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Purpose: We examine the timing, patterns and predictors of 90-day readmission after robotic radical cystectomy., Materials and Methods: From September 2009 to March 2017, 271 consecutive patients undergoing robotic radical cystectomy with intent to cure bladder cancer (intracorporeal diversion 253, 93%) were identified from our prospectively collated institutional database. Readmission was defined as any subsequent inpatient admission or unplanned visit occurring within 90 days from discharge after the index hospitalization. Multiple readmissions were defined as 2 or more readmissions within a 90-day period. Logistic regression analysis was used to identify independent factors related to single and multiple 90-day readmissions., Results: A total of 78 (28.8%) patients were readmitted at least once within 90 days after discharge, of whom 20 (25.6%) reported multiple readmissions. The cumulative duration of readmission was 6.2 (6.17) days with 6 (7.6%) patients having less than 24 hours readmission. Metabolic, infectious, genitourinary and gastrointestinal complications were identified as the primary cause of readmission in 39.5%, 23.5%, 22.3% and 17%, respectively. Fifty percent of readmissions occurred in the first 2 weeks after hospital discharge. On multivariable logistic regression analysis in-hospital infections (OR 2.85, p=0.001) were independent predictors for overall readmission. Male gender (OR 3.5, p=0.02) and in-hospital infections (OR 4.35, p=0.002) were independent predictors for multiple readmissions., Conclusions: The 90-day readmission rate following robotic radical cystectomy is significant. In-hospital infections and male gender were independent factors for readmission. Most readmissions occurred in the first 2 weeks following discharge, with metabolic derangements and infections being the most common causes.

Objective: To propose a standardisable composite method for reporting outcomes of radical cystectomy (RC) that incorporates both perioperative morbidity and oncological adequacy., Patients and Methods: From July 2010 to December 2017, 277 consecutive patients who underwent robot-assisted RC with intracorporeal urinary diversion (UD) for bladder cancer at our Institution were prospectively analysed. Patients who simultaneously demonstrated negative soft tissue surgical margins (STSMs), ≥16 lymph node (LN) yield, absence of major (grade III-IV) complications at 90 days, absence of UD-related long-term sequelae and absence of clinical recurrence at ≤12 months, were considered as having achieved the RC-pentafecta. A multivariable logistic regression model was assessed to measure predictors for achieving RC-pentafecta., Results and Limitations: Since 2010, 270 of 277 patients that had completed at least 12 months of follow-up were included. Over a mean follow-up of 22.3 months, ≥16 LN yield, negative STSMs, absence of major complications at 90 days, and absence of UD-related surgical sequelae and clinical recurrence at ≤12 months were observed in 93.0%, 98.9%, 76.7%, 81.5% and 92.2%, patients, respectively, resulting in a RC-pentafecta rate of 53.3%. Multivariable logistic regression analysis revealed age (odds ratio [OR] 0.95; P = 0.002), type of UD (OR 2.19; P = 0.01) and pN stage (OR 0.48; P = 0.03) as independent predictors for achieving RC-pentafecta., Conclusions: We present a RC-pentafecta as a standardisable composite endpoint that incorporates perioperative morbidity and oncological adequacy as a potential tool to assess quality of RC. This tool may be useful for assessing the learning curve and calculating cost-effectiveness amongst others but needs to be externally validated in future studies., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

