Gender differences in radical cystectomy: complications and blood loss

Preoperative predictors of prolonged length of stay in radical cystectomy: a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Program Dataset

Background

Radical cystectomy (RC) is considered a complex procedure that entails significant morbidity and mortality.

Objectives

We aimed to determine pre-operative patient characteristics that help predict a prolonged length of hospital stay (PLOS) following RC.

Design and Methods

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to select patients who underwent RC between the years 2011 and 2020. Prolonged length of stay was defined as a hospital stay ⩾9 days. We compared patient demographics, pre-operative labs, surgical characteristics, and medical history between patients with or without PLOS. Multivariable logistic regression models controlling for pre-operative characteristics and propensity score matching for post-operative complications were conducted to control for possible confounders.

Results

The analysis yielded details of 19,158 RC patients of which 6007 (31%) patients had a PLOS. Patients with PLOS were more likely to have post-operative complications that could serve as predictors for the PLOS rather than their pre-operative characteristics. Hence, we matched our cohort for these complications. After matching, patient pre-operative characteristics that predict PLOS included female gender (Odds Ratio (OR) = 5.91), 10-year increase in age (OR = 1.15), non-White race (OR = 1.98), partially or totally dependent functional health status (OR = 2.86), bleeding disorders (OR = 4.67), congestive heart failure (OR = 1.59), pre-operative transfusion (OR = 3.03), and a 20-min increase in operative time (OR = 1.01) (p < 0.046).

Conclusion

Patient demographics and pre-operative factors can help predict PLOS in RC patients. These predictors could serve as tools for patient counseling and risk stratification.

Radical cystectomy in women: Impact of the robot-assisted versus open approach on surgical outcomes

OBJECTIVES

To perform a comparison of complications following open versus robot-assisted radical cystectomy (RC) among women who undergo the procedure. Studies comparing robotic to open RC have been mixed without a clear delineation of which patients benefit the most from one modality vs. the other, leading to continued debate.

PATIENTS AND METHODS

This was a retrospective study of women who underwent either open or robotic RC at the MD Anderson Cancer Center from 1/2014 to 6/2018. Co-morbidities, pathologic data, and complications were assessed with descriptive statistics, along with uni- and multivariable logistic regression.

RESULTS

122 women underwent either open (n = 76) or robotic (n = 46) RC. Open RC was associated with greater intraoperative blood loss (median EBL 775 ml vs. 300 ml, P < 0.001). In both uni- and multivariable analyses, open RC was associated with a greater odds of intraoperative transfusion compared to robotic RC (odds ratio 6.49, 95% CI 2.85-14.78, P < 0.001). Women undergoing open RC were also at greater odds of receiving 4 or more units of packed red blood cells (odds ratio 5.46 (1.75-17.02), P = 0.003). Robotic RC conferred a higher median lymph node yield (27 vs. 20 nodes, P, <0.001) and operative times (median 513 min vs. 391.5 min, P < 0.001). There were no differences in margin positivity, length of stay, or readmission rates at 30 and 90 days.

CONCLUSIONS

Robotic RC was associated with a significantly lower risk of transfusion and EBL, and a higher median lymph node yield and operative time. Unique anatomic considerations may in part be responsible for these findings.

Surgical Complications of Urinary Diversion

Urinary diversion (UD) with an intestinal segment has significant risks of short- and long-term complications. With modern reporting criteria, understanding of the true prevalence and spectrum of these complications has improved. Methods to minimize early postoperative complications include enhanced recovery pathways, restricted intraoperative fluid protocols, and referral to high-volume centers. With long-term follow-up after UD, the risk of complications steadily rises. Late surgical complications include ureterointestinal anastomotic strictures, urolithiasis, and stomal issues. Patients with UDs require close surveillance to monitor for anatomic, infectious, and metabolic complications and surgeons who perform UD should be aware of the risk and timing of postoperative complications.

How to lower postoperative complications after radical cystectomy - a review

Introduction

Lowering morbidity and mortality after RC is subject of considerable interest. Lately, many evidence-based data on improvements in operative technique, anesthetic management, and patient care have been published.

In this article, we present a review of literature on how to lower postoperative complications after RC.

Material and methods

The Medline, and Web of Science databases were searched without a time limit on February 2016 using the terms ‘cystectomy’ in conjunction with ‘radical’, ‘bladder cancer’, ‘complications’ or ‘management’. Boolean operators (NOT, AND, OR) were also used in succession to narrow and broaden the search. The search was limited to the English, Polish and Spanish literature.

Results

Many complications may be avoided by appropriate patient selection and meticulous introduction of care protocols.

Conclusions

RC as treatment free of complications, even in the hands of an experienced urologist, does not exist. A large number of complications are acceptable in the name of good long-term results. Optimum results are possible with proper surgical technique, good patients and urinary diversion selection and proper patient management in the pre-, peri, and postoperative period.

Sex disparities in use of chemotherapy and survival in patients with advanced bladder cancer

BACKGROUND

Women with advanced bladder cancer have inferior survival compared with men. However, women treated on clinical trials do not appear to have a survival disadvantage. Less frequent administration of systemic chemotherapy in women with advanced bladder cancer may contribute to their inferior survival.

METHODS

The authors identified patients diagnosed with stage IV bladder cancer from 1998 through 2010 using the National Cancer Data Base, a national outcomes database that includes 70% of all newly diagnosed cancer cases in the United States. Sex differences in demographics, systemic chemotherapy administration, and overall survival (OS) were compared.

