RESUMEN
BACKGROUND: The clinical impact of prolonged steep Trendelenburg position and CO2 pneumoperitoneum during robot-assisted radical cystectomy (RC) on intraoperative conditions and immediate postoperative recovery remains to be assessed. The current study investigates intraoperative and immediate postoperative outcomes for open RC (ORC) versus robot-assisted RC with intracorporal urinary diversion (iRARC) in a blinded randomised trial. We hypothesised that ORC would result in a faster haemodynamic and respiratory post-anaesthesia care unit (PACU) recovery compared to iRARC. METHODS: This study is a predefined sub-analysis of a single-centre, double-blinded, randomised feasibility study. Fifty bladder cancer patients were randomly assigned to ORC (n = 25) or iRARC (n = 25). Patients, PACU staff, and ward personnel were blinded to the surgical technique. Both randomisation arms followed the same anaesthesiologic procedure, fluid treatment plan, and PACU care. The primary outcome was immediate postoperative recovery using a standardised PACU Discharge Criteria (PACU-DC) score. Secondary outcomes included respiration- and arterial O2 saturation scores as well as perioperative interventions and recordings. RESULTS: All patients underwent the allocated treatment. The total PACU-DC score was highest 6 h postoperatively with no difference in the total score between randomisation arms (p = 0.80). Both the ORC and iRARC groups maintained a mean respiration- and arterial O2 saturation score below 1 (out of 3) throughout PACU stay. The iRARC patients had significantly, but clinically acceptable, higher maximum airway pressure and arterial blood pressure, as well as lower minimum pH levels. The ORC group received significantly more opioids after extubation but marginally less analgesics in the PACU, compared to the iRARC group. CONCLUSIONS: A prolonged Trendelenburg position and CO2 pneumoperitoneum was well-tolerated during iRARC, and immediate postoperative recovery was similar for ORC and iRARC patients.
Asunto(s)
Neumoperitoneo , Procedimientos Quirúrgicos Robotizados , Robótica , Humanos , Cistectomía/efectos adversos , Cistectomía/métodos , Dióxido de Carbono , Resultado del Tratamiento , Procedimientos Quirúrgicos Robotizados/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
PURPOSE: This study aims to examine quality of life (QoL) before and after radical cystectomy (RC) and compare robot-assisted laparoscopy with intracorporeal urinary diversion (iRARC) to open radical cystectomy (ORC). METHODS: This study is a predefined secondary analysis of a single-centre, double-blinded, randomised feasibility trial. Fifty patients were randomly assigned to iRARC with ileal conduit (n = 25) or ORC with ileal conduit (n = 25). Patients were followed 90 days postoperatively. The primary outcome was patient-reported QoL using the EORTC Cancer-30 and muscle-invasive bladder cancer BLM-30 QoL questionnaires before and after RC. Differences between randomisation arms as well as changes over time were evaluated. Secondary outcomes included 30- and 90 day complication rates, 90 day readmission rates, and 90 day days-alive-and-out-of-hospital and their relationship to QoL. RESULTS: All patients underwent the allocated treatment. We found no difference in QoL, complication rates, readmission rates, and days-alive-and-out-of-hospital between randomisation arms. An overall improvement in QoL was found in the following domains: future perspectives, emotional functioning, and social functioning. Sexual functioning worsened postoperatively. There was no association between having experienced a major complication or lengthy hospitalisation and worse postoperative QoL. CONCLUSION: The QoL does not appear to depend on surgical technique. Apart from sexual functioning, patients report stable or improved QoL within the first 90 postoperative days.
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Procedimientos Quirúrgicos Robotizados , Robótica , Neoplasias de la Vejiga Urinaria , Derivación Urinaria , Cistectomía/métodos , Estudios de Factibilidad , Humanos , Complicaciones Posoperatorias/etiología , Calidad de Vida , Procedimientos Quirúrgicos Robotizados/métodos , Resultado del Tratamiento , Neoplasias de la Vejiga Urinaria/etiología , Derivación Urinaria/métodosRESUMEN
OBJECTIVE: To report microbial pathogens detected at infection-related readmissions, including their susceptibility to antimicrobials. MATERIALS AND METHODS: A retrospective review of 785 patients who underwent radical cystectomy for bladder cancer at a tertiary center in Denmark between 2009 and 2019. All patients received prophylactic cefuroxime preoperatively and pivmecillinam at stent- or catheter removal. Data were collected through the national medical records and microbiology database. The primary outcome was readmission rate and pathogens detected at infection-related readmissions. Univariable and multivariable regression analyses were carried out to identify risk factors of readmission. RESULTS: Within 90days of surgery, 225 (29%) patients experienced at least one infection-related readmission. The most common pathogen identified was Enterococcus spp (24% of all positive samples). In blood cultures, the most dominant species were Escherichia coli (29%) and Staphylococcus spp (26%). Due to the heterogeneity in microbial species identified, more than one-third of the bacteria where mecillinam was tested showed resistance. Most isolates were susceptible to piperacillin+tazobactam. Orthotopic neobladder and continent cutaneous reservoir were associated with the highest risk of infection-related readmission compared to ileal conduit (odds ratios 2.78 [95%CI 1.66;4.65] and 3.08 [95%CI 1.58;5.98], respectively). Patients with diabetes had an increased risk of infection-related readmission compared to patients without diabetes (odds ratio 1.67 [95%CI 1.02;2.73]). CONCLUSION: Nearly one-third of all patients experienced at least one postoperative infection-related readmission with a wide range of microbial etiologies. Generalizability of our results is uncertain, but the data can be used to plan interventional trials of antibiotic prophylaxis.
