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1.
J Urol ; 205(1): 174-182, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32856988

RESUMO

PURPOSE: There is a lack of data on true long-term functional outcome of orthotopic bladder substitution. The primary study objective was to report our 35-year clinical experience. MATERIALS AND METHODS: Since October 1985, 259 male patients from a large single center radical cystectomy series with complete followup of more than 60 months (median 121, range 60-267) without recurrence, irradiation or undiversion that might have affected the functional outcome, were included. RESULTS: Median age at radical cystectomy and at survey was 63 (range 23-81) and 75 (range 43-92) years, respectively. Overall 87% of patients voided spontaneously and residual-free. This rate decreased with increasing age at the time of surgery (less than 50 years old 94%, 70 years old or older 82%). Overall day/nighttime continence rates were 90%/82%. These rates decreased with increasing age at the time of surgery from 100%/88% to 87%/80%. The overall pad-free rate was 71%/47%. Bicarbonate use decreased from 51% (5 years) to 19% (25 years). Patients with a followup of more than 20 years had the lowest rate of residual urine and clean intermittent catheterization (0.0%) as well as use of more than 1 pad at daytime/nighttime (6.3%/12.5%) and mucus obstruction (0.0%). Serum creatinine showed only the age related increase. The surgical complication rate was 27% and correlated inversely with functional results (chi-squared 11.227, p <0.005), even when the younger age at the time of surgery (younger than 60 years) was related to higher rates of surgical complications (chi-squared 6.80, p <0.05). CONCLUSIONS: The ileal neobladder represents an excellent long-term option for urinary diversion with an acceptable complication rate.


Assuntos
Íleo/cirurgia , Complicações Pós-Operatórias/epidemiologia , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/efeitos adversos , Incontinência Urinária/epidemiologia , Coletores de Urina/efeitos adversos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cistectomia/efeitos adversos , Feminino , Seguimentos , Humanos , Incidência , Tampões Absorventes para a Incontinência Urinária/estatística & dados numéricos , Cateterismo Uretral Intermitente/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Prospectivos , Índice de Gravidade de Doença , Resultado do Tratamento , Bexiga Urinária/patologia , Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/patologia , Derivação Urinária/métodos , Incontinência Urinária/diagnóstico , Incontinência Urinária/etiologia , Incontinência Urinária/terapia , Adulto Jovem
2.
Urol Clin North Am ; 48(1): 51-70, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33218594

RESUMO

Robotic-assisted radical cystectomy has gained increasing popularity over the past decade. Initially, the procedure was performed with extracorporeal urinary diversion given the technical challenges of the intracorporeal approach. Since then, innovative techniques have been described to facilitate bowel manipulation, assess ureteral and mesenteric vasculature, and perform ureteroenteric and urethro-ileal anastomosis. Overcoming the learning curve associated with intracorporeal urinary diversion can lead to decreased blood loss, shorter operative times, and faster convalescence, particularly with enhanced recovery protocols. Herein we review technical points, complications, outcomes, and future innovations in intracorporeal urinary diversion."


Assuntos
Cistectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias da Bexiga Urinária/cirurgia , Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Cistectomia/estatística & dados numéricos , Recuperação Pós-Cirúrgica Melhorada , Previsões , Humanos , Curva de Aprendizado , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Derivação Urinária/estatística & dados numéricos , Derivação Urinária/tendências
3.
Medicine (Baltimore) ; 99(42): e22135, 2020 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-33080671