RESULTS

A total of 23,981 patients were identified (35% of whom were female). Compared with men, women were older, more likely to be black, and less likely to be insured (P<.01 for all). The Charlson-Deyo comorbidity score did not differ between men and women. Women were less likely to receive systemic chemotherapy than men (45% vs 52%; adjusted relative risk, 0.91 [95% confidence interval (95% CI), 0.88-0.94]). Women had a lower median OS compared with men (8.0 months [95% CI, 7.7-8.3 months] vs 9.8 months [95% CI, 9.5-10.0 months]; P<.001). OS remained lower for women on multivariable analysis, even after adjusting for the administration of systemic chemotherapy (hazard ratio for death, 1.11 [95% CI, 1.08-1.15]).

CONCLUSIONS

Women are less likely than men to receive systemic chemotherapy for advanced bladder cancer and this difference may partially account for the poorer OS observed in women. However, OS remains lower in women independent of chemotherapy use, and may be related to unmeasured comorbidities, functional status, or tumor biology. Cancer 2016;122:2012-20. © 2016 American Cancer Society.

Risk factors of postoperative complications after radical cystectomy with continent or conduit urinary diversion in Armenia

To estimate the surgical volume and the incidence of in-hospital complications of RC in Armenia from 2005 to 2012, and to investigate potential risk factors of complications. The study utilized a retrospective chart review in a cohort of patients who had RC followed by either continent or conduit urinary diversion in all hospitals of Armenia from 2005 to 2012. A detailed chart review was conducted abstracting information on baseline demographic and clinical characteristics, surgical procedural details, postoperative management and in-hospital complications. Multivariable logistic regression analysis was applied to estimate the independent risk factors for developing ‘any postoperative complication’. The total study sample included 273 patients (mean age = 58.5 years, 93.4 % men). Overall, 28.9 % (n = 79) of patients had at least one in-hospital complication. The hospital mortality rate was 4.8 % (n = 13). The most frequent types of complications were wound-related (10.3 %), gastrointestinal (9.2 %) and infectious (7.0 %). The ischemic heart disease (OR = 3.3, 95 % CI 1.5–7.4), perioperative transfusion (OR = 2.0, 1.1–3.6), glucose level [OR = 0.71 (0.63–0.95)], and hospital type (OR = 2.3, 95 % CI 1.1–4.7) were independent predictors of postoperative complications. The rate of RC complications in Armenia was similar to those observed in other countries. Future prospective studies should evaluate the effect of RC complications on long-term outcomes and costs in Armenia. Policy recommendations should address the issues regarding surgeon training and hospital volume to decrease the risk of RC complications.

Alvimopan: A cost-effective tool to decrease cystectomy length of stay

INTRODUCTION

We sought to evaluate the cost effectiveness of perioperative use of alvimopan in cystectomy and urinary diversion. A recent randomized controlled trial demonstrated the efficacy of alvimopan in reducing postoperative ileus and length of stay in cystectomy; however, a major limitation was the exclusion of epidural analgesia.

MATERIALS AND METHODS

Eighty-six cystectomy and urinary diversion procedures performed by seven surgeons were analyzed between January 2008 and April 2012. The first 50 patients did not receive alvimopan perioperatively, while the subsequent 36 received a single dose of 12 mg preoperatively and then 12 mg every 12 hours for 15 doses or until discharge.

RESULTS

The groups were equal with respect to age, gender, indication, surgeon, and type of diversion. Patients who received alvimopan experienced a shorter length of stay (LOS) versus those in who did not receive alvimopan (10.5 vs. 8.6 days, p = 0.005, 95% CI 0.6-3.3). Readmission for ileus was low in both alvimopan and control groups (0% and 4.4%, respectively). Costs were significantly lower in the alvimopan group than the control groups (2012 USD 32,443 vs. 40,604 p <0.001). This difference stood up to multivariate analysis with a $7,062 difference in hospital stay.

CONCLUSIONS

Use of alvimopan in the routine perioperative care of our cystectomy and urinary diversion patients has decreased LOS by 1.9 days. Additionally, institution of routine perioperative alvimopan has reduced costs by $7,062 per admission (20% reduction). This demonstrates a real world application of alvimopan at a moderate volume center.

Short-term perioperative outcomes of patients treated with radical cystectomy for bladder cancer included in the National Surgical Quality Improvement Program (NSQIP) database

INTRODUCTION

We report the contemporary outcomes of radical cystectomy (RC) in patients with bladder cancer using a national, prospective perioperative database specifically developed to assess the quality of surgical care.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried from 2006 to 2011 for RC. Data on postoperative complications, operative time, length of stay, blood transfusions, readmission, and mortality within 30 days from surgery were abstracted.

RESULTS

Overall, 1094 patients undergoing RC were identified. Rates of overall complications, transfusions, prolonged length of hospitalization, readmission, and perioperative mortality were 31.1%, 34.4%, 25.9%, 20.2%, and 2.7%, respectively. Body mass index represented an independent predictor of overall complications on multivariate analysis (p = 0.04). Baseline comorbidity status was associated with increased odds of postoperative complications, prolonged operative time, transfusion, prolonged hospitalization, and perioperative mortality. In particular, patients with cardiovascular comorbidities were 2.4 times more likely to die within 30 days following cystectomy compared to their healthier counterparts (p = 0.04). Men had lower odds of prolonged operative time and blood transfusions (p ≤ 0.03). Finally, the receipt of a continent urinary diversion was the only predictor of readmission (p = 0.02). Our results are limited by their retrospective nature and by the lack of adjustment for hospital and tumour volume.

CONCLUSIONS

Complications, transfusions, readmission, and perioperative mortality remain relatively common events in patients undergoing RC for bladder cancer. In an era where many advocate the need for prospective multi-institutional data collection as a means of improving quality of care, our study provides data on short-term outcomes after RC from a national quality improvement initiative.

