Influence of laparoscopic surgery on the outcomes of radical cystectomy within a multimodal rehabilitation protocol.

INTRODUCTION AND OBJECTIVE: The implementation of Enhanced Recover After Surgery (ERAS) multimodal rehabilitation protocols in radical cystectomy has shown to improve outcomes in hospital stay and complications. The aim of this analysis is to evaluate the impact of laparoscopic surgery on radical cystectomy within a multimodal rehabilitation program. MATERIAL AND METHODS: The study was carried out in a third level center between 2011 and 2020 including patients with bladder cancer submitted to radical cystectomy according to an ERAS (Enhanced Recovery After Surgery) protocol and the Spanish Multimodal Rehabilitation Group (GERM) with 20 items to be fulfilled. RESULTS: A total of 250 radical cystectomies were performed throughout the study period, 42.8% by open surgery (OS) and 57.2% by laparoscopic surgery (LS). The groups are comparable in demographic and clinical variables (p > 0.05). Operative time was longer in the LS group (248.4 ±â€¯55.0 vs. 286.2 ±â€¯51.9 min; p < 0.001). However, bleeding was significantly lower in the LS group (417.5 ±â€¯365.7 vs. 877.9 ±â€¯529.7 cc; p < 0.001), as was the need for blood transfusion (33.6% vs. 58.9%; p < 0.001). Postoperative length of stay (11.5 ±â€¯10.5 vs. 20.1 ±â€¯17.2 days; p < 0.001), total and major complications were also significantly lower in this group (LS). The readmission rate was lower in the LS group but not significantly (36.4% vs. 29.4%; p = 0.237). The difference between 90-day mortality in both groups was not statistically significant (2.8% LS vs. 4.3% OS; p = 0.546). The differences were maintained in the multivariate models. CONCLUSIONS: Laparoscopic surgery within a multimodal rehabilitation program increases operative time but significantly decreases intraoperative bleeding, transfusion requirements, postoperative length of stay, and complications.

Resultados perioperatorios y oncológicos a largo plazo de los pacientes con variantes histológicas de cáncer vesical sometidos a cistectomía radical: un análisis de emparejamiento por índices de propensión con carcinoma urotelial puro / The perioperative and long-term outcomes of patients with variant histology bladder cancer undergoing radical cystectomy: A propensity score-matched analysis with pure urothelial carcinoma

Objetivos Evaluar los resultados perioperatorios y a largo plazo de la cistectomía radical en los pacientes con variantes histológicas frente a los pacientes con patrón histológico de carcinoma urotelial puro. Métodos Los pacientes diagnosticados de carcinoma vesical con variantes histológicas fueron emparejados con aquellos diagnosticados de carcinoma urotelial puro en una proporción de 1:3 mediante un análisis de puntuación de propensión. Los 2 grupos se compararon en términos de resultados perioperatorios y morbimortalidad a largo plazo. Resultados En el presente estudio retrospectivo se incluyeron 148 individuos (37 con variantes histológicas de CU y 111 con carcinoma urotelial puro). Un total de 107 (72,3%) individuos presentaron al menos una complicación perioperatoria según la clasificación de Clavien-Dindo. Esta proporción fue similar entre los pacientes con carcinoma urotelial frente a aquellos con variante histológica (p=0,22). En cuanto a las complicaciones a largo plazo, el número de pacientes con hernia incisional clínicamente significativa que requirió cirugía (14 [12,7%] frente a 3 [8,3%]; p=0,68], estenosis uretero-intestinal/uretero-cutánea o cualquier otra complicación relacionada con la derivación urinaria aplicada (15 [13,6%] frente a 7 [19,4%]; p=0,56], o el número de pacientes que presentaron septicemia (17 [15,5%] frente a 10 [27,8%]; p=0,16] u obstrucción del tracto urinario (12 [10,9%] frente a 4 [11,1%]; p>0,99] durante el seguimiento fue similar para el grupo carcinoma urotelial y el de variante histológica. Según el análisis de supervivencia con curvas de Kaplan-Meier y el modelo de regresión de Cox univariante, el riesgo de muerte por cualquier causa era mayor en los pacientes con variante histológica que en los de patrón histológico puro (log-rank test=0,045; hazard ratio: 1,7; intervalo de confianza del 95%: 1,01-2,87; p=0,047). Conclusiones La morbimortalidad perioperatorias son comparables . (AU)

