EUROPEAN UROLOGY 65 (2014) 340–347

available at www.sciencedirect.com journal homepage: www.europeanurology.com

Platinum Priority – Bladder Cancer Editorial by Matthew Brown and Benjamin Challacombe on pp. 348–349 of this issue

Analysis of Intracorporeal Compared with Extracorporeal Urinary Diversion After Robot-assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium Kamran Ahmed a, Shahid A. Khan a, Matthew H. Hayn b, Piyush K. Agarwal c, Ketan K. Badani d, M. Derya Balbay e, Erik P. Castle f, Prokar Dasgupta a, Reza Ghavamian g, Khurshid A. Guru h,*, Ashok K. Hemal i, Brent K. Hollenbeck j, Adam S. Kibel k, Mani Menon c, Alex Mottrie l, Kenneth Nepple k, John G. Pattaras m, James O. Peabody c, Vassilis Poulakis n, Raj S. Pruthi o, Joan Palou Redorta p, Koon-Ho Rha q, Lee Richstone r, Matthias Saar s, Douglas S. Scherr t, Stefan Siemer s, Michael Stoeckle s, Eric M. Wallen o, Alon Z. Weizer j, Peter Wiklund u, Timothy Wilson v, Michael Woods w, Muhammad Shamim Khan a a

MRC Centre for Transplantation, King’s College London, Department of Urology, Guy’s Hospital, London, UK; b Maine Medical Center, Division of Urology,

Portland, ME, USA; c Henry Ford Health System, Detroit, MI, USA;

d

Columbia University Medical Center, New York, NY, USA;

e

Memorial S¸is¸li Hospital,

Istanbul, Turkey; f Mayo Clinic, Scottsdale, AZ, USA; g Montefiore Medical Center, UN Hospital Albert Einstein College of Medicine, Bronx, NY, USA; h Roswell Park Cancer Institute, Buffalo, NY, USA; i Wake Forest University Baptist Medical Center, Salem, NC, USA; j University of Michigan Health System, Ann Arbor, MI, USA;

k

Washington University School of Medicine, St. Louis, MO, USA; l Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium;

Medicine, Atlanta, GA, USA; q

n

Doctor’s Hospital of Athens, Athens, Greece; o University of North Carolina, NC, USA;

p

m

Emory University School of

Fundacio Puigvert, Barcelona, Spain;

Yonsei University Health Systems Severance Hospital, Seoul, Korea; r Arthur Smith Institute for Urology, New Hyde Park, NY, USA; s University Clinics of

Saarland, Homburg, Germany; t Weill Cornell Medical College, New York, NY, USA; u Karolinska University Hospital, Stockholm, Sweden; v City of Hope and Beckman Research Institute, Duarte, CA, USA;

w

Loyola University Medical Center, Maywood, IL, USA

Article info

Abstract

Article history: Accepted September 25, 2013 Published online ahead of print on October 9, 2013

Background: Intracorporeal urinary diversion (ICUD) has the potential benefits of a smaller incision, reduced pain, decreased bowel exposure, and reduced risk of fluid imbalance. Objective: To compare the perioperative outcomes of patients undergoing extracorporeal urinary diversion (ECUD) and ICUD following robot-assisted radical cystectomy (RARC). Design, setting, and participants: We reviewed the database of the International Robotic Cystectomy Consortium (IRCC) (18 international centers), with 935 patients who had undergone RARC and pelvic lymph node dissection (PLND) between 2003 and 2011. Intervention: All patients within the IRCC underwent RARC and PLND as indicated. The urinary diversion was performed either intracorporeally or extracorporeally. Outcome measurements and statistical analysis: Demographic data, perioperative outcomes, and complications in patients undergoing ICUD or ECUD were compared. All patients had at least a 90-d follow-up. The Fisher exact test was used to summarize categorical variables and the Wilcoxon rank sum test or Kruskal-Wallis test for continuous variables.

