Learning curve for intracorporeal robotic Padua ileal bladder: 10-year functional assessment from a high-volume single-centre series.

OBJECTIVES: To assess the impact of the learning curve (LC) on perioperative and long-term functional outcomes of a consecutive single-centre series of robot-assisted radical cystectomy with Padua intracorporeal orthotopic neobladder. PATIENTS AND METHODS: Patients treated between 2013 and 2022 were included, with ≥1 year of follow-up. The entire cohort was divided in tertiles. Categorical and continuous variables were compared. Joinpoint regression analysis was used to identify significant changes over the decade in linear slope of the 1-year day- and night-time continence. Uni- and multivariable Cox regression analyses identified predictors of day- and night-time continence recovery. Day-time continence was defined as 'totally dry' (no pads), night-time continence as pad wetness ≤50 mL (one safety pad). RESULTS: Overall, 200 patients were included. The mean hospital stay (P = 0.002) and 30-day complications (P = 0.04) significantly reduced over time; the LC significantly impacted on Trifecta achievement (P < 0.001). The 1-year day- and night-time continence probabilities displayed a significant improving trend (day-time continence annual average percentage change [AAPC] 11.45%, P < 0.001; night-time continence AAPC 10.05%, P = 0.009). The LC was an independent predictor of day- (hazard ratio [HR] 1.008; P < 0.001) and night-time continence (HR 1.004; P = 0.03) over time. CONCLUSION: Patients at the beginning of the LC had significantly longer hospitalisations, more postoperative complications, and lower Trifecta rates. At the 10-year analyses, we observed a significant improving trend for both the 1-year day- and night-time continence probabilities, highlighting the crucial role of the LC. However, we are unable to assess the case volume needed to achieve a plateau in terms of day- and night-time continence rates.

Double-Layered Hand-Sewn versus Stapled Intestinal Anastomosis in Patients Who Underwent Ileal Urinary Diversion in Radical Cystectomy: A Comparative and Cost Effective Study.

INTRODUCTION: Intestinal anastomosis can be performed by hand suturing (single layer or double layer) or by a mechanical suturing machine. The aim of the study was to compare complications, operative time, and costs of the intestinal anastomosis techniques. METHODS: A retrospective comparative study was conducted including patients who underwent radical cystectomy and uretero-ileo-cutaneostomy or vescica ileale Padovana orthotopic neobladder. Double-layered hand-sewn intestinal anastomosis (HS-IA) were performed using Vicryl stitches. Mechanical-stapled intestinal anastomosis (MS-IA) were performed with a mechanical stapler. RESULTS: Data of 195 patients who underwent were collected. 100 (51.3%) patients underwent HS-IA and 95 (48.7%) patients underwent MS-IA. Considering the complications classified according to Clavien-Dindo, a statistical difference with higher incidence for grade one in the HS-IA both in the ileal conduit group and in the neobladder one than the MS-IA (15.8% and 8.7%, respectively, in HS-IA vs. 1.7% and none in MS-IA). There is not a significant difference in time to flatus and time to defecation. Difference is recorded in the ileal conduit groups for the length of stay (10 days, range 9-12 with HS-IA vs. 13 days range 12-16 days with MS-IA (p < 0.001). The cost of the suture thread used for a single operation was 0.40 euros, whereas the overall cost of a disposable mechanical stapler and one refill was 350.00 €. CONCLUSION: Both HS-IA and MS-IA are safe and effective for patients. The cost for the stapling device is 350 €, in contrast, the cost for Vicryl sutures is negligible.

Prophylactic Mesh Placement With Ileal Conduit: A Cost-effectiveness Analysis.

