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Background: To investigate the impact of different urinary diversion (UD) techniques on the peri- and postoperative complications of robot-assisted radical cystectomy (RARC) with ileal conduit. Methods: We retrospectively analyzed 373 patients undergoing RARC with ileal conduit at 11 institutions in Japan between April 2018 and December 2021. Propensity score weighting was performed to adjust for confounding factors such as age, sex, body mass index, performance status, American Society of Anesthesiologists score, previous abdominal surgery, neoadjuvant chemotherapy, and preoperative high T stage (≥ cT3) and high N stage (≥ cN1). Perioperative complications were then compared among three groups: extracorporeal, intracorporeal, and hybrid urinary diversion (ECUD, ICUD, and HUD, respectively). Results: A total of 150, 68, and 155 patients received ECUD, HUD, and ICUD, respectively. Bowel reconstruction time and UD time were significantly shorter in the ECUD group (p < 0.001), and console time was significantly longer and blood loss was significantly higher in the ICUD group (p < 0.001). For postoperative complications (Clavien–Dindo Classification grade ≥ 3), surgical site infection (p = 0.004), pelvic abscess (p = 0.013), anastomotic urine leak (p = 0.007), and pelvic organ prolapse (p = 0.011) significantly occurred in the ECUD group. For all grades, ileus was more common in the HUD group, whereas anastomotic stricture was more common in the ECUD group compared with the other groups (p < 0.05). Conclusions: Severe complications did not increase after HUD and ICUD compared with ECUD; however, console time tended to be longer and blood loss was slightly higher during RARC. [ABSTRACT FROM AUTHOR]

This document is a retracted article titled "Long-term results of standard procedures in urology: the ileal neobladder." The authors of the article withdrew it on May 8, 2006. The article was written by R. E. Hautmann, J. E. Gschwend, B. G. Volkmer from the Department of Urology at the University of Ulm in Germany, and M. Schumacher and U. E. Studer from the Department of Urology at the University of Berne in Switzerland. The article was published in the World Journal of Urology in 2006. [Extracted from the article]

Purpose: To extend the indications of kidney-sparing surgery (KSS) for ureter cancer by comparing the oncological outcomes between patients with upper tract urothelial carcinoma (UTUC) who underwent radical nephroureterectomy (RNU) or KSS. Methods: We retrospectively reviewed 708 patients with UTUC who underwent RNU (N = 646) or KSS (N = 62) between 2011 and 2019 to analyze the oncologic outcomes and prognostic factors. Subgroup analyses were performed for patients with unifocal ureteral urothelial carcinoma (UC). Results: No significant difference was observed in the overall survival (OS) or cancer-specific survival (CSS) between RNU and KSS (distal ureterectomy with reimplantation (N = 33), ureterectomy with ileal ureter (N = 14), ureteroscopic tumor resection (N = 10), and ureterectomy with ureteroureterostomy (N = 5)). Among 269 (38.0%) patients with unifocal ureteral UC, 219 and 50 patients underwent RNU and KSS, respectively. OS and CSS were not significantly different between these two groups. Pathologic stage was a significant risk factor in multivariate analysis (hazard ratio = 2.621; p = 0.000). Among 646 RNU patients, 219 (33.9%) had unifocal ureteral UC, 40 (18.3%) with low-grade tumors. Among these, 13 (5.9%) patients with unifocal, low-grade and small (< 2 cm) tumors received nephroureterectomy. Conclusion: Kidney-sparing surgery should be regarded as an important alternative to RNU for patients with unifocal ureteral UC thought to have noninvasive disease to preserve renal function and reduce overtreatment. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate return to work (RTW), health-related quality of life (HRQoL) and psychosocial distress (PD) after radical cystectomy (RC) and creation of an ileal conduit (IC) or an orthotopic ileal neobladder (NB) for bladder cancer. Methods: The study relied on prospectively collected data for 842 patients, who underwent 3 weeks of inpatient rehabilitation (IR) after surgery between April 2018 and December 2019. HRQoL (EORTC QLQ-C30) and PD (Questionnaire on Stress in Cancer Patients [QSC-R10]) were evaluated at the beginning (T1) and end (T2) of IR as well as both 6 (T3) and 12 months after surgery (T4). Regression analyses were performed to identify predictors of HRQoL and RTW, respectively. Results: Two hundred thirty patients (IC n = 51, NB n = 179) were employed before surgery (27.3%). HRQoL improved steadily, while high PD was present in 51.0% of patients at T4. RTW rate was 86.8 and 80.6% at T3 and T4, respectively. Linear regression analysis identified RTW as the only predictor for better HRQoL at T4 (OR [odds ratio] 12.823, 95% CI [confidence interval] 2.927–22.720, p = 0.012). Multivariate regression analysis identified age ≤ 59 years (OR 7.842; 95% CI 2.495–24.645; p < 0.001) as an independent positive predictor and lymph node metastasis (OR 0.220; 95% CI 0.054–0.893; p = 0.034) as an independent negative predictor of RTW at T4. Conclusion: Global HRQoL improved steadily during the follow-up and RTW rates are high. However, patients often reported high PD, reflecting a need for additional psychosocial support within aftercare. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to report on functional outcomes in a large cohort of patients who underwent inpatient rehabilitation (IR) in a highly specialized, high-volume German urologic rehabilitation center after radical cystectomy (RC) and creation of an ileal neobladder (INB). Methods: Data for 842 patients, who underwent three weeks of IR after RC and urinary diversion between April 2018 and December 2019 were prospectively collected. INB patients were surveyed on continence and sexual function. Data were collected at 4 weeks (T1), 6 months (T2), and 12 months (T3) after RC. Multivariate logistic regressions were performed to identify predictors of better functional outcomes. Results: INB was chosen as urinary diversion in 395 patients (357 male, 38 female). Social continence (maximum of one safety pad/24 h) was reported by 78.3% of men and 64.0% of women at T3. Severe incontinence was reported by 27.3% of men and 44.0% of women. Male sex was identified as an independent predictor for the use of no pads at T3 (OR 4.110; 95% CI 1.153–14.655; p = 0.029). Nerve-sparing surgery was identified as an independent predictor both for the use of only a safety pad (OR 1.918; 95% CI 1.031–3.569; p = 0.040) and good erectile function at T3 (OR 4.377; 95% CI 1.582–12.110; p = 0.004). Conclusion: Urologists should aspire for nerve-sparing surgery. When advising patients before RC, functional outcomes (continence, sexual function) should be given special attention. Women should be counseled on potentially prolonged urinary incontinence. [ABSTRACT FROM AUTHOR]

Background: Parastomal incisional hernia (PH) is a frequent complication following the creation of an ileal conduit (IC), and it can be a significant detriment to quality of life. The aim of this study was to evaluate outcomes of PH repair following IC for urinary diversion. Method: A multicenter retrospective study was conducted of 6 academic hospitals in France. The study's population included patients who underwent surgical treatment for parastomal hernia following IC creation from 2013 to 2021. Results: Fifty-one patients were included in the study. Median follow up was 15.3 months. Eighteen patients presented with a recurrence (35%), with a median time to recurrence of 11.1 months. The vast majority of PH repair was performed through an open approach (88%). With regard to technique, Keyhole was the most reported technique (46%) followed by Sugarbaker (22%) and suture only (20%). The Keyhole technique was associated with a higher risk of recurrence compared to the Sugarbaker technique (52% vs 10%, p = 0.046). Overall, there was a 7.8% rate of major complications without a statistical difference between PH repair techniques for major complications. Conclusion: Surgical treatment of parastomal hernia following IC was associated with a high risk of recurrence. Novel surgical approaches to PH repair should be considered. [ABSTRACT FROM AUTHOR]

In our own series of BC-patients undergoing open-RC and UD, the overall perioperative complication rate was comparatively higher (Table 1). Dear Editor, With great interest, we read the long-term results of bladder cancer (BC) patients treated with robot-assisted radical cystectomy (RC) and urinary diversion (UD) by Tuderti et al. [[1]]. Detailed reporting of clinical and pathological parameters, and comprehensive depiction of complication-intervention events and grading is required to ensure comparability of survival and morbidity outcomes. [Extracted from the article]

