Control of bleeding from a recurrent tumor at a uretero-ileal anastomosis by electrocoagulation via an ileal conduit.

Introduction: Bladder cancer is characterized by spatial and temporal recurrence in the urinary tract. We describe a case of recurrence at a uretero-ileal anastomosis after radical cystectomy and nephroureterectomy. It was difficult to control bleeding from the tumor, but hemostasis was achieved. Case presentation: A 73-year-old man with a history of radical cystectomy and reconstruction of the ileal conduit and right nephroureterectomy was diagnosed with recurrence at the uretero-ileal anastomosis site. Bleeding from the tumor could not be controlled by flexible gastrointestinal endoscopy. The patient underwent coagulation via an ileal conduit approach using a rigid scope and bipolar electrocautery, which is usually a modality for transurethral resection. Conclusion: This is the first report in which a modality normally used for transurethral resection was used to control bleeding in a patient with an ileal conduit. This application is useful in cases open surgery or additional irradiation might be difficult.

The significance of SARC-F scores in predicting postoperative outcomes of older adults undergoing elective major surgery for urologic cancer.

BACKGROUND & AIMS: Recently, the strength, assistance with walking, rise from a chair, climb stairs, and falls (SARC-F) questionnaire has been developed to screen patients with signs of sarcopenia. However, its clinical benefit remains uncertain in elderly patients undergoing elective major surgeries. This study aimed to explore the role of the SARC-F questionnaire as a screening tool for patients who plan to undergo elective major surgery for urologic cancer and to also evaluate correlations of SARC-F scores with established indicators of sarcopenia. METHODS: This retrospective observational study enrolled 815 patients over 40 years of age undergoing elective major surgery for urologic cancer and who were screened with the SARC-F questionnaire, preoperatively. The primary endpoint was an association between SARC-F scores and postoperative ambulation failure. Here we define postoperative ambulation failure as a condition where a patient is unable to walk independently within 2 days after surgery and required physical rehabilitation or was transferred to other hospitals in a bedridden state. The secondary endpoint was an association between SARC-F scores and overall survival (OS). Psoas muscle density (PMD) and psoas muscle index (PMI) were calculated from abdominal computed tomography images, and their correlations with SARC-F scores grouped by sex. RESULTS: Of the 815 patients, 738 (91%) were male and the median age was 72 years. Although SARC-F scores weakly correlated with PMD in males and moderately correlated in females (ρ = -0.222 and ρ = -0.474, respectively), their correlation with PMI was negligible (ρ = -0.179 and ρ = -0.084, respectively). SARC-F scores successfully discriminate postoperative ambulation failure in both males and females with the respective area under the receiver operating characteristic curve of 0.856 and 0.813. Multivariate analysis also showed that SARC-F scores greater than 4 are an independent risk factor of postoperative ambulation failure along with older age, lower PMD, and poor performance status. SARC-F scores greater than 4 were significantly associated with a shorter OS in the whole cohort (P < 0.001) and a subgroup of patients undergoing radical cystectomy (P = 0.03; median follow-up of 515 days). CONCLUSIONS: The SARC-F questionnaire might be applicable to identify elderly patients at a higher risk of unfavourable outcomes after major urologic cancer surgery. A randomised controlled trial is necessary to confirm this finding.

Rapid geriatric screening tools predict inability to manage stoma by oneself after urinary diversion: G8 and IADL-modified G8.