OBJECTIVE: To determine the cost-effectiveness of mesh placement in patients undergoing ileal conduit urinary diversion for bladder cancer. Long-term studies have shown that parastomal hernias (PSH) occur in more than half of all stomas. Mesh prophylaxis has been shown to reduce PSH after end-colostomy and ileal conduits. However, no cost-effectiveness studies on mesh prophylaxis have been performed for this population. METHODS: We created a Markov model incorporating the costs and effectiveness of mesh prophylaxis for patients undergoing radical cystectomy and ileal conduit construction. Costs were obtained from the literature and adjusted to 2022 US dollars. Effectiveness was measured in quality-adjusted life years (QALY). 1- and 2-way sensitivity analyses were performed to test the robustness of our model. RESULTS: In stage I-IV bladder cancer, prophylactic mesh placement was costlier, but more effective in providing quality of life compared with no mesh placement at index surgery. Average incremental cost between the 2 strategies across all stages was an additional $897 when mesh was utilized. Incremental effectiveness averaged 0.49 additional QALY across all stages. This resulted in an incremental cost-effectiveness ratio of $2114.71/QALY. Sensitivity analyses indicated that benefit of mesh placement was sensitive to the probability of mesh infection. CONCLUSION: In patients undergoing ileal conduit urinary diversion for bladder cancer, mesh prophylaxis at the time of radical cystectomy is an overall cost-effective strategy in preventing PSH for patients presenting with all stages of bladder cancer.

Uretero-enteric Strictures After Robot Assisted Radical Cystectomy: Prevalence and Management Over Two Decades.

INTRODUCTION: To evaluate the prevalence, predictors, management, and trends for ureteroenteric strictures (UES) after robot-assisted radical cystectomy (RARC). METHODS: Retrospective review of our RARC database was performed (2005-2022). UES was described in terms of timing, laterality, and management. Kaplan-Meier curves were used to depict time to UES. Local regression was used to assess trend of UES over time and multivariable regression to identify variables associated with UES. RESULTS: UES occurred in 109 patients (15%). UES occurred in 13%, 17%, and 19% at 1, 3, and 5 years after RARC, respectively. Incidence of UES decreased in 2017, coinciding with stentless uretero-enteric anastomosis. UES occurred on the right in 33%, on the left in 46%, and bilaterally in 21%. All patients were initially managed by nephrostomy/stent. Surgical revision was required in 45% of patients, of which 13% developed recurrent UES after revision. On MVA, UES formation was associated with ureteral stents (OR 2.27, 95%CI 1.01-5.10, P = .05) and receipt of neoadjuvant chemotherapy (OR 2.01, 95%CI 1.24-3.25, P = .005). CONCLUSION: UES occurred in 15% of patients after RARC, with 45% of patients requiring surgical reimplantation. Ureteral stents and the receipt of neoadjuvant chemotherapy were associated with UES formation.

Cost-analysis of robot-assisted radical cystectomy in Europe: A cross-country comparison.

BACKGROUND: Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is surging worldwide. Aim of the study was to perform a multicentric cost-analysis of RARC by comparing the gross cost of the intervention across hospitals in four different European countries. METHODS: Patients who underwent RARC + ICUD were recruited from eleven European centers in four European countries (Belgium, France, Netherlands, and UK) between 2015 and 2020. Costs were divided into six parts: cost for hospital stay, cost for ICU stay, cost for surgical theater occupation, cost for transfusion, cost for robotic instruments, and cost for stapling instruments. These costs were individually assessed for each patient. RESULTS: A total of 490 patients were included. Median operative time was 300(270-360) minutes and median hospital length-of-stay was 11(8-15) days. The average total cost of RARC was 14.794€ (95%CI 14.300-15.200€). A significant difference was found for the total cost, as well as the various subcosts abovementioned, between the four included countries. Different sets and types of robotic instruments were used by each center, leading to a difference in cost of robotic instrumentation. Nearly 84% of costs of RARC were due to hospital stay (42%), ICU stay (3%) and operative time (39%), while 16% of costs were due to robotic (8%) and stapling (8%) instruments. CONCLUSION: Costs and subcosts of RARC + ICUD vary significantly across European countries and are mainly dependent of hospital length-of-stay and operative time rather than robotic instrumentation. Decreasing length-of-stay and reducing operative time could help to decrease the cost of RARC and make it more widely accessible.

Urodynamic assessment and quality of life outcomes of robot-assisted totally intracorporeal radical cystectomy and orthotopic neobladder for bladder cancer: a preliminary study.

