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Perioperative complications of conduit urinary diversion with concomitant cystectomy for benign indications: A population-based analysis.
Brown ET, Osborn D, Mock S, Ni S, Graves AJ, Milam L, Milam D, Kaufman MR, Dmochowski RR, Reynolds WS
(2017) Neurourol Urodyn 36: 1411-1416
MeSH Terms: Adolescent, Adult, Aged, Aged, 80 and over, Cystectomy, Female, Humans, Lower Urinary Tract Symptoms, Male, Middle Aged, Postoperative Complications, Preoperative Care, Urinary Diversion, Young Adult
Show Abstract · Added September 16, 2019
AIMS - Beyond single-institution case series, limited data are available to describe risks of performing a concurrent cystectomy at the time of urinary diversion for benign end-stage lower urinary tract dysfunction. Using a population-representative sample, this study aimed to analyze factors associated with perioperative complications in patients undergoing urinary diversion with or without cystectomy.
METHODS - A representative sample of patients undergoing urinary diversion for benign indications was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Perioperative complications of urinary diversion with and without concomitant cystectomy were identified and coded using the International Classification of Diseases, version 9. Multivariate logistic regression models identified hospital and patient-level characteristics associated with complications of concomitant cystectomy with urinary diversion.
RESULTS - There were 15,717 records for urinary diversion identified, of which 31.8% demonstrated perioperative complications: urinary diversion with concurrent cystectomy (35.0%) and urinary diversion without concomitant cystectomy (30.6%). Comparing the two groups, a concomitant cystectomy at the time of urinary diversion was significantly associated with a complication (OR = 1.23, 95%CI: 1.03-1.48). Comorbid conditions of obesity, pulmonary circulation disease, drug abuse, weight loss, and electrolyte disorders were positively associated with a complication, while private insurance and southern geographic region were negatively associated.
CONCLUSIONS - A concomitant cystectomy with urinary diversion for refractory lower urinary tract dysfunction elevates risk in this population-representative sample, particularly in those with certain comorbid conditions. This analysis provides critical information for preoperative patient counseling.
© 2016 Wiley Periodicals, Inc.
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MeSH Terms
Temporal Trends in Conduit Urinary Diversion With Concomitant Cystectomy for Benign Indications: A Population-based Analysis.
Brown ET, Osborn D, Mock S, Ni S, Graves AJ, Milam L, Milam D, Kaufman MR, Dmochowski RR, Reynolds WS
(2016) Urology 98: 70-74
MeSH Terms: Adolescent, Adult, Aged, Aged, 80 and over, Clinical Decision-Making, Cystectomy, Female, Humans, Male, Middle Aged, Population Surveillance, United States, Urinary Bladder Diseases, Urinary Diversion, Young Adult
Show Abstract · Added September 16, 2019
OBJECTIVE - To describe national trends in cystectomy at the time of urinary diversion for benign indications. Multiple practice patterns exist regarding the necessity for concomitant cystectomy with urinary diversion for benign end-stage lower urinary tract dysfunction. Beyond single-institution reports, limited data are available to describe how concurrent cystectomy is employed on a national level.
MATERIALS AND METHODS - A representative sample of patients undergoing urinary diversion for benign indications with or without concurrent cystectomy was identified from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2011. Using multivariate logistic regression models, we identified hospital- and patient-level characteristics associated with concomitant cystectomy with urinary diversion.
RESULTS - There was an increase in the proportion of concomitant cystectomy at the time of urinary diversion from 20% to 35% (P < .001) between 1998 and 2011. The increase in simultaneous cystectomy over time occurred at teaching hospitals (vs community hospitals), in older patients, in male patients, in the Medicare population (vs private insurance and Medicaid), and in those with certain diagnoses.
CONCLUSION - There has been an overall increase in the use of cystectomy at the time of urinary diversion for benign indications on a national level, although the indications driving this clinical decision appear inconsistent.
Copyright © 2016 Elsevier Inc. All rights reserved.
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Cystectomy with urinary diversion for benign disease: indications and outcomes.
