Bricker ileal conduit vs. Cutaneous ureterostomy after radical cystectomy for bladder cancer: a systematic review

ABSTRACT Purpose: A systematic review of the literature with available published literature to compare ileal conduit (IC) and cutaneous ureterostomy (CU) urinary diversions (UD) in terms of perioperative, functional, and oncological outcomes of high-risk elderly patients treated with radical cystectomy (RC). Protocol Registration: PROSPERO ID CRD42020168851. Materials and Methods: A systematic review, according to the PRISMA Statement, was performed. Search through the Medline, Embase, Scopus, Scielo, Lilacs, and Cochrane Database until July 2020. Results: The literature search yielded 2,883 citations and were selected eight studies, including 1096 patients. A total of 707 patients underwent IC and 389 CU. Surgical procedures and outcomes, complications, mortality, and quality of life were analyzed. Conclusions: CU seems to be a safe alternative for the elderly and more frail patients. It is associated with faster surgery, less blood loss, lower transfusion rates, a lower necessity of intensive care, and shorter hospital stay. According to most studies, complications are less frequent after CU, even though mortality rates are similar. Studies with long-term follow up are awaited.

Laparoscopic Radical Cystectomy in the Elderly - Results of a Single Center LRC only Series

ABSTRACT Objective: To compare outcome of laparoscopic radical cystectomy (LRC) with ileal conduit in 22 elderly ( (≥75 years) versus 51 younger (<75 years) patients. patients. Materials and Methods: Analysis of prospectively gathered data of a single institution LRC only series was performed. Selection bias for LRC versus non-surgical treatments was assessed with data retrieved from the Netherlands Cancer Registry. Results: Median age difference between LRC groups was 9.0 years. (77.0 versus 68.0 years). Both groups had similar surgical indications, body mass index and gender distribution. Charlson Comorbidity Index score was 3 versus 4 in ≥50% of younger and elderly patients. Median operative time (340 versus 341 min) and estimated blood loss (<500 versus >500mL) did not differ between groups. Median total hospital stay was 12.0 versus 14.0 days for younger and elderly patients. Grade I-II 90-d complication rate was higher for elderly patients (68 versus 43%, p=0.05). Grade III-V 90-d complication rate was equal for both groups (23 versus 29%, p=0.557). 90-d mortality rate was higher for elderly patients (14 versus 4%, p=0.157). Median follow-up was 40.0 months for younger and 57.0 months for elderly patients. Estimated overall and cancer-specific survival at 5years. was 46% versus 35% and 64% versus 64% for younger and elderly patients respectively. Conclusions: Our results suggest that LRC is feasible in elderly patients, where a non-surgical treatment is usually favoured.

Prognostic features for quality of life after radical cystectomy and orthotopic neobladder

ABSTRACT Purpose: To analyse prognostic features on quality of life (QoL) following radical cystectomy and urinary diversion via orthotopic neobladder in a single-centre patient cohort. Materials and Methods: Postoperative QoL of 152 patients was assessed retrospectively using the validated QLQ-C30 questionnaire. Potential associations of patient's quality of life including pre-and intraoperative characteristics, surgeon experience, postoperative time course, adjuvant therapies, and functional outcome were defined a priori and evaluated. Mann-Whitney-U-, Kruskal-Wallis-, Spearman correlation and post hoc-testing were used. A multivariate analysis using a multiple logistic regression model was performed. A p value <0.05 was considered to be statistically significant. Results: Median follow-up was 48 months. Univariate analysis of prognostic features for health-related QoL revealed a significant impact of gender (p=0.019), performance status (p<0.001), experience of surgeon (>100 previous cystectomies, p=0.007), and nerve-sparing surgery (p=0.001). Patients who underwent secondary chemotherapy or radiotherapy had significant lower QLQ-C30 scores (p=0.04, p=0.02 respectively). Patients who were asymptomatic had a significantly higher quality of life (p<0.001). A significant impact of severity of incontinence based on ICIQ-SF score (p<0.001) and daily pad usage (p<0.001), existence of daytime incontinence (p<0.001), existence of urgency symptoms (p=0.007), and IIEF-5 score (p<0.001) could be observed. In multivariate analysis, independent prognostic relevance could be confirmed for preoperative ECOG performance status of 0 (p=0.020 vs. ECOG 1, p=0.047 vs. ECOG 2), experience of the respective surgeon (≥100 vs. <100 previous cystectomies, p=0.021), and daytime continence (p=0.032). Conclusion: In the present study, we report health-related QoL outcomes in a contemporary patient cohort and confirm preoperative ECOG status, surgeon experience and daytime incontinence as independent prognostic features for a good postoperative QoL.