PURPOSE: Few data exist regarding the functional outcomes of robot-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder. The aim of this study was to evaluate the urodynamic and functional outcomes in patients undergoing RARC and totally intracorporeal orthotopic neobladder for bladder cancer. METHODS: In this monocentric, observational study carried out between 2016 and 2020, consecutive patients undergoing RARC and intracorporeal orthotopic neobladder in the Department of Urology, Pitié-Salpêtrière Hospital, were included. Reconstruction was totally intracorporeal Y-shaped neobladder. Main outcomes were urodynamic findings 6 months post-surgery, continence and quality of life (QoL). Continence was defined by no pad or one safety pad. International Consultation on Incontinence Questionnaire (ICIQ), International Index of Erectile Function questionnaire (IIEF-5) and Bladder Cancer Index (BCI) scores were recorded. RESULTS: Fourteen male patients were included (median age: 64 years [IQR 54-67]. Median maximal neobladder cystometric capacity was 495 ml [IQR 410-606] and median compliance was 35.5 ml/cm H2O [IQR 28-62]. All patients had post-void residual volume < 30 ml, except for three (22%) who required clean intermittent-self catheterisation. Daytime continence was achieved in 10 patients (71%) and night-time continence in two (14.3%). Median ICIQ score was 7 [IQR 5-11]. Postoperative erectile function was present in 7% of patients (mean IIEF-5 = 5 [IQR 2-7]). Thirteen patients (93%) were satisfied with their choice of neobladder. CONCLUSION: RARC with totally intracorporeal orthotopic neobladder for bladder cancer provides satisfactory urodynamic results and good QoL. These findings should be confirmed long-term.

Reporting and grading of complications for intracorporeal robot-assisted radical cystectomy: an in-depth short-term morbidity assessment using the novel Comprehensive Complication Index®.

OBJECTIVE: To assess suitability of Comprehensive Complication Index (CCI®) vs. Clavien-Dindo classification (CDC) to capture 30-day morbidity after robot-assisted radical cystectomy (RARC). MATERIALS AND METHODS: A total of 128 patients with bladder cancer (BCa) undergoing intracorporeal RARC with pelvic lymph node dissection between 2015 and 2021 were included in a retrospective bi-institutional study, which adhered to standardized reporting criteria. Thirty-day complications were captured according to a procedure-specific catalog. Each complication was graded by the CDC and the CCI®. Multivariable linear regression (MVA) was used to identify predictors of higher morbidity. RESULTS: 381 complications were identified in 118 patients (92%). 55 (43%), 43 (34%), and 20 (16%) suffered from CDC grade I-II, IIIa, and ≥ IIIb complications, respectively. 16 (13%), 27 (21%), and 2 patients (1.6%) were reoperated, readmitted, and died within 30 days, respectively. 31 patients (24%) were upgraded to most severe complication (CCI® ≥ 33.7) when calculating morbidity burden compared to corresponding CDC grade accounting only for the highest complication. In MVA, only age was a positive estimate (0.44; 95% CI = 0.03-0.86; p = 0.04) for increased cumulative morbidity. CONCLUSION: The CCI® estimates of 30-day morbidity after RARC were substantially higher compared to CDC alone. These measurements are a prerequisite to tailor patient counseling regarding surgical approach, urinary diversion, and comparability of results between institutions.

Ostomy and Continent Diversion Patient Bill of Rights: Research Validation of Standards of Care.

An estimated 725,000 to 1 million people are living with an ostomy or continent diversion in the United States, and approximately 100,000 ostomy surgeries are performed each year in the United States. As a result of ostomy surgery, bodily waste is rerouted from its usual path because of malfunctioning parts of the urinary or digestive system. An ostomy can be temporary or permanent. The ostomy community is an underserved population of patients. United Ostomy Associations of America, Inc (UOAA), is a nonprofit organization dedicated to promoting quality of life for people with ostomies and continent diversions through information, support, advocacy, and collaboration. Over the years, UOAA has received hundreds of stories from people who have received inadequate care. In the United States, patients receiving medical care have certain health rights. For ostomy and continent diversion patients, these rights are known as the "You Matter! Know What to Expect and Know Your Rights-Ostomy and Continent Diversion Patient Bill of Rights" (PBOR). These rights define and provide a guide to patients and health care professionals as to what the best practices are when receiving and providing high-quality ostomy care during all phases of the surgical experience. This includes preoperative to postoperative care and throughout the life span when living with an ostomy or continent diversion. In 2020, the National Quality Forum released "The Care We Need: Driving Better Health Outcomes for People and Communities," a National Quality Task Force report that provides a road map where every person in every community can expect to consistently and predictably receive high-quality care by 2030 (thecareweneed.org). One of the core strategic objectives this report stated is to ensure appropriate, safe, and accessible care. Actionable opportunities to drive change include accelerating adoption of leading practices. The adoption of the PBOR best practices will drive the health care quality improvement change needed for the ostomy and continent diversion population. There are concerns in the ostomy and continent diversion communities among patients and health care professionals that the standards of care outlined in the PBOR are not occurring across the United States in all health care settings. There are further concerns stated by health care professionals that the patient-centered recommendations outlined in the PBOR need to be strengthened by being supported with available published health care evidence. The work of this task force was to bring together members of UOAA's Advocacy Committee, members of the Wound, Ostomy, and Continence Nurses Society (WOCN Society) Public Policy and Advocacy Committee, and representatives from surgical organizations and industry to create a systemic change by validating through evidence the Ostomy and Continent Diversion PBOR. Through the work of the task force, each component of the PBOR has been substantiated as evidence-based. Thus, this article validates the PBOR as a guideline for high-quality standards of ostomy care. We show that when patients receive the standards of care as outlined in the PBOR, there is improved quality of care. We can now recognize that until every ostomy or continent diversion patient receives these health care rights, in all health care settings, will they truly be realized and respected as human rights in the United States and thus people living with an ostomy or continent diversion will receive "the care they need."