Peri-operative morbidity associated with radical cystectomy in a multicenter database of community and academic hospitals

Objective

To characterize the frequency and timing of complications following radical cystectomy in a cohort of patients treated at community and academic hospitals.

Patients and Methods

Radical cystectomy patients captured from NSQIP hospitals from January 1 2006 to December 31 2012 were included. Baseline information and complications were abstracted by study surgical clinical reviewers through a validated process of medical record review and direct patient contact. We determined the incidence and timing of each complication and calculated their associations with patient and operative characteristics.

Results

2303 radical cystectomy patients met inclusion criteria. 1115 (48%) patients were over 70 years old and 1819 (79%) were male. Median hospital stay was 8 days (IQR 7–13 days). 1273 (55.3%) patients experienced at least 1 post-operative complication of which 191 (15.6%) occurred after hospital discharge. The most common complication was blood transfusion (n = 875; 38.0%), followed by infectious complications with 218 (9.5%) urinary tract infections, 193 (8.4%) surgical site infections, and 223 (9.7%) sepsis events. 73 (3.2%) patients had fascial dehiscence, 82 (4.0%) developed a deep vein thrombosis, and 67 (2.9%) died. Factors independently associated with the occurrence of any post-operative complication included: age, female gender, ASA class, pre-operative sepsis, COPD, low serum albumin concentration, pre-operative radiotherapy, pre-operative transfusion >4 units, and operative time >6 hours (all p<0.05).

Conclusion

Complications remain common following radical cystectomy and a considerable proportion occur after discharge from hospital. This study identifies risk factors for complications and quality improvement needs.

Comparison of Complications from Radical Cystectomy between Old-Old versus Oldest-Old Patients

Introduction: The purpose of this study was to evaluate and compare complications after radical cystectomy in patients aged ≥75 years. Materials and Methods: 251 patients aged 75-95 years (median 79) underwent radical cystectomy between 2000 and 2012 at four institutions. The patients were divided into two groups: ≥75-84 years of age (group 1) versus ≥85 years of age (group 2). Comorbidities, body mass index, and complications were obtained retrospectively, except at the Central Hospital of Bolzano and Weill Cornell Medical Center, which collected data prospectively. Cancer-specific survival, overall mortality, hospital stay, clinical outcome and complications were assessed. Complications were categorized using the Clavien-Dindo classification reporting system. The mean follow-up was 21 months. Results: The median hospital stay was 17 (2-91) days. Perioperative Clavien-Dindo grade ≥III complications were seen in 24.1% (48/199) of group 1 patients and 19.2% (10/52) of group 2 patients (p = 0.045). 30- and 90-day mortality was 4.5 and 13.5% in group 1 and 6.5 and 32.3% in group 2, respectively. Only the 90-day mortality rate was statistically significant (p < 0.05) between the two groups. The 3-year overall survival was 40% in group 1 and 34% in group 2. The 3-year cancer-specific survival was 52% in group 1 and 50% in group 2. Conclusions: We evaluated a large series of elderly (≥75 years) patients undergoing radical cystectomy at four institutions. Comparing patients aged ≥75-84 and ≥85 years revealed no significant difference in complications, 30-day mortality, overall and cancer-specific survival rates. Only 90-day mortality rates were significantly higher in the ≥85-year-old patients.

Is postoperative epidural analgesia better than patient-controlled analgesia for radical cystectomy?

Background:

The purpose of this study was to evaluate postoperative epidural analgesia (EPA) and intravenous patient-controlled analgesia (PCA) in terms of morbidity and mortality in patients undergoing radical cystectomy for bladder cancer.

Methods:

A retrospective study on patients undergoing radical cystectomy for clinical Tis-4N0M0 urothelial carcinoma of the bladder was performed. Patients were separated into two groups: primary EPA or PCA for postoperative analgesia. The surgical complication severity was determined according to the Clavien system. Mann-Whitney U tests, χ2 with Yates’ correction, or Fisher’s exact test were used. Predictive risk factors were explored using univariable and multivariable Cox regression models.

Results:

Of the 274 patients studied, 209 (76%) received EPA and 65 (24%) had PCA. Baseline balance was observed. Similar complication rates were observed between the EPA (36%) and PCA (34%) ( p=0.382). Patients greater than 70 years of age had more complications (35% vs 21%, p=0.002). PCA patients had higher rates of high-grade complications compared with EPA patients [40% vs 20% ( p=0.0007)]. Only age at time of surgery ( p=0.032) was associated with complications. Patients with pulmonary disease had a higher risk of complications ( p=0.001). EPA or PCA were not predictors for overall survival.

Conclusions:

There does not appear to be a significant difference in terms of morbidity or mortality between EPA and PCA following radical cystectomy (RC). Rare, catastrophic complications specific to EPA may occur. Standardized reporting of surgical complications is essential to compare studies and appropriately counsel patients.

Preoperative risk factors related to bladder cancer rehabilitation: a registry study

INTRODUCTION

Patients diagnosed with (muscle-) invasive bladder cancer (IBC) are more likely to harbour comorbidities due to their advanced age at diagnosis. Under-nutrition is a predictor for postoperative morbidity and mortality in cancer patients, but under-reported in urology. Understanding the IBC patient profile before major surgery could facilitate and optimise outcome of the surgical patient.

BACKGROUND/OBJECTIVES

To identify preoperative risk factors for early rehabilitation before radical cystectomy (RC).

SUBJECTS/METHODS

A historical registry-based study of 76 patients referred for RC at Aarhus University Hospital, Denmark (DK) in 2009. Early rehabilitation was defined by length of stay (LOS) postoperatively with a cutoff ≥11 days. High comorbidity was expressed by the charlson comorbidity index score (CCI) ≥3. LOS was calculated by linking the unique Civil Registration Number with the National Patient Registry. Preoperative nutritional risk was identified using the screening tool, nutritional risk score 2002 (NRS) of the European Society of Clinical Nutrition and Metabolism. Multivariate analysis was used to identify risk factors for early rehabilitation.

