Perioperative blood transfusion in radical cystectomy: Analysis of the National Surgical Quality Improvement Program database

Impact of Smoking Habit on Perioperative Morbidity in Patients Treated with Radical Cystectomy for Urothelial Bladder Cancer: A Systematic Review and Meta-analysis

CONTEXT

Smoking habit at the time of surgery is associated with higher perioperative complications and mortality across different types of surgeries. In recent years, several studies have attempted to explore the influence of smoking on perioperative outcomes following radical cystectomy (RC) for urothelial bladder cancer (UBC) with contradictory results.

OBJECTIVE

To systematically investigate and meta-analyze the association between smoking habit and perioperative morbidity and mortality in UBC patients treated with RC.

EVIDENCE ACQUISITION

A systematic review of the literature published between January 2000 and January 2020 investigating the impact of smoking habit on perioperative outcomes of patients treated with RC for UBC was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and the Cochrane Handbook for Systematic Reviews of Interventions.

EVIDENCE SYNTHESIS

Overall, 27 articles involving 27 854 patients were included in the systematic review, and of these, 11 studies were included in the meta-analysis. The studies included showed a moderate to high risk of bias. Smoking status (smokers vs nonsmokers) was significantly associated with the onset of major postoperative complications (hazard ratio [HR] 1.87, 95% confidence interval [CI] 1.51-2.32; I2 = 0%), infections (HR 1.34, 95% CI 1.02-1.72; I2 = 66.2%), and mortality (HR 1.84, 95% CI 1.14-2.98; I2 = 4.9%).

CONCLUSIONS

Smoking status at the time of RC is associated with increased risk for major postoperative complications, infections, and mortality. These results suggest the need for strict postoperative monitoring in smokers due to the increased risk of experiencing adverse events and underline the need for intensive smoking cessation interventions in the preoperative setting.

PATIENT SUMMARY

In this study, we reviewed the impact of smoking habit on perioperative outcomes following radical cystectomy (RC). Based on the available data, the impact of smoking on morbidity and mortality after RC is significant and relevant; as such, every effort should be made in the preoperative setting to encourage smoking cessation.

Predictors for Perioperative Blood Transfusion in Patients Undergoing Open