Urinary Diversion With or Without Concomitant Cystectomy for Benign Conditions: A Comparative Morbidity Assessment According to the Updated European Association of Urology Guidelines on Reporting and Grading of Complications.

BACKGROUND: Evidence is scarce on morbidity after urinary diversion ± cystectomy as treatment for benign bladder indications. OBJECTIVE: To conduct a morbidity assessment and to evaluate the impact of concomitant subtrigonal cystectomy (SC) versus urinary diversion (UD) alone. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective study of 97 patients with benign bladder conditions between 2009 and 2017. INTERVENTION: Open UD and/or concomitant SC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Data for 30-d complications were extracted using a procedure-specific catalog and were graded according to the Clavien-Dindo classification (CDC), and Comprehensive Complication Index (CCI) values were calculated. Traditional morbidity endpoints focused on the comparative morbidity of UD + SC versus UD alone. Multivariable regressions were computed to evaluate the impact of SC versus UD alone on cumulative morbidity. Subgroup analyses were repeated for patients with previous irradiation. RESULTS AND LIMITATIONS: Of 97 patients, 46 (47%) underwent UD + SC and 51 (53%) underwent UD alone. Forty-nine patients (51%) had a history of abdominopelvic radiotherapy. Overall, 69 (71%) patients underwent continent UD and 26 (27%) underwent a Mitrofanoff procedure. We registered 390 complications in 97 (100%) patients, the majority of which were classified as minor (CDC grade ≤IIIa; 93%). Overall, three patients (3.1%) were readmitted and no patient died within 30 d. On multivariable analyses, neither concomitant SC nor previous radiotherapy was associated with higher cumulative morbidity (all p = 0.2). Similarly, concomitant SC was not predictive of a higher complication burden in the irradiation subgroup (all p ≥ 0.05). Limitations include heterogeneity for indications and a lack of information on the radiation dose and field. CONCLUSIONS: In a high-volume referral center, neither SC nor abdominopelvic radiotherapy increased perioperative cumulative morbidity for patients with benign bladder conditions undergoing UD. This is particularly relevant for patients who would benefit from concomitant SC to avert adverse sequelae related to the retained bladder. PATIENT SUMMARY: Urinary diversion (UD) is a surgical procedure to create a new way for urine to exit the body. We found that among patients undergoing UD for benign bladder conditions, those who also have their bladder removed and patients who have received previous radiotherapy do not experience more complications.

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center.

INTRODUCTION: Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. MATERIAL AND METHODS: Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t-test for independent groups or Mann-Whitney test. Statistical significance if P < .05. RESULTS: The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Uretericre implantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). CONCLUSION: Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Three-port approach vs standard laparoscopic radical cystectomy with an ileal conduit: a single-centre retrospective study.

