Is Fast Track protocol a safe tool to reduce hospitalization time after radical cystectomy with ileal urinary diversion? Initial results from a single high-volume centre

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.

Download Full-text

Perioperative outcomes of fast track protocol applied to patients treated with radical cystectomy and intestinal urinary diversion: A comparison with standard management in a high-volume center

European Urology Supplements ◽

10.1016/s1569-9056(19)33686-3 ◽

2019 ◽

Vol 18 (9) ◽

pp. e3280-e3281

Author(s):

A. Ercolino ◽

F. Mineo Bianchi ◽

F. Chessa ◽

A. Colella ◽

D. Recenti ◽

...

Keyword(s):

Radical Cystectomy ◽

Urinary Diversion ◽

Fast Track ◽

High Volume ◽

Perioperative Outcomes ◽

Standard Management ◽

High Volume Center

Download Full-text

Fast track protocol applied to patients treated with radical cystectomy and intestinal urinary diversion: An update of a two year prospective randomized study in a high-volume center

European Urology Supplements ◽

10.1016/s1569-9056(18)33146-4 ◽

2018 ◽

Vol 17 (8) ◽

pp. 223-224

Author(s):

A. Ercolino ◽

F. Chessa ◽

F. Mineo Bianchi ◽

C. Casablanca ◽

E. Lupardi ◽

...

Keyword(s):

Radical Cystectomy ◽

Urinary Diversion ◽

Fast Track ◽

Randomized Study ◽

High Volume ◽

Prospective Randomized Study ◽

High Volume Center

Download Full-text

Complications of Radical Cystectomy and Orthotopic Reconstruction

Advances in Urology ◽

10.1155/2015/323157 ◽

2015 ◽

Vol 2015 ◽

pp. 1-7 ◽

Cited By ~ 17

Author(s):

Wei Shen Tan ◽

Benjamin W. Lamb ◽

John D. Kelly

Keyword(s):

Radical Cystectomy ◽

Urinary Diversion ◽

Enhanced Recovery ◽

Length Of Hospital Stay ◽

High Volume ◽

Late Complications ◽

Minimal Invasive ◽

Morbidity And Mortality ◽

Direct Result ◽

The Uk

Radical cystectomy and orthotopic reconstruction significant morbidity and mortality despite advances in minimal invasive and robotic technology. In this review, we will discuss early and late complications, as well as describe efforts to minimize morbidity and mortality, with a focus on ileal orthotopic bladder substitute (OBS). We summarise efforts to minimize morbidity and mortality including enhanced recovery as well as early and late complications seen after radical cystectomy and OBS. Centralisation of complex cancer services in the UK has led to a fall in mortality and high volume institutions have a significantly lower rate of 30-day mortality compared to low volume institutions. Enhanced recovery pathways have resulted in shorter length of hospital stay and potentially a reduction in morbidity. Early complications of radical cystectomy occur as a direct result of the surgery itself while late complications, which can occur even after 10 years after surgery, are due to urinary diversion. OBS represents the ideal urinary diversion for patients without contraindications. However, all patients with OBS should have regular long term follow-up for oncological surveillance and to identify complications should they arise.

Download Full-text

Levels of Prothrombin Fragment F1+2 in Patients with Hyperhomocysteinemia and a History of Venous Thromboembolism

Thrombosis and Haemostasis ◽

10.1055/s-0038-1665405 ◽

1997 ◽

Vol 78 (05) ◽

pp. 1327-1331 ◽

Cited By ~ 21

Author(s):

Paul A Kyrle ◽

Andreas Stümpflen ◽

Mirko Hirschl ◽

Christine Bialonczyk ◽

Kurt Herkner ◽

...

Keyword(s):

