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Pfail J, Capellan J, Passarelli R, Kaldany A, Chua K, Lichtbroun B, Srivastava A, Golombos D, Jang TL, Pitt HA, Packiam VT, Ghodoussipour S. National Surgical Quality Improvement Program audit of contemporary perioperative care for radical cystectomy. BJU Int 2025; 135:140-147. [PMID: 39087422 PMCID: PMC11628928 DOI: 10.1111/bju.16492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
OBJECTIVE To examine the impact of increased compliance to contemporary perioperative care measures, as outlined by enhanced recover after surgery (ERAS) guidelines, among patients undergoing radical cystectomy (RC). PATIENTS AND METHODS From the National Surgical Quality Improvement Program database we captured patients undergoing RC between 2019 and 2021. We identified five perioperative care measures: regional anaesthesia block, thromboembolism prophylaxis, ≤24 h perioperative antibiotic administration, absence of bowel preparation, and early oral diet. We stratified patients by the number of measures utilised (one to five). Statistical endpoints included 30-day complications, hospital length of stay (LOS), readmissions, and optimal RC outcome. Optimal RC outcome was defined as absence of any postoperative complication, re-operation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable regressions with Bonferroni correction were performed to assess the association between use of contemporary perioperative care measures and outcomes. RESULTS Of the 3702 patients who underwent RC, 73 (2%), 417 (11%), 1010 (27%), 1454 (39%), and 748 (20%) received one, two, three, four, and five interventions, respectively. On multivariable analysis, increased perioperative care measures were associated with lower odds of any complication (odds ratio [OR] 0.66, 99% confidence interval [CI] 0.6-0.73), and shorter LOS (β -0.82, 99% CI -0.99 to -0.65). Furthermore, patients with increased compliance to contemporary care measures had increased odds of an optimal outcome (OR 1.38, 99% CI 1.26-1.51). CONCLUSIONS Among the measures we assessed, greater adherence yielded improved postoperative outcomes among patients undergoing RC. Our work supports the efficacy of ERAS protocols in reducing the morbidity associated with RC.
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Affiliation(s)
- John Pfail
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
| | - Jasmin Capellan
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
| | - Rachel Passarelli
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
| | - Alain Kaldany
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
| | - Kevin Chua
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
| | - Benjamin Lichtbroun
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
| | - Arnav Srivastava
- Dow Division of Health Services Research, Department of UrologyUniversity of MichiganAnn ArborMIUSA
| | - David Golombos
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
| | - Thomas L. Jang
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
| | | | - Vignesh T. Packiam
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
| | - Saum Ghodoussipour
- Section of Urologic OncologyRutgers Cancer Institute and Rutgers Robert Wood Johnson Medical SchoolNew BrunswickNJUSA
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Rich JM, Garden EB, Arroyave JS, Elkun Y, Ranti D, Pfail JL, Klahr R, Omidele OO, Adams-Sommer V, Patel G, Schaefer SH, Brown C, Badani K, Lavallee E, Mehrazin R, Attalla K, Waingankar N, Wiklund P, Sfakianos JP. Infections After Adoption of Antibiogram-directed Prophylaxis and Intracorporeal Urinary Diversion for Robot-assisted Radical Cystectomy. Eur Urol Focus 2024; 10:612-619. [PMID: 37838593 DOI: 10.1016/j.euf.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/01/2023] [Accepted: 09/19/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has significantly decreased the morbidity associated with radical cystectomy. However, infectious complications including sepsis, urinary tract (UTIs), wound (WIs), and intra-abdominal (AIs) infections remain common. OBJECTIVE To assess whether intracorporeal urinary diversion (ICUD) and antibiogram-directed antimicrobial prophylaxis would decrease infections after robotic-assisted radical cystectomy (RARC). DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis was performed of a prospectively maintained database of patients undergoing RARC between 2014 and 2022 at a tertiary care institution, identifying two groups based on adherence to a prospectively implemented modified ERAS protocol for RARC: modified-ERAS-ICUD and antibiogram-directed ampicillin-sulbactam, gentamicin, and fluconazole prophylaxis were utilized (from January 2019 to present time), and unmodified-ERAS-extracorporeal urinary diversion (UD) and guideline-recommended cephalosporin-based prophylaxis regimen were utilized (from November 2014 to June 2018). Patients receiving other prophylaxis regimens were excluded. INTERVENTION ICUD and antibiogram-directed infectious prophylaxis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was UTIs within 30 and 90 d postoperatively. The secondary outcomes were WIs, AIs, and sepsis within 30 and 90 d postoperatively, and Clostridioides difficile infection (CDI) within 90 d postoperatively. RESULTS AND LIMITATIONS A total of 396 patients were studied (modified-ERAS: 258 [65.2%], unmodified-ERAS: 138 [34.8%]). UD via a neobladder was more common in the modified-ERAS cohort; all other intercohort demographic differences were not statistically different. Comparing cohorts, modified-ERAS had significantly reduced rates of 30-d (7.8% vs 15.9%, p = 0.027) and 90-d UTIs (11.2% vs 25.4%, p = 0.001), and 30-d WIs (1.2% vs. 8.7%, p < 0.001); neither group had a WI after 30 d. Rates of AIs, sepsis, and CDI did not differ between groups. On multivariate regression, the modified-ERAS protocol correlated with a reduced risk of UTIs and WIs (all p < 0.01). The primary limitation is the retrospective study design. CONCLUSIONS Utilization of ICUD and antibiogram-based prophylaxis correlates with significantly decreased UTIs and WIs after RARC. PATIENT SUMMARY In this study of infections after robotic radical cystectomy for bladder cancer, we found that intracorporeal (performed entirely inside the body) urinary diversion and an institution-specific antibiogram-directed antibiotic prophylaxis regimen led to fewer urinary tract infections and wound infections at our institution.
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Affiliation(s)
- Jordan M Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Evan B Garden
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Yuval Elkun
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Ranti
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John L Pfail
- Department of Urology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Rebecca Klahr
- Department of Medicine, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Olamide O Omidele
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Gopi Patel
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah Hall Schaefer
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Conner Brown
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ketan Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Etienne Lavallee
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Passarelli R, Pfail J, Kaldany A, Chua K, Lichtbroun B, Patel HV, Srivastava A, Golombos D, Jang TL, Packiam VT, Ghodoussipour S. The Association Between Duration of Antibiotics and Infectious Complications Following Radical Cystectomy: Analysis of the 2019-2021 NSQIP Database. Urology 2024; 189:64-69. [PMID: 38648953 DOI: 10.1016/j.urology.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/21/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVES To identify the impact of the duration of peri-operative antibiotics on infectious complications following radical cystectomy. METHODS The National Surgical Quality Improvement Project (NSQIP) targeted database was queried for patients undergoing radical cystectomy from 2019 to 2021. Baseline patient characteristics were collected. Antibiotic duration was classified as <24 hours (short), 24-72 hours (intermediate) or >72 hours (long). Infectious complication data were collected including surgical site infection (SSI), urinary tract infection (UTI), organ space infection, pneumonia, sepsis, and clostridium difficile infection up to 30 days after surgery. Univariate and multivariable analyses were performed to compare duration of antibiotic therapy to infectious outcomes. RESULTS Of the 4363 patients who underwent radical cystectomy, 3250 (74%), 827 (19%) and 286 (6.6%) received short, intermediate, and long duration of peri-operative antibiotics, respectively. Infectious complication occurred in 954 (22%) patients, including 227 (5.2%) SSI, 280 (6.4%) UTI, 268(6.1%) organ space infection, 87 (2%) pneumonia, and 378 (8.7%) sepsis. Clostridium difficile infection occurred in 89 (2%) patients. On multivariable analysis, there was no significant difference in overall infectious complication rates with long-duration antibiotics. However, intermediate duration of antibiotics in open surgery was associated with a decreased risk of SSI (OR 0.58; 95%CI 0.37-0.91) compared to those treated with short-term antibiotics. CONCLUSION Despite guideline recommendations, 26% of patients in this database received >24 hours of peri-operative antibiotics without decreased risk of overall infectious complication. An intermediate course of antibiotics decreased risk of SSI in open surgery compared to the guideline recommend <24-hour course. Greater education regarding antibiotic stewardship and further studies investigating infectious complications are warranted.
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Affiliation(s)
- Rachel Passarelli
- Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ.
| | - John Pfail
- Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ
| | - Alain Kaldany
- Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ
| | - Kevin Chua
- Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ
| | | | - Hiren V Patel
- Department of Urology, University of California at San Francisco, San Francisco, CA
| | - Arnav Srivastava
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor MI
| | - David Golombos
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Thomas L Jang
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Vignesh T Packiam
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Berndl F, Frerichmann J, Berndl T. Prevention and management of urinary tract infections after cystectomy. Curr Opin Urol 2023; 33:200-205. [PMID: 36861762 DOI: 10.1097/mou.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW To give an overview of the most relevant recent literature about urinary tract infections (UTI) after radical cystectomy and to discuss them in the context of new individualized therapy approaches and possible preventive measures. RECENT FINDINGS UTI following radical cystectomy is a common complication associated with significant morbidity and readmission risk. Recent literature focuses on the identification of risk factors and the optimization of management. The risk factors most commonly associated with increased risk for UTI were perioperative blood transfusions and orthotopic neobladder (ONB). Furthermore, the effect of perioperative antibiotic regimens on rates of postoperative infections has been studied, but no consistent significant changes in UTI rates have yet been identified. Guidelines should be based on urologic studies and, wherever appropriate, should be uniform in design to encourage more frequent adherence. Furthermore, understanding the pathomechanisms leading to the development of UTI after radical cystectomy needs to be more central to discussions. SUMMARY Uniform definition of UTI, characteristics of bacterial pathogens involved, and type and duration of antibiotics used and identification of clinical risk factors must be the focus of well designed prospective studies to enable reduction of the most common complication after radical cystectomy.