BACKGROUND: This study aimed to evaluate the effect of the three-port approach and conventional five-port laparoscopic radical cystectomy (LRC) with an ileal conduit. METHODS: Eighty-four patients, who were diagnosed with high-risk non-muscle-invasive and muscle-invasive bladder carcinoma and underwent LRC with an ileal conduit between January 2018 and April 2020, were retrospectively evaluated. Thirty and fifty-four patients respectively underwent the three-port approach and five-port LRC. Clinical characteristics, pathological data, perioperative outcomes, and follow-up data were analysed. RESULTS: There were no differences in perioperatively surgical outcome, including pathology type, prostate adenocarcinoma incidence, tumour staging, and postoperative creatinine levels between the two groups. The operative time (271.3 ± 24.03 vs. 279.57 ± 48.47 min, P = 0.299), estimated blood loss (65 vs. 90 mL, P = 0.352), time to passage of flatus (8 vs. 10 days, P = 0.084), and duration of hospitalisation post-surgery (11 vs. 12 days, P = 0.922) were no clear difference between both groups. Compared with the five-port group, the three-port LRC group was related to lower inpatient costs (12 453 vs. 14 134 $, P = 0.021). Our follow-up results indicated that the rate of postoperative complications, 90-day mortality, and the oncological outcome did not show meaningful differences between these two groups. CONCLUSIONS: Three-port LRC with an ileal conduit is technically safe and feasible for the treatment of bladder cancer. On comparing the three-port LRC with the five-port LRC, our technique does not increase the rate of short-term and long-term complications and tumour recurrence, but the treatment costs of the former were reduced.

Impact of radiation on the incidence and management of ureteroenteric strictures: a contemporary single center analysis.

BACKGROUND: Ureteroenteric stricture incidence has been reported as high as 20% after urinary diversion. Many patients have undergone prior radiotherapy for prostate, urothelial, colorectal, or gynecologic malignancy. We sought to evaluate the differences between ureteroenteric stricture occurrence between patients who had radiation prior to urinary diversion and those who did not. METHODS: An IRB-approved cystectomy database was utilized to identify ureteroenteric strictures among 215 patients who underwent urinary diversion at a single academic center between 2016 and 2020. Chart abstraction was conducted to determine the presence of confirmed stricture in these patients, defined as endoscopic diagnosis or definitive imaging findings. Strictures due to malignant ureteral recurrence were excluded (3 patients). Statistical analysis was performed using chi squared test, t-test, and Wilcoxon Rank-Sum Test, logistic regression, and Kaplan-Meier analysis of stricture by cancer type. RESULTS: 65 patients had radiation prior to urinary diversion; 150 patients did not have a history of radiation therapy. Benign ureteroenteric stricture rate was 5.3% (8/150) in the non-radiated cohort and 23% (15/65) in the radiated cohort (p = < 0.001). Initial management of stricture was percutaneous nephrostomy (PCN) in 78% (18/23) and the remaining 22% (5/23) were managed with primary retrograde ureteral stent placement. Long term management included ureteral reimplantation in 30.4% (7/23). CONCLUSIONS: Our study demonstrates a significant increase in rate of ureteroenteric strictures in radiated patients as compared to non-radiated patients. The insult of radiation on the ureteral microvascular supply is likely implicated in the cause of these strictures. Further study is needed to optimize surgical approach such as utilization of fluorescence angiography for open and robotic approaches.

[Quality assessment of radical cystectomy-opportunities, risks, challenges]. / Qualitätsparameter bei der radikalen Zystektomie ­ Chancen, Risiken, Herausforderungen.

Radical cystectomy (RC) is the standard treatment for nonmetastatic muscle-invasive urothelial carcinoma of the urinary bladder. It is associated with relevant morbidity and mortality. After RC, the 5­year overall survival rate is approximately 60%. In the context of the present work, quality parameters of RC divided into oncological/functional criteria and freedom from complications are identified and summarized. A PubMed search was performed. In addition to early criteria such as negative surgical margins, performance of pelvic lymphadenectomy, creation of a continent urinary diversion or preservation of sexual function, long-term criteria were identified such as the absence of higher-grade postoperative complications, recurrence-free survival and the preservation of health-related quality of life. The early criteria are suitable for individualized therapy planning, whereas the long-term criteria can be used for quality monitoring.

Utilizing time-driven activity-based costing to determine open radical cystectomy and ileal conduit surgical episode cost drivers.