RESULTS

The proportion of patients at preoperative nutritional risk was 26% (95% confidence interval (CI): (95% CI: 17; 37) and 43% of patients held a high CCI (95% CI: 33; 55). Prolonged LOS was independently associated with female gender (P=0.02) and age ≥70 years (P=0.04). NRS and CCI were not associated with LOS.

CONCLUSIONS

Attention should be focused on women and elderly patients undergoing RC to optimise early rehabilitation and reduce LOS. It is still unknown whether preoperative nutritional risk and comorbidity are obstacles in early rehabilitation of RC patients.

Systematic assessment of complications and outcome of radical cystectomy undertaken with curative intent in patients with comorbidity and over 75 years of age

OBJECTIVE

To evaluate the complications, survival and oncological outcome of patients ≥75 years of age after radical cystectomy for muscle-invasive bladder cancer.

PATIENTS AND METHODS

Between April 1993 and August 2010, 765 patients with muscle-invasive bladder cancer underwent radical cystectomy at one high-volume center. Of these, 70 patients were ≥75 years of age. All 70 patients had at least one severe systemic comorbidity with an American Society of Anesthesiologists score of 3. Primary endpoints of this retrospective study were overall and recurrence-free survival with a mean follow-up of 22 months (1-159). Perioperative parameters such as need for blood transfusions, hospital stay, mortality, short- and long-term complications were also assessed. Complications were graded according to the Clavien-Dindo classification.

RESULTS

Perioperative complications occurred in 23/70 patients (33%) with a 30-day mortality rate of 1.4%. 16/70 patients (23%) developed late complications requiring hospitalization. Within 30 days of surgery, according to the Clavien-Dindo grading, 27% had no complications, 3% grade 1, 49% grade 2, 14% grade 3, 6% grade 4 and 1.4% grade 5 complications. Within 31-90 days after surgery, 76% had grade 1 complications, 3% grade 2, 6% grade 3, 9% grade 4 and 6% grade 4 complications. The calculated 5- and 8-year overall survival rates were 30 and 25%, respectively, with a recurrence-free survival rate of 52% at 5 and 42% at 8 years.

CONCLUSIONS

Radical cystectomy is an appropriate and effective treatment for comorbid elderly patients. The oncological long-term outcome is the same as in younger patients while overall survival is comparatively lower. Mortality and complication-related morbidity are comparable to those in younger patients with modern perioperative management.

Our experiences with robot-assisted laparoscopic radical cystectomy: orthotopic neobladder by the suprapubic incision method

PURPOSE

To report our technique for and experience with robot-assisted laparoscopic radical cystectomy (RARC) with orthotopic neobladder (ON) formation in a cohort of bladder cancer patients.

MATERIALS AND METHODS

Between December 2007 and December 2011, a total of 35 patients underwent RARC. The patients' mean age was 63.3 years and their mean body mass index was 23.7 kg/m(2). Thirty patients had a clinical stage of T2 or higher. Postoperative mean follow-up duration was 25.5 months. In 5 patients, a 4-cm midline infraumbilical skin incision was made for an ileal conduit (IC) and the stoma formation was similar to the open procedure. In 30 patients undergoing the ON procedure, the skin for specimen removal and extracorporeal enterocystoplasty was incised infraumbilically in the early 5 cases with redocking (ON-I) and suprapubically in the latter 25 cases without redocking (ON-S).

RESULTS

The mean operative times of the IC, ON-I, and ON-S groups were 442.5, 646.0, and 531.3 minutes, respectively (p=0.001). Mean console and lymph node dissection time were not significantly different between the groups. Mean urinary diversion times in each group were 68.8, 125.0, and 118.8 minutes, respectively (p=0.001). In the comparison between the ON-I and ON-S group, only operative time was significant. Four patients required a blood transfusion. We had no cases of intraabdominal organ injury or open conversion. Thiry-three patients (94.2%) had a pathologic stage of T2 or higher. Two patients (5.7%) had lymph node-positive disease. Postoperative complications included ileus (n=4), stricture in the uretero-ileal junction (n=2), and vesicovaginal fistula (n=1).

CONCLUSIONS

Our robotic neobladder-suprapubic incision without redocking procedure is easier and more rapid than that of infraumbilical incision with redocking.

Perioperative morbidity of radical cystectomy: A review

A systematic review of the literature on perioperative morbidity (POM) was done using Medline software with a combination of keywords like mortality, morbidity, and complications. In addition, we review the analysis of our hospital data of 261 Radical cystectomies (RCs) performed in an 11-year period and our latest clinical pathway for RC. Age range in our series was 50 to 81 years with 240 males and 21 females. RCs were performed by intraperitoneal method in 172 patients and by our extraperitoneal (EP) method in 89 patients. Urinary diversion was ileal conduit in 159 patients and neobladder in 102 patients. Blood loss ranged between 500 and 1500 ccs. Postoperative mortality occurred in eight patients (3%). Among the other early post-op complications, major urinary leak was seen in nine and minor in 11, requiring PCN in five patients and reoperation in four patients. Bowel leak or obstruction was seen in six and four patients, respectively, requiring reoperation in six patients. EP RC in our series showed some benefit in reduction of POM. The mortality of RC has declined but the POM still ranges from 11 to 68%, as reported in 23 series (1999-2008) comprising of 14 076 patients. Various risk factors leading to POM and some corrective measures are discussed in detail. However, most of these series are retrospective and lack standard complication reporting, which limits the comparison of outcomes. Various modifications in open surgical technique and laparoscopic and Robotic approaches are aimed at reduction in mortality and POM of RC.

