Potential impact of postoperative early complications on the timing of adjuvant chemotherapy in patients undergoing radical cystectomy: a high-volume tertiary cancer center experience. Perioperative outcomes of minimally invasive versus open radical cystectomy: A single-center experience Propensity Score Analysis of Radical Cystectomy Versus Bladder-Sparing Trimodal Therapy in the Setting of a Multidisciplinary Bladder Cancer Clinic. A comparison of postoperative complications in open versus robotic cystectomy. Matched comparison of robotic-assisted and open radical cystectomy. Comparative Effectiveness of Trimodal Therapy Versus Radical Cystectomy for Localized Muscle-invasive Urothelial Carcinoma of the Bladder. Robot-assisted radical cystectomy with intracorporeal urinary diversion versus open radical cystectomy (iROC): protocol for a randomised controlled trial with internal feasibility study Preliminary Comparative Effectiveness of Robotic Versus Open Radical Cystectomy in Elderly Patients. The effects of adjusting for case mix on mortality and length of stay following radical cystectomy. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Identifying risk factors for potentially avoidable complications following radical cystectomy. Randomised phase III study of neoadjuvant chemotherapy with methotrexate, doxorubicin, vinblastine and cisplatin followed by radical cystectomy compared with radical cystectomy alone for muscle-invasive bladder cancer: Japan Clinical Oncology Group Study JCOG0209. Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. Comparison of outcomes between trimodal therapy and radical cystectomy in muscle-invasive bladder cancer: a propensity score matching analysis. Clinical and patient‐reported outcomes of SPARE – a randomised feasibility study of selective bladder preservation versus radical cystectomy Radical cystectomy versus bladder-preserving therapy for muscle-invasive urothelial carcinoma: examining confounding and misclassification biasin cancer observational comparative effectiveness research. Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Prospective evaluation of a molecular marker panel for prediction of recurrence and cancer-specific survival after radical cystectomy. Perioperative and mid-term oncologic outcomes of robotic assisted radical cystectomy with totally intracorporeal neobladder: Results of a propensity score matched comparison with open cohort from a single-centre series. Robot-assisted radical cystectomy versus open radical cystectomy: a complete cost analysis. Urethral catheter‐less robotic‐assisted radical prostatectomy Is robot-assisted radical cystectomy superior to standard open radical cystectomy? An Indian perspective Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Multidisciplinary rehabilitation can impact on health-related quality of life outcome in radical cystectomy: secondary reported outcome of a randomized controlled trial Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Radical cystectomy for urothelial carcinoma of the bladder without neoadjuvant or adjuvant therapy: long-term results in 1100 patients. Bladder preservation in selected patients with muscle-invasive bladder cancer by complete transurethral resection of the bladder plus systemic chemotherapy: long-term follow-up of a phase 2 nonrandomized comparative trial with radical cystectomy. Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. Alvimopan provides rapid gastrointestinal recovery without nasogastric tube decompression after radical cystectomy and urinary diversion. Radical Cystectomy is the best choice for most patients with muscle-invasive bladder cancer? Opinion: No Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: Oncologic Outcomes. Robotic versus open radical cystectomy: prospective comparison of perioperative and pathologic outcomes in Japan. Real-World Impact of Minimally Invasive Versus Open Radical Cystectomy on Perioperative Outcomes and Spending.
BACKGROUND Perioperative cisplatin combination chemotherapy is associated with a survival benefit in patients with invasive bladder cancer ( BCa ) . However , in a recent report from the National Cancer Data base ( NCDB ) , only 11.6 % of stage III BCa patients received perioperative chemotherapy , the majority in the adjuvant setting . OBJECTIVE We explore the impact of postoperative complications on the timing of adjuvant chemotherapy . DESIGN , SETTING , AND PARTICIPANTS An independent review board approved the review of 1142 consecutive radical cystectomies ( RC ) , and data from these cases were entered into a prospect i ve complication data base ( 1995 - 2005 ) which was utilized and retrospectively review ed for accuracy at a single , academic , tertiary cancer center . INTERVENTIONS All patients underwent RC/urinary diversion by high-volume , fellowship-trained , urologic oncologists . MEASUREMENTS All complications within 90 d of surgery were defined and grade d using a five- grade modification of the original Clavien system utilized at Memorial Sloan-Kettering Cancer Center and stratified into 11 categories . Grade 2 - 5 complications typically prohibit starting adjuvant chemotherapy . Univariate and multivariable logistic regression were used to evaluate variables associated with complications . RESULTS AND LIMITATIONS Overall , 64 % ( 735 of 1142 patients ) experienced one or more complications , of which 83 % ( 611 of 735 ) were grade 2 - 5 . Furthermore , 57 % of grade 2 - 5 complications ( 347 of 611 ) occurred between discharge and 90 d , 38 % ( 233 of 611 ) within 6 wk , and 19 % ( 114 of 611 ) between 6 wk and 12 wk , the general time frame for adjuvant chemotherapy . Overall , 26 % ( 298 of 1142 patients ) required readmission . Surgical morbidity at a high-volume tertiary cancer center may not reflect the case mix or surgical experience seen in the community setting . CONCLUSION This series demonstrates that 30 % of patients ( 347 of 1142 ) undergoing RC may not have been able to receive adjuvant chemotherapy due to postoperative complications . This information should be taken into consideration when planning multimodal therapy and further supports the use of perioperative chemotherapy in the neoadjuvant setting Introduction : Open radical cystectomy ( RC ) is associated with significant morbidity and the role of minimally invasive surgery ( MIS ) in reducing morbidity of RC is controversial A direct comparison of various surgical modalities on perioperative outcomes is lacking in the Indian literature . We evaluated outcomes of minimally invasive ( robotic and laparoscopic ) versus open RC with pelvic lymph node dissection ( PLND ) performed at our institute from 2014 to 2016 . Methods : Eighty-three patients of RC with PLND were prospect ively analyzed from December 2014 to February 2016 . All patients of muscle invasive urothelial cancer of the bladder undergoing RC ( open or MIS ) were included in the study . Based on patients preference they were assigned to one of the three groups ( Open RC , robot-assisted RC , or laparoscopic RC ) . Their demographic profile , preoperative disease stage , operative data like operative time , blood loss , intraoperative complications , histopathological data like pathological stage , lymph-node yield etc . , postoperative complications if any and total duration of stay were recorded . These data of laparoscopic , open , and robotic cystectomies were compared in terms of various demographic , histopathologic parameters and perioperative outcomes . Results : Twenty-nine patients ( 34.93 % ) underwent minimally invasive RC with PLND ( 5 laparoscopic and 24 robotic ) . The median age of patients was 58 years .  Mean number of lymph nodes removed was 22.5 ± 14.6 . The total number of lymph nodes removed in laparoscopic surgery was 104 with a yield of 20.6 per patient , in robotic surgery were 627 with a yield of 26.1 per patient , and in open surgery were 1119 with a yield of 20.7 per patient ( P = 0.004 ) . Clavien-Dindo Grade 2 and 3 complications were seen in 37.5 % of robotic , 60 % of laparoscopic , and 55.54 % of open RC . Average blood loss and operative time in laparoscopic , robotic , and open RC were 511.53 ± 311.02 ml , 552.08 ± 267.63 ml , and 512.05 ± 213.9 ml and 8.23 ± 1.36 h ( hrs ) , 7.53 ± 1.92 h , and 5.85 ± 1.76 h , respectively ( P = 0.68 and < 0.001 , respectively ) . Conclusions : MIS is associated with significantly longer operative time than open RC . Robotic RC has significantly higher lymph node yield than open or laparoscopic RC . Minimally invasive RC is equivalent to open surgery in terms of perioperative morbidity , mortality , and blood loss Purpose Multidisciplinary management improves complex treatment decision making in cancer care , but its impact for bladder cancer ( BC ) has not been documented . Although radical cystectomy ( RC ) currently is viewed as the st and ard of care for muscle-invasive bladder cancer ( MIBC ) , radiotherapy-based , bladder-sparing trimodal therapy ( TMT ) that combines transurethral resection of bladder tumor , chemotherapy for radiation sensitization , and external beam radiotherapy has emerged as a valid treatment option . In the absence of r and omized studies , this study compared the oncologic outcomes between patients treated with RC or TMT  by using a propensity score matched-cohort analysis . Methods Data from patients treated in a multidisciplinary bladder cancer clinic ( MDBCC ) from 2008 to 2013 were review ed retrospectively . Those who received TMT for MIBC were identified and matched ( for sex , cT and cN stage , Eastern Cooperative Oncology Group status , Charlson comorbidity score , treatment date , age , carcinoma in situ status , and hydronephrosis ) with propensity scores to patients who underwent RC .  