Is the Complication Rate of Radical Cystectomy Predictive of the Complication Rate of Other Urological Procedures?

Source: UroToday

A higher hospital radical cystectomy volume appears to lead to a lower risk of complications only after other common urological oncological procedures, namely radical prostatectomy and nephrectomy, but not after nononcological urology procedures.

This abstract found that hospitals that performed radical cystectomy (removal of the bladder and surrounding tissue for bladder cancer) had less complcations for kidney and prostate cancer surgery as well.

I have been perfoming radical cystecomies my whole career and started perfoming these robotically 3 1/2 years ago. Although I thought performing the more complex surgery helpe me in other surgeries, I didnt realize that a study would show less complications for these other procedures.

Best of AUA Orlando 2008 for Prostate Cancer

Source: Urology Times
Robotic Surgery
Presented by Ashutosh K. Tewari, MD,
Weill-Cornell Medical College, New York.

* Robot-assisted laparoscopic partial nephrectomy is associated with shorter hospital stay and less bleeding, but the warm ischemia time is still around 30 minutes.

* Studies comparing robot-assisted laparoscopic cystectomy and open radical cystectomy show similar oncologic outcomes. At a high-volume tertiary care center, the robotic technique was more cost-efficient, but that finding needs to be confirmed at other centers. Other remaining issues regarding the robotic procedure include the need to define how the reconstruction should be performed, the extent of the lymphadenectomy, and ensuring clear margins at lateral areas.

* A study of almost 4,000 patients reaffirms the safety of robotic-assisted laparoscopic prostatectomy (RALP). Rates of major surgical, major medical, and minor medical complications were all ≤0.7%, and the rate of minor surgical complications was 3.3%.

* Studies comparing open and RALP show the surgeon is the most important variable in determining outcome.

* Extended lymph node dissection should be performed in high-risk prostate cancer patients, and can be done with RALP.

* A total reconstruction procedure including anterior and posterior restoration of the vesicourethral junction is associated with early return to continence and improvement in overall continence rates.

Some of the highlights from the AUA
Of interest is the growing application of robotic surgery for smaller kidney cancers (partial nephrectomy) and bladder cancer, which I have been performing since 2005 myself.

The other very important adaption is the posterior and anterior reconstruction of the urinary tract during robotic prostatectomy, which I have performing for over a year after attending Dr Tewari’s conference.

Is Robotic Radical Cystectomy an Appropriate Treatment for Bladder Cancer? Short-Term Oncologic and Clinical Follow-Up in 50 Consecutive Patients

Source: UroToday

Robotic cystectomy was performed in 40 men and 10 women at a mean age of 63.6 years. Of the 50 patients, 66% had Stage pT2 or less, 14% had pT3 disease, and 20% Stage N+ disease. No patient had positive surgical margins.

This abstract is from one of the leading centers for robotic cystectomy. They show relatively low morbidity for a major surgery. I have done about 20 cystectomies robotically and have switched almost all of my major bladder cancer surgery to this approach. I think I am performing the same oncological operation as open, but have seen less blood less and quicker recoveries.

Colorectal and Urological Cancers May be Markers for Each Other – in Hematology/Oncology, Colon Cancer

MedPage Today

Dr. Rubin and colleagues calculated standard incidence ratios (SIRs) of observed to expected cases of invasive colorectal cancer for each urologic cancer site and vice versa.
The analysis showed:
* Patients with previous ureteral cancer had an 80% increase in the risk of subsequent colorectal cancer, with an incidence ratio of 1.80 and a 95% confidence interval from 1.46 to 2.20.
* Those with renal pelvis cancer had a 44% increase in the risk of colorectal disease, with an incidence ratio of 1.44 and a 95% confidence interval from 1.20 to 1.72.
* Patients with bladder or renal parenchymal cancer had small but statistically significant increases in the risk of subsequent colorectal cancer, but the researchers concluded the increases were probably not clinically significant.
* The risk for any urologic cancer was increased after a diagnosis of colorectal cancer, with an incidence ratio of 1.24 and a 95% confidence interval from 1.20 to 1.28.