Purpose: To identify pre-surgical imaging predictive value and factors associated with the clinicopathologic discrepancy for implication of definitive pelvic radiotherapy in clinically node-negative bladder cancer. Method: The documented data of bladder cancer patients who underwent radical cystectomy plus pelvic lymphadenectomy were collected retrospectively. Patients' characteristics, last imaging, pathology reports, disease-specific survival and overall survival were retrieved. Results: From 142 patients, pre-surgical imaging had a sensitivity of 76.4%, specificity of 73.7%, positive predictive value (PPV) of 94.9%, and negative predictive value (NPV) of 32.6% (p value < 0.0001) for detection of muscle invasion. Also, for detection of positive lymph nodes, imaging had a sensitivity of 31.8%, specificity of 85.7%, PPV of 50%, and NPV of 73.7% (p value: 0.022). 44.4% of study population were upstaged after surgery (24.6% associated with N-upstaging) and 18.3% were downstaged (12% associated with N-downstaging). Receipt of neoadjuvant chemotherapy and T-stage were not correlated with N-upstaging. On multivariate analysis, lymphovascular invasion (LVI) maintained its significance for independent prediction of upstaging (OR 3.3, 95% CI 1.5–7.5, p value: 0.004) and inversely with downstaging (OR 0.34, 95% CI 0.12–0.96, p value: 0.04). Older age (OR 1.03, 95% CI 1.0–1.05, p value 0.047), positive margins (OR 2.1, 95% CI 1.2–3.8, p value 0.011), presence of LVI (OR 2.5, 95% CI 1.4–4.7, p value 0.003), perineural invasion (OR 2.0, 95% CI 1.2–3.4, p value 0.013), and lymph node ratio (OR 1.011, 95% CI 1.001–1.021, p value 0.03) were associated with worse survival. Also, N-upstaging independently predicted a worse survival after controlling for surgical pathology stage (OR 2.3, 95% CI 1.2–4.5, p value 0.011). Conclusions: The optimal target volume in definitive chemoradiotherapy of node-negative bladder cancer patients remains to be established. Since then, customizing the treatment is considered especially for positive LVI in TURBT specimen. [ABSTRACT FROM AUTHOR]

Purpose: Despite surgical and anesthetic progress, radical cystectomy for bladder cancer remains one of the most morbid surgeries in urology. The objective of our study was to describe intraoperative complications and to assess the impact of surgical approach on morbidity. Methods: We retrospectively reviewed medical records of patients treated by radical cystectomy for localized muscle invasive bladder cancer between 2015 and 2020, following the Martin et al. criteria for complications reports. All intraoperative adverse events were graded according to the EAUiaiC scores. Multivariate regression models were used to determine predicting factors of complications. Results: A total of 318 patients were included for analysis. Among them, 17 patients (5.4%) presented an intraoperative complication. No preoperative oncological or clinical factor was associated with the occurrence of an intraoperative complication. Surgical approach had no impact on morbidity. Both overall survival (HR 2.02; CI95% 0.87–4.68; p = 0.101) and recurrence-free survival (HR 1.856; CI95% 0.804–4.284; p = 0.147) were not associated with intraoperative complication. Conclusion: Radical cystectomy remains a highly morbid surgery and surgical approach did not improve the complication rate. Perioperative morbidity has a significant impact on patient survival. The association between intraoperative and postoperative complications illustrates the cumulative effect of perioperative events that are associated with survival. [ABSTRACT FROM AUTHOR]

Purpose: To compare the perioperative and oncologic outcomes between minimally invasive pelvic organ-preserving radical cystectomy (MIPOPRC) and open pelvic organ-preserving radical cystectomy (open POPRC) among female patients with bladder cancer (BCa). Methods: We identified female patients who underwent POPRC for BCa at three centers between January 2006 and April 2018. Female patients who underwent open POPRC were matched with those who underwent MIPOPRC using 1:1 propensity score (PS) matching. The patient demographics and perioperative and oncologic outcomes were evaluated for the comparison between MIPOPRC and open POPRC. Results: Among the 158 patients enrolled, 83 patients underwent MIPOPRC, and 75 underwent open POPRC. A total of 60 MIPOPRC and 60 open POPRC patients were matched successfully. The cancer-specific survival (CSS) and recurrence-free survival (RFS) did not differ significantly in the propensity score-weighted cohort (p = 0.297 and p = 0.600, respectively). Subgroup analysis by age and pathologic stage in the matched cohort revealed that CSS and RFS were with no differences among all subgroups. Moreover, multivariable Cox regression analyses showed that the surgical approach (MIPOPRC vs open POPRC) was not a predictor of CSS (p = 0.250). Conclusion: MIPOPRC was non-inferior to open POPRC in terms of oncologic outcomes among female patients. MIPOPRC could be technically feasible in selected female patients with BCa. [ABSTRACT FROM AUTHOR]

Purpose: To explore the impact of ileal conduit (IC), orthotopic ileal neobladder, and MAINZ Pouch I on renal function (RF) over time. Methods: We performed a retrospective, cohort study including consecutive patients who underwent open radical cystectomy due to bladder cancer from November 2013 to June 2022. RF deterioration was calculated based on the estimated glomerular filtration rate (eGFR) through the CKD-EPI creatinine equation. A linear mixed-effects model was constructed, adjusting for multiple risk factors. The probability of achieving an eGFR reduction greater than 25% compared to baseline among different urinary diversion techniques was assessed using a Kaplan–Meier curve. Results: Overall, 107 patients received IC, 28 neobladder, and 20 MAINZ Pouch I. Those receiving IC were older and displayed more comorbidities. At follow-up, eGFR was lower by 0.09 mL/min/1.73m2 (confidence interval − 5.87 to 5.69, p = 0.975) in patients receiving neobladder compared to those receiving IC. Similarly, eGFR was higher by 4.64 mL/min/1.73m2 (confidence interval − 1.57 to 10.85, p = 0.143) in patients receiving pouch compared to those receiving IC. Accordingly, patients with higher preoperative eGFR (p < 0.001), lower age (p = 0.048), non-T4 histological tumor (p = 0.027) and absence of septicemia at follow-up (p = 0.002) presented higher eGFR values at follow-up. The three UD techniques did not differ significantly in the time-to-event analysis (log-rank test = 0.29). Conclusions: A substantial proportion of patients undergoing urinary diversion with IC, orthotopic ileal neobladder, or MAINZ Pouch I develop RF deterioration at follow-up. No significant differences were observed among the three UD techniques in terms of eGFR decline in the long-term. [ABSTRACT FROM AUTHOR]

Purpose: Cystectomy associated with non-continent ileal diversion is a common surgery in patients with neurogenic bladder. Few data are available, especially for the robotic approach. Our purpose was to compare open cystectomy (OC) and robot-assisted radical cystectomy (RARC) with ileal conduit, regarding peri- and post-operative outcomes. Methods: We included each patient who underwent cystectomy and ileal conduit for neurogenic bladder in a referral-center between January 2017 and November 2021. Data were retrospectively analyzed. Median follow-up was 16.6 months [IQR: 5; 41]. All patients had neurogenic bladder with failure of conservative treatment and/or impacted Quality of Life (QoL). Open cystectomy with non-continent ileal diversion and robot-assisted cystectomy with intra-corporeal non-continent ileal diversion were compared. Primary endpoint was postoperative complications. Secondary endpoints were length of hospital stay (LOS), surgery duration, blood loss and ureteral anastomosis stricture. Results: A total of 123 patients were included, n = 85 (69.1%) undergoing OC and n = 38 (30.9%) RARC. Significant differences were observed for: operative time (OC 266.9 ± 64 vs. RARC 205.8 ± 55.5 min, p < 0.001), blood loss (OC 737.7 ± 515.8 vs. RARC 245.8 ± 169.6 ml, p < 0.001), delay until feeding resumption (OC 7.1 ± 4.7 vs. RARC 5.5 ± 2.9 days, p = 0.05) and mean LOS (OC 21.6 ± 13.9 vs. RARC 16.2 ± 7.6 days, p = 0.03). In RARC group, there were 10.5% complications Clavien-Dindo > 2 whereas 23.8% complications underwent in the OC group (p = 0.1). Conclusion: RARC is a safe approach for management of neurological bladder showing significantly better perioperative outcomes. [ABSTRACT FROM AUTHOR]

Here we present a mini-invasive technique to treat stoma prolapse using a linear stapler (Fig. Stoma complications (including parastomal hernia, stoma prolapse, stenosis, and retraction) are the most frequent indication for reoperation in these patients [[2]]. 1Repair of a 7-cm stoma prolapse (a) by linear stapler in a 59-year-old male patient who underwent ileal conduit procedure by the Wallace technique (conjoined, refluxing, end-to-end ureteroenteric anastomosis) 1 year before admission. [Extracted from the article]

