Fast track program in patients undergoing radical cystectomy: results in 362 consecutive patients.

BACKGROUND: This article outlines our current perioperative management of patients undergoing cystectomy and urinary diversion using advancements in perioperative care to allow for early institution of an oral diet and early hospital discharge. STUDY DESIGN: Three hundred sixty-two consecutive patients underwent radical cystectomy and urinary diversion with curative intent (2001 through 2008). Each underwent a perioperative care plan ("fast track" program). Throughout our experience, evidence-based modifications to this program were instituted. We analyzed the impact of these modifications and report the outcomes with the most recent 100 patients in whom no additional modification has been used. RESULTS: Mean age of patients is 66.3 years, with 44% of the patients older than age 70 years and 12% older than age 80 years. We found no detrimental effects to immediate removal of the orogastric tube at the end of the procedure, but found a beneficial effect of empiric metoclopramide use, with lower rates of nausea and vomiting. Perioperative antibiotic coverage has been reduced to 24 hours as per American Urological Association guidelines. Gum-chewing has also been shown to be of benefit with regard to a more rapid recovery of bowel function. Use of nonnarcotic analgesics (eg, ketrolac) has also been central in the pathway. Finally, early institution of an oral diet has been an original and central component to our fast track program. CONCLUSIONS: Successful application of a fast track program has been applied to our patients undergoing radical cystectomy and urinary diversion, with the potential to use evidence-based modifications to reduce morbidity and improve recovery.

Robotic-assisted laparoscopic intracorporeal urinary diversion.

BACKGROUND: Recent small case series have now been reported for robotic-assisted laparoscopic radical cystectomy (RALRC). In most of these series, the urinary diversion has been performed in an extracorporeal fashion. There have been few case reports of an intracorporeal diversion and little description of the technique of such a procedure. OBJECTIVE: In this paper, we report our initial experience with robotic-assisted laparoscopic intracorporeal urinary diversion, describing stepwise the surgical procedure itself and evaluating perioperative and pathologic outcomes of this novel procedure. DESIGN, SETTING, AND PARTICIPANTS: We studied a single-institution case series of patients undergoing robotic-assisted cystectomy and intracorporeal urinary diversion for clinically localized urothelial carcinoma of the bladder (n=10) or for a noncompliant dysfunctional bladder refractory to more conservative management (n=2). Historical comparisons are also made to a consecutive case series of 20 patients undergoing robotic radical cystectomy and extracorporeal urinary diversion. SURGICAL PROCEDURE: RALRC and intracorporeal urinary diversion, including ileal conduit (n=9) and orthotopic ileal neobladder (n=3). MEASUREMENTS: The stepwise operative procedure is described in detail. Outcome measures evaluated in this series included operative variables, hospital recovery, and complication rate. Comparisons were made to a contemporaneous series of 20 patients who underwent a robotic cystectomy with extracorporeal diversion during this time period (from an experience of >100 robotic cystectomy patients since 2005). RESULTS AND LIMITATIONS: Twelve patients (mean age: 60.9 yr) underwent an intracorporeal diversion. Mean operating-room time of all patients was 5.3h, and mean surgical blood loss was 221ml. Mean time to flatus, bowel movement, and hospital discharge was 2.2 d, 3.2 d, and 4.5 d, respectively. Eleven of the 12 patients were discharged on or before postoperative day 5. There were six postoperative complications in five patients (42%), with one complication being Clavien grade 3 or higher. The major limitations of the study are the small sample size and the nonrandomized nature of the compared treatment groups (intracorporeal vs extracorporeal), which limits the ability to directly compare the techniques at a high level of scientific confidence. CONCLUSIONS: Our initial experience with robotic-assisted laparoscopic intracorporeal diversion appears to be favorable with acceptable operative and short-term clinical outcomes.

Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results.