INTRODUCTION: This study aimed to evaluate whether functional screening, as assessed by the Geriatric-8 (G8) and the instrumental activities of daily living (IADL)-modified G8, are associated with the inability to manage a stoma by themselves in patients with bladder cancer who underwent robot-assisted radical cystectomy. MATERIALS AND METHODS: We analyzed a total of 110 consecutive patients with bladder cancer who underwent robot-assisted radical cystectomy and were screened preoperatively using the G8 and the IADL-modified G8 at our institution between January 2020 and December 2022. Patients who could not undergo geriatric screening at the preoperative clinic before surgery and patients who underwent orthotopic neobladder construction were excluded. We evaluated the association between clinical factors, including scores of G8 and IADL-modified G8, and the inability to manage a stoma by oneself. For both G8 and IADL-modified G8, a cutoff value of ≤14 was set. RESULTS: Of the 110 patients, the median age was 77 years, 92 (84%) patients were male and 47 (43%) patients were unable to manage a stoma by themselves. The geriatric assessment indicated that 64 patients (58%) were classified in the low G8 (≤14) group and 66 patients (60%) were classified in the low IADL-modified G8 (≤14) group. The values of area under the receiver operating characteristic curve for predicting inability to manage stoma by oneself were 0.725 for the G8 and 0.734 for the IADL-modified G8, respectively. Multivariate analysis including the G8 revealed that age ≥ 80, Charlson comorbidity index of ≥3, and G8 ≤ 14 (odds ratio [OR] = 4.9; 95% confidence interval [CI] = 1.8-13.0; P = 0.002) were independent risk factors for inability to manage a stoma by oneself. Likewise, multivariate analysis including the IADL-modified G8 revealed that age ≥ 80, Charlson comorbidity index of ≥3, and IADL-modified G8 ≤ 14 (OR = 5.4; 95% CI = 1.9-14.0; P = 0.001) were independent risk factors for inability to manage a stoma by oneself. DISCUSSION: Screening using G8 and IADL-modified G8 may predict patients who have difficulty self-managing their stomas.

Impact of perinephric fat volume and the Mayo Adhesive Probability score on time to clamping in robot-assisted partial nephrectomy.

The aim of this study is to evaluate the association of perinephric fat volume (PNFV) and the Mayo Adhesive Probability (MAP) score with time to clamping (TTC) in robot-assisted partial nephrectomy (RAPN). The study subjects consisted of 73 tumors in 72 patients who underwent transperitoneal RAPN at a single cancer center between February 2020 and July 2022. Clinical characteristics including R.E.N.A.L. nephrometry score, MAP score and PNFV were evaluated in a multivariate analysis in relation to TTC, which was classified into two groups based on median TTC. PNFV and MAP score were analyzed separately. PNFVs were measured by SYNAPSE VINCENT® by a single expert urologist. Median TTC was 67 (range: 36-119) min. Spearman's rank correlation analysis indicated that a significant correlation was observed between PNFV and MAP score with a value of 0.81 (p < 0.0001). Univariate analysis revealed that R.E.N.A.L. nephrometry score ≥ 7 (p = 0.036), posterior tumor location (p = 0.033), MAP score ≥ 3 (p = 0.02) and PNFV ≥ 250 ml (p = 0.02) were significant factors for prolonged TTC. In a multivariate analysis including PNFV (analysis 1), R.E.N.A.L. nephrometry score ≥ 7 (OR 3.54, p = 0.018) and PNFV ≥ 250cm3 (OR 3.94, p = 0.010) were independent factors for prolonged TTC. Similarly for MAP score (analysis 2), R.E.N.A.L. nephrometry score ≥ 7 (OR 3.54, p = 0.018) and MAP score ≥ 3 (OR 3.94, p = 0.010) were independent factors for prolonged TTC. Both MAP score and PNFV may have a significant impact on TTC.

Simultaneous robot-assisted nephroureterectomy and radical cystectomy.

Introduction: We present a case of simultaneous robot-assisted radical nephroureterectomy (RANU) and robot-assisted radical cystectomy (RARC) for muscle-invasive bladder cancer with concomitant upper urinary tract urothelial carcinoma. Case presentation: A 59-year-old Japanese man was diagnosed with right ureteral cancer and muscle-invasive bladder cancer. We performed RANU and RARC simultaneously; three of the ports used for RANU were diverted to RARC. Console times for RANU and RARC were 66 and 207 minutes, respectively. Total operative time was 386 minutes. The intraoperative blood loss was estimated 255 ml. The patient was discharged on postoperative day 18 without complications. Conclusion: We reported our experience with simultaneous RANU and RARC for muscle-invasive bladder cancer with concomitant right ureteral cancer. To the best of our knowledge, this is the first report of its kind in Japan.