Purpose: Few data exist regarding the functional outcomes of robot-assisted radical cystectomy (RARC) with intracorporeal orthotopic neobladder. The aim of this study was to evaluate the urodynamic and functional outcomes in patients undergoing RARC and totally intracorporeal orthotopic neobladder for bladder cancer. Methods: In this monocentric, observational study carried out between 2016 and 2020, consecutive patients undergoing RARC and intracorporeal orthotopic neobladder in the Department of Urology, Pitié-Salpêtrière Hospital, were included. Reconstruction was totally intracorporeal Y-shaped neobladder. Main outcomes were urodynamic findings 6 months post-surgery, continence and quality of life (QoL). Continence was defined by no pad or one safety pad. International Consultation on Incontinence Questionnaire (ICIQ), International Index of Erectile Function questionnaire (IIEF-5) and Bladder Cancer Index (BCI) scores were recorded. Results: Fourteen male patients were included (median age: 64 years [IQR 54–67]. Median maximal neobladder cystometric capacity was 495 ml [IQR 410–606] and median compliance was 35.5 ml/cm H2O [IQR 28–62]. All patients had post-void residual volume < 30 ml, except for three (22%) who required clean intermittent-self catheterisation. Daytime continence was achieved in 10 patients (71%) and night-time continence in two (14.3%). Median ICIQ score was 7 [IQR 5–11]. Postoperative erectile function was present in 7% of patients (mean IIEF-5 = 5 [IQR 2–7]). Thirteen patients (93%) were satisfied with their choice of neobladder. Conclusion: RARC with totally intracorporeal orthotopic neobladder for bladder cancer provides satisfactory urodynamic results and good QoL. These findings should be confirmed long-term. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the role of low intra-abdominal pressure (IAP) in improving postoperative recovery in Robotic-assisted radical cystectomy (RARC) and intracorporeal ileal conduit urinary diversion (ICUD). Methods: A retrospective case–control study of 49 bladder cancer patients offered RARC/ICUD with standard (12 mmHg, n = 24) or low IAP (8 mmHg, n = 25). Outcomes of interest included length of procedure (LoP), estimated blood loss (EBL), blood transfusion, margin positivity rates, time to first flatus (TtFF), time to first bowel movement (TtFBM), ileus and small bowel obstruction (SBO) rates, time to safe discharge (TtSD), postoperative hospital stay (PHS) and pain levels on a postoperative day (POD) 1 and 3. Perioperative complications were recorded using the Clavien-Dindo system. Results: Demographic and baseline clinical characteristics, LoP, EBL and margin positivity rates were similar between groups. No transfusions were recorded. Median (IQR) TtFF, TtFBM and TtSD were significantly longer in Group 1 vs Group 2 (4 (1) vs 2 (1), 7 (3) vs 6 (2) and 8.5 (5.75) vs 5.0 (1), respectively). PHS and rates of postoperative ileus and SBO were lower in Group 2, however not statistically significant. Severe pain was uncommon in both groups but moderate/severe pain was significantly higher in Group 1 (95.8% vs 48% on POD1 and 62.5% vs 16% on POD3). No significant intraoperative complications were recorded and ≥ Grade 3 postoperative complications at 30 and 90 days were similar. Conclusion: With limitations, Low-IAP RARC can be safely offered to RARC/ICUD patients and leads to faster bowel recovery, and shorter time to safe discharge compared to standard pneumoperitoneum. [ABSTRACT FROM AUTHOR]

Purpose: Radical cystectomy in people with spinal cord injury (SCI) provides numerous additional difficulties, compared to able-bodied people. Therefore, it is important to obtain information from an experienced team about optimally managing these patients. Methods: Surgical procedures, based on the experience of 12 radical cystectomies in SCI patients with bladder cancer between January 1st, 2001, and December 31st, 2020, were recorded and the operative and perioperative clinical data were evaluated. Surgery was performed in a high-volume center by the surgeon most experienced in radical cystectomies, assisted by the neuro-urologist, involved in the care of the patient from the spinal cord center. Furthermore, a checklist based on the experience of the surgeon and the assisting neuro-urologist was developed. Results: SCI patients mostly suffered from an advanced disease and were always operated by the same team. The hospital stays ranged from 23 to 134 days (median 42 days). Four of the patients suffered from a postoperative paralytic ileus. Otherwise, both the operation time and the intraoperative blood loss as well as intraoperative and postoperative complications were basically comparable with those in able-bodied patients. The special features of radical cystectomy in SCI bladder cancer patients are described. Furthermore, a checklist addressing preoperative red flags, intra-operative challenges and post-operative challenges is presented. Conclusion: Radical cystectomy in SCI patients should be performed in a high-volume department by the most experienced surgical team. The inclusion of the urologist caring for the patient from the spinal cord injury center is highly recommended. [ABSTRACT FROM AUTHOR]

Objective: To determine whether use of neoadjuvant chemotherapy (NAC) is associated with a higher risk of post-operative complications following radical cystectomy (RC) for bladder cancer (BCa). Materials and methods: We retrospectively reviewed records of patients undergoing RC for non-metastatic urothelial BCa at 13 tertiary care centres from 2007–2019. Patients who received NAC ('NAC + RC' group) were compared with those who underwent upfront RC ('RC alone' group) for intra-operative variables, incidence of post-operative complications as per the Clavien–Dindo classification (CDC) and rates of re-admission and re-intervention. Multivariable logistic regression analysis was performed to determine predictors of CDC overall and CDC major (grade III–V) complications. We also analysed the trend of NAC utilization over the study period. Results: Of the 3113 patients included, 968 (31.1%) received NAC while the remaining 2145 (68.9%) underwent upfront RC for BCa. There was no significant difference between the NAC + RC and RC alone groups with regards to 30-day CDC overall (53.2% vs 54.6%, p = 0.4) and CDC major (15.5% vs 16.5%, p = 0.6) complications. The two groups were comparable for the rate of surgical re-intervention (14.6% in each group) and re-hospitalization (19.6% in NAC + RC vs 17.9% in RC alone, p = 0.2%) at 90 days. On multivariable regression analysis, NAC use was not found to be a significant predictor of 90-day CDC overall (OR 1.02, CI 0.87–1.19, p = 0.7) and CDC major (OR 1.05, CI 0.87–1.26, p = 0.6) complications. We also observed that the rate of NAC utilization increased significantly (p < 0.001) from 11.1% in 2007 to 41.2% in 2019, reaching a maximum of 48.3% in 2018. Conclusion: This large multicentre analysis with a substantial rate of NAC utilization showed that NAC use does not lead to an increased risk of post-operative complications following RC for BCa. This calls for increasing NAC use to allow patients to avail of its proven oncologic benefit. [ABSTRACT FROM AUTHOR]

The management of Crohn's disease has evolved significantly over the past 20 years. The arrival of biologic therapies has altered not only the management and outcomes but also rates for refractory disease requiring surgery. New surgical techniques have paralleled these medical advances, and this article will provide an overview of these new modalities as well as their outcomes. This is the first of a three-part series and will focus on terminal ileal and ileocolic disease. [ABSTRACT FROM AUTHOR]

Background: Liver-type fatty acid-binding protein (L-FABP) in urine is one of the early diagnostic biomarkers for acute and chronic kidney injuries. Although this protein is also identified in the intestine, there is no verified reference value for patients with intestinal urinary diversion (UD). The aim of the present study was to measure L-FABP values in such patients and compare them with the results for patients without UD. Methods: Spot urine specimens were collected from 41 patients with UD and 50 subjects without UD with estimated glomerular filtration rates of over 60 ml/min/1.73 m2, and the L-FABP values were measured. The normal upper cutoff value in healthy subjects without UD is considered to be 7.24 μg/g Cr. First, the median values of the two groups were compared. Next, the subjects with negative proteinuria and without comorbidities associated with renal function were further selected and the median values of the groups were compared. Results: The mean age was significantly higher in the UD group. The types of UD were ileal conduit (38 patients) and ileal neobladder (three patients). The median L-FABP value in the UD group was significantly higher than that in the non-diversion group (89.1 μg/g Cr vs. 2.0 μg/g Cr, p < 0.0001). After adjustment for their backgrounds, the median value remained higher in the UD group. Conclusions: L-FABP values in subjects with UD are higher than in those without UD. By this result, to develop a reference value in patients with intestinal UD population, further studies are required. [ABSTRACT FROM AUTHOR]

Purpose: Although gastric conduit cancer (GCC) arising after esophagectomy is increasingly being reported, therapeutic strategies for resectable GCC have yet to be optimized. We investigated clinicopathological features of patients undergoing endoscopic versus more invasive surgical treatments for GCC and compared their outcomes. Methods: Fifty-one patients, who had a history of esophagectomy with gastric conduit reconstruction for esophageal cancer and underwent resection for metachronous GCC, were identified. Their characteristics and outcomes were retrospectively reviewed. Results: There were 48 males and three females, ranging in age from 46–86 years. Twelve patients underwent surgery for GCC (group S) and 39 underwent only endoscopic resection (group E). The most common cause of death was pneumonia (10/51, 19.6%). Neither overall survival nor cumulative incidence of pneumonia-caused death differed significantly between the two groups (P = 0.60, 0.84, respectively). In group S, partial gastrectomy was performed in four cases and total gastrectomy in seven. Partial resections, including three antrectomy without sternotomy or intrathoracic procedures, were completed with significantly shorter operative durations than total resections (median 208 vs 513 min, P = 0.012). GCC recurrence was experienced in two cases: one undergoing open approach partial resection of the corpus and the other thoracoscopic total gastrectomy. Conclusion: Even compared with endoscopic treatment, outcomes following surgery for GCC appeared to be acceptable. Open approach total gastric gastrectomy could be the most radical modality, while other less invasive alternatives, e.g., antrectomy, are also an option. Clinicians may select a treatment strategy balancing radicality and patient status, reflecting tolerance to invasive procedures. [ABSTRACT FROM AUTHOR]