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Lavallee E, Sfakianos J, Mehrazin R, Wiklund P. Detailed Description of the Karolinska Technique for Intracorporeal Studer Neobladder Reconstruction. J Endourol 2022; 36:S67-S72. [PMID: 36154454 DOI: 10.1089/end.2022.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In the last two decades, surgical techniques for intracorporeal urinary diversion have been developed with the aim of reducing surgical morbidity. Although increasing constantly, the numbers of urologists offering intracorporeal neobladder reconstruction remain limited due to the complex nature of the procedure. In this article, we aim to provide a detailed description of the surgical technique we currently use at our institution. This technique was initially developed and perfected at the Karolinska Institutet in Sweden starting in 2003. It is a reproducible surgical approach with standardized and well-defined surgical steps. We give a detailed description of the surgical steps and provide tips and tricks to address specific situations and to increase efficiency. We also review the indications, the preoperative considerations, equipment necessary, postoperative considerations, and clinical outcomes for this procedure. Finally, we provide an accompanying didactic surgical video. We believe that this standardized approach can be learned and reproduced safely by motivated robotic surgeons.
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Affiliation(s)
- Etienne Lavallee
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA.,Department of Surgery, Faculty of Medicine, Laval University, Québec, Canada
| | - John Sfakianos
- Department of Surgery, Faculty of Medicine, Laval University, Québec, Canada
| | - Reza Mehrazin
- Department of Surgery, Faculty of Medicine, Laval University, Québec, Canada
| | - Peter Wiklund
- Department of Surgery, Faculty of Medicine, Laval University, Québec, Canada.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Zhu G, Zhang Z, Zhao K, Yin X, Zhang Y, Wang Z, Li C, Sui Y, Li X, Yang H, Xing N, Wang K. Laparoscopic radical cystectomy with pelvic lymph node dissection and ileal orthotopic neobladder by a total extraperitoneal approach: Our initial technique and short-term outcomes. Investig Clin Urol 2022; 63:523-530. [PMID: 36067997 PMCID: PMC9448677 DOI: 10.4111/icu.20220156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/29/2022] [Accepted: 06/22/2022] [Indexed: 11/18/2022] Open
Abstract
PURPOSE With the increasing application of laparoscopic or robot-assisted radical cystectomy, a reliable and promising method is needed for reducing postoperative complications. We describe the short-term outcomes of totally extraperitoneal laparoscopic radical cystectomy (TELRC) with extraperitoneal pelvic lymph node dissection (EPLND) and extraperitoneal ileal orthotopic neobladder (EION) techniques. MATERIALS AND METHODS From January 2020 to December 2021, we performed TELRC and EPLND with EION in 72 patients in our center. The accompanying video highlights our novel techniques. The patients' demographic data, intraoperative data, and perioperative complications were collected, and short-term oncological and functional results are reported. RESULTS All procedures were technically successful without conversion to open surgery. The patients' mean body mass index was 26.22±5.71. Median age was 57.51±12.34 years. Average hospital stay was 13.78±4.62 days. Median intraoperative blood loss was 112.92±88.56 mL. No blood transfusion was needed during the operations and only one blood transfusion was performed during the perioperative period. Mean operating time was 259.44±49.84 minutes. Average cost was US$9,875.71±1,873.08. Postoperative short-term complications included short-term ileus (n=3), infection (n=13), leakage of urine (n=11), and lymph fistula (n=7). One late complication of unilateral vesicoureteral anastomotic stenosis occurred. The mean follow-up was 13.42±8.77 months, and no patient developed local or systemic recurrence. The short-term follow-up and small cohort of patients limited our evaluation of outcomes. CONCLUSIONS TELRC with PLND and EION was technically feasible and clinically promising, with a reduced potential harm of postoperative complications. Long-term follow-up and a larger cohort of patients are needed for further study.
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Affiliation(s)
- Guanqun Zhu
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zongliang Zhang
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Kai Zhao
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinbao Yin
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yulian Zhang
- Department of Gynecology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhenlin Wang
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chen Li
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuanming Sui
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xueyu Li
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Han Yang
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Nianzeng Xing
- Department of Urology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Wang
- Department of Urology, the Affiliated Hospital of Qingdao University, Qingdao, China.
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Gabriel PÉ, Siebert M, Le Fouler A, Van Glabeke E, Trésallet C. Management of gastro-intestinal emergencies in patients with ileal conduit ureteral diversion. J Visc Surg 2022; 159:399-408. [PMID: 35690581 DOI: 10.1016/j.jviscsurg.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Radical cystectomy with urinary deviation is performed increasingly in France. Ileal conduit ureteral diversion (ICUD), described by Bricker and widely used after this type of radical resection, leads to substantial anatomic modifications that are potential danger zones during subsequent gastro-intestinal or urinary tract operations. Injury to the urinary diversion apparatus can lead to disastrous complications in these patients who are often elderly and frail. General surgeons are most often called upon to re-operate these patients, either for an ICUD-related gastro-intestinal complication, or for an unrelated abdominal emergency that arises later (bowel obstruction, infection, cancer). During such operations, certain anatomic structures are particularly exposed to injury that may be irreversible, particularly, the mesentery of the ileal conduit and the left ureter. Approaching the right lower quadrant, the dissection of the ileo-ileal anastomosis or of the left mesocolon are the procedures or maneuvers that pose the most risk. A number of simple but effective preventive measures are available and must be known, such as to operate the patient with an urologist or to insert ureteral stents before surgery. Preoperative contrast-enhanced computed tomography with late phase urinary imaging is essential to assess the anatomic modifications and anticipate the operative procedural steps. Finally, one should not hesitate to disinsert the stoma and proceed with retrograde dissection, thus facilitating the identification of the ileal conduit, the mesentery and the ureters.
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Affiliation(s)
- P-É Gabriel
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne Hospital Group, AP-HP, 93000 Bobigny, France; Paris Seine-Saint-Denis University Hospitals (Paris 13), Sorbonne Paris Nord, Paris, France
| | - M Siebert
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne Hospital Group, AP-HP, 93000 Bobigny, France; Paris Seine-Saint-Denis University Hospitals (Paris 13), Sorbonne Paris Nord, Paris, France
| | - A Le Fouler
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne Hospital Group, AP-HP, 93000 Bobigny, France; Paris Seine-Saint-Denis University Hospitals (Paris 13), Sorbonne Paris Nord, Paris, France
| | - E Van Glabeke
- Inter-hospital Urology Federation of Seine Saint-Denis, CHI André-Grégoire, 93100 Montreuil, France
| | - C Trésallet
- Department of Digestive, Bariatric and Endocrine Surgery, Avicenne Hospital Group, AP-HP, 93000 Bobigny, France; Paris Seine-Saint-Denis University Hospitals (Paris 13), Sorbonne Paris Nord, Paris, France.
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Labbate CV, Kuchta K, Park S, Agarwal PK, Smith ND. Incidence of Preoperative Antibiotic Use and Its Association with Postoperative Infectious Complications after Radical Cystectomy. Urology 2022; 164:169-177. [PMID: 35218864 DOI: 10.1016/j.urology.2022.01.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/19/2021] [Accepted: 01/19/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine exposure rates to antibiotics prior to radical cystectomy and determine if there is correlation with post-operative infections. METHODS AND MATERIALS 2248 patients were identified in the 2016 SEER-Medicare linkage who underwent radical cystectomy between 2008 and 2014 with complete prescription information. An outpatient prescription for an antibiotic within 30 days prior to cystectomy was considered exposure. Antibiotic class and combinations were recorded. Postoperative infectious diagnoses and readmissions were tabulated within 30 days of cystectomy. RESULTS Fifty one percent of patients (n = 1149) were prescribed an outpatient antibiotic prior to cystectomy. Patients receiving antibiotics were more likely to be female (31% vs 25%, P < .01) and had been diagnosed with an infection (17% vs 11%, P < .01). Antibiotic bowel prophylaxis was prescribed to 42% of patients receiving antibiotics. Postoperatively, the exposure group had higher rates of any infection, (56% vs 51% P < .01) and UTI (36% vs 31% P < .01). All-cause readmission within 30 days was higher in the exposure cohort (26% vs 22%, P = .02) Multivariable logistic regression showed outpatient preoperative antibiotics were an independent risk factor for any infection (HR 1.19, P < .05) and readmission (hazards ratio 1.24, P = .03) in the 30 days after radical cystectomy. CONCLUSION Outpatient antibiotic use prior to radical cystectomy is common and may be associated with increased risk of postoperative infection and readmission. Antibiotic use prior to radical cystectomy should be examined as a modifiable factor to decrease post-operative morbidity.
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Affiliation(s)
| | | | - Sangtae Park
- North Shore University Health System, Evanston, IL
| | | | - Norm D Smith
- North Shore University Health System, Evanston, IL
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Ali S, Latif T, Sheikh MA, Shafiq MB, Zahra DEZ, Abu Bakar M. Review of Perioperative Care Pathway for Children With Renal Tumors. Cureus 2022; 14:e24928. [PMID: 35706749 PMCID: PMC9187842 DOI: 10.7759/cureus.24928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 11/05/2022] Open
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Lu X, Jiang H, Wang D, Wang Y, Chen Q, Chen S, Chen M. Early Warning Models to Predict the 90-Day Urinary Tract Infection Risk After Radical Cystectomy and Urinary Diversion for Patients With Bladder Cancer. Front Surg 2022; 8:782029. [PMID: 35127802 PMCID: PMC8814316 DOI: 10.3389/fsurg.2021.782029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose To develop and validate a nomogram of the 90-day urinary tract infection (UTI) risk for patients with bladder cancer undergoing radical cystectomy (RC) and urinary diversion. Patients and Methods The predictive nomogram was based on a retrospective study on the consecutive patients who underwent RC and urinary diversion for bladder cancer between January 2014 and March 2021. The incidence and microbiology of UTI were reported. The univariate and multivariate logistic analyses were conducted to determine independent risk factors associated with UTI. The predictive accuracy and discriminatory ability of the established nomogram were evaluated by the concordance index (C-index) and decision curve analysis (DCA). The performance of the model was validated internally. Results A total of 220 patients were included and the incidence of UTI within 90 days was 27.3%. The most commonly identified pathogens were Enterococcus (42.0%), Escherichia coli (21.70%), and Candida (13.0%). Urinary diversion type, Charlson comorbidities index (CCI), stricture, and prognostic nutritional index (PNI) were included in the nomogram. The C-index of the nomogram for predicting UTI was 0.858 (95% CI: 0.593–0.953). In the validation cohort, the nomogram also showed high-predictive accuracy. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) index indicated that PNI led to improvement in predictive ability. Conclusion The proposed early warning model shows great accuracy in predicting the incidence of 90-day UTI after RC and urinary diversion in patients with bladder cancer.