This study showed an increase risk of colon cancer after urinary tract cancers.

Clinical Outcomes after Sexuality Preserving Cystectomy and Neobladder (Prostate Sparing Cystectomy) in 44 Patients

From Urotoday

Functional results with regard to erectile function and urinary continence after prostate sparing cystectomy are good. Oncological results have been promising, but need to be confirmed after longer followup and in larger trials.

For men in need of a bladder removal for bladder cancer, my practice has always consisted of removing the entire prostate as well. This is what I learned at Indiana and have continued to do in NJ. As far as I know, urologic oncologists in the USA all agree on this.

In Europe I have read several studies that have left the prostate capsule or most of the prostate in place. I think you will see a higher rate of pelvic recurrences and bladder cancer recurrence in the prostate, as well as new prostate cancers this way. I do agree that men will have less side effects in regards to erections and continence potentially.
I have been performing robotic cystectomies for about 3 years now and feel that I can perform a more careful operation around the erection nerves and urinary muscles. I hope to improve on our past results while still removing the entire prostate with the bladder.

Robotic surgery summary- October/November 2007

In October and November I performed 46 robotic surgeries, including 35 dvPs, 4 partial nephrectomies, 2 nephrectomies, 2 radical cystectomies including a bladder replacement in a woman, 1 simple prostatectomy, a stone procedure to remove a large left kidney stone, and a removal of a piece of ureter and re-implant for ureteral cancer.
The most important operation was the anterior exenteration (removal of bladder) and bladder replacement in a female, the first operation to be done completely robotic for me of this type.

One nice trend I have been noticing is a significant improvement in the recovery of urinary control with the reconstruction sutures I have added to the robotic prostatectomy. Most patients are having decent control by 4-6 weeks. I will be looking at the data in more detail in a few months to see how much of an improvement the addition of these sutures has added.

Robotic surgery summary- July/August 2007

For the summer months I had the pleasure of inviting my new associate, Dr. Brent Yanke, into our practice.
We spent July together and he is now on his own performing most of his robotic surgery. He was well trained at Thomas Jefferson and had participated in over 100 robotic operations.
In July and August I performed 30 robotic surgeries, including 22 dvPs, a pyeloplasty, 3 nephrectomies, 1 nephro-ureterectomy, a lymph node dissection for testicular cancer, a simple prostatectomy, and a nerve-sparing cysto-prostatetcomy and neobladder for bladder cancer.
The most important accomplishment was the bladder cancer operation. This was the first time that I have made a new bladder with the robot. Our patient had only a small incision in the lower abdomen to remove the specimen and went home in 3 days.

Robotic surgery summary- May/June 2007

I have been neglectful during the summer with keeping up on my blog.
I will hope to catch up and keep my monthly postings of how things are going in my practice.
In May and June I performed 32 dvPs, a nephrectomy, a simple prostatectomy, and a partial nephrectomy.
The nephrectomy was the live telecast for intuitive surgical at the AUA.
The cystectomy was notable because it was the first time that my team and I did a closed urinary diversion. Traditionally, we have been performing the second half of the operation with a small incision. This time we made an ileal conduit with the daVinci robot as well.
The simple prostatectomy was my 10th, giving me one of the worlds largest experience.

Robotic radical cystectectomy for bladder cancer

UroToday – Robotic vs Open Radical Cystectomy: Prospective Comparison of Perioperative Outcomes and Pathological Measures of Early Oncological Efficacy – Abstract

Robotic-assisted RC appears to offer some operative and perioperative benefits compared with the open approach without compromising pathological measures of early oncological efficacy, such as lymph node yield and margin status. Larger, randomized studies with long-term follow-up are required to confirm these findings and establish oncological equivalence

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