RESUMO

PURPOSE: We present a new approach for urine drainage in pediatric patients following laparoscopic pyeloplasty, the trans-uretero-cystic external urethral stent (TEUS). METHODS: We retrospectively identified 85 children who underwent laparoscopic pyeloplasty from July 2015 to June 2017. The included children were assigned to group A (double-J stent) or group B (TEUS). In group A, the double-J stent was removed by a cystoscopy under anesthesia after 1 month, while in group B, the external stent was removed after 5 to 7 days. We examined the durations of operation, hospital stay and the frequency of stent-related complications including urinary leakage, stent dislocation, stent occlusion, and urinary tract infection. RESULTS: The operation time was significantly longer for patients in group B than for those in group A. No significant difference was observed between the groups regarding stent-related complications. In group A, 4 patients need auxiliary stent re-insertion for the management of complications, 2 developed urinary tract infection, and 2 had stent occlusion. In group B, none needed auxiliary stent re-insertion for complications and avoided re-operation. CONCLUSIONS: In children, the outcome of external stent implantation was similar to that using double-J stent, and the use of the former approach may be beneficial for younger children.


Assuntos
Laparoscopia/métodos , Stents , Obstrução Ureteral/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Criança , Pré-Escolar , Cistoscopia , Remoção de Dispositivo , Feminino , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Derivação Urinária/métodos
5.
Int J Clin Oncol ; 25(7): 1377-1384, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32318904

RESUMO

BACKGROUND: Radical cystectomy (RC) is the primary treatment strategy for muscle invasive bladder cancer (MIBC). However, it carries a high risk of urethral recurrence (UR) in male patients. The risk factors and oncological outcomes of UR remain unclear. We aimed to identify the risk factors and oncological outcomes of UR in male patients with MIBC after RC combined with urinary diversion. METHODS: After propensity score matching, we evaluated 137 male patients with MIBC who underwent RC combined with urinary diversion at our center between January 1, 2007 and December 31, 2015. Patient demographics, comorbidity, and perioperative data were recorded. Univariate and multivariate Cox proportional hazards regression were used to estimate the hazard ratio and 95% confidence intervals. Cancer-specific survival (CSS) and overall survival (OS) were measured using the Kaplan-Meier curve with log-rank test. P < 0.05 was considered statistically significant. RESULTS: Of the 310 patients, 30 (9.7%) patients underwent UR. In the matched group, the independent risk factors of UR were history of TURB (HR = 3.069, P = 0.018), tumor stage (T3 vs. T2, HR = 3.997, P = 0.014; T4 vs. T2, HR = 2.962, P = 0.015), and tumor multifocality (HR = 2.854, P = 0.011). The CSS and OS of patients with UR were equivalent to the patients without UR (P = 0.295, P = 0.616). CONCLUSION: This propensity score-matched case-control study showed that UR is not rare in male patients with MIBC after RC combined with urinary diversion. We identified three independent risk factors of UR: history of TURB, tumor stage, and tumor mutifocality. The oncological outcomes were equivalent between patients with and without UR. These findings could help improve treatment strategies and follow-up schedules.


Assuntos
Cistectomia/métodos , Neoplasias Uretrais/patologia , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Idoso , Estudos de Casos e Controles , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Pontuação de Propensão , Modelos de Riscos Proporcionais , Fatores de Risco , Resultado do Tratamento , Neoplasias Uretrais/mortalidade , Neoplasias Uretrais/secundário , Neoplasias da Bexiga Urinária/mortalidade , Neoplasias da Bexiga Urinária/patologia
6.
Vet Surg ; 49(5): 1052-1057, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32324904

RESUMO

OBJECTIVE: To report the occurrence and describe the management of pubic fractures after the use of an extended transpelvic urethrostomy (TPU) to treat postprostatic intrapelvic urethral obstruction and laceration in a cat. ANIMAL: One 6-year-old domestic short-haired cat. STUDY DESIGN: Case report. METHODS: A cat was presented with urethral obstruction and laceration confirmed by positive contrast retrograde urethrography. Temporary urinary diversion was performed. An attempt was made to perform perineal urethrostomy, but the cranial location of the laceration precluded this technique. An extended TPU was performed, which required removal of 30% to 60% greater length of pelvic bone than has been previously described. RESULTS: Bilateral pubic ramus fractures occurred 1 week after surgery, from which the cat clinically improved with cage rest, and exhibited evidence of healing according to computed tomography after 8 weeks. CONCLUSION: Extended TPU used to treat postprostatic intrapelvic urethral laceration may lead to pubic fractures postoperatively. CLINICAL SIGNIFICANCE: It may be prudent to rest any cat that has had a TPU or extended TPU to reduce fracture risk.


