Search

Purpose: While radical cystectomy (RC) is the standard of care for muscle invasive bladder cancer (MIBC), partial cystectomy (PC) is an effective alternative in select patients. We sought to examine differences in survival for RC and PC in a hospital-based registry., Material and Methods: We identified patients diagnosed with cT2-4 bladder cancer who underwent RC or PC from 2003 to 2015 in the National Cancer Database (NCDB). Using inverse probability treatment weighting (IPTW) to control for known confounders, we compared the primary outcome of overall survival (OS) in patients who underwent RC vs. PC. Kaplan-Meier survival analysis, univariable and multivariable Cox proportional hazards modeling were used. We performed a secondary survival analysis for a subcohort of patients with cT2, cN0, tumor size ≤5 cm, and no concurrent carcinoma in situ (CIS), who may be optimal candidates for PC., Results: A total of 22,534 patients met inclusion criteria, of which 6.9% (1,457) underwent PC. RC had longer median OS than PC (67.8 vs. 54.1 months) and on Cox regression analysis (HR 0.88, 95% CI, 0.80-0.95, P = 0.002). However, in our subcohort, there was no difference in OS between RC and PC (HR 1.02, 95% CI, 0.9-1.2, P = 0.74). PC was associated with increased time from surgery to any systemic therapy or death in the subcohort., Conclusions: Among patients with clinically organ-confined MIBC, PC appears to afford similar survival outcomes to RC in a large national data set. The safety and tolerability of PC may warrant consideration in highly selected patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: To assess the impact of N-methylnaltrexone, a peripherally acting mu-opioid receptor antagonist, on the post-operative recovery of patients undergoing robotic-assisted radical cystectomy for bladder cancer., Methods: We retrospectively reviewed patients undergoing robotic-assisted radical cystectomy by a single surgeon (KC) prior to (control group) and after (treatment group) the routine use of N-methylnaltrexone. Kaplan-Meier curves and the log-rank test were used to quantify time to flatus, bowel movement, and discharge. Daily mean opioid use, daily pain assessment rating, and episodes of severe pain (7-10/10) were compared. Gastrointestinal-related complications, including ileus, emesis, and/or need for post-op nasogastric tube placement, and 30-day readmissions were also compared between groups. Charge capture data were compared between groups to analyze cost impact., Results: 29 patients each in the control and treatment group met inclusion criteria. Patients receiving N-methylnaltrexone had reduced length of stay compared with no N-methylnaltrexone (median 4 vs. 7 days, p < 0.01). Time to flatus and bowel movement, however, were similar. In a multivariable analysis controlling for possible confounders, however, the improvement in length of stay associated with N-methylnaltrexone use did not reach statistical significance (p = 0.11). Episodes of severe pain and composite gastrointestinal-related complications were reduced in the N-methylnaltrexone group (44.8% vs. 10.3%, p < 0.01). The reduction in length of stay was associated with approximately $10,500 in cost savings per patient., Conclusions: In this study, N-methylnaltrexone was associated with reduced length of stay, fewer episodes of severe pain, and reduced costs. These results provide the impetus for further study.

Background: Neoadjuvant chemotherapy (NAC) has been shown to improve survival in patients with urothelial carcinoma (UC). However, there are a subset of patients who do not respond or progress despite systemic treatment., Methods: Data from the National Cancer Database on patients who underwent a radical cystectomy (RC) with or without NAC from 2006 to 2013 were abstracted. Covariates were balanced using inverse probability weighting methods. The primary outcome of overall survival in patients with residual disease by stage was evaluated using 90-day conditional landmark analysis and Cox proportional hazards modeling. Secondary outcome of predictors of residual disease was evaluated using multivariable logistic regression analysis., Results: A total of 20,128 patients met our inclusion criteria; 16,058 patients underwent RC only (80%) and 4070 underwent RC with NAC (20%). Patients who received NAC were younger and healthier, treated at an academic center, and presented with higher stage. NAC was associated with improved overall survival amongst patients with cT3-4aN0 (HR 0.84 95% CI 0.73-0.97; p = 0.02) and cN+ (HR 0.70, 95% CI 0.58-0.86; p = 0.001). Predictors of no residual disease were NAC (OR 0.17, 95% CI 0.14-0.21; p < 0.001) and treatment at an academic facility (OR 0.47, 95% CI 0.37-0.60; p < 0.001). Patients with cT3-4a or cN+ had increased odds of having residual UC (OR 2.01, 95% CI 1.53-2.64; p < 0.001, and OR 2.14, 95% CI 1.43-3.21; p < 0.001, respectively) compared with cT2., Conclusion: In patients with residual UC, NAC is associated with a significant survival benefit in higher stage disease only. Furthermore, those treated with NAC or at an academic center were less likely to have residual disease. Given the toxicity of NAC, more prudent patient selection for NAC is warranted and requires further study.