Objective: To access the feasibility of palliative cystoprostatectomy/pelvic exenteration in patients with bladder/rectal invasion due to prostate cancer (PC). Patients and methods: Twenty-five men with cT4 PC were retrospectively identified in the institutional databases of six tertiary referral centers in the last decade. Local invasion was documented by CT or MRI scans and was confirmed by urethrocystoscopy. Oncological therapies, local symptoms, previous local treatments, time from diagnosis to intervention and type of surgical procedure were recorded. Patients were divided into groups: ADT group (12 pts) and 13 pts without any history of previous local/systemic treatments for PCa (nonADT groups). Perioperative complications were classified using the Clavien–Dindo system. Overall survival (OS) was defined as the time from surgery to death from any cause. A Cox regression analysis, stratified for ISUP score and previous hormonal treatment (ADT) was also performed for survival analysis. Results: Ileal conduit was the main urinary diversion in both cohorts. For the entire cohort, complication rate was 44%. No significant differences regarding perioperative complications and complication severity between both subgroups were observed (p = 0.2). Median follow-up was 15 months (range 3–41) for the entire cohort with a median survival of 15 months (95% CI 10.1–19.9). In Cox regression analysis stratified for ISUP score, no statistically significant differences in OS in patients with and without previous ADT before cystectomy or exenteration were observed (HR 3.26, 95% CI 0.62–17.23, p = 0.164). Conclusion: Palliative cystoprostatectomy and pelvic exenteration represent viable treatment options associated with acceptable morbidity and good short-term survival outcome. [ABSTRACT FROM AUTHOR]

Purpose: Ileal orthotopic neobladder (IONB) reconstruction is the preferred urinary diversion among selected patients who have undergone radical cystectomy (RC) for bladder cancer (BCa). There is insufficient data regarding patients' quality of life (QoL), sexual and urinary outcomes. Our objectives were to assess QoL in a multicentre cohort study, and to identify related clinical, oncological and functional factors. Methods: Patients who underwent RC with IONB reconstruction for BCa from 2010 to 2017 at one of the three French hospitals completed the following self-reported questionnaires: European Organization for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and bladder cancer specific instruments (QLQ-BLM30). To assess urinary symptoms, patients completed the Urinary Symptom Profile questionnaire (USP) and a three-day voiding diary. Univariate and multivariate analyses were computed to identify clinical, pathological, and functional predictors of global QoL score. Results: Seventy-three patients completed questionnaires. The median age was 64 years and 86.3% were men. The median interval between surgery and responses to questionnaires was 36 months (range 12–96). Fifty-five percent of patients presented a high global QoL (EORTC-QLQC30, median score 75). A pre-RC American Society of Anesthesiologists score > 2, active neoplasia, sexual inactivity, and stress urinary incontinence were associated with a worse QoL. After a multivariate analysis, sexual inactivity was the only independent factor related to an altered QoL. Conclusion: Patients with IONB reconstruction after RC have a high global QoL. Sexual activity could independently impact the global QoL, and it should be assessed pre- and post-operatively by urologists. [ABSTRACT FROM AUTHOR]

Logically, a PSH will evolve from insignificant to larger size, but whether a CT diagnosis of a "low-stage" PSH according to M-M has increased risk of developing into a symptomatic hernia is not clear, especially not for mesh-protected stomas. The European Hernia Society's classification of parastomal hernia (PSH) [[1]] is based on size and concurrence of incisional hernia (IH) as perceived intraoperatively - and thus related to difficulty in repair. For patients diagnosed with PSH either clinically or by CT, the average ostomy size was 644 mm SP 2 sp (SD 275 mm SP 2 sp ) at the first CT and increased by a mean of 337 mm SP 2 sp (SD 293 mm SP 2 sp ). In the patients without PSH, the mean ostomy size was 466 mm SP 2 sp (SD 134 mm SP 2 sp ) at the first CT and increased by 67 mm SP 2 sp (SD 238 mm SP 2 sp ) at the last CT. [Extracted from the article]

Objectives: To evaluate the impact of histological variants on oncological outcomes of patients with muscle-invasive bladder cancer treated with open radical cystectomy and furthermore to determine any association between survival and each histotype of bladder cancer. Materials and methods: Data from 525 consecutive patients with muscle-invasive bladder cancer treated with radical cystectomy between January 2008 and May 2019 were collected retrospectively. The Kaplan–Meier curves and multivariable analysis addressed the role of histological variants in recurrence, cancer-specific and overall mortality between all subgroups. Results: Of 525 patients, 131 (25.0%) showed a histological variant at radical cystectomy. With a median follow-up of 31 months, 209 (39.8%) recurrences, 184 (35.0%) cancer-related deaths and 260 (49.5%) overall deaths were reported. The presence of histological variant was associated with advanced tumour stage, the presence of concomitant carcinoma in situ, lymph node metastasis, lymphovascular invasion and positive surgical margins compared to pure urothelial bladder cancer (all p values <.008) and resulted as an independent risk factor for cancer-specific mortality (p = 0.001). Patients with a histological variant were at significantly higher risk for recurrence, cancer-specific mortality and overall mortality (all p values ≤.001). Micropapillary, sarcomatoid or small cell differentiation was associated with reduced survival. Conclusion: The presence of histological variants at radical cystectomy seems to be weakly associated with reduced survival compared to pure urothelial bladder cancer paired for pathologic stage. The association of histological variants with advanced and biologically aggressive tumours suggests the need for attention on the overall management of these patients, in particular for micropapillary, sarcomatoid and small cell differentiation. [ABSTRACT FROM AUTHOR]

Introduction: Total pelvic exenteration (TPE) for rectal cancers is associated with significant morbidity. We evaluated the complications related to urinary reconstruction following TPE and factors predicting urologic morbidity. Methods: Retrospective analysis of TPE patients with incontinent urinary diversions between August 2013 and January 2020. Results: One hundred TPE were performed with 96 ileal conduits (IC). Early complications occurred in 10 patients that included uretero-ileal leaks (5%), conduit-related complications (3%), and acute pyelonephritis (3%). Late complications were seen in 26% of patients with uretero-intestinal strictures in 11%. Mortality attributable to urinary complications was seen in 2%. No single factor, including prior radiation, recurrent disease, type of anastomosis, or blood loss, predicted development of urinary morbidity. Conclusion: Conduit urinary diversion following TPE is associated with high urinary morbidity rate but low mortality. It can be safely performed even after previous surgeries and radiation by a dedicated colorectal team. [ABSTRACT FROM AUTHOR]

Purpose: We aim to assess the safety of decreasing ureteral stenting duration following Radical Cystectomy with Urinary Diversion (RCUD). Materials and methods: We analyzed a prospectively and retrospectively collected dataset for cystectomy patients at our tertiary center. Adult patient who underwent RCUD for malignancy from January 2013 to February 2018 were included. Patients with a history of abdominal/pelvic radiation and continent diversions were excluded. The patient population was divided to late stent removal group (LSR-POD 14) and early stent removal group (ESR-POD5). Our endpoints were total stent duration, 90-day readmission, 90-day total-UTI, 90-day urinary-readmissions, complications and Ureteroenteric Stricture (UES) rates. Statistical methods included t test, Chi-squared test and multivariate logistic regression. Results: One hundred and seventy-eight patients were included in the final analysis after inclusion/exclusion criteria were applied. The LSR (n = 74) and ESR (n = 104) groups were similar in preoperative characteristics except higher intracorporeal ileal conduit formation in ESR. The duration of stenting decreased significantly from approximately 15.5–5 days (P < 0.001). The LSR had higher 90-day overall readmission rates (OR = 2.57, 95% CI 1.19–5.53, P = 0.016) and total-UTIs (OR = 2.36, 95%CI 1.11–5.04, P = 0.026). With a median follow-up of 9.8 months, UES was similar between the two groups. Conclusion: Shorter ureteral stent duration is a safe and non-inferior option following RCUD. It allows for stent removal prior to discharge and less outpatient visits. In addition, decreasing stent duration was linked decreased readmissions and total-UTIs without increased risk of UES. However, future studies are needed to establish causality and promote stent duration change. [ABSTRACT FROM AUTHOR]