Keywords: Robot-assisted Robotic radical cystectomy Complications Outcomes Urinary diversion Intracorporeal urinary diversion Extracorporeal urinary diversion

* Corresponding author. Roswell Park Cancer Institute, Urologic Oncology, Elm and Carlton Streets, Buffalo, NY 14225, USA. Tel. +1 716 845 7612; Fax: +1 716 845 3300. E-mail address: [email protected] (K.A. Guru). 0302-2838/$ – see back matter # 2013 Published by Elsevier B.V. on behalf of European Association of Urology. http://dx.doi.org/10.1016/j.eururo.2013.09.042

EUROPEAN UROLOGY 65 (2014) 340–347

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Results and limitations: Of 935 patients who had RARC and PLND, 167 patients underwent ICUD (ileal conduit: 106; neobladder: 61), and 768 patients had an ECUD (ileal conduit: 570; neobladder: 198). Postoperative complications data were available for 817 patients, with a minimum follow-up of 90 d. There was no difference in age, gender, body mass index, American Society of Anesthesiologists grade, or rate of prior abdominal surgery between the groups. The operative time was equivalent (414 min), with the median hospital stay being marginally longer for the ICUD group (9 d vs 8 d, p = 0.086). No difference in the reoperation rates at 30 d was noted between the groups. The 90-d complication rate was not significant between the two groups, but a trend favoring ICUD over ECUD was noted (41% vs 49%, p = 0.05). Gastrointestinal complications were significantly lower in the ICUD group ( p  0.001). Patients with ICUD were at a lower risk of experiencing a postoperative complication at 90 d (32%) (odds ratio: 0.68; 95% confidence interval, 0.50–0.94; p = 0.02). Being a retrospective study was the main limitation. Conclusions: Robot-assisted ICUD can be accomplished safely, with comparable outcomes to open urinary diversion. In this cohort, patients undergoing ICUD had a relatively lower risk of complications. # 2013 Published by Elsevier B.V. on behalf of European Association of Urology.

1.

Introduction

Robot-assisted radical cystectomy (RARC) is being performed for patients with muscle-invasive and high-risk superficial bladder cancers at a number of centers with access to robotic technology [1]. Recent studies have reported no significant differences in the oncologic efficacy following either RARC or open radical cystectomy (ORC) [2,3]. With increasing expertise, RARC is likely to become the minimally invasive technique of choice for patients seeking radical cystectomy. Traditionally, following completion of RARC, an extracorporeal urinary diversion (ECUD) was preferred because of the complexity of the procedure [4,5]. The evolution of robotic surgery, with its threedimensional vision and improved ergonomics (EndoWrist technology), has made intracorporeal suturing easier. This situation adds a new dimension to reconstructive surgery, enabling the surgeon to perform both continent and incontinent urinary diversions intracorporeally [6–9]. Intracorporeal urinary diversion (ICUD) is gaining popularity as a viable alternative to ECUD, with the potential benefits of a smaller incision, reduced pain, decreased bowel exposure, and reduced risk of fluid imbalances [10,11]. At present, however, there are a limited number of studies evaluating the benefits of ICUD compared with ECUD. This article aims to compare perioperative outcomes and complications of ICUD and ECUD following RARC from a multi-institutional, prospectively maintained database, the International Robotic Cystectomy Consortium (IRCC).

2.2.

Study design

Perioperative data, including standardized complications, were collected for 935 patients who underwent RARC at 18 participating institutions. All participating institutions performed robotic cystectomies. Information pertaining to the number and type of extirpative (open vs robotic) procedures for each institution was not available. All data/complications were retrospectively identified by a review of the inpatient and outpatient notes, imaging findings, and physician correspondence. The data included patient demographics (age, gender, body mass index [BMI]); American Society of Anesthesiologists (ASA) score; race/ethnicity; indication; any neoadjuvant chemotherapy; previous radiotherapy; prior abdominal surgery; hydronephrosis; operative time; estimated blood loss (EBL); number of units transfused, if any; pathologic stage; length of stay (LOS); reoperations; readmissions; interventional radiology procedures; and postoperative complications based on the modified Clavien system [12]. The operative technique used for RARC and pelvic lymph node dissection (PLND) varied according to the individual surgeon and institution. We have attempted to present our findings in accordance with the European Association of Urology recommendations on grading and reporting of complications after urologic surgical procedures [13].

2.3.

