Perioperative outcomes of goal-directed versus conventional fluid therapy in radical cystectomy with enhanced recovery protocol

Does the Administration of Intravenous Fluid Matter in the Context of the Incidence of Postoperative Complications After Radical Cystectomy?

Introduction: Intravenous fluid management is integral to perioperative care, particularly under enhanced recovery after surgery (ERAS) protocols. In radical cystectomy (RC), which carries high risks of complications and mortality, optimizing fluid management poses a significant challenge due to the absence of definitive guidelines. Aim: the purpose of this study was to investigate the effects of intravenous fluid administration on postoperative complications in patients undergoing RC. Material and methods: This study involved 288 patients who underwent laparoscopic RC and urinary diversion from 2018 to 2022. ERAS protocols were implemented for all patients. Participants were divided into four groups based on the type of urinary diversion (ureterocutaneostomy vs. ileal conduit) and the intraoperative fluid volume input (less than 1000 mL vs. more than 1000 mL). Postoperative complications were evaluated at 30 and 90 days post-surgery using the Clavien-Dindo scale. The fluid management effectiveness was measured using the absolute Vascular Bed Filling Index (aVBFI) and the adjusted Vascular Bed Filling Index (adjVFBI). Results: The UCS is associated with a lower risk of increased severity of postoperative complications. The administration of more than 1000 mL of fluids was associated with a higher risk of complications (p = 0.035). However, after adjusting for the duration of the surgery and BMI, this association did not hold statistical significance, indicating that fluid volume alone is not a direct predictor of postoperative complications. At aVBFI values between zero and eight, urinary diversion using the UCS method is associated with a lower risk of complications compared to the IC. When aVBFI equals eight, the differences in the severity of complications between the UCS and the IC are minimal. However, when aVBFI exceeds eight, the IC is associated with fewer complications during the 30 days post-operation compared to the UCS. The correlation between the adjVFBI (B = -0.27; 95% CI: -0.45 to -0.08; p = 0.005) and the severity of complications up to 30 days postoperatively is similar to that seen with the aVBFI. Similarly, the correlation of the adjVFBI with the method of urinary diversion (B = 0.24; 95% CI: 0.06 to 0.43; p = 0.011) resembles that of the aVBFI. The volume of fluids administered and the indices aVBFI and adjVFBI did not influence the occurrence of complications 90 days postoperatively. Conclusions: The volume of fluids administered is not a factor directly affecting the occurrence of complications following RC when the ERAS protocol is used. The amount of intraoperative fluid administration should be adjusted according to the intraoperative blood loss. Our findings endorse the utility of aVBFI and adjVFBI as valuable tools in guiding fluid therapy within the framework of ERAS protocols. However, further multicenter randomized trials are needed to definitively determine the best fluid therapy regimen for patients undergoing RC.

Survival of Patients with Chronic Kidney Disease Treated with Radical Cystectomy and Risk Factors of Glomerular Filtration Rate Loss Following Radical Cystectomy: Two Systematic Reviews and Meta-analyses of Interplay Between Radical Cystectomy and Renal Function

CONTEXT

There is no high-level evidence regarding the risk factors of glomerular filtration rate (GFR) loss following radical cystectomy (RC) and survival outcomes of patients with chronic kidney disease (CKD) undergoing RC.

OBJECTIVE

To identify the risk factors of CKD in patients treated with RC for bladder cancer and to assess overall and oncological survival of patients with CKD who underwent RC.

EVIDENCE ACQUISITION

According to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement, two systematic reviews were performed for studies published before September 30, 2022, assessing (1) risk factors of renal function (RF) decline following RC and (2) overall and oncological outcomes of CKD patients treated with RC.

EVIDENCE SYNTHESIS

A total of 21 and 17 studies were included for qualitative and quantitative syntheses, respectively. The first meta-analysis of ten studies (15 502 patients) identified these factors to be significantly associated with GFR loss following RC: advanced age, lower baseline RF, higher Charlson Comorbidity Index (CCI), diabetes mellitus, hypertension, postoperative hydronephrosis, ureteroenteric stricture, and locally advanced disease (hazard ratios [HRs] 1.03, 1.22, 1.5, 1.27, 1.24, 1.69, 1.92, and 5.13, respectively), while sex, preoperative hydronephrosis, perioperative chemotherapy, and diversion type were not. The second meta-analysis of seven studies (6900 patients) demonstrated significantly worse metastasis-free, cancer-specific, and overall survival in patients with higher CKD stages than in those with lower stages (HRs 1.54, 2.09, and 1.47, respectively).

CONCLUSIONS

Current evidence suggests that older age, lower baseline RF, higher CCI, diabetes mellitus, hypertension, postoperative hydronephrosis, ureteroenteric stricture, and locally advanced disease are associated with long-term GFR loss following RC. In addition, patients with higher stages of CKD have worse long-term overall and oncological outcomes following RC. These data may help in counseling and decision-making regarding therapy and preventive measures.