Objectives To assess the perioperative and long-term outcomes after open radical cystectomy in patients with histological variants versus pure urothelial carcinoma. Methods Patients with a variant histology carcinoma of the urinary bladder were matched through a propensity score analysis with those with pure urothelial carcinoma on a 1:3 ratio. The two groups were compared in terms of perioperative and long-term morbidity and mortality. Results Overall, 148 individuals were included in the present retrospective study (37 with variant histology and 111 with pure urothelial carcinoma). A total of 107 (72.3%) individuals presented at least one perioperative complication based on the Clavien-Dindo classification. This proportion was similar between patients with urothelial versus variant histology carcinoma (P=.22). In the long term, the number of patients with clinically significant incisional hernia requiring surgery [14 (12.7%) vs 3 (8.3%), P=.68], uretero-intestinal/uretero-cutaneous strictures or any other complication related to the applied urinary diversion [15 (13.6%) vs 7 (19.4%), P=.56], as well as the number of patients presenting with septicemia [17 (15.5%) vs 10 (27.8%), P=.16] or with urinary tract obstruction [12 (10.9%) vs 4 (11.1%), P>.99] at follow-up did not differ between urothelial versus variant histology carcinoma. The survival analysis with Kaplan-Meier curves and the univariate Cox regression model suggested that the risk of death from any cause was increased in patients with variant compared to pure urothelial histology (log-rank test=.045, hazard ratio: 1.7, 95% confidence interval: 1.01-2.87, P=.047). Conclusions Perioperative morbidity and mortality are comparable in patients with variant histology versus pure urothelial carcinoma. (AU)

Aplicación de protocolos ERAS (Enhanced Recovery After Surgery) en pacientes cistectomizados: el camino hacia la estandarización. Una revisión sistemática / Implementation of ERAS (Enhanced Recovery After Surgery) protocols for radical cystectomy patients: The pathway to standardization. A systematic review

CONTEXTO: El desarrollo de protocolos ERAS (Enhanced Recovery After Surgery) en pacientes sometidos a cirugía mayor ha aportado beneficios perioperatorios en diversas disciplinas. En urología, su principal aplicación se centra en pacientes sometidos a cistectomía radical. OBJETIVO: Revisión sistemática de la literatura disponible de protocolos ERAS aplicados a pacientes intervenidos de cistectomía radical, tanto a nivel de resultados perioperatorios como en el análisis de su implementación. Adquisición de la evidencia: Se realizó búsqueda bibliográfica en base de datos electrónicas Pubmed, Embase, Cochrane y Scopus, utilizando los términos «Cystectomy», «Enhanced Recovery After Surgery» y «Fast-Track». Se seleccionaron estudios aleatorizados y no aleatorizados que comparasen la implementación de un protocolo ERAS en pacientes sometidos a cistectomía radical frente a un protocolo tradicional. Síntesis de la evidencia: Se identificaron 869 artículos; 25 fueron seleccionados para el análisis final: 22 estudios no aleatorizados y 3 aleatorizados. No se detectaron diferencias en cuanto a características demográficas entre los distintos estudios. Se identificaron diferencias estadísticamente significativas a favor del protocolo ERAS en tiempo de estancia hospitalaria, tasa de complicaciones mayores, tiempo a primera deambulación y recuperación intestinal. En el análisis de protocolos se detectó una alta variabilidad, tanto en número de ítems como en método de implementación. CONCLUSIONES: El carácter multidisciplinar y el número de ítems de los protocolos ERAS conlleva una alta heterogeneidad en su implementación. Se requieren más estudios aleatorizados, estandarización a la hora de reportar y analizar resultados, así como un análisis sistemático de la adherencia posterior para aumentar la comparabilidad entre grupos