Cost benefits of intraoperative cell salvage in radical cystectomy

Objective:

We have looked into the clinical and financial benefits of using intra-operative cell salvage (ICS) as a method to reduce the amount of autologous blood transfusion (ABT) requirement for our radical cystectomy (RC) patients.

Materials and Methods:

Fifteen consecutive patients undergoing radical cystectomy received cell salvaged blood (ICS), while 15 did not (NCS). The cost of using the cell saver, number of homologous transfusions, survival, and recurrences were recorded and compared using paired t-test and chi-square test between the two groups. A Dideco Electa® (Sorin Group, Electa, Italy) cell saver machine was used for all the patients in the ICS group and leukocyte filters were used on the salvaged blood before the autologous transfusion.

Results:

The mean age was 63 years (53–72 years), 66 years (46–79 years) in ICS and NCS groups, respectively (P = 0.368). All 15 (100%) patients in the NCS group required an allogenic transfusion compared to 9/15 (60%) in the ICS group (P = 0.08). There was a significant reduction in the mean volume of allogenic blood transfused with the use of cell saver. Median follow-up was 23 and 21 months in the ICS and NCS group with 10 and 4 patients alive at last follow-up, respectively. There was a saving of 355 pounds per patient in the ICS group compared to the NCS group.

Conclusion:

Our initial study shows that cell savage is feasible and safe in patients undergoing radical cystectomy. It does not adversely affect the medium term outcome of patients undergoing RC and is also cost effective.

[Radical cystectomy--analysis of postoperative course]

BACKGROUND/AIM

Radical cystectomy is a method of choice in the therapy of infiltrative bladder cancer. The aim of this research was to analyze postoperative course after radical cystectomy (length of hospitalization, most frequent complications and utilization of antibiotics and transfusions).

METHODS

We analyzed the records of 82 patients operated on in the Department of Urology, Clinical Center of Vojvodina, in a three-year period. In order to aquire data World Health Organization (WHO) has developed Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) methodology. Defined daily dose (DDD) is the assumed average maintenance dose per day for a drug use for its main indication.

RESULTS

Continent urinary derivation was preformed in 23.15% cases. Postoperative complications occurred in 18.29% of patients. Average blood utilization was 2.19 units. Blood utilization for continent derivations (n=48) was 4.6 units, and incontinent ones 3.36 units. Totally 159.33 DDD/100 bed days were used.

CONCLUSION

When preforming continent derivation there is a significant increase in blood utilization. Frequency of postoperative complications correlates to those reported in the literature.

Operative blood loss, blood transfusion, and 30-day mortality in older patients after major noncardiac surgery

OBJECTIVE

Anemia and operative blood loss are common in the elderly, but evidence is lacking on whether intraoperative blood transfusions can reduce the risk of postoperative death.

METHODS

We analyzed retrospective data from 239,286 patients 65 years of older who underwent major noncardiac surgery in 1997 to 2004 at veteran hospitals nationwide. Propensity-score matching was used to adjust for differences between patients who received intraoperative blood transfusions (9.4%) and those who did not, and data were used to determine the association between intraoperative blood transfusion and 30-day postoperative mortality.

RESULTS

After propensity-score matching, intraoperative blood transfusion was associated with mortality risk reductions in patients with preoperative hematocrit levels of <24% (odds ratio: 0.60, 95% CI: 0.41-0.87), and in patients with hematocrit of 30% or greater when there is substantial (500-999 mL) blood loss (odds ratio: 0.35, 95% CI: 0.22-0.56 for hematocrit levels between 30%-35.9% and 0.78, 95% CI: 0.62-0.97 for hematocrit levels of 36% or greater). When operative blood loss was <500 mL, transfusion was not associated with mortality reductions for patients with hematocrit levels of 24% or greater, and conferred increased mortality risks in patients with preoperative hematocrit levels between 30% to 35.9% (odds ratio 1.29, 95% CI: 1.04-1.60).

CONCLUSIONS

Intraoperative blood transfusion is associated with a lower 30-day postoperative mortality among elderly patients undergoing major noncardiac surgery if there is substantial operative blood loss or low preoperative hematocrit levels (<24%). Transfusion is associated with increased mortality risks for those with preoperative hematocrit levels between 30% and 35.9% and <500 mL of blood loss.

Cardiac history and risk of post-cystectomy cardiac complications

OBJECTIVES

To evaluate risk factors for postoperative cardiac complications (POCC). Patients undergoing cystectomy often have significant baseline cardiac disease. Despite preoperative medical optimization, postoperative cardiac complications remain a significant source of morbidity.

METHODS

A retrospective review of all radical cystectomies for bladder cancer between January 2004 and September 2006 was performed. Twelve preoperative risk factors were evaluated, including age, Charlson Comorbidity Index, type of urinary diversion, and previous cardiac history. All complications, including myocardial infarction (MI) and new onset arrhythmia, were recorded for 90 days postoperatively. Univariate and multivariate analysis were performed.

RESULTS

A total of 283 patients underwent cystectomy for bladder cancer between January/2004 and September 2006. The median age of the cohort was 70 (35-90) years. Of 283 patients, 64 (23%) had a significant preoperative cardiac history, including 18 (6%) with prior coronary artery bypass and 30 (11%) with a history of MIs. Thirty-one (11%) patients had either new onset arrhythmia (22, 8%) or MI (10, 4%) and 1 had both. On univariate analysis, cardiac history, age, type of urinary diversion, and the Charlson Comorbidity Index demonstrated significance. The risk of POCC was associated with ileal conduit urinary diversion (P = .026, OR 5.58 [1.23-25.36]) and the Charlson Index score (P = .030, OR 1.28 [1.024-1.60]) on multivariate analysis.

