Search Results (29)

Background/Objectives: While robot-assisted radical cystectomy (RARC) has shown potential benefits over open radical cystectomy (ORC), such as reduced blood loss and quicker recovery, its adoption has been limited because of its complexity and long learning curve, especially for urinary diversion. We assessed whether a RARC program with fully intracorporeal urinary diversion could be safely implemented in a hospital with no prior experience in RARC, but with expertise in ORC and other robotic surgeries. We also compared perioperative outcomes and complications between RARC and ORC during the implementation phase. Methods: This retrospective comparative study included 50 consecutive patients who underwent RARC between June 2023 and January 2025 and 50 patients previously treated with ORC. All RARC cases were performed with intracorporeal urinary diversion. A structured proctoring program guided two surgeons through a stepwise training approach by an expert RARC surgeon. Perioperative outcomes and 90-day complications were compared. Results: All RARC procedures were completed fully intracorporeally with no conversions to open surgery. Compared with ORC, RARC was associated with significantly shorter operative times (for ileal conduit diversion) and hospital stays, lower estimated blood loss, and fewer postoperative complications. There were no differences in intraoperative complications. Worst single grade ≥ 3 complications were significantly less frequent in the RARC than the ORC group (11 [11%] versus 21 [21%], p = 0.045). On multivariable analysis, the robotic approach independently predicted fewer any-grade complications (odds ratio 0.81, 95% confidence intervals 0.65–0.95, p = 0.01). Conclusions: A RARC program can be safely and effectively implemented in a previously RARC-naïve centre with existing surgical expertise. The robotic approach offers clear perioperative benefits and may represent a favourable alternative to open surgery. Full article

The use of ileum for ureteral reconstruction was first described in 1906. Since then, its utilization has evolved considerably. Early in the history of ileal ureters, urologists were limited by a lack of familiarity with bowel harvesting and handling. The popularization of ileal conduits for urinary diversions, however, allowed urologists to familiarize themselves with the use of ileum and paved the way for broader applications. With the emergence of laparoscopy and, later, robotic-assisted surgery, the application of ileal ureteral replacement expanded the capabilities of reconstructive urologists. This article describes the historical development of surgical techniques for ileal ureter replacement and the integration of new technologies aiding in improved outcomes, and anticipates potential future directions. In contemporary practice, robotic-assisted ileal ureteral replacement is used in cases of extensive ureteral obstruction or damage. Advantages of the robotic platform include reduced blood loss, shorter recovery time and hospital length of stay, and superior operative ergonomics. Although robotic ileal ureter replacement is a complex and challenging surgery with notable complications, studies have demonstrated the efficacy and safety of this technique in patients with an otherwise end-stage ureter. In addition, the robotic approach has provided urologists the ability to conduct complex reconstructive surgeries including bilateral ureteral replacement in conjunction with bladder augmentation or a urinary diversion. Long-term studies and continued innovation are necessary to further improve the surgical techniques, outcomes, and scope of ileal ureter reconstruction. Full article

Background: Perioperative fluid management plays a critical role in optimizing recovery after radical cystectomy. Various strategies, such as restrictive fluid therapy, goal-directed fluid therapy (GDFT), and warmed fluids, have been studied for their impact on complications and outcomes. However, the optimal approach remains uncertain. Methods: We conducted a systematic review in accordance with PRISMA 2020 guidelines. A PubMed search was performed in January 2025. Eligible studies included randomized controlled trials (RCTs) and observational studies published in English that assessed perioperative fluid strategies in radical cystectomy. Two reviewers independently selected studies, with a third resolving discrepancies. Data were extracted on study characteristics, interventions, and outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Due to heterogeneity, narrative synthesis was used. Results: Seventeen studies (eight RCTs, nine observational; total n = 3519) were included. Three publications based on a single RCT (n = 167) showed that restrictive fluid therapy with norepinephrine significantly reduced blood loss (p < 0.0001), transfusions (p = 0.0006), complications (p = 0.006), and hospital stay (p = 0.02), with a trend toward fewer 90-day complications (p = 0.12). Six studies (four RCTs, two observational) evaluated GDFT. Doppler- and SVV-based GDFT reduced ileus, nausea, wound infections, and blood loss, although findings on renal function and length of stay were mixed. One RCT showed that warmed fluids reduced transfusion needs (p = 0.028) and hospital stay (p = 0.05). VBFI (Vascular Bed Filling Index)- and aVBFI (adjusted Vascular Bed Filling Index)-guided strategies may lower complications in ileal conduit patients, but evidence remains limited. Conclusions: Restrictive fluid therapy with norepinephrine appears to improve outcomes after radical cystectomy. GDFT and warmed fluids show potential benefits, but findings are inconsistent. Further high-quality trials are needed to define the optimal strategy. Full article