CONTEXT: The development of ERAS (Enhanced Recovery After Surgery) protocols in patients undergoing major surgery has brought perioperative benefits in several disciplines. Its main application in urology is focused on patients undergoing radical cystectomy. OBJECTIVE: Systematic review of the available literature on ERAS protocols applied to patients undergoing radical cystectomy in terms of perioperative outcomes as well in the analysis of their implementation. Evidence acquisition: A bibliographic search was conducted in the electronic databases PubMed, Embase, Cochrane and Scopus, using the terms «Cystectomy», «Enhanced Recovery After Surgery» and «Fast-Track». Randomized and non-randomized studies that compared the implementation of an ERAS protocol versus a traditional protocol in patients undergoing radical cystectomy were selected. Evidence synthesis: 869 articles were identified; 25 were selected for final analysis: 22 non-randomized and 3 randomized studies. No differences were observed in terms of demographic characteristics between studies. Statistically significant differences were identified in favor of the ERAS protocol: length of hospital stay, major complication rate, time to first ambulation and return of bowel function. In the analysis of protocols, a high variability was detected in the number of items and in the implementation method. CONCLUSIONS: The multidisciplinary nature and the number of items of the ERAS protocols imply a high heterogeneity in their implementation. Further randomized studies, standardized reporting and analyzing results, as well as a systematic analysis of subsequent adherence are required to increase comparability between groups

Multimodal Prehabilitation to Enhance Functional Capacity Following Radical Cystectomy: A Randomized Controlled Trial.

BACKGROUND: In patients with bladder cancer, poor functional status has remarkable deleterious effects on postoperative outcome and prognosis. Conditioning intervention initiated before surgery has the potential to reduce functional decline attributable to surgery. Nonetheless, evidence is lacking in patients undergoing radical cystectomy. OBJECTIVE: To determine whether a preoperative multimodal intervention (prehabilitation) is feasible and effective in radical cystectomy. DESIGN, SETTING, AND PARTICIPANTS: This study, conducted at an academic tertiary health care institution, enrolled adult patients scheduled for radical cystectomy. From August 2013 to October 2017, 70 patients were randomized: 35 to multimodal prehabilitation (prehab group) and 35 to standard care (control group). INTERVENTION: Multimodal prehabilitation was a preoperative conditioning intervention including aerobic and resistance exercise, diet therapy, and relaxation techniques. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was perioperative change in functional capacity, measured with the distance covered during a 6-min walk test (6MWD), assessed at baseline, before surgery, and at 4 and 8 wk after surgery. Data were compared using robust mixed linear models for repeated measures. RESULTS AND LIMITATIONS: Preoperative change in 6MWD compared with baseline was not significantly different between groups (prehab group 40.8 [114.0] m vs control group 9.7 (108.4) m, p=0.250). However, at 4 wk after surgery, a significant difference in functional capacity was detected (6MWD, prehab group -15.4 [142.5] m vs control group -97.9 [123.8] m, p=0.014). No intervention-related adverse effects were reported. CONCLUSIONS: Data suggested that multimodal prehabilitation resulted in faster functional recovery after radical cystectomy. PATIENT SUMMARY: After major cancer surgery, people usually feel week and tired, and have less energy to perform activities of daily living. In this study, we showed that using the time before surgery to promote exercise and good nutrition could fasten recovery after the surgical removal of the bladder.

Effect of neurovascular bundle sparing radical cystectomy on post-operative continence and sexual function: A systematic review and meta-analysis.

BACKGROUND: It is unclear whether the neurovascular bundle (NVB) sparing could improve post-operative urinary continence and potency. Furthermore, concern remains regarding the impact of nerve-sparing (NS) radical cystectomy (RC) on oncological outcomes. OBJECTIVES: The primary objective of this meta-analysis was to evaluate whether in men undergoing NS RC could improve post-operative urinary continence and potency. The secondary objective was to assess whether NS RC could compromise the oncological control. MATERIALS AND METHODS: A systematic search of the PubMed and Web of Science was performed in February 2020, yielding 1446 unique records. A total of 13 comparative cohort studies were included. Risk of bias in each study was assessed separately by two authors using the Newcastle-Ottawa Scale (NOS). RESULTS: Data from 921 participants in 12 studies were synthesized in the present meta-analysis. Meta-analysis revealed that NS compared with non-nerve sparing (NNS) results in improved post-operative potency, daytime continence, and nocturnal continence. RRs were 9.35 (P < .00001) in potency, 1.11 (P = .045) in daytime continence, and 1.33 (P = .002) in nocturnal continence, respectively. Furthermore, no differences were found in the included studies reporting oncological outcomes. RRs were 0.88 (P = .61) in local and/or distant recurrence between two groups. A sensitivity analysis of prospective studies indicated consistent results. DISCUSSION AND CONCLUSION: This meta-analysis indicates that NS RC can improve post-operative potency, and daytime and nocturnal urinary continence, without compromising oncological control, compared with NNS RC in men.