Extended aganglionosis (TIA) is the presence of some viable aganglionic gut distal to the levelling jejunostomy. Different surgical procedures (including transplantation) have been proposed with inconclusive results. We conceived a new procedure named skipped aganglionic lengthening transposition (SALT) consisting of multiple pedicled isoperistaltic transpositions of aganglionic ileal loops interposed to normoganglionic jejunum. The innovative aspect consists of taking advantage of the propulsive effect of normoganglionated bowel to progress enteric content throughout interposed aganglionic loops down to the stoma. The procedure was adopted in a male patient who was born with 30 cm of normoganglionated jejunum. SALT was performed when the baby was 18 months. Three 5-cm pedicled isoperistaltic aganglionic loops of small bowel were interposed each 10 cm of normoganglionic jejunum with an overall 36% length gain (from 42 to 57 cm). Postoperative course was uneventful. 6 months postoperatively, an upper gastrointestinal series showed normal progression without dilatations. A laparoscopic gastrostomy was performed due to food aversion 6 months postoperatively, demonstrating impressive anatomic and functional postoperative results. The procedure provides promising and unique opportunity for patients with TIA with encouraging outlook for the near future. [ABSTRACT FROM AUTHOR]

Purpose: To perform an internal audit 5 years after implementation of our enhanced recovery after surgery (ERAS) protocol for patients undergoing radical cystectomy and to investigate the importance of physician driven compliance on outcomes. Methods: Using a prospectively maintained database, 472 consecutive patients were identified who underwent radical cystectomy with ERAS from July 2013 to July 2017. Compliance was measured by a Composite Compliance Score (CCS) generated as a percentage of 16 interventions. Patients with higher than median compliance were compared to patients with lower compliance. The primary outcome was length of stay. Secondary outcomes included complication and readmission rates. Multivariable regressions were used to control for differences between groups. Results: In 2013, median CCS was 81% and subsequently ranged from 81 to 88%. Five-year median CCS was 88%. Patients with higher compliance (CCS ≥ 88%, n = 262), as compared to those with lower compliance (CCS < 88%, n = 210), were younger (median 70.3 vs 72.7 years, p = 0.047), healthier (ASA3–4 81% vs 89.9%, p = 0.007), received more orthotopic diversions (59.2% vs 37.6%, p < 0.0001), more often had open surgery (78.5% vs 51.9%, p < 0.0001) and had shorter median operative times (5.5 vs 6.3 h, p = 0.005). Median length of stay was 4 days. Higher compliance was associated with shorter hospital stays (β = − 0.85, 95% CI − 1.62 to − 0.07) and decreased 30-day readmissions (OR 0.58, 95% CI 0.35–0.96). Conclusions: Greater ERAS compliance was achieved in younger and healthier patients. Patients with greater compliance had a decreased length of stay by almost 1 day and reduced odds of 30-day readmissions. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of an Enhanced Recovery After Surgery (ERAS) program on complications and length of stay (LOS) after radical cystectomy (RC) and to assess if the number and type of components of ERAS play a key role on the decrease of surgical morbidity. Materials and methods: We analyzed the data of 277 patients prospectively recruited in 11 hospitals undergoing RC initially managed according to local practice (Group I) and later within an ERAS program (Group II). Two main outcomes were defined: 90-day complications rate and LOS. As secondary variables we studied 90-day mortality, 30-day readmission and transfusion rate. Results: Patients in Group II had a higher use of ERAS measures (98.6%) than those in Group I (78.2%) (p < 0.05). Patients in Groups I and II experienced similar complications (70.5% vs. 66%, p = 0.42). LOS was not different between Groups I and II (12.5 and 14 days, respectively, p = 0.59). The risk of having any complication decreases for patients having more than 15 ERAS measures adopted [RR = 0.815; 95% confidence interval (CI) 0.667–0.996; p = 0.045]. Avoidance of transfusion and nasogastric tube, prevention of ileus, early ambulation and a fast uptake of a regular diet are independently associated with the absence of complications. Conclusions: Complications and LOS after RC were not modified by the introduction of an ERAS program. We hypothesize that at least 15 measures should be applied to maximize the benefit of ERAS [ABSTRACT FROM AUTHOR]

Background: Radical cystectomy (RC) has a high morbidity and leads to a significant socio-economic burden. We aimed to investigate pre-, intra-, and post-operative variables to create a novel score predicting both post-operative clinical (complications) and economic (length of hospital stay) outcome after RC. Methods: We retrospectively evaluated clinical and histopathological data of 317 patients after RC. We performed univariate and multivariate logistic regression analyses to identify variables associated with post-operative clinical (30-day morbidity according to Clavien–Dindo complications) and economic (length of hospital stay) outcome. Results: In multivariate analysis, a high number of intraoperative transfusions (T) of packed red blood cells predicted major complications (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.10–2.58, p = 0.017), preoperative potassium (P) level predicted three or more complications (OR for high preoperative potassium 0.71, 95% CI 0.52–0.98, p = 0.037), and high drain (D) loss on post-operative day 1 predicted a longer hospital stay ≥ 22 days (OR 1.57, 95% CI 1.04–2.35, p = 0.003). The PT2D-Score was able to predict three or more complications (area under the curve: 0.70, 95% CI 0.61–0.78, p < 0.001) and a hospital stay of ≥ 22 days in patients after radical cystectomy (area under the curve: 0.63, 95% confidence interval 0.53–0.72, p = 0.012). Conclusions: The novel PT2D-Score combines preoperative potassium level, intraoperative blood transfusion, and post-operative drain loss to predict both clinical (30-day morbidity) and economic (length of hospital stay) outcome for patients undergoing RC. After validation in a larger cohort, the novel PT2D-Score might serve as an additional criterion to identify patients for intensified monitoring after RC. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: We reviewed a case of concomitant advanced pelvic organ prolapse and partial small bowel obstruction managed via transvaginal small bowel resection and native tissue prolapse repair. Methods: The patient is an 82-year-old woman with a history of a radical cystectomy and ileal conduit 2 years prior for bladder cancer that was transferred from an outside hospital for incarcerated prolapse including a small bowel obstruction with transition point inside the prolapse. She had previously unsuccessfully tried several pessaries for her prolapse. She was widowed and not sexually active. After conservative management of her bowel obstruction was unsuccessful, she was taken to the operating room for transvaginal prolapse repair. Intraoperatively, we encountered an isolated area of indurated bowel adherent to the prolapse. Colorectal surgery performed a transvaginal small bowel resection with stapled anastomosis, and a modified LeFort colpocleisis was performed to address her prolapse. Her postoperative course was uncomplicated, and at 6 months, she reported normal bowel function and had no evidence of prolapse recurrence. Conclusion: We present a case of incidental bowel pathology during vaginal prolapse surgery, requiring a small bowel resection. This case demonstrates the feasibility of this procedure when working with a multi-disciplinary team and localized bowel pathology. [ABSTRACT FROM AUTHOR]

Objectives: To determine risk factors influencing the incidence of parastomal hernia (PH) associated with ileal conduit (IC). Methods: A total of 194 Japanese patients who underwent IC diversion followed by regular postoperative radiographic follow-up from 2005 through 2016 were enrolled. The diagnosis of PH was determined by computed tomography (CT) for patients with and without related symptoms. The cumulative incidence of PH was assessed by the Kaplan–Meier method. The log-rank test and a multivariate Cox proportional hazards model were used to evaluate risk factors associated with the incidence of PH. Results: PH was observed in 20 patients (10.3%) after a median follow-up of 25.5 months. Of the 20 patients, three were symptomatic. The cumulative incidences were 3.6%, 10.1% and 15.1% at 1, 2 and 5 years after operation, respectively. The median body mass index (BMI) was 23.1 kg/m2 (IQR 20.4–24.6). The BMI and diameter of the passage through the rectus abdominis muscle for the IC (DPRAM) were significant predictors for PH (p = 0.04 and p < 0.001, respectively). In proportional hazards regression analysis, DPRAM ≥ 2.4 cm was the only independent risk factor for developing PH (HR 10.94, 95% CI 3.66–32.64). Conclusions: The incidence of PH in the current Japanese series was relatively low. Even in the population with low BMI, higher BMI might have an impact on incidence of PH. Moreover, DPRAM was also significantly associated with the incidence, suggesting that the operative procedure for creation of the passage is critical for future development of PH. [ABSTRACT FROM AUTHOR]