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Affiliation(s)
- Xun Lu
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
| | - Hua Jiang
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
| | - Dong Wang
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
| | - Yiduo Wang
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
| | - Qi Chen
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
- Department of Interventional Radiology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
| | - Shuqiu Chen
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
- Shuqiu Chen
| | - Ming Chen
- Department of Urology, Affiliated Zhongda Hospital of Southeast University, Nanjing, China
- Surgical Research Center, Institute of Urology, School of Medicine, Southeast University, Nanjing, China
- *Correspondence: Ming Chen
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Schulz GB, Volz Y, Jokisch F, Casuscelli J, Eismann L, Pfitzinger P, Stief CG, Schlenker B. [Enhanced Recovery After Surgery (ERAS®) after radical cystectomy-current data]. Urologe A 2021; 60:162-168. [PMID: 33439288 DOI: 10.1007/s00120-020-01435-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Radical cystectomy is associated with considerable morbidity and mortality. Based on the solid evidence in colorectal surgery, fast-track/ERAS® (Enhanced Recovery After Surgery) protocols have been developed to improve the perioperative management of patients undergoing radical cystectomy. OBJECTIVES To review the literature and guidelines and evaluate the evidence regarding the different components of ERAS® protocols. MATERIALS AND METHODS Systemic literature search and evaluation of relevant guidelines. RESULTS The majority of ERAS® recommendations for radical cystectomy are based on extrapolations of abdominal surgery studies. Four randomized, controlled trials and one ERAS® guideline were published for radical cystectomy. ERAS® seems to shorten length of stay without increasing the complication rate. Key elements are no bowel preparation, no nasogastric tube, optimized fluid substitution, multimodal pain management, early mobilization, and oral diet. CONCLUSIONS Implementation of ERAS® requires multidisciplinary collaboration. Individualization of an ERAS® program, identification of the most important components and adaption to the specific needs of radical cystectomy patients are future goals.
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Affiliation(s)
- G B Schulz
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland.
| | - Y Volz
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - F Jokisch
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - J Casuscelli
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - L Eismann
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - P Pfitzinger
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - C G Stief
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - B Schlenker
- Urologische Klinik und Poliklinik, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
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12
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Cai PY, Khan AI, Shoag JE, Scherr DS. Robotic Radical Cystectomy in the Contemporary Management of Bladder Cancer. Urol Clin North Am 2020; 48:45-50. [PMID: 33218593 DOI: 10.1016/j.ucl.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
"The robotic approach for radical cystectomy has become increasingly adopted by the urologic oncology community, as it has been shown to have equivalent oncologic outcomes with shorter hospital stay and fewer perioperative transfusions. Consensus guidelines from expert surgeons have been published to provide guidance on all aspects of how to implement the robotic approach in the urologic oncology clinic."
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Affiliation(s)
- Peter Y Cai
- Department of Urology, New York Presbyterian - Weill Cornell Medicine, 525 East 68th Street, Starr 900, New York, NY 10065, USA
| | - Aleem I Khan
- Department of Urology, New York Presbyterian - Weill Cornell Medicine, 525 East 68th Street, Starr 900, New York, NY 10065, USA
| | - Jonathan E Shoag
- Department of Urology, New York Presbyterian - Weill Cornell Medicine, 525 East 68th Street, Starr 900, New York, NY 10065, USA
| | - Douglas S Scherr
- Department of Urology, New York Presbyterian - Weill Cornell Medicine, 525 East 68th Street, Starr 900, New York, NY 10065, USA.
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13
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Symeonidis EN, Falagas ME, Dimitriadis F. Urinary tract infections in patients undergoing radical cystectomy and urinary diversion: challenges and considerations in antibiotic prophylaxis. Transl Androl Urol 2019; 8:286-289. [PMID: 31555550 PMCID: PMC6732096 DOI: 10.21037/tau.2019.07.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/21/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Evangelos N. Symeonidis
- 1 Department of Urology, Aristotle University of Thessaloniki, “G. Gennimatas” General Hospital, Thessaloniki, Greece
| | - Matthew E. Falagas
- Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece
- Department of Medicine, Henry Dunant Hospital Center, Athens, Greece
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Fotios Dimitriadis
- 1 Department of Urology, Aristotle University of Thessaloniki, “G. Gennimatas” General Hospital, Thessaloniki, Greece
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14
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Fujimura T. Current status and future perspective of robot-assisted radical cystectomy for invasive bladder cancer. Int J Urol 2019; 26:1033-1042. [PMID: 31364203 DOI: 10.1111/iju.14076] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/30/2019] [Indexed: 12/21/2022]
Abstract
The current status of robot-assisted radical cystectomy was reviewed 16 years after the initial robot-assisted radical cystectomy for the treatment of invasive bladder cancer. Articles associated with robot-assisted radical cystectomy and written in English were selected from the PubMed database from January 2003 to February 2019. The present review article focused on the distribution of robot-assisted radical cystectomy, patient selection, preoperative management, surgical technique, lymph node dissection, urinary diversion, recurrence pattern, oncological outcomes, cost, learning curve, complications and educational programs. A total of 400 articles were divided according to the country of the first author's affiliation. The USA was the most dominant at 198 (50%), whereas the number of articles from the countries belonging to the Urological Association of Asia was 15 (3.8%) for China, 17 (4.3%) for South Korea, 10 (2.5%) for Japan, eight (2%) for Taiwan, eight (2%) for Turkey and one (0.2%) for Iran. The percentage of robot-assisted radical cystectomy carried out is increasing, and intracorporeal urinary diversion and ileal neobladder are also frequently carried out. With a refined technique being performed in high-volume centers, robot-assisted radical cystectomy has contributed to the reduction in transfusion rate, length of stay and severe complications; however, it has not yet shown any cancer-specific survival benefits. Robot-assisted radical cystectomy is not fully spread throughout the Urological Association of Asia. Further investigation with respect to worldwide results is needed to prove the real benefit of robot-assisted radical cystectomy regarding low morbidity, reduced total medical cost, and survival benefit. In the era of precision medicine, appropriate drug and surgery will be given based on each genetic profile.
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Affiliation(s)
- Tetsuya Fujimura
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
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15
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Katz M, Silverstein N, Coll P, Sullivan G, Mortensen EM, Sachs A, Gross JB, Girard E, Liang J, Ristau BT, Stevenson C, Smith PP, Shames BD, Millea R, Ali I, Poulos CM, Ramaraj AB, Otukoya AO, Nolan J, Wahla Z, Hardy C, Al-Naggar I, Bliss LA, McFadden DW. Surgical care of the geriatric patient. Curr Probl Surg 2019; 56:260-329. [DOI: 10.1067/j.cpsurg.2019.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 03/13/2019] [Indexed: 12/15/2022]
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16
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Haider M, Ladurner C, Mayr R, Tandogdu Z, Fritsche HM, Fradet V, Comploj E, Pycha A, Lemire F, Lacombe L, Fradet Y, Toren P, Lodde M. Use and duration of antibiotic prophylaxis and the rate of urinary tract infection after radical cystectomy for bladder cancer: Results of a multicentric series. Urol Oncol 2019; 37:300.e9-300.e15. [PMID: 30871997 DOI: 10.1016/j.urolonc.2019.01.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 01/05/2019] [Accepted: 01/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To assess the rate of urinary tract infection (UTI), the characteristics of the bacterial aetiological agents involved, the type and duration of antibiotics used, and the clinical risk factors of UTI in a multi-institutional cohort of patients who had undergone radical cystectomy (RC). PATIENTS AND METHODS The pre- and postoperative characteristics of patients who had undergone open RC at 1 of 3 institutions between 2009 and 2015 were analyzed by means of the patient charts. Patients were classified according to the presence or absence of UTI. Analysis of the severity of UTI was based on the EAU/EAU Section of Infections in Urology (ESIU) classification system. The bacterial aetiological agents and their antibiotic susceptibility were also assessed. Factors predicting postoperative UTI were identified using univariable and multivariable logistic regression analysis. RESULTS Of 217 patients, 42 (19.4%) had developed postoperative UTI, of whom 50% had urosepsis or uroseptic shock. Multivariable analysis showed continent urinary derivation as the only significant predictor of UTI with an odds ratio of 5.03 (95% confidence interval 2.12-11.9, P < 0.001). The duration of perioperative antibiotic prophylaxis was not associated with an increased risk of UTI. Enterococcus was the most commonly isolated bacteria (25.7%), but this species is not covered by the recommended antibiotic prophylaxis. CONCLUSION Patients with continent urinary diversion after RC have a significantly higher risk of developing UTI. Prolonged perioperative administration of antibiotics does not seem to reduce the risk of UTI. Enterococcus as the most commonly isolated bacteria is not covered by most recommended antibiotic prophylaxis regimens. Therefore different antibiotic regimens should be considered for high-risk patients.