Assuntos
Fraturas Ósseas/veterinária , Complicações Pós-Operatórias/veterinária , Osso Púbico/lesões , Uretra/cirurgia , Obstrução Uretral/veterinária , Animais , Gatos , Fraturas Ósseas/cirurgia , Masculino , Ossos Pélvicos , Complicações Pós-Operatórias/patologia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Reconstrutivos , Obstrução Uretral/cirurgia , Derivação Urinária/métodos
8.
J Robot Surg ; 14(6): 813-820, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32200541

RESUMO

Robot-assisted radical cystectomy with intracorporeal urinary diversion is one of the most challenging procedures in urological surgery. Over the past 15 years, this procedure has gained in popularity and the number of procedures performed has increased significantly. While ileal conduit remains the most common diversion, orthotopic neobladders are also formed in a few expert centres that have developed their technique for totally intracorporeal neobladder. The objective of this review is to summarise the techniques currently used to perform totally intracorporeal neobladder with a special focus on their functional outcomes, such as continence or sexual function. The techniques described are the Karolinska-modified Studer neobladder, the USC-modified Studer neobladder, the pyramid pouch, the Y-pouch, and the vesica Ileale Padovana, some trying to totally reproduce the steps of open surgery and others trying to simplify them. Functional outcomes vary depending on the technique performed. Standardisation in assessing outcomes is lacking, as well as objective outcome measurements with questionnaires or urodynamic assessments. Current evidence shows acceptable functional outcomes after totally intracorporeal neobladder construction, but larger prospective randomised series with longer follow-up, better defined outcomes, and more objective measurements are needed in the future.


Assuntos
Cistectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias da Bexiga Urinária/cirurgia , Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Feminino , Humanos , Íleo , Masculino , Recuperação de Função Fisiológica , Resultado do Tratamento , Neoplasias da Bexiga Urinária/fisiopatologia , Micção , Urodinâmica
9.
J Robot Surg ; 14(5): 739-744, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32020512

RESUMO

The objective was to describe our step-by-step technique for robot-assisted orthotopic "W" ileal neobladder (INB) for urinary diversion following radical cystectomy for oncological purpose, and to report the outcomes of this technique for the first six male patients treated at our center. Patients underwent robot-assisted radical cystoprostatectomy for bladder cancer and had a "W" ileal neaobladder as urinary diversion. Our surgical technique is described step by step and video illustrated. Patients and operative data were collected and reported. The Expanded Prostate Cancer Index Composite Short Form (EPIC-26) self-administered questionnaire was used to assess the urinary, sexual and bowel functions outcomes at 90 days postoperatively. The mean operative time was 475 min [420-525] and mean length of stay was 13 days [11-15]. No major complications occurred (Clavien grade ≥ 3). Regarding the continence four patients reported they leaked urine rarely or never and two patients having urine leak once a day. Two patients did not wear any pad, the four others reported using pad at night. Two patients reported urinary function as not a problem, one as a very small problem, two as a small problem and one as a moderate problem. These results from our six first cases using the technique described here are promising with interesting early functional outcomes. This has to be confirmed on larger cohort and with long-term follow-up.