CONCLUSIONS

Multiple, inter-related factors may predict cardiac complications in the early postoperative period. Despite perioperative optimization, patients with a prior cardiac history should be counseled, regarding the increased risk of postoperative cardiac complications. The association between cardiac complications and ileal conduit diversion highlights the selection bias toward patients with preexisting comorbid disease.

Complications following radical cystectomy for bladder cancer in the elderly

CONTEXT

The incidence of bladder cancer increases with advancing age. Considering the increasing life expectancy and the increasing proportion of elderly people in the general population, radical cystectomy will be considered for a growing number of elderly patients who suffer from muscle-invasive or recurrent bladder cancer.

OBJECTIVE

This article reviews contemporary complication and mortality rates after radical cystectomy in elderly patients and the relationship between age and short-term outcome after this procedure.

EVIDENCE ACQUISITION

A literature review was performed using the PubMed database with combinations of the following keywords cystectomy, elderly, complications, and comorbidity. English-language articles published in the year 2000 or later were reviewed. Papers were included in this review if the authors investigated any relationship between age and complication rates with radical cystectomy for bladder cancer or if they reported complication rates stratified by age groups.

EVIDENCE SYNTHESIS

Perioperative morbidity and mortality are increased and continence rates after orthotopic urinary diversion are impaired in elderly patients undergoing radical cystectomy. Complications are frequent in this population, particularly when an extended postoperative period (90 d instead of 30 d) is considered.

CONCLUSIONS

Although age alone does not preclude radical cystectomy for muscle-invasive or recurrent bladder cancer or for certain types of urinary diversion, careful surveillance is required, even after the first 30 d after surgery. Excellent perioperative management may contribute to the prevention of morbidity and mortality of radical cystectomy, supplementary to the skills of the surgeon, and is probably a reason for the better perioperative results obtained in high-volume centers.

Surgical apgar outcome score: perioperative risk assessment for radical cystectomy

PURPOSE

Currently objective perioperative risk assessment metrics are lacking for radical cystectomy. Using a simple 10-point scale similar to neonatal Apgar assessment we evaluated whether a surgical outcome score calculated immediately after radical cystectomy would predict major complications and mortality.

MATERIALS AND METHODS

We identified 155 consecutive radical cystectomies performed between 2005 and 2007 at our institution. Data were collected on 45 preoperative and intraoperative variables. We used a framework established by the National Surgical Quality Improvement Program to evaluate major complications within 30 days of surgery. We used a 10-point scoring system that had been previously validated in general and vascular surgery populations, comprising estimated blood loss, lowest heart rate and lowest mean arterial pressure.

RESULTS

A total of 40 (26%) patients undergoing radical cystectomy experienced a major complication within 30 days of the operation. There was a progressive decrease in complications with increasing surgical Apgar score, in that patients with a low vs a high Apgar score were more likely to experience complications (OR 6.9, 95% CI 1.9-24.2). Coronary artery disease, American Society of Anesthesiologists class, intraoperative blood transfusion, volume of intravenous fluid administered and female gender were also associated with major complications (p <0.05).

CONCLUSIONS

In patients undergoing radical cystectomy the surgical Apgar score predicts major postoperative complications and death. This simple and objective postoperative metric may be used to dictate the intensity of care. Prospective studies are needed to determine whether treatment decisions based on this scoring system improve radical cystectomy outcomes.

Impact of stapling devices on radical cystectomy: comparative study between low- and high-volume surgeons

OBJECTIVES

To compare effectiveness in terms of blood loss and operative time of stapling devices among surgeons with different levels of surgical volume.

METHODS

We evaluated a group of 29 male patients with invasive bladder cancer who underwent radical cystectomy by two groups of surgeons. The first group included two high-volume surgeons, and the second group two low-volume surgeons. All cystectomies were performed using the multifire autosuture articulated vascular Endo-GIA. We compared patients with a series of 28 patients who had undergone radical cystectomy during the same period using standard technique by the same surgeons. Blood loss was defined as the difference between the hemoglobin at the beginning and at the end of cystectomy.

RESULTS

In the group of high-volume surgeons, the mean operative time was 81.4 +/- 17 minutes and 79.3 +/- 20 minutes for the classical and stapler arm, respectively (P = 0.551). In the low-volume surgeons group, the mean operative time was 114.3 +/- 22 minutes and 92.4 +/- 12 minutes for the two methods (P = 0.003). The mean intraoperative blood loss in the experienced surgeons was 2.3 +/- 0.82 g/dL and 1.49 +/- 0.66 g/dL for the classical and stapler arm, respectively (P = 0.008). In the group of low-volume surgeons, the difference in hemoglobin was 3.02 +/- 0.84 g/dL and 1.91 +/- 0.6 g/dL for the two methods (P = 0.02).

CONCLUSIONS

Stapling devices seem to make cystectomy safer and faster in surgeons with different surgical volumes. The group of low-volume surgeons benefited more.

Intraoperative cell salvage during radical cystectomy does not affect long-term survival

OBJECTIVES

To evaluate the risk of long-term recurrence for patients who received cell-salvaged blood during radical cystectomy (RC).

METHODS

We retrospectively analyzed an RC database and compared those who did and did not receive cell-salvaged blood according to baseline parameters, pathologic outcomes, and recurrence.

RESULTS

A total of 378 patients underwent RC between 1992 and 2005 by one surgeon. Of these, 65 (17.2%) received cell-salvaged blood and 313 (82.8%) did not. The two groups had similar baseline characteristics. There were no differences between the two groups when compared by pathologic stage. The median follow-up for patients who did and did not receive cell-salvaged blood was 19.1 and 20.7 months, respectively (P = 0.464). The 3-year disease-specific survival rate for the two groups was 72.2% and 73.0%, respectively (P = 0.90).

