Morbidity and mortality after robot-assisted radical cystectomy with intracorporeal urinary diversion in octogenarians: results from the European Association of Urology Robotic Urology Section Scientific Working Group

OBJECTIVES: To evaluate the postoperative complication and mortality rate following laparoscopic radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in octogenarians. PATIENTS AND METHODS: We conducted a retrospective analysis comparing postoperative complication and mortality rates depending on age in a consecutive series of 1890 patients who underwent RARC with ICUD for bladder cancer between 2004 and 2018 in 10 European centres. Outcomes of patients aged <80 years and those aged ≥80 years were compared with regard to postoperative complications (Clavien–Dindo grading) and mortality rate. Cancer-specific mortality (CSM) and other-cause mortality (OCM) after surgery were calculated using the non-parametric Aalen-Johansen estimator. RESULTS: A total of 1726 patients aged <80 years and 164 aged ≥80 years were included in the analysis. The 30- and 90-day rate for high-grade (Clavien–Dindo grades III–V) complications were 15% and 21% for patients aged <80 years compared to 11% and 13% for patients aged ≥80 years (P = 0.2 and P = 0.03), respectively. In a multivariable logistic regression analysis adjusting for pre- and postoperative variables, age ≥80 years was not an independent predictor of high-grade complications (odds ratio 0.6, 95% confidence interval 0.3–1.1; P = 0.12). The non-cancer-related 90-day mortality was 2.3% for patients aged ≥80 years and 1.8% for those aged <80 years, respectively (P = 0.7). The estimated 12-month CSM and OCM rates for those aged <80 years were 8% and 3%, and for those aged ≥80 years, 15% and 8%, respectively (P = 0.009 and P < 0.001). CONCLUSIONS: The minimally invasive approach to RARC with ICUD for bladder cancer in well-selected elderly patients (aged ≥80 years) achieved a tolerable high-grade complication rate; the 90-day postoperative mortality rate was driven by cancer progression and the non-cancer-related rate was equivalent to that of patients aged <80 years. However, an increased OCM rate in this elderly group after the first year should be taken into account. These results will support clinicians and patients when balancing cancer-related vs treatment-related risks and benefits

Oncological outcomes of totally intracorporeal robot-assisted radical cystectomy: results from the ERUS scientific working group

ABSTRACT: INTRODUCTION AND OBJECTIVES Data on the oncological outcomes in patients undergoing robot-assisted radical cystectomy (RARC) is limited. Globally extracorporeal urinary diversion following RARC remains the most common approach despite potential advantages of a completely minimally invasive approach. We report oncological outcomes and associated prognostic factors from a multi-institutional European database focusing on the centres performing totally intracorporeal RARC. METHODS In the ERUS scientific working group database, 467 patients underwent totally intracorporeal RARC for bladder cancer between 2003 and 2014. Clinical and pathological data at the time of the latest follow-up was reviewed. Recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS) were the outcomes of interest and evaluated using the Kaplan Meier estimator. Multivariable Cox regression analysis was performed to identify factors associated with outcomes of interest. RESULTS Mean age was 67 years, 80% were men. 384 (82%) patients were alive at the time of the analysis. Median follow-up was 17.9 months (range 1-130 months). 87 patients (19%) had undergone surgery 3 or more years' ago. Median follow-up of patients alive was 16 months. 31% patients had pathological non organ-confined disease. Positive surgical margins were present in 5%; median lymph node yield was 18 with 19% of patients having positive lymph nodes. The 3-year RFS, CSS and OS were 73%, 75% and 73% respectively. On multivariable analysis, non-organ confined disease was found to impact RFS, CSS and OS (HR 4.0, 4.3 and 4.2 respectively) and LN positive disease was associated with poorer RFS (HR 2.1). Histopathology stage pT0 was a positive prognostic indicator associated with better RFS, CSS and OS (HR 0.15, 0.16 and 0.74 respectively). CONCLUSIONS This is the largest reported multi-institutional cohort of totally intracorporeal RARC showing acceptable medium term survival outcomes comparable to open radical cystectomy series. The ERUS scientific working group database indicates that a totally intracorporeal approach is replicable

Loss of endocytic clathrin-coated pits upon acute depletion of phosphatidylinositol 4,5-bisphosphate

Phosphatidylinositol 4,5-bisphosphate [PI(4,5)P(2)], a phosphoinositide concentrated predominantly in the plasma membrane, binds endocytic clathrin adaptors, many of their accessory factors, and a variety of actin-regulatory proteins. Here we have used fluorescent fusion proteins and total internal reflection fluorescence microscopy to investigate the effect of acute PI(4,5)P(2) breakdown on the dynamics of endocytic clathrin-coated pit components and of the actin regulatory complex, Arp2/3. PI(4,5)P(2) breakdown was achieved by the inducible recruitment to the plasma membrane of an inositol 5-phosphatase module through the rapamycin/FRB/FKBP system or by treatment with ionomycin. PI(4,5)P(2) depletion resulted in a dramatic loss of clathrin puncta, which correlated with a massive dissociation of endocytic adaptors from the plasma membrane. Remaining clathrin spots at the cell surface had only weak fluorescence and were static over time. Dynamin and the p20 subunit of the Arp2/3 actin regulatory complex, which were concentrated at late-stage clathrin-coated pits and in lamellipodia, also dissociated from the plasma membrane, and these changes correlated with an arrest of motility at the cell edge. These findings demonstrate the critical importance of PI(4,5)P(2) in clathrin coat dynamics and Arp2/3-dependent actin regulation

