Outcomes and learning curve for robotic-assisted radical cystectomy: an Australian experience.

BACKGROUND: This study aimed to describe perioperative, oncological and learning curve outcomes for robotic-assisted radical cystectomy (RARC) across the first 100 cases performed by an Australian high-volume, fellowship-trained robotic surgeon. METHODS: A retrospective cohort study was performed on a consecutive group of 100 patients who underwent RARC between 2010 and 2016 in Brisbane, Australia. Perioperative, oncological and survival data were collected. Demographic, survival and learning curve analyses were performed in MedCalc. RESULTS: A total of 100 patients underwent RARC over the study period. Median operative time was 389 min, with a reduction in median times from 420 to 330 min when comparing the first 50 versus the second 50 patients (P < 0.001). Median estimated blood loss was 500 mL, while urinary diversion was performed extracorporeally in 20 patients, intracorporeally in 69 patients and using a hybrid technique in 11 patients. Median length of hospital stay was 11 days. Post-operative complications occurred in 56% of patients (Clavien-Dindo classification I-II 32%, III-V 24%). Positive operative margins were 2% and median lymph node yield was 21 nodes. Overall recurrence-free survival was 50.3 months. CONCLUSION: Initial short-term experience with RARC shows favourable outcomes with regard to operative, perioperative and pathological indicators compared to open radical cystectomy and other RARC series.

Incidencia y mortalidad del cáncer de vejiga en Costa Rica y Panamá, 2007-2013 / Incidence and mortality of bladder cancer in Costa Rica and Panama, 2007-2013

Resumen Objetivo: Se desconoce el comportamiento epidemiológico del cáncer de vejiga en Panamá y Costa Rica; globalmente, se reporta un aumento de la incidencia de dicha patología. Este estudio tiene como propósito reportar la incidencia, mortalidad y severidad del cáncer de vejiga, durante el período comprendido entre 2007 y 2013, en ambos países. Métodos: Se realiza un análisis epidemiológico transversal en el periodo comprendido entre 2007 y 2013, contemplando los casos incidentes y fallecidos por cáncer de vejiga en Costa Rica y Panamá. La tasa de incidencia y mortalidad anual para cada uno de los países y según sexo fue estimada de acuerdo con las proyecciones anuales de población. La severidad del comportamiento de la esta neoplasia se evaluó mediante la razón de incidencia / mortalidad. Resultados: Se identifica un total de 2048 casos de cáncer de vejiga. Se evidencia un aumento de las tasas de incidencia y mortalidad en los últimos 3 años del periodo de estudio, con un compromiso mayor en el sexo masculino. La tasa de incidencia aumentó de 2007 a 2013 en un 42,3 % en Costa Rica y un 71,4 % en Panamá. En dicho periodo, la mortalidad aumentó un 25,9 % para Costa Rica y un 44,7 % para Panamá. La razón de incidencia / mortalidad se mantuvo estable para ambos países durante el periodo de estudio. Conclusión: Existe una tendencia creciente en las tasas de incidencia y mortalidad por cáncer de vejiga, en Costa Rica y Panamá.

Abstract Aim: The incidence and mortality of bladder cancer has increased in some regions of the world. However, the epidemiological profile of this neoplasia is largely unknown in Panama and Costa Rica. Therefore, the aim of this study was to report the incidence, mortality, and severity of this disease during years 2007 to 2013. Methods: An epidemiological cross-sectional study was conducted between 2007 and 2013 with all incident and mortality cases of bladder cancer in Costa Rica and Panama. The annual incidence and mortality rates for each country, and according by sex were estimated based on the annual population estimates. The incidence/mortality ratio was estimated as a measure to evaluate the severity of the pathology. Results: A total of 2048 cases of bladder cancer were included. During the last 3 years of the study period we detected an increased in incidence and mortality rates, predominately in males. The incidence rate increased from year 2007 to year 2013 in 42.3% and 71.4% in Costa Rica and Panama, respectively. During the same period the mortality rate also increased 25.9% in Costa Rica and 44.7% in Panama. The incidence/ mortality rate had a steady behavior during the study period. Conclusion: These findings confirm a growing trend in the incidence and mortality rates of bladder cancer in Costa Rica and Panama.

