Brandon Otto

A Comparison of Postoperative Complications in Open versus Robotic Cystectomy

BACKGROUND Robotic cystectomy is an emerging alternative for treatment of invasive bladder cancer (BCa). However, reduction in postoperative morbidity relative to the open approach has not been demonstrated. OBJECTIVE To compare complication rates in patients undergoing robotic versus open radical cystectomy (RC). DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study of 187 consecutive patients undergoing RC at our institution-104 open RC, 83 robotic RC. INTERVENTION Open or robotic RC with urinary diversion. MEASUREMENTS Demographic, perioperative, and complication data were recorded prospectively. Thirty-day and 90-d complication rates were assessed using the modified Clavien complication scale. Data were evaluated using chi(2) and multivariate logistic regression analyses. RESULTS AND LIMITATIONS At 30 d, the open group demonstrated a higher overall complication rate (59% vs 41%; p=0.04) as well as more major complications (30% vs 10%; p=0.007). At 90 d, the overall complication rate was greater in the open group, but this was not statistically significant (62% vs 48%; p=0.07). However, there was a significantly higher major complication rate in the open cohort (31% vs 17%; p=0.03). When subjected to logistic regression analysis, robotic cystectomy was an independent predictor of fewer overall and major complications at 30 and 90 d. High American Society of Anesthesiologists (ASA) score (3-4) and longer surgical time were independent predictors of major complications. Though this is one of the largest published RC series, the sample size is relatively small. Moreover, despite the two patient cohorts being similarly matched, the study was not performed in a randomized fashion. CONCLUSIONS Patients undergoing robotic cystectomy experienced fewer postoperative complications than those undergoing open cystectomy. Robotic cystectomy is an independent predictor of fewer overall and major complications. Until long-term oncologic results are available, robotic cystectomy should still be considered investigational.

Critical analysis of complications after robotic-assisted radical cystectomy with identification of preoperative and operative risk factors

Study Type – Therapy (case series)
 Level of Evidence 4

Robotic-assisted Radical Cystectomy With Extracorporeal Urinary Diversion for Urothelial Carcinoma of the Bladder: Analysis of Complications and Oncologic Outcomes in 175 Patients With a Median Follow-up of 3 Years

OBJECTIVE To report oncologic outcomes and complications after robotic-assisted radical cystectomy (RARC). MATERIALS AND METHODS From March 2004 to August 2011, 175 consecutive patients underwent RARC with extracorporeal urinary diversion at our institution by a single surgeon. The study design was prospective. Perioperative parameters and postoperative complications were prospectively collected using the modified Clavien system. Recurrence-free survival and cancer-specific survival curves were generated using the Kaplan-Meier method. RESULTS A total of 145 men and 30 women with a median age of 73 years and a median body mass index of 27 kg/m(2) underwent RARC. Four patients (2.3%) required conversion to open surgery because of difficulty to progress. One hundred nine patients (62%) underwent a transcutaneous ileal conduit, 40 patients (23%) an orthotopic neobladder, and 26 (15%) a continent cutaneous conduit. The median operating time was 360 minutes (interquartile range [IQR]: 300-420). The median estimated blood loss was 400 mL (IQR: 250-612), with a transfusion rate of 17.0%. The median postoperative length of stay was 7.0 days (IQR: 5.2-10). Early (<30 days) and late surgery-related complications (30-90 days) occurred in 74 (42%) and 59 (34%) patients, respectively. The perioperative mortality rate was 2.8%. The positive soft tissue surgical margins rate was 5%. The median number of lymph nodes removed was 19 (IQR: 12-28). The median follow-up was 37 months (IQR: 21.5-53.5). Actuarial recurrence-free survival and cancer-specific survival at 2, 3, and 5 years after RARC were 67%, 63%, 63% and 73%, 68%, 66%, respectively. CONCLUSION RARC achieved mid-term oncologic efficacy. Moreover, the complication rates were comparable with open radical cystectomy series.

