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To analyze the long-term effects of continent (neobladder) compared with incontinent (ileal conduit) urinary diversion.We carried out a retrospective review of our departmental database. Estimated glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. Neobladder and ileal conduit patients were matched in a 1:2 ratio and a propensity score-matched analysis was carried out. Data were summarized using descriptive analysis. Trend plots were generated using baseline and follow-up creatinine values to compare estimated glomerular filtration rate at 3 months, then annually for 5 years. Variables associated with estimated glomerular filtration rate were assessed using multivariate linear analysis.Our cohort consisted of 137 patients (neobladder n = 50 and ileal conduit n = 87) with a median follow-up time of 3 years (interquartile range 1-7 years). The ileal conduit group had shorter operative times (352 vs 444 min, P 0.01), intracorporeal diversions were more common (66% vs 44%, P = 0.01), had prior abdominal surgery (66% vs 38%, P 0.01) and had radiation (9% vs 0%, P = 0.03). The neobladder group more commonly had recurrent urinary tract infections (22% vs 3%, P 0.01) and a steeper decrease in estimated glomerular filtration rate in the first year. On multivariate linear analysis, age/year (-0.59), body mass index per kg/mIleal conduits and neobladders showed a similar effect on the estimated glomerular filtration rate up to 5 years after robot-assisted radical cystectomy. Recurrent urinary tract infections were associated with a worse estimated glomerular filtration rate.

To identify trends in complications following robot-assisted radical cystectomy (RARC) using a multi-institutional database, the International Robotic Cystectomy Consortium (IRCC).A retrospective review of the IRCC database was performed (2976 patients, 26 institutions from 11 countries). Postoperative complications were categorized as overall or high grade (≥ Clavien Dindo III) and were further categorized based on type/organ site. Descriptive statistics was used to summarize the data. Multivariate analysis (MVA) was used to identify variables associated with overall and high-grade complications. Cochran-Armitage trend test was used to describe the trend of complications over time.1777 (60%) patients developed postoperative complications following RARC, 51% of complications occurred within 30 days of RARC, 19% between 30-90 days, and 30% after 90 days. 835 patients (28%) experienced high-grade complications. Infectious complications (25%) were the most prevalent, while bleeding (1%) was the least. The incidence of complications was stable between 2002-2021. Gastrointestinal and neurologic postoperative complications increased significantly (P.01, for both) between 2005 and 2020 while thromboembolic (P = .03) and wound complications (P.01) decreased. On MVA, BMI (OR 1.03, 95%CI 1.01-1.05, P.01), prior abdominal surgery (OR 1.26, 95%CI 1.03-1.56, P = .03), receipt of neobladder (OR 1.52, 95%CI 1.17-1.99, P.01), positive nodal disease (OR 1.33, 95%CI 1.05-1.70, P = .02), length of inpatient stay (OR 1.04, 95%CI 1.02-1.05, P.01) and ICU admission (OR 1.67, 95%CI 1.36-2.06, P.01) were associated with high-grade complications.Overall and high-grade complications after RARC remained stable between 2002-2021. GI and neurologic complications increased, while thromboembolic and wound complications decreased.

INTRODUCTION AND OBJECTIVE:We investigated the outcomes of pT0 after robot-assisted radical cystectomy (RARC).METHODS:A retrospective review of the International Robotic Cystectomy Consortium datab...

To analyze the impact of neoadjuvant chemotherapy on survival and recurrence patterns in muscle-invasive bladder cancer after robot-assisted radical cystectomy.The International Robotic Cystectomy Consortium database was reviewed to identify patients who underwent robot-assisted radical cystectomy for muscle-invasive bladder cancer between 2002 and 2019. Survival outcomes, response rates, and recurrence patterns were compared between patients who received neoadjuvant chemotherapy and those who did not. Survival distributions were estimated using Kaplan-Meier analyses and compared using the log-rank test.A total of 1370 patients with muscle-invasive bladder cancer were identified, of whom 353 (26%) received neoadjuvant chemotherapy. After a median follow-up of 27 months, neoadjuvant chemotherapy recipients had higher 3-year overall survival (74% vs 57%; log-rank P 0.01), 3-year cancer-specific survival (83% vs 73%; log-rank P = 0.03), and 3-year relapse-free survival (64% vs 48%; log-rank P 0.01). Neoadjuvant chemotherapy was a predictor of higher overall survival, cancer-specific survival, and relapse-free survival in univariate but not multivariate analysis. Pathological downstaging (46% vs 23%; P 0.01), complete responses (24% vs 8%; P 0.01), and margin negativity (95% vs 91%; P 0.01) at robot-assisted radical cystectomy were more common in the neoadjuvant chemotherapy group. Neoadjuvant chemotherapy recipients had lower distant (15% vs 22%; P 0.01) but similar locoregional (12% vs 13%; P = 0.93) recurrence rates.In this analysis from a large international database, patients with muscle-invasive bladder cancer who received neoadjuvant chemotherapy before robot-assisted radical cystectomy had higher rates of survival, pathological downstaging, and margin-negative resections. They also experienced fewer distant recurrences.

