Group (ECOG) index (≥2) were associated with short survival on multivariable analysis. These two risk factors were used to divide patients into three groups by survival type: favourable (no factors), intermediate (one factor) and unfavourable (two factors). The median survival at 1, 6, and 12 months was 94.4%, 57.3% and 44.9% in the favourable group; 78.0%, 36.3%, and 15.5% in the intermediate group; and 46.4%, 14.3%, and 7.1% in the unfavourable group (P < 0.001). CONCLUSIONS: Our stratification model may be useful to determine whether UD is indicated for patients with MUO.

Urinary diversion: tailored solutions for individual patients.

PURPOSE OF REVIEW: Various urinary diversions are at disposition for reconstructive surgery after cystectomy. The chosen diversion has a strong impact on patients' life regarding complications and quality of life. The purpose of this review is to summarize the current tendency to adapt surgical solutions to individual needs of the patient. RECENT FINDINGS: Tailored surgery requires that the surgeon has been trained in the handling of all gut segments. Only in this case can he react to anatomical variants, patient comorbidities and oncological circumstances, as well as to the prognosis and the social circumstances of the patient with a tailored diversion. Changing demography and ageing populations with increasing incidence of muscle invasive bladder cancer request new, less invasive methods of urinary diversions. There is little evidence as to which is the best urinary diversion due to a lack of well designed studies. SUMMARY: The ileum conduit is still the most used urinary diversion worldwide. However, there are multiple techniques available to us, which guarantee the safest solution in combination with the highest quality of life for the construction of tailored urinary diversion.

Impact of the use of bowel for urinary diversion on perioperative complications and 90-day mortality in patients aged 75 years or older.

OBJECTIVE: A potential strategy to decrease the high complication rate of radical cystectomy (RC) in the elderly is to avoid the use of bowel for urinary diversion. The aim of this study was to address this issue in a multicentre study of patients aged ≥ 75 years. PATIENTS AND METHODS: We performed a retrospective, multicentre study of a consecutive series of patients aged ≥ 75 years who underwent RC for muscle-invasive bladder cancer between 2006 and 2010. Medical, surgical and wound complications were graded according to the modified Clavien-Dindo classification. RESULTS: A total of 256 patients (68% men, mean age 79.6 years) were analysed. 204 (80%) patients received a urinary diversion with use of bowel and 52 (20%) a ureterocutaneostomy (UC). Patients with UC were older (82.0 vs. 78.9 years, p < 0.001) and had a higher ASA score (2.6 vs. 2.3, p = 0.007), while the mean Charlson score was lower (4.2 vs. 5.6, p < 0.001). Patients with UC had a shorter operating time (279 vs. 311 min, p = 0.002) and a shorter period in the intensive care unit (0.9 vs. 2.2 days). The overall rate of severe complications graded as Clavien III-V was significantly lower in the UC group (11.5%) as compared to patients receiving bowel for urinary diversion (25.0%) (p = 0.003). Severe (Clavien grade III-V) medical (3.9 vs. 10.3%) and surgical (2.1 vs. 14.1%) complications were all less frequent in the UC group. Inpatient, 30- and 90-day mortality was 5.8, 7.7 and 17.3% in the UC group as compared to 3.9, 5.9 and 6.9% in the bowel cohort, respectively. CONCLUSION: UC following RC is associated with a lower complication rate in geriatric patients. The constantly increasing cohort of geriatric, multimorbid patients requiring cystectomy might justify reconsideration of this form of diversion.

Incidence and risk factors of 30-day early and 90-day late morbidity and mortality of radical cystectomy during a 13-year follow-up: a comparative propensity-score matched analysis of complications between neobladder and ileal conduit.