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are increasingly used in patients with type 2 diabetes, chronic kidney disease, and heart failure. However, their safety and efficacy in patients with congenital or surgically altered urogenital anatomy remains underexplored. Methods: We conducted a narrative review of current evidence regarding the use of SGLT2i in patients with urinary tract malformations, urinary diversions, and functional voiding disorders. Key risks, clinical considerations, and management strategies were synthesized from the existing literature and case reports. Results: Patients with benign prostatic hyperplasia, vesicoureteral reflux, neurogenic bladder, nephrostomies, and ileal conduits may face increased risks of urinary tract infections, fungal colonization, and therapy-related complications due to persistent glycosuria and altered urinary flow. Nevertheless, these patients may still benefit from SGLT2i’s systemic renal and cardiovascular effects. Individualized risk assessment, close monitoring, and multidisciplinary management are essential. Conclusions: Patients with urological abnormalities represent a high-risk but potentially high-reward population for SGLT2i therapy. A cautious, tailored approach is necessary, and future dedicated research is urgently needed to better guide clinical practice. Full article

Introduction: Intravenous fluid management is integral to perioperative care, particularly under enhanced recovery after surgery (ERAS) protocols. In radical cystectomy (RC), which carries high risks of complications and mortality, optimizing fluid management poses a significant challenge due to the absence of definitive guidelines. Aim: the purpose of this study was to investigate the effects of intravenous fluid administration on postoperative complications in patients undergoing RC. Material and methods: This study involved 288 patients who underwent laparoscopic RC and urinary diversion from 2018 to 2022. ERAS protocols were implemented for all patients. Participants were divided into four groups based on the type of urinary diversion (ureterocutaneostomy vs. ileal conduit) and the intraoperative fluid volume input (less than 1000 mL vs. more than 1000 mL). Postoperative complications were evaluated at 30 and 90 days post-surgery using the Clavien-Dindo scale. The fluid management effectiveness was measured using the absolute Vascular Bed Filling Index (aVBFI) and the adjusted Vascular Bed Filling Index (adjVFBI). Results: The UCS is associated with a lower risk of increased severity of postoperative complications. The administration of more than 1000 mL of fluids was associated with a higher risk of complications (p = 0.035). However, after adjusting for the duration of the surgery and BMI, this association did not hold statistical significance, indicating that fluid volume alone is not a direct predictor of postoperative complications. At aVBFI values between zero and eight, urinary diversion using the UCS method is associated with a lower risk of complications compared to the IC. When aVBFI equals eight, the differences in the severity of complications between the UCS and the IC are minimal. However, when aVBFI exceeds eight, the IC is associated with fewer complications during the 30 days post-operation compared to the UCS. The correlation between the adjVFBI (B = −0.27; 95% CI: −0.45 to −0.08; p = 0.005) and the severity of complications up to 30 days postoperatively is similar to that seen with the aVBFI. Similarly, the correlation of the adjVFBI with the method of urinary diversion (B = 0.24; 95% CI: 0.06 to 0.43; p = 0.011) resembles that of the aVBFI. The volume of fluids administered and the indices aVBFI and adjVFBI did not influence the occurrence of complications 90 days postoperatively. Conclusions: The volume of fluids administered is not a factor directly affecting the occurrence of complications following RC when the ERAS protocol is used. The amount of intraoperative fluid administration should be adjusted according to the intraoperative blood loss. Our findings endorse the utility of aVBFI and adjVFBI as valuable tools in guiding fluid therapy within the framework of ERAS protocols. However, further multicenter randomized trials are needed to definitively determine the best fluid therapy regimen for patients undergoing RC. Full article

