Michael C. Large

The Impact of Mechanical Bowel Preparation on Postoperative Complications for Patients Undergoing Cystectomy and Urinary Diversion

PURPOSE The benefit of routine mechanical bowel preparation for patients undergoing radical cystectomy is not well established. We compared postoperative complications in patients who did or did not undergo mechanical bowel preparation before radical cystectomy. MATERIALS AND METHODS In 2008 a single surgeon (GDS) performed open radical cystectomy with an ileal conduit or orthotopic neobladder in 105 consecutive patients with preoperative mechanical bowel preparation consisting of 4 l GoLYTELY®. In 2009 radical cystectomy with an ileal conduit or orthotopic neobladder was performed in 75 consecutive patients without mechanical bowel preparation. A comprehensive database provided clinical, pathological and outcome data. RESULTS All patients had complete perioperative data available. The 2 groups were similar in age, Charlson comorbidity score, diversion type, receipt of neoadjuvant radiation or chemotherapy, blood loss, hospital stay, time to diet and pathological stage. Postoperative urinary tract infection, wound dehiscence and perioperative death rates were similar in the 2 groups. Clostridium difficile infection developed within 30 days of surgery in 11 of 105 vs 2 of 75 patients with vs without mechanical bowel preparation (p = 0.08). When adjusted for the annual hospital-wide C. difficile rate, the difference remained insignificant (p = 0.21). Clavien grade 3 or greater abdominal and gastrointestinal complications, including fascial dehiscence, abdominal abscess, small bowel obstruction, bowel leak and entero-diversion fistula, developed in 7 of 105 patients with (6.7%) vs 11 of 75 without (14.7%) mechanical bowel preparation (p = 0.08). CONCLUSIONS The use of mechanical bowel preparation for patients undergoing radical cystectomy with an ileal conduit or orthotopic neobladder does not seem to impact the rates of perioperative infectious, wound and bowel complications. Larger series with multiple surgeons are necessary to confirm these findings.

Knotless closure of the collecting system and renal parenchyma with a novel barbed suture during laparoscopic porcine partial nephrectomy

INTRODUCTION Closure of the urinary collecting system and renal parenchyma is a technically challenging aspect of laparoscopic nephron-sparing surgery and an obstacle to its more widespread use. A novel barbed polydioxanone suture material Quill self-retaining suture (SRS) (Angiotech Pharmaceuticals) has been introduced for knot-free tissue approximation. We compared the outcomes of Quill SRS versus a conventional technique for kidney and collecting system closure during laparoscopic porcine partial nephrectomy. METHODS After approval of the Institutional Animal Care and Use Committee, 10 female pigs underwent bilateral transperitoneal laparoscopic lower pole heminephrectomy. Closure of the collecting system and approximation of the renal parenchyma was performed in two layers using continuous knotless barbed suture for one kidney (Quill SRS) and polyglactin (Vicryl) with absorbable polydioxanone clips (LapraTy; Ethicon) on the contralateral kidney. For both techniques, the collecting system was closed with 2-0 suture and renal parenchyma with #1 suture. Warm ischemia and suturing time were recorded, and resected tissue was weighed. All animals were sacrificed 1 week after surgery. Serum hemoglobin and visual inspection at necropsy were used to assess for bleeding; visual inspection of the peritoneum and bilateral retrograde pyelography were used to assess for urinary fistula. RESULTS Mean (+/-standard deviation [SD]) weight of resected tissue (barbed, 34 +/- 13 g; clips, 34 +/- 11 g; p = 0.6), mean (+/-SD) ischemia time (barbed, 34 +/- 8 minutes; clips, 34 +/- 10 minutes; p = 0.7), and mean (+/-SD) suturing time (barbed, 21 +/- 4 minutes; clips, 22 +/- 7 minutes; p = 0.7) were similar between groups. No animal had a visible hematoma or urinoma at necropsy. On retrograde pyelography, a small urinary leak was found in two kidneys in each group (p = 0.6). CONCLUSIONS In a porcine laparoscopic partial nephrectomy model, it appears that knotless barbed suture is as effective, efficient, and safe as a conventional technique. Further evaluation in humans is warranted and required.

Sex disparities in diagnosis of bladder cancer after initial presentation with hematuria: A nationwide claims-based investigation

Women have disproportionately higher mortality rates relative to incidence for bladder cancer. Multiple etiologies have been proposed, including delayed diagnosis and treatment. Guidelines recommend ruling out malignancy in men and women presenting with hematuria. This study sought to determine the difference in timing from presentation with hematuria to diagnosis of bladder cancer in women versus men.