Outcomes of interest

The primary outcome of interest was to establish whether robot-assisted ICUD following RARC could be safely accomplished by comparing its perioperative, operative, and postsurgical outcomes with open urinary diversion. The operative outcomes measured were operative time, EBL, blood transfusion (BT) requirement, and LOS. The postoperative parameters of interest were the 30- and 90-d complication and readmission rates. All complications within 90 d of surgery were identified, defined, graded

2.

Materials and methods

according to modification of the Clavien system, and further grouped into 12 categories by organ system and categorized into low grade

2.1.

International Robotic Cystectomy Consortium database

A retrospective review of a prospectively maintained (Institutional

(grade 1–2) and high grade (grade 3–5) [12].

2.4.

Statistical analysis

Review Board I 97906–approved) database of the IRCC (a mixture of 18 academic and private institutions) comprising >935 patients treated

Statistical analysis was performed using the Fisher exact test to

with RARC for clinically localized bladder cancer from 2003 to 2011 was

summarize categorical variables and the Wilcoxon rank sum test or

analyzed. The IRCC is a collaborative effort that enables all participating

Kruskal-Wallis test for continuous variables. Logistic regression analysis

institutions to monitor their progress and share various aspects of

was performed to evaluate predictors of at least one complication of any

evolving novel techniques.

grade. Separate analyses were performed for high-grade (grade 3–5)

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EUROPEAN UROLOGY 65 (2014) 340–347

complications. Models were fitted separately for preoperative and intraoperative variables. Variables analyzed included gender, age (10-yr age groups), BMI, preoperative chemotherapy, case number, operative time, EBL, transfusion status (yes/no), type of urinary diversion (continent vs conduit), location of urinary diversion (extracorporeal vs intracorporeal), and ASA score (2 vs >2). Statistical analyses were performed using Stata v.11.0 (StataCorp, College Station, TX, USA).

3.

Results

A total of 935 patients underwent RARC and PLND at 18 member institutions of the IRCC with either ICUD or ECUD. Of these patients, 768 had ECUD (570 conduits and 198 neobladders, 26%), and 167 patients had their urinary diversion constructed intracorporeally (106 conduits and 61 neobladders, 36.5%). Of the 18 institutions in the IRCC, 10 performed their urinary diversions only extracorporeally, while 8 participating centers carried them out both intracorporeally and extracorporeally. Eighty-one ICUDs (55%) were performed at institutions with a caseload of 0.05). Approximately 40% of the patients in both groups had stage cT3 or greater disease. Of the patients who developed complications, 43% in the ECUD group and 35% in the ICUD group presented with a complication within 30 d of surgery ( p = 0.07). The readmission rate for ICUD compared with ECUD at 30 d was 5% and 15%, respectively ( p  0.001), and the 90-d readmission rate was 12% and 19%, respectively ( p = 0.016). The number of patients returning to the operating room within 30 d, however, was similar in both groups ( p = 0.421). The 90-d mortality events were higher in the ECUD group than the ICUD group (4.9% vs 1.6%, p = 0.043) (Table 2).

Table 1 – Preoperative characteristics and perioperative parameters* Preoperative characteristics Age, yr Mean  SD Median (range) Male gender, no. (%) BMI, kg/m2 Mean  SD Obese (>30), no. (%) ASA score 3, no. (%) Prior abdominal surgery, no. (%) Preoperative chemotherapy, no. (%) Preoperative irradiation, no. (%) Diversion type, no. (%) Ileal conduit Continent

All

ECUD

ICUD

p value

67  11 68 (28–92) 758 (81)

68  11 68 (28–92) 640 (81)

66  11 66 (40–87) 118 (80)

27  5 230 (27) 409 (51) 387 (47) 107 (14) 15 (2)

27  5 198 (27) 366 (52) 336 (46) 97 (15) 14 (3)

28  5 32 (27) 43 (47) 51 (55) 10 (11) 1 (1)

0.815 0.897 0.378 0.086 0.317 0.384

676 (72) 259 (28)

589 (75) 198 (25)

87 (59) 61 (41)

Analysis of intracorporeal compared with extracorporeal urinary diversion after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

Intracorporeal urinary diversion (ICUD) has the potential benefits of a smaller incision, reduced pain, decreased bowel exposure, and reduced risk of ...
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