Complication Rate after Radical Cystectomy Depends on the Surgical Technique and Patient's Clinical Status.

PURPOSE: This study aimed to explore the complication rates of radical cystectomy in patients with muscle-invasive bladder cancer and identify potential risk factors. METHODS: A total of 553 patients were included: 131 were operated on via an open approach (ORC), 242 patients via a laparoscopic method (LRC), and 180 by a robot-assisted procedure (RARC). Patient age, gender, American Society of Anesthesiologists (ASA) score, urinary diversion type, preoperative albumin level, body mass index (BMI), pathological (TNM) stage, and surgical times were collected. The severity of complications was classified according to the Clavien-Dindo scale (Grades 1-5). RESULTS: The surgical technique was significantly related to the number of complications (p < 0.00005). Grade 1 complications were observed most frequently following LRC (52.5%) and RARC (51.1%), whereas mostly Grade 2 complications were detected after ORC (78.6%). Those with less severe complications had significantly higher albumin levels than those with more severe complications (p < 0.05). Patients with an elevated BMI had fewer complications if a minimally invasive approach was used rather than ORC. The patient's general condition (ASA score) did not impact the number of complications, and urinary diversion type did not affect the severity of the complications. Mean surgical time differed according to the urinary diversion type in patients with a similar TNM stage (p < 0.005); however, no difference was found in those with more locally advanced disease. Longer operation time and lower protein concentration were associated with higher probability of complication rate, that is, Clavien-Dindo score 3-5. CONCLUSIONS: The risk of complications after RC is not related to the type of urinary diversion, and can be reduced by using a minimally invasive surgical technique, especially in patients with high BMI.

A Personalized Approach to Radical Cystectomy Can Decrease Its Complication Rates.

The aim of this study was to assess the influence of a patient's general status on perioperative morbidity and mortality after radical cystectomy, and to assess which of the used scales is best for the prediction of major complications. The data of 331 patients with muscle-invasive bladder cancer, who underwent radical cystectomy, were analyzed. The general status was assessed according to the American Society of Anesthesiologists (ASA), Charlson Comorbidity Index (CCI), Eastern Cooperative Oncology Group (ECOG), and Geriatric-8 (G-8) scales. Complications were classified according to the Clavien-Dindo classification system. In a group of patients with the highest complication rate according to the Clavien-Dindo scale, (i) statistically more patients rated high according to the ASA and ECOG scales, (ii) patients had significantly higher CCI scores (minor complications (I-II), and (iii) there were significantly more patients rated as frail with G8-predominantly those with 11 points or fewer in the scale. A patient's general status should be assessed before the start of therapy because patients with a high risk of death or serious complications (evaluated with any rating scale) should be offered conservative treatment. None of the scales can describe the risk of cystectomy, because the percentage of patients with major complications among those who achieved worse score results on any scale was not significantly different from the percentage of patients with major complications in the general group.

A Comprehensive Approach to Clinical Staging of Bladder Cancer.

BACKGROUND: A significant number of patients with advanced urothelial cell carcinoma are under- or over-staged. Implementation of clinical variables could be useful for improving the accuracy of clinical staging. AIM: To explore the differences between clinical and pathological diagnosis in patients with UCC, and to identify clinical variables that might play a role in under- or overstating. MATERIALS: A total of 553 patients after radical cystectomy were included in the analysis. Clinical stage of the disease was diagnosed according to CT or MRI in relation to clinical data. RESULTS: Higher clinical stage correlated with a higher pathological stage (p < 0.00005), but in 306 patients did not correspond (142 patients were under-staged and 164 over-staged). Over half (54.2%) of the patients staged as cT1-cT2 were misdiagnosed: 137 patients were under-staged and 133 over-staged. Hydronephrosis was associated with a higher pathological stage (p < 0.000005), mostly pT3-4 (45.13% had pT4 disease) and higher risk of nodal metastasis (p = 0.0028). The highest percentage of PSM was found in patients with pT4 (33.12%). CONCLUSIONS: Clinical staging of bladder cancer is poorly executed, with one third of patients under-staged and one third over-staged. To improve accuracy, we recommend a multimodal approach, combining histopathological evaluation with results of imaging studies.

Age and risk of major complications in patients undergoing radical cystectomy for muscle invasive bladder cancer.