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Affiliation(s)
- Maximilian Haider
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany.
| | | | - Roman Mayr
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Zafer Tandogdu
- Department of Urology, Northern Institute for Cancer Research, University of Newcastle, Newcastle, United Kingdom
| | | | | | - Evi Comploj
- Department of Urology, General Hospital of Bolzano, Bolzano, Italy; Department of Research, College of Health Care Professions Claudiana, Bolzano, Italy
| | - Armin Pycha
- Department of Urology, General Hospital of Bolzano, Bolzano, Italy; Sigmund Freud Private University, Medical School, Vienna, Austria
| | | | - Louis Lacombe
- Department of Urology, Laval University, Québec, Canada
| | - Yves Fradet
- Department of Urology, Laval University, Québec, Canada
| | - Paul Toren
- Department of Urology, Laval University, Québec, Canada
| | - Michele Lodde
- Department of Urology, Laval University, Québec, Canada
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17
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Poinas G, Blache J, Kassab-Chahmi D, Evrard P, Artus P, Alfonsi P, Rébillard X, Beaussier M, Cerantola Y, Coloby P, Drapier É, Houédé N, Masson-Lecomt A, Rouprêt M, Le Normand L, Gamé X, Bosset P, Delaunay L, Fendler J, Ecoffey C, Cuvelier G. Version courte des recommandations de la récupération ameliorée après chirurgie (RAAC) pour la cystectomie : mesures techniques. Prog Urol 2019; 29:63-75. [DOI: 10.1016/j.purol.2018.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 11/28/2018] [Accepted: 12/01/2018] [Indexed: 12/20/2022]
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18
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Miller R, Heinlen JE. Reported rates of clostridium difficile following radical cystectomy in national datasets compared to individual institutions. Urol Oncol 2018; 36:526.e7-526.e11. [PMID: 30228097 DOI: 10.1016/j.urolonc.2018.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/28/2018] [Accepted: 08/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is an important cause of hospital acquired morbidity with implications for quality of care. Radical cystectomy is a surgical procedure associated with high rates of morbidity one of which is a high rate of CDI. The rate of CDI among patients undergoing radical cystectomy may be estimated based on the reports from single institutions or by querying national databases. This study aims to compare rates of CDI reported in single institution series with rates obtained from national datasets. METHODS A search was conducted on PubMed and Google Scholar using the terms "cystectomy+difficile" and "cystectomy+complication." Three hundred fifty articles were screened and 46 met criteria for inclusion based on the presence of specific rates of C. difficile following radical cystectomy. In the case of articles reporting on the same database, only the article with a larger sample size was included in the pooled analysis. One study reviewing a single institution was excluded from pooled analysis because it did not relate the rate of CDI specifically with cystectomy. Multi-institutional studies were not included in pooled analysis. RESULTS After exclusion of repeated data and multi-institutional studies, the pooled analysis consisted of 39 studies. Thirty five articles reported rates of CDI in single institutions and 4 articles reported rates found in national databases. Studies focusing on a single institution reported an average 5.02% (standard deviation = 4.88) incidence of CDI, compared to an average of 1.92% (standard deviation = 0.22) in databases. The rate of CDI found by totaling patients and incidence of infection found that databases show a rate of 1.95%, while institutions show a rate of 4.11% (P < 0.0000001). CONCLUSION The rate of CDI following radical cystectomy may be underestimated in national databases. This has implications for the development of health policy and quality measures based on the rate of CDI.
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Affiliation(s)
- Reece Miller
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
| | - Jonathan E Heinlen
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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19
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Saltzman AF, Warncke JC, Colvin AN, Carrasco A, Roach JP, Bruny JL, Cost NG. Development of a postoperative care pathway for children with renal tumors. J Pediatr Urol 2018; 14:326.e1-326.e6. [PMID: 29891188 DOI: 10.1016/j.jpurol.2018.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/03/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE To identify the factors associated with a shorter postoperative stay, as an initial step to develop a care pathway for children undergoing extirpative kidney surgery. STUDY DESIGN This study retrospectively reviewed patients managed with upfront open radical nephrectomy for renal tumors between 2005 and 2016 at a pediatric tertiary care facility. Univariate and multivariate logistic regression were performed to identify factors associated with early discharge (by postoperative day 4). RESULTS A total of 84 patients met inclusion criteria. Median age was 28.1 months (range 1.8-193.1). Thirty-four (40.5%) patients had a nasogastric tube postoperatively. The patients were advanced to a clear liquid diet on a median postoperative day 2 (range 0-7) and regular diet on a median postoperative day 3 (range 1-8). Median time from surgery to discharge was 5 days (range 2-12), with 38 (45.2%) discharged early. Univariate and multivariate logistic regression analyses showed that earlier resumption of regular diet (OR 0.523, P = 0.028) was positively associated with early discharge. Other analyzed factors were not significant (see Table). DISCUSSION Timely initiation of adjuvant therapy is a specific requirement of Children's Oncology Group (COG) protocols. Chemotherapy and radiation therapy are ideally initiated simultaneously, as early as possible, within 2 weeks of surgery. Thus, factors that can facilitate early discharge from the hospital can maximize protocol adherence with respect to timing of adjuvant therapy initiation and optimize patient outcome. This study shed light on several postoperative factors and how these relate to postoperative stay and recovery. Specifically, tumor size, pre-operative bowel preparation, extent of lymph node sampling, stage, operative time, estimated blood loss, surgical service, postoperative nasogastric tube use, transfusion, and chemotherapy prior to discharge were not associated with discharge timing. Early re-feeding was associated with early discharge. Thus, it seems reasonable that, when developing a postoperative care pathway for these patients, these factors be considered and specifically encourage early re-feeding. In pediatrics, data on early recovery after surgery protocols are limited, and high-quality studies are unavailable. Within pediatric urology, early recovery after surgery protocols in children undergoing major urologic reconstruction have been shown to reduce hospital stay and can decrease complication rates. It seems reasonable that a similar pathway can be applied to children undergoing radical nephrectomy for suspected malignancy. CONCLUSIONS For children with renal tumors who underwent radical nephrectomy, early re-feeding was associated with a shorter time to discharge. Use of bowel preparation and nasogastric tube did not appear to shorten time to discharge. These data are important for developing postoperative care pathways for these patients.
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Affiliation(s)
- A F Saltzman
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - J C Warncke
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - A N Colvin
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - A Carrasco
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - J P Roach
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - J L Bruny
- Department of Surgery, Division of Pediatric Surgery, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA
| | - N G Cost
- Department of Surgery, Division of Urology, University of Colorado School of Medicine and the Children's Hospital of Colorado, Aurora, CO, USA.
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20
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Mano R, Goldberg H, Stabholz Y, Hazan D, Margel D, Kedar D, Baniel J, Yossepowitch O. Urinary Tract Infections After Urinary Diversion-Different Occurrence Patterns in Patients With Ileal Conduit and Orthotopic Neobladder. Urology 2018; 116:87-92. [PMID: 29626568 DOI: 10.1016/j.urology.2018.03.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/13/2018] [Accepted: 03/22/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To compare the incidence rate of urinary tract infections (UTIs) and associated pathogens between patients with ileal conduit and patients with orthotopic neobladder urinary diversion. PATIENTS AND METHODS The medical records of 179 patients treated with radical cystectomy between 2006 and 2011 were reviewed and data pertaining to postoperative UTI were collected. UTI incidence was reported at 3 months' intervals and compared by diversion type. Preoperative predictors of UTI were evaluated with Cox regression analyses. RESULTS The study cohort included 130 patients with ileal conduit and 49 patients with orthotopic neobladder. Patients with a neobladder were younger (P <.001). Median follow-up was 38 months (IQR [interquartile range], 11-63). Median time from surgery to first infection was 1.5 months (IQR, 1-12.5) for patients with a neobladder and 11 months (IQR, 2.5-27) for patients with a conduit (P = .04). During the first 3 months after surgery, 29% of the patients with a neobladder and 8% of the patients with ileal conduit had a UTI episode (P = .001). Rates of UTI did not differ during subsequent follow-up. Diversion type was not associated with UTI on multivariable analysis. Escherichia coli was the most common pathogen in patients with a conduit (58%), and Klebsiella spp. in patients with a neobladder (29%). CONCLUSION The risk of UTI is significantly higher in patients with a neobladder during the first 3 months after surgery and comparable to patients with ileal conduit during subsequent follow-up. These findings may facilitate preoperative counseling regarding the expected risk of UTI after urinary diversion.
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Affiliation(s)
- Roy Mano
- Department of Urology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Hanan Goldberg
- Department of Urology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Stabholz
- Department of Urology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Danny Hazan
- Department of Urology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Margel
- Department of Urology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Kedar
- Department of Urology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jack Baniel
- Department of Urology, Rabin Medical Center, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Yossepowitch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Urology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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21
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Postoperative management of radical cystectomy. Review of the evidence on the prevention and treatment of urological complications. Actas Urol Esp 2018; 42:143-151. [PMID: 28587844 DOI: 10.1016/j.acuro.2017.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/28/2017] [Indexed: 01/01/2023]
Abstract
INTRODUCTION AND OBJECTIVES This review article focuses on the prevention and management of the most common postoperative urological complications of radical cystectomy. We reviewed the current literature and conducted an analysis of frequency, prevention and treatment of complications. ACQUISITION OF EVIDENCE We conducted a search on Medline to identify original articles, literature reviews and editorials focusing on the urological complications of radical cystectomy during the first 90 days after surgery. We identified those series that included more than 100 patients. SYNTHESIS OF THE EVIDENCE The literature regarding the prevention and treatment of complications after cystectomy is in general retrospective and nonstandardised. The level of evidence is generally low, and it is difficult to make evidence-based recommendations. CONCLUSIONS Progress has been made in recent years in reducing mortality and preventing the complications of cystectomy. The most common complications are gastrointestinal, for which significant efforts have been made to implement ERAS and Fast Track protocols. The complications that can most significantly change patients' quality of life are urinary stoma.
