Risks and benefits of pelvic lymphadenectomy in octogenarians undergoing radical cystectomy due to urothelial carcinoma of the bladder.

OBJECTIVES: According to current guidelines, radical cystectomy (RC) should be combined with an extended pelvic lymphadenectomy (PLND) as therapeutic and staging instrument. Objective of this study was to analyze the influence of PLND on survival rates and complication rates in a selected group of elderly patients with a minimum age of 80 years. MATERIALS AND METHODS: In this single-center retrospective analysis, we evaluated 102 patients who underwent RC due to UCB from 2004 to 2015 at our institution. In 74 patients (73%), RC was combined with PLND; in 28 cases (27%), RC was performed without PLND. Impact of PLND on cancer specific survival (CSS), overall survival (OS) and progression-free survival (PFS) was analyzed using log-rank test and COX regression model. RESULTS: In univariate analysis of the data, we were not able to show a significant impact of PLND on CSS (p = 0.606), OS (p = 0.979) or PFS (p = 0.883). Also in multivariate analysis of the data, we were not able to identify PLND as an independent prognostic parameter on survival rates of patients undergoing RC, neither for CSS (p = 0.912) nor OS (p = 0.618) or PFS (p = 0.900). CONCLUSIONS: Our small and single-center study was not able to demonstrate a significant independent influence of PLND on CSS, OS and PFS in octogenarians undergoing RC due to UCB. There is no doubt that RC should usually be combined with PLND, but the results of this small data set with a selected patient cohort indicate that RC without PLND might be an option in selected cases of elderly patients.

Impact of preoperative hemoglobin and CRP levels on cancer-specific survival in patients undergoing radical cystectomy for transitional cell carcinoma of the bladder: results of a single-center study.

PURPOSE: Different blood parameters have shown to be associated with patient's oncological outcome. There is only limited knowledge about the prognostic relevance of routine blood parameters in patients undergoing radical cystectomy for transitional cell carcinoma (TCC). Therefore, we retrospectively analyzed the influence of preoperative C-reactive protein (CRP) and hemoglobin (Hb) levels on overall survival (OS) and cancer-specific survival (CSS). MATERIALS AND METHODS: Preoperative CRP and Hb levels were available in 664 patients who underwent RC due to TCC from 2004 to 2013 at our institution. More men than women (77 vs. 23 %) underwent surgery with a median age of 70 years (35-97). Median follow-up time was 24 months (max. 108). Outcome was analyzed using Kaplan-Meier method, log-rank test, and Cox regression models. RESULTS: Median CRP level was 0.5 mg/dl (0.1-28.3), and median Hb level was 13.4 g/dl (6.7-17.9). Patients with CRP value above the median died significantly earlier due to their disease than those with CRP below the median (median CSS 19 vs. 70 months; p < 0.001). Patients with preoperative Hb level below the median had significantly worse outcome than those with Hb level above the median (median CSS 25 vs. 78 months; p < 0.001). In multivariate analysis, CRP and Hb levels were independent prognostic parameters regarding CSS/OS (CRP p = 0.016/p = 0.004; Hb p = 0.006/p = 0.004, respectively). CONCLUSIONS: In our single-center study, preoperative CRP and Hb levels were found to be independent prognostic factors, indicating impaired outcome in patients undergoing RC for TCC. These findings could be used for individual risk stratification and optimization of therapeutic strategies.

A new concept for early recovery after surgery for patients undergoing radical cystectomy for bladder cancer: results of a prospective randomized study.