OBJECTIVES: Patients undergoing radical cystectomy represent a particularly resource-intensive patient population. Time-driven activity based costing (TDABC) assigns time to events and then costs are based on the people involved in providing care for specific events. To determine the major cost drivers of radical cystectomy care we used a TDABC analysis for the cystectomy care pathway. SUBJECTS AND METHODS: We retrospectively reviewed a random sample of 100 patients out of 717 eligible patients undergoing open radical cystectomy and ileal conduit for bladder cancer at our institution between 2012 and 2015. We defined the cycle of care as beginning at the preoperative clinic visit and ending with the 90-day postoperative clinic visit. TDABC was carried out with construction of detailed process maps. Capacity cost rates were calculated and the care cycle was divided into 3 phases: surgical, inpatient, and readmissions. Costs were normalized to the lowest cost driver within the cohort. RESULTS: The mean length of stay was 6.9 days. Total inpatient care was the main driver of cost for radical cystectomy making up 32% of the total costs. Inpatient costs were mainly driven by inpatient staff care (76%). Readmissions were responsible for 29% of costs. Surgery was 31% of the costs, with the majority derived from operating room staff costs (65%). CONCLUSION: The major driver of cost in a radical cystectomy pathway is the inpatient stay, closely followed by operating room costs. Surgical costs, inpatient care and readmissions all remain significant sources of expense for cystectomy and efforts to reduce cystectomy costs should be focused in these areas.

How the Beneficial Effects of Alvimopan Differ With Surgical Approach for Radical Cystectomy.

OBJECTIVE: To assess whether the beneficial perioperative effects of alvimopan differ with surgical approach for patients who undergo open radical cystectomy (ORC) vs robot-assisted radical cystectomy (RARC). METHODS: This retrospective study reviewed all patients who underwent cystectomy with urinary diversion at our institution between January 1, 2007, and January 1, 2018. Data were collected on demographic characteristics, comorbidities, surgical approach, alvimopan therapy, hospital length of stay (LOS), days until return of bowel function (ROBF), and complications. Outcomes and interactions were evaluated through regression analysis. RESULTS: Among 573 patients, 236 (41.2%) underwent RARC, 337 (58.8%) underwent ORC, and 205 (35.8%) received alvimopan. Comparison of 4 cohorts (ORC with alvimopan, ORC without alvimopan, RARC with alvimopan, and RARC without alvimopan) showed that patients who underwent ORC without alvimopan had the highest rate of postoperative ileus (25.6%, P = .02), longest median hospital LOS (7 days, P < .001), and longest time until ROBF (4 days, P < .001). On multivariable analysis, the interaction between surgical approach and alvimopan use was significant for the outcome of ROBF (estimate, 1.109; 95% confidence interval, 0.418-1.800; P = .002). In the RARC cohort, multivariable analysis showed no benefit of alvimopan with respect to ileus (P = .27), LOS (P = .09), or ROBF (P = .36). Regarding joint effects of robotic approach and alvimopan, RARC had no effect on gastrointestinal tract outcomes. CONCLUSION: We observed a diminished beneficial effect of alvimopan among patients undergoing RARC and a statistically significant benefit of alvimopan among patients undergoing ORC. The implications of these findings may permit more selective medication use for patients who would benefit the most from this drug.

Increasing use of positron emission tomography among medicare beneficiaries undergoing radical cystectomy.

OBJECTIVE: To examine factors associated with PET scan use in the pre-operative evaluation of patients diagnosed with bladder cancer. METHODS: Using SEER-Medicare data, we identified bladder cancer patients who underwent radical cystectomy from 2006 to 2011 (n = 4,138). The primary outcome was PET scan use within 6 months before surgery. To examine predictors of PET scan use, we fit a mixed logit model with health service area as a random effect to account for patients nested within health service areas. We also calculated the adjusted probability of use over time and examined variation among the highest volume surgeons. RESULTS: Among the 4,138 patients, 406 (10%) received a pre-operative PET scan. The adjusted probability of a patient undergoing a PET scan increased from 0.04 in 2004 to 0.10 in 2011 (p < .001). Among the 78 highest volume surgeons, there was significant variation in PET scan use (p < .001). Patients with non-urothelial histology, measurement of alkaline phosphatase levels, and receipt of neoadjuvant chemotherapy were more likely to receive PET scan (all p < .05). CONCLUSION: Use of PET prior to radical cystectomy doubled over a 5-year period, suggesting its increased use in patients with muscle-invasive bladder cancer, particularly those with high-risk disease. Whether its use is warranted and improves patient outcomes is not clear and requires further studies.

Current status and future perspective of robot-assisted radical cystectomy for invasive bladder cancer.