BACKGROUND: In recent years, surgeons have begun to report case series of minimally invasive approaches to radical cystectomy, including robotic-assisted techniques demonstrating the surgical feasibility of this procedure with the potential of lower blood loss and more rapid return of bowel function and hospital discharge. Despite these experiences and observations, at this point high levels of clinical evidence with regard to the benefits of robotic cystectomy are absent, and the current experiences represent case series with limited comparisons to historical controls at best. OBJECTIVE: We report our results on a prospective randomized trial of open versus robotic-assisted laparoscopic radical cystectomy with regard to perioperative outcomes, complications, and short-term narcotic usage. DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized single-center noninferiority study comparing open versus robotic approaches to cystectomy in patients who are candidates for radical cystectomy for urothelial carcinoma of the bladder. Of the 41 patients who underwent surgery, 21 were randomized to the robotic approach and 20 to the open technique. INTERVENTION: Radical cystectomy, bilateral pelvic lymphadenectomy, and urinary diversion by either an open approach or by a robotic-assisted laparoscopic technique. MEASUREMENTS: The primary end point was lymph node (LN) yield with a noninferiority margin of four LNs. Secondary end points included demographic characteristics, perioperative outcomes, pathologic results, and short-term narcotic use. RESULTS AND LIMITATIONS: On univariate analysis, no significant differences were found between the two groups with regard to age, sex, body mass index, American Society of Anesthesiologists classification, anticoagulation regimen of aspirin, clinical stage, or diversion type. Significant differences were noted in operating room time, estimated blood loss, time to flatus, time to bowel movement, and use of inpatient morphine sulfate equivalents. There was no significant difference in regard to overall complication rate or hospital stay. On surgical pathology, in the robotic group 14 patients had pT2 disease or higher; 3 patients had pT3/T4 disease; and 4 patients had node-positive disease. In the open group, eight patients had pT2 disease or higher; five patients had pT3/T4 disease; and seven patients had node-positive disease. The mean number of LNs removed was 19 in the robotic group versus18 in the open group. Potential study limitations include the limited clinical and oncologic follow-up and the relatively small and single-institution nature of the study. CONCLUSIONS: We present the results of a prospective randomized controlled noninferiority study with a primary end point of LN yield, demonstrating the robotic approach to be noninferior to the open approach. The robotic approach also compares favorably with the open approach in several perioperative parameters.

Robotic radical cystectomy for bladder cancer: surgical and pathological outcomes in 100 consecutive cases.

PURPOSE: Radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. Recently some surgeons have begun to describe outcomes associated with less invasive surgical approaches to this disease such as laparoscopic or robotic assisted techniques. We report our maturing experience with 100 consecutive cases of robotic assisted laparoscopic radical cystectomy with regard to perioperative results, pathological outcomes and surgical complications. MATERIALS AND METHODS: A total of 100 consecutive patients (73 male and 27 female) underwent robotic radical cystectomy and urinary diversion at our institution from January 2006 to January 2009 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes and complication rate. RESULTS: Mean age of this cohort was 65.5 years (range 33 to 86). Of the patients 61 underwent ileal conduit diversion, 38 received a neobladder and 1 had no urinary diversion (renal failure). Mean operating room time for all patients was 4.6 hours (median 4.3) and mean surgical blood loss was 271 ml (median 250). On surgical pathology 40% of the cases were pT1 or less disease, 27% were pT2, 13% were pT3/T4 disease and 20% were node positive. Mean number of lymph nodes removed was 19 (range 8 to 40). In no case was there a positive surgical margin. Mean days to flatus were 2.1, bowel movement 2.8 and discharge home 4.9. There were 41 postoperative complications in 36 patients with 8% having a major complication (Clavien grade 3 or higher) and 11% being readmitted within 30 days of surgery. At a mean followup of 21 months 15 patients had disease recurrence and 6 died of disease. CONCLUSIONS: We report a relatively large and maturing experience with robotic radical cystectomy for the treatment of bladder cancer providing acceptable surgical and pathological outcomes. These results support continued efforts to refine the surgical management of high risk bladder cancer.