CONCLUSIONS

Intraoperative cell salvage is a safe blood management strategy for patients undergoing RC. There is no increased risk of metastatic disease or death for those who receive cell-salvaged blood. Concerns about spreading tumors cells by IOCS during RC would seem unwarranted. However, only a prospective, multicenter, randomized trial would provide the most valid assessment of the safety of IOCS.

[Laparoscopic cystectomy and transileal ureterostomy for neurogenic vesicosphincteric disorders. Evaluation of morbidity]

OBJECTIVES

To evaluate the morbidity and mortality of laparoscopic cystectomy combined with transileal ureterostomy to treat neurogenic vesicosphincteric disorders.

MATERIAL

Prospective study performed between february 2004 and april 2006 on 26 consecutive patients with a mean age of 55.0 +/- 12.7 years treated by laparoscopic cystectomy for neurogenic vesicosphincteric disorders. The underlying neurological disease was multiple sclerosis (MS) in 20 cases, spinal cord injury in 4 cases and transverse myelitis in 2 cases. The median preoperative ASA score was 3 (range: 2-3).

RESULTS

No open conversion was necessary. One intraoperative complication was observed (vascular injury). No perioperative death was observed. The nasogastric tube was maintained postoperatively for an average of 8.69 +/- 5.9 hours. The mean time to resumption of oral fluids was 1.4 +/- 0.7 days and mean time to resumption of solids was 2.6 +/- 1.0 days. The mean time to resumption of bowel movements was 3.8 +/- 3.2 days. The mean intensive care stay was 3.9 +/- 1.1 days. Two postoperative complications were observed in the same patient (ileus and bronchial congestion). Postoperative narcotic analgesics were necessary in 60% of cases. The mean hospital stay was 10.3 +/- 4.1 days. Two late postoperative complications were observed in the same patient (two episodes of pyelonephritis).

CONCLUSION

Laparoscopic cystectomy has a low morbidity in neurological patients, allowing early return of feeding and a moderate length of hospital stay.

Standards for Surgical Complication Reporting in Urologic Oncology: Time for a Change

OBJECTIVES

No standards for reporting surgical morbidity exist in the urologic oncology literature, yet surgical outcomes are used to assess the success of surgical techniques and surgeon competency. This study analyzes the quality of complication reporting in the urologic literature.

METHODS

Reports identified by a MEDLINE search reporting surgical outcomes after radical prostatectomy, radical cystectomy, retroperitoneal node dissection, and radical/partial nephrectomy were analyzed using 10 established criteria for surgical complication reporting. Open (n = 73) and minimally invasive (n = 36) surgical series of 50 patients or more published from January 1995 to December 2005 were reviewed.

RESULTS

A total of 109 studies reporting the outcomes for 146,961 patients, including 95 retrospective (87%), 11 prospective (10%), 1 randomized (1%), and 2 population-based (2%) studies were analyzed. Of the 10 critical reporting elements, 2% met 9 to 10, 21% met 7 to 8, 43% met 5 to 6, 30% met 3 to 4, and 4% met 1 to 2 criteria. The most commonly underreported criteria were complication definitions in 79%, complication severity/grade in 67%, outpatient data in 63%, comorbidities in 59%, and the duration of the reporting period in 56%. Additionally, 47% of minimally invasive surgical series met fewer than 5 of the 10 reporting criteria compared with 28% of open series. Of the 36 studies reporting complication severity, a numeric grading system was used in 7 (19%), with 29 (81%) of 36 using a "major versus minor" categorization but using 26 different definitions of what constituted "major."

CONCLUSIONS

The disparity in the quality of surgical complication reporting in urologic oncology makes it impossible to compare the morbidity of surgical techniques and outcomes. Standard guidelines need to be established.

Influence of Post-Cystectomy Complications on Cost and Subsequent Outcome

PURPOSE

Of commonly performed urological cancer procedures radical cystectomy is associated with the highest morbidity and mortality. The impact of each individual type of complication or a combination of them on various outcome measures, such as mortality, charges and length of stay, is unclear. We quantified the impact of specific post-cystectomy complications and combinations thereof in terms of mortality, charges and length of stay.

MATERIALS AND METHODS

All 6,577 patients undergoing radical cystectomy for bladder cancer were identified from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (1998 to 2002). The prevalence of different International Classification of Diseases, 9th Revision, Clinical Modification coded complications following cystectomy were determined. Outcome variables of interest were in-hospital mortality, total charges and length of stay. The association between types of complications and measured outcomes were examined using univariate and multivariate regression models. The cumulative impact of multiple complications and various combinations of complications on outcomes was also examined.

RESULTS

The overall complication rate was 28.4% in 1,869 cases and the mortality rate was 2.6%. Median total charges was 41,905 dollars and median length of stay was 9 days. Overall 20.7% of patients had 1, 6.1% had 2, 1.2% had 3 and 0.42% had greater than 3 complications. At least 1 complication almost doubled the odds of mortality and increased median total charges and length of stay by 15,000 dollars and 4 days, respectively. We defined expected levels of increase in the various outcome measures with increasing numbers of complications. The combination of postoperative infection and respiratory complication had the greatest impact on mortality, while the combination of wound and urinary tract infection had the greatest impact on length of stay and total charges.

CONCLUSIONS

Although most patients undergoing cystectomy are older and have multiple comorbidities, the postoperative complications with the most significant impact were those directly related to surgery (primary complications). Secondary complications (cardiac, respiratory, vascular, etc) appear to have less of an impact on most common outcome measures. Hence, the greatest gains can be achieved by limiting primary complications. These data could be used to develop benchmarks of expected levels of primary and secondary complications after cystectomy.