Assuntos
Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Gravação em Vídeo , Adulto , Idoso , Cistectomia/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Inquéritos e Questionários , Resultado do Tratamento , Neoplasias da Bexiga Urinária/fisiopatologia
10.
Transplant Proc ; 52(2): 608-613, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32085860

RESUMO

BACKGROUND: A higher prevalence of bladder cancer is reported in solid organ recipients, and advanced cancer requires radical cystectomy combined with urinary diversion. Surgery is technically challenging in kidney transplant recipients because of urinary tract abnormalities. Here, we describe the use of a robot-assisted approach in a kidney transplant recipient. CASE PRESENTATION: The etiology of the patient's end-stage renal disease was bilateral hypoplastic kidney. The patient started to receive hemodialysis at 19 years of age and underwent living-related kidney transplant at 23 years of age. Thirteen years later, he was diagnosed with invasive urothelial carcinoma and underwent robot-assisted radical cystectomy with extracorporeal neobladder construction under open laparotomy. Surgery was indicated to enhance suture flexibility and dissection of the peribladder tissues. Although the patient had an intraperitoneal infection caused by leakage from the vesicourethral anastomosis site and required drainage of the abscess, his condition stabilized after antibiotic treatment. CONCLUSION: This case outlines the effectiveness of the robot-assisted approach in patients with urinary tract abnormalities, such as kidney transplant recipients.


Assuntos
Cistectomia/métodos , Falência Renal Crônica/cirurgia , Transplante de Rim/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Derivação Urinária/métodos , Carcinoma de Células de Transição/complicações , Carcinoma de Células de Transição/cirurgia , Humanos , Falência Renal Crônica/etiologia , Masculino , Resultado do Tratamento , Neoplasias da Bexiga Urinária/complicações , Neoplasias da Bexiga Urinária/cirurgia , Adulto Jovem
11.
Arch Ital Urol Androl ; 91(4): 230-236, 2020 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-31937087

RESUMO

INTRODUCTION AND AIM: Radical Cystectomy (RC) with ileal urinary diversion is one of the most complex urological surgical procedure, and many Fast Track (FT) protocols have been described to reduce hospitalization, without increasing postoperatory complications. We present the one-year results of a dedicated protocol developed at a high volume centre. MATERIALS AND METHODS: The FT protocol was designed after a review of the literature and a multidisciplinary collegiate discussion, and it was applied to patients scheduled to open RC with intestinal urinary diversion. To validate its feasibility, we compared its results with data collected from a 1:1 matched population of patients who had undergone the same surgical procedure, without the implementation of the FT protocol. RESULTS: We enrolled in the FT group 11 (55%) patients scheduled to RC with ileal conduit diversion, and 9 patients (45%) scheduled to orthotopic neobladder (Studer) substitution, while a numerically equivalent population was enrolled in the control group, matched according to age at surgery, BMI, gender, ASA score, CCI, preoperative stage and type of urinary diversion. No statistically significant difference was found in terms of pre-operatory and intra-operatory domains. Median overall age was 71 years (Inter Quartile Range - IQR: 63-76) and mean operatory time was 276 ± 57 minutes. Hospitalization time was significantly reduced in the FT group, considering oralization and canalization items we found a significant advantage in the FT group. No statistically significant difference was found in the control of the post-operatory pain. We found no difference, in terms of both early and late complications ratio, among the two populations. Complications graded Clavien ≥ 3 were found in 4 patients of the control group (20%), while in only one patient (5%) in the Fast Track group, though this difference was not statistically significant. CONCLUSIONS: The Fast Track protocol developed in this study has proven to be effective in significantly reducing hospitalization time in patients submitted to RC with intestinal urinary diversion, without increasing post-operatory complications ratio.


Assuntos
Cistectomia/métodos , Hospitalização/estatística & dados numéricos , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
12.
Curr Urol Rep ; 21(1): 2, 2020 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-31960158

RESUMO

PURPOSE OF REVIEW: Classically, kidney transplantation (KT) consists of heterotopic implantation of the renal graft in the iliac fossa with vascular anastomosis on the iliac vessel and reimplantation of the graft ureter in the bladder of the recipient. However, a wide range of variations exist in both vascular anastomosis and urinary diversion that the non-transplant surgeon should know. RECENT FINDINGS: For any pelvic surgery in a KT patient, the non-transplant surgeon should preoperatively evaluate the anatomy of the graft, its vascularization and its urinary tract. The transplant ureter should be identified and secured by preoperative JJ stenting whenever needed. For any surgery, maintenance and control of both immunosuppressive treatment and renal function is crucial. The advice or even the assistance of a transplant surgeon should be required because any damage to vascularization or urinary drainage of the renal graft could have dramatic and definitive consequences on graft function.