Background/Objectives: Radical cystectomy (RC) represents one of the most complex and morbid surgical procedures in the field of Urology. Extraperitoneal open RC has emerged as an alternative to the traditional transperitoneal approach for the treatment of muscle-invasive bladder cancer. Frailty is one of the most important risk factors for perioperative morbidity and mortality, and this category of patients can benefit the most from the extraperitoneal approach. The purpose of this study was to evaluate the feasibility and the safety of extraperitoneal open RC in our experience; Methods: We retrospectively collected the data of 75 frail patients who underwent an extraperitoneal open RC, performed by a single experienced surgeon. We assessed their frailty status using the simplified frailty index (sFI). We recorded data regarding general characteristics, intraoperative, pathological, and postoperative complications, and mortality (within 90 days); Results: We analyzed 61 males and 14 females with an sFI equal to or higher than 3. The median age was 77 years. Fifty-one patients had an ASA score of 3 or more. Sixty procedures were with radical intention, while fifteen were palliative. Cutaneous ureterostomy was performed in 70 cases and extraperitonized ileal conduit in five cases. The median operative time was 150 min. The median blood loss was 400 mL. The median time to flatus was 2 days. The median postoperative stay was 7 days. Thirteen patients had Clavien–Dindo III or IV complications. Two patients died in first 90 days postoperatively; Conclusions: The extraperitoneal open RC in frail patients was demonstrated to be a feasible and safe alternative approach in definitive treatment or a palliative setting in our experience. Full article

Background: The incidence of urinary tract infections (UTIs) after radical cystectomy (RC) with urinary diversion (UD), the typical pathogens, and associated patient risk factors have not been well documented. In this study, we examined the incidence of post-op UTIs after RC to identify associated risk factors. Methods: Single-center, retrospective case series of 386 patients with bladder cancer who underwent RC with UD between 2012 and 2024. The primary objective was UTI incidence, defined by the frequency of patients with urine culture with >10⁵ colony-forming units per high-powered field, spanning from post-op day 0 (POD0) to 90 days after discharge. Isolated pathogens were reported. Risk factors for UTIs were assessed. Results: The average age was 69 years old at surgery, and patients were predominantly male (80%). The cumulative incidence of post-op UTIs was 14%, among which 12 patients had more than one UTI. The UTI incidence was 2%, 8%, and 7% during the immediate post-op period, within 30 days, and within 31–90 days, respectively. Isolated pathogens included Escherichia coli (26%), Enterococcus faecalis (24%), Klebsiella pneumoniae (21%), and Pseudomonas species (21%). In the immediate post-op period, female sex was the only significant risk factor. At 31 to 90 days, cutaneous ureterostomy UD was the predominant risk factor for UTIs. For ileal conduit patients, those with a Wallace ureteral anastomosis were associated with UTI 31–90 days from discharge for RC. Conclusions: Our retrospective data suggests the incidence of UTIs and their causative pathogens after RC differ based on post-operative time points and vary according to different patient risk factors. Full article

Background: Radical cystectomy (RC) with the formation of an ileal orthotopic neobladder (ONB) may adversely affect long-term health-related quality of life (HRQOL). An advanced age at the time of ONB construction could further exacerbate the decline in HRQOL. This study aims to establish an evidence-based age threshold at the time of RC with ONB, beyond which a significant deterioration in HRQOL is observed. Methods: We retrospectively analyzed all bladder cancer patients in our department between 2013 and 2022 that fulfilled the EORTC-QLQ-C30 questionnaire preoperatively, as well as at 3 and 12 months after RC with ONB. Patients receiving neoadjuvant or adjuvant chemotherapy or benign/palliative RC were excluded. Results: Overall, 120 patients (81% males) with a mean age of 66 ± 9.6 years underwent RC with ONB and fulfilled the selection criteria. The Global Health Status (GHS) of the EORTC-QLQ-C30 was 64 ± 23 preoperatively, was 64 ± 20 three months postoperatively, and was 68 ± 23 twelve months postoperatively. Overall, 80 (67%) patients presented an increase in GHS at twelve months compared to their preoperative values. The perioperative complications did not differ between patients with decreased and increased GHS. Patients with increased GHS had values of 58 ± 24 preoperatively, 67 ± 19 at 3 months, and 77 ± 16 at 12 months. Patients with decreased GHS had values of 76 ± 16 preoperatively, 57 ± 21 at 3 months, and 50 ± 25 at 12 months. Using ROC analyses with Youden’s index, we defined a threshold of 70 years, after which RC with ONB may lead to worse GHS twelve months postoperatively. Worse continence outcomes were the only perioperative and long-term parameters that predicted worse HRQOL in elderly patients. Conclusions: Based on HRQOL, we suggest that RC with an ileal conduit as a urinary diversion should be recommended in patients older than 70 years. Full article