Background: Performing a tension-free anastomosis following extensive left-sided colorectal resection can be challenging due to limited length. The retro-ileal pull-through approach, where the colon is carefully delivered to the pelvis through a mesenteric window made under the ileocolic vessels, is a technique to perform such an anastomosis. Methods: This series is a retrospective review of patients who underwent a colorectal or coloanal anastomosis using the retro-ileal pull-through approach. Patient demographics, operative reports, and short-term outcomes were reviewed. Results: Seven patients had a retro-ileal pull-through technique with colorectal or coloanal anastomosis. The cohort included 3 patients who had a Hartman's reversal, 3 who had a redo colorectal anastomosis and one in whom this technique was used in an acute setting for sigmoid colectomy for acute perforated diverticulitis with primary anastomosis. Successful implementation of the technique was achieved in all patients with good short-term outcomes. Conclusions: In our cohort of patients, a retro-ileal pull-through technique was shown to be a successful approach to achieve a tension-free colorectal or coloanal anastomosis in various scenarios. This technique may prevent performing an ileorectal anastomosis or a permanent colostomy. We believe that this approach should be popularized among colorectal surgeons dealing with complicated colorectal operations. [ABSTRACT FROM AUTHOR]

Each suture was passed through the patch and once it was transposed to close the defect the sutures were tied, obtaining resolution of the lateral prolapse. Keywords: Lateral vaginal wall defect; Pelvic organ prolapse; Vaginal bulging; Radical cystectomy EN Lateral vaginal wall defect Pelvic organ prolapse Vaginal bulging Radical cystectomy 2301 2303 3 08/09/21 20210801 NES 210801 To date, and to our knowledge, lateral pelvic organ prolapse (POP) has never been described [[1]]. Lateral vaginal wall defect, Pelvic organ prolapse, Vaginal bulging, Radical cystectomy. [Extracted from the article]

Purpose: To report survival outcomes after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) for recurrent/muscle-invasive non-metastatic bladder cancer. Methods: Prospectively maintained databases were queried for "robotic cystectomy AND ICUD". Patients treated after October 2013 and those treated without curative intent were excluded. Kaplan–Meier method was used to plot stage-specific survival outcomes, computed at 1, 2, and 5 years after surgery. Univariable and multivariable Cox analyses assessed predictors of recurrence-free (RFS), cancer-specific (CSS) and overall (OS) survival. Results: 113 consecutive patients were included, mostly men (82%). Neoadjuvant chemotherapy was performed in 23% of cases, median lymph node (LN) yield was 36 (IQR 28–45) and the rate of positive surgical margins (PSM) was 8%. Orthotopic ileal neobladder was the preferred ICUD type (57%). An organ-confined disease was observed in 51% of cases and 21% were pT0 on final histology. Overall, 5-year RFS, CSS and OS probabilities were 58 ± 5%, 61 ± 5% and 54 ± 5%, respectively. At Kaplan–Meier method, tumor stage group was a significant predictor of survival probabilities (all p < 0.001) and this was confirmed at multivariable Cox regression analysis (RFS-OR 2.29; 95% CI 1.58–3.32; p < 0.001) (CSS-OR 1.82; 95% CI 1.3–2.53; p < 0.001) (OS-OR 2.14; 95% CI 1.46–3.14; p < 0.001). PSM status was associated to CSS (OR 2.54; 95% CI 1.13–5.69; p = 0.024) and OS (OR 2.82; 95% CI 1.17–6.77; p = 0.021), but did not predict RFS (p = 0.062). Conclusions: Long-term oncologic outcomes after RARC with ICUD appear similar to recent robotic series with extracorporeal diversion and historical open experiences. [ABSTRACT FROM AUTHOR]

Background: Extensive multi-visceral resection, including components of the urinary tract, is often required to achieve clear resection margins, which is now well established as a key predictor of long-term survival for locally advanced pelvic tumours. The aims of this study were to analyse major morbidity and factors predicting complications and long-term outcomes following a urological procedure within extended radical resections. Methods: Data were collected from prospective databases at two high-volume institutions specialising in extended radical resections for locally advanced and recurrent pelvic malignancies between 1990 and 2015. The primary endpoints were general major complications (Clavien–Dindo ≥ 3) and factors influencing complications and overall survival after urological resection. Results: A total of 646 consecutive patients requiring an extended radical resection for locally advanced or recurrent pelvic malignancies were identified. The median age was 63 years (range 19–89 years) and the majority were female (371; 57.4%). A urological resection was performed as part of the resection in 226 patients (35.0%). The overall 30-day major complication rate was significantly higher in the urological intervention group (23%; n = 52) compared to the non-urological group (12.9%; n = 54 patients; p = 0.001). Intestinal anastomotic leak (p = 0.001) and intra-abdominal collections (p = 0.001) were more common in the urological cohort. Ileal conduit formation was an independent predictor of major morbidity (OR 1.95; 95% CI 1.24–3.07; p = 0.004). Independent prognostic markers for poor 5-year survival following urological procedures were recurrent tumour, cardiovascular disease, previous thromboembolic event and postoperative pulmonary embolism. Conclusions: Extended radical resections which include a urological resection are associated with significantly more major morbidity than those without urological resection. Ileal conduit formation is independently associated with the development of major morbidity. Five-year overall survival is no different for patients who had or did not have urological resection as part of extended radical surgery for locally advanced or recurrent pelvic malignancy. [ABSTRACT FROM AUTHOR]

Purpose: To objectively quantify continence rates and to correlate continence outcomes with health-related quality of life (HRQOL) after radical cystectomy and orthotopic ileal neobladder (ONB). Methods: Questionnaires were sent to 244 patients who underwent radical cystectomy with ONB between 2004 and 2015, and information about the current continence status was retrieved. To objectify postoperative urine loss, daytime and nocturnal pad tests were performed. Continence was defined as need of up to one safety pad. HRQOL was assessed using EORTC QLQ-C30 scoring with global health status being the primary endpoint. Statistical analysis included Fisher's test, Mann–Whitney U test, Pearson's rank correlation, and binary regression models (p < 0.05). Results: 178 patients (73.0%) answered the QLQ-C30 questionnaires and were included in the study. Median follow-up was 61 months. Median daytime pad use was 1 and median daily urine loss based on pad testing was 4.0 g, leading to a daytime continence rate of 48.5%. Continence had a significant impact on postoperative HRQOL (p = 0.017). ICIQ-SF score (p = 0.001, OR = 0.805) and need for condom catheter during nighttime (p = 0.015, OR = 0.123) were independent predictors for worse HRQOL outcomes based on global health status. A history of pelvic floor muscle training was an independent predictor of increased HRQOL (p = 0.009, OR = 10.459). Conclusions: Need of condom urinals and higher ICIQ-SF scores are independent predictors for worse HRQOL outcomes. We show significant beneficial effects of pelvic floor muscle training on patients' HRQOL. [ABSTRACT FROM AUTHOR]

Objectives: To determine and investigate the intraoperative factors that contribute to a change in plan from continent orthotopic neobladder to ileal conduit or continent cutaneous diversion at the time of radical cystectomy. Subjects and methods: A retrospective review of our prospectively maintained bladder cancer database was performed. Of the 711 patients who underwent radical cystectomy from 2012 to 2016, 387 (54.4%) had given consent to have a NB. Of these 387 patients, 348 (89.9%) ultimately received a neobladder while 34 (8.8%) received an ileal conduit and 5 (1.3%) continent cutaneous diversion. The factors involved in the intraoperative change of plan were examined in this study. Results: Patients who ultimately received a neobladder were significantly more likely to have clinical node-negative disease (p = 0.045), negative soft tissue margins (p = 0.001), lower body mass index (p = 0.045) and higher volume surgeons (p < 0.001). Oncologic reasons for intraoperative conversions were more common than technical reasons (58.3% vs 35.9%), in both robotic and open surgical techniques. The choice of surgical approach (open vs robotic) did not influence the rate of intraoperative conversion. Conclusion: The factors influencing intraoperative decision not to perform neobladder are predominantly oncologic rather than technical. A clear understanding of the factors involved in influencing the intraoperative change in the urinary diversion plan may improve shared decision making in patients undergoing radical cystectomy in the future. [ABSTRACT FROM AUTHOR]