Impact of Perioperative Multidisciplinary Rehabilitation Pathway on Early Outcomes after Robot-assisted Radical Cystectomy: A Matched Analysis.

OBJECTIVE: To investigate the effect of incorporating physical rehabilitation, nutrition and psychosocial care as part of the "NEEW" (Nutrition, Exercise, patient Education and Wellness) on perioperative outcomes after robot-assisted radical cystectomy. METHODS: Patients were divided into 2 groups: pathway group (NEEW in addition to enhanced recovery after surgery), vs prepathway group, before NEEW initiation (enhanced recovery after surgery only). Propensity score matching was performed (ratio 1:2 ratio). Perioperative outcomes were analyzed and compared. Multivariate analyses were modeled to assess for association between NEEW pathway and postoperative outcomes. RESULTS: One hundred and niney-two were included in the study: 64 patients (33%) in the pathway group vs 128 patients (67%) in the prepathway group. Pathway group had shorter median inpatient stay (5 vs 6 days, P <.01), faster bowel recovery (3 vs 4 days, P <.01), and better pain scores, and demonstrated fewer 30-day high grade complications (5% vs 16%, P = .02). On multivariate analysis, the NEEW pathway was associated with shorter hospital stay (1.75 days shorter), faster bowel recovery (1 day faster), longer functional mobility time (4 minutes longer) and less pain scores (average 1 point less). CONCLUSION: Standardized perioperative pathway with weekly multidisciplinary team meeting was associated with improved short-term perioperative outcomes after robot-assisted radical cystectomy.

Early continence after ileal neobladder: objective data from inpatient rehabilitation.

PURPOSE: To evaluate early continence of patients who underwent inpatient rehabilitation after radical cystectomy (RC) and orthotopic bladder substitution (ONB). METHODS: We conducted a retrospective analysis on the data of 283 patients who underwent a three weeks inpatient rehabilitation after RC and ONB for bladder cancer between January 2016 and July 2017. All patients were treated with a special multimodal continence therapy. The continence status was evaluated by measuring urine loss by a 24-h pad test and urine volume on uroflowmetry at the beginning (T1) and at the end (T2) of inpatient rehabilitation. Multivariate linear regression analysis was performed to identify independent predictors of urine loss. RESULTS: Median patient age was 63 years. NS was documented for 142 patients (50.2%). Median urine loss decreased significantly (p < 0.001) in the 24-h pad test, from 442 gm at T1 (median 29 days after surgery) to 88 gm at T2 (median 50 days after surgery). Urine volume increased significantly (p < 0.001) from a median of 78 ml at T1 to a median of 157 ml at T2. Age (p = 0.002), diabetes (p = 0.031), obesity (p = 0.003), and nerve sparing (p = 0.011) were identified as independent predictors for urine loss at the end of inpatient rehabilitation. CONCLUSION: Continence improved significantly during the three weeks of inpatient rehabilitation. Younger age, the absence of diabetes or obesity, and NS resulted in better continence in the early postoperative period after ONB.