Muscle-Invasive Urothelial Carcinoma of the Bladder

Muscle-invasive urothelial (transitional cell) carcinoma is a potentially lethal condition for which an attempt at curative surgery is required. Clinical staging does not allow for accurate determination of eventual pathologic status. Muscle-invasive urothelial carcinoma is a highly progressive disease, and initiation of definitive therapy within 3 months of diagnosis is worthwhile. Age is not a contraindication for aggressive surgical care, and surgical candidates should be evaluated in the context of overall medical comorbidity. In those patients who undergo surgery, clinical pathways may streamline care. Radical cystectomy remains the "gold standard" of therapy, providing 5-year survival rates of 75% to 80% in patients with organ-confined disease, yet organ-sparing procedures demonstrate clinical effectiveness as well. Cystectomy should be undertaken with the intent of performing complete pelvic lymph node dissection and attaining surgically negative margins. In younger female patients, the preservation of reproductive organs may be achieved in many cases. Prostate- and seminal vesicle-preserving cystectomy has been performed, yet the long-term safety and efficacy of such a procedure remains to be determined. Laparoscopic and robotic cystectomy procedures continue to be explored by several investigators. The role of "radical transurethral resection" in muscle-invasive disease is limited to a small cohort of patients, and, when it is performed, cystectomy may be required to consolidate therapy. Postoperative follow-up after cystectomy should occur over short intervals during the first 2 years and can be extended, but not discontinued, beyond that time. Currently, no tumor markers have been prospectively validated to help guide clinical decision making, and prospective trials incorporating marker data should be encouraged.

Radical cystectomy with ileal conduit diversion: early prospective evaluation of the impact of robotic assistance

OBJECTIVE

To compare the performance of radical cystectomy with ileal conduit diversion by standard methods with that using the assistance of the daVinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA).

PATIENTS AND METHODS

From November 2003 to August 2005, we performed 30 radical cystectomies with ileal conduit urinary diversions on patients with bladder cancer. Seven patients (one woman) had a cystectomy with the daVinci system and 23 (nine women) had a standard cystectomy. Data were collected prospectively, including estimated blood loss (EBL), transfusion requirement, operative duration, hospital stay and body mass index (BMI), and compared.

RESULTS

The mean EBL and transfusion requirements for standard and daVinci-assisted cases was 1109 and 479 mL (P = 0.002) and 2.7 and 1.6 units (P = 0.14), respectively. Four of seven patients received a transfusion in the robotic group, and 20 of 23 in the standard group (P = 0.084). The mean operative duration was 638 and 507 min (P = 0.005) for the daVinci and standard group, respectively, with respective mean hospital stays of 11 and 13 days (P = 0.52). There was no difference in patient BMI between the groups (P = 0.22).

CONCLUSION

The daVinci-assisted cystectomy appears to offer some advantages over standard cystectomy. Larger randomized studies are needed to confirm these findings.

Complications after radical cystectomy: Analysis of population-based data

OBJECTIVES

To determine the morbidity and mortality from radical cystectomy in a nationally representative population-derived sample. Complications after radical cystectomy have been reported from large single-institution series but population-based representative data are lacking.

METHODS

All patients undergoing radical cystectomy for bladder cancer were identified from the National Inpatient Sample data set of the Health Care Utilization Project (1998 to 2002). The prevalence of different complications coded according to the International Classification of Diseases, version 9, after cystectomy were determined. Independent hospital and patient-related factors associated with the occurrence of a complication were determined by logistic regression analysis. The prevalence of complication by type and frequency were compared with that in other large reported series.

RESULTS

The in-hospital mortality rate was 2.57%, and at least one complication other than death occurred in 28.4% of patients. These rates were comparable to those reported in published studies. Younger patients had a lower likelihood of complications. Younger patients and those undergoing cystectomy at large bed size, urban, teaching hospitals were less likely to have secondary complications after surgery, and younger patients, women, and those undergoing cystectomy at high-volume hospitals were less likely to have primary complications directly related to their surgery.

CONCLUSIONS

The overall morbidity and mortality rates after radical cystectomy in a population-based sample were comparable to those reported from individual centers. Larger centers in urban locations may have lower complication rates but only hospitals performing a high volume of cystectomies were associated with fewer primary surgery-related complications.

Comparative Outcomes of Bladder Cancer

OBJECTIVE

To compare the survival of women and men with transitional cell bladder cancer.

METHODS

We used the Surveillance Epidemiology and End Results database to identify patients aged 35 years or older diagnosed with bladder cancer between 1991 and 2001 actively followed up. We excluded cases diagnosed by autopsy or death certificates and those of unknown race. We used Cox proportional hazard regression to analyze survival in patients with advanced disease.

RESULTS

Of the 31,009 patients meeting eligibility criteria, 26.7% were women. Median age at diagnosis for women and men was 72 and 70 years, respectively. Regional disease was diagnosed in 20.3% of white women and 35.5% of African-American women, compared with only 17.6% of white men and 25.9% of African-American men (P < .001). Increased age, African-American race, and being female significantly increased the hazard of death (hazard ratio [HR] 1.037, 95% confidence interval [CI] 1,034-1.041; HR 1.402, 95% CI 1.187-1.656; and HR 1.842, 95% CI 1.158-2.931).

CONCLUSION

Women with bladder cancer, particularly African-Americans, have shorter survival. This is partially explained by higher risk of diagnosis with poorly differentiated tumors, advanced stage, and advanced age. Women should be targeted for timely diagnosis.

LEVEL OF EVIDENCE

II-2.