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22
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Rollins KE, Javanmard-Emamghissi H, Lobo DN. Impact of mechanical bowel preparation in elective colorectal surgery: A meta-analysis. World J Gastroenterol 2018; 24:519-536. [PMID: 29398873 PMCID: PMC5787787 DOI: 10.3748/wjg.v24.i4.519] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 10/25/2017] [Accepted: 11/08/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery. METHODS Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. RESULTS A total of 36 studies (23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates (OR = 0.90, 95%CI: 0.74 to 1.10, P = 0.32), surgical site infection (OR = 0.99, 95%CI: 0.80 to 1.24, P = 0.96), intra-abdominal collection (OR = 0.86, 95%CI: 0.63 to 1.17, P = 0.34), mortality (OR = 0.85, 95%CI: 0.57 to 1.27, P = 0.43), reoperation (OR = 0.91, 95%CI: 0.75 to 1.12, P = 0.38) or hospital length of stay (overall mean difference 0.11 d, 95%CI: -0.51 to 0.73, P = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlled trials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. CONCLUSION In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery.
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Affiliation(s)
- Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Hannah Javanmard-Emamghissi
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
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23
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Clifford TG, Katebian B, Van Horn CM, Bazargani ST, Cai J, Miranda G, Daneshmand S, Djaladat H. Urinary tract infections following radical cystectomy and urinary diversion: a review of 1133 patients. World J Urol 2018; 36:775-781. [PMID: 29372354 DOI: 10.1007/s00345-018-2181-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/05/2018] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To investigate the incidence and microbiology of urinary tract infection (UTI) within 90 days following radical cystectomy (RC) and urinary diversion. METHODS We reviewed 1133 patients who underwent RC for bladder cancer at our institution between 2003 and 2013; 815 patients (72%) underwent orthotopic diversion, 274 (24%) ileal conduit, and 44 (4%) continent cutaneous diversion. 90-day postoperative UTI incidence, culture results, antibiotic sensitivity/resistance and treatment were recorded through retrospective review. Fisher's exact test, Kruskal-Wallis test, and multivariable analysis were performed. RESULTS A total of 151 urinary tract infections were recorded in 123 patients (11%) during the first 90 days postoperatively. 21/123 (17%) had multiple infections and 25 (20%) had urosepsis in this time span. Gram-negative rods were the most common etiology (54% of positive cultures). 52% of UTI episodes led to readmission. There was no significant difference in UTI rate, etiologic microbiology (Gram-negative rods, Gram-positive cocci, fungi), or antibiotic sensitivity and resistance patterns between diversion groups. Resistance to quinolones was evident in 87.5% of Gram-positive and 35% of Gram-negative bacteria. In multivariable analysis, Charlson Comorbidity Index > 2 was associated with higher 90-day UTI rate (OR = 1.8, 95% CI 1.1-2.9, p = 0.05) and Candida UTI (OR 5.6, 95% CI 1.6-26.5, p = 0.04). CONCLUSIONS UTI is a common complication and cause of readmission following radical cystectomy and urinary diversion. These infections are commonly caused by Gram-negative rods. High comorbidity index is an independent risk factor for postoperative UTI, but diversion type is not.
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Affiliation(s)
- Thomas G Clifford
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Behrod Katebian
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Christine M Van Horn
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Soroush T Bazargani
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Jie Cai
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Gus Miranda
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Siamak Daneshmand
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA
| | - Hooman Djaladat
- USC Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90089, USA.
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Cotter KJ, Fan Y, Sieger GK, Weight CJ, Konety BR. Prevalence of Clostridium Difficile Infection in Patients After Radical Cystectomy and Neoadjuvant Chemotherapy. Bladder Cancer 2017; 3:305-310. [PMID: 29152554 PMCID: PMC5676759 DOI: 10.3233/blc-170132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Objectives: Clostridium Difficile is the most common cause of nosocomial infectious diarrhea. This study evaluates the prevalence and predictors of Clostridium Difficile infections in patients undergoing radical cystectomy with or without neoadjuvant chemotherapy. Methods: Retrospective chart review was performed of all patients undergoing cystectomy and urinary diversion at a single institution from 2011–2017. Infection was documented in all cases with testing for Clostridium Difficile polymerase chain reaction toxin B. Patient and disease related factors were compared for those who received neoadjuvant chemotherapy vs. those who did not in order to identify potential risk factors associated with C. Difficile infections. Chi squared test and logistic regression analysis were used to determine statistical significance. Results: Of 350 patients who underwent cystectomy, 41 (11.7%) developed Clostridium Difficile in the 30 day post-operative period. The prevalence of C. Difficile infection was higher amongst the patients undergoing cystectomy compared to the non-cystectomy admissions at our hospital (11.7 vs. 2.9%). Incidence was not significantly different among those who underwent cystectomy for bladder cancer versus those who underwent the procedure for other reasons. Median time to diagnosis was 6 days (range 3–28 days). The prevalence of C. Diff infections was not significantly different among those who received neoadjuvant chemotherapy vs. those who did not (11% vs. 10.4% p = 0.72). A significant association between C. Difficile infection was not seen with proton pump inhibitor use (p = 0.48), patient BMI (p = 0.67), chemotherapeutic regimen (p = 0.94), individual surgeon (p = 0.54), type of urinary diversion (0.41), or peri-operative antibiotic redosing (p = 0.26). Conclusions: Clostridium Difficile infection has a higher prevalence in patients undergoing cystectomy. No significant association between prevalence and exposure to neoadjuvant chemotherapy was seen.
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Affiliation(s)
| | - Yunhua Fan
- University of Minnesota Department of Urology, Minneapolis, MN, USA
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Heinlen JE, Salinas L, Cookson MS. Clostridium difficile Infection in Contemporary Urologic Practice. Urology 2017; 111:23-27. [PMID: 28688849 DOI: 10.1016/j.urology.2017.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/20/2017] [Accepted: 06/26/2017] [Indexed: 11/29/2022]
Abstract
Clostridium difficile infection (CDI) is a high-impact hospital-acquired condition and a chief driver of excess morbidity, mortality, and treatment cost. The diagnosis, treatment, and prevention of CDI are key components of any hospital-based practice. Urologists see a small percentage of all patients with CDI, but traditionally utilize antibiotic agents that put patients at risk of CDI. Urologic procedures making use of bowel have a significantly higher rate of CDI than other procedures. This review addresses concepts that practicing urologists should be aware of and should be able to put into practice to diagnose, treat, and prevent CDI.
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Affiliation(s)
- Jonathan E Heinlen
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
| | - Linda Salinas
- Department of Internal Medicine, Institute for Infectious Disease, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Michael S Cookson
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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26
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Olsen U, Brox JI, Bjørk IT. Preoperative bowel preparation versus no preparation before spinal surgery: A randomised clinical trial. Int J Orthop Trauma Nurs 2016; 23:3-13. [DOI: 10.1016/j.ijotn.2016.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/23/2015] [Accepted: 02/04/2016] [Indexed: 01/24/2023]
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Collins JW, Patel H, Adding C, Annerstedt M, Dasgupta P, Khan SM, Artibani W, Gaston R, Piechaud T, Catto JW, Koupparis A, Rowe E, Perry M, Issa R, McGrath J, Kelly J, Schumacher M, Wijburg C, Canda AE, Balbay MD, Decaestecker K, Schwentner C, Stenzl A, Edeling S, Pokupić S, Stockle M, Siemer S, Sanchez-Salas R, Cathelineau X, Weston R, Johnson M, D'Hondt F, Mottrie A, Hosseini A, Wiklund PN. Enhanced Recovery After Robot-assisted Radical Cystectomy: EAU Robotic Urology Section Scientific Working Group Consensus View. Eur Urol 2016; 70:649-660. [PMID: 27234997 DOI: 10.1016/j.eururo.2016.05.020] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 05/12/2016] [Indexed: 12/17/2022]
Abstract
CONTEXT Radical cystectomy (RC) is associated with frequent morbidity and prolonged length of stay (LOS) irrespective of surgical approach. Increasing evidence from colorectal surgery indicates that minimally invasive surgery and enhanced recovery programmes (ERPs) can reduce surgical morbidity and LOS. ERPs are now recognised as an important component of surgical management for RC. However, there is comparatively little evidence for ERPs after robot-assisted radical cystectomy (RARC). Due to the multimodal nature of ERPs, they are not easily validated through randomised controlled trials. OBJECTIVE To provide a European Association of Urology (EAU) Robotic Urology Section (ERUS) policy on ERPs to guide standardised perioperative management of RARC patients. EVIDENCE ACQUISITION The guidance was formulated in four phases: (1) systematic literature review of evidence for ERPs in robotic, laparoscopic, and open RC; (2) an online questionnaire survey formulated and sent to ERUS Scientific Working Group members; (3) achievement of consensus from an expert panel using the Delphi process; and (4) a standardised reporting template to audit compliance and outcome designed and approved by the committee. EVIDENCE SYNTHESIS Consensus was reached in multiple areas of an ERP for RARC. The key principles include patient education, optimisation of nutrition, RARC approach, standardised anaesthetic, analgesic, and antiemetic regimens, and early mobilisation. CONCLUSIONS This consensus represents the views of an expert panel established to advise ERUS on ERPs for RARC. The ERUS Scientific Working Group recognises the role of ERPs and endorses them as standardised perioperative care for patients undergoing RARC. ERPs in robotic surgery will continue to evolve with technological and pharmaceutical advances and increasing understanding of the role of surgery-specific ERPs. PATIENT SUMMARY There is currently a lack of high-level evidence exploring the benefits of enhanced recovery programmes (ERPs) in patients undergoing robot-assisted radical cystectomy (RARC). We reported a consensus view on a standardised ERP specific to patients undergoing RARC. It was formulated by experts from high-volume RARC hospitals in Europe, combining current evidence for ERPs with experts' knowledge of perioperative care for robotic surgery.