Overall survival and disease-specific survival ( DSS ) were assessed with Cox proportional hazards modeling and a competing risk analysis , respectively . Results A total of 112 patients with MIBC were included after matching ( 56 who had been treated with TMT , and 56 who underwent RC ) . The median age was 68.0 years , and 29.5 % had stage cT3/cT4 disease . At a median follow-up of 4.51 years , there were 20 deaths ( 35.7 % ) in the RC group ( 13 as a result of BC ) and 22 deaths ( 39.3 % ) in the TMT group ( 13 as a result of BC ) . The 5-year DSS rate was 73.2 % and 76.6 % in the RC and TMT groups , respectively ( P = .49 ) . Salvage cystectomy was performed in 6 ( 10.7 % ) of 56 patients who received TMT . Conclusion In the setting of a MDBCC , TMT yielded survival outcomes similar to those of matched patients who underwent RC . Appropriately selected patients with MIBC should be offered the opportunity to discuss various treatment options , including organ-sparing TMT BACKGROUND Robotic cystectomy is an emerging alternative for treatment of invasive bladder cancer ( BCa ) . However , reduction in postoperative morbidity relative to the open approach has not been demonstrated . OBJECTIVE To compare complication rates in patients undergoing robotic versus open radical cystectomy ( RC ) .  DESIGN , SETTING , AND PARTICIPANTS A prospect i ve cohort study of 187 consecutive patients undergoing RC at our institution-104 open RC , 83 robotic RC .  INTERVENTION Open or robotic RC with urinary diversion . MEASUREMENTS Demographic , perioperative , and complication data were recorded prospect ively . Thirty-day and 90-d complication rates were assessed using the modified Clavien complication scale . Data were evaluated using chi(2 ) and multivariate logistic regression analyses . RESULTS AND LIMITATIONS At 30 d , the open group demonstrated a higher overall complication rate ( 59 % vs 41 % ; p=0.04 ) as well as more major complications ( 30 % vs 10 % ; p=0.007 ) . At 90 d , the overall complication rate was greater in the open group , but this was not statistically significant ( 62 % vs 48 % ; p=0.07 ) . However , there was a significantly higher major complication rate in the open cohort ( 31 % vs 17 % ; p=0.03 ) . When subjected to logistic regression analysis , robotic cystectomy was an independent predictor of fewer overall and major complications at 30 and 90 d. High American Society of Anesthesiologists ( ASA ) score ( 3 - 4 ) and longer surgical time were independent predictors of major complications . Though this is one of the largest published RC series , the sample size is relatively small . Moreover , despite the two patient cohorts being similarly matched , the study was not performed in a r and omized fashion . CONCLUSIONS Patients undergoing robotic cystectomy  experienced fewer postoperative complications than those undergoing open cystectomy . Robotic cystectomy is an independent predictor of fewer overall and major complications . Until long-term oncologic results are available , robotic cystectomy should still be considered investigational OBJECTIVE To evaluate our initial robotic-assisted radical cystectomy ( RARC ) experience compared with a robust open radical cystectomy ( ORC ) series performed at a single institution using a matched-pair analysis . Although early results suggest that RARC is safe , with favorable perioperative and early oncologic outcomes , limited data exist comparing ORC and RARC . METHODS  RARC and ORC patients were identified through a prospect ively maintained institutional review board-approved bladder cancer data base . RARC and ORC cases performed from September 2007 to November 2010 were matched 1:2 by age , sex , urinary diversion , and clinical stage . The perioperative , complication , and pathologic outcomes were compared . RESULTS A total of 50 RARC and 100 ORC cases were review ed , with a median follow-up of 8 and 13.5 months , respectively . No differences in the demographic parameters were present between the 2 groups . RARC was associated with a significantly decreased median estimated blood loss ( 350 vs 475 mL ) and 30-day transfusion rate ( 2 % vs 24 % ) but with longer operative times ( 454.9 vs 349.1 minutes ) . No difference was found in the rate of 30-day minor or major Clavien complications , length of stay , or 30-day readmissions between groups . The 90-day mortality rate was 3 % versus 0 % for ORC and RARC , respectively . No difference in the final pathologic findings , number of lymph nodes removed , or margin status was identified . CONCLUSION Early experience with RARC compared with a robust ORC experience demonstrated similar perioperative and pathologic outcomes . Continued experience with RARC has the potential to bring improved perioperative results Given the lack of r and omized evidence comparing trimodal therapy ( TMT ) to radical cystectomy ( RC ) for muscle-invasive urothelial carcinoma of the bladder ( UCB ) , we performed an observational cohort study to examine the comparative effectiveness of these two definitive treatments . Within the National Cancer Data Base (2004 - 2011),we identified 1257 ( 9.8 % ) and 11 586 ( 90.2 % ) patients who received TMT and RC , respectively . Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier analysis showed that median overall survival ( OS ) was similar between the TMT ( 40 mo , 95 % confidence interval [ CI ] 34 - 46 ) and RC groups ( 43 mo 95 % CI 41 - 45 ; p=0.3 ) . In IPTW-adjusted Cox regression analysis with a time-varying covariate , TMT was associated with a significant adverse impact on long-term OS ( hazard ratio 1.37 , 95 % CI 1.16 - 1.59 ; p<0.001 ) . Interaction terms indicated that the adverse treatment effect of TMT versus RC decreased with age ( p=0.004 ) , while there was no significant interaction with gender ( p=0.6 ) , Charlson comorbidity index ( p=0.09 ) or cT stage ( p=0.8 ) . In conclusion , we found that TMT was generally associated with worse long-term OS compared to RC for muscle-invasive UCB . However , the survival benefit of RC should be weighed against the risks of surgery , especially in older patients . These results are preliminary and emphasize the need for a r and omized controlled trial to compare TMT versus RC . PATIENT SUMMARY We examined the comparative effectiveness of trimodal therapy versus radical cystectomy for muscle-invasive urothelial carcinoma of the bladder . We found that trimodal therapy was generally associated with worse long-term overall survival , although there may be no difference with radical cystectomy in older individuals Introduction Bladder cancer ( BC ) is a common malignancy and one of the most expensive to manage . Radical cystectomy ( RC ) with pelvic lymphadenectomy is a gold st and ard treatment for high-risk BC . Reductions in morbidity and mortality from RC may be achieved through robot-assisted RC ( RARC ) . Prospect i ve comparisons between open RC ( ORC ) and RARC have been limited by sample size , use of extracorporeal reconstruction and use of outcomes important for ORC . Conversely , while RARC is gaining in popularity , there is little evidence to suggest it is superior to ORC . We are undertaking a prospect i ve r and omised controlled trial ( RCT ) to compare RARC with intracorporeal reconstruction ( iRARC ) and ORC using multimodal outcomes to explore qualitative and quantitative recovery after surgery . Methods and analysis iROC is a multicentre prospect i ve RCT in English National Health Service ( NHS ) cancer centres . We will r and omise 320 patients undergoing RC to either iRARC or ORC . Treatment allocation will occur after trial entry and consent . The primary outcome is days alive and out of hospital within the first 90 days from surgery . Secondary outcomes will measure functional recovery ( activity trackers , chair-to-st and tests and health related quality of life ( HRQOL ) question naires ) , morbidity ( complications and readmissions ) , cost-effectiveness ( using EuroQol-5 Domain-5 levels ( EQ-5D-5L ) and unit costs ) and surgeon fatigue . Patients will be analysed according to intention to treat . The primary outcome will be transformed and analysed using regression . All statistical assumptions will be investigated . Secondary outcomes will be analysed using appropriate regression methods . An internal feasibility study of the first 30 patients will evaluate recruitment rates , acceptance of r and omised treatment choice , compliance outcome collection and to revise our sample size . Ethics and dissemination The study has ethical approval ( REC reference 16/NE/0418 ) . Findings will be made available to patients , clinicians , funders and the NHS through peer- review ed publications , social media and patient support groups . Trial registration numbers IS RCT N13680280 and NCT03049410 INTRODUCTION Treatment for muscle-invasive bladder cancer ( MIBC ) remains highly morbid despite improving surgical techniques . As the median age of diagnosis is 73 , many patients are elderly at the time of cystectomy . We compare perioperative surgical outcomes in elderly patients undergoing robotic vs open radical cystectomy ( RC ) .  