Osborn DJ, Dmochowski RR, Kaufman MR, Milam DF, Mock S, Reynolds WS
(2014) Urology 83: 1433-7
MeSH Terms: Adult, Age Distribution, Aged, Blood Loss, Surgical, Cohort Studies, Cystectomy, Female, Humans, Incidence, Length of Stay, Male, Middle Aged, Operative Time, Postoperative Complications, Predictive Value of Tests, Prognosis, Reoperation, Retrospective Studies, Sex Distribution, Treatment Outcome, Urinary Bladder Diseases, Urinary Diversion
Show Abstract · Added May 20, 2014
OBJECTIVE - To analyze what factors contribute to a worse outcome after cystectomy and urinary diversion for benign disease as measured by the frequency of severe complications.
METHODS - A retrospective review was performed of consecutive patients who underwent a cystectomy for benign disease. The primary outcome was the type and severity of complications, according to Clavien-Dindo scale.
RESULTS - A total of 139 patients underwent cystectomy with diversion for benign diseases over the study period. The most common indications for surgery were spinal cord injury (32%) and radiation damage to the bladder (18%). The average preoperative age-adjusted Charlson comorbidity index was 4.6. Seventy-four patients (53%) underwent supratrigonal cystectomy. Mean surgery duration was 344±103 minutes, and the mean estimated blood loss was 476±379 mL. The most common complications were perioperative blood transfusion, prolonged ileus, and pyelonephritis. Seventy-nine patients (57%) had a complication grade≥II on the Clavien-Dindo scale. This did not differ based on indication for surgery, age, gender, body mass index, age-adjusted Charlson comorbidity index, estimated blood loss, or type of cystectomy. After adjustment, only duration of surgery in 10-minute increments (odds ratio, 1.07; 95% confidence interval, 1.02-1.12; P=.007) was associated with an increased incidence of serious complication.
CONCLUSION - Most of the patients experience some complication after cystectomy and urinary diversion for benign indications. Duration of surgery is an important variable that can affect outcome.
Published by Elsevier Inc.
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22 MeSH Terms
Outcomes of incontinent ileovesicostomy in the pediatric patient.
Ching CB, Stephany HA, Juliano TM, Clayton DB, Tanaka ST, Thomas JC, Adams MC, Brock JW, Pope JC
(2014) J Urol 191: 445-50
MeSH Terms: Adolescent, Child, Child, Preschool, Comorbidity, Cystostomy, Female, Humans, Ileostomy, Infant, Intermittent Urethral Catheterization, Male, Meningomyelocele, Postoperative Complications, Reconstructive Surgical Procedures, Retrospective Studies, Treatment Outcome, Urinary Bladder, Neurogenic, Urinary Diversion, Urinary Incontinence, Urodynamics
Show Abstract · Added February 19, 2015
PURPOSE - Ileovesicostomy is a reconstructive option in complex urological cases but pediatric specific outcomes are lacking. We report our results with pediatric ileovesicostomy.
MATERIALS AND METHODS - We retrospectively evaluated patients younger than 18 years undergoing incontinent ileovesicostomy at Vanderbilt University. History, urinary tract management and operative course were reviewed in the electronic medical record. Particular attention was given to immediate and long-term postoperative complications.
RESULTS - Nine patients underwent incontinent ileovesicostomy between 2000 and 2013 at a mean age of 10.3 years (range 1.4 to 15.5). Surgical indication was sequelae of neurogenic or nonneurogenic neurogenic bladder (such as infection or worsening hydronephrosis) in 5 patients, reversal of vesicostomy in 3 and closure of cloacal exstrophy in 1. All 9 patients were thought incapable of reliable clean intermittent catheterization due to family unwillingness, poor social support or patient refusal. Median followup was 11.5 months (mean 48.2, range 1.3 to 144.8). Immediate postoperative complications included ileus requiring total parenteral nutrition and a wound infection in 1 patient. Long-term complications included urinary tract infection in 2 patients (febrile in 1 and positive culture for foul smelling urine in 1), stomal issues in 2 and temporary urethral leakage in 1. Constipation affected 3 children in long-term followup (all with neurogenic bowel preoperatively). Postoperative creatinine was stable or improved in all patients.