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Affiliation(s)
- Justin W Collins
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Hiten Patel
- Department of Urology, University Hospital of Northern Norway, Tromsø, Norway
| | - Christofer Adding
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Walter Artibani
- Department of Urology, Verona University Hospital, Verona, Italy
| | | | | | - James W Catto
- Department of Urology, Sheffield University Hospital, Sheffield, UK
| | | | - Edward Rowe
- Department of Urology, Bristol Urological Institute, Bristol, UK
| | | | - Rami Issa
- Department of Urology, St Georges, London, UK
| | - John McGrath
- Department of Urology, Royal Devon and Exeter Hospital, Exeter, UK
| | | | | | - Carl Wijburg
- Department of Urology, Rijnstate, Arnhem, Netherlands
| | | | - Meviana D Balbay
- Department of Urology, Memorial Sisli Hospital, Istanbul, Turkey
| | | | | | - Arnulf Stenzl
- Department of Urology, University of Tuebingen, Tubingen, Germany
| | | | - Sasa Pokupić
- Department of Urology, Da Vinci Zentrum, Hanover, Germany
| | - Michael Stockle
- Department of Urology, Universittatsklinikum des Saarlandes, Homburg, Germany
| | - Stefan Siemer
- Department of Urology, Universittatsklinikum des Saarlandes, Homburg, Germany
| | | | | | - Robin Weston
- Department of Urology, Royal Liverpool Hospital, Liverpool, UK
| | - Mark Johnson
- Department of Urology, Newcastle upon Tyne Hospitals, Newcastle, UK
| | | | | | - Abolfazl Hosseini
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden
| | - Peter N Wiklund
- Department of Urology, Karolinska University Hospital, Stockholm, Sweden.
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Azhar RA, Bochner B, Catto J, Goh AC, Kelly J, Patel HD, Pruthi RS, Thalmann GN, Desai M. Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs. Eur Urol 2016; 70:176-187. [PMID: 26970912 PMCID: PMC5514421 DOI: 10.1016/j.eururo.2016.02.051] [Citation(s) in RCA: 203] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 02/17/2016] [Indexed: 02/08/2023]
Abstract
CONTEXT Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times. OBJECTIVE To overview the use and key elements of ERAS pathways, and define needs for future clinical trials. EVIDENCE ACQUISITION A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms "postoperative period," "postoperative care," "enhanced recovery after surgery," "enhanced recovery," "accelerated recovery," "fast track recovery," "recovery program," "recovery pathway", "ERAS," and "urology" or "cystectomy" or "urologic surgery." EVIDENCE SYNTHESIS We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6h and perioperative liquid-carbohydrate loading up to 2h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters. CONCLUSIONS ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery. PATIENT SUMMARY This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials.
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Affiliation(s)
- Raed A Azhar
- Urology Department, King Abdulaziz University, Jeddah, Saudi Arabia; USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Bernard Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - James Catto
- Academic Units of Urology and Molecular Oncology, University of Sheffield, Sheffield, South Yorkshire, UK
| | - Alvin C Goh
- Department of Urology, Houston Methodist Hospital, Houston, TX, USA
| | - John Kelly
- Division of Surgery and Interventional Science, UCL Medical School, University College London, London, UK
| | - Hiten D Patel
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Raj S Pruthi
- Division of Urologic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - George N Thalmann
- Department of Urology, University Hospital Inselspital, Bern, Switzerland
| | - Mihir Desai
- USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Kim KH, Yoon HS, Yoon H, Chung WS, Sim BS, Lee DH. Febrile Urinary Tract Infection after Radical Cystectomy and Ileal Neobladder in Patients with Bladder Cancer. J Korean Med Sci 2016; 31:1100-4. [PMID: 27366009 PMCID: PMC4901003 DOI: 10.3346/jkms.2016.31.7.1100] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 04/04/2016] [Indexed: 11/20/2022] Open
Abstract
Urinary tract infection (UTI) is one of the most common complications after radical cystectomy and orthotopic neobladder reconstruction. This study investigated the incidence and implicated pathogen of febrile UTI after ileal neobladder reconstruction and identify clinical and urodynamic parameters associated with febrile UTI. From January 2001 to May 2015, 236 patients who underwent radical cystectomy and ileal neobladder were included in this study. Fifty-five episodes of febrile UTI were identified in 46 patients (19.4%). The probability of febrile UTI was 17.6% and 19.8% at 6 months and 24 months after surgery, respectively. While, Escherichia coli was the most common implicated pathogen (22/55, 40.0%), Enterococcus spp. were the most common pathogen during the first month after surgery (18/33, 54.5%). In multivariate logistic regression analysis, ureteral stricture was an independent risk factor associated with febrile UTI (OR 5.93, P = 0.023). However, ureteral stricture accounted for only 6 episodes (10.9%, 6/55) of febrile UTI. Most episodes of febrile UTI occurred within 6 months after surgery. Thus, to identify risk factors associated with febrile UTI in the initial postoperative period, we assessed videourodynamics within 6 months after surgery in 38 patients. On videourodyamic examination, vesicoureteral reflux (VUR) was identified in 16 patients (42.1%). The rate of VUR presence in patients who had febrile UTI was not significantly different from those in patients without febrile UTI (50% vs. 39.3%, P = 0.556). Patients with febrile UTI had significantly larger residual urine volume (212.0 ± 193.7 vs. 90.5 ± 148.2, P = 0.048) than those without. E. coli and Enterococcus spp. are common pathogens and ureteral stricture and residual urine are risk factors for UTI after ileal neobladder reconstruction.
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Affiliation(s)
- Kwang Hyun Kim
- Department of Urology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyun Suk Yoon
- Department of Urology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hana Yoon
- Department of Urology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Woo Sik Chung
- Department of Urology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Bong Suk Sim
- Department of Urology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Dong Hyeon Lee
- Department of Urology, Ewha Womans University School of Medicine, Seoul, Korea
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31
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Moschini M, Simone G, Stenzl A, Gill IS, Catto J. Critical Review of Outcomes from Radical Cystectomy: Can Complications from Radical Cystectomy Be Reduced by Surgical Volume and Robotic Surgery? Eur Urol Focus 2016; 2:19-29. [PMID: 28723446 DOI: 10.1016/j.euf.2016.03.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/03/2016] [Indexed: 12/12/2022]
Abstract
CONTEXT Radical cystectomy (RC) is a highly complex procedure with multiple risks for perioperative complications. OBJECTIVE We reviewed the literature to report perioperative outcomes and the incidence of complications in contemporary RC series. We focused on the potential impact of surgical approach and surgeon volume on these outcomes. EVIDENCE ACQUISITION A systematic literature search was performed in December 2015 using the Medline, Embase, and Web of Science databases for articles published in English between 2005 and 2015. The search strategy included the terms complications, cystectomy, robotic assisted radical cystectomy, and surgical volume, alone or in combination. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. EVIDENCE SYNTHESIS Our searches retrieved 49 papers. Open RC (ORC) and robot-assisted RC (RARC) are morbid procedures with consistent risk of perioperative complications (mean weighted incidence: 48.7%; range: 27.0-72.5%). Higher hospital and surgeon volumes were associated with reduced risks of perioperative complications. Prior robotic expertise in radical prostatectomy showed a beneficial protective risk on development of complications after RARC. Surgical volume appears to be a good predictor of safety in ORC and RARC. RARC is associated with reduced estimated blood loss and lower perioperative transfusion rates compared with ORC. Further evidence is needed to support the reproducibility of intracorporeal diversion during RARC, beyond large tertiary referral centers. Several strategies have been demonstrated to be effective for reducing the risk of incurring perioperative complications and should be pursued by physicians. CONCLUSIONS Despite improvements in quality of care, RC remains a challenging procedure with high morbidity, regardless of surgical approach. RARC is a safe procedure with potential advantages in terms of reduced blood loss and transfusion rates. Surgical volume appears to be related to the improvement of perioperative outcomes and complications. PATIENT SUMMARY Radical cystectomy is a challenging and morbid procedure. The robotic approach has gained popularity and proved to be safe and effective in tertiary referral centers, although further studies are needed to confirm its wide reproducibility. Centers with higher surgical volume have lower incidence of perioperative complications.
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Affiliation(s)
- Marco Moschini
- Unit of Urology/Division of Oncology, IRCCS Ospedale San Raffaele, URI Milan, Milan, Italy.
| | - Giuseppe Simone
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Arnulf Stenzl
- Department of Urology, University Hospital Tübingen, Tübingen, Germany
| | - Inderbir S Gill
- University of Southern California Institute of Urology, Keck School of Medicine, Catherine and Joseph Aresty Department of Urology, Los Angeles, CA, USA
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
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Enhanced recovery protocols (ERP) in robotic cystectomy surgery. Review of current status and trends. Curr Urol Rep 2015; 16:32. [PMID: 25850413 DOI: 10.1007/s11934-015-0497-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Open radical cystectomy with pelvic lymphadenectomy and urinary diversion is associated with a high complication rate. Robotic-assisted laparoscopic radical cystectomy is increasingly performed in many urologic surgical departments in an effort to reduce surgical stress and decrease perioperative morbidity. Robotic cystectomy survival studies demonstrate similar oncologic outcomes compared to the open procedure. Enhanced recovery protocols (ERP) after major surgery are multimodal perioperative interventions to reduce surgical stress, complications, and patient convalescence. Evidence for different ERP interventions are currently mainly from colorectal surgery and recently adapted to major urologic operations including cystectomy. Guidelines for perioperative care after open radical cystectomy for bladder cancer were recently published, but these recommendations may differ when considering a robotic approach. Therefore, we look at the current evidence for ERP in both open and robotic radical cystectomy and the potential for improving ERPs in robotic cystectomy by utilizing a totally intracorporeal robotic cystectomy approach. We also present the Karolinska ERP currently utilized in totally intracorporeal robotic cystectomy.