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Diabetes Mellitus , Neoplasias de la Vejiga Urinaria , Derivación Urinaria , Humanos , Cistectomía/efectos adversos , Cistectomía/métodos , Readmisión del Paciente , Neoplasias de la Vejiga Urinaria/cirugía , Neoplasias de la Vejiga Urinaria/etiología , Vejiga Urinaria , Derivación Urinaria/métodos , Escherichia coli , Estudios Retrospectivos , Complicaciones Posoperatorias/etiologíaRESUMEN
OBJECTIVE: To report incidence of acute kidney injury (AKI) following radical cystectomy (RC) for bladder cancer and evaluate risk factors for AKI as well as the impact of AKI on development of long-term renal insufficiency. METHODS: A retrospective analysis of patients undergoing RC between 2010 and 2020 at a high-volume tertiary referral center. AKI was graded according to the Kidney Disease Improving Global Outcome (KDIGO) criteria within 90days of surgery. Long-term renal insufficiency was defined as estimated glomerular function <45â¯mL/min. Cumulative incidence and Cox Proportional Hazards models were used to evaluate both short- and long-term loss of renal function and investigate their association with pre- and perioperative variables. RESULTS: AKI occurred in 332 out of 755 patients (44%) within 90days. Preoperative chronic hypertension and obesity were independent preoperative risk factors. Robot-assisted RC was associated with a higher risk of AKI compared to open RC in multivariable analyses. The absolute risk of developing long-term renal insufficiency was 8.7% (95%CI: 5.6-12) after 5years in patients without AKI and 26% (95%CI: 16-36) in patients with KDIGO-stage ≥2. In multivariable analysis, both KDIGO-stage 1 and ≥2 were independently associated with long-term estimated glomerular filtration rate <45â¯mL/min. CONCLUSION: A significant number of patients experienced AKI after RC, and even patients with KDIGO-stage 1 were at increased risk of long-term renal insufficiency. Recognizing pre- and perioperative risk factors can identify patients where close surveillance and early intervention may help minimize renal function decline following RC.
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Lesión Renal Aguda , Cistectomía , Neoplasias de la Vejiga Urinaria , Humanos , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/etiología , Cistectomía/efectos adversos , Incidencia , Estudios Retrospectivos , Factores de Riesgo , Neoplasias de la Vejiga Urinaria/epidemiología , Neoplasias de la Vejiga Urinaria/cirugía , Neoplasias de la Vejiga Urinaria/complicacionesRESUMEN
OBJECTIVE: To evaluate long-term renal function following radical cystectomy (RC) for bladder cancer and identify risk factors associated with postoperative decline in renal function. METHODS: The study included patients who underwent RC at a single centre in Denmark between 2009 and 2019. Data was collected through national electronic medical records. Renal function was evaluated by estimated glomerular filtration rate (eGFR) using pre- and postoperative creatinine measurements. Cumulative incidence and Cox Proportional Hazards models were used to describe the loss of renal function and its association with clinicopathological variables, as well as its effect on mortality. RESULTS: After exclusions, 670 patients were eligible for analyses. Median follow-up time was 6.2 years (interquartile range 4.0 -8.4). The proportion of patients with renal insufficiency (eGFR<45 mL/min) increased from 8.9% before RC to 19% 5 years after surgery. A total of 610 patients with preoperative eGFR≥45 were included in survival analyses. The absolute risk of renal function decline to CKD stage G3b or worse (eGFR<45 mL/min) was 17% (95% CI 14 -20) at 5 years postoperatively. Loss of renal function was not significantly associated with higher all-cause mortality. In multivariate analysis lower preoperative eGFR, diabetes mellitus, prior pelvic radiation therapy, continent urinary diversion types, and postoperative ureteral stricture were all independently associated with renal function decline. CONCLUSION: The long-term renal function decreases considerably for a large number of RC patients. Recognizing preoperative risk factors could identify patients who benefit from enhanced renal surveillance or early intervention for modifiable factors to minimize renal insufficiency following RC.