CONCLUSIONS - Ileovesicostomy is a viable approach in children left with few other options, particularly those who are noncompliant or physically/socially unable to handle catheterization. This operation can help keep such patients out of diapers.
Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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20 MeSH Terms
Ureteroenteric anastomotic strictures after radical cystectomy-does operative approach matter?
Anderson CB, Morgan TM, Kappa S, Moore D, Clark PE, Davis R, Penson DF, Barocas DA, Smith JA, Cookson MS, Chang SS
(2013) J Urol 189: 541-7
MeSH Terms: Aged, Anastomosis, Surgical, Constriction, Pathologic, Cystectomy, Female, Humans, Intestines, Male, Prospective Studies, Urinary Bladder, Urinary Diversion
Show Abstract · Added March 5, 2014
PURPOSE - Robot-assisted laparoscopic radical cystectomy has been increasingly used to decrease the morbidity of radical cystectomy. However, whether it truly lowers the complication rate compared to open radical cystectomy is not well established. We examined the benign ureteroenteric anastomotic stricture rates of open and robot-assisted laparoscopic radical cystectomy.
MATERIALS AND METHODS - In the 478 consecutive patients who underwent radical cystectomy at our institution from December 2007 to December 2011 we examined the proportion diagnosed with benign ureteroenteric anastomotic stricture. Clinicopathological variables were compared by treatment group. Cox multivariable analysis was performed to determine which patient or disease specific factors were independently associated with stricture diagnosis.
RESULTS - A total of 375 patients (78.5%) underwent open radical cystectomy and 103 (21.5%) underwent robot-assisted laparoscopic radical cystectomy. Of the patients 45 (9.4%) were diagnosed with ureteroenteric anastomotic stricture a median of 5.3 months postoperatively. There was no difference in the stricture rate between the open and robot-assisted groups (8.5% vs 12.6%, p = 0.21). On adjusted Cox proportional hazards analysis no patient variable was independently associated with stricture diagnosis, including operative approach.
CONCLUSIONS - Of the patients 9.4% were diagnosed with benign ureteroenteric anastomotic stricture after radical cystectomy with no significant difference in the risk of diagnosis by surgical approach. No patient or disease specific factor was independently associated with an increased risk of stricture diagnosis. Ureteroenteric anastomotic stricture is likely related to surgical technique. Continued efforts are needed to refine the technique of open and robot-assisted laparoscopic radical cystectomy to minimize the occurrence of this critical complication.
Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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11 MeSH Terms
Voiding function in women with orthotopic neobladder urinary diversion.
Anderson CB, Cookson MS, Chang SS, Clark PE, Smith JA, Kaufman MR
(2012) J Urol 188: 200-4
MeSH Terms: Female, Follow-Up Studies, Humans, Incidence, Middle Aged, Postoperative Complications, Retrospective Studies, Treatment Outcome, Urinary Bladder Neoplasms, Urinary Diversion, Urinary Incontinence, Urination
Show Abstract · Added May 27, 2014
PURPOSE - Most long-term morbidity after radical cystectomy is related to the urinary diversion or reconstruction. While there are benefits to an orthotopic neobladder, there can be a substantial risk of voiding dysfunction in women. We examine the prevalence of postoperative voiding complications in women who underwent orthotopic neobladder diversion.
MATERIALS AND METHODS - We identified all women who underwent radical cystectomy and orthotopic neobladder for bladder cancer at our institution from 1996 to 2011 (51) and included patients with regular clinic followup (49). The presence and severity of incontinence and hypercontinence were evaluated at routine clinic visits. Unadjusted analyses were performed to measure the association between patient variables and voiding symptoms, with p < 0.05 considered significant.
RESULTS - Daytime incontinence, nighttime incontinence and hypercontinence were reported by 43%, 55% and 31% of women, respectively. A neobladder-vaginal fistula developed in 3 women (6%). On unadjusted analysis having daytime incontinence was associated with a concurrent or previous hysterectomy (p = 0.031), but not with age, disease stage, preoperative incontinence, year of surgery or sparing the vaginal wall. The severity of daytime incontinence was associated with preoperative incontinence only (p = 0.02). The presence and severity of nighttime incontinence were associated with patient age only (p = 0.013, p = 0.005, respectively). Hypercontinence was not associated with any variable.