Aplicación del protocolo ERAS (Enhanced Recovery After Surgery) en cistectomía radical / Applying the ERAS (Enhanced Recovery After Surgery) protocol in radical cystectomy

El protocolo ERAS (Enhanced Recovery After Surgery), se originó en la década de los 90 cuando dos grupos de investigadores presentaron diferentes propuestas para mejorar la evolución postoperatoria de los pacientes intervenidos en cirugía electiva. En el año 2001 se organizó el grupo ERAS integrado por diferentes unidades de cirugía procedentes del norte de Europa (Escocia, Suecia, Dinamarca, Noruega y Holanda). Este grupo realizó un consenso que denominaron el proyecto ERAS, caracterizado por un programa de rehabilitación multimodal para pacientes intervenidos quirúrgicamente de manera programada. El protocolo incluye una combinación de estrategias preoperatorias, intraoperatorias y postoperatorias basadas en la evidencia científica de que mejorar la recuperación y funcionalidad de los pacientes posterior al evento quirúrgico minimiza la respuesta al estrés quirúrgico. Además, esta actuación sobre factores implicados en la respuesta biológica a la agresión impacta en las complicaciones postoperatorias, y disminuye la estancia hospitalaria y los costos de hospitalización. El equipo de profesionales encargado del paciente es responsable de tres elementos clave que afectan el resultado después de la cirugía: el primero es el control de las reacciones de estrés a la cirugía, el segundo la terapia de fluidos y el tercero la analgesia. El reconocimiento de la importancia de estos tres componentes del protocolo ERAS ha llevado a la descripción de un "enfoque trimodal" para la optimización de los resultados en la cirugía urológica como la cistectomía radical

The ERAS (Enhanced Recovery After Surgery) protocol, originated in the 1990s when two groups of researchers presented different proposals to improve the postoperative evolution of patients undergoing elective surgery. In 2001, the ERAS group was organized, consisting of different surgery units from northern Europe (Scotland, Sweden, Denmark, Norway, and the Netherlands). This group made a consensus that they called the ERAS project, characterized by a multimodal rehabilitation program for surgically operated patients on a scheduled basis. The protocol includes a combination of preoperative, intraoperative, and postoperative strategies based on scientific evidence. That improves the recovery and functionality of patients after the surgical event minimizes the response to surgical stress. Besides, this action on factors involved in the biological response to aggression impacts postoperative complications and decreases hospital stay and hospitalization costs. The professionals in charge of the patient are responsible for three key elements that affect the outcome after surgery: the first is the control of stress reactions to surgery, the second is fluid therapy, and the third is analgesia. The trimodal approach leads to improving the results in urological surgery, such as radical cystectomy

The CanMoRe trial - evaluating the effects of an exercise intervention after robotic-assisted radical cystectomy for urinary bladder cancer: the study protocol of a randomised controlled trial.

BACKGROUND: Patients who have undergone radical cystectomy for urinary bladder cancer are not sufficiently physically active and therefore may suffer complications leading to readmissions. A physical rehabilitation programme early postoperatively might prevent or at least alleviate these potential complications and improve physical function. The main aim of the CanMoRe trial is to evaluate the impact of a standardised and individually adapted exercise intervention in primary health care to improve physical function (primary outcome) and habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications in patients undergoing robotic-assisted radical cystectomy for urinary bladder cancer. METHODS: In total, 120 patients will be included and assigned to either intervention or control arm of the study. All patients will receive preoperative information on the importance of early mobilisation and during the hospital stay they will follow a standard protocol for enhanced mobilisation. The intervention group will be given a referral to a physiotherapist in primary health care close to their home. Within the third week after discharge, the intervention group will begin 12 weeks of biweekly exercise. The exercise programme includes aerobic and strengthening exercises. The control group will receive oral and written information about a home-based exercise programme. Physical function will serve as the primary outcome and will be measured using the Six-minute walk test. Secondary outcomes are gait speed, handgrip strength, leg strength, habitual physical activity, health-related quality of life, fatigue, psychological wellbeing and readmissions due to complications. The measurements will be conducted at discharge (i.e. baseline), post-intervention and 1 year after surgery. To evaluate the effects of the intervention mixed or linear regression models according to the intention to treat procedure will be used. DISCUSSION: This proposed randomised controlled trial has the potential to provide new knowledge within rehabilitation after radical cystectomy for urinary bladder cancer. The programme should be easy to apply to other patient groups undergoing abdominal surgery for cancer and has the potential to change the health care chain for these patients. TRIAL REGISTRATION: ClinicalTrials.gov. Clinical trial registration number NCT03998579 . First posted June 26, 2019.