Background: The Vescica Ileale Padovana (VIP) was first described in 1989 as a technique for total bladder replacement, and gained popularity due to technical simplicity and functional advantages., Objective: To report preliminary results and a detailed step-by-step surgical technique description of robot-assisted VIP (ra-VIP) that replicates the open technique principles., Design, Setting, and Participants: We report the data of 15 consecutive patients who underwent robot-assisted radical cystectomy (RARC) and totally intracorporeal ra-VIP at our institution from April 2015 to March 2017., Surgical Procedure: RARC, extended pelvic lymph-node dissection, and totally intracorporeal ra-VIP. An enhanced recovery after surgery (ERAS) protocol was adopted in most cases., Measurements: Perioperative outcomes (operating time, blood loss, transfusion rate, and hospital stay), readmission for early (30d) and late (90d) postoperative complications, pathological and oncological outcomes, and overall/cancer-specific survival were reported., Results and Limitations: The median (interquartile range) age was 60 (54-66)yr. The median body mass index was 24 (24-25). The median American Society of Anesthesiologists score was 2 (2-2). The operative time was 390 (284-470)min and the estimated blood loss was 300 (50-900) ml. No conversion to open technique was reported. The median hospital stay was 17 (12-23)d. Three patients received postoperative transfusions. Six patients had 90-d major complications. One patient was readmitted after discharge and reported a long-term sequela. One positive margin was reported. At a mean follow-up of 17 (13-25)mo, 14 (93%) patients were alive: one patient died from disease progression. Daytime continence rate at 12mo was 62%., Conclusions: Our preliminary results showed that ra-VIP appears to be a feasible technique for robot-assisted totally intracorporeal bladder replacement following robotic radical cystectomy., Patient Summary: Vescica Ileale Padovana (VIP) was first described almost 30yr ago for bladder replacement after radical cystectomy. We report a step-by-step technique of robot-assisted VIP that follows the open surgical principles of detubularization and double folding, mixing the advantages of VIP with the benefits of the robotic approach., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate the impact of indocyanine green (ICG) for assessing ureteric vascularity on the rate of uretero-enteric stricture formation after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD)., Patients and Methods: We identified 179 patients undergoing RARC and ICUD between January 2014 and May 2017, and divided the patients into two groups based on the utilisation of ICG for the assessment of ureteric vascularity (non-ICG group and ICG group). We retrospectively reviewed the medical records to identify the length of ureter excised. Demographic, perioperative outcomes (including 90-day complications and readmissions), and the rate of uretero-enteric stricture were compared between the two groups. The two groups were compared using the t-test for continuous variables and the chi-squared test for categorical variables. A P < 0.05 was considered statistically significant., Results: A total of 132 and 47 patients were in the non-ICG group and the ICG group, respectively. There were no differences in baseline characteristics and perioperative outcomes including operating time, estimated blood loss, and length of stay. The ICG group was associated with a greater length of ureter being excised during the uretero-enteric anastomosis and a greater proportion of patients having long segment (>5 cm) ureteric resection. The median follow-up was 14 and 12 months in the non-ICG and ICG groups, respectively. The ICG group was associated with no uretero-enteric strictures compared to a per-patient stricture rate of 10.6% and a per-ureter stricture rate of 6.6% in the non-ICG group (P = 0.020 and P = 0.013, respectively)., Conclusion: The use of ICG fluorescence to assess distal ureteric vascularity during RARC and ICUD may reduce the risk of ischaemic uretero-enteric strictures. The technique is simple, safe, and reproducible. Larger studies with longer follow-up are needed to confirm our findings., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

Objective: To present a review of the technical aspects of robotic intracorporeal ileal conduit  (IC) reconstruction after robot assisted radical cystectomy (RARC). METHODS: A non-systematic review is performed in order  to summarize technical aspects on robot assisted ileal conduit procedure following radical cystectomy in patients with muscle invasive bladder cancer.  RESULTS: Radical cystectomy with pelvic lymph node dissection and urinary diversion is the gold-standard therapy for localized muscle-invasive bladder cancer. IC is the most common diversion utilized by surgeons. Minimally invasive approaches to IC were proposed with the intention of decreasing the morbidity associated to open surgery. Several oncological, and functional factors should be taken into consideration for the selection of patients undergoing this procedure together with surgeons and patients' preferences. The stoma marking of the patient is of critical importance. Identification of the ureters should be done assuring careful handling of the tissue and then isolation of the bowel segments should be performed after confirming proper length of the segment. Side to side anastomosis of the antimesenteric borders of the bowel is performed with linear staplers, and the ureteroileal anastomosis is done. Finally, the ileal conduit is positioned close to the stoma marking site and is fixed to the skin. Urinary diversion and radical cystectomy is a very morbid procedure. Mainly, complications are gastrointestinal, stoma-related, or associated to the ureter-enteric anastomosis.  CONCLUSIONS: The advantages of the robotic platform concerning postoperative outcomes may be more evident if the procedure is done in an intracorporeal fashion. Proper knowledge and mastery of the technical aspects of this procedure are critical.