OBJECTIVE: We report on the short and late morbidity and mortality of ileal conduit and neobladder after radical cystectomy with their associated risk factors. METHODS: We retrospectively collected data on 308 non-metastatic bladder cancer patients who underwent radical cystectomy with either ileal conduit or neobladder for a curative intent from January 1999 to December 2011. Post-operative morbidity and mortality of 30-day (early) and 90-day (late) complication with their risk factors were examined in association with different types of urinary diversion. A comparative analysis using propensity-score matching was performed with matching variables of age, sex, number of underlying diseases and pathologic T and N stages, lymph node dissection, operative time and time of surgical year for comparison of the early and late morbidities between ileal conduit and neobladder. RESULTS: During the median follow-up of 46.6 months, early and late morbidities were 29.5% (n=91) and 19.8% (n=61), and complication-related mortalities were 2.2 and 6.6%, respectively. The type of urinary diversion significantly affected only the late complications (early: neobladder 57 vs. ileal conduit 47, P=0.096; late: neobladder 67 vs. ileal conduit 37, P<0.001). However, after propensity-score matching, no significant differences in early and late morbidities were observed between neobladder and ileal conduit. For risk factors of morbidity, number of removed lymph node states and hypertension were independently significant for both early and late complications (P<0.05). CONCLUSIONS: The type of urinary diversion affected only late complication, however, results of the matching analysis showed no significant differences in early and late morbidities between neobladder and ileal conduit.

The role of mechanical bowel preparation before ileal urinary diversion: a systematic review and meta-analysis.

BACKGROUND: Although the use of mechanical bowel preparation (MBP) is still widely promoted as the dogma before patients undergo ileal urinary diversion, an increasing number of clinical trials have suggested that there is no benefit. Thus, we performed a meta-analysis to evaluate the efficacy of MBP in ileal urinary diversion surgery. METHODS: A literature search was performed in electronic databases, including PubMed, Embase, Science Citation Index Expanded as well as the Cochrane Library and the Cochrane Clinical Trials Registry, from 1966 to January 1, 2013. Clinical trials comparing outcomes of MBP versus no MBP for ileal urinary diversion surgery were included in the meta-analysis. Pooled odds ratios with 95% confidence intervals were calculated using the fixed- or random-effects models. RESULTS: In total, two randomized controlled trials and five cohort studies were included in this meta-analysis. The primary outcomes, such as bowel leak and bowel obstruction, showed no statistical difference between the two groups. Additionally, the overall mortality rate and death rate related to operation also manifested that MBP does not offer an advantage over the no MBP. CONCLUSION: This meta-analysis suggests that MBP does not reduce the incidence of perioperative complications in urinary diversion compared with no MBP. However, large randomized controlled clinical trials are needed to confirm this finding.

Fast track surgery to reduce short-term complications following radical cystectomy and intestinal urinary diversion with Vescica Ileale Padovana neobladder: proposal for a tailored enhanced recovery protocol and preliminary report from a pilot study.

OBJECTIVE: Different fast track programs for patients undergoing radical cystectomy (RC) can be found in the current literature. The aim of this work was to develop a new enhanced recovery protocol (ERP). PATIENTS AND METHODS: The ERP was designed after a structured literature review focusing on reduced bowel preparation, standardized feeding, postoperative nausea, vomiting and pain control. In order to test the ERP, a pilot observational prospective cohort study was planned, enrolling all patients consecutively undergoing RC and Vescica Ileale Padovana (VIP) neobladder. These patients were compared with a matched group of subjects who had undergone RC and VIP neobladder before implementation of the ERP. To achieve good comparability, a propensity score-matching was performed. The primary aim was to assess the ERP's feasibility; the secondary outcome measures were early morbidity and mortality. RESULTS AND LIMITATIONS: After an exhaustive literature search and a multidisciplinary consultation, an ERP was designed. Nine consecutive patients participated in the pilot study and were compared to 13 patients treated before implementation of the ERP. We did not find any statistically significant difference in terms of mortality rate (none died peri- or postoperatively in both groups). The complication rate, according to the modified Clavien classification, was significantly lower in the ERP group (22.22 vs. 84.61%, p < 0.004). The major limitations are the low number of patients enrolled to test the protocol and the lack of randomization for the comparative evaluations. CONCLUSION: The introduction of our ERP was proven to be feasible in the management of patients undergoing RC and intestinal urinary diversion with VIP neobladder. The postoperative course was enhanced by a significant reduction in both nasogastric tube insertion and parenteral nutrition support, with early postoperative feeding. All these findings were associated with no deleterious effect on morbidity or mortality, indeed there was a reduced occurrence of postoperative complication rates.

Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy.