Urine retention in cattle putatively associated with injection of an ivermectin and closantel anthelmintic formulation into the ischiorectal fossa.

CASE HISTORY: A group of 39, 19-22-month-old Friesian bulls were administered an ivermectin/closantel anthelmintic via intended S/C injection in the ischiorectal fossa on 15 June 2017 (Day 0). Over the next 50 days, 22 affected bulls presented various degrees of anorexia, abdominal pain and urine dribbling. Seventeen bulls were examined by transrectal ultrasonography which revealed urinary bladder distension in all 17, and peritoneal fluid accumulation in some. Overall, eight bulls died or were subjected to euthanasia. On-farm postmortem examination of three bulls revealed urinary bladder rupture. CLINICAL FINDINGS: On Day 50 one affected live bull was admitted to Massey University for further investigation. This bull continuously dribbled urine and had an overtly distended urinary bladder as determined by rectal palpation and ultrasonography. PATHOLOGICAL FINDINGS: Postmortem examination of this bull revealed a markedly distended urinary bladder, massive subcapsular and pericapsular renal oedema with retroperitoneal fluid accumulation, minimal hydronephrosis and no evidence of mechanical urinary outflow obstruction. The right ischiorectal fossa contained multifocal areas of tissue fibrosis that extended into areas innervated by the distal cutaneous branch of the pudendal nerve and the pelvic nerve. Histopathological changes consisted of extensive fibrosis, myonecrosis and neurodegeneration, and evidence of granulation tissue and inflammation at the putative injection site and in surrounding tissues. DIAGNOSIS: A local inflammatory reaction at the presumed injection site together with localised peripheral neurodegeneration and myelopathy may have led to detrusor-sphincter dyssynergia causing urine retention. CLINICAL RELEVANCE: These cases of urine retention and bladder rupture in cattle were of putative iatrogenic origin. Veterinarians should be aware of this rare complication after S/C injections in the ischiorectal fossa.

Mortality following augmentation cystoplasty: A transitional urologist's viewpoint.

INTRODUCTION: Three complications have been hypothesized to increase patient mortality following enterocystoplasty: spontaneous bladder perforation, bladder neoplasia, and chronic renal failure (CRF). The present study examined risk of their occurrence and discussed ways to improve the quality of care. MATERIALS AND METHODS: The present transitional clinic followed 385 patients with a history of bladder augmentation using either ileal, sigmoid, or ascending colon. The median age was 37 years (range 16-71). Median follow-up interval after augmentation was 26 years (range 2-59). DISCUSSION: Spontaneous rupture of the bladder occurred in 3% (13/385), with one associated death (0.25%, 1/385). Spontaneous bladder rupture significantly correlated with substance abuse, non-compliance with catheterization, and mental/physical disabilities that required the use of surrogates to perform and monitor intermittent catheterization (P < 0.01). Of the 203 patients that were followed for ≥10 years, 4% (8/203) developed a bladder tumor. In comparison, 2.5% (5/203) of an age-matched control population, managed by anticholinergics and intermittent catheterization, developed a bladder tumor. Therefore, enterocystoplasty cannot be associated with an increased risk of cancer development (P = 0.397). Chronic renal failure ≥ Stage 3 arose in 15% (58/385), and 1% (4/385) of the patients died as a result of this complication. Obese patients (BMI ≥30) catheterizing per urethra were more likely to be non-compliant with catheterization and develop CRF compared with obese patients with a continent catheterizable stoma (P > 0.001). These findings suggest that compliance with intermittent catheterization and renal preservation are enhanced by the presence of a catheterizable abdominal stoma. CONCLUSION: The individual's intellectual and physical capability to obey medical directives, refrain from high-risk habits, maintain a healthy weight, and comply with long-term follow-up visits were all critical to the enduring success of bladder augmentation.

[Stages of diagnosis and surgical treatment for combined bladder injuries].

