Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. Clinical and patient‐reported outcomes of SPARE – a randomised feasibility study of selective bladder preservation versus radical cystectomy Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Robot-assisted radical cystectomy with intracorporeal urinary diversion versus open radical cystectomy (iROC): protocol for a randomised controlled trial with internal feasibility study 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. Perioperative outcomes of minimally invasive versus open radical cystectomy: A single-center experience 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. Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial. Identifying risk factors for potentially avoidable complications following radical cystectomy. A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer A comparison of postoperative complications in open versus robotic cystectomy. Prospective, Randomized Clinical Trial Comparing use of Intraoperative Transesophageal Echocardiography to Standard Care during Radical Cystectomy Morbidity and Mortality Outcomes of Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy at a Single Tertiary Institution: Towards a New Perspective of This Treatment 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. Preliminary Comparative Effectiveness of Robotic Versus Open Radical Cystectomy in Elderly Patients.
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 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 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 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 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 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 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 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  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 Objective : A prospect i ve r and omized controlled trial ( RCT ) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer . Aims : This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT . Methods : Patients for elective resection for colorectal cancer were offered trial entry . Participants were stratified by sex and requirement for a total mesorectal excision and central ly r and omized .  Multimodal patients received intravenous fluid restriction , unrestricted oral intake with prokinetic agents , early ambulation , and fixed regimen epidural analgesia . Control patients received intravenous fluids to prevent oliguria , restricted oral intake until return of bowel motility , and weaning regimen epidural analgesia . Adherence to both regimens was reinforced using a daily checklist and protocol guidance sheets . Discharge decision was made using preagreed criteria . The primary endpoint was postoperative stay , and achievement of independence milestones . Secondary endpoints were postoperative complications , readmission rates , and mortality . Analysis was by intention to treat . Results : Seventy patients were recruited . Approximately one fourth underwent TME . Median ages were similar ( 69.3 vs. 73.0 years ) . The median stay was significantly reduced in the multimodal group ( 5 vs. 7 days ; P < 0.001 , Mann-Whitney U test ) . Patients in the control arm were 2.5 times as likely to require a postoperative stay of more than 5 days . Patients in the multimodal group had less cardiorespiratory and anastomotic complications but more readmissions . There were 2 deaths , both controls . Conclusions : This RCT provides level 1b evidence that a multimodal management protocol can significantly reduce postoperative stay following colorectal cancer surgery . Morbidity and mortality are not increased 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 Purpose : Our prospect i ve , r and omized clinical study aims to evaluate the utility of intraoperative transesophageal echocardiography ( TEE ) in patients undergoing radical cystectomy . Material s and Methods : Eighty patients were r and omized to a st and ard of care group or the intervention group that received continuous intraoperative TEE .  Data are presented as means ± st and ard deviations , median ( 25th percentile , 75th percentile ) , or numbers and percentages . Characteristics were compared between groups using independent sample t-tests , Wilcoxon – Mann – Whitney tests or Chi-square tests , as appropriate . All tests were two-sided and P < 0.05 was considered to indicate statistical significance . Results : Both groups had similar preoperative demographic characteristics . There was a significant difference between central line insertion with all insertions in the control group ( 15 % , 6 vs. 0 % , 0 ; P < 0.003 ) . Of all the perioperative complications , 80 % occurred in the control group versus 20 % in the TEE group , with 21 % of controls experiencing a cardiac or pulmonary complication compared to 5 % in the TEE group ( 8 vs. 2 , P < 0.04 ) . The control group patients were more likely to have adverse cardiac complications than the TEE group ( 15 % , 6 vs. 3 % , 1 ; P < 0.040 ) . Postoperative cardiac arrhythmia was observed only in the control group ( 13 % , 5 vs. 0 % , 0 ; P < .007 ) . Prolonged intubation was only observed in the control group ( 10 % , 4 vs. 0 % , 0 ; P < 0.017 ) . Conclusion : TEE can be a useful monitoring tool in patients undergoing radical cystectomy , limiting the use of central line insertion and potentially translating into earlier extubation and decreased postoperative cardiac morbidities Introduction : Cytoreductive surgery ( CRS ) combined with perioperative intraperitoneal chemotherapy ( PIC ) is a treatment option for peritoneal surface malignancy . Despite the survival benefits , this treatment was previously associated with a high morbidity and mortality rates and the perception of the poor perioperative outcomes associated with this regimen remains . The aim of this study was to report the perioperative outcomes of  CRS and PIC from a single institution to review factors that are associated with a poor perioperative outcome . Methods : The clinical - and treatment-related data of 243 consecutive procedures performed were prospect ively collected and retrospectively review ed . Adverse events were rated according to the National Cancer Institute 's Common Toxicity Criteria ( grade I – V ) . Univariate and multivariate analyses were performed to identify significant clinical and treatment-related factors for a poor perioperative outcome ( grade s III/IV/V morbidity ) . Results : The perioperative mortality rate was 3 % . The rate of severe morbidity was 43 % . Multivariate analysis demonstrated that left upper quadrant peritonectomy ( P < 0.001 ) and small bowel resection ( P < 0.01 ) were factors that predicted for a poor perioperative outcome . Conclusions : The morbidity and mortality rates of CRS and PIC are within an acceptable range for a major gastrointestinal surgery which is performed with a curative intent . Patient selection is important in ensuring that suitable patients receive this treatment . A new perspective of this treatment needs to be sought 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 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
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 .