MATERIAL S AND METHODS Patients > 75 years at time of RC were identified . Demographic , clinicopathologic , and perioperative variables were examined . Estimated blood loss ( EBL ) and length of stay ( LOS ) data were collected with multivariate linear regression analysis performed to assess whether technique was independently associated with outcomes . RESULTS Eighty-seven patients > 75 years of age underwent cystectomy for MIBC ( 58 open , 29 robotic ) . Mean age was 79.6 ( ±3.2 ) and 79.2 ( ±3.5 ) for open and robotic groups , respectively ( p = 0.64 ) . There were no significant differences in baseline comorbidities , clinical or pathologic stage , or use of neoadjuvant chemotherapy . The mean number of lymph nodes removed was similar ( p = 0.08 ) . Robotic cystectomy had significantly longer mean OR times ( p < 0.001 ) . On multivariate analyses , robotic surgery was associated with -389cc less EBL ( 95 % CI -547 to -230 , p < 0.001 ) and a -1.5-day-shortened LOS ( 95%CI -2.9 to -0.2 , p = 0.02 ) compared with open surgery . There were no significant differences in surgical complications or 90-day readmission rates between the two groups . CONCLUSIONS Robotic cystectomy  is safe and feasible in an elderly population . We observed longer OR times  with robotic surgery , but with decreased EBL , shorter hospital stays , and comparable complication and readmission rates  with open RC . Larger prospect i ve studies are required to confirm these findings PURPOSE Prior studies evaluating quality of care following  radical cystectomy  have been constrained by the use of retrospective review s of single institutional series and limited ability to examine risk factors in a comprehensive manner . Characterization of these factors could enhance preoperative patient counseling and facilitate perioperative management , thereby improving the quality of patient care . MATERIAL S AND METHODS The National Surgical Quality Improvement Project is a prospect i ve quality management initiative at 123 Veterans Affairs Medical Centers nationwide . The project collects preoperative clinical and intraoperative data , and outcomes on a wide variety of surgical procedures from multiple surgical disciplines . Since 1991 , 2,538 radical cystectomies have been captured by the National Surgical Quality Improvement Project . Modeling using logistic regression was performed to identify preoperative risk factors associated with mortality and prolonged length of stay ( greater than 90th percentile ) after radical cystectomy . RESULTS The 30 and 90-day mortality rates following cystectomy were 2.9 % and 6.8 % , respectively , and median hospital stay was 11 days ( 90th percentile 30 ) . Robust preoperative factors associated with mortality and prolonged length of stay that uniformly increased risk were older patient age ( OR 1.2 to 1.4 ) , American Society of Anesthesiologists class 3 or greater ( OR 1.5 to 3.3 ) , dependent functional status ( OR 1.7 to 2.0 ) and low serum albumin ( OR 2.1 to 12.0 ) . CONCLUSIONS A defined set of preoperative risk factors is independently associated with greater mortality and hospital stay following radical cystectomy . The breadth of these factors suggests that complex case mix adjustment is m and atory when comparing outcomes . Implementation of novel processes directed toward minimizing patient risk has the potential to improve outcomes following cystectomy BACKGROUND Reporting methodology is highly variable and nonst and ardized , yet surgical outcomes are utilized in clinical trial design and evaluation of healthcare provider performance . OBJECTIVE We sought to define the type , incidence , and severity of early postoperative morbidities following  radical cystectomy ( RC )  using a st and ardized reporting methodology . DESIGN , SETTING , AND PARTICIPANTS Between 1995 and 2005 , 1142 consecutive RCs were entered into a prospect i ve complication data base and retrospectively review ed for accuracy . All patients underwent RC/urinary diversion by high-volume fellowship-trained urologic oncologists . MEASUREMENTS All complications within 90 d of surgery were analyzed and grade d according to the Memorial Sloan-Kettering Cancer Center complication grading system . Complications were defined and stratified into 11 specific categories . Univariate and multivariate regression models were used to define predictors of complications . RESULTS AND LIMITATIONS Sixty-four percent ( 735/1142 ) of patients experienced a complication within 90 d of surgery . Among patients experiencing a complication , 67 % experienced a complication during the operative hospital admission and 58 % following discharge . Overall , the highest grade of complication was grade 0 in 36 % ( n=407 ) , grade 1 - 2 in 51 % ( n=582 ) , and grade 3 - 5 in 13 % ( n=153 ) . Gastrointestinal complications were most common ( 29 % ) , followed by infectious complications ( 25 % ) and wound-related complications ( 15 % ) . The 30-d mortality rate was 1.5 % . CONCLUSIONS Surgical morbidity following RC is significant and , when strict reporting guidelines are incorporated , higher than previously published . Accurate reporting of postoperative complications after RC is essential for counseling patients , combined modality treatment planning , clinical trial design , and assessment of surgical success PURPOSE  Morbidity after radical cystectomy  is common and associated with increased health care re source use . Accurate characterization of complications after cystectomy , associated patient specific risk factors , and perioperative processes of care are essential to directing changes in perioperative management that will reduce morbidity and improve the quality of patient care . MATERIAL S AND METHODS The National Surgical Quality Improvement Program ( NSQIP ) is a prospect i ve quality management initiative of 123 Veterans Affairs Medical Centers nationwide . The NSQIP collects clinical information , intraoperative data and outcomes on a wide variety of surgical procedures from multiple surgical disciplines . Since 1991 , 2,538 radical cystectomy procedures have been captured by the NSQIP . Modeling using logistic regression was performed to identify patient specific risk factors and perioperative process measures associated with postoperative morbidity . RESULTS Of the 2,538 subjects at least 1 postoperative complication developed in 774 ( 30.5 % ) . The most frequent complication was ileus ( 10 % ) . Several factors were associated with the development of a complication , including age , dependent functional status , preoperative dyspnea , preoperative acute renal failure , chronic steroid use , preoperative alcohol consumption , American Society of Anesthesiology score , use of general anesthetic , operative time , intraoperative blood requirement and surgeon level of training . CONCLUSIONS Morbidity remains high after cystectomy with 30.5 % of subjects experiencing at least 1 complication . Measurable patient specific risk factors and perioperative processes associated with postoperative morbidity following cystectomy are now delineated which allows for improved risk stratification , patient counseling , and the development of novel processes that may incrementally reduce risk and improve outcomes BACKGROUND This study aim ed to determine the clinical benefit of neoadjuvant methotrexate , doxorubicin , vinblastine , and cisplatin ( MVAC ) in patients with muscle-invasive bladder cancer ( MIBC ) treated with radical cystectomy . PATIENTS AND METHODS Patients with MIBC ( T2 - 4aN0M0 ) were r and omised to receive two cycles of neoadjuvant MVAC followed by radical cystectomy ( NAC arm ) or radical cystectomy alone ( RC arm ) . The primary end point was overall survival ( OS ) . Secondary end points were progression-free survival , surgery-related complications , adverse events during chemotherapy , proportion with no residual tumour in the cystectomy specimens , and quality of life . To detect an improvement in 5-year OS from 45 % in the RC arm to 57 % in the NAC arm with 80 % power , 176 events were required per arm . RESULTS Patients ( N = 130 ) were r and omly assigned to the RC arm ( N = 66 ) and the NAC arm ( N = 64 ) . The patient registration was terminated before reaching the initially planned number of patients because of slow accrual . At the second interim analysis just after the early stoppage of patient accrual , the Data and Safety Monitoring Committee recommended early publication of the results because the trial did not have enough power to draw a confirmatory conclusion . OS of the NAC arm was better than that of the RC arm , although the difference was not statistically significant [ hazard ratio 0.65 , multiplicity adjusted 99.99 % confidence interval 0.19 - 2.18 , one-sided P = 0.07 ] . In the NAC arm and the RC arm , 34 % and 9 % of the patients had pT0 , respectively ( P < 0.01 ) . In subgroup analyses , OS in almost all subgroups was in favour of NAC . CONCLUSIONS This trial showed a significantly increased pT0 proportion and favourable OS of patients who received neoadjuvant MVAC . NAC with MVAC can still be considered promising as a st and ard treatment . UMIN CLINICAL TRIALS REGISTRY IDENTIFIER C000000093 BACKGROUND Open radical cystectomy ( ORC ) and urinary diversion in patients with bladder cancer ( BCa ) are associated with significant perioperative complication risk . OBJECTIVE To compare perioperative complications between robot-assisted radical cystectomy ( RARC ) and ORC techniques . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve r and omized controlled trial was conducted during 2010 and 2013 in BCa patients scheduled for definitive treatment by radical cystectomy ( RC ) , pelvic lymph node dissection ( PLND ) , and urinary diversion . Patients were r and omized to ORC/PLND or RARC/PLND , both with open urinary diversion .  Patients were followed for 90 d postoperatively . INTERVENTION St and ard ORC or RARC with PLND ; all urinary diversions were performed via an open approach . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcomes were overall 90-d grade 2 - 5 complications defined by a modified Clavien system . Secondary outcomes included comparison of high- grade complications , estimated blood loss , operative time , pathologic outcomes , 3- and 6-mo patient-reported quality -of-life ( QOL ) outcomes , and total operative room and inpatient costs . Differences in binary outcomes were assessed with the chi-square test , with differences in continuous outcomes assessed by analysis of covariance with r and omization group as covariate and , for QOL end points , baseline score . RESULTS AND LIMITATIONS The trial enrolled 124 patients , of whom 118 were r and omized and underwent RC/PLND . Sixty were r and omized to RARC and 58 to ORC . At 90 d , grade 2 - 5 complications were observed in 62 % and 66 % of RARC and ORC patients , respectively ( 95 % confidence interval for difference , -21 % to -13 % ; p=0.7 ) . The similar rates of grade 2 - 5 complications at our m and ated interim analysis met futility criteria ; thus , early closure of the trial occurred . The RARC group had lower mean intraoperative blood loss ( p=0.027 ) but significantly longer operative time than the ORC group ( p<0.001 ) . Pathologic variables including positive surgical margins and lymph node yields were similar . Mean hospital stay was 8 d in both arms ( st and ard deviation , 3 and 5 d , respectively ; p=0.5 ) . Three- and 6-mo QOL outcomes were similar between arms . Cost analysis demonstrated an advantage to ORC compared with RARC . A limitation is the setting at a single high-volume , referral center ; our findings may not be generalizable to all setting s. CONCLUSIONS This trial failed to identify a large advantage for robot-assisted techniques over st and ard open surgery for patients undergoing RC/PLND and urinary diversion . Similar 90-d complication rates , hospital stay , pathologic outcomes , and 3- and 6-mo QOL outcomes were observed regardless of surgical technique . PATIENT SUMMARY Of 118 patients with bladder cancer who underwent radical cystectomy , pelvic lymph node dissection , and urinary diversion , half were r and omized to open surgery and half to robot-assisted laparoscopic surgery .  We compared the rate of complications within 90 d after surgery for the open group versus the robotic group and found no significant difference between the two groups . TRIAL REGISTRATION Clinical Trials.gov identifier NCT01076387 , www . clinical trials.gov PURPOSE  Radical cystectomy  remains associated with significant morbidity . Most series report outcomes with relatively short-term followup that may underestimate the true magnitude of the procedure and many report length of hospital stay but ignore readmission rates . We analyzed the predictors of early ( 30 days or less ) , late ( 31 to 90 days ) and cumulative 90-day hospital readmissions , as well as morbidity and mortality rates . MATERIAL S AND METHODS We review ed our prospect ively collected data base of 753 patients who underwent radical cystectomy for urothelial cancer between January 2001 and December 2007 . We examined the relationship between clinical variables and readmission rates during the early , late and 90-day postoperative period , and review ed mortality and perioperative morbidity rates . RESULTS There were 200 ( 26.6 % ) patients readmitted in the first 90 days following radical cystectomy . Of these patients 148 ( 19.7 % ) were readmitted early , 81 ( 10.8 % ) were readmitted late , and 29 ( 3.9 % ) had an early and late readmission . Logistical regression revealed gender ( OR 1.50 , 95 % CI 1.00 - 2.27 , p = 0.05 ) , age adjusted Charlson comorbidity index ( OR 1.19 , 95 % CI 1.06 - 1.34 , p = 0.003 ) and any postoperative complications before discharge home ( OR 1.84 , 95 % CI 1.19 - 2.83 , p = 0.006 ) as independent predictors of 90-day readmission . The 30 and 90-day mortality rates were 2.1 % ( 16 ) and 6.9 % ( 52 ) , respectively . CONCLUSIONS Readmission rates after radical cystectomy are significant , approaching 27 % within the first 90 days . Gender and age adjusted Charlson comorbidity index were independent predictors providing preoperative information identifying patients more likely to require readmission or possibly to benefit from a longer initial hospital stay Although radical cystectomy ( RC ) is considered as the st and ard therapy for muscle-invasive bladder cancer ( MIBC ) , trimodal therapy ( TMT ) combining transurethral resection of the tumor with radiotherapy and chemotherapy is increasingly recommended as an alternative approach for bladder preservation . In the absence of r and omized trials , we compared the clinical outcomes between RC and TMT using propensity score matching with 50 patients in the RC arm and 29 patients in the TMT arm . With respective median follow-up periods of 23 and 32 months for the RC and TMT groups , 5-year distant metastasis-free survival ( 58 % vs. 67 % ) , overall survival ( 56 % vs. 57 % ) , and cancer-specific survival ( 69 % vs. 63 % ) rates between the RC and TMT groups , respectively , were similar . However , the 5-year local recurrence-free survival was significantly better in the RC group than in the TMT group ( 74 % vs. 35 % ) . Following TMT , acute grade 3 hematological ( n = 2 ) and late grade 3 genitourinary ( n = 1 ) toxicities were reported . These findings demonstrated that oncological outcomes of TMT were comparable with those of RC , except for poorer local control . Large-scale , r and omized trials are warranted to confirm the findings of the present retrospective comparison and to guide toward best treatment options To test the feasibility of a r and omised trial in muscle‐invasive bladder cancer ( MIBC ) and compare outcomes in patients who receive neoadjuvant chemotherapy followed by radical cystectomy ( RC ) or selective bladder preservation ( SBP )  , where definitive treatment [ RC or radiotherapy ( RT ) ] is determined by response to chemotherapy OBJECTIVES Radical cystectomy ( RC ) is the st and ard treatment for muscle-invasive urothelial carcinoma of the bladder . Trimodality bladder-preserving therapy ( BPT ) is an alternative to RC , but r and omized comparisons of RC versus BPT have proven infeasible . To compare RC versus BPT , we undertook an observational cohort study using registry and administrative cl aims data from the Surveillance , Epidemiology and End Results -Medicare data base . METHODS We identified patients age 65 years or older diagnosed between 1995 and 2005 who received RC ( n = 1426 ) or BPT ( n = 417 ) . We examined confounding and stage misclassification in the comparison of RC and BPT by using multivariable adjustment , propensity score-based adjustment , instrumental variable ( IV ) analysis , and simulations . RESULTS Patients who received BPT were older and more likely to have comorbid disease . After propensity score adjustment , BPT was associated with an increased hazard of death from any cause ( hazard ratio [ HR ] 1.26 ; 95 % confidence interval [ CI ] 1.05 - 1.53 ) and from bladder cancer ( HR 1.31 ; 95 % CI 0.97 - 1.77 ) . Using the local area cystectomy rate as an instrument , IV analysis demonstrated no differences in survival between BPT and RC ( death from any cause HR 1.06 ; 95 % CI 0.78 - 1.31 ; death from bladder cancer HR 0.94 ; 95 % CI 0.55 - 1.18 ) . Simulation studies for stage misclassification yielded results consistent with the IV analysis . CONCLUSIONS Survival estimates in an observational cohort of patients who underwent  RC  versus  BPT  differ by analytic method . Multivariable and propensity score adjustment revealed greater mortality associated with BPT relative to RC , while IV analysis and simulation studies suggest that the two treatments are associated with similar survival outcomes BACKGROUND Despite recent improvements , radical cystectomy ( RC ) is still associated with adverse rates for 90-d mortality . OBJECTIVE To vali date the performance of the Isbarn nomogram incorporating age and postoperative tumor characteristics for predicting 90-d RC mortality in a multicenter series and to generate a new nomogram based strictly on preoperative parameters . DESIGN , SETTING , AND PARTICIPANTS Data of 679 bladder cancer ( BCa ) patients treated with RC at 18 institutions in 2011 were prospect ively collected , from which 597 patients were eligible for final analysis . INTERVENTION RC for BCa . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS An established prediction tool , the Isbarn nomogram , was applied to our cohort . For the purpose of external validation , model discrimination was measured using the receiver operating characteristics-derived area under the curve . Calibration plots examined the relationship between predicted and observed probabilities . Univariable and multivariable logistic regression models were fitted to assess the impact of preoperative characteristics on 90-d mortality . RESULTS AND LIMITATIONS The 30- , 60- , and 90-d mortality rates in the development cohort ( n=597 ) were 2.7 % , 6.7 % , and 9.0 % , respectively . The Isbarn nomogram predicted individual 90-d mortality with an accuracy of 68.6 % . Our preoperative multivariable model identified age ( odds ratio [OR]:1.052 ) , American Society of Anesthesiologists score ( OR : 2.274 ) , hospital volume ( OR : 0.982 ) , clinical ly lymphatic metastases ( OR : 4.111 ) , and clinical ly distant metastases ( OR : 7.788 ) ( all p<0.05 ) as independent predictors of 90-d mortality ( predictive accuracy : 78.8 % ) . Our conclusions are limited by the lack of an external validation of the preoperative model . CONCLUSIONS The Isbarn nomogram was vali date d with moderate discrimination . Our newly developed model consisting of preoperative characteristics might outperform existing models . Our model might be particularly suitable for preoperative patient counseling . PATIENT SUMMARY The current report vali date d an established nomogram predicting 90-d mortality in patients with bladder cancer after radical cystectomy ( RC ) .  We developed a new prediction tool consisting of strictly preoperative parameters , thus allowing clinicians an optimal consultation for RC c and i date BACKGROUND Retrospective studies demonstrated that cell cycle-related and proliferation biomarkers add information to st and ard pathologic tumor features after radical cystectomy ( RC ) . There are no prospect i ve studies validating the clinical utility of markers in bladder cancer . OBJECTIVE To prospect ively determine whether a panel of biomarkers could identify patients with urothelial carcinoma of the bladder ( UCB ) who were likely to experience disease recurrence or mortality . DESIGN , SETTING , AND PARTICIPANTS Between January 2007 and January 2012 , every patient with high- grade bladder cancer , including 216 patients treated with RC and lymphadenectomy  , underwent immunohistochemical staining for tumor protein p53 ( Tp53 ) ; cyclin-dependent kinase inhibitor 1A ( p21 , Cip1 ) ( CDKN1A ) ; cyclin-dependent kinase inhibitor 1B ( p27 , Kip1 ) ; antigen identified by monoclonal antibody Ki-67 ( MKI67 ) ; and cyclin E1 . INTERVENTION Every patient underwent RC and lymphadenectomy , and marker staining . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Cox regression analyses tested the ability of the number of altered biomarkers to predict recurrence or cancer-specific mortality ( CSM ) . RESULTS AND LIMITATIONS Pathologic stage among the study population was pT0 ( 5 % ) , pT1 ( 35 % ) , pT2 ( 19 % ) , pT3 ( 29 % ) , and pT4 ( 13 % ) ; lymphovascular invasion ( LVI ) was seen in 34 % . The median number of removed lymph nodes was 23 , and 60 patients had lymph node involvement ( LNI ) . Median follow-up was 20 mo . Expression of p53 , p21 , p27 , cyclin E1 , and Ki-67 were altered in 54 % , 26 % , 46 % , 15 % , and 75 % patients , respectively . In univariable analyses , pT stage , LNI , LVI , perioperative chemotherapy ( CTx ) , margin status , and number of altered biomarkers predicted disease recurrence . In a multivariable model adjusting for pathologic stage , margins , LNI , and adjuvant CTx , only LVI and number of altered biomarkers were independent predictors of recurrence and CSM . The concordance index of a baseline model predicting CSM ( including pathologic stage , margins , LVI , LNI , and adjuvant CTx ) was 80 % and improved to 83 % with addition of the number of altered markers . CONCLUSIONS Molecular markers improve the prediction of recurrence and CSM after RC . They may identify patients who might benefit from additional treatments and closer surveillance after cystectomy AIM In this study , we compared perioperative and oncologic outcomes of patients treated with either open or robot-assisted radical cystectomy and intracorporeal neobladder at a tertiary care center . METHODS The institutional prospect i ve bladder cancer data base was queried for " cystectomy with curative intent " and " neobladder " . All patients underwent robot-assisted radical cystectomy and intracorporeal neobladder or open radical cystectomy and orthotopic neobladder for high- grade non-muscle invasive bladder cancer or muscle invasive bladder cancer with a follow-up length ≥2 years were included . A 1:1 propensity score matching analysis was used . Kaplan-Meier method was performed to compare oncologic outcomes of selected cohorts . Survival rates were computed at 1,2,3 and 4 years after surgery and the log rank test was applied to assess statistical significance between the matched groups . RESULTS Overall , 363 patients ( 299 open and 64 robotic ) were included .  Open radical cystectomy patients were more frequently male ( p = 0.08 ) , with higher pT stages ( p = 0.003 ) , lower incidence of urothelial histologies ( p = 0.05 ) and lesser adoption of neoadjuvant chemotherapy ( < 0.001 ) . After applying the propensity score matching , 64 robot-assisted radical cystectomy patients were matched with 46 open radical cystectomy cases ( all p ≥ 0.22 ) . Open cohort showed a higher rate of perioperative overall complications ( 91.3 % vs 42.2 % , p 0.001 ) . At Kaplan-Meier analysis robotic and open cohorts displayed comparable disease-free survival ( log-rank p = 0.746 ) , cancer-specific survival ( p = 0.753 ) and overall-survival rates ( p = 0.909 ) . CONCLUSIONS Robot-assisted radical cystectomy and intracorporeal neobladder provides comparable oncologic outcomes of open radical cystectomy and orthotopic neobladder at intermediate term survival analysis OBJECTIVES To perform a complete cost analysis comparing  robot assisted radical cystectomy ( RARC ) versus open radical cystectomy ( ORC ) . MATERIAL AND METHODS After institutional review board approval for data collection , we prospect ively recorded perioperative outcomes and costs , such as hospital stay , transfusion rate , readmission rate , and medications for consecutive patients undergoing RARC or ORC .  Using actual cost data , we developed a cost decision tree model to determine typical perioperative costs for both RARC and ORC . Multivariate sensitivity analysis was performed to eluci date which variables had the greatest impact on overall cost . Breakeven points with ORC were calculated using our model to better evaluate variable influence . In addition to the above modeled analysis , actual patient costs , including complications 30 days from surgery , were also compared for each procedure . RESULTS Our model analysis showed that operative time and length of stay had the greatest impact on perioperative costs .  Robotic cystectomy became more expensive than open cystectomy at the following break-even points : operating room ( OR ) time greater than 361 minutes , length of stay greater than 6.6 days , or robotic OR supply cost exceeding $ 5853 . RARC was 16 % more expensive when only comparing direct operative costs . Interestingly , actual total patient costs revealed a 38 % cost advantage favoring RARC due to increased hospitalization costs for ORC in our cohort . CONCLUSIONS RARC can provide a cost-effective alternative to ORC with operative time and length of stay being the most critical cost determinants . Higher complication rates with ORC make total actual costs much higher than RARC © 2 0 1 0 T H E A U T H O R S J O U R N A L C O M P I L A T I O N © 2 0 1 0 B J U I N T E R N A T I O N A L 1 2 0 1 8 Faiz O , Brown T , Colucci G , Kennedy RH . A cohort study of results following  elective colonic resection  within an enhanced recovery programme . Colorectal Dis 2009 ; 11 : 366–72 9 Lassen K , Soop M , Nygren J et al. Consensus review of optimal perioperative care in colorectal surgery . Enhanced Recovery After Surgery ( ERAS ) Group Recommendations . Arch Surg 2009 ; 144 : 961–9 10 Halaszynski TM , Juda R , Silverman DG . Optimizing postoperative outcomes with efficient preoperative assessment and management . Crit Care Med 2004 ; 32 ( Suppl . ) : S76–86 11 Guenaga KF , Matos D , Castro AA , Atallah A , Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery . Cochrane Data base Syst Rev 2005 ; ( 1 ) : CDOO1544 12 Shafii M , Murphy DM , Donovan MG , Hickey DP . Is mechanical bowel preparation necessary in patients undergoing cystectomy and urinary diversion . BJU Int 2002 ; 89 : 879–81 13 Smith AF , Pittaway AJ . Premedication for anxiety in adult day surgery : up date of Cochrane Data base Syst Rev 2000 : CD002192 . Cochrane Data base Syst