OBJECTIVES: To examine postoperative complications in a contemporary series of patients after radical cystectomy using a standardized reporting system, and to identify readily available preoperative risk factors. METHODS: Using the modified Clavien-Dindo classification, we assessed the 90-day postoperative clinical course of 535 bladder cancer patients who underwent radical cystectomy and urinary diversion (ileal conduit n = 349, ileal neobladder n = 186) between June 2003 and February 2012 at a single institution. All Martin criteria for standardized reporting of complications were met. Uni- and multivariable analyses for prediction of complications were carried out; covariates included body mass index, Charlson Comorbidity Index, age, sex, American Society of Anesthesiologists Score, neoadjuvant chemotherapy, prior abdominal or pelvic surgery, localized tumor and urinary diversion type. RESULTS: The 90-day rates for overall (Clavien-Dindo classification I-V) and high-grade complications (Clavien-Dindo classification III-V), as well as mortality (Clavien-Dindo classification V), were 56.4, 18.7 and 3.9%, respectively. Infections (16.4%), bleeding (14.2%) and gastrointestinal complications (10.7%) were the most common adverse outcomes. Independent risk factors for overall complications were body mass index (odds ratio 1.08) and Charlson Comorbidity Index ≥3 (odds ratio 1.93). Risk factors for high-grade complications were Charlson Comorbidity Index ≥3 (odds ratio 1.86), American Society of Anesthesiologists Score ≥3 (odds ratio 1.92) and body mass index (odds ratio 1.07, all P < 0.03). CONCLUSIONS: Radical cystectomy is associated with significant morbidity; nevertheless, the majority of complications are minor. Charlson Comorbidity Index, American Society of Anesthesiologists Score and body mass index might help to identify patients at risk for high-grade complications after radical cystectomy.

Simple modification in Hautmann neobladder to carry out left ureteroileal anastmosis without mobilization of the ureter.

We describe a simple modification in Hautmann neobladder that involves an elongation of its left chimney to advance it through the pelvic mesocolon in order to reach the left ureter in its original place. This technique was carried out on 27 patients who had Hautmann pouch after radical cystectomy, and we reported the outcome and complications that occurred at the site of urteteroileal anastomosis in the first 3 years after surgery. The modification was applied easily without any perioperative complications that were related to this step in particular. During follow up of these cases, we lost three patients who died before the end of the third postoperative year. At a mean follow up of 41.3 ± 10.2 months, we have not detected any cases of stricture formation or ureteral recurrence at the sites of the ureteroileal anastmosis. There was only one patient who developed acute pyelonephritis (3.7%) as a result of reflux.

Radical cystectomy and orthotopic urinary diversion in male patients with pT4a urothelial bladder carcinoma: oncological outcomes.

The aim of the present study was to evaluate the oncological outcomes of radical cystectomy followed by orthotopic urinary diversion in male patients with urothelial bladder carcinoma involving prostatic stroma (pT4a). A total of 1964 patients with urothelial bladder carcinoma who underwent cystectomy between 1971 and 2008 were retrospectively analyzed. Among them, male patients with pT4aN0M0 disease at cystectomy and orthotopic urinary diversion were identified and included in the analysis. Exclusion criteria were perioperative mortality and primary urethrectomy. The outcomes were urethral recurrence, local recurrence, recurrence-free survival and overall survival. Univariate and log-rank statistics were used to examine associations between variables and outcome. A total of 33 patients (1.7%) entered the study with a median age of 71 years. Median follow up was 4.8 years (range 0.1-21 years). A total of two urethral recurrences (6%) occurred at a median of 2.4 years after cystectomy. No patient had local recurrence. The 5-year recurrence-free survival and overall survival was 56% ± 10% and 56% ± 9%, respectively. The probability of urethral and local recurrence after orthotopic diversion in pT4a urothelial bladder carcinoma patients is low. Thus, orthotopic urinary diversion appears to be oncologically safe in this patient population.

Gender-dependent cancer-specific survival following radical cystectomy.