Simple Summary: Bladder cancer is the second most common genitourinary malignancy. Robotic-assisted radical cystectomy has demonstrated comparable efficacy in treating bladder cancer to open radical cystectomy. Due to the features of the procedure itself and the often weak general health status of patients, radical cystectomy is related to a significant incidence of complications. During the last decades, robotic surgery has spread in bladder cancer treatment in order to take advantage of the benefits of minimally invasive surgery. However, the majority of evidence in the literature comes from cT2-T3 muscle-invasive bladder cancer. The management of patients with cT4 stage represents a relevant surgical challenge. The aim of the present study is to compare intra- and postoperative outcomes of robot-assisted and open radical cystectomy in the treatment of patients with a pT4a MIBC in a pathological report. We compared the perioperative outcomes of open (ORC) vs. robot-assisted (RARC) radical cystectomy in the treatment of pT4a MIBC. In total, 212 patients underwent ORC (102 patients, Group A) vs. RARC (110 patients, Group B) for pT4a bladder cancer. Patients were prospectively followed and retrospectively reviewed. We assessed operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of stay, transfusion rate, and oncological outcomes. Preoperative features were comparable. The mean operative time was 232.8 vs. 189.2 min (p = 0.04), and mean EBL was 832.8 vs. 523.7 mL in Group A vs. B (p = 0.04). An intraoperative transfusion was performed in 32 (31.4%) vs. 11 (10.0%) cases during ORC vs. RARC (p = 0.03). The intraoperative complications rate was comparable. The mean length of stay was shorter after RARC (12.6 vs. 7.2 days, p = 0.02). Postoperative transfusions were performed in 36 (35.3%) vs. 13 (11.8%) cases (p = 0.03), and postoperative complications occurred in 37 (36.3%) vs. 29 (26.4%) patients in Groups A vs. B (p = 0.05). The positive surgical margin (PSM) rate was lower after RARC. No differences were recorded according to the oncological outcomes. ORC and RARC are feasible treatments for the management of pT4a bladder tumors. Minimally invasive surgery provides shorter operative time, bleeding, transfusion rate, postoperative complications, length of stay, and PSM rate. [ABSTRACT FROM AUTHOR]

Simple Summary: The oncological outcome of curative intent surgery for urothelial carcinoma of the bladder could be impacted by facility caseload and surgical experience. In this review of 27,272 cases of radical cystectomy and pelvic exenteration, as the annual caseload of surgery at the facility decreased, the all-cause mortality for the patients increased significantly. The caseload of the facility where radical cystectomy and pelvic exenteration were performed had a direct and significant impact on the overall survival for the patients. The role of surgical experience and its impact on the survival requires further investigation. A cohort of patients undergoing radical cystectomy or anterior pelvic exenteration for localized bladder cancer between 2006 and 2013 at 1143 facilities across the United States was identified using the National Cancer Database and analyzed. Using overall survival (OS) as the primary outcome, the relationship between facility annual caseload (FAC) and facility annual surgical caseload (FASC) for those undergoing curative surgery was examined. Four volume groups (VG) depending on caseload using both FAC and FASC were defined. These included VG1: below 50th percentile, VG2: 50th–74th percentile, VG3: 75th–89th percentile, and VG4: 90th and above. Between 2006 and 2013, 27,272 patients underwent surgery for localized bladder cancer. The median OS was 59.66 months (95% CI: 57.79–61.77). OS improved significantly as caseload increased. The unadjusted median OS difference between VG1 and VG4 was 15.35 months (64.3 vs. 48.95 months, HR 1.19 95% CI: 1.13–1.25, p < 0.001) for FAC. This figure was 19.84 months (66.89 vs. 47.05 months, HR 1.25 95% CI: 1.18–1.32, p < 0.0001) for FASC. This analysis revealed a significant and clinically important survival advantage for curative bladder cancer surgery at highly experienced centers. [ABSTRACT FROM AUTHOR]

Simple Summary: With enhanced recovery after surgery protocols, it is now possible to decrease a patient's length of stay in the hospital and administer adjuvant chemotherapy earlier than before. Our study analyzed 7056 patients who underwent a radical cystectomy and subsequent adjuvant chemotherapy to determine if an earlier timing of adjuvant chemotherapy would affect survival outcomes. We found that earlier time to adjuvant therapy showed a survival benefit, and a benefit persisted regardless of timing when compared to controls. (1) Purpose: To assess the survival benefit for different times to adjuvant chemotherapy after a radical cystectomy. (2) Materials and Methods: We systematically searched PubMed®, Cochrane Central®, Scopus®, and Web of Science® library databases for original articles that looked at timing to adjuvant chemotherapy after radical cystectomy. Primary endpoints were five-year survival, progression free survival, and overall survival. Available multivariable hazard ratios and corresponding 95% CIs were included in the qualitative analysis. The risk of bias was completed for nonrandomized studies. (3) Results: Using PRISMA guidelines, our electronic search resulted in a total of 1862 records. After a detailed review, we selected four studies that addressed the impact of the timing of adjuvant chemotherapy for patients who underwent radical cystectomy. (4) Conclusion: A survival benefit was seen with an earlier administration of adjuvant chemotherapy, albeit a benefit persists for delayed chemotherapy post-radical cystectomy. A safe and ethical approach at this time would be to administer adjuvant chemotherapy as early in the postoperative period as possible, given the known survival benefit of such therapy (9–11% absolute survival benefit at five years). [ABSTRACT FROM AUTHOR]

