RESUMEN
OBJECTIVE: This article describes the authors' experiences with the implementation of the Enhanced Recovery After Surgery (ERAS) protocol for open radical cystectomy (ORC). Adherence to the ERAS cystectomy protocol was assessed; secondary outcome measures were impact on perioperative complication rate (Clavien-Dindo classification), time to first defecation, postoperative length of stay and hospital readmission rate. MATERIALS AND METHODS: This retrospective feasibility study compared outcomes with patients in a historical control group. The study group (ERAS) consisted of 31 consecutive patients undergoing ORC and urinary diversion during 1 year from 1 January to 31 December 2011. The control group (pre-ERAS) comprised 39 consecutive patients operated on during 2010. Follow-up was 30 days. RESULTS: There were no significant demographic differences between the two groups, and no differences in complications graded Clavien III or above, or in total length of stay. The ERAS group had statistically significantly shorter mean time to first passage of stool and statistically significantly lower readmission frequency than the pre-ERAS group. The number of patients was small and the study was not randomized; moreover, the use of historical controls inevitably introduced different types of bias. CONCLUSIONS: Introduction of the ERAS protocol is clearly feasible in cystectomy, and may improve clinical outcomes in terms of faster return of bowel function and reduction of readmission within 30 days. However, more and larger studies are needed to prove the efficacy of ERAS for patients undergoing ORC.
Asunto(s)
Carcinoma de Células Transicionales/cirugía , Protocolos Clínicos , Cistectomía/rehabilitación , Readmisión del Paciente/estadística & datos numéricos , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias/epidemiología , Cuidados Preoperatorios/métodos , Neoplasias de la Vejiga Urinaria/cirugía , Derivación Urinaria/rehabilitación , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Estudios de Cohortes , Femenino , Estudio Históricamente Controlado , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVE: Cystectomy combined with pelvic lymph-node dissection and urinary diversion entails high morbidity and mortality. Improvements are needed, and a first step is to collect information on the current situation. In 2011, this group took the initiative to start a population-based database in Sweden (population 9.5 million in 2011) with prospective registration of patients and complications until 90 days after cystectomy. This article reports findings from the first year of registration. MATERIAL AND METHODS: Participation was voluntary, and data were reported by local urologists or research nurses. Perioperative parameters and early complications classified according to the modified Clavien system were registered, and selected variables of possible importance for complications were analysed by univariate and multivariate logistic regression. RESULTS: During 2011, 285 (65%) of 435 cystectomies performed in Sweden were registered in the database, the majority reported by the seven academic centres. Median blood loss was 1000 ml, operating time 318 min, and length of hospital stay 15 days. Any complications were registered for 103 patients (36%). Clavien grades 1-2 and 3-5 were noted in 19% and 15%, respectively. Thirty-seven patients (13%) were reoperated on at least once. In logistic regression analysis elevated risk of complications was significantly associated with operating time exceeding 318 min in both univariate and multivariate analysis, and with age 76-89 years only in multivariate analysis. CONCLUSIONS: It was feasible to start a national population-based registry of radical cystectomies for bladder cancer. The evaluation of the first year shows an increased risk of complications in patients with longer operating time and higher age. The results agree with some previously published series but should be interpreted with caution considering the relatively low coverage, which is expected to be higher in the future.
Asunto(s)
Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Cistectomía/métodos , Tempo Operativo , Periodo Perioperatorio/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Neoplasias de la Vejiga Urinaria/cirugía , Factores de Edad , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Incidencia , Modelos Logísticos , Masculino , Estudios Prospectivos , Sistema de Registros , Factores de Riesgo , Suecia/epidemiología , Factores de TiempoRESUMEN
OBJECTIVE: ⢠To describe and compare long-term defecation disturbances in patients who had undergone a cystectomy due to urinary bladder cancer with non-continent urostomies, continent reservoirs and orthotopic neobladder urinary diversions. PATIENTS AND METHODS: ⢠During their follow-up we attempted to contact all men and women aged 30-80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals. ⢠During a qualitative phase we identified defecation disturbances as a distressful symptom and included this item in a study-specific questionnaire together with free-hand comments. The patients completed the questionnaire at home. ⢠Outcome variables were dichotomized and the results are presented as relative risks with 95% confidence interval. RESULTS: ⢠The questionnaire was returned from 452 (92%) of 491 identified patients. Up to 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability). ⢠A sense of decreased straining capacity was reported by 20% of the men and women with non-continent urostomy and 14% and 8% of those with continent reservoirs and orthotopic neobladders, respectively. CONCLUSIONS: ⢠Of the cystectomized individuals 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability). ⢠Those wanting to improve the situation for bladder cancer survivors may consider communicating before surgery the possibility of stool-emptying problems, and asking about them after surgery.