OBJECTIVE: To assess the impact of detailed clinical and histopathological criteria on gender-dependent cancer-specific survival (CSS) in a large consecutive series of patients following radical cystectomy (RCE) for muscle-invasive bladder cancer (MIBC). PATIENTS AND METHODS: Between 1992 and 2007, 388 men and 133 women (25.5%) underwent RCE for MIBC. A prospectively maintained database was analysed retrospectively. Uni- and multivariable Cox-regression analyses calculated the impact of detailed clinical and histopathological criteria on CSS. Median follow-up was 59 months (2-162). RESULTS: Among clinical and histopathological parameters, only type of urinary diversion differed between men and women. In univariable analysis, CSS did not differ between genders. In multivariable Cox-regression analysis, advanced pT-stage (HR = 2.12; P < 0.001), lymphovascular invasion (LVI) (HR = 3.47; P < 0.001), time interval between diagnosis of MIBC and RCE exceeding 90 days (HR = 2.07; P < 0.001) and female gender (HR = 1.35; P = 0.048) were related to reduced CSS. In separate multivariable Cox-models for time period of surgery between 1992 an 1999 (HR = 1.52; P = 0.050), age ≤55 years (HR = 3.00; P = 0.022), presence of LVI (HR = 1.45; P = 0.031) and female gender were associated with independent reduced CSS. CONCLUSION: Established clinical and histopathological parameters do not differ significantly between both genders in the present series. Reduced CSS in women is present in historic cohorts possibly suggesting improvement in management over the last years. In particular, female gender has a significant negative impact on CSS in patients younger of age and with positive LVI status possibly suggesting different clinical phenotypes.

The role of exenterative surgery and urinary diversion in persistent or locally recurrent gynecological malignancy: complications and survival.

OBJECTIVE: Treatment options in patients with persistent or locally recurrent cervical cancer are limited. The aim of this study was to determine the chance of cure and associated morbidity following pelvic exenteration. PATIENTS AND METHODS: Consecutive patients who underwent pelvic exenteration between January 1992 and December 2006 at the University Hospital of Bern or the Karlsruhe Medical Center were evaluated. Time to recurrence, type of exenteration and urinary diversion, pathological stage, postoperative complications and survival were assessed. RESULTS: Initial therapy prior to diagnosis of persistent or locally recurrent disease included radiation therapy in 51%. Anterior exenteration was performed in 37 (86%) and total exenteration in 6 (14%). Half of the women underwent additional procedures. A continent urinary diversion was constructed in 16 and an ileal conduit in 27 patients. Early postoperative complications were generally minor and only 2 patients required surgical intervention. Four intestinal fistulas were successfully treated conservatively. Late complications were mainly tumor-related. Complication rates associated with the urinary diversion were low and there was no difference in complications between continent and incontinent diversions. The overall disease-specific 5-year survival rate after exenteration was 36.5%. Survival correlated significantly with surgical margin status. CONCLUSION: In patients with persistent or locally recurrent gynecological malignancy of the pelvis, exenteration is a viable option with long-term survival in over one third of patients. Continent urinary diversion did not show higher complication rates than an ileal conduit and should be considered even in irradiated patients. This may be of greater significance in younger patients in whom an intact body image can play an important role in quality of life.

Radical surgical treatment of the urinary bladder cancer in patients over the age of 60--our experiences.

The goal of the paper was the analysis of patients over the age of 60 suffering from the urinary bladder cancer that underwent radical surgical treatment of the urinary bladder and establishing urine derivation. In the 1972-2008 period 2405 patients with the urinary bladder cancer were treated, 296 (12.3%) of whom underwent radical surgical treatment. The average age was between 60 and 80 years--in 207 (70%) patients. In our patients there were 190 patients (91.6%) with transitional cell cancers. According to TNM classification, T3 stage in 92 (44.4%) patients and T2 stage in 85 (41%) patients were predominant in our study. According to histological criteria, the most common stage was G3 stage--in 151 (73%) patients. Radical cystectomy or combined with urethrectomy was performed in 178 (86%) patients. Unfortunately, in 12% of them (T3 and T4 stages) the inner iliac blood vessels were tied off due to a progressive cancer. The outer supravesical urine derivation (Bricker, U-tubing nephrostomy, and ureterocutaneostomy) was done in 163 (78.7%) patients. The inner derivation (Coffey, ureteroileosigmoidostomy, Mainz-Pouch II) was performed in 17 (8.2%) patients and neovesica (Hautmann, Studer) in 24 (11.5%)patients. There were 74 (35.7%) patients with early postoperative complications. Among them the most dominant were the surgical complications--in 28 (13.5%) patients and distant organ complications--in 22 (10.6%) patients. In 75 (36%)patients with negative nodes the survival rate was 55% after five years. In 73 (35%) patients with positive nodes the survival rate was 27% after five years.

Radical cystectomy for urothelial carcinoma of the bladder: an analysis of perioperative and survival outcome.