Purpose: To assess how trends in urinary diversion (UD) type following radical cystectomy (RC) have changed in recent years and investigate pre-operative predictors of UD type., Methods: Data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2011 to 2015. We quantified the percentages of continent diversions (CD) versus incontinent diversions (ID) completed over this time frame. Using univariate and multivariable logistic regression analyses, we compared UD type across year of operation as well as predictors of type of diversion., Results: We identified 4790 patients in the cohort, of which 81% underwent an incontinent diversion. Patients undergoing incontinent diversions were older (p < 0.001), more likely to be female (p < 0.001), had higher American Society of Anesthesiologists (ASA) classification (p < 0.001) and had more comorbidities with worse preoperative lab values. On multivariable analysis, the odds of incontinent diversion increased per year (OR 1.16, 95% CI 1.06-1.26; p = 0.001). Neoadjuvant chemotherapy (NAC) was associated with lower odds of receiving an ID (OR 0.33, 95% CI 0.17-0.64; p = 0.001). Being male, healthy and young were associated with higher odds of CD., Conclusion: We demonstrate that there has been a decrease in continent diversion use in recent years. Neoadjuvant chemotherapy, proxies of life expectancy and gender are significant predictors of continent diversion. Further investigation to determine the underlying cause of decreased utilization of CD is warranted.

Background: We evaluated the complications, mortality, hospital length of stay (LOS), and cost for patients with diabetes undergoing radical cystectomy (RC)., Materials and Methods: Data were extracted from the National (Nationwide) Inpatient Sample for 2001 to 2012 using the "International Classification of Diseases, Ninth Revision, Clinical Modification" codes for patients with uncontrolled diabetes (UD) (patients with diabetes receiving treatment that did not keep the blood glucose at acceptable levels) and controlled diabetes (CD) (patients with diabetes not otherwise stated as uncontrolled) who had undergone RC. χ 2 and Wilcoxon rank sum tests and multivariable regression analysis were used for statistics. The LOS and cost are presented as the median and interquartile range., Results: In the present study, 989 patients had UD, 15,693 CD, and 73,603 had no diabetes (ND). Postoperative complications were significantly more common in the UD group (73%) than in the CD (51%) and ND (52%) groups (P < .0001). On multivariable analysis, the UD group were more likely than the CD group to have any complication (odds ratio [OR], 2.3; 95% confidence interval [CI], 2.0-2.7), including renal (OR, 2.1; 95% CI, 1.8-2.4) and infectious (OR, 2.7; 95% CI, 2.3-3.1) complications. Patients with UD were also 4.3 times (95% CI, 3.1-5.8) more likely to die after surgery than were patients with CD. The ND group was slightly more likely than the CD group to experience any complication (OR, 1.13; 95% CI, 1.09-1.17) and death (OR, 1.6; 95% CI, 1.4-1.8). The LOS and cost for UD patients were greater than for CD patients. On multivariable analysis, UD patients had a 30% increase in LOS and 23% increase in cost (P < .0001)., Conclusion: The findings from the present study have demonstrated an increase in post-RC complications rates, hospital mortality, and hospital resource usage for patients with UD undergoing RC. UD might be a modifiable preoperative risk factor for post-RC morbidity and mortality. Further studies are needed to validate this association., (Published by Elsevier Inc.)

Open radical cystectomy (ORC) remains the gold standard for treatment of muscle-invasive bladder cancer and certain cases of high-risk noninvasive bladder cancer. However, ORC is associated with significant morbidity, and there is promise of improved outcomes with the emergence of minimally invasive surgery. Because of the increased adoption of robotic radical cystectomy (RRC), we sought to review the current literature on the robotic approach. We explored the surgical techniques, perioperative and postoperative complications, oncologic and functional outcomes, and quality of life of patients with RRC versus ORC. Current data appear to favor RRC in perioperative outcomes and patient recovery, although RRC continues to be associated with longer surgical times and higher costs. Oncologic data are also promising, however data on long-term oncologic outcomes are insufficient. To date, there is evidence of similar functional outcomes between RRC and ORC continence, but there is a paucity of rigorous, standardized studies on health-related quality of life for continent versus incontinent diversion. Even as use of RRC steadily grows, there is a lack of consensus on the type of approach and urinary diversion that is optimal. We assessed the influence of surgeon experience on the totally intracorporeal urinary diversion and its feasibility to be widely adopted. We aimed to answer the question of whether there are significant benefits to RRC, and furthermore, of the effect of the approach on the choice of urinary diversion., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: To investigate the trends in the performance of radical cystectomy (RC) versus partial cystectomy (PC) in the United States over the past 10 years and compare postoperative outcomes between two procedures., Materials and Methods: The data was captured from the Nationwide Inpatient Sample (NIS) 2001-2010 using the appropriate ICD-9-CM diagnosis and procedure codes. Patient sociodemographics, comorbidities and in-hospital complications after PC and RC were compared, taking into account some hospital characteristics. A chi-square analysis including a Cochran-Armitage trend test and a multivariable logistic regression analysis were employed., Results: RC rate increased from 84.8% in 2001 to 90.3% in 2010, while PC decreased from 15.2% to 9.7% (p < 0.0001). PC patients were older than their RC counterparts (72.1 ± 11.3 versus 68.6 ± 10.1 years; p < 0.0001), had higher prevalence of major comorbidities, but decreased rate of postoperative complications overall (21.3% versus 38.6%; p < 0.001). The greatest rates of PC utilization were found in the Northeast and South (12.8% and 12.7%). The frequency of PC was 18.9% in non-teaching hospitals compared to 9.0% in teaching hospitals (p < 0.0001). In multivariate analysis, females, octogenarians, patients with hypertension and obesity, and patients in non-teaching and rural hospitals were more likely to receive PC., Conclusions: Despite the potential advantages in cancer control offered by RC, PC is being performed more frequently on the elderly, female patients, patients with hypertension and obesity, in non-teaching and rural hospitals, and in certain United States geographic regions, which can be partially explained by disparities in access to high volume cancer centers.