A novel predictive model for postoperative delirium using multiple geriatric screening factors.

OBJECTIVES: The purpose of this study was to develop a new composite score to accurately predict postoperative delirium (POD) after major urological cancer surgery. METHODS: Our retrospective analysis included, in total, 449 consecutive patients who experienced major urological cancer surgery and a preoperative geriatric functional assessment at our institution (development cohort). Geriatric functional assessments included Geriatric 8, Instrumental Activities of Daily Living, and mini-cognitive assessment instrument (Mini-Cog). Multivariate analysis was used to identify factors related to POD and combined to create a predictive score. The composite score was externally validated using a cohort of 92 consecutive pancreatic cancer patients who underwent pancreaticoduodenectomy and a preoperative geriatric functional assessment (validation cohort). The predictive accuracy and performance of the composite score were evaluated using the area under the receiver operating characteristic curves (AUC) and calibration plots. RESULTS: In multivariate analysis of a development cohort, the following factors were significantly associated with POD: a Mini-Cog score of <3 (odds ratio [OR] = 9.5; p < 0.001), disability in the responsibility for medication (OR = 4.1; p = 0.03), and the preoperative use of benzodiazepine (OR = 6.4; p < 0.001). The composite score of these three factors showed excellent discrimination in predicting POD, with AUC values of 0.819 and 0.804 in development and validation cohorts, respectively. Calibration plots showing predicted probability and actual observation in both cohorts showed good agreement. CONCLUSIONS: A combined model of Mini-Cog, a disability in the responsibility for medication, and preoperative benzodiazepine use showed excellent discriminative power in predicting POD.

Predictive value of the G8 and the IADL-modified G8 screening tools for postoperative delirium following major urological cancer surgery.

INTRODUCTION: The purpose of this study was to evaluate whether the Geriatric-8 (G8) and the instrumental activities of daily living (IADL)-modified G8 are associated with the occurrence of postoperative delirium after major urological cancer surgery. MATERIALS AND METHODS: We retrospectively analyzed a total of 415 consecutive patients who underwent major urologic cancer surgery and were screened preoperatively using the G8 and the IADL-modified G8 at our institution between January 2020 and July 2021. For both the G8 and the IADL-modified G8, a cut-off value of 14 was used. All patients underwent perioperative management according to the Enhanced Recovery After Surgery protocol formulated at our institution. Delirium was diagnosed using the Confusion Assessment Method. The relationship between these screening tests and clinical variables was examined. Predictive accuracy was evaluated by the area under the receiver operating characteristic curve (AUC). To determine the risk factors for the occurrence of postoperative delirium, univariate and multivariate analyses were performed. RESULTS: Of the 415 patients, 160 (39%) were assigned to the low G8 (score ≤ 14) group and 166 (40%) to the low IADL-modified G8 (score ≤ 14) group. The median age of the patients was 72 years. Postoperative delirium occurred in 31 patients (7%). The AUC values for predicting postoperative delirium were 0.69 for the G8 and 0.71 for the IADL-modified G8. Multivariate analysis for the G8 showed that G8 ≤ 14 (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.2-6.0; P = 0.02), preoperative use of benzodiazepine (OR = 3.8; 95% CI = 1.6-8.6; P = 0.002), and operative time ≥ 237 min (OR = 3.3; 95% CI = 1.5-7.1; P = 0.003) were independent risk factors for postoperative delirium. Similarly, for the IADL-modified G8, IADL-modified G8 ≤ 14 (OR = 2.6; 95% CI = 1.1-5.8; P = 0.02), preoperative use of benzodiazepine (OR = 3.9; 95% CI = 1.7-8.8; P = 0.001), and operative time ≥ 237 min (OR = 3.3; 95% CI = 1.5-7.2; P = 0.003) were independent risk factors for postoperative delirium. DISCUSSION: The G8 and the IADL-modified G8 screening may allow for better identification of patients at risk of postoperative delirium.