Psychometric characteristics of a condition-specific, health-related quality-of-life survey: the FACT-Vanderbilt Cystectomy Index.

OBJECTIVE Radical cystectomy (RC) for bladder cancer can be associated with significant morbidity and alterations in health-related quality of life (HRQOL). The Functional Assessment of Cancer Therapy--Vanderbilt Cystectomy Index (FACT-VCI) is a condition-specific HRQOL survey for patients undergoing RC and urinary diversion (UD) for bladder cancer. This study evaluates the reliability, validity, and responsiveness of the Vanderbilt cystectomy index (VCI). METHODS The FACT-VCI was administered to patients with bladder cancer undergoing RC and UD (n = 190) at 2 major cancer centers. Statistical methods included principal components analysis, Cronbachs coefficient alpha, and nonparametric correlation coefficients. The Functional Assessment of Cancer Therapy--General (FACT-G) was used to test criterion-related validity and a linear mixed model tested the effects of time and diversion type on longitudinal VCI scores. RESULTS A single summary score of 15 gender-neutral items (VCI-15) represented the optimum solution for postoperative data, which was internally consistent (α = 0.85), had strong retest reliability (ρ = 0.891), and was associated with all FACT-G scales and total score (ρ ≥ 0.38, P <.001). Preoperatively, the VCI-15 was internally consistent (α = 0.77) and was associated with the FACT-G physical and functional scales and total score (ρ ≥ 0.41, P <.001). Although VCI-15 scores at postoperative year 1 did not differ from preoperative values overall (P = .145), they did differ by diversion type (P = .027), with no substantive change after orthotopic neobladder (40 ± 9 vs 39 ± 10) but with a clinically significant improvement after an ileal conduit (39 ± 11 vs 44 ± 11). CONCLUSION The VCI-15 is a reliable and valid condition-specific HRQOL survey for patients with bladder cancer undergoing RC and UD. Future studies of RC patients should measure HRQOL using validated, condition-specific forms, such as the FACT-VCI.

Robotic paediatric urology

Whats known on the subject? and What does the study add?

Incidence, Risk Factors, and Complications of Postoperative Delirium in Elderly Patients Undergoing Radical Cystectomy

OBJECTIVE To identify the risk factors for, and complications associated with, the development of delirium after radical cystectomy. MATERIALS AND METHODS From July 2008 to December 2009, 59 patients, aged ≥65 years and undergoing radical cystectomy, were prospectively enrolled. The baseline cognitive status was assessed using the Mini-Mental Status Examination. Postoperative delirium was assessed using the Confusion Assessment Method. RESULTS A total of 49 patients completed the surgery and all assessments. The incidence of postoperative delirium was 29%, with duration of 1-5 days. On univariate analysis, older age and preoperative Mini-Mental Status Examination score were associated with postoperative delirium. On multivariate analysis, only age was associated with postoperative delirium (odds ratio 1.52, 95% confidence interval 1.04-2.22, P=.03). The 2 groups did not differ in pathologic stage, length of surgery, intraoperative and postoperative narcotic usage, body mass index, age-adjusted Charlson comorbidity index, activities of daily living scores, smoking history, preoperative hematocrit, estimated blood loss, urinary tract infection, interval to a regular diet, or length of hospital stay. The patients who developed postoperative delirium were more likely to undergo readmission (odds ratio 10.7, 95% confidence interval 2.2-51.8, P=.01) and reoperation (odds ratio 9.2, 95% confidence interval 1.5-55.3, P=.03) but did not differ in the 90-day and 1-year mortality rates or incidence of postoperative complications. CONCLUSION In patients aged≥65 years, a lower preoperative Mini-Mental Status Examination score and older age were significantly associated with the development of postcystectomy delirium, as measured using the Confusion Assessment Method. The patients who developed delirium were more likely to undergo readmission and reoperation. Larger studies with multiple surgeons are needed to validate these findings.

