Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

Purpose:While the presence of residual disease at the time of radical cystectomy for bladder cancer is an established prognostic indicator, controversy remains regarding the importance of maximal transurethral resection prior to neoadjuvant chemotherapy. We characterized the influence of maximal transurethral resection on pathological and survival outcomes using a large, multi-institutional cohort.Materials and Methods:We identified 785 patients from a multi-institutional cohort undergoing radical cystectomy for muscle-invasive bladder cancer after neoadjuvant chemotherapy. We employed bivariate comparisons and stratified multivariable models to quantify the effect of maximal transurethral resection on pathological findings at cystectomy and survival.Results:Of 785 patients, 579 (74%) underwent maximal transurethral resection. Incomplete transurethral resection was more frequent in patients with more advanced clinical tumor (cT) and nodal (cN) stage (P < .001 and P < .01, respectively), with more advanced ypT stage at cystectomy and higher rates of positive surgical margins (P < .01 and P < .05, respectively). In multivariable models, maximal transurethral resection was associated with downstaging at cystectomy (adjusted odds ratio 1.6, 95% CI 1.1-2.5). In Cox proportional hazards analysis, maximal transurethral resection was not associated with overall survival (adjusted HR 0.8, 95% CI 0.6-1.1).Conclusions:In patients undergoing transurethral resection for muscle-invasive bladder cancer prior to neoadjuvant chemotherapy, maximal resection may improve pathological response at cystectomy. However, the ultimate effects on long-term survival and oncologic outcomes warrant further investigation.

Background: Robotic-assisted surgery (RAS) has been rapidlyadopted in urology, especially in the United States. Although lessprevalent in Canada, RAS is a growing and controversial field that has implications for resident training. We report on the status and perception of RAS among Canadian urology residents.Methods: All Canadian urology residents from anglophone programs were contacted by email and asked to participate in anonline survey. Current resident exposure to, and perception of,RAS was assessed.Results: Of the residents contacted (n = 128), 50 (39%) completed the survey. Of the respondents, 52% have been involved in RAS. Those who have not been involved in RAS express lower interest and lesser knowledge of RAS. Ninety-two percent of respondents feel the use of RAS will increase, although only 29% feel this is feasible in Canada. Just 24% and 36% feel RAS to be superior to open and laparoscopic techniques, respectively. Sixty-eight percent of residents in programs with a robot viewed it as detrimental to training, whereas 81% of residents in programs without one viewedits absence to either have no impact, or even be beneficial. Bothgroups expressed a desire for more experience with RAS.Conclusion: The resident experience with respect to RAS is mixed. Overall, residents view RAS as an expanding field with potentially negative impacts on their present training, although they appear to desire the acquisition of more experience in RAS. We plan to monitor the evolution of these perceptions over next four years.

No abstract

No abstract