The current status of robot-assisted radical cystectomy was reviewed 16 years after the initial robot-assisted radical cystectomy for the treatment of invasive bladder cancer. Articles associated with robot-assisted radical cystectomy and written in English were selected from the PubMed database from January 2003 to February 2019. The present review article focused on the distribution of robot-assisted radical cystectomy, patient selection, preoperative management, surgical technique, lymph node dissection, urinary diversion, recurrence pattern, oncological outcomes, cost, learning curve, complications and educational programs. A total of 400 articles were divided according to the country of the first author's affiliation. The USA was the most dominant at 198 (50%), whereas the number of articles from the countries belonging to the Urological Association of Asia was 15 (3.8%) for China, 17 (4.3%) for South Korea, 10 (2.5%) for Japan, eight (2%) for Taiwan, eight (2%) for Turkey and one (0.2%) for Iran. The percentage of robot-assisted radical cystectomy carried out is increasing, and intracorporeal urinary diversion and ileal neobladder are also frequently carried out. With a refined technique being performed in high-volume centers, robot-assisted radical cystectomy has contributed to the reduction in transfusion rate, length of stay and severe complications; however, it has not yet shown any cancer-specific survival benefits. Robot-assisted radical cystectomy is not fully spread throughout the Urological Association of Asia. Further investigation with respect to worldwide results is needed to prove the real benefit of robot-assisted radical cystectomy regarding low morbidity, reduced total medical cost, and survival benefit. In the era of precision medicine, appropriate drug and surgery will be given based on each genetic profile.

Gender differences in oncologic and functional outcomes in patients with bladder cancer undergoing radical cystectomy with urinary diversion.

PURPOSE OF REVIEW: The purpose of this article is to review and summarize recent data on gender differences in oncologic and functional outcomes in women undergoing radical cystectomy with urinary diversion as contemporary studies have highlighted a potential disparity in outcomes between men and women. RECENT FINDINGS: Gender (being a woman) as a social determinant of health negatively affects oncologic outcome in women with bladder cancer treated with radical cystectomy secondary to delays in diagnosis, treatment, and misdiagnosis. Sex (being female) negatively affects oncologic outcome in women with bladder cancer treated with radical cystectomy through tumor and host biology. Female patients present with advance stage and basal molecular subtype tumors enriched with squamous and sarcomatoid histology. Preliminary studies implicate the hormonal axis in differential bladder cancer development and progression between women and men. After radical cystectomy, functional outcomes (urinary, sexual, and overall quality of life) are poorly assessed in women yet important for both physicians and patients for clinical decision-making and counseling. SUMMARY: Future research (clinical trials, assessment of functional outcomes using gender-specific measures) must include women with bladder cancer and raise awareness regarding the gaps in knowledge and care for these patients.

Assessment of complications following urinary diversion for benign indications.

INTRODUCTION: To evaluate complications following urinary diversion for non-malignant conditions. MATERIALS AND METHODS: We performed a retrospective review of patients undergoing urinary diversion for benign indications between 2000 and 2017. Data collected including patient demographic and clinical characteristics, surgical characteristics, and complications. Complications were graded using Clavien-Dindo classification and were categorized as early versus delayed (≤ versus > 90 day postoperatively). Logistic regression assessed for predictors of developing any postoperative complication. RESULTS: A total of 68 patients were identified for study analysis with median follow up of 24 (7-72) months. Sixty-eight and 25% of patients underwent diversion for neurogenic bladder and complications related to pelvic radiation, respectively. A majority (90%) underwent ileal conduit with the remainder undergoing continent diversion. A total of 121 complications were identified, comprising 50 early and 72 delayed. Overall, 77% of patients had at least one complication during the follow up period. Fifty-one percent of patients experienced early complication, while 66% of patients experienced delayed complications. Complications of Clavien-Dindo Score ≥ IIIB were seen in 48% of patients. The most common early complication was wound infection (12%); delayed was urinary tract infection (39%). Multivariable logistic regression modeling found no independent predictors of complication, although the best-fit model included BMI, diabetes, presence of multiple comorbidities, and operative time (hr) as positive predictors of complication. CONCLUSION: Our study demonstrates that urinary diversion for benign etiologies is associated with a significant rate of complication. A large percentage of these complications occur in the delayed period and are classified as severe complications.