Enhanced recovery after surgery (ERAS) protocols in patients undergoing radical cystectomy with ileal urinary diversions: A randomized controlled trial.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols were introduced in clinical practice to reduce complication rates and hospital stay. We performed a randomized controlled single center study to evaluate perioperative benefits of an adapted ERAS protocol in patients with bladder cancer who underwent radical cystectomy (RC) and ileal urinary diversions (IUD). MATERIALS AND METHODS: Forty five from 90 consecutive randomized patients were enrolled in an adapted ERAS protocol. Length of stay, diet issues, return of bowel function, readmission rates and complications were examined. RESULTS: Among patients following ERAS protocol, we found a significant reduction in time to first flatus (1 vs 5 days, P < .001), time to first stool (2 vs 5 days, P < .001), time to normal diet (5 vs 6 days, P < .001) and length of stay (16 vs 18 days, P < .001). Also, postoperative ileus at less than 4 days was lower than in non-ERAS patients (15.6% vs 24.4%), but with a marginal trend toward significance (P = .05). Readmission rate was lower in the ERAS group, but the difference did not reach statistical significance. We also found a lower readmission and complication rate in patients with ERAS protocol (6.6% vs 11.1%, P = .23 and 46.6% vs 57.5%, P = .29, respectively). CONCLUSIONS: Implementation of ERAS protocol for patients undergoing RC in our center was associated with a significant reduction in the time to the first flatus, time to the first stool, time to a normal diet, length of hospital stay.

Reducing Readmissions Following Radical Cystectomy: Moving Beyond Enhanced Recovery.

OBJECTIVE: To assess readmission outcomes of a traditional ER pathway as well as a targeted postdischarge intervention aimed at reducing hospital readmissions following RC. METHODS: A prospectively maintained clinical database was used to identify patients undergoing RC before and after implementation of an ER protocol at our institution. An additional intervention aimed at reducing hospital readmission included close postdischarge follow-up and outpatient intravenous hydration (ER+). Inpatient length of stay (LOS) and readmission rates were compared between groups using Wilcoxon Rank Sum and chi-square, respectively. Univariate and multivariate logistic regression was used to identify factors associated with hospital readmission. RESULTS: A total of 320 patients underwent RC, including 111 and 209 patients before and after ER implementation. Median (IQR) LOS decreased from 8.0 (6.0-11.0) days to 5.0 (4.0-7.0) days following ER implementation (P <.0001). Readmissions, however, were unchanged following ER implementation (P = .49). An additional targeted readmission reduction intervention (ER+) was associated with significantly reduced hospital readmissions compared to traditional ER alone (ER+ 5.9%, traditional ER 20.3%, P = .017). CONCLUSION: ER protocols consistently demonstrate reductions in LOS, and should be the standard of care following RC. In order to reduce readmissions, the urologic community must expand beyond traditional ER pathways. We report significant reductions in hospital readmission among RC patients receiving a targeted postdischarge intervention beyond traditional ER alone.

Can robotic-assisted radical cystectomy provide patients with a smaller trauma and faster recovery period? A systematic review and meta-analysis of comparative trials.

OBJECTIVE: This article explores the differences in the effectiveness and safety of the treatment of bladder cancer (BC) by robotic-assisted radical cystectomy (RARC) and laparoscopic radical cystectomy (LRC). METHODS: A systematic search was performed using databases including Medline, PubMed and Web of Science within a limited period from January 1, 2000, to September 1, 2019. RevMan 5.3 was used for calculation and statistical analyses. RESULTS: We performed meta-analysis on operation time, estimated blood loss, intraoperative blood transfusion, positive surgical margin, oral intake time, length of hospital stay, complication and other indicators, and found that there were no statistically significant differences between LRC and RARC. CONCLUSION: Our meta-analysis results show that LRC and RARC have similar results on the effectiveness and safety of BC. For those medical institutions that cannot perform robot-assisted surgery but are seeking minimally invasive and faster postoperative recovery, LRC is worth considering. However, a larger sample size, more rigorous design and longer follow-up randomized controlled trials are still needed to support our conclusions.