Assuntos
Transplante de Rim/métodos , Pelve/cirurgia , Transplantes/anatomia & histologia , Humanos , Transplantados , Transplantes/irrigação sanguínea , Derivação Urinária/métodos
13.
Curr Urol Rep ; 21(1): 3, 2020 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-31960193

RESUMO

PURPOSE OF REVIEW: In the setting of kidney transplantation, the ureter is a common source for complications. As a result, prevention of ureteral complications and their management is of crucial importance. In this context, the purpose of this review is to summarize recent literature on the ureter in the kidney transplant setting with a special focus on new findings. We conducted a PubMed and Medline search over the last 10 years to identify all new publications related to ureteroneoimplantations, stents and management of complications in the kidney transplant setting. RECENT FINDINGS: Performance of the "Lich-Gregoir" technique for ureteroneocystostomy seems to be favourable in regard to postoperative complications when compared with other methods described in the literature. Moreover, major urologic complications can be further reduced by ureteral stenting. A new approach for management of ureteral strictures in renal transplants is presented. We discussed the usage of a ureteral stent covered with a biostable polymer aiming to prevent tissue ingrowth into the lumen as a new option for management of ureteral stricture in the kidney transplant setting.


Assuntos
Transplante de Rim/métodos , Ureter/cirurgia , Obstrução Ureteral/terapia , Derivação Urinária/efeitos adversos , Derivação Urinária/métodos , Anastomose Cirúrgica/efeitos adversos , Constrição Patológica , Humanos , Stents , Obstrução Ureteral/etiologia
14.
J Robot Surg ; 14(2): 261-269, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31124038

RESUMO

The aim of the study is to report surgical and early functional outcomes of first 100 patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD) in a single center. The main surgeon (A.P.) attended a modular training program at a referring center mentored by a worldwide-recognized robotic surgeon (P.W.). The program consisted of: (a) 10 h of theoretical lessons; (b) video session (c) step-by-step in vivo modular training. Each procedure was performed as taught, without any technique variation. Demographics, intra-operative data and post-operative complications, along with early functional outcomes, were recorded for each patient. We retrospectively evaluated the first consecutive 100 patients submitted to RARC with totally ICUD from July 2015 to December 2018. Median age at surgery was 69 years (IQR 60-74). 52 (52%), 32 (32%), and 17 (17%) patients received orthotopic neobladder, ileal conduit and uretero-cutaneostomy, respectively. Median operative time was 410 min. A median number of lymph nodes retrieved were 27 and median estimated blood loss was 240 mL with median hospitalization time of 7 days. All procedures were completed successfully without open conversion. A statistically significant improvement was found in the late (30-90 post-operative days) post-operative complications (p = 0.02) and operative time for urinary derivation. At multivariate logistic regression model ASA score ≥ 3 (OR = 4.2, p = 0.002) and number of lymph nodes retrieved (OR = 1.16, p = 0.02) were found to be predictors of 90-day complications. An adequate modular training is paramount to obtain successful results and reduce the learning curve of RARC, as demonstrated by our experience.


Assuntos
Cistectomia/educação , Cistectomia/métodos , Curva de Aprendizado , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/métodos , Derivação Urinária/educação , Derivação Urinária/métodos , Idoso , Feminino , Humanos , Masculino , Resultado do Tratamento , Neoplasias da Bexiga Urinária/cirurgia
15.
Urology ; 135: 57-65, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31618656