PATIENT SUMMARY

Several factors have been identified that can help identify patients at risk for glomerular filtration rate loss after radical cystectomy (RC). Chronic kidney disease is associated with poor cancer- and non-cancer-specific outcomes following RC.

The effect of goal-directed hemodynamic therapy on clinical outcomes in patients undergoing radical cystectomy: a randomized controlled trial

BACKGROUND

This study investigated the effects of intraoperative goal-directed hemodynamic therapy (GDHT) on postoperative outcomes in patients undergoing open radical cystectomy.

METHODS

This prospective, single-center, randomized controlled trial included 82 patients scheduled for open radical cystectomy between September 2018 and November 2021. The GDHT group (n = 39) received the stroke volume index- and cardiac index-based hemodynamic management using advanced hemodynamic monitoring, while the control group (n = 36) received the standard care under the discretion of attending anesthesiologists during surgery. The primary outcome was the incidence of a composite of in-hospital postoperative complications during hospital stays.

RESULTS

A total of 75 patients were included in the final analysis. There was no significant difference in the incidence of in-hospital postoperative complications (28/39 [71.8%] vs. 30/36 [83.3%], risk difference [95% CI], -0.12 [-0.30 to 0.07], P = 0.359) between the groups. The amounts of intraoperative fluid administered were similar between the groups (2700 [2175-3250] vs. 2900 [1950-3700] ml, median difference [95% CI] -200 [-875 to 825], P = 0.714). The secondary outcomes, including the incidence of seven major postoperative complications, duration of hospital stay, duration of intensive care unit stay, and grade of complications, were comparable between the two groups. Trends in postoperative estimated glomerular filtration rate, serum creatinine, and C-reactive protein did not differ significantly between the two groups.

CONCLUSIONS

Intraoperative GDHT did not reduce the incidence of postoperative in-hospital complications during the hospital stay in patients who underwent open radical cystectomy.

TRIAL REGISTRATION

This study was registered at http://www.

CLINICALTRIALS

gov (Registration number: NCT03505112; date of registration: 23/04/2018).

Implication of age-related changes on anesthesia management

Elderly patients have a high risk of perioperative morbidity and mortality. Pluri-morbidities, polypharmacy, and functional dependence may have a great impact on intraoperative management and request specific cautions. In addition to surgical stress, several perioperative noxious stimuli such as fasting, blood loss, postoperative pain, nausea and vomiting, drug adverse reactions, and immobility may trigger a derangement leading to perioperative complications. Older patients have a high risk of major hemodynamic derangement due to aging of the cardiovascular system and associated comorbidities. The hemodynamic monitoring as well as fluid therapy should be the most accurate as possible. Aging is accompanied by decreased renal function, which is related to a reduction in renal blood flow, renal mass, and the number and size of functioning nephrons. Drugs eliminated predominantly by the renal route need dosage adjustments based on residual renal function. Liver mass, hepatic blood flow, and intrinsic metabolic activity are decreased in the elderly, and all drugs metabolized by the liver have a variable half-life, thus requiring dose reduction. Decreased neural plasticity contributes to a high risk for postoperative delirium. Monitoring of anesthesia depth should be mandatory to avoid overdosage of hypnotic drugs. Prevention of postoperative pulmonary complications requires both protective ventilation strategies and adequate recovery of neuromuscular function at the end of surgery. Avoidance of hypothermia cannot be missed. The aim of this review is to describe comprehensive strategies for intraoperative management plans tailored to meet the unique needs of elderly surgical patients, thus improving outcomes in this vulnerable population.

Association between early postradical cystectomy kidney injury and perioperative outcome in enhanced recovery era

OBJECTIVE

To evaluate the incidence and predictors of early postoperative acute kidney injury (EP-AKI) during index hospitalization following radical cystectomy and its association with postoperative outcomes.

METHODS

All patients with bladder cancer who underwent radical cystectomy with intent-to-cure at our center between 2012 and 2020 were reviewed. EP-AKI during index hospitalization was evaluated using the Acute Kidney Injury Network criteria. The association between EP-AKI and demographics, clinicopathologic features, and perioperative outcomes, including length of hospital stay, complication rate, and readmission rate, were examined. A logistic regression analysis was performed to evaluate the predictors of EP-AKI.

RESULTS

Overall, 435 patients met eligibility, of whom 112 (26%) experienced EP-AKI during index hospitalization (90 [21%] stage 1, 17 [4%] stage 2, and 5 [1%] stage 3). EP-AKI was associated with a longer mean operative time (6.8 vs. 6.1 hours; P < 0.001), higher mean length of hospital stay (6.3 vs. 5.6; P = 0.02), 30-day complication rate (71% vs. 51%; P < 0.001), 90-day complication rate (81% vs. 69%; P = 0.01) and 90-day readmission rate (37% vs. 33%; P = 0.04). The rate of complications increased at higher stages of AKI. On multivariable analysis, perioperative blood transfusion (OR: 1.84, P = 0.02) and continent diversion (OR: 3.29, P < 0.001) were independent predictors of EP-AKI.