PURPOSE: Early recovery after surgery concepts have gained wide acceptance in various surgical specialties. However, limited data are available for radical cystectomy. A new early recovery after surgery concept was compared to a more conservative regimen in patients undergoing radical cystectomy for bladder cancer. MATERIALS AND METHODS: A total of 101 consecutive patients were prospectively randomized to early recovery after surgery (62) or a conservative regimen (39) (intended randomization ratio was 2 early recovery after surgery-to-1 conservative regimen). Primary end points were differences in quality of life, and secondary end points included postoperative morbidity, demand for analgesics, time spent in the intermediate care unit, mobility and number of gastrointestinal events during hospital stay. RESULTS: Quality of life parameters, as measured by the EORTC (European Organization for the Research and Treatment of Cancer) Quality of Life questionnaire QLQ-30 did not change significantly between postoperative days 3 and 7 and at discharge from hospital in the conservative regimen group, whereas a significant improvement was observed in the early recovery after surgery group. Postoperative morbidity was lower in the early recovery after surgery group in terms of wound healing disorders (p = 0.006), fever (p = 0.004) and thrombosis (p = 0.027). The demand for analgesics was significantly lower in the early recovery after surgery group. The amount of food consumed in relation to the amount of food offered was significantly higher for the early recovery after surgery group as early as day 3 (p = 0.02). Time spent in the intermediate care unit was significantly shorter for the early recovery after surgery group (p <0.001). There were no significant differences between the groups with respect to gastrointestinal events. The main limitations of this study were the lack of long-term data as well as the single center approach. CONCLUSIONS: Early recovery after surgery of patients who underwent radical cystectomy appears to have significant benefits compared to a conservative regimen in terms of postoperative morbidity, quality of life, use of analgesics and time spent in the intermediate care unit.

Feasibility of radical cystectomy in exclusive spinal and/or epidural anaesthesia.

PURPOSE: Muscle invasive bladder cancer can be found predominantly in elderly people with a high likelihood of suffering from concomitant diseases; especially in these patients, the risks associated with general anaesthesia during radical cystectomy can be the limiting factor of performing an otherwise indicated radical operation. To overcome this limitation, we analysed the feasibility of performing radical cystectomy in exclusive spinal and/or epidural anaesthesia. METHODS: Between March and June 2010, nine patients underwent radical cystectomy in exclusive spinal and/or epidural anaesthesia. These patients were either not willing or unfit to undergo radical cystectomy in general anaesthesia. A continent urinary diversion (ileum neobladder) and an ileum-conduit were performed in five patients and four patients, respectively. The feasibility of radical cystectomy in regional anaesthesia was tested using a variety of parameters. RESULTS: All nine procedures could be performed under strict regional anaesthesia. Mean operation time was 206 min (range 146-265 min), mean intraoperative blood loss was 622 ml (range 200-1,500 ml), mean postoperative time at intermediate care was 1 day (range 0-3 days) and mean length of hospital stay was 21.8 days (range 17-26 days). Analgesics of the WHO class I, II and III were applied for 5.7, 1.2 and 2.8 days mean, respectively. CONCLUSION: Performance of radical cystectomy in exclusive spinal and/or epidural anaesthesia is feasible and can be considered particularly in those patients who would be otherwise unfit to undergo radical cystectomy in general anaesthesia. This new operative and anaesthesiological concept could also play an important role in new fast track regimens.

Acoustic radiation force impulse imaging of the testes: a preliminary experience.

PURPOSE: Acoustic radiation force impulse imaging (ARFI) is a newly developed technique for the sonographic quantification of tissue elasticity. It has been used in the assessment of various abdominal organs. The testes are extraabdominal organs with limited overlying tissue, making them ideally suited to ARFI assessment. To our knowledge no published data exist on ARFI elastography of the testes. METHOD: 23 male volunteers (mean age 45.13 ± 17.3, range 23-75) with no known testicular pathology underwent normal B-mode sonography with ARFI elastometry of both testes using a Siemens Acuson S2000™ (Siemens Healthcare, Germany) system. 15 measurements were performed on each testis; 5 each in the upper pole, middle portion and lower pole. Results were statistically evaluated. RESULTS: 95% of the SWV values were found to lie within the reference interval ranging from 0.62 to 1.01 m/s. There was a significant association between measured SWV and age (P = 0.0056) and testicular volume (P = 0.0003). CONCLUSION: ARFI elastometry proved to be feasible in the assessment of testicular stiffness. Older age and lower testicular volumes were associated with increased parenchymal stiffness. Further studies with more subjects may be required to define the normal range of values for each age group.