Venous Thromboembolism ◽

Thrombin Generation ◽

Oral Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Control Group ◽

Prothrombin Fragment ◽

Hemostatic System ◽

Significant Difference ◽

System Activation ◽

One Year

SummaryIncreased thrombin generation occurs in many individuals with inherited defects in the antithrombin or protein C anticoagulant pathways and is also seen in patients with thrombosis without a defined clotting abnormality. Hyperhomocysteinemia (H-HC) is an important risk factor of venous thromboembolism (VTE). We prospectively followed 48 patients with H-HC (median age 62 years, range 26-83; 18 males) and 183 patients (median age 50 years, range 18-85; 83 males) without H-HC for a period of up to one year. Prothrombin fragment Fl+2 (Fl+2) was determined in the patient’s plasma as a measure of thrombin generation during and at several time points after discontinuation of secondary thromboprophylaxis with oral anticoagulants. While on anticoagulants, patients with H-HC had significantly higher Fl+2 levels than patients without H-HC (mean 0.52 ± 0.49 nmol/1, median 0.4, range 0.2-2.8, versus 0.36 ± 0.2 nmol/1, median 0.3, range 0.1-2.1; p = 0.02). Three weeks and 3,6,9 and 12 months after discontinuation of oral anticoagulants, up to 20% of the patients with H-HC and 5 to 6% without H-HC had higher Fl+2 levels than a corresponding age- and sex-matched control group. 16% of the patients with H-HC and 4% of the patients without H-HC had either Fl+2 levels above the upper limit of normal controls at least at 2 occasions or (an) elevated Fl+2 level(s) followed by recurrent VTE. No statistical significant difference in the Fl+2 levels was seen between patients with and without H-HC. We conclude that a permanent hemostatic system activation is detectable in a proportion of patients with H-HC after discontinuation of oral anticoagulant therapy following VTE. Furthermore, secondary thromboprophylaxis with conventional doses of oral anticoagulants may not be sufficient to suppress hemostatic system activation in patients with H-HC.

Download Full-text

Radical Cystectomy in Elderly Patients

Urologia Journal ◽

10.1177/039156039306000104 ◽

1993 ◽

Vol 60 (1) ◽

pp. 19-22

Author(s):

P. Bassi ◽

M. Gholam Alipour ◽

G.L. Drago Ferrante ◽

N. Piazza ◽

N. Panza ◽

...

Keyword(s):

Elderly Patients ◽

Radical Cystectomy ◽

Urinary Diversion ◽

Length Of Hospital Stay ◽

Wound Dehiscence ◽

The Elderly ◽

Elderly Group ◽

Medical Complications ◽

Control Group ◽

Pelvic Hematoma

Radical cystectomy is the most common treatment for deeply invasive bladder cancer; due to reported operative risks, concerns have been expressed regarding the suitability of this operation in elderly patients. We reviewed the morbility and mortality rates in 50 patients aged 70 years and over (elderly group), undergoing radical cystectomy and urinary diversion, to verify if this procedure could be considered as initial treatment in older-age patients. The findings were compared with those observed in 50 patients aged 40 to 69 years (control group). In the elderly group there was no operative mortality; however 2 patients (4%) died post-operatively due to pulmonary embolism and multi-organ-failure syndrome respectively. Four patients (8%) were re-operated due to intestinal obstruction (2 pts), pelvic hematoma (1 pt) and wound dehiscence (1 pt). Wound separation was the more frequent complication (15%); 6% of patients experienced extended intestinal atonia. The length of hospital stay was 17.1 days. In the control group, surgical complications were comparable to those observed in the elderly group: furthermore medical complications were more frequent. In conclusion, these data suggest that radical cystectomy and urinary diversion can be safely performed in the elderly. Radical surgery is an effective treatment modality for elderly individuals who are in reasonably good general health. A higher incidence of medical complications must be expected in elderly patients.

Download Full-text

Efficacy of Aidi Injection and Brucea javanica Oil Emulsion Injection in Rectal Cancer during CapeOX Adjuvant Chemotherapy

BioMed Research International ◽

10.1155/2021/2033353 ◽

2021 ◽

Vol 2021 ◽

pp. 1-8

Author(s):

Wenjun Meng ◽

Xiaoge Zeng ◽

Yuchen Gao ◽

Qi Chen ◽

Lian Bai

Keyword(s):