62 case histories of patients with bladder injuries who were admitted in the Department of Urology and Emergency Surgery of the Republican Scientific Center of Emergency Medicine (RRCEM) from 2001 to 2010 were retrospectively analyzed. 15 (24.2%) patients with hematuria or urethremorrhagia were admitted in the emergency room within an hour after the injury onset. Three (4.8%) patients were hospitalized in the period 1-3 h since injury onset, 12 (19.3%) patients since 3-6 hours, 5 (8.1%) - since 6 to 12 h, 16 (25 8%) patients - since 12 to 24 hours, and 11 (17.7%) patients - after 24 hours. Concomitant injury of the bladder with fractures of the pelvic occurred in 21 (33.8%) cases. At the time of admission in the emergency room, I-II degree traumatic shock was diagnosed in 37 (60%) of patients, III-IV degree traumatic shock - in 11 (17,7%). All 62 patients had a complete rupture of the bladder, 37 (59.6%) of patients had intraperitoneal rupture, 23 (37.1%) - extraperitoneal rupture, and only 2 (3.3%) - mixed rupture. Strict adherence to the RRCEM algorithm of diagnosis and treatment of patients with bladder injuries have substantially improved the efficiency of complex of medical and diagnostic measures and improved the outcomes of this group of patients - mortality was 12.9%.

[The results of orthotopic plastic reconstruction of the urinary bladder with gastric and iliac graft].

To compare the results of postoperative plastic reconstruction of the urinary bladder (PRUB) with gastric and iliac graft, we studied 205 patients (150 males, 73.2%; 55 females, 26.8% aged 23-72 years, mean age 62.1 +/- 0.5 years) who had undergone orthotopic PRUB. Artificial bladder was created in 26 (12.7%) patients of a stomach pedicle segment, in 174 (84.9%)--of a detubulated iliac segment, in 5 (2.4%)--of a sigmoid segment. Early and late postoperative complications in using small intestinal segment reached 14.0 and 10.4%, respectively, lethality being 2.6%; in using gastric segment made up 3.9 and 8.7%, respectively, lethal outcomes were absent. Patients after PRUB had neither disorders of acid-base balance nor defects in electrolytic balance of blood. Urodynamic parameters were close to physiological ones. Thus, satisfactory clinical and functional results of urinary bladder orthotopic reconstruction even in long-term follow-up confirm advantages of orthotopic reconstruction of the lower urinary tracts in diseases of the urinary bladder.

Carcinoma in a bladder diverticulum: presentation and treatment outcome.

PURPOSE: In this retrospective review we characterize the outcomes of patients treated for transitional cell carcinoma in a bladder diverticulum. MATERIALS AND METHODS: Between 1986 and 2001, 39 patients were treated for tumors in a bladder diverticulum. All patients underwent initial transurethral resection of the tumor. Based on cystoscopic evaluation, bimanual examination and computerized tomography findings, tumors were classified as superficial (Ta, Tis), superficially invasive confined to diverticulum (T1) or extra diverticular (T3+). Patients with superficial or superficially invasive disease were treated either conservatively with repeat transurethral resection, or with partial or radical cystectomy. Patients with extra diverticular extension were treated with partial or radical cystectomy when amenable to surgical extirpation. Predictors of outcome were assessed by univariate and multivariate analyses. End point was overall and disease-specific survival. RESULTS: Of our cohort of 39 patients 13 (33%) presented with superficial disease, 13 (33%) with superficially invasive tumors and 13 (33%) with invasive (extra diverticular) disease. Actuarial 5-year disease specific survival for the cohort was 72 +/- 5.4%. Significant differences in 5-year disease specific survival were observed among patients presenting with superficial tumors (83 +/- 9%), superficially invasive tumors (67 +/- 7%) and extra diverticular disease (45 +/- 14%). Of the patients presenting with T1 tumors the primary mode of treatment did not correlate with outcome. In a multivariate model clinical staging was the only independent predictor of outcome and concomitant carcinoma in situ reached borderline significance. CONCLUSIONS: Our data support a conservative approach for tumors confined to the bladder diverticulum, provided complete removal is feasible and close surveillance ensues.

[Are their individual decisions for urinary diversion? Indications and results of 200 consecutive patients]. / Gibt es eine individuelle Entscheidung zur Harnableitung? Indikation und Ergebnisse bei 200 konsekutiven Patienten.

