Comparison of open and laparoscopic radical cystectomy as regards long-term oncological outcomes for bladder cancer

Objective: Recently, the laparoscopic technique has become widely accepted as a minimally invasive modality which reduces morbidity and provides similar oncological outcomes to open surgery. However, the number of clinical trials comparing laparoscopic and open radical cystectomy are limited. The objectives of this study are to compare the long-term oncological outcomes between open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) for bladder cancer. Materials and Methods: Out of 144 radical cystectomy patients admitted to our institute from January 2006 to December 2016, 87 patients were categorized as being in the LRC group, and 57 patients in the ORC group. Baseline characteristics, perioperative variables, and pathology results were collected retrospectively. Oncological outcomes including overall survival (OS), recurrence-free survival (RFS) and cancer-specific survival (CSS) were analyzed and compared between the two groups. Results: The mean age of the patients was 64.19 ± 9.89 years in the ORC group and 61.90 ± 10.47 years in the LRC group. The most frequent urinary diversion procedure in both groups was ileal conduit. All pathology results between the LRC group and the ORC group showed no statistical significance. The median follow-up duration was 57.18 ± 44.68 months in the ORC group and 53.96 ± 34.97 months in the LRC group. There was no statistically significant difference in overall survival (OS), recurrence-free survival (RFS) and cancer-specific survival (CSS) between the groups (p = 0.322, 0.946, and 0.528, respectively). Conclusion: Our study demonstrated that the long-term oncological outcome of LRC is comparable to ORC in the management of bladder cancer. LRC is an alternative option to open radical cystectomy and is safe, effective, and feasible. However, further large comparative studies with adequate long-term follow-up are recommended to support our results.

Association between Ureteral Clamping Time and Acute Kidney Injury during Robot-Assisted Radical Cystectomy

Robot-assisted radical cystectomy (RARC) is replacing open radical cystectomy (ORC) and requires clamping of the ureters, resulting in a predisposition to postrenal acute kidney injury (AKI). We investigated the association between ureteral clamping or its duration and acute/chronic postoperative kidney function. Patients who underwent radical cystectomy (robotic or open) at two tertiary institutions during 2002–2021 were retrospectively enrolled. In those who underwent RARC, the maximum postoperative percentage serum creatinine level (%sCre) change was plotted against ureteral clamping duration. They were divided into two groups using the median clamping time (210 min), and the maximum %sCre change and percentage estimated glomerular filtration rate (%eGFR) change at 3–6 months (chronic) were compared between the ORC (no clamp), RARC < 210, and RARC ≥ 210 groups. In 44 RARC patients, a weak correlation was observed between the duration of ureteral clamping and %Cre change (R2 = 0.22, p = 0.001). Baseline serum creatinine levels were comparable between the groups. However, %sCre change was significantly larger in the RARC ≥ 210 group (N = 17, +32.1%) than those in the RARC < 210 (N = 27, +6.1%) and ORC (N = 76, +9.5%) groups (both, p < 0.001). Chronic %eGFR change was comparable between the groups. Longer clamping of the ureter during RARC may precipitate AKI; therefore, the clamping duration should be minimized.

Cost of Care in Open Cystectomy Patients Across Time and Space: Does it matter?

BACKGROUND: Many variables may affect the cost of open radical cystectomy (RC) care, including surgical approach, diversion type, patient comorbidities, and postoperative complications. OBJECTIVE: To determine factors associated with changes in cost of care following open radical cystectomy (ORC) for bladder cancer using the National Inpatient Sample (NIS). METHODS: Patients in the NIS with a diagnosis of bladder cancer who underwent ORC with ileal conduit from 2012–2017 using ICD-9-CM and ICD-10-CM codes were identified. Baseline demographics including age, race, region, postoperative complications, and length of stay were obtained. Univariable and multivariable logistic regression were used to identify factors associated with cost variation including demographics, clinical characteristics, surgical factors, and discharge quarter (Q1-Q4). RESULTS: 5,189 patients were included in the analysis, with 4,379 at urban teaching hospitals. On multivariable regression analysis, female sex [$1,734 ($1,024–2,444) p < 0.001)], a greater Elixhauser comorbidity score [$93 ($62–124), p < 0.001], presence of any inpatient complication [$1,531 ($894–2,168), p < 0.001], and greater length of stay [$1,665 ($1,536–1,793), p < 0.001] were associated with a greater cost of hospitalization. Discharge in Q3 (July to September) relative to Q2 (April to June) was associated with a higher cost [$1,113 ($292–1,933), p = 0.008. Trends were similar at urban non-teaching and rural hospitals, except discharge quarter was not associated with a significant change in cost. CONCLUSIONS: Significant differences in cost of ORC with ileal conduit exist with respect to patient sex, medical comorbidities, and discharge timing. These differences may relate to greater disease burden in female patients, patient complexity, and variation in postoperative care in academic programs.