Orthotopic Neobladder Versus Indiana Pouch in Women: A Comparison of Health Related Quality of Life Outcomes

PURPOSE Little is known about the health related quality of life of women who have undergone continent urinary diversion. We compared health related quality of life outcomes for women who underwent radical cystectomy with an orthotopic neobladder or Indiana pouch. MATERIALS AND METHODS From 1995 to June 2008 a single surgeon (GDS) performed radical cystectomy with an orthotopic neobladder in 47 women and radical cystectomy with an Indiana pouch in 45. A comprehensive database provided clinical, pathological and outcomes data. The validated Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index was mailed to 92 patients. RESULTS Complete data were available for 87% of patients treated with radical cystectomy with an orthotopic neobladder and 93% of those treated with radical cystectomy with an Indiana pouch, with a median followup of 34 and 24 months, respectively (p = 0.8). Median (IQR) age was 65 (58, 71) and 61.5 (51, 67) years for patients with an orthotopic neobladder and Indiana pouch, respectively (p = 0.03). No significant differences were found for pathological stage, nodal status, blood loss, Clavien grade III or greater complications, adjuvant therapy or hospital stay between the 2 treatment groups, or between respondents and nonrespondents. Five-year survival rates for patients with an orthotopic neobladder and Indiana pouch were 65% and 58%, respectively (p = 0.9). There were 21 (75%) living patients with an orthotopic neobladder and 19 (61%) with an Indiana pouch who completed the Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index, and physical (p = 0.53), social (p = 0.97), emotional (p = 0.61), functional (p = 0.55) and radical cystectomy specific (p = 0.54) health related quality of life domains were not significantly different between the groups. CONCLUSIONS Women undergoing radical cystectomy with an orthotopic neobladder vs an Indiana pouch have similar health related quality of life outcomes. Larger series with longer followup and multiple surgeons are necessary to confirm these findings.

The Impact of Running versus Interrupted Anastomosis on Ureterointestinal Stricture Rate after Radical Cystectomy

PURPOSE Benign ureterointestinal anastomotic stricture is not uncommon after radical cystectomy and urinary diversion. We studied the impact of the running vs the interrupted technique on the ureterointestinal anastomotic stricture rate. MATERIALS AND METHODS From July 2007 to December 2008 interrupted end-to-side anastomoses were created and from January 2009 to July 2010 running anastomoses were created. The primary study end point was time to ureterointestinal anastomotic stricture. RESULTS Of 266 consecutive patients 258 were alive 30 days after radical cystectomy, including 149 and 109 with an interrupted and a running anastomosis, respectively. The groups did not differ in age, gender, body mass index, age adjusted Charlson comorbidity index, receipt of chemotherapy or radiation, blood loss, operative time, diversion type or postoperative pathological findings. The stricture rate per ureter was 8.5% (25 of 293) and 12.7% (27 of 213) in the interrupted and running groups, respectively (p = 0.14). Univariate analysis suggested that postoperative urinary tract infection (HR 2.1, 95% CI 1.1-4.1, p = 0.04) and Clavien grade 3 or greater complications (HR 2.6, 95% CI 1.4-4.9, p <0.01) were associated with ureterointestinal anastomotic stricture. On multivariate analysis postoperative urinary tract infection (HR 2.4, 95% CI 1.2-5.1, p = 0.02) and running technique (HR 1.9, 95% CI 1.0-3.7, p = 0.05) were associated with ureterointestinal anastomotic stricture. Median time to stricture and followup was 289 (IQR 120-352) and 351 days (IQR 132-719) in the running cohort vs 213 (IQR 123-417) and 497 days (IQR 174-1,289) in the interrupted cohort, respectively. Of the 52 strictures 33 (63%) developed within 1 year. Kaplan-Meier analysis controlling for differential followup showed a trend toward higher freedom from stricture for the interrupted ureterointestinal anastomosis (p = 0.06). CONCLUSIONS A running anastomosis and postoperative urinary tract infection may be associated with ureterointestinal anastomotic stricture. Larger series with multiple surgeons are needed to confirm these findings.

Cystectomy and urinary diversion as management of treatment-refractory benign disease: The impact of preoperative urological conditions on perioperative outcomes

To investigate perioperative outcomes associated with cystectomy and urinary diversion for treatment‐refractory benign urological disease.

The effect of length of ureteral resection on benign ureterointestinal stricture rate in ileal conduit or ileal neobladder urinary diversion following radical cystectomy.

OBJECTIVES To assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion. METHODS AND MATERIALS We identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis. RESULTS A total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211-927). Median time to stricture formation was 235 (IQR: 134-352) and 232 days (IQR: 132-351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P = 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication≥III (hazard ratio = 2.11, 1.01-4.40) and urine leak (hazard ratio = 3.37, 1.08-10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side. CONCLUSIONS The etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not significantly affect stricture rate.