RESUMO

OBJECTIVE: To evaluate differences in the incidence of benign ureteroenteric stricture, we compared stricture rates of robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) using Surveillance, Epidemiology, and End Results-Medicare data. METHODS: We identified 332 RARC and 1449 ORC performed between 2009 and 2014 to determine stricture rates at 6, 12, and 24 months following surgery. We defined ureteroenteric stricture as the need for procedural intervention. Additionally, we compared the incidence of stricture diagnosis. Multivariable proportional hazards regression was performed to determine factors associated with stricture development. RESULTS: The incidence of ureteroenteric stricture at 6 and 12 months was higher for RARC vs ORC at 12.1% vs 7.0% (P < .01) and 15.0% vs 9.5% (P = .01), respectively. RARC vs ORC stricture incidence at 2 years did not differ significantly at 14.6% vs 11.4% (P = .29). Similarly, the stricture diagnosis rates were significantly lower following ORC at 6, 12, and 24 months (P < .05). In adjusted analysis, RARC (HR 1.64, 95%CI 1.23-2.19) and preoperative hydronephrosis (HR 1.51, 95% CI 1.17-1.94) were associated with the development of stricture. Higher hospital volume was associated with a lower risk of stricture (HR 0.40, 95%CI 0.26-0.63). CONCLUSION: RARC is associated with a higher rate of ureteroenteric stricture diagnosis and intervention on a population-based level that is mitigated by higher hospital volume. A significant study limitation is inability to differentiate extracorporeal vs intracorporeal diversion. However, a stricture complication compounds the financial burden of care and efforts must be pursued to improve this surgical outcome.


Assuntos
Cistectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Obstrução Ureteral/epidemiologia , Derivação Urinária/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Carcinoma de Células de Transição/cirurgia , Constrição Patológica/epidemiologia , Constrição Patológica/etiologia , Constrição Patológica/cirurgia , Cistectomia/métodos , Feminino , Humanos , Incidência , Intestinos/cirurgia , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento , Ureter/cirurgia , Obstrução Ureteral/etiologia , Obstrução Ureteral/cirurgia , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/métodos
16.
J Urol ; 203(3): 512-521, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31580189

RESUMO

PURPOSE: Bladder cancer management options include open radical cystectomy and robot-assisted radical cystectomy with intracorporeal or extracorporeal urinary diversion. The existing literature shows no difference in the major complication rate between open radical cystectomy and extracorporeal urinary diversion. However, the emerging popularity of intracorporeal urinary diversion has exposed the need to compare a completely intracorporeal method to alternative approaches. To our knowledge the robotic intracorporeal advantage regarding major complications has not yet been established in an evaluation of all 3 modalities. We compared outcomes and complications of open, intracorporeal and extracorporeal cystectomy techniques at a high volume institution. MATERIALS AND METHODS: We queried a prospectively maintained database for patients who underwent radical cystectomy from 2011 to 2018 for an oncologic indication. Perioperative and pathological outcomes, and 30 and 90-day major complications were assessed. Statistical analyses were done using the Pearson chi-square, Kruskal-Wallis and Kaplan-Meier tests, and multivariable regression. RESULTS: A total of 948 patients met the study criteria, including 272, 301 and 375 treated with open radical cystectomy, intracorporeal urinary diversion and extracorporeal urinary diversion, respectively. Median followup was 26 months. Intracorporeal urinary diversion cases had lower estimated blood loss (p <0.001), shorter hospitalization (p <0.001) and a lower ileus rate (p=0.023) than extracorporeal urinary diversion and open radical cystectomy cases. Importantly, intracorporeal urinary diversion was associated with lower 30 and 90-day major complication rates vs extracorporeal urinary diversion and open radical cystectomy (90-day Clavien-Dindo III-V 16.9% vs 24.8% and 26.1%, respectively, p=0.015). There was no significant difference in the readmission rate according to the surgical approach. Multivariable predictors of increased 90-day major complications were patient age, the Charlson Comorbidity Index and operative time. On multivariable analysis intracorporeal urinary diversion was associated with reduced 90-day major complications (OR 0.58, p=0.037). CONCLUSIONS: In a 3-way comparison intracorporeal urinary diversion demonstrated a lower major complication rate and perioperative benefits compared to extracorporeal urinary diversion and open radical cystectomy.