Incidence, Etiology, Prevention and Management of Ureteroenteric Strictures after Robot-Assisted Radical Cystectomy: A Review of Published Evidence and Personal Experience

Benign ureteroenteric anastomosis strictures (UESs) are one of many critical complications that may cause irreversible disability following robot-assisted radical cystectomy (RARC). Previous studies have shown that the incidence rates of UES after RARC can reach 25.3%, with RARC having higher UES incidence rates compared to open radical cystectomy. Various known and unknown factors are involved in the occurrence of UES. To minimize the incidence of UES after RARC, our group has standardized the procedure and technique for intracorporeal urinary diversion by applying the following five strategies: (1) wide delicate dissection of the ureter and preservation of the periureteral tissues; (2) gentle handling of the ureter and security of periureteral tissues at the anastomotic site; (3) use of indocyanine green to confirm good blood supply; (4) standardization of the ample ureteral spatulation length for Wallace ureteroenteric anastomosis through objective measurements; and (5) development of an institutional standardized procedure manual. This review focused on the incidence, etiology, prevention, and management of UES after RARC to bring attention to the incidence of this complication while also proposing standardized surgical procedures to minimize its incidence after RARC.

Laparoscopic cystectomy with lymphadenectomy and ileoconduitis creation: А case report

Relevance: Radical cystectomy remains the “gold standard” of treatment for muscle-invasive and locally advanced bladder cancer. The article describes the capacity and technique of laparoscopic cystoprostatectomy with lymphadenectomy and the creation of an ileoconduitis in bladder cancer, since the authors could not find publications on conducting laparoscopic cystoprostatectomy with the creation of an ileoconduitis in oncological and urological clinics in Kazakhstan by domestic specialists. The purpose was to describe an attempt to reproduce laparoscopically the method of open radical cystectomy as accurately as possible. Results: In the described case, the patient diagnosed with the bladder cancer T2N0M0 IIst underwent surgery in the form of laparoscopic cystectomy with lymphadenectomy and the creation of an ileoconduitis. This method of surgical intervention is minimally invasive, less traumatic, and ensures quick recovery in the postoperative period. Conclusion: Laparoscopic execution of radical cystectomy allows preserving the advantages of minimally invasive interventions without losing the reliability of the well-proven open surgery. Currently, the implementation of such minimally invasive surgical interventions is possible in many clinics in Kazakhstan, equipped with endoscopic video equipment, if there are specialists experienced in open surgery.

EP.TH.104An interesting case of Post-ITU delirium

A 75-year old golf-player underwent an open radical cystectomy for a grade 3 bladder carcinoma. His medical history was unremarkable. Post-operatively, he was admitted to the ITU for observation and transferred to the ward after 3 days. On the 5th day post-op, he developed sudden SOB, tachypnoea and hypotension. Blood gas analysis revealed T1 respiratory failure and lactate of 3.3. He was commenced on anticoagulants and a CTPA incidentally found multiple small pulmonary emboli- suspected to be chronic. He developed severe HAP and was transferred back to ITU. 10 days later after improvement he was stepped down. His oral intake had significantly reduced and his urine output was low. He was alert but ward nurses found him to be vacant and significantly confused after his second step down. A CXR was unremarkable. He reported hallucinations and was struggling with his memory. A week later, he was transferred to a community hospital for rehabilitation as his delirium was improving. In the community, he experienced ongoing confusion and hallucinations. Nurses noted hematochezia and jaundice and he was re-admitted with abdominal pain and pyrexia. His LFTs were severely deranged and he was initiated on antibiotics for possible cholangitis. USS abdomen, CT and MRCP revealed no obvious cause of obstruction. A probable diagnosis of viral hepatitis was made by the Gastroenterologist which spontaneously resolved. CT head for confusion screen revealed right frontal lobe ischaemia with severe gliosis- possibly post-operative. The psychiatric team reviewed the patient and he was diagnosed with post-ITU delirium.