CONCLUSIONS - Among women with orthotopic neobladder after radical cystectomy we identified a significant prevalence of voiding dysfunction. We recommend preoperative discussion of these possible complications with any woman interested in orthotopic neobladder to establish realistic expectations. For properly selected women who understand these risks, orthotopic neobladder may be an appropriate diversion choice.
Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
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12 MeSH Terms
Management of nephrostomy drains and ureteral stents.
Adamo R, Saad WE, Brown DB
(2009) Tech Vasc Interv Radiol 12: 193-204
MeSH Terms: Algorithms, Catheters, Indwelling, Clinical Protocols, Drainage, Humans, Nephrostomy, Percutaneous, Patient Selection, Prosthesis Design, Radiography, Interventional, Stents, Treatment Outcome, Ureteral Obstruction, Urinary Diversion
Show Abstract · Added March 5, 2014
Nephroureteral and double J stents are routinely placed by interventional radiologists but quality literature on placement and management of these devices is limited. The purpose of this review is to detail indications for ureteral stent placement, review the types of antegrade and retrograde devices that are placed including technical tips, and discuss management of common complications that occur in this patient population. An algorithm for placement and management is included.
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13 MeSH Terms
Urinary diversion trends at a high volume, single American tertiary care center.
Lowrance WT, Rumohr JA, Clark PE, Chang SS, Smith JA, Cookson MS
(2009) J Urol 182: 2369-74
MeSH Terms: Aged, Cystectomy, Female, Hospitals, Humans, Male, Middle Aged, United States, Urinary Bladder Neoplasms, Urinary Diversion, Urinary Reservoirs, Continent
Show Abstract · Added May 27, 2014
PURPOSE - We analyzed patient characteristics and practice patterns at our institution with time, and identified current patterns and factors contributing to the choice of urinary diversion.
MATERIALS AND METHODS - We reviewed the records of 553 consecutive radical cystectomy and urinary diversions performed from January 2000 to July 2005. Multivariate analysis was done to determine significant differences in diversion choice.
RESULTS - We analyzed the records of 539 patients, including 338 with an ileal conduit and 201 with a neobladder. Patients with a neobladder were younger (mean age 62 vs 71 years) and had fewer comorbidities (American Society of Anesthesiologists class greater than 2 in 31% vs 69%) than those with an ileal conduit. Mean age and the percent of American Society of Anesthesiologists class 3 or 4 cases increased during the study. Neobladder represented 47% of urinary diversions in 2000 and 21% in 2005. On multivariate analysis age (p <0.001), gender (p = 0.004), surgery year (p = 0.002), American Society of Anesthesiologists class greater than 2 (p = 0.004), organ confined disease (p = 0.01) and surgeon (p <0.001) independently predicted diversion choice. Patients were dichotomized into young (younger than 65 years) and old (65 years old or older) groups. Overall 59% of younger and 26% of older patients received a neobladder (p <0.001).
CONCLUSIONS - There was a significant trend toward the more liberal use of ileal conduit urinary diversion. Patients with female gender, advanced age, significant medical comorbidity or locally advanced disease were less likely to undergo neobladder urinary diversion. This trend is partly explained by surgeon preference combined with an aging, more comorbid patient population. Neobladder continues to be the most commonly performed urinary diversion in patients younger than 65 years.
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11 MeSH Terms
Long-term oncological outcomes in women undergoing radical cystectomy and orthotopic diversion for bladder cancer.
Stein JP, Penson DF, Lee C, Cai J, Miranda G, Skinner DG
(2009) J Urol 181: 2052-8; discussion 2058-9
MeSH Terms: Adult, Aged, Aged, 80 and over, Carcinoma, Transitional Cell, Cohort Studies, Cystectomy, Disease-Free Survival, Female, Follow-Up Studies, Humans, Kaplan-Meier Estimate, Middle Aged, Neoplasm Recurrence, Local, Neoplasm Staging, Probability, Retrospective Studies, Risk Assessment, Survival Rate, Time Factors, Treatment Outcome, Urinary Bladder Neoplasms, Urinary Diversion, Urinary Reservoirs, Continent
Show Abstract · Added March 5, 2014
PURPOSE - We compared oncological outcomes in women undergoing radical cystectomy and orthotopic diversion for bladder transitional cell carcinoma.