Simple Summary: Radical cystectomy is a surgical procedure used in the treatment of bladder cancer. It can potentially cure a patient of their disease, but it is associated with risks including long hospital stays and high complication rates. Here, we evaluated how certain factors related to a patient and/or their surgery may impact their discharge to home versus to a rehabilitation facility after surgery. This study found that patients that are older, living alone prior to surgery, and/or have a major post-operative complication are more likely to be discharged to a rehabilitation facility. Recognizing these factors prior to surgery may help identify which patients may require discharge to a rehabilitation facility and can help patients and urologists better plan for the postoperative course. Radical cystectomy (RC) is a complex procedure associated with lengthy hospital stays and high complication and readmission rates. We evaluated the impact of patient, surgical, and perioperative factors on discharge disposition following RC at a tertiary referral center. From 2012 to 2019, all bladder cancer patients undergoing RC at our institution were identified (n = 1153). Patients were classified based on discharge disposition: to home or to continued facility-based rehabilitation centers (CFRs, n = 180 (15.61%) patients). On multivariate analysis of patient factors only, age [Risk Ratio (RR): 1.07, p < 0.001)], single marital status (RR: 1.09, p < 0.001), and living alone prior to surgery (RR: 2.55, p = 0.004) were significant predictors of discharge to CFRs. Multivariate analysis of patient, surgical, and perioperative factors indicated age (RR: 1.09, p < 0.001), single marital status (RR: 3.9, p < 0.001), living alone prior to surgery (RR: 2.42, p = 0.01), and major post-operative (Clavien > 3) complications (RR: 3.44, p < 0.001) were significant independent predictors of discharge to CFRs. Of note, ERAS did not significantly impact discharge disposition. Specific patient and perioperative factors significantly impact discharge disposition. Patients who are older, living alone prior to surgery, and/or have a major post-operative complication are more likely to be discharged to CFRs after RC. [ABSTRACT FROM AUTHOR]

Simple Summary: Our study analyzed 138,151 radical cystectomy patient encounters to determine which patient and facility characteristics are associated with discharge home and discharge to continued rehabilitation facilities. We used multivariate logistic regression to statistically analyze these datapoints while controlling for other variables. We found that older age, single/widowed marital status, female gender, increased Charlson Comorbidity Index, Medicaid, and Medicare insurance and open surgery are associated with Continued Rehabilitation Facility (CRF) discharge. Objective: To assess predictors of discharge disposition—either home or to a CRF—after undergoing RC for bladder cancer in the United States. Methods: In this retrospective, cohort study, patients were divided into two cohorts: those discharged home and those discharged to CRF. We examined patient, surgical, and hospital characteristics. Multivariable logistic regression models were used to control for selected variables. All statistical tests were two-sided. Patients were derived from the Premier Healthcare Database. International classification of disease (ICD)-9 (<2014), ICD-10 (≥2015), and Current Procedural Terminology (CPT) codes were used to identify patient diagnoses and encounters. The population consisted of 138,151 patients who underwent RC for bladder cancer between 1 January 2000 and 31 December 2019. Results: Of 138,151 patients, 24,922 (18.0%) were admitted to CRFs. Multivariate analysis revealed that older age, single/widowed marital status, female gender, increased Charlson Comorbidity Index, Medicaid, and Medicare insurance are associated with CRF discharge. Rural hospital location, self-pay status, increased annual surgeon case, and robotic surgical approach are associated with home discharge. Conclusions: Several specific patient, surgical, and facility characteristics were identified that may significantly impact discharge disposition after RC for bladder cancer. [ABSTRACT FROM AUTHOR]

In 2012, the European Association of Urology (EAU) Ad Hoc Panel proposed a standardised methodology on reporting and grading complications after urological surgical procedures. The aim of the current study was to assess the impact of this implementation on complications reporting for patients undergoing robot-assisted radical cystectomy (RARC). A systematic review of all English-language original articles published on RARC until March 2020 was performed using PubMed, Scopus, and Web of Science databases. The study selection process followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) criteria. The quality of reporting and grading complication was evaluated according to the EAU recommendations. Our analysis failed to observe a statistically significant improvement in reporting outcomes after the EAU guidelines recommendations except for three of the 14 criteria proposed (ie, follow-up duration, utilisation of a severity grade system, and risk factors included in the analyses). A lower statistically significant adherence to outcome reporting in terms of inclusion of readmissions and causes (p = 0.02), was observed. In this study, we evaluated the impact of the proposed European Association of Urology (EAU) standardised reporting tool for urological complications, in patients treated with robot-assisted radical cystectomy. A low adherence to EAU guidelines recommendations for complications reporting was observed. We failed to observe a significant improvement in reporting robot-assisted radical cystectomy outcomes after the 2012 European Association of Urology (EAU) guidelines recommendations on reporting and grading complications after urological surgical procedures. There is an impending need to widely adopt the standardised predefined 14-item criteria proposed by the EAU Guidelines Panel to avoid underestimating the rate of complications and to improve patient counselling. [ABSTRACT FROM AUTHOR]