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Ortega-Lucea S, Martínez-Ubieto J, Júdez-Legaristi D, Muñoz-Rodriguez L, Gil-Bona J, Pascual-Bellosta A. The results of implementing a fast-track protocol in radical cystectomy in a tertiary hospital. Actas Urol Esp 2015; 39:620-7. [PMID: 26142895 DOI: 10.1016/j.acuro.2015.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/24/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Radical cystectomy (RC) is the urological procedure associated with the highest rates of morbidity, mortality and hospital stay. The implementation of fast-track programs seeks to speed postsurgical recovery. Its application to radical cystectomy has yielded positive results. OBJECTIVES To assess the results of the fast-track protocol in RC at our hospital, in terms of morbidity, mortality and hospital stay, comparing these results with those of patients who underwent RC following the classic protocol. To thereby ascertain whether the implementation of the fast-track protocol represents a reduced number and severity of complications and shorter hospital stays. MATERIAL AND METHODS Ambispective cohort study of patients who underwent RC between January 2010 and October 2012 by either protocol (classic and fast-track). We analyzed the patient characteristics, intraoperative variables, postoperative complications (according to the Clavien classification), hospital stay and recovery stay. RESULTS Ninety-nine patients were included, 51 following the classic protocol and 48 following the fast-track protocol. The groups were homogeneous. The hospital stay and recovery stay were longer in the classic group than in the fast-track group (29 and 2 days, respectively, vs. 17 and 1 day). There was less intraoperative bleeding in the fast track group (600mL) than in the traditional group (1,000mL). Of the 99 patients, 31 (60.8%) of the classic group presented a postoperative complication, while the fast-track group had 14 (29.2%), most of which were minor (Clavien degrees 1 and 2). In the multivariate analysis, the type of protocol and the number of comorbidities were significant. CONCLUSIONS The implementation of the fast-track protocol in RC was associated with a significant reduction in intraoperative and postoperative complications and hospital stay.
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Hupe MC, Kramer MW, Merseburger AS. Preoperative and modifiable factors to lower postoperative complications after radical cystectomy. Curr Urol Rep 2015; 16:19. [PMID: 25691438 DOI: 10.1007/s11934-015-0493-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Radical cystectomy is the gold standard for muscle-invasive bladder cancer. It is a challenging procedure comprising of two steps: removal of the bladder followed by construction of a new urinary diversion. Despite advances in surgical and postoperative management within the last decades, postoperative complication rates for this procedure are still considerably high. Many complications are avoidable in the pre-/intra-/postoperative setting by carefully selecting patients eligible for this procedure and by considering prophylactic measures. Fast-track concepts demonstrate current intentions to optimize perioperative management. This review summarizes the most recent studies and findings on how to lower postoperative complications with the help of preoperative and modifiable factors.
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Affiliation(s)
- Marie C Hupe
- Department of Urology and Urologic Oncology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany,
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35
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Pariser JJ, Anderson BB, Pearce SM, Han Z, Rodriguez JA, Landon E, Pisano JC, Smith ND, Steinberg GD. The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy. Urol Oncol 2015; 34:121.e9-14. [PMID: 26572724 DOI: 10.1016/j.urolonc.2015.10.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/28/2015] [Accepted: 10/09/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC. MATERIALS AND METHODS In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3g, gentamicin 4mg/kg, and fluconazole 400mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates. RESULTS In total, 386 patients were studied (258 before the change and 128 after). The overall infection rate decreased with the new regimen (41% vs. 30%, P = 0.043) with improvements in wound (14% vs. 6%, P = 0.025) and fungal (10% vs. 3%, P = 0.021) infections. Median length of stay decreased from 8 (interquartile range [IQR]: 7-12) to 7 (IQR: 7-10) days (P = 0.008). On multivariate analysis, the new regimen decreased the risk of infections (odds ratio [OR] = 0.58, 95% CI [0.35-0.99], P = 0.044) whereas body mass index, operating room time, smoking, and total parenteral nutrition increased the risk (all P< 0.05). CONCLUSIONS Risk factors for infection after RC include body mass index, operating room time, smoking, and total parenteral nutrition use. Changing from cefoxitin to broader, culture-directed antimicrobial prophylaxis, based on institutional data to include antifungal coverage, decreased postoperative infections.
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Affiliation(s)
- Joseph J Pariser
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL.
| | - Blake B Anderson
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Shane M Pearce
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Zhe Han
- Department of Pharmaceutical Services, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Joseph A Rodriguez
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Emily Landon
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Jennifer C Pisano
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Norm D Smith
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Gary D Steinberg
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
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Matulewicz RS, Brennan J, Pruthi RS, Kundu SD, Gonzalez CM, Meeks JJ. Radical Cystectomy Perioperative Care Redesign. Urology 2015; 86:1076-86. [PMID: 26383615 DOI: 10.1016/j.urology.2015.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/19/2015] [Accepted: 09/01/2015] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To present an evidence-based review of the perioperative management of the radical cystectomy (RC) patient in the context of a care redesign initiative. METHODS A comprehensive review of the key factors associated with perioperative management of the RC patient was completed. PubMed, Medline, and the Cochrane databases were queried via a computerized search. Specific topics were reviewed within the scope of the three major phases of perioperative management: preoperative, intraoperative, and postoperative. Preference was given to evidence from prospective randomized trials, meta-analyses, and systematic reviews. RESULTS Preoperative considerations to improve care in the RC patient should include multi-disciplinary medical optimization, patient education, and formal coordination of care. Efforts to mitigate the risk of malnutrition and reduce postoperative gastrointestinal complications may include carbohydrate loading, protein nutrition supplementation, and avoiding bowel preparation. Intraoperatively, a fluid and opioid sparing protocol may reduce fluid shifts and avoid complications from paralytic ileus. Finally, enhanced recovery protocols including novel medications, early feeding, and multi-modal analgesia approaches are associated with earlier postoperative convalescence. CONCLUSION RC is a complex and morbid procedure that may benefit from care redesign. Evidence based quality improvement is integral to this process. We hope that this review will help guide further improvement initiatives for RC.
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Affiliation(s)
- Richard S Matulewicz
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL.
| | - Jeffrey Brennan
- Department of Anesthesia, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Raj S Pruthi
- Department of Urology, UNC School of Medicine, Chapel Hill, NC
| | - Shilajit D Kundu
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Chris M Gonzalez
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Joshua J Meeks
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, IL
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Liu NW, Shatagopam K, Monn MF, Kaimakliotis HZ, Cary C, Boris RS, Mellon MJ, Masterson TA, Foster RS, Gardner TA, Bihrle R, House MG, Koch MO. Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series. Urol Oncol 2015; 33:503.e17-22. [PMID: 26278363 DOI: 10.1016/j.urolonc.2015.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/23/2015] [Accepted: 07/10/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION This study seeks to evaluate the incidence and associated risk factors of Clostridium difficile infection (CDI) in patients undergoing radical cystectomy (RC) for bladder cancer. METHODS We retrospectively reviewed a single institution׳s bladder cancer database including all patients who underwent RC between 2010 and 2013. CDI was diagnosed by detection of Clostridium difficile toxin B gene using polymerase chain reaction-based stool assay in patients with clinically significant diarrhea within 90 days of the index operation. A multivariable logistic regression model was used to identify demographics and perioperative factors associated with developing CDI. RESULTS Of the 552 patients who underwent RC, postoperative CDI occurred in 49 patients (8.8%) with a median time to diagnosis after RC of 7 days (interquartile range: 5-19). Of the 122 readmissions for postoperative complications, 10% (n = 12) were related to CDI; 2 patients died of sepsis directly related to severe CDI. On multivariate logistic regression, the use of chronic antacid therapy (odds ratio = 1.9, 95% CI: 1.02-3.68, P = 0.04) and antibiotic exposure greater than 7 days (odds ratio = 2.2, 95% CI: 1.11-4.44, P = 0.02) were independently associated with developing CDI. The use of preoperative antibiotics for positive findings on urine culture within 30 days before surgery was not statistically significantly associated with development of CDI (P = 0.06). CONCLUSIONS The development of CDI occurs in 8.8% of patients undergoing RC. Our study demonstrates that use of chronic antacid therapy and long duration of antimicrobial exposure are associated with development of CDI. Efforts focusing on minimizing antibiotic exposure in patients undergoing RC are needed, and perioperative antimicrobial prophylaxis guidelines should be followed.
