Jon A. Rumohr

Contemporary Open Radical Cystectomy: Analysis of Perioperative Outcomes

PURPOSE The feasibility of laparoscopic or robotic assisted radical cystectomy has been demonstrated in several small series, but the specific advantages are uncertain and require comparisons to more recent results that incorporate refinements in open technique and perioperative management. We reviewed our contemporary radical cystectomy series to evaluate perioperative outcome measures which could be affected by surgical approach for the purpose of establishing contemporary benchmarks for future comparisons. MATERIALS AND METHODS The medical records of 553 consecutive patients undergoing radical cystectomy from January 2000 through June of 2005 were reviewed. Perioperative and demographic data, type of urinary diversion, hospital stay, complications and perioperative mortality were examined. RESULTS Median patient age was 69 years (range 22 to 94) and average American Society of Anesthesiologists classification was 2.7. Median operative time was 258 minutes (range 89 to 801). Mean operative time for ileal conduit diversion was 271 vs 312 minutes for neobladder diversion. Median blood loss was 600 ml (range 200 to 4,200). A total of 210 patients (38%) received a blood transfusion either intraoperatively or within the first 30 days of their procedure. Median length of hospital stay was 6 days (range 4 to 79). Minor and major complications occurred in 209 (38%) and 41 (7.4%) patients, respectively. Perioperative mortality was 1.7%. CONCLUSIONS These results demonstrate that contemporary radical cystectomy can be accomplished through an open operative approach consistently with acceptable morbidity/mortality and with a median length of stay of less than 1 week. Efforts to further reduce morbidity and improve outcomes should continue.

Urinary Diversion Trends at a High Volume, Single American Tertiary Care Center

PURPOSE We analyzed patient characteristics and practice patterns at our institution with time, and identified current patterns and factors contributing to the choice of urinary diversion. MATERIALS AND METHODS We reviewed the records of 553 consecutive radical cystectomy and urinary diversions performed from January 2000 to July 2005. Multivariate analysis was done to determine significant differences in diversion choice. RESULTS We analyzed the records of 539 patients, including 338 with an ileal conduit and 201 with a neobladder. Patients with a neobladder were younger (mean age 62 vs 71 years) and had fewer comorbidities (American Society of Anesthesiologists class greater than 2 in 31% vs 69%) than those with an ileal conduit. Mean age and the percent of American Society of Anesthesiologists class 3 or 4 cases increased during the study. Neobladder represented 47% of urinary diversions in 2000 and 21% in 2005. On multivariate analysis age (p <0.001), gender (p = 0.004), surgery year (p = 0.002), American Society of Anesthesiologists class greater than 2 (p = 0.004), organ confined disease (p = 0.01) and surgeon (p <0.001) independently predicted diversion choice. Patients were dichotomized into young (younger than 65 years) and old (65 years old or older) groups. Overall 59% of younger and 26% of older patients received a neobladder (p <0.001). CONCLUSIONS There was a significant trend toward the more liberal use of ileal conduit urinary diversion. Patients with female gender, advanced age, significant medical comorbidity or locally advanced disease were less likely to undergo neobladder urinary diversion. This trend is partly explained by surgeon preference combined with an aging, more comorbid patient population. Neobladder continues to be the most commonly performed urinary diversion in patients younger than 65 years.

Comparison of American Joint Committee on Cancer pathologic stage T3a versus T3b urothelial carcinoma: Analysis of patient outcomes

The radical cystectomy experience at Vanderbilt University Medical Center was scrutinized to determine whether there was a difference in survival between patients with lymph node‐negative pathologic T3a versus pathologic T3b urothelial carcinoma of the bladder.

Comparison of American Joint Committee on Cancer Pathological Stage T2a Versus T2b Urothelial Carcinoma: Analysis of Patient Outcomes in Organ Confined Bladder Cancer

PURPOSE We determined whether there is a difference in survival parameters in patients with pathological T2a vs T2b urothelial carcinoma of the bladder. MATERIALS AND METHODS We reviewed clinical data on patients who underwent radical cystectomy for urothelial carcinoma between 1995 and 2005. Patients with nontransitional cell bladder cancer, nodal disease or unknown nodal status were excluded from review. Of the 790 reviewed patients 123 (15.4%) were diagnosed with lymph node negative pathological T2 urothelial cancer of the bladder. The impact of pathological substaging (pT2a vs pT2b) was examined to determine the effect on overall, disease specific and recurrence-free survival. RESULTS Mean patient age was 65.3 years (range 35 to 84). Median overall followup was 29 months (range 0.53 to 144.27). Median followup in patients alive at last followup was 48.3 months (range 1.1 to 139.9). Actuarial overall survival at 5 years was 52.8% in pT2a cases and 49.6% in pT2b cases (p = 0.89). Actuarial disease specific survival at 5 years was 70.6% in pT2a cases and 65.0% in pT2b cases (p = 0.38). Actuarial recurrence-free survival at 5 years was 74.5% in pT2a cases and 76.2% in pT2b cases (p = 0.93). CONCLUSIONS In this series no significant difference was noted in overall, disease specific and recurrence-free survival when comparing lymph node negative pT2a vs pT2b urothelial cancer of the bladder following radical cystectomy. Future revisions of the American Joint Committee on Cancer staging system may consider simplifying pathological staging by consolidating these substages.