Synchronous prostatic adenocarcinoma found in patients with muscle-invasive bladder cancer (MIBC) that undergo radical cistoprostatectomy is not uncommon. Nonetheless, the occurrence of collision metastasis, where both prostate cancer and bladder cancer involve the same lymph node, is exceptionally uncommon, with few cases being reported in the literature. We present a case of a 65-year-old patient diagnosed with MIBC who underwent laparoscopic radical cistoprostatectomy with extended lymph node dissection and intracorporeal ileal conduit. The final pathology revealed urothelial carcinoma pT3bN1 as well as prostatic adenocarcinoma pT3bN1. One lymph node presented metastasis from both bladder cancer and prostate cancer. Full article

Objective: The aim of the study was to find tools to assess patient characteristics that would help in choosing between orthotopic neobladder and ileal conduit in patients undergoing radical cystectomy. An additional goal was to search for aids that improve preoperative counseling to support patients in the decision-making process. Methods: A systematic review of MEDLINE, Web of Science, and Scopus databases was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, in April 2024. Inclusion criteria were specified in PICO format. Two reviewers independently screened titles/abstracts and full papers. Upon study selection, the results and conclusions from the studies were abstracted and quantitatively summarized in the results section of this article. Results: Seven articles, involving a total 834 patients, were included. One article described frailty, two reviewed cognitive status, one article described functional dexterity, one described personality, two articles reviewed patients’ values and goals, and one article reviewed role of patient–physician dialogue in the context of choosing UD after RC. The reviewed articles identified tools and approaches that could be valuable in evaluating the suitability for continent urinary diversion (CUD) or incontinent urinary diversion (ICUD). Conclusions: This is the first systematic review that summarizes the new available methods of patient assessment which improve preoperative counseling and choosing the most suitable UD after RC. Efficient tools for this purpose are still missing, and further studies that will aid in creating a simple aid for patient selection are necessary. Full article

Bladder cancer ranks as the 10th most prevalent cancer globally with an increasing incidence. Radical cystectomy combined with urinary diversion represents the standard treatment for muscle-invasive bladder cancer, offering a range of techniques tailored to patient factors. Overall, urinary diversions are divided into non-continent and continent. Among the first category, cutaneous ureterostomy and ileal conduit represent the most common procedures while in the second category, it could be possible to describe another subclassification which includes ureterosigmoidostomy, continent diversions requiring catheterization and orthotopic voiding pouches and neobladders. In this comprehensive review, urinary diversions are described in their technical aspects, providing a summary of almost all alternatives to urinary diversion post-radical cystectomy. Full article

Background: This study aims to compare perioperative morbidity and drainage tube dependence following open radical cystectomy (ORC) with ileal conduit (IC) or cutaneous ureterostomy (CU) for bladder cancer. Methods: A single-center, retrospective cohort study of patients undergoing ORC with IC or CU urinary diversion between 2020 and 2023 was carried out. The 90-day perioperative morbidity, as per Clavien–Dindo (C.D.) complication rates (Minor C.D. I–II, Major C.D. III–V), and urinary drainage tube dependence (ureteral stent or nephrostomy tube) after tube-free trial were assessed. Results: The study included 56 patients (IC: 26, CU: 30) with a 14-month median follow-up. At 90 days after IC or CU, the frequencies of any, minor, and major C.D. complications were similar (any—69% vs. 77%; minor—61% vs. 73%; major—46% vs. 30%, respectively, p > 0.2). Tube-free trial was performed in 86% of patients with similar rates of tube replacement (19% IC vs. 32% CU, p = 0.34) and tube-free survival at 12 months was assessed (76% IC vs. 70% CU, p = 0.31). Conclusions: Compared to the ORC+IC, ORC+CU has similar rates of both 90-day perioperative complications and 12-month tube-free dependence. CU should be offered to select patients as an alternative to IC urinary diversion after RC. Full article