Assuntos
Cistectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Resultado do Tratamento
18.
Urology ; 137: 206-207, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31790786

RESUMO

OBJECTIVE: Robot-assisted laparoscopic (RAL) techniques for the management of neurogenic bladder involves complex procedures using lower urinary tract and bowel. When medical therapy fails, surgery aims to preserve upper tract function and social continence.1 Traditionally, the procedure was performed in an open approach, but newer minimally-invasive techniques offer improved cosmesis, reduced pain and length of stay.2 A series of 38 cases showed the feasibility and safety of this approach.3 Here, we describe a RAL bladder neck reconstruction with appendicovesicostomy in a 7-year-old with neurogenic bladder (Fig. 1). METHODS: The patient was placed in a lithotomy position followed by double-J and Foley catheter placement. With an open Hasson technique, a 12-mm, two 8-mm, and a 5-mm port were positioned. The bladder is prefilled with saline (80 mL) and a cystotomy is performed. The tubularization is completed in 2 layers achieving a 3-cm tunnel (Figs. 2-3). The appendix is implanted in the posterior wall of the bladder with a submucosal tunnel. Ultimately, 2 suprapubic tubes are placed and the bladder is closed in a single layer. RESULTS: No complications reported, operative time was 5 hours and estimated blood loss was 50 mL. At 1-month follow-up, double-J stents were removed and the patient reported catheterizing well with good continence and well-healed incisions. CONCLUSION: Robotic continence procedures have demonstrated to be a safe and effective alternative. Here, we presented a satisfactory outcome using RAL bladder neck reconstruction with appendicovesicostomy in a 7 years old with persistent incontinence, despite untethering and maximal anticholinergic therapy.


Assuntos
Laparoscopia/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Bexiga Urinaria Neurogênica , Derivação Urinária/métodos , Procedimentos Cirúrgicos Urológicos/métodos , Criança , Humanos , Masculino , Duração da Cirurgia , Resultado do Tratamento , Bexiga Urinária/cirurgia , Bexiga Urinaria Neurogênica/complicações , Bexiga Urinaria Neurogênica/cirurgia , Incontinência Urinária/etiologia , Incontinência Urinária/cirurgia
19.
Int Braz J Urol ; 46(1): 108-115, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31851467

RESUMO

OBJECTIVE: Cystectomy with urinary diversion is the gold standard for muscle invasive bladder cancer. It also may be performed as part of pelvic exenteration for non-urologic malignancy, neurogenic bladder dysfunction, and chronic conditions that result in a non-functional bladder (e.g., interstitial cystitis, radiation cystitis). Our objective is to describe the surgical technique of urinary diversion using large intestine as a conduit whilst creating an end colostomy, thereby avoiding a primary bowel anastomosis and to show its applicability with respect to urologic conditions. MATERIALS AND METHODS: We retrospectively reviewed five cases from a single institution that utilized the described method of urinary diversion with large intestine. We describe operative times, hospital length of stay (LOS), and describe post-operative complications. RESULTS: Five patients with a variety of urologic and oncologic pathology underwent the described procedures. Their operative times ranged from 5 hours to 11 hours and one patient experienced a Clavien III complication. CONCLUSION: We describe five patients who underwent this procedure for various medical indications, and describe their outcomes, and believe dual diversion of urinary and gastrointestinal systems with colon as a urinary conduit to be an excellent surgical option for the appropriate surgical candidate.


Assuntos
Colo Sigmoide/cirurgia , Colostomia/métodos , Derivação Urinária/métodos , Adulto , Anastomose Cirúrgica , Cistectomia/métodos , Humanos , Tempo de Internação , Masculino , Ilustração Médica , Pessoa de Meia-Idade , Duração da Cirurgia , Reprodutibilidade dos Testes , Resultado do Tratamento , Doenças da Bexiga Urinária/cirurgia
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