INTRODUCTION: Radical cystectomy is the treatment of choice for patients with muscle invasive bladder cancer (MIBC), but it may be unsafe in older patients. AIM: In this study, we investigated whether age and selected clinical characteristics were associated with outcomes of radical cystectomy. MATERIAL AND METHODS: We enrolled 434 patients with MIBC who underwent radical cystectomy between 2012 and 2016, and we classified them into three age groups: < 65, 66-74, and ≥ 75 years. Postoperative complications were classified on the Clavien-Dindo scale. Regression models were used to find predictors of major postoperative complications (Clavien-Dindo score of 3 or more), long hospital stay (> 7 days), blood loss, and operating time. The models included American Society of Anesthesiologists scores, age group, sex, body mass index, Tumor Nodes Metastasis scores, type of urine derivation (ileal conduit or orthotopic bladder vs. ureterocutaneostomy), and operation type (open vs. laparoscopic). RESULTS: In the regression models, age was not a significant predictor of major complications, long hospital stay, or blood loss (p ≥ 0.206). Older age was associated with shorter surgery times (p = 0.002). Higher preoperative American Society of Anesthesiologists scores tended to be associated with a greater risk of major complications (odds ratio, 1.47; p = 0.092). CONCLUSIONS: Older age was not associated with an increased risk of major complications in patients who undergo radical cystectomy because of MIBC. Therefore, older age alone should not be a contraindication to this operation.

Can laparoscopic cystectomy become the method of choice in the treatment of invasive urothelial urinary bladder cancer?

BACKGROUND: Radical cystectomy with pelvic lymphadenectomy is the method of choice for muscle-invasive urothelial cell cancer (UCC) treatment and provides the best cancer-specific survival. It can be performed as an open radical cystectomy (ORC), laparoscopic radical cystectomy (LRC) or robot-assisted surgery (RARC). OBJECTIVES: The aim of this study was to compare laparoscopic and open radical cystectomy in terms of perioperative and oncological results. MATERIAL AND METHODS: This retrospective study included 260 patients who underwent surgery due to invasive bladder cancer. A laparoscopic radical cystectomy (LRC) was performed on 131 patients and an open radical cystectomy (ORC) on 129 patients. Group was stratified according to the urinary diversion. Oncologic results expressed as perioperative variables were analyzed, adjusted to the type of urinary diversion. RESULTS: The LRC patients were in worse perioperative condition according to the American Society of Anesthesiologists (ASA) score than the ORC group (3.1 and 2.52, respectively; p = 0.001). The serum protein level was significantly lower in the ORC group, with no difference in body mass index (BMI) between the groups. The median operation time was significantly shorter in the LRC group with ileal conduit and uretero-cutaneostomy than in the same groups operated using open approach (252.5 min and 180 min vs 290 min and 225 min, respectively), as was the hospital discharge time (8.18 days and 11.63 days, respectively; p = 0.004). In both LRC groups, median blood loss was lower, compared with corresponding ORC groups (325 mL and 400 ml vs 800 mL and 1,100 mL, respectively; p < 0.001 in both cases). The level of complications was significantly lower in both LRC groups than in the ORC groups (p < 0.001 and p = 0.001, respectively). The lymph node yield was 12 in the LRC group and 10 in the ORC group. The LRC group had a lower positive surgical margins ratio. CONCLUSIONS: The laparoscopic approach should be a valid option for radical cystectomy, given the fewer complications, smaller blood loss, and shorter operating and hospitalization times experienced by patients who underwent a laparoscopic cystectomy.

Correlation between malnutrition, body mass index and complications in patients with urinary bladder cancer who underwent radical cystectomy.

BACKGROUND: Nutrition is the 3rd most important factor in surgery, following anesthesia and asepsis. Until now, it has been a poorly explored field of urology. The relationship between malnutrition and postoperative complications has been proven beyond doubt in general surgery, where 30% of patients are operated in a malnutrition state. OBJECTIVES: The aim of our work was to assess the influence of malnutrition, defined by nutritional risk screening (NRS) scale and body mass index (BMI), on postoperative results in patients with bladder cancer after radical cystectomy. MATERIAL AND METHODS: The research was carried out at 8 urological centers between 2012 and 2014, and included patients with bladder cancer at stage from T2 to T4, who underwent radical cystectomy. The degree of malnutrition was assessed with the aid of the NRS 2002 questionnaire. Other examined parameters were BMI, age, type of operation, and the number of complications, the latter of which were measured by applying the Clavien-Dindo scale. RESULTS: A total of 125 patients were enrolled in our study, out of whom 64 (51.2%) were undernourished. According to the BMI, most of the patients were overweight - 50 (40%) or had normal body weight - 49 (39.2%); 24 (19.2%) were obese, and 2 (1.6%) were underweight. CONCLUSIONS: There was no relationship between malnutrition, defined by the NRS scale, and postoperative complications, and we did not find a significant relationship between the other tested variables. We observed only 1 significant relationship between the nutrition state, measured by BMI scale, and the degree in Clavien-Dindo scale. Body mass index under 18.5 and over 30 increased postoperative complications. Nowadays, the recommended scale is NRS 2002, which is based mostly on loss of weight. In our patients, qualitative malnutrition is more probable than quantitative malnutrition.