HRQOL related to urinary diversion in Radical Cystectomy: a systematic review of recent literature.

INTRODUCTION: The health-related QoL is a patient-centered evaluation covering several aspects. This evaluation seems to be particularly important in patients submitted to radical cystectomy (RC) and urinary diversion with ileal conduit (IC) or a neobladder (NB). OBJECTIVE: Review all recent data comparing QoL outcomes after radical cystectomy with NB and IC diversions. EVIDENCE ACQUISITION: A systematic search in PubMed/Medline, Embase, and Cochrane databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement in December 2018. All articles published from January 01, 2012 to December 31, 2018, were included. A study was considered relevant if it compared QoL outcomes using validated questionnaires (EORTC QLQ C30, FACT-G, FACT-BL, FACT-VCI, and BCI). EVIDENCE SYNTHESIS: In 11 included studies, a total of 1389 participants were accounted (730 NB and 659 IC cases). The studies were conducted in 8 different countries, two were prospective, and none was randomized. There were two studies favoring results with a neobladder, 3 with incontinent diversion and 6 with no differences. The EORTC-QLQ-C30 was the most used instrument (5 studies) followed by FACT VCI and BCI (3 studies each). Given the heterogeneity of data and lack of prospective studies, a meta-analysis was not performed. CONCLUSION: No superiority of one urinary diversion was characterized. It seems that the choice must be individualized with an extensive preoperative orientation of the patient and their relatives. That will probably infl uence how the patient accepts the new condition.

Guía RICA en la cistectomía / No disponible

Los pacientes quirúrgicos experimentan, cada vez más, importantes beneficios derivados de los avances en anestesia, en el control del dolor, en la cirugía mínimamente invasiva y en la asistencia perioperatoria. Por otra parte, aumenta el número de procedimientos, la edad de los pacientes y consecuentemente el riesgo de padecer complicaciones. Los programas de rehabilitación multimodal (PRM) surgen en los años 90 como un nuevo concepto del cuidado pre y posoperatorio, cuyo objetivo principal es disminuir la estancia hospitalaria mediante la reducción de complicaciones posoperatorias y del estrés quirúrgico. Presentamos el documento que alberga todo el proceso de rehabilitación y recuperación (RICA) para pacientes cistectomizados en nuestro hospital

Surgical patients experience significant benefits provided by advances in anaesthesia, pain control, minimally invasive surgery, and preoperative assessment. Furthermore, its importance is enhanced if we consider, patient’s age and consequently the risk of developing consequences. The aim of multimodal rehabilitation programs (MMRP) is to decrease the impact of the length of hospital stay by reducing postoperative complications and stress response to surgery. The present study attempts to show the rehabilitation process and recovery for cystectomized patients in our hospital

HRQOL related to urinary diversion in Radical Cystectomy: a systematic review of recent literature

ABSTRACT Introduction: The health-related QoL is a patient-centered evaluation covering several aspects. This evaluation seems to be particularly important in patients submitted to radical cystectomy (RC) and urinary diversion with ileal conduit (IC) or a neobladder (NB). Objective: Review all recent data comparing QoL outcomes after radical cystectomy with NB and IC diversions. Evidence Acquisition: A systematic search in PubMed/Medline, Embase, and Cochrane databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement in December 2018. All articles published from January 01, 2012 to December 31, 2018, were included. A study was considered relevant if it compared QoL outcomes using validated questionnaires (EORTC QLQ C30, FACT-G, FACT-BL, FACT-VCI, and BCI). Evidence Synthesis: In 11 included studies, a total of 1389 participants were accounted (730 NB and 659 IC cases). The studies were conducted in 8 different countries, two were prospective, and none was randomized. There were two studies favoring results with a neobladder, 3 with incontinent diversion and 6 with no differences. The EORTC-QLQ-C30 was the most used instrument (5 studies) followed by FACT VCI and BCI (3 studies each). Given the heterogeneity of data and lack of prospective studies, a meta-analysis was not performed. Conclusion: No superiority of one urinary diversion was characterized. It seems that the choice must be individualized with an extensive preoperative orientation of the patient and their relatives. That will probably influence how the patient accepts the new condition.