Incidental Prostate Cancer in Transurethral Resection of the Prostate Specimens in the Modern Era

Objectives. To identify rates of incidentally detected prostate cancer in patients undergoing surgical management of benign prostatic hyperplasia (BPH). Materials and Methods. A retrospective review was performed on all transurethral resections of the prostate (TURP) regardless of technique from 2006 to 2011 at a single tertiary care institution. 793 men (ages 45–90) were identified by pathology specimen. Those with a known diagnosis of prostate cancer prior to TURP were excluded (n = 22) from the analysis. Results. 760 patients had benign pathology; eleven (1.4%) patients were found to have prostate cancer. Grade of disease ranged from Gleason 3 + 3 = 6 to Gleason 3 + 4 = 7. Nine patients had cT1a disease and two had cT1b disease. Seven patients were managed by active surveillance with no further events, one patient underwent radiation, and three patients underwent radical prostatectomy. Conclusions. Our series demonstrates that 1.4% of patients were found to have prostate cancer, of these 0.5% required treatment. Given the low incidental prostate cancer detection rate, the value of pathologic review of TURP specimens may be limited depending on the patient population.

MP50-06 HYDRONEPHROSIS AFTER URETERAL ACCESS SHEATH USE

RESULTS: At t0, all the fibers had less than 7.5W. For fragmentation parameters (Figure 2A), there was a statistical difference between the 5 groups at 0 minutes (p1⁄40.042) and 1 minute of laser use (p1⁄40.042). After 1 minute of laser use, there was no statistical differences between the 5 groups. For dusting parameters (Figure 2B), there was a statistical difference at 0 minutes (p1⁄40.022). At the 1-minute analysis and after, all the results were not statistically different. Laser fibers are made with two layers of silica with different refractive indices, which allow the light to travel along the fiber until the fiber tip. When the interaction of the two layers of silica is damaged, as in lithotripsy, or after cleaving the fiber, the energy leaks through the fissures and the power output is decreased. CONCLUSIONS: Cleaving the fiber tip may restore its effectiveness to the fiber but, as we demonstrated, only for a limited time. Though, cleaving the fiber tip may preserve the scopes from damages.

PD21-11 PCNL IN GERIATRIC PATIENTS: AN EVALUATION OF OUTCOMES, COMPLICATIONS AND DISCHARGE NEEDS

INTRODUCTION AND OBJECTIVES: Growing numbers of geriatric patients present for definitive management of kidney stones. Geriatric patients with large stones may be candidates for percutaneous nephrostolithotomy (PCNL), however their care-related needs may differ from younger patients. We reviewed our PCNL experience in geriatric patients to better define surgical outcomes, complications, and discharge needs. METHODS: We retrospectively analyzed patients undergoing PCNL from 2012-2015 in our institution. Preoperative characteristics, surgical outcomes, complications, and discharge needs were compared between two groups: geriatric patients (aged 65 years) and nongeriatric patients (<65years). Statistical analysis was performed with students t-test and chi-squared test. RESULTS: We analyzed 287 consecutive patients: 89(31%) patients 65 years; 198(69%) patients <65 years (mean age 72 vs 48 years, p<0.001). The results can be seen in Table 1. Geriatric patients were more likely Caucasian (91% vs 73.7%, p1⁄40.001), had fewer positive preoperative urine cultures (27% vs 41.6%, p1⁄40.017), and had higher American Society of Anesthesiologist scores (mean 2.83 vs 2.55, p<0.001). OR time (mean 159 vs 185 minutes, p1⁄40.003) and estimated blood loss (41 vs 56 mL, p1⁄40.014) were less in the geriatric group. The residual stone fragment size was less after one procedure (0-2 mm: 72.9% vs 58.5%; 3-4 mm: 15.6% vs 17.5%; >4 mm: 11.5% vs 24%, p1⁄40.024) in the geriatric group. There were no differences in 30 day readmissions (12.4% vs 12.6%, p1⁄40.95), total complications (30.3% vs 27.3%, p1⁄40.594) or major complications (9.0% vs 5.6% Clavien III p1⁄40.279) between the geriatric and non-geriatric groups respectively. Length of stay (3.1 vs 3.2 days, p1⁄40.852) was similar between the groups, however the geriatric group was more often discharged with services to assist with nephrostomy tubes or wound dressings (21.3% vs 9.1%, p1⁄40.016). CONCLUSIONS: PCNL is an acceptable surgical option in appropriately selected geriatric patients. These patients require more home nursing care, but otherwise do well compared to younger patients. This information may be helpful for both patient counseling and discharge planning in the geriatric stone population. Source of Funding: None