Rectal Cancer ◽

Adjuvant Chemotherapy ◽

Control Group ◽

Oil Emulsion ◽

Brucea Javanica ◽

Significant Difference ◽

Hand Foot Syndrome ◽

Aidi Injection ◽

One Year ◽

Brucea Javanica Oil

Background. Adjuvant chemotherapy with CapeOX regimen is widely used in resected rectal cancer, which brings benefits to patients. But drug-related toxicities are severe during this process; thus, survival outcomes may potentially be affected. This study explored the efficacy of two Chinese herbal injections, Aidi injection (ADI) and Brucea javanica oil emulsion injection (BJOEI), as adjuvant drugs in CapeOX adjuvant chemotherapy on rectal cancer patients. Methods. A total of 240 cases were enrolled in this retrospective study. 80 cases received CapeOX with ADI (the ADI group), 80 cases received CapeOX with BJOEI (the BJOEI group), and the rest 80 cases received CapeOX alone (the control group). After four cycles’ chemotherapy, adverse reactions (ADRs) and quality of life (QOL) were analyzed. Then, patients received follow-up for at least one year, and the endpoint was disease-free survival (DFS). Results. All patients completed at least four cycles’ adjuvant chemotherapy. The incidence of leukopenia and thrombocytopenia was significantly lower in the ADI group; the incidence of nausea was significantly lower in the BJOEI group; the incidence of hand-foot syndrome was significantly lower in both the ADI group and BJOEI group. Significant difference was found in the control group regarding the Karnofsky Performance Status (KPS) scores prior and posttreatment. No difference was found among three groups regarding one-year DFS. Conclusion. As adjuvant drugs for rectal cancer during CapeOX chemotherapy, ADI shows advantages in decreasing leukopenia and thrombocytopenia, while BJOEI results better in remitting nausea. Both two CHIs had positive impacts on decreasing hand-foot syndrome and the maintenance of patients’ QOL. It is worthy of further study and promotion for CHIs.

Download Full-text

The association of the affordable care's Medicaid expansion on survival in gynecologic cancer: A National Cancer Database study.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.1501 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 1501-1501

Author(s):

Anna Jo Smith ◽

Jeremy Applebaum ◽

Amanda Nickles Fader

Keyword(s):

Rural Women ◽

Gynecologic Cancer ◽

Intervention Group ◽

Control Group ◽

Cancer Type ◽

National Cancer Database ◽

Medicaid Expansion ◽

Difference In Differences ◽

Significant Difference ◽

One Year

1501 Background: Under the Affordable Care Act’s 2014 Medicaid expansion, more than 12 million Americans gained health insurance. Whether such gains in insurance improve survival in gynecologic cancer is unknown. This study aims to determine whether Medicaid expansion is associated with improved survival among women with gynecologic cancers. Methods: We conducted a retrospective cohort study using a difference-in-differences study design comparing insurance status, stage at diagnosis, delays in treatment, and one-year survival before and after the ACA’s Medicaid expansion in Medicaid expansion states (intervention group) compared to women in non-expansion states (control group). Using hospital-reported data from the 2010-2016 National Cancer Database, we compared outcomes overall for women ages 40-64 years old with endometrial, cervical, ovarian, or vulva/vaginal cancer and then stratified by cancer type, stage, race, and rural/urban status. We adjusted for patient (area-level income, area-level education, distance traveled for care, comorbidities), clinical (co-morbidities, grade) and hospital (academic facility) characteristics. Results: Our sample included 241,713 women with gynecologic cancer, 119,392 in expansion states and 122,321 in non-expansion states. Post-Medicaid expansion, there was a statistically significant 0.8 % increase in 1-year survival among patients in expansion states compared to non-expansion states (95% CI 0.1-1.5). There was also a significant reduction in uninsurance (-1.1%, 95%CI, --1.5, -0.7) and delays of 30+ days from diagnosis to treatment (-2.4%, 95%CI -3.4, -1.2). There was no significant change in early-stage diagnosis (0%; 95%CI -0.7-0.7). Improvements in one-year survival after Medicaid expansion were driven by ovarian cancer (difference-in-differences 2.2%, 95%CI 0.6-3.8) and in white women (difference-in-differences 0.8%, 95%CI 0.1-1.5), while there was no significant difference in one-year survival for non-white or rural women. Conclusions: The Affordable Care Act’s Medicaid expansion was significantly associated with 1-year survival and insurance access among patients with gynecologic cancer. Insurance expansion efforts in non-Medicaid expansion states may improve survival for women with gynecologic cancer.