Purpose: To assess the long-term complications, pain status, sexual function and quality of life after cystectomy for bladder pain syndrome (BPS). Methods: We retrospectively reviewed functional variables for 35 patients (34 women/1 man, 67 ± 9 years old) who underwent cystectomy due to BPS since 1993 in our department. Cystectomy was offered to patients with BPS refractory to conservative treatments. Six cystectomies with ileal conduit (17.1%) and 29 supratrigonal cystectomies with enterocystoplasty (82.9%) were performed. Prospectively, patients completed questionnaires on pain [BPIC-SS, visual analogue scale (VAS) for pain], health-related quality of life (EQ-5D) and sexual function (FSFI; 2–36), rated satisfaction with surgery (0–10) and reported whether they would undergo the same surgery again. Results: Mean follow-up was 107 ± 83 months. In two (5.7%) patients, pain persisted and in one patient (2.8%) pain recurred after 20 months. Significant improvements in daytime and nighttime frequency and bladder capacity were observed postoperatively. 21 patients completed questionnaires. Mean BPIC-SS was 7.5 ± 8.4, mean VAS score 2.5 ± 2.8. 14 (66.7%) patients reported no problems related to pain on the EQ-5D, similar to our regional reference population. 13 (61.9%) patients had sexual intercourse after surgery, ten of them without pain. Mean FSFI score was 9.5 ± 9. Satisfaction with surgery was 8.8 ± 1.7 and 20 (95.2%) patients would undergo the same surgery again. Conclusion: Pain persistence or recurrence after cystectomy for BPS is infrequent. Quality of life related to pain is similar to that in the general population and patients can resume sexual activity without pain. [ABSTRACT FROM AUTHOR]

Background: Fecal diversion for chronic, non-healing wounds improves quality of life, assists in wound healing, and helps to prepare for reconstructive surgery. While commonplace, little has been published regarding the safety of diversion in this patient subgroup. The purpose of this study is to elucidate the morbidity and mortality of fecal diversion for chronic wounds and to identify those patients with disproportionately high perioperative risk. Methods: Retrospective analyses were performed using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database and an institutional database. The primary outcome analyzed was 30-day mortality and secondary outcomes included 30-day morbidity and readmission rate. Results: Eight hundred fifty-nine patients were identified in the NSQIP database who underwent diversion compared to 3990 who did not. In unmatched data, there were no significant differences in substantial 30-day morbidities. In matched data, diverted patients had a significantly lower perioperative mortality. Fifty-six patients were identified in the institutional review who were diverted for non-healing wounds. Fifty percent of patients with a preoperative ejection fraction of less than 30% died within 30 days of surgery (LR 6.58, p = 0.045). Conclusions: The NSQIP review indicates that fecal diversion does not inherently increase 30-day perioperative morbidity or mortality. While 30-day morbidity remains high, the institutional review suggests that patients with cardiac dysfunction contribute to the majority of complications. As such, an ejection fraction less than 30% may be a relative contraindication to immediate diversion. Medical optimization and elective diversion should be considered whenever feasible. Level of Evidence: Level III, risk / prognostic study. [ABSTRACT FROM AUTHOR]

Purpose: To compare perioperative outcomes and complications of extracorporeal (ECUD) vs intracorporeal urinary diversion (ICUD) in patients after undergoing robot-assisted radical cystectomy (RARC) at five referral centers in France.Methods: We retrospectively reviewed our multi-institutional, prospectively-collected database to select patients undergoing RARC between 2010 and 2016 with at least 3 months of follow-up. At each center, the surgery was performed by one surgeon with extensive experience in robotic surgery and radical cystectomy but no prior experience in RARC.Results: Overall, 108 patients were included. ECUD and ICUD were performed in 34 (31.5%) and 74 (68.5%) patients, respectively. Patient characteristics were comparable among the two groups, except for a higher proportion of patients with high surgical risk (ASA score ≥ 3) in the ECUD group. Ileal conduit and ileal neobladder were performed in 63/108 (58%) and 45/108 (42%) cases, respectively. Ileal conduit was performed more often with an extracorporeal approach while ileal neobladder with an intracorporeal approach. Overall, operative time, length of hospital stay, positive margin rate, and number of lymph nodes removed did not significantly differ among the two cohorts. Estimated blood loss and transfusion rates were significantly higher in the ECUD group. Rate of early (38.2 vs 47.3%, p = 0.4) and late (29.4 vs 18.9%, p = 0.2) surgical complications did not significantly differ between the ECUD and ICUD groups. Results were comparable in the subgroup analysis in the ileal conduit subpopulation.Conclusion: In our real-life, multi-institutional study, RARC with ICUD achieved perioperative outcomes and complication rates comparable to those of RARC with ECUD. [ABSTRACT FROM AUTHOR]

Purpose: Given the difficulty of durable repairs, there is continued interest in hernia prevention. One emerging prevention technique for parastomal hernias is prophylactic mesh placement, whereby mesh is inserted during the index procedure as hernia prophylaxis. We evaluated our experience using prophylactic mesh when creating an ileal conduit.Methods: We retrospectively reviewed patients undergoing robotic cystectomy with ileal conduit from 6/2010 to 8/2017. Patient demographics and operative/perioperative outcomes were documented. We evaluated hernia recurrence using postoperative computed tomography scanning or physical exam. Prophylactic mesh was inserted at the operating surgeon's discretion using a synthetic resorbable or biologic mesh.Results: During the study period, 38 patients underwent robotic-assisted cystectomy with ileal conduit formation. Average patient age was 68 years, with 28 (74%) male and 35 (92%) Caucasian patients. Three patients (8%) required conversion to open, and one patient (3%) had a concomitant colorectal resection. Thirty-one (88%) patients had postoperative computed tomography scanning. Prophylactic mesh was used in 18 patients (47%) in a retrorectus position. Of these, 15 (83%) patients had synthetic resorbable mesh and 3 (17%) patients had biologic mesh. At average follow-up of 21 months, one hernia recurred (5%) in a patient without mesh placement at the time of ileal conduit. At an average follow-up of 11 months, there have been no recurrences and no mesh-related complications in the prophylactic mesh group.Conclusions: Using prophylactic mesh in ileal conduit, creation is feasible and may decrease the parastomal hernia formation rate. Further study of using synthetic resorbable and biologic meshes for hernia prophylaxis is warranted. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to assess the short-term and long-term consequences of diverting loop ileostomy (DLI) omission in ileal pouch-anal anastomosis (IPAA) surgery complicated by postoperative pelvic sepsis.Methods: This was a retrospective review of a prospectively maintained database. Of 4031 patients who underwent IPAA in 1983–2014, 357 developed IPAA-related pelvic sepsis with or without anastomotic dehiscence. Patients with Crohn’s disease or cancer were excluded. The patient cohort was divided into two groups, depending on the presence or absence of DLI. Patient characteristics, short-term and long-term outcomes were compared. Long-term pouch survival was estimated with the Kaplan–Meier method. Quality of life (QOL) in the groups was compared at the latest follow-up.Results: Three hundred and twenty-six patients developing pelvic sepsis had diversion at the time of IPAA (D group) and in 31 who developed pelvic sepsis DLI had been omitted (O group). The length of hospital stay was significantly longer in the O group 11.5 (3–33) days versus 8 (2–59) days in the D group (p = 0.006). Forty-eight percent of patients from the O group with anastomotic leak underwent reoperation and had a DLI formed at this second procedure versus 12% in the D group requiring reoperation (p < 0.0001). In long-term follow-up, there was no difference in pouch survival between the groups: 99 versus 97% after 5 years and 88 versus 87% after 10 years, in the O group and D group, respectively (p = 0.40). There was no difference in QOL observed between the groups.Conclusions: Omission of DLI in selected patients who had IPAA surgery did not increase pouch failure or adversely affect QOL in the long term, if pelvic sepsis occurred. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate stool habits and associated quality of life (QoL) in a matched pair analysis of patients who underwent continent cutaneous diversion using the ileocecal segment [Mainz pouch I (MzPI)] with an intussuscepted ileal nipple as efferent segment with those receiving an ileal conduit (IC) after radical cystectomy. Methods: We identified 250 patients who underwent radical cystectomy and urinary diversion (UD) with either MzPI with an ileal nipple or IC in our database. A detailed history of stool habits using the modified Wexner score was obtained, and questions addressing general lifestyle, comparison of symptom differences before and after surgery considering bowel function as well as bowel-associated QoL were assessed. Results: Forty-five age- and sex-matched pairs could be compared. Overall, stool incontinence ( p = 0.481) and the Wexner score ( p = 0.464) revealed no differences between both groups. However, patients with MzPI as compared to those with IC had significant higher rates of stool frequency (53 vs 31 %), softer stool consistencies (60 vs 13 %), diarrhea (62 vs 20 %) and a lower rate of constipation (4 vs 22 %). Patients with MzPI had a trend toward lower bowel-associated QoL compared with patients with IC. Similarly, the MzPI group reported a significantly impaired overall postoperative QoL (51 %) compared to the IC group (29 %) ( p = 0.024). Conclusions: Patients following UD by MzPI have an increased stool frequency and softer stool consistency. However, there is no difference between both groups in terms of de novo stool incontinence. Change in bowel habits should be part of preoperative informed consent in any kind of UD. Careful patient selection is of paramount importance. [ABSTRACT FROM AUTHOR]