Rev 2003 ; ( 1 ) : CD002192 14 Gerts WH , Pineo GF , Heit JA et al. Prevention of venous thromboembolism : the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy . Chest 2004 ; 126 : 338S–400S 15 Fearon KC , Luff R. The nutritional management of surgical patients : enhanced recovery after surgery . Proc Nutr Soc 2003 ; 62 : 807–11 16 Noblett SE , Watson DS , Huong H , Davison B , Hainsworth PJ , Horgan AF . Pre-operative oral carbohydrate loading in colorectal surgery : a r and omized controlled trial . Colorectal Dis 2006 ; 8 : 563–9 17 Wong PF , Kumar S , Bohra A et al. R and omized clinical trial of perioperative systemic warming in major elective abdominal surgery . Br J Surg 2007 ; 94 : 421–6 18 Ratnaraj J , Kabon B , Talcoff MR , Sessler DI , Kurz A. Supplemental oxygen and carbon dioxide each increase subcutaneous and intestinal intramural oxygenation . Anesth Analg 2004 ; 99 : 207–11 19 Grief R , Akça O , Horn EP , Kurz A , Sessler DI . Supplemental perioperative oxygen to reduce the incidence of surgical wound infection . Outcomes Research Group . N Engl J Med 2000 ; 342 : 161–7 20 Grief R , Laciny S , Rapf B , Hickle RS , Sessler DI . Supplemental oxygen reduces the incidence of post operative nausea and vomiting . Anesthesiology 1999 ; 91 : 1246–52 21 HTA . Full report : systematic review of the clinical effectiveness and cost effectiveness of oesophageal Doppler monitoring in critically ill and high risk surgical patients . Available at : http:// www.hta.ac.uk/project/.asp . Accessed 5 December 2009 22 Cepeda MS , Carr DB , Mir and a N , Diaz A , Silva C , Morales O. Comparison of morphine , ketorolac , and their combination for postoperative pain : results from a large , r and omised , double blind trial . Anaesthesiology 2005 ; 103 : 1225–32 23 Arumainayagam N , McGrath J , Jefferson KP , Gillatt DA . Introduction of an enhanced recovery protocol for radical cystectomy . BJU Int 2008 ; 101 : 698–701 24 Pruthi RS , Chun J , Richman M. Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan . Urology 2003 ; 62 : 661–6 25 Chang SS , Baumgartner RG , Wells N et al. Causes of increased hospital stay after radical cystectomy in a clinical pathway setting . J Urol 2002 ; 167 : 208– Introduction : Open radical cystectomy ( ORC ) has been the st and ard treatment for muscle-invasive bladder cancer , but this is associated with significant morbidity and mortality . Robot-assisted radical cystectomy ( RARC ) has been proposed as minimally invasive alternative with improved morbidity and acceptable oncological outcomes , but a large series featuring RARC and their comparison with ORC is still lacking in India despite more than a decade of its inception . We have conducted this study with an objective to see the feasibility of RARC in the Indian context and compare it with contemporary st and ard . Methods : This is a prospect i ve cohort study conducted at two tertiary cancer institutes . We have evaluated the patients pertaining to operative and early post-operative factors from January 2014 to December 2015 . Necessary statistical tests applied to see comparability of the arms and their outcomes . Results : A total of 170 patients underwent surgery for carcinoma bladder ( 45 ORC while 125 RARC ) .  Intraoperative blood loss ( RARC and ORC : 228 and 529 ml ) and average transfusion rate were lower with RARC . A trend towards benefit was noted in favour of robotic arm in terms of mean complication rate  ( RARC and ORC : 54 and 39 % ) . Conclusions : The present study has shown comparable surgical and early post-operative outcomes with clear advantage of robotic approach in terms of intraoperative blood transfusion and lymph node yield . Although the study was non-r and omised in nature , it should provide substantial evidence on safety and feasibility of RARC in the Indian context and a reference point of evidence to look ahead BACKGROUND In recent years , surgeons have begun to report case series of minimally invasive approaches to radical cystectomy , including robotic-assisted techniques demonstrating the surgical feasibility of this procedure with the potential of lower blood loss and more rapid return of bowel function and hospital discharge . Despite these experiences and observations , at this point high levels of clinical evidence with regard to the benefits of robotic cystectomy are absent , and the current experiences represent case series with limited comparisons to historical controls at best . OBJECTIVE We report our results on a prospect i ve r and omized trial of open versus robotic-assisted laparoscopic radical cystectomy with regard to perioperative outcomes , complications , and short-term narcotic usage . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve r and omized single-center noninferiority study comparing open versus robotic approaches to cystectomy in patients who are c and i date s for radical cystectomy for urothelial carcinoma of the bladder . Of the 41 patients who underwent surgery , 21 were r and omized to the robotic approach and 20 to the open technique . INTERVENTION Radical cystectomy , bilateral pelvic lymphadenectomy , and urinary diversion by either an open approach or by a robotic-assisted laparoscopic technique . MEASUREMENTS The primary end point was lymph node ( LN ) yield with a noninferiority margin of four LNs . Secondary end points included demographic characteristics , perioperative outcomes , pathologic results , and short-term narcotic use . RESULTS AND LIMITATIONS On univariate analysis , no significant differences were found between the two groups with regard to age , sex , body mass index , American Society of Anesthesiologists classification , anticoagulation regimen of aspirin , clinical stage , or diversion type . Significant differences were noted in operating room time , estimated blood loss , time to flatus , time to bowel movement , and use of inpatient morphine sulfate equivalents . There was no significant difference in regard to overall complication rate or hospital stay . On surgical pathology , in the robotic group 14 patients had pT2 disease or higher ; 3 patients had pT3/T4 disease ; and 4 patients had node-positive disease . In the open group , eight patients had pT2 disease or higher ; five patients had pT3/T4 disease ; and seven patients had node-positive disease . The mean number of LNs removed was 19 in the robotic group versus18 in the open group . Potential study limitations include the limited clinical and oncologic follow-up and the relatively small and single-institution nature of the study . CONCLUSIONS We present the results of a prospect i ve r and omized controlled noninferiority study with a primary end point of LN yield , demonstrating the robotic approach to be noninferior to the open approach . The robotic approach also compares favorably with the open approach in several perioperative parameters Purpose Health related quality of life ( HRQoL ) is an important outcome in cancer care , although it is not well reported in surgical uro-oncology . Radical cystectomy ( RC ) with lymph-node dissection is the st and ard treatment of muscle-invasive bladder cancer and high-risk noninvasive bladder cancer . A wide range of impairments are reported postsurgery . The aims were to evaluate whether a st and ardized pre- and postoperative physical exercise program and enhanced mobilization can impact on HRQoL and inpatient satisfaction in RC , as defined by the European Organisation for Research and Treatment of Cancer ( EORTC ) . Material s and methods Patients were r and omized to fast-track RC and intervention ( nI=50 ) or fast-track st and ard treatment ( nS=57 ) .  HRQoL and inpatient satisfaction was measured using valid question naires : EORTC Quality of Life Question naire Core 30 ( QLQ-C30 ) combined with the disease-specific EORTC BLS24 ( baseline ) , and EORTC BLM30 ( follow-up ) , and IN-PATSAT32 inpatient-satisfaction survey at discharge . Efficacy was defined as the differences in HRQoL-scores between treatment groups at the 4-month follow-up . Results The intervention group significantly improved HRQoL scores in dyspnea ( P≤0.05 ) , constipation ( P<0.02 ) , and abdominal flatulence ( P≤0.05 ) compared to the st and ard group . In contrast , the st and ard group reported significantly reduced symptoms in sleeping pattern ( P≤0.04 ) and clinical ly relevant differences in role function , body function , and fatigue . The intervention did not compromise inpatient satisfaction . Conclusion We found no overall impact on global HRQoL due to a physical rehabilitation program . However , pre- and postoperative physical rehabilitation can significantly and positively impact on HRQoL aspects related to bowel management and respiratory function ( dyspnea ) without compromising inpatient satisfaction . These results highlight the role of multimodal rehabilitation , including physical exercises in fast-track RC BACKGROUND Radical cystectomy ( RC ) for bladder cancer is frequently associated with delayed gastrointestinal ( GI ) recovery that prolongs hospital length of stay ( LOS ) . OBJECTIVE To assess the efficacy of alvimopan to accelerate GI recovery after RC . DESIGN , SETTING , AND PARTICIPANTS We conducted a r and omized double-blind placebo-controlled trial in patients undergoing RC and receiving postoperative intravenous patient-controlled opioid analgesics .  