Download Full-text

Endovascular reflux-elimination of perforating veins by RFITT and foam sclerotherapy

Phlebologie ◽

10.12687/phleb2217-1-2015 ◽

2015 ◽

Vol 44 (01) ◽

pp. 13-17

Author(s):

J. Duben ◽

J. Gatek ◽

T. Saha ◽

G. Hnatkova ◽

L. Hnatek

Keyword(s):

Varicose Veins ◽

Control Group ◽

Foam Sclerotherapy ◽

Perforating Veins ◽

Significant Difference ◽

Power Setting ◽

Group 3 ◽

Group 2 ◽

One Year ◽

Group 1

SummaryIntroduction: During the last years, many endovascular techniques have been developed in order to eliminate not only the reflux in stem veins but in perforating veins and their tributaries, too.Aim: The aim of this study was to use endo -vascular RFITT and the foam sclerotherapy for the occlusion of perforating veins as the prime source of reflux and their tributaries.Material and Methods: The Celon method was used for the thermal treatment. Polydocalon with the concentration 1% and 2% with DSS technique was used for the foam sclerotherapy. The RFITT was accomplished in 127 perforating veins in total. This group was divided into three subgroups. The first one consists of patients where only RFITT was carried out (n= 41), in the second, there were patients with RFITT realized with sclerotherapy during one session (n= 48), in the third, RFITT was completed with sclerotherapy in one month after the RFITT intervention (n= 38). The control group included perforating veins treated only with sclerotherapy (n= 81). The power setting 6W was used on the generator during the RFITT with CelonProSurge micro and 18W for usage of Celon ProCurve probe.Results: The effectiveness of the procedure in the group 1 was 8.8%, in the group two 93.7%, in the group three 92.1% and in the control group 76.5% in one year follow up. There was no significant difference between the effectiveness in groups 1, 2 and 3. The marginal difference was among all three groups with RFITT and the control group. Significant differences were in the parameter of the extinction of visible varicose veins with the reflux from perforators. The extinction was faster in group 3 than in group 2 and in the control group and the slowest was in group 1. The significant difference was observed between groups 2 and 3 compared with group 1 and the margin difference was between groups 2 and 3 compared with the control group. No significant difference was observed between groups 1 and the control group.Conclusions: All procedures are effective. The most important is the combination of RFITT and the sclerotherapy one month after thermal intervention. This is associated with a low risk of recanalization and the fastest extinction of visible varicose veins.

Download Full-text

Role of Functional Biomarkers to Identify Early Vitamin B12 Deficiency in Patients with Sleeve Gastrectomy: A Cross-Sectional Study

Medicina ◽

10.3390/medicina56030142 ◽

2020 ◽

Vol 56 (3) ◽

pp. 142

Author(s):

Osama Y. Al-Dirbashi ◽

Charu Sharma ◽

Nahid Al Dahouri ◽

Anas Al Aidaros ◽

Shamma Al-Muhairi ◽

...

Keyword(s):

Sleeve Gastrectomy ◽

Vitamin B12 ◽

Cross Sectional Study ◽

Control Group ◽

Sectional Study ◽

Cross Sectional ◽

Significant Difference ◽

B12 Deficiency ◽

One Year ◽

Functional Biomarkers

Background and objectives: Although laparoscopic sleeve gastrectomy (LSG) is effective for obesity management, postoperative vitamin B12 (B12) deficiency is of major concern. In this cross-sectional study, we assessed the levels of B12 and its related functional biomarkers, namely, total homocysteine (tHcy), methylmalonic acid (MMA), folate, methylcitric acid (MCA), and hemoglobin (Hb), in one-year postoperative LSG patients and matched controls. Materials and Methods: Plasma B12, tHcy, MMA, folate, and MCA were measured in matched controls (n = 66) and patients (n = 71) using validated liquid chromatography-tandem mass spectrometry techniques and protocols in the United Arab Emirates (UAE). Results: The median B12 concentration in patients (177 pmol/L) was significantly lower (p < 0.001) than in the controls (334.7 pmol/L). The tHcy and MMA levels were significantly increased (p < 0.001 and p = 0.011, respectively) and folate levels were significantly decreased (p = 0.001) in the LSG patients compared to the controls. Interestingly, no significant difference in MCA levels were observed between the two groups. The levels of tHcy and MMA were concomitantly increased with the decreased folate levels in postoperative LSG patients when compared with the controls. The Hb levels were significantly lower in males and females in the patient group compared with those in the control group, respectively (p = 0.005 and p = 0.043). Conclusions: This is the first report of serum levels of B12 and its functional biomarkers in postoperative LSG patients among a local population from the UAE. Our findings revealed significant alterations of the B12 biomarkers, total B12, MMA, and tHcy in one-year postoperative LSG patients.

Download Full-text