A hierarchical structure is where all individuals are organized according to importance and are subordinate to a single person. In the operating room (OR), this structure may negatively impact the quality of communication and jeopardize patient safety. We examined how the surgical team's hierarchical relationships affect the frequency and timing of risk communication, and their influence on situational awareness (SA) in the OR.Overhead cameras and lapel microphones were used to record the OR environment. Recordings and transcriptions of 10 robot-assisted prostatectomies were examined for risk utterances among team members. Utterances were classified by sender-recipient exchange, timing (determined by phrasing to be proactive or reactive to an error/negative event), and the Oxford Non-Technical Skills (NOTECHS) SA score. Surgeon's and trainee surgeon's utterances were classified by their on-console status. Chi-square tests were used to determine associations between dependent factors, and ANOVAs were used to evaluate the effect of hierarchy and timing on NOTECHS score.Of 4,583 examined utterances, 329 (7%) were risk-related. There was no significant difference in utterance frequency based on hierarchical status of sender and recipient (p = 0.16). Utterances made by the surgeon or trainee surgeon had higher NOTECHS scores when off versus on the console (scores: 1.8 vs 2.4, p 0.01). These utterances were more reactive on the console (32%) and proactive off the console (28%). Proactive utterances had higher NOTECHS scores than reactive utterances (scores: 2.5 vs 1.8, p 0.01).The surgical hierarchy significantly impacted the frequency of risk communication within the OR. Timing and on-console status further influenced the efficacy of risk communication.

Defects in pharyngeal mechanical and neuromuscular control are required for the development of obstructive sleep apnea. Obesity and age are known sleep apnea risk factors, leading us to hypothesize that specific defects in upper airway neuromechanical control are associated with weight and age in a mouse model. In anesthetized, spontaneously breathing young and old wild-type C57BL/6J mice, genioglossus electromyographic activity (EMGGG) was monitored and upper airway pressure-flow dynamics were characterized during ramp decreases in nasal pressure (Pn, cmH2O). Specific body weights were targeted by controlling caloric intake. The passive critical pressure (Pcrit) was derived from pressure-flow relationships during expiration. The Pn threshold at which inspiratory flow limitation (IFL) developed and tonic and phasic EMGGG activity during IFL were quantified to assess the phasic modulation of pharyngeal patency. The passive Pcrit increased progressively with increasing body weight and increased more in the old than young mice. Tonic EMGGG decreased and phasic EMGGG increased significantly with obesity. During ramp decreases in Pn, IFL developed at a higher (less negative) Pn threshold in the obese than lean mice, although the frequency of IFL decreased with age and weight. The findings suggest that weight imposes mechanical loads on the upper airway that are greater in the old than young mice. The susceptibility to upper airway obstruction increases with age and weight as tonic neuromuscular activity falls. IFL can elicit phasic responses in normal mice that mitigate or eliminate the obstruction altogether.

Obesity is associated with alterations in upper airway collapsibility during sleep. Obese, leptin-deficient mice demonstrate blunted ventilatory control, leading us to hypothesize that ( 1) obesity and leptin deficiency would predispose to worsening neuromechanical upper airway function and that ( 2) leptin replacement would acutely reverse neuromuscular defects in the absence of weight loss. In age-matched, anesthetized, spontaneously breathing C57BL/6J (BL6) and ob− /ob− mice, we characterized upper airway pressure-flow dynamics during ramp decreases in nasal pressure (PN) to determine the passive expiratory critical pressure (PCRIT) and active responses to reductions in PN, including the percentage of ramps showing inspiratory flow limitation (IFL; frequency), the PN threshold at which IFL developed, maximum inspiratory airflow (Vimax), and genioglossus electromyographic (EMGGG) activity. Elevations in body weight were associated with progressive elevations in PCRIT (0.1 ± 0.02 cmH2O/g), independent of mouse strain. PCRIT was also elevated in ob− /ob− compared with BL6 mice (1.6 ± 0.1 cmH2O), independent of weight. Both obesity and leptin deficiency were associated with significantly higher IFL frequency and PN threshold and lower Vimax. Very obese ob− /ob− mice treated with leptin compared with nontreated mice showed a decrease in IFL frequency (from 63.5 ± 2.9 to 30.0 ± 8.6%) and PN threshold (from −0.8 ± 1.1 to −5.6 ± 0.8 cmH2O) and increase in Vimax (from 354.1 ± 25.3 to 659.0 ± 71.8 μl/s). Nevertheless, passive PCRIT in leptin-treated mice did not differ significantly from that seen in nontreated ob− /ob− mice. The findings suggest that weight and leptin deficiency produced defects in upper airway neuromechanical control and that leptin reversed defects in active neuromuscular responses acutely without reducing mechanical loads.