Asunto(s)
Cistectomía/efectos adversos , Defecación/fisiología , Complicaciones Posoperatorias/fisiopatología , Neoplasias de la Vejiga Urinaria/cirugía , Derivación Urinaria/efectos adversos , Reservorios Urinarios Continentes/efectos adversos , Adulto , Anciano , Anciano de 80 o más Años , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Calidad de VidaRESUMEN
OBJECTIVE: To compare the functional outcome of two types of orthotopic bladder substitution, the S-shaped and the U-shaped neobladder, with respect to leakage, functional capacity and quality of life. MATERIAL AND METHODS: Between 1999 and 2007, 45 male patients with urinary bladder cancer were treated with cystectomy and orthotopic bladder substitution; 23 with the S-shaped bladder ad modum Schreiter and 22 with the U-shaped bladder ad modum Studer. Patients were followed up by a urologist and a specialized nurse (urotherapist) at 1, 3 and 6 months. At each visit the patient completed a voiding chart, a weighted pad test and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). Differences between the groups in functional outcome and quality of life variables were analysed by Student's t test using SPSS software. RESULTS: Mean maximum bladder capacity increased over time. At 6 months, the S-bladder had a larger capacity than the U-bladder (525 ml vs 423 ml). Patients with an S-bladder had less urine leakage at all follow-ups, although this was statistically significant only at 6 months regarding day-time incontinence and at all visits regarding night-time incontinence. The mean urine leakage at 6 months was 7 g (day) and 30 g (night) in the S-bladder group and 50 g (day) and 250 g (night) in the U-bladder group. However, quality of life did not differ between the groups. CONCLUSION: The S-bladder had better bladder capacity and less leakage than the U-bladder, but these differences did not translate into differences in quality of life. The results should be confirmed in larger prospective studies.
Asunto(s)
Aparatos Ortopédicos , Prótesis e Implantes , Diseño de Prótesis , Neoplasias de la Vejiga Urinaria/cirugía , Vejiga Urinaria/fisiología , Anciano , Cistotomía , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Enuresis Nocturna/epidemiología , Prevalencia , Prostatectomía , Calidad de Vida , Resultado del Tratamiento , Vejiga Urinaria/cirugíaRESUMEN
OBJECTIVES: To determine whether or not an improved hygiene can lessen the incidence of symptomatic urinary tract infections (UTIs) in patients treated by cystectomy for urinary bladder cancer. PATIENTS AND METHODS: We attempted to contact during their follow-up all men and women aged 30-80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals. During a qualitative phase we identified hygienic measures and included them in a study-specific questionnaire. The patients completed the questionnaire at home. Outcome variables were dichotomized and the results presented as relative risks (RR) with 95% confidence interval. RESULTS: We received the questionnaire from 452 (92%) of 491 identified patients. The proportion of patients who had a symptomatic UTI in the previous year was 22% for orthotopic neobladder and cutaneous continent reservoir, and 23% for non-continent urostomy diversion. The RR for a UTI was 1.1 (0.5-2.5) for 'never washing hands' before handling with catheters or ostomy material. Patients with diabetes mellitus had a RR of 2.1 (1.4-3.2) for having a symptomatic UTI. CONCLUSIONS: We could not confirm lack of hygiene measures as a cause of UTI for men and women who had a cystectomy with urinary diversion. Patients with diabetes mellitus have a greater risk of contracting a UTI.
Asunto(s)
Cistectomía , Higiene , Complicaciones Posoperatorias/prevención & control , Sobrevivientes/estadística & datos numéricos , Neoplasias de la Vejiga Urinaria/cirugía , Infecciones Urinarias/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Calidad de Vida , Derivación Urinaria , Reservorios Urinarios Continentes , Infecciones Urinarias/etiologíaRESUMEN
OBJECTIVES: To evaluate the response rate for intravesical gemcitabine given in three different schedules to patients with recurrent multiple carcinoma of the urinary bladder Stage Ta, grade 1-2, in whom all but one marker lesion was removed. Furthermore, we sought to define the safety profile. METHODS: This was a multicenter, open-label, randomized, Phase II study in which gemcitabine 2000 mg in 100 mL of unbuffered saline was instilled as a single dose (n = 11), two doses per week for 3 weeks (n = 11), or once weekly for 6 weeks (n = 10). Efficacy was evaluated using cystoscopy after 9 weeks. Toxicity was evaluated by assessing the liver, kidney, bone marrow, and coagulation function at defined intervals and by questionnaire. RESULTS: A total of 32 patients were included, 2 of whom were subsequently excluded because of protocol violations. The overall complete remission rate was 31%. The respective subgroup response rate was 10% in the single-dose group, 44% in the once-weekly group, and 40% in the twice-weekly group. The most common side effect was nausea. One patient withdrew because of nausea and fever, and an additional 2 patients had reversible hematologic toxicity (mild thrombocytopenia causing delayed instillation and mild anemia). The side effects were generally in the multiple-dose groups, with an overrepresentation in women. Ten patients were unable to retain the drug intravesically for the full hour. CONCLUSIONS: The results of our study have shown that gemcitabine has a tumor ablative effect when given intravesically for bladder cancer. A single dose seemed ineffective, and the multiple dosing regimens seemed effective. The side effects were generally mild.