MATERIALS AND METHODS - From 1990 to 2005, 201 women underwent radical cystectomy, including 120 with an orthotopic neobladder. Median followup was 8.6 years. The clinical course, and pathological and oncological outcomes in these 120 women were analyzed and compared to those in 81 women undergoing radical cystectomy and cutaneous diversion during the same period.
RESULTS - Overall 3 of 120 women (2.5%) who received a neobladder died perioperatively. In this group the tumor was pathologically organ confined in 73 patients (61%), extravesical in 18 (15%) and lymph node positive in 29 (24%). Overall 5 and 10-year recurrence-free survival was 62% and 55%, respectively. Five and 10-year recurrence-free survival in patients with organ confined and extravesical disease was similar at 75% and 67%, and 71% and 71%, respectively. Patients with lymph node positive disease had significantly worse 5 and 10-year recurrence-free survival (24% and 19%, respectively). One woman had recurrence in the urethra and 2 (1.7%) had local recurrence. As stratified by pathological subgroups, similar outcomes were observed when comparing women with an orthotopic neobladder to the 81 who underwent cutaneous diversion.
CONCLUSIONS - Orthotopic diversion does not compromise the oncological outcome in women after radical cystectomy for bladder transitional cell carcinoma. Excellent local and urethral control may be expected. Women with node positive disease are at highest risk for recurrence. Similar outcomes were observed in women undergoing cutaneous diversion.
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23 MeSH Terms
Neovesical-urethral anastomotic stricture after orthotopic urinary diversion: presentation and management.
Patel SG, Cookson MS, Clark PE, Smith JA, Chang SS
(2008) BJU Int 101: 219-22
MeSH Terms: Anastomosis, Surgical, Cystectomy, Follow-Up Studies, Humans, Male, Retrospective Studies, Risk Factors, Treatment Outcome, Urethral Stricture, Urinary Bladder Neck Obstruction, Urinary Catheterization, Urinary Diversion, Urination Disorders
Show Abstract · Added May 27, 2014
OBJECTIVE - To assess the frequency, presentation, treatment, and outcomes of bladder neck contractures (BNCs) among patients who had an orthotopic urinary diversion after radical cystectomy.
PATIENTS AND METHODS - We retrospectively examined our single-institution database of 788 patients who had a radical cystectomy from 1 January 1996 to 4 January 2006 for BNC; variables evaluated included presentation, degree of stricture/contracture, clinical management, and outcomes after management.
RESULTS - Of the 374 patients who had an orthotopic urinary diversion, 11 (2.9%) men developed BNC; four BNCs were between 17 F and 22 F, six were <17 F, and one was pinhole-sized. Nine of the 11 patients presented with voiding difficulties, one in complete retention after complicated urinary tract infection, and one with new-onset nocturnal urinary incontinence. The treatment of BNC included cystoscopic dilatation in the clinic in six and under anaesthesia in three, and transurethral incision with a Collins knife or holmium laser in seven. After treatment, all patients were instructed to use continuous intermittent catheterization (CIC). Ten patients had follow-up data available after the intervention, with a mean (range) follow-up of 40.6 (10.6-98.0) months. Six patients were stricture-free for a mean period of 35.4 (10.6-98.0) months, while four patients had a recurrence within a mean of 7.4 (1.3-17.1) months. At the last follow-up, nine of the 10 patients were using CIC. No patient had significant daytime or night-time incontinence after treatment.
CONCLUSION - BNC develops in a small proportion of patients undergoing orthotopic urinary diversion, with most patients presenting with voiding difficulty. Most will require transurethral incision rather than an office-based dilatation. After endoscopic incision to correct BNC, we recommend CIC to ensure complete emptying and to maintain the patency of the anastomotic stricture.
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13 MeSH Terms