OBJECTIVE: To review the outcomes in a large group of patients treated with radical cystectomy (RC) for urothelial cancer (UC) of the bladder, by one surgical team. PATIENTS AND METHODS: In all, 504 patients had RC for UC of the bladder between 1992 and 2007; 432 met the inclusion criteria and were analysed for survival and disease recurrence. RESULTS: Of the 432 patients, (mean age 69 years; mean follow-up 38 months, range 1-172), 240 (56%) and 179 (41%) had an ileal conduit and orthotopic neobladder for urinary diversion, respectively. The mortality rate within 30 days of RC was 2%; 105 (24%) patients developed local and/or distant recurrence with a mean interval of 13.6 months. The overall survival, recurrence-free survival (RFS) and disease-specific survival (DSS) at 5 years was 58%, 64% and 74%, respectively, and 43%, 62% and 68% at 10 years. The 5-year RFS and DSS for those with organ-confined, node-negative tumours was 81% and 91%, compared to 46% and 56% in those with extravesical extension and lymph node-negative tumours. The RFS and DSS of patients with lymph node metastasis at 5 years was 29% and 40%, respectively. CONCLUSION: Our study reaffirms that RC with bilateral pelvic lymph node dissection offers a reasonable possibility of disease control at 5 years, with a DSS of 74%. However, there is a need for an earlier diagnosis and effective systemic therapy if additional gains in survival are to be delivered.

Terminal patients with urinary diversion: are there specific treatment or nursing care problems in the primary healthcare sector?

OBJECTIVE: To investigate the treatment and nursing care problems related to the type of urinary diversion in terminal patients experienced by the primary healthcare sector. METHODS: A questionnaire about treatment and nursing care problems related to urinary diversion was sent to general practitioners (GPs) and district nurse units (DNUs) that had been in contact with 1 of 71 patients who died following cystectomy in a 5-year period. The patients had 1 of 3 types of urinary diversion: ileal conduit (IC), Indiana pouch (IP), or Hautmann orthotopic neobladder (NB). RESULTS: Both GPs and DNUs reported significant difference in problems associated with the 3 types of urinary diversion favoring the IC (P = .049 and .025, respectively). However, clinical decisions about urinary diversion types are often based on incontinent versus continent diversions. When divided into continent versus incontinent diversions, the analysis revealed no differences in the number of problems (P = .31 and .052, respectively). Comparing IC and NB alone made the difference even less significant (P = .82 and .23, respectively). CONCLUSIONS: It seems that there are no major disadvantages with one type of urinary diversion when compared to the other as perceived by primary healthcare providers. Relevant and thorough information should be provided to GPs and DNUs in order to minimize problems with all forms of urinary diversion.

Mortality following augmentation cystoplasty: A transitional urologist's viewpoint.

INTRODUCTION: Three complications have been hypothesized to increase patient mortality following enterocystoplasty: spontaneous bladder perforation, bladder neoplasia, and chronic renal failure (CRF). The present study examined risk of their occurrence and discussed ways to improve the quality of care. MATERIALS AND METHODS: The present transitional clinic followed 385 patients with a history of bladder augmentation using either ileal, sigmoid, or ascending colon. The median age was 37 years (range 16-71). Median follow-up interval after augmentation was 26 years (range 2-59). DISCUSSION: Spontaneous rupture of the bladder occurred in 3% (13/385), with one associated death (0.25%, 1/385). Spontaneous bladder rupture significantly correlated with substance abuse, non-compliance with catheterization, and mental/physical disabilities that required the use of surrogates to perform and monitor intermittent catheterization (P < 0.01). Of the 203 patients that were followed for ≥10 years, 4% (8/203) developed a bladder tumor. In comparison, 2.5% (5/203) of an age-matched control population, managed by anticholinergics and intermittent catheterization, developed a bladder tumor. Therefore, enterocystoplasty cannot be associated with an increased risk of cancer development (P = 0.397). Chronic renal failure ≥ Stage 3 arose in 15% (58/385), and 1% (4/385) of the patients died as a result of this complication. Obese patients (BMI ≥30) catheterizing per urethra were more likely to be non-compliant with catheterization and develop CRF compared with obese patients with a continent catheterizable stoma (P > 0.001). These findings suggest that compliance with intermittent catheterization and renal preservation are enhanced by the presence of a catheterizable abdominal stoma. CONCLUSION: The individual's intellectual and physical capability to obey medical directives, refrain from high-risk habits, maintain a healthy weight, and comply with long-term follow-up visits were all critical to the enduring success of bladder augmentation.