Benefits and Complications during the Stay at an Early Rehabilitation Facility after Radical Cystectomy and Orthotopic Ileum Neobladder Reconstruction.

PURPOSE: Early rehabilitation (ER) after radical cystectomy (RC) seems to be crucial for quality of life, education and prevention of complications after hospital discharge. We investigated an inpatient ER setting for bladder cancer (BC) patients. METHODS: In total, 103 BC patients who underwent ileum neobladder reconstruction were included. The major issues from the patients' point of view, functional outcome parameters and complications during ER were analysed. A Wilcoxon signed rank test was used to compare body mass index (BMI) and diurnal as well as nocturnal use of urinary pads before and after ER. RESULTS: At the beginning of ER, the median Karnovsky performance scale score was 70% (interquartile range [IQR] 70-90%) and the mean BMI was 25.8 kg/m2 (IQR 21.9-27.9). The 4 most common complaints were urinary incontinence (80.6%), general weakness (73.8%), urinary mucus (49.5%) and mental distress (44.7%). During the programme, 28.2% of patients had a urinary tract infection requiring antibiotics and 15.5% presented a symptomatic acidosis. Median diurnal use of urinary pads significantly decreased during ER (4 vs. 3; p < 0.001). At the end of the ER programme, 76.0, 54.8 and 30.8% of the patients indicated an improvement of their physical capacity, incontinence and psychological distress respectively. CONCLUSIONS: Our study demonstrates the need for postoperative rehabilitation after RC. Further investigations should compare outcome parameters to ambulatory and outpatient ER models.

An Update in Enhanced Recovery Following Radical Cystectomy.

PURPOSE OF REVIEW: The purpose of the study is to review and summarize major additions to the literature as pertains to enhanced recovery protocols after radical cystectomy in the past year. RECENT FINDINGS: Enhanced recovery after surgery protocols is multimodal pathways that include elements to optimize all stages of care including preoperative, intraoperative and postoperative measures. Several authors have recently presented their results with initial implementation of an enhanced recovery protocol after radical cystectomy, while others have begun to examine outcomes beyond the index admission and to refine the various targeted components of the protocol. Enhanced recovery after surgery protocols has revolutionized patient care following radical cystectomy, a procedure still burdened by high complication rates and lengthy hospital stay. Although still lacking in universal implementation and standardization of the protocol, significant advancements are made each year as we move towards best practice.

Efficacy and safety of low-intensity shock wave therapy in penile rehabilitation post nerve-sparing radical cystoprostatectomy: a randomized controlled trial.

AIM: To evaluate the role of low-intensity extra corporeal shock wave therapy (LI-ESWT) in penile rehabilitation (PR) post nerve-sparing radical cystoprostatectomy (NS-RCP). MATERIALS AND METHODS: This study included 152 sexually active men with muscle invasive bladder cancer. After bilateral NS-RCP with orthotopic diversion by a single expert surgeon between June 2014 and July 2016, 128 patients were available categorized into three groups: LI-ESWT group (42 patients), phosphodiesterase type-5 inhibitors (PDE5i) group (43 patients), and control group (43 patients). RESULTS: Mean age was 53.2 ± 6.5 years. Mean ± SD follow-up period was 21 ± 8 months. During first follow-up FU1, all patients of the three groups had insufficient erection for vaginal penetration; with decrease of preoperative IIEF-EF mean score from 27.9 to 6.9. Potency recovery rates at 9 months were 76.2%, 79.1%, and 60.5% in LI-ESWT, PDE5i, and control groups, respectively. There was statistically significant increase in IIEF-EF and EHS scores during all follow-up periods in all the study groups (p < 0.001). However, there was no significant difference between the three groups during all follow-up periods. Statistical evaluation showed no significant difference in continence and oncological outcomes during all follow-up points among the three groups (p = 0.55 and 0.07, respectively). CONCLUSIONS: During last follow-up, 16% more patients in LI-ESWT group had recovery of potency as compared to the control group. Although the difference is not statistically significant, but of clinical importance. LI-ESWT is safe as oral PDE5i in penile rehabilitation post nerve-sparing radical cystoprostatectomy.