Perioperative Strategies to Reduce Postoperative Complications After Radical Cystectomy

Efficacy and Safety of Stroke Volume Variation-Guided Fluid Therapy for Reducing Blood Loss and Transfusion Requirements During Radical Cystectomy: A Randomized Clinical Trial

Radical cystectomy, which is performed to treat muscle-invasive bladder tumors, is among the most difficult urological surgical procedures and puts patients at risk of intraoperative blood loss and transfusion. Fluid management via stroke volume variation (SVV) is associated with reduced intraoperative blood loss. Therefore, we evaluated the efficacy and safety of SVV-guided fluid therapy for reducing blood loss and transfusion requirements in patients undergoing radical cystectomy.This study included 48 patients who underwent radical cystectomy, and these patients were randomly allocated to the control group and maintained at <10% SVV (n = 24) or allocated to the trial group and maintained at 10% to 20% SVV (n = 24). The primary endpoints were comparisons of the amounts of intraoperative blood loss and transfused red blood cells (RBCs) between the control and trial groups during radical cystectomy. Intraoperative blood loss was evaluated through the estimated blood loss and estimated red cell mass loss. The secondary endpoints were comparisons of the postoperative outcomes between groups.A total of 46 patients were included in the final analysis: 23 patients in the control group and 23 patients in the trial group. The SVV values in the trial group were significantly higher than in the control group. Estimated blood loss, estimated red cell mass loss, and RBC transfusion requirements in the trial group were significantly lower than in the control group (734.3 ± 321.5 mL vs 1096.5 ± 623.9 mL, P = 0.019; 274.1 ± 207.8 mL vs 553.1 ± 298.7 mL, P <0.001; 0.5 ± 0.8 units vs 1.9 ± 2.2 units, P = 0.005). There were no significant differences in postoperative outcomes between the two groups.SVV-guided fluid therapy (SVV maintained at 10%-20%) can reduce blood loss and transfusion requirements in patients undergoing radical cystectomy without resulting in adverse outcomes. These findings provide useful information for optimal fluid management during radical cystectomy.

Critical Review of Outcomes from Radical Cystectomy: Can Complications from Radical Cystectomy Be Reduced by Surgical Volume and Robotic Surgery?

CONTEXT

Radical cystectomy (RC) is a highly complex procedure with multiple risks for perioperative complications.

OBJECTIVE

We reviewed the literature to report perioperative outcomes and the incidence of complications in contemporary RC series. We focused on the potential impact of surgical approach and surgeon volume on these outcomes.

EVIDENCE ACQUISITION

A systematic literature search was performed in December 2015 using the Medline, Embase, and Web of Science databases for articles published in English between 2005 and 2015. The search strategy included the terms complications, cystectomy, robotic assisted radical cystectomy, and surgical volume, alone or in combination. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed.

EVIDENCE SYNTHESIS

Our searches retrieved 49 papers. Open RC (ORC) and robot-assisted RC (RARC) are morbid procedures with consistent risk of perioperative complications (mean weighted incidence: 48.7%; range: 27.0-72.5%). Higher hospital and surgeon volumes were associated with reduced risks of perioperative complications. Prior robotic expertise in radical prostatectomy showed a beneficial protective risk on development of complications after RARC. Surgical volume appears to be a good predictor of safety in ORC and RARC. RARC is associated with reduced estimated blood loss and lower perioperative transfusion rates compared with ORC. Further evidence is needed to support the reproducibility of intracorporeal diversion during RARC, beyond large tertiary referral centers. Several strategies have been demonstrated to be effective for reducing the risk of incurring perioperative complications and should be pursued by physicians.

CONCLUSIONS

Despite improvements in quality of care, RC remains a challenging procedure with high morbidity, regardless of surgical approach. RARC is a safe procedure with potential advantages in terms of reduced blood loss and transfusion rates. Surgical volume appears to be related to the improvement of perioperative outcomes and complications.

PATIENT SUMMARY

Radical cystectomy is a challenging and morbid procedure. The robotic approach has gained popularity and proved to be safe and effective in tertiary referral centers, although further studies are needed to confirm its wide reproducibility. Centers with higher surgical volume have lower incidence of perioperative complications.