During the past 20 years many continent urinary diversions have been established. The indications includes pelvic tumors, especially bladder cancer, and structural and functional disorders of the lower urinary tract with irreversible damage of storage or continence function. Given the variety of surgical diversion techniques, it seems feasible to consider the patient's individual pathoanatomical situation as well as his/her personal wishes. We report on 200 consecutive patients with supravesical urinary diversion. The analysis includes indications surgical technique, intra-and postoperative complications and patients' quality of life. The peri- and postoperative morbidity rate was 18.5%. Complications mainly comprised infections and obstruction of the urinary tract. The mortality rate was 4.5% and causes of death included bleeding, infection, urinary extravasation and bowel atonia. Patients with malignant disease and only palliative treatment showed disappointing results after on operation including continent urinary diversion: 30% of them had early complications. Several female patients with a catherizable continent urinary diversion could not handle the catheterization of the pouch, although the function of the urinary diversion was excellent. Therefore an indwelling catheter was placed in all these patients. Our analysis shows that the choice of urinary diversion has to consider the patient's pathoanatomical situation, as well as his/her age, general condition, mental and manual skills. In addition, renal function, the metabolic situation and previous therapies may influence the decision regarding supravesical urinary diversion in an individual case.

[Ileal neobladder]. / La neovejiga ileal.

Since April 1986, 227 patients received an ileal neobladder at our institution. Of these patients 206 underwent simultaneous radical cystectomy for bladder cancer, and 21 received a bladder augmentation. The mean postoperative follow-up ranges from 3-71 months. Perioperative mortality was 2.55 percent, 15 percent of the patients died later than 2 months postoperatively, 13.4 percent due to tumor progression, 1.5 percent because of pneumonia, severe metabolic acidosis, myocardial infarction and apoplexia. Day and night continence was preserved in 77 percent of the patients with a follow-up of more than 2 years; severe stress incontinence was found in 2 patients, and night time incontinence needing some external device in 4.6 percent. 11.5 percent with mild stress incontinence do not require further treatment. Our experience with this relatively simple procedure is excellent: the need for re-operation is low and the high reservoir capacity results in early continence in most cases. This concept offers a genuine alternative to any form of cutaneous urinary diversion with an incidence of complications not higher than after standard supravesical urinary diversion.

Acute abdominal pain caused by spontaneous perforation of the urinary bladder.

Patients with acute spontaneous bladder perforation have the symptoms and signs of an acute condition of the abdomen which, as a surgical emergency, requires prompt operative treatment. Bladder perforation should be suspected as the cause of this abdominal catastrophe if the history and findings indicate a urinary tract disorder. If the surgeon knows preoperatively that the bladder is perforated, he is able to plan and perform the appropriate surgical procedure with greater dispatch and certainty. The correct preoperative diagnosis should be made more frequently if the primary care physician develops a greater awareness of the possibility of spontaneous bladder perforation as the cause of an acute condition of the abdomen. With earlier diagnosis and earlier surgical treatment, the present reported mortality of 25 per cent for those patients with this condition is likely to be reduced.

Critical evaluation of 1-stage cystectomy--reducing morbidity and mortality.

Although it is a major surgical effort removal of the bladder can be done with reasonable safety. In our opinion cystectomy and urinary diversion by an ileal conduit can be performed as a conjoined procedure without need for staging to reduce risks. Mortality up to 3 months postoperatively was 3.9 per cent and the major complication rate for surviving patients was 18.6 per cent. Minor complications occurred in 28.7 per cent of all patients but were treated easily. We did not note increased morbidity after radical cystectomy compared to other types of cystectomy. A higher complication rate was noted in patients who had undergone preoperative radiation treatment, and wound infection rate was higher in patients with neurogenic bladder dysfunction and chronic cystitis. The advantages of 1-stage compared to 2-stage cystectomy would include the fact that it eliminates the need for a second operation, saves considerable expense by virtue of shortened hospitalization and an earlier resumption of the patient's productivity, achieves early removal of the malignancy, decreases the chances of infection by avoiding a second laparotomy in the presence of a stoma and allows better exposure in the absence of previous ureteroileal anastomoses.