INTERVENTION Oral alvimopan 12 mg ( maximum : 15 inpatient doses ) versus placebo . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The two-component primary end point was time to upper ( first tolerance of solid food ) and lower ( first bowel movement ) GI recovery ( GI-2 ) . Time to discharge order written , postoperative LOS , postoperative ileus (POI)-related morbidity , opioid consumption , and adverse events ( AEs ) were evaluated . An independent adjudication of cardiovascular AEs was performed . RESULTS AND LIMITATIONS Patients were r and omized to alvimopan ( n=143 ) or placebo ( n=137 ) ; 277 patients were included in the modified intention-to-treat population . The alvimopan cohort experienced quicker GI-2 recovery ( 5.5 vs 6.8 d ; hazard ratio : 1.8 ; p<0.0001 ) , shorter mean LOS ( 7.4 vs 10.1 d ; p=0.0051 ) , and fewer episodes of POI-related morbidity ( 8.4 % vs 29.1 % ; p<0.001 ) . The incidence of opioid consumption and AEs or serious AEs ( SAEs ) was comparable except for POI , which was lower in the alvimopan group ( AEs : 7 % vs 26 % ; SAEs : 5 % vs 20 % , respectively ) . Cardiovascular AEs occurred in 8.4 % ( alvimopan ) and 15.3 % ( placebo ) of patients ( p=0.09 ) . Generalizability may be limited due to the exclusion of epidural analgesia and the inclusion of mostly high-volume centers utilizing open laparotomy . CONCLUSIONS Alvimopan is a useful addition to a st and ardized care pathway in patients undergoing RC by accelerating GI recovery and shortening LOS , with a safety profile similar to placebo . PATIENT SUMMARY This study examined the effects of alvimopan on bowel recovery in patients undergoing radical cystectomy for bladder cancer . Patients receiving alvimopan experienced quicker bowel recovery and had a shorter hospital stay compared with those who received placebo , with comparable safety . TRIAL REGISTRATION Clinical Trials.gov identifier NCT00708201 BACKGROUND The optimal treatment strategy for muscle-invasive bladder cancer ( BCa ) remains controversial . OBJECTIVE Better define the long-term outcomes of radical cystectomy ( RC ) alone for BCa and determine the impact of pathologic downstaging after transurethral resection in a large and homogeneous single-center series . DESIGN , SETTING , AND PARTICIPANTS A cohort of 1100 patients undergoing RC with pelvic lymph node dissection ( PLND ) without neoadjuvant therapy for urothelial carcinoma of the bladder between January 1 , 1986 , and December 2009 was evaluated . Patients with other than metastases to the pelvic lymph nodes were excluded . Median age was 65 yr .  Clinical course , pathologic characteristics , and long-term outcomes were evaluated . Follow-up was obtained until December 2009 with a median of 38 mo and a completeness of 96.5 % . INTERVENTION RC with PLND ; urinary diversion with ileal neobladder whenever possible . MEASUREMENTS Primary end points were disease-specific survival ( DSS ) , recurrence-free survival ( RFS ) , and overall survival ( OS ) according to the tumor stage of the RC specimen versus the maximum tumor stage . The log-rank test was used to compare subgroups . RESULTS AND LIMITATIONS The 30-d ( 90-d ) mortality rate was 3.2 % ( 5.2 % ) . The 10-yr OS , DSS , and RFS rates were 44.3 % , 66.8 % , and 65.5 % , respectively . Based on the tumor stage of the RC specimen , the 10-yr DSS rate was pT0/a/is/1 pN0 : 90.5 % , pT2a/b pN0 : 66.8 % , pT3a/b pN0 : 59.7 % , pT4a/b pN0 : 36.6 % , and pTall pN+ : 16.7 % . Downstaging by transurethral resection of the prostate was observed in 382 patients . Patients with maximum tumor stage pT2a/b pN0 had distinctly better 10-yr DSS rates than those with pT2a/b pN0 in the RC specimen : pT2a pN0 : 92.2 % versus 73.8 % ; pT2b : 75.0 % versus 62.0 % . A total of 49 % female and 80 % male patients received an ileal neobladder . CONCLUSIONS This contemporary and homogeneous single-center series found acceptable OS , DFS , and RFS for patients undergoing RC . Pathologic downstaging had a significant impact on survival BACKGROUND Many phase 2 bladder-sparing programmes using transurethral resection of the bladder ( TURB ) plus chemotherapy or radio-chemotherapy have been undertaken , but some controversies remain . OBJECTIVE To determine the efficacy of complete TURB plus three cycles of cisplatin-based chemotherapy in selected patients with muscle-invasive bladder cancer ( MIBC ) . DESIGN , SETTING , AND PARTICIPANTS A phase 2 nonr and omized trial was design ed that included patients with MIBC who underwent complete TURB with positive biopsies of the tumour bed . Patients with negative biopsies of the tumour bed , with macroscopically residual tumour , with hydronephrosis , or with distant metastasis were excluded from this trial . Patients included in this trial were offered three cycles of systemic chemotherapy or radical cystectomy ( RC ) . Clinical response ( cR ) was denoted by either no tumour or the presence of Ta1-Tis bladder tumour at 3-mo evaluation ; clinical non-response ( cNR ) was denoted by cases of muscle-invasive tumour or distant metastasis . Of 146 patients who entered this trial , 75 choose the bladder-sparing programme and 71 chose RC . MEASUREMENTS At 5 yr and 10 yr , the cancer-specific survival ( CSS ) rate was 64.5 % and 59.8 % , respectively , with no significant difference compared to the RC arm ( p=0.544 ) . The progression-free survival with bladder preserved was 52.6 % and 34.5 % , respectively . In multivariate analysis , cR was the only predictive factor for survival ( p=0.001 ) and bladder preservation ( p=0.000 ) . RESULTS AND LIMITATIONS This was not a r and omized trial , and patients were included over 16 yr . However , no modifications were made to the therapy schedule except from chemotherapy schemes considered st and ard at the time . CONCLUSIONS Patients with microscopic residual cancer after complete TURB seem to be good c and i date s for the bladder-sparing programme using three cycles of systemic chemotherapy , with CSS comparable to RC PURPOSE Robotic assisted laparoscopic radical cystectomy for bladder cancer has been reported with potential for improvement in perioperative morbidity compared to the open approach . However , most studies are retrospective with significant selection bias . MATERIAL S AND METHODS A pilot prospect i ve r and omized trial evaluating perioperative outcomes and oncologic efficacy of open vs robotic assisted laparoscopic radical cystectomy for consecutive patients was performed from July 2009 to June 2011 . RESULTS To date 47 patients have been r and omized with data available on 40 patients for analysis . Each group was similar with regard to age , gender , race , body mass index and comorbidities , as well as previous surgeries , operative time , postoperative complications and final pathological stage . We observed no significant differences between oncologic outcomes of positive margins ( 5 % each , p = 0.50 ) or number of lymph nodes removed for open radical cystectomy ( 23 , IQR 15 - 28 ) vs robotic assisted laparoscopic radical cystectomy ( 11 , IQR 8.75 - 21.5 ) groups ( p = 0.135 ) . The robotic assisted laparoscopic radical cystectomy group ( 400 ml , IQR 300 - 762.5 ) was noted to have decreased estimated blood loss compared to the open radical cystectomy group ( 800 ml , IQR 400 - 1,100 ) and trended toward a decreased rate of excessive length of stay ( greater than 5 days ) ( 65 % vs 90 % , p = 0.11 ) compared to the open radical cystectomy group . The robotic group also trended toward fewer transfusions ( 40 % vs 50 % , p = 0.26 ) . CONCLUSIONS Our study vali date s the concept of r and omizing patients with bladder cancer undergoing radical cystectomy to an open or robotic approach . Our results suggest no significant differences in surrogates of oncologic efficacy . Robotic assisted laparoscopic radical cystectomy demonstrates potential benefits of decreased estimated blood loss and decreased hospital stay compared to open radical cystectomy . Our results need to be vali date d in a larger multicenter prospect i ve r and omized clinical trial INTRODUCTION Radical cystectomy is associated with significant morbidity , with rates of gastrointestinal complications as high as 30 % . Alvimopan is a mu opioid receptor antagonist that has been shown in r and omized control trials to accelerate gastrointestinal recovery in patients undergoing bowel resection with primary anastamosis . We report our experience with gastrointestinal recovery for patients undergoing cystectomy with urinary diversion treated with alvimopan .  MATERIAL S AND METHODS Between January 2008 and August 2011 , 50 consecutive patients underwent radical cystectomy with urinary diversion at our institution . The first 27 patients in our study did not receive alvimopan preoperatively . The latter 23 patients received perioperative alvimopan and were without postoperative nasogastric decompression .  