Radical cystectomy with W-shaped orthotopic ileal neobladder constructed with non-absorbable titanium staples-long term follow-up

Purposes We retrospectively assessed our experience with the W-shaped orthotopic ileal pouch, which was constructed with non –absorbable titanium staples. For these purpose, we discuss the results of bladder capacity, urinary continence and early and long-term postoperative complications. Materials and Methods We included in the study 17 patients who underwent radical cystoprostatectomy followed by construction of an orthotopic W-shaped ileal pouch between October 2000 and November 2009. A 65-70 cm segment of ileum was isolated and prearranged into a W- configuration, leaving two 10 cm intact segments on both sides of the ileal fragment. In our technique we entirely anatomized all adjacent limbs in order to create a sphere-shaped pouch. The ureters were directly anastomized to both intact segments of the ileal division. All our patients underwent pouchscopy 6 months after operation and annually. Results Mean operative time for neobladder reconstruction and ureteral anastomoses was 87 ± 7.67 minutes. In one patient a leak from the ileo-ileal anastomosis was confirmed on the 3rd day after operation. In 2 cases unilateral stricture of the ureteral-neobladder anastomosis was documented. Staple lines were mostly covered with ileal mucosa after 6 months. The mean functional bladder capacity was 340 ± 27.6 mL and 375 ± 43.4 mL at 6 and 12 months, respectively. First-year daytime and nighttime continence was good and acceptable in 90% and 78% of patients, while it increased to 95% during the 2nd year. Conclusions The long term follow-up shows that non-absorbable titanium staples can be safely used for creation of an orthotopic ileal neobladder. However, these data should be further validated in a larger series of patients. .

Robotic-assisted laparoscopic radical cystectomy: surgical and oncological outcomes

PURPOSE:Our first 91 consecutive cases undergoing a robotic assisted cystectomy were analyzed regarding perioperative outcomes, pathological stages and surgical complications. MATERIALS AND METHODS: Between 2007 and 2010 a total of 91 patients (76 male and 15 female), 86 with clinically localized bladder cancer and 5 with non-urothelial tumors underwent a radical robotic assisted cystectomy. We analyzed the perioperative factors, length of hospital stay, pathological outcomes and complication rates. RESULTS: Mean age was 65.6 years (range 28 to 82). Among the 91 patients, 68 were submitted to an ileal conduit and 23 to a neobladder procedure for urinary diversion. Mean operating time was 412 min (range: 243-618 min.) and mean blood loss was 294 mL (range: 50-2000 mL). In 29% of the cases with urothelial carcinoma the T-stage was pT1 or less, 38% were pT2; 26% and 7% were classified as pT3 and pT4, respectively. 14% of cases had lymph node positive disease. Mean number of lymph nodes removed was 15 (range 4 to 33). Positive surgical margins occurred in 2 cases (2.1%). Mean days to flatus were 2.13, bowel movement 2.88 and inpatient stay 18.8 (range: 10-33). There were 45 postoperative complications with 11% major (Clavien grade 3 or higher). At a mean follow-up of 15 months 10 patients had disease recurrence and 6 died of the disease. CONCLUSIONS: Our experience demonstrates that robotic assisted radical cystectomies for the treatment of bladder cancers seems to be very promising regarding surgical and oncological outcomes.