Privatization of Public Services in Leipzig: A Balancing Act between Efficiency and Legitimacy

Privatization, City finances, Municipal services, Efficiency and legitimacy in public services,

Robot-assisted Radical Cystectomy with Orthotopic Neobladder Reconstruction: Techniques and Functional Outcomes in Males

Background: Little is known regarding functional outcomes after robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction. Objective: To report on urinary continence (UC) and erectile function (EF) at 12 mo after RARC and ICNB reconstruction and investigate predictors of these outcomes. Design, setting, and participants: We used data from a multi-institutional database of patients who underwent RARC and ICNB reconstruction for bladder cancer. Surgical procedure: The cystoprostatectomy sensu stricto followed the conventional steps. ICNB reconstruction was performed at the physician's discretion according to the Studer/Wiklund, S pouch, Gaston, vescica ileale Padovana, or Hautmann technique. The techniques are detailed in the video accompanying the article. Measurements: The outcomes measured were UC and EF at 12 mo. Results and limitations: A total of 732 male patients were identified with a median age at diagnosis of 64 yr (interquartile range 58-70). The ICNB reconstruction technique was Studer/Wiklund in 74%, S pouch in 1.5%, Gaston in 19%, vescica ileale Padovana in 1.5%, and Hautmann in 4% of cases. The 12-mo UC rate was 86% for daytime and 66% for nighttime continence, including patients who reported the use of a safety pad (20% and 32%, respectively). The 12-mo EF rate was 55%, including men who reported potency with the aid of phosphodiesterase type 5 inhibitors (24%). After adjusting for potential confounders, neobladder type was not associated with UC. Unilateral nerve-sparing (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.88-7.85; p&nbsp;&lt;&nbsp;0.001) and bilateral nerve-sparing (OR 6.25, 95% CI 3.55-11.0; p&nbsp;&lt;&nbsp;0.001), were positively associated with EF, whereas age (OR 0.93, 95% CI 0.91-0.95; p&nbsp;&lt;&nbsp;0.001) and an American Society of Anesthesiologists score of 3 (OR 0.46, 95% CI 0.25-0.89; p&nbsp;&lt;&nbsp;0.02) were inversely associated with EF. Conclusions: RARC and ICNB reconstruction are generally associated with good functional outcomes in terms of UC. EF is highly affected by the degree of nerve preservation, age, and comorbidities. Patient summary: We investigated functional outcomes after robot-assisted removal of the bladder in terms of urinary continence and erectile function. We found that, in general, patients have relatively good functional outcomes at 12 months after surgery

How can we reduce morbidity after robot‐assisted radical cystectomy with intracorporeal neobladder? A report on postoperative complications by the European Association of Urology Robotic Urology Section Scientific Working Group

robotic neobladde

Anterior vertebral body replacement with a titanium implant of adjustable height: a prospective clinical study

In the operative treatment of spinal injuries, the reconstruction of the anterior column of the thoracolumbar spine is still controversial. We conducted a prospective clinical study to investigate the clinical and radiological outcome of 50 patients treated with a vertebral body replacement of adjustable height (Synex™). Fifty consecutive patients were evaluated during in-patient treatment and at 12 and 20 months post-operatively in clinical notes and radiographs. 38/50 patients were operated for traumatic fractures. Out of 50 patients 45 attended the follow-up clinic 1 year post-operatively and 39 of these patients were examined after 20 months. Twenty-five patients returned to pre-injury activities within 1 year. This number increased to 29/39 patients at 20 months. Seventy-three percent of the patients returned to their job. After 1 year 25/45 patients complained of little or no back pain and 6 months later six patients were limited in their back function. At 1 year only three patients complained of surgical site pain which was improved at their final follow-up at 20 months. Individual satisfaction was determined using a score on a visual analog scale containing 19 questions on back pain, and functional limitation of the spine that has to be filled in by the patients at three different points of time. The score decreased from 87/100 pre-operatively to 65/100 at 1 year follow-up (P<0.001). The average permanent correction of the injured vertebra was 16.8° (88%) including 2.3° (12%) loss of correction at 12 months after operation. Bony integration was obtained in 83%. Early and intermediate outcome with the Synex™ vertebral replacement device for reconstruction of the anterior column appears promising. The loss of correction or reduction was only minimal. On the basis of our results we recommend the Synex™ implant as an alternative for the fixation and stabilisation of thoracolumbar fractures. However, long-term results and a clinically random control study are still required