Background: Despite existing standardized surgical techniques and the development of new perioperative care protocols, radical cystectomy (RC) morbidity remains a serious challenge for urologists. Postoperative ileus (POI) is one of the most common postoperative complications, often leading to a longer length of stay (LOS). The aim of our study was to assess the impact of compliance to the Enhanced Recovery After Surgery (ERAS^®) protocol on bowel recovery, 30-day complications and LOS after RC for bladder cancer (BC). Methods: Data from consecutive patients undergoing RC for BC within an ERAS^® dedicated protocol were analyzed. Exclusion criteria were urinary diversion other than ileal conduit and palliative RC. Patients were divided into two groups according to their compliance (A: low-compliance and B: high-compliance). ERAS^® compliance was extracted from the ERAS^® Interactive Audit System (EIAS) database. Postoperative complications were prospectively recorded by a dedicated study nurse 30 days after RC. POI was defined as the placement of a nasogastric tube. Logistic regression analysis was used to identify predictors of 30-day complications and POI. Results: After considering the exclusion criteria, 108 patients were included for the final analysis. The median global compliance to the ERAS^® protocol was 61%. A total of 78 (72%) patients had a compliance <65% (group A), while the remaining 30 (28%) had a compliance >65% (group B). No significant differences were found among the two groups regarding the 30-day complication rate (86% in group A versus 73% in group B, p = 0.82) and LOS (14 days in group A versus 15 days in group B, p = 0.82). The time to stool was significantly shorter in group B (4 days versus 6 days, p = 0.02), and the time to tolerate solid food was slightly faster in group B but not significant (8 versus 7 days, p = 0.23). The POI rate was significantly lower in patients with a higher ERAS^® compliance (20% versus 46%, p = 0.01). A multivariate analysis showed that ERAS^® compliance was not significantly associated with 30-day total complications. However, a lower compliance to the ERAS^® protocol and age > 75 years were significant independent predictors of POI. Conclusions: Our study provides further evidence to support the beneficial effect of the ERAS^® protocol in patients undergoing RC, particularly in terms of facilitating a faster recovery of bowel function and preventing POI. Future research should focus on investigating novel approaches and interventions to improve compliance with the ERAS^® protocol. This may involve patient education, multidisciplinary teamwork, and continuous quality improvement initiatives. Full article

Background: It is unknown whether more complex UD, such as orthotopic neobladder and abdominal pouch, may be associated with higher OCM rates than ileal conduit. We addressed this knowledge gap within the SEER database 2004–2020. Methods: All T1-T4aN₀M₀ radical cystectomy (RC) patients were identified. After 1:1 propensity score matching (PSM), cumulative incidence plots, univariable and multivariable competing-risks regression (CRR) models were used to test differences in OCM rates according to UD type (orthotopic neobladder vs. abdominal pouch vs. ileal conduit). Results: Of all 3008 RC patients, 2380 (79%) underwent ileal conduit vs. 628 (21%) who underwent continent UD (268 orthotopic neobladder and 360 abdominal pouch). After PSM relative to ileal conduit, neither continent UD (13 vs. 15%; p = 0.1) nor orthotopic neobladder (13 vs. 16%; p = 0.4) nor abdominal pouch (13 vs. 15%; p = 0.2) were associated with higher 10-year OCM rates. After PSM and after adjustment for cancer-specific mortality (CSM), as well as after multivariable adjustments relative to ileal conduit, neither continent UD (Hazard Ratio [HR]:0.73; p = 0.1), nor orthotopic neobladder (HR:0.84; p = 0.5) nor abdominal pouch (HR:0.77; p = 0.2) were associated with higher OCM. Conclusions: It appears that more complex UD types, such as orthotopic neobladder and abdominal pouch are not associated with higher OCM relative to ileal conduit. Full article

Men with prostate cancer have the daunting task of selecting from multiple modalities of treatment. The long-term effects of radiation therapy are only now being recognized. For both patients and surgeons, the end-stage irradiated bladder poses numerous problems and challenges. Specifically, irradiated bladders with urosymphyseal fistula, radiation cystitis, and rectourethral fistula are challenging to manage and treat. This review outlines the presentation, workup, and management including cystectomy for these three devastating late complications of radiation therapy. There are special considerations when performing benign cystectomy that are not typically considered during oncologic cystectomy. We discuss an overview of the current literature regarding the “end-stage bladder” resulting from radiation therapy and the important considerations that must be acknowledged when managing these patients. It is shown that many of the less invasive and conservative options ultimately lead to cystectomy. Indeed, our review concludes that cystectomy with urinary diversion is a safe and viable option in select irradiated patients with the goal to improve quality of life. Full article