Return of bowel function , initiation of diet , and gastrointestinal complications were evaluated . RESULTS Times to first flatus ( 3.1 versus 5.6 days , p < 0.001 , 95 % CI 1.66 - 3.26 ) and bowel movement ( 3.8 versus 6.0 days , p < 0.001 , 95 % CI 1.35 - 2.99 ) were significantly shorter in those patients who received alvimopan . Additionally , the initiation of clear liquid diet ( 4.1 versus 6.3 days , p < 0.001 , 95 % CI 1.20 - 3.12 ) , regular diet ( 5.7 versus 7.3 days , p = 0.023 , 95 % CI 0.57 - 2.63 ) and hospital discharge ( 7.4 versus 9.5 days , p = 0.04 , 95 % CI 0.03 - 4.21 ) were accelerated in the alvimopan cohort . There were no incidences of prolonged ileus in patients who received perioperative alvimopan ( 0 % versus 25.9 % , p = 0.012 ) . CONCLUSION In our experience , the use of alvimopan perioperatively significantly accelerates the rate of gastrointestinal recovery and hospital discharge , eliminates the need for nasogastric tube decompression , and reduces the incidence of postoperative ileus in patients following radical cystectomy and urinary diversion Progress is a hallmark of human civilization . Over the past centuries , it became easier , faster and safer to travel from point A to point B , and the choices of transportation are now numerous , making it at times challenging for travelers to make their selection and forcing them to buy guidebooks , research travel websites and sometimes even contact the travel agents . Perhaps sailing was once the only way of crossing the ocean , but with advent of aviation it is no longer the case . Similarly , upfront radical surgeries were once patients ’ only hope for cure radical mastectomy for patients with breast cancer , amputation for patients with extremity sarcoma ,  laryngectomy  for patients with laryngeal cancer , radical prostatectomy for patients with prostate cancer , abdominoperineal resection  for patients with anal carcinoma . However , over the past 40 years the field of oncology has embraced organ preservation , often , but not always , through r and omized clinical trials showing equivalent outcomes with smaller surgeries and adjuvant radiation therapy , or replacement of upfront surgery with definitive chemoradiation therapy , reserving organ extirpation for salvage in case of local recurrences . The management of muscle-invasive bladder cancer ( MIBC ) is no different ( 1 ) . Stating that one treatment – such as radical cystectomy – is the best choice for most patients with a particular disease – such as muscle-invasive bladder cancer – is no different from advertising a particular mode of transportation . One treatment never fits all , and the best choice of treatment modality for an individual patient starts with a multi-disciplinary evaluation and inclusion of patients and their caregivers in the decision process . An open discussion of all issues related to radical cystectomy ( RC ) and reconstruction options on one h and , and tri-modality bladder preservation therapy with chemoradiation ( TMT ) on the other h and allows for the ultimate informed consent and highest patient satisfaction . Most discussion s of bladder preservation for MIBC are centered on two themes – efficacy and toxicity BACKGROUND Open radical cystectomy ( ORC ) has proven to be an important component in the treatment of high-risk bladder cancer ( BCa ) . ORC surgical morbidity remains high ; therefore , minimally invasive surgical techniques have been introduced in an attempt to improve patient outcomes . OBJECTIVE To compare cancer outcomes in BCa patients managed with ORC or robotic-assisted radical cystectomy ( RARC ) .  DESIGN , SETTING , AND PARTICIPANTS A prospect i ve , r and omized trial was completed between 2010 and 2013 . Patients were r and omized to ORC/pelvic lymphadenectomy ( PLND ) or RARC/PLND , with all undergoing open/extracorporeal urinary diversion .  Median follow-up was 4.9 ( IQR : 3.9 - 5.9 ) yr after surgery among surviving patients . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Secondary outcomes to the trial included recurrence-free , cancer-specific , and overall survival . RESULTS AND LIMITATIONS The trial r and omized 118 patients who underwent RC/PLND and urinary diversion . Sixty were r and omized to RARC and 58 to ORC . Four RARC-assigned patients refused r and omization and received ORC ; however , an intention to treat analysis was performed . No differences were observed in recurrence ( hazard ratio [ HR ] : 1.27 ; 95 % confidence interval [ CI ] : 0.69 - 2.36 ; p=0.4 ) or cancer-specific survival ( p=0.4 ) . No difference in overall survival was observed ( p=0.8 ) . However , the pattern of first recurrence demonstrated a nonstatistically significant increase in metastatic sites for those undergoing ORC ( sub-HR [ sHR ] : 2.21 ; 95 % CI : 0.96 - 5.12 ; p=0.064 ) and a greater number of local/abdominal sites in the RARC-treated patients ( sHR : 0.34 ; 95 % CI : 0.12 - 0.93 ; p=0.035 ) . The major limitation to this study is that the trial was not powered to determine differences in cancer recurrences , survival outcomes , or patterns of recurrence . CONCLUSIONS The secondary outcomes from our r and omized trial did not definitively demonstrate differences in cancer outcomes in patients treated with  ORC  or RARC . However , differences in observed patterns of first recurrence highlight the need for future studies . PATIENT SUMMARY Of 118 patients r and omly assigned to undergo radical cystectomy/pelvic lymphadenectomy and urinary diversion , half were assigned to open surgery and half to robot-assisted techniques . We found no difference in risk of recurring or dying of bladder cancer between the two groups OBJECTIVE In Japan , no study has compared the perioperative outcomes observed between robot-assisted radical cystectomy ( RARC ) and open radical cystectomy ( ORC ) . This study aim ed at a prospect i ve comparison of the perioperative outcomes between RARC and ORC performed by a single surgeon . METHODS Between 2008 and 2011 , 26 bladder cancer patients underwent radical cystectomy by one surgeon , 11 robotically and 15 by open procedure .  We prospect ively collected perioperative and pathological data for these 26 patients , and retrospectively compared these two different surgical procedures . RESULTS The RARC cohort had a significant decrease in both estimated blood loss ( 656.9 vs. 1788.7 ml , P=0.0015 ) and allogeneic transfusion requirement ( 0 vs. 40 % , P=0.0237 ) . The total operative time was almost the same ( P=0.2306 ) but increased duration of bladder removal and lymphadenectomy was observed in the RARC cohort ( P=0.0049 ) . Surgery-related complication rates within 30 days were not significantly different ( P=0.4185 ) . Positive surgical margin was observed in three patients in the ORC cohort and in one patient in the RARC cohort ( P=0.4664 ) . The RARC cohort had a larger number of removed lymph nodes than the ORC cohort , and the difference was statistically significant ( 20.7 vs. 13.8 , P=0.0421 ) . CONCLUSIONS We confirmed that RARC is safe and yields acceptable outcomes in comparison with ORC for the treatment of bladder cancer if it is performed by a surgeon who has experience of over 60 cases of robot-assisted radical prostatectomy . It is hoped that RARC will gain acceptance in Japan as a minimally invasive surgery for muscle-invasive bladder cancer OBJECTIVE To evaluate the effect of the minimally invasive approach on spending and perioperative outcomes for patients undergoing radical cystectomy for bladder cancer . In a r and omized control trial conducted at high-volume centers , robotic , and open cystectomy were shown to have similar outcomes . However , because the majority of cystectomies are performed in low-volume centers , it is unknown whether these findings are broadly generalizable . MATERIAL S AND METHODS We identified Medicare patients who underwent radical cystectomy for bladder cancer between 2008 and 2015 . We examined the length of stay , readmission rate , and 90-day spending after minimally invasive or open cystectomy . We used multiple regressions to estimate the association between minimally invasive surgery and the outcomes , accounting for patient , hospital , and surgeon factors that may influence these outcomes . RESULTS Of 4760 patients , 693 ( 14.6 % ) underwent  minimally invasive cystectomy  and 4067 ( 85.4 % ) had an open approach . Minimally invasive cystectomy was associated with shorter length of stay ( 10.1 days vs 11.9 days , P < .001 ) , but no difference in readmission rate ( 27.4 % vs 26.8 % , P = .77 ) . Minimally invasive cystectomy was associated with lower adjusted 90-day episode spending ( $ 34,369 vs $ 38,071 , P < .001 ) . CONCLUSION In patients across diverse institutions in the United States , minimally invasive cystectomy was associated with a shorter length of stay than open cystectomy and reduced 90-day episode spending , but with no significant difference in readmission rate
Intraoperatively , a fluid and opioid sparing protocol may reduce fluid shifts and avoid complications from paralytic ileus .
Finally , enhanced recovery protocol s including novel medications , early feeding , and multi-modal analgesia approaches are associated with earlier postoperative convalescence .
CONCLUSION RC is a complex and morbid procedure that may benefit from care re design .
OBJECTIVE To present an evidence -based review of the perioperative management of the radical cystectomy ( RC ) patient in the context of a care re design initiative .