Laparoscopic Radical Cystectomy: a 5-year review of a single institute's operative data and complications and a systematic review of the literature

OBJECTIVE: We aim to evaluate our experience and results with laparoscopic radical cystectomy and conduct a systematic review of studies reporting on 50 or more procedures. MATERIALS AND METHODS: Between February 2006 and March 2011, a prospective study in a single institute on patients with bladder cancer who underwent laparoscopic radical cystectomy was conducted. A search of the Cochrane Library, PubMed, Medline, and Scopus databases was conducted for studies reporting on 50 or more laparoscopic radical cystectomy procedures to compare with our results. RESULTS: Sixty men and five women underwent laparoscopic radical cystectomy during the 5-year study period. Thirty-nine patients were submitted to ileal conduits, 24 to neobladders, and two patients to ureterocutaneostomies. The mean operative time was 294 ± 27 minutes, the mean blood loss was 249.69 ± 95.59 millilitres, the mean length of hospital stay was 9.42 ± 2 days, the mean morphine requirement was 3.69 ± 0.8 days. The overall complication rate was 44.6% (29/65). However, the majority of the patients with complications (90% (26/29)) had minor complications treated conservatively with no further surgical intervention needed. The literature search found seven studies, which reported on their institutions' laparoscopic radical cystectomy results of 50 or more patients. Generally, our results were similar to other reported studies of the same calibre. CONCLUSION: Laparoscopic radical cystectomy is a safe and efficient modality of treatment of bladder cancer. However, it comes with a steep learning curve, once overcome, can provide an alternative to open radical cystectomy.

Gynecologic-tract sparing extra peritoneal retrograde radical cystectomy with neobladder

OBJECTIVE: We report on a series of female patients with transitional cell carcinoma of the bladder who underwent extraperitoneal retrograde radical cystectomy sparing the female reproductive organs with neobladder creation. MATERIALS AND METHODS: 14 female patients between the ages of 45 and 72 years who underwent gynecologic-tract sparing cystectomy (GTSC) with neobladder between 1997 and 2002 were retrospectively reviewed. Our surgical technique is also described. Radical cystectomy is accomplished by a retrograde method sparing the uterus, adnexa, vagina and distal urethra. An orthotopic neobladder was constructed using small bowel or sigmoid colon, brought extraperitoneally, and anastomosed to the distal urethra. RESULTS: Operating time ranged from 4.5 to six hours with a mean of 5.3 hours. Ten patients were able to void satisfactorily while four required self-catheterization for complete emptying of the bladder. Seven patients were continent day and night and another 7 reported varying degrees of daytime and nighttime incontinence. One patient died of metastases and another of pelvic recurrence. There were no urethral recurrences. Patient satisfaction with the procedure was high. CONCLUSIONS: Gynecologic-tract sparing cystectomy with orthotopic neobladder is a viable alternative in female patients with muscle invasive traditional cell carcinoma of the bladder, providing oncological safety with improved quality of life. Our extraperitoneal technique, which is an extension of our successful experience with retrograde extraperitoneal radical cystectomy in men, minimizes intraoperative complications and simplifies the management of post-operative morbidity with the neobladder.

Results from three municipal hospitals regarding radical cystectomy on elderly patients

OBJECTIVE: Radical cystectomy is the standard treatment for invasive bladder carcinoma in elderly patients at major surgical centers. As yet no data are available as to the question whether radical surgery on the genitourinary tract of patients over 75 can also be carried out at municipal hospitals with comparable intra and postoperative morbidity, and respective mortality. MATERIALS AND METHODS: 452 radical cystectomies and urinary diversions as ileum conduits or ileum neobladders due to transitional cell carcinoma were carried out at three municipal hospitals between 1992 and 2004. At the time of the surgery, 44 patients (9.7 percent) were > 75 (75-84) (Group-1), by comparison 408 patients were younger than 75 (35-74) (Group-2). Comparisons are to be made between the groups for 30 day mortality, 30 day reoperation rate, early complication rate (< 3 months), late complication rate (> 3 months), progression-free survival, and overall survival. The results are to be discussed in view of the international literature. Mean follow-up was 49 months (median: 38 months). RESULTS: The perioperative mortality in Group-1 was 2.3 percent compared to 2.5 percent in Group-2 (p = 0.942). There was no significant difference in the perioperative mortality with regard to the different case load of the evaluated hospital. There were no significant group differences regarding the 30 day reoperation rate, early and late complications. Progression-free and overall survival of all patients after 5 years was 56.1 percent and 53.6 percent respectively; here again the differences between the age groups was not significant (p = 0.384 and p = 0.210). Our results for patients > 75 do not differ from the published data of large clinics with a high cystectomy frequency. CONCLUSIONS: Our data confirm that radical cystectomy on elderly patients can also be carried out in municipal hospitals with acceptable mortality and morbidity rates. Of prime importance is a careful...