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Affiliation(s)
- Nick W Liu
- Department of Urology, Indiana University Health, Indianapolis, IN.
| | | | - M Francesca Monn
- Department of Urology, Indiana University Health, Indianapolis, IN
| | | | - Clint Cary
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Ronald S Boris
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Matthew J Mellon
- Department of Urology, Indiana University Health, Indianapolis, IN
| | | | - Richard S Foster
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Thomas A Gardner
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Richard Bihrle
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Michael G House
- Department of Urology, Indiana University Health, Indianapolis, IN
| | - Michael O Koch
- Department of Urology, Indiana University Health, Indianapolis, IN
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Arnold A, Aitchison LP, Abbott J. Preoperative Mechanical Bowel Preparation for Abdominal, Laparoscopic, and Vaginal Surgery: A Systematic Review. J Minim Invasive Gynecol 2015; 22:737-52. [DOI: 10.1016/j.jmig.2015.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/02/2015] [Accepted: 04/02/2015] [Indexed: 12/14/2022]
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Tomaszewski JJ, Smaldone MC. Perioperative Strategies to Reduce Postoperative Complications After Radical Cystectomy. Curr Urol Rep 2015; 16:26. [DOI: 10.1007/s11934-015-0503-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Best practices in robot-assisted radical cystectomy and urinary reconstruction: recommendations of the Pasadena Consensus Panel. Eur Urol 2015; 67:363-75. [PMID: 25582930 DOI: 10.1016/j.eururo.2014.12.009] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 12/03/2014] [Indexed: 12/20/2022]
Abstract
CONTEXT Robot-assisted surgery is increasingly used for radical cystectomy (RC) and urinary reconstruction. Sufficient data have accumulated to allow evidence-based consensus on key issues such as perioperative management, comparative effectiveness on surgical complications, and oncologic short- to midterm outcomes. OBJECTIVE A 2-d conference of experts on RC and urinary reconstruction was organized in Pasadena, California, and the City of Hope Cancer Center in Duarte, California, to systematically review existing peer-reviewed literature on robot-assisted RC (RARC), extended lymphadenectomy, and urinary reconstruction. No commercial support was obtained for the conference. EVIDENCE ACQUISITION A systematic review of the literature was performed in agreement with the PRISMA statement. EVIDENCE SYNTHESIS Systematic literature reviews and individual presentations were discussed, and consensus on all key issues was obtained. Most operative, intermediate-term oncologic, functional, and complication outcomes are similar between open RC (ORC) and RARC. RARC consistently results in less blood loss and a reduced need for transfusion during surgery. RARC generally requires longer operative time than ORC, particularly with intracorporeal reconstruction. Robotic assistance provides ergonomic value for surgeons. Surgeon experience and institutional volume strongly predict favorable outcomes for either open or robotic techniques. CONCLUSIONS RARC appears to be similar to ORC in terms of operative, pathologic, intermediate-term oncologic, complication, and most functional outcomes. RARC consistently results in less blood loss and a reduced need for transfusion during surgery. RARC can be more expensive than ORC, although high procedural volume may attenuate this difference. PATIENT SUMMARY Robot-assisted radical cystectomy (RARC) is an alternative to open surgery for patients with bladder cancer who require removal of their bladder and reconstruction of their urinary tract. RARC appears to be similar to open surgery for most important outcomes such as the rate of complications and intermediate-term cancer-specific survival. Although RARC has some ergonomic advantages for surgeons and may result in less blood loss during surgery, it is more time consuming and may be more expensive than open surgery.
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Stewart D, Inouye BM, Goldstein SD, Shah BB, Massanyi EZ, DiCarlo H, Kern AJ, Tourchi A, Baradaran N, Gearhart JP. Pediatric surgical complications of major genitourinary reconstruction in the exstrophy-epispadias complex. J Pediatr Surg 2015; 50:167-70. [PMID: 25598117 DOI: 10.1016/j.jpedsurg.2014.10.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Urinary continence is the goal of exstrophy-epispadias complex (EEC) reconstruction. Patients may require a continent urinary diversion (CUD) if they are a poor candidate for bladder neck reconstruction or are receiving an augmentation cystoplasty (AC) or neobladder (NB). This study was designed to identify the incidence of surgical complications among various bowel segments typically used for CUD. METHODS A prospectively kept database of 1078 patients with EEC at a tertiary referral center from 1980 to 2012 was reviewed for major genitourinary reconstruction. Patient demographics, surgical indications, perioperative complications, and outcomes were recorded. RESULTS Among reviewed EEC patients, 134 underwent CUD (81 male, 53 female). Concomitant AC was performed in 106 patients and NB in 11. Median follow up time after initial diversion was 5 years. The most common CUD bowel segments were appendix and ileum. The most common surgical complications after CUD were small bowel obstruction, post-operative ileus, and intraabdominal abscess. There was a significantly increased risk in the occurrence of pelvic or abdominal abscess when colon was used as a conduit compared to all other bowel segments (OR=16.7, 95% CI: 1.16-239) and following NB creation compared to AC (OR=39.4, 95% CI: 3.66-423). At postoperative follow-up, 98% of patients were continent of urine via their stoma. CONCLUSION We report the largest series to date examining CUD in the EEC population. The increased risk of abdominal and pelvic abscesses in patients who receive a colon CUD and undergo NB compared to AC indicates that while surgical complications following major genitourinary reconstruction are rare, they do occur. Practitioners must be wary of potential complications that are best managed by a multi-disciplinary team approach.
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Affiliation(s)
- Dylan Stewart
- The Johns Hopkins University School of Medicine, Division of Pediatric Surgery, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Baltimore, MD 21287
| | - Brian M Inouye
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
| | - Seth D Goldstein
- The Johns Hopkins University School of Medicine, Division of Pediatric Surgery, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Baltimore, MD 21287
| | - Bhavik B Shah
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
| | - Eric Z Massanyi
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
| | - Heather DiCarlo
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
| | - Adam J Kern
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
| | - Ali Tourchi
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
| | - Nima Baradaran
- Medical University of South Carolina, Department of Urology, 171 Ashley Ave, Charleston, SC 29425
| | - John P Gearhart
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287.
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Patient Selection, Operative Technique, and Contemporary Outcomes of Continent Catheterizable Diversion: the Indiana Pouch. CURRENT BLADDER DYSFUNCTION REPORTS 2014. [DOI: 10.1007/s11884-014-0265-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Deng S, Dong Q, Wang J, Zhang P. The role of mechanical bowel preparation before ileal urinary diversion: a systematic review and meta-analysis. Urol Int 2014; 92:339-48. [PMID: 24642687 DOI: 10.1159/000354326] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/11/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although the use of mechanical bowel preparation (MBP) is still widely promoted as the dogma before patients undergo ileal urinary diversion, an increasing number of clinical trials have suggested that there is no benefit. Thus, we performed a meta-analysis to evaluate the efficacy of MBP in ileal urinary diversion surgery. METHODS A literature search was performed in electronic databases, including PubMed, Embase, Science Citation Index Expanded as well as the Cochrane Library and the Cochrane Clinical Trials Registry, from 1966 to January 1, 2013. Clinical trials comparing outcomes of MBP versus no MBP for ileal urinary diversion surgery were included in the meta-analysis. Pooled odds ratios with 95% confidence intervals were calculated using the fixed- or random-effects models. RESULTS In total, two randomized controlled trials and five cohort studies were included in this meta-analysis. The primary outcomes, such as bowel leak and bowel obstruction, showed no statistical difference between the two groups. Additionally, the overall mortality rate and death rate related to operation also manifested that MBP does not offer an advantage over the no MBP. CONCLUSION This meta-analysis suggests that MBP does not reduce the incidence of perioperative complications in urinary diversion compared with no MBP. However, large randomized controlled clinical trials are needed to confirm this finding.
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Affiliation(s)
- Shi Deng
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
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Kelly ME, McGuire BB, Nason GJ, Lennon GM, Mulvin DW, Galvin DJ, Quinlan DM. Peri-operative management in urinary diversion surgery: A time for change? Surgeon 2013; 13:127-31. [PMID: 24135285 DOI: 10.1016/j.surge.2013.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/15/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Bowel preparation was established as part of the pre-operative course for patients undergoing ileal conduit formation since the late 1970's. Rationales for its use include reduction in infection and wound complications, technically easier anastomosis and earlier return to bowel function. However, recent reports have challenged this practice. Traditionally antibiotics were also administered for several days prior to surgery with the assumption that bacterial load was reduced. Modification of antibiotic protocols resulted from evidence-based findings. Furthermore, publications emphasizing the benefit of Enhanced Recovery Protocols/Programmes (ERP) have become contemporary. METHODS An online multiple-choice questionnaire (via Monkey Survey) was administered to all consultant urologists in Ireland. This national cross-sectional study evaluated the use of bowel preparation and antibiotic prophylaxis prior to urinary diversion. In addition, we also assessed consultant urologists' awareness of ERP and their views on the introduction and implementation of such a national program. RESULTS Of the 41 consultant urologists surveyed, 80.4% (n = 33) responded. 63.6% routinely used bowel preparation. Klean Prep was the most commonly used bowel preparation. 80.9% of urologists admit their patient's one-day pre-operatively for bowel preparation, with 87.8% using antibiotic prophylaxis at anesthesia induction, and 18.1% continuing the antibiotics for 24-48 h post-operatively. Although 74% of consultants are aware of ERP, only 66.6% are in favor of their national implementation. CONCLUSION The majority of Irish urologists use bowel preparation prior to ileal conduit formation. Substantial recent evidence has emerged showing no difference in infective complications or anastomotic leakage when bowel preparation was not used. National guidelines would be beneficial regarding the use of bowel preparation, antibiotic prophylaxis and ERP for urinary diversion surgery.
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Affiliation(s)
- M E Kelly
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
| | - B B McGuire
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - G J Nason
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - G M Lennon
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D W Mulvin
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D J Galvin
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D M Quinlan
- Department of Urology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Zaid HB, Kaffenberger SD, Chang SS. Improvements in safety and recovery following cystectomy: reassessing the role of pre-operative bowel preparation and interventions to speed return of post-operative bowel function. Curr Urol Rep 2013; 14:78-83. [PMID: 23397271 DOI: 10.1007/s11934-012-0300-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For radical cystectomy, historical practice trends have favored the use of preoperative bowel preparations to reduce complications, including surgical site infections, ileus, and anastomotic leaks. However, emerging data has questioned this practice. Postoperative cystectomy care also remains in flux, as new pharmacologic agents that may potentiate earlier return of bowel function are studied. We review the current literature with regards to preoperative and postoperative cystectomy bowel management.
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Affiliation(s)
- Harras B Zaid
- Department of Urologic Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN 37232-2765, USA.
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