CONCLUSION

A quarter of cystectomy patients experience acute kidney injury during index hospitalization, which is associated with higher length of stay, postoperative complication, and readmission rates. Perioperative blood transfusion and continent diversion are independent predictors of such injury.

Application of a protocol for enhanced recovery after radical cystectomy: a before-and-after cohort study

PURPOSE

Radical cystectomy with urinary diversion is a major urological surgery burdened both by a high rate of short- and long-term complications and by a high emotional and psychological impact. Post-operative recovery is extremely important and the application of ERAS protocols can facilitate the return to functional autonomy. The aim of the present study was to verify the efficacy of our ERAS programme on outcomes of recovery after surgery of patients undergoing radical cystectomy with various urinary diversions.

METHODS

This is a before-after study comparing the historical group (n. 77) of radical cystectomies following a peri-operative standard of care with the prospective observational group (n. 83) following our ERAS programme. Recovery after surgery outcomes evaluated were length of stay, re-admission rate at 30-90/days and post-operative complications.

RESULTS

Patients treated following the ERAS protocol presented less intra-operative blood loss (p < 0.001) and less intra-operative fluid infusions (p < 0.001). Time of first flatus was shorter in the ERAS group, though no difference was found in timing of nasogastric tube removal and defecation. Removal of drainage was done significantly earlier in the ERAS group. The median length of stay decreased from 12 to 9 days (p = 0.003) with a significant reduction also in re-admission rates at 30 and long-term complications at 90 days from surgery.

CONCLUSION

The application of an opioid-free ERAS protocol to patients undergoing open radical cystectomy was associated, as compared with prior traditional care, with significant reductions of recovery time and length of stay, number of total in-hospital complications, in particular functional ileus and re-admissions by 30 and 90 days after surgery.

Goal-Directed Fluid Therapy Does Not Impact Renal Outcomes in an Enhanced Recovery Program

BACKGROUND

Goal-directed fluid therapy (GDFT) has been proposed as a cornerstone for Enhanced Recovery After Surgery (ERAS) programs, particularly among high-risk patients undergoing high-risk surgery. However, due to the increased advocacy of euvolemia before surgery, the utility of GDFT in the context of ERAS is being questioned. Our primary objective was to determine whether GDFT has any impact on daily postoperative renal outcomes among high-risk patients undergoing thoracic surgery in an ERAS program.

METHODS

All patients included in this study were high-risk with a baseline GFR below 90 mL/min/1.73m² and classified as American Society of Anesthesiologists status III/IV. Patients were categorized into two groups according to the intraoperative use of GDFT. Both groups were matched in a 1:1 fashion using propensity scores. Our renal outcomes included changes in daily glomerular filtration rates (GFRs) from post-anesthesia care unit through postoperative day 5.

RESULTS

In total 451 matched pairs were included in this analysis. Both groups had similar demographics and clinical characteristics. Patients treated with GDFT received more ephedrine (5mg [0-15] vs 0mg [0-15], P=0.03) and less volume of fluids (1163±484mL vs 1246±626mL, P=0.03) compared to those in the standard group. The incidence of AKI was similar in both groups (5.1% in the GDFT group vs 7.1% in non-GDFT group, P=0.57). Mixed effect analysis showed no significant differences in the trajectory of postoperative GFRs between both groups (P=0.59).

CONCLUSIONS

GDFT does not impact postoperative renal function compared to standard of care among high-risk patients in an ERAS program for thoracic pulmonary surgery.

Updates on enhanced recovery after surgery for radical cystectomy

Enhanced Recovery after Surgery (ERAS) is a multimodal pathway that provides evidence-based guidance for improving perioperative care and outcomes in patients undergoing surgery. In 2013, the ERAS society released its original guidelines for radical cystectomy (RC) for bladder cancer (BC), adopting much of its supporting data from colorectal literature. In the last decade, growing interest in ERAS has increased RC-specific ERAS research, including prospective randomized controlled trials (RCTs). Collective data suggest ERAS contributes to improved complication rates, decreased hospital length-of-stay, and/or time to bowel recovery. Various institutions have adopted modified versions of the ERAS pathway, yet there remains a lack of consensus on the efficacy of specific ERAS items and standardization of the protocol. In this review, we summarize updated evidence and practice patterns of ERAS pathways for RC since the introduction of the original 2013 guidelines. Novel target interventions, including use of immunonutrition, prehabilitation, alvimopan, and methods of local analgesia are reviewed. Finally, we discuss barriers to implementing and future steps in advancing the ERAS movement.