Background: Pouchitis is the most frequent complication after ileal pouch-anal anastomosis for refractory ulcerative colitis. A non-standardized preventative treatment exists. Sulfasalazine has proved effective in acute pouchitis therapy.Aims: The aim of this study was to retrospectively evaluate the effect of sulfasalazine in primary prophylaxis of pouchitis after proctocolectomy with ileal pouch-anal anastomosis.Methods: Data files of patients who underwent total proctocolectomy with ileal pouch-anal anastomosis for refractory ulcerative colitis and/or dysplasia from January 2007 to December 2014, with a follow-up until August 2015, were analyzed. After closure of loop ileostomy, on a voluntary basis, patients received a primary prophylaxis of pouchitis with sulfasalazine (2000 mg per day) continually until acute pouchitis flare and/or drop out due to side effects.Results: Follow-up data were available for 51 of the 55 surgical patients. Median follow-up time was 68 months (range 10-104). Thirty postoperative complications occurred in 25 patients. 45% of patients developed pouchitis. Sulfasalazine prophylaxis was administered in 39.2% of patients; 15% of the these developed pouchitis versus 64.5% (20/31) of the non-sulfasalazine patients (p < 0.001). Pouchitis-free survival curves were 90.55 months in sulfasalazine patients and 44.46 in non-sulfasalazine patients (log-rank test p = 0.001, Breslow p = 0.001).Conclusion: Sulfasalazine may be potentially administered in pouchitis prophylaxis after proctocolectomy with ileal pouch-anal anastomosis, but large prospectively controlled trials are needed. [ABSTRACT FROM AUTHOR]

Purpose: The natural history of development of Parastomal hernia (PH) following cystectomy and ileal conduit diversion is poorly understood. The aim of this study was to systematically review the frequency and risk factors of PH following ileal conduit diversion.Methods: A systematic review of literature was performed and the Cochrane, EMBASE and PubMed databases were searched from 1st January 1985 to 30th April 2016. All articles reporting occurrence of PH following cystectomy and ileal conduit diversion were analysed. The primary outcome measure was the frequency of development of PH. Secondary outcome measures were risk factors for PH development, complications of PH, frequency of PH repair and recurrence of PH.Results: Twelve articles of the 63 originally identified were analysed. Sample sizes ranged from 36 to 1057 patients with a pooled total of 3170 undergoing ileal conduit surgery. Age at the time of surgery ranged from 31 to 92 years. Of the 3170 patients who underwent ileal conduit surgery, 529 patients (17.1%) developed a PH based on either clinical examination or cross sectional imaging. Female gender, high BMI, low preoperative albumin and previous laparotomy were significantly associated with the development of PH in two studies. Repair of PH was offered to 8-75% of patients. The rate of recurrence following repair of PH was reported to range from 27 to 50%.Conclusion: A PH is frequent following cystectomy and ileal conduit urinary diversion. The diagnosis of a PH depends upon duration of clinical follow-up and the use of cross-sectional imaging. The recurrence rates following the repair of a PH remain substantial. [ABSTRACT FROM AUTHOR]

Purpose: Ileal conduit (IC) is the most frequent urinary diversion (UD) performed after radical cystectomy (RC). We reviewed the literature to investigate the factors influencing the choice of this diversion and its complications. Methods: A literature search (PubMed) was performed for all English language publications on UDs performed for treatment of bladder cancer from 1950 to 2015. The literature review was focused on studies reporting outcome of IC and its comparison with other types of UDs. Results: IC is the most common UD performed in elderly patients undergoing RC for bladder cancer. Long-term studies looking at the change in renal function after UD report a universal decline in the glomerular filtration rate; however, this decline in renal function is the least for IC. There is a significant morbidity of RC (20-56 %), which can be attributed to patient factors, surgical technique and hospital volume. Modern concepts of bowel preparation, postoperative nutrition, early enteral feeding and involvement of stoma therapists have helped improve the outcomes. The quality of life is preserved, and in many including elderly, it may be improved with IC UD. Conclusions: IC is the most commonly performed UD following radical cystectomy. It is associated with acceptable morbidity and has the lowest reoperation rates as compared to continent diversion. It is also the procedure of choice for most patients' elderly patients as well as patients with limited dexterity, poor motivation, anatomical restrictions and poor renal function. Studies measuring HRQOL report excellent patient acceptability, especially in the elderly population. [ABSTRACT FROM AUTHOR]

Introduction: Restorative proctocolectomy has become the standard surgical procedure for familial adenomatous polyposis (FAP) patients. The use of stapler devices has initiated a controversial discussion concerning the ileal pouch-anal reconstruction. Some authors advocate a handsewn anastomosis after transanal mucosectomy. A double-stapled anastomosis leads to better functional results but seems to bear a higher risk of residual rectal mucosa with dysplasia and adenomas. The present study systematically analyses the rate of residual rectal mucosa after restorative proctocolectomy and handsewn vs. stapled anastomosis. Patients and methods: One hundred FAP patients after restorative proctocolectomy undergoing regular follow-up at our outpatient clinic were included in the study. Proctoscopy with standardised biopsy sampling was performed. Results: Of the 100 patients, 50 had undergone a stapled and 50 a handsewn anastomosis. Median follow-up was 146.1 months (handsewn) vs. 44.8 months (stapled) ( P < 0.0001). Eighty-seven patients received a proctoscopy with standardised biopsy sampling. Thirteen patients had been diagnosed with residual rectal mucosa before. Sixty-three patients (63 %) showed remaining rectal mucosa (42 (66.6 %) stapler, 21 (33.3 %) handsewn, P < 0.0001). Patients after stapled anastomosis had higher rates of circular rectal mucosa seams, while small mucosa islets predominated in the handsewn group. The rate of rectal adenomas was significantly higher in the stapler group (21 vs. 10, P = 0.02). Conclusion: Rectal mucosa, especially wide mucosa seams, as well as rectal adenomas are found significantly more often after a stapled than after a handsewn anastomosis. As the follow-up interval in the stapler group was significantly shorter, the impact of these findings may still be underestimated. [ABSTRACT FROM AUTHOR]

Background: Little is known about the disparity of choices between three urinary diversions after radical cystectomy, focusing on patient and institutional factors. Methods: We identified urothelial carcinoma patients who received radical cystectomy with cutaneous ureterostomy, ileal conduit or continent reservoir using the Japanese Diagnosis Procedure Combination database from 2007 to 2012. Data comprised age, sex, comorbidities (converted into the Charlson index), TNM classification (converted into oncological stage), hospitals' academic status, hospital volume, bed volume and geographical region. Multivariate ordinal logistic regression analyses fitted with the proportional odds model were performed to analyze factors affecting urinary diversion choices. For dependent variables, the three diversions were converted into an ordinal variable in order of complexity: cutaneous ureterostomy (reference), ileal conduit and continent reservoir. Geographical variations were also examined by multivariate logistic regression models. Results: A total of 4790 patients (1131 cutaneous ureterostomies [23.6 %], 2970 ileal conduits [62.0 %] and 689 continent reservoirs [14.4 %]) were included. Ordinal logistic regression analyses showed that male sex, lower age, lower Charlson index, early tumor stage, higher hospital volume (≥3.4 cases/year) and larger bed volume (≥450 beds) were significantly associated with the preference of more complex urinary diversion. Significant geographical disparity was also found. Conclusion: Good patient condition and early oncological status, as well as institutional factors, including high hospital volume, large bed volume and specific geographical regions, are independently related to the likelihood of choosing complex diversions. Recognizing this disparity would help reinforce the need for clinical practice uniformity. [ABSTRACT FROM AUTHOR]

Fast-track surgery (FTS), which combines various techniques with evidence-based adjustments, is aimed to reduce postoperative morbidity, attenuate surgical stress response, thereby accelerating recovery and shorting length of stay. To further investigate the effectiveness of fast-track surgery, we compared the short-term outcomes of laparoscopic radical cystectomy and ileal conduit diversion for Chinese bladder cancer patients with FTS or with CS in our hospital. Patients with bladder cancer were included and divided into two consecutive groups: CS group and FTS group. Duration to first flatus and regular diet, postoperative hospital days, hospital expense, incidence of complications and postoperative surgical stress response were compared. There was no significant difference between the two groups in age, sex, BMI and postoperative TNM classification. Compared with the CS group, the FTS group had significantly shorter duration to first flatus, time to regular diet, postoperative hospital days and hospital expense, less complications, lower white blood count (WBC) and serum of C-reactive protein (CRP) on postoperative day 5 and 7. Our study indicates that FTS program is safe and efficacious for Chinese patients undergoing laparoscopic radical cystectomy and ileal conduit diversion. It can accelerate recovery, reduce stress action, shorten postoperative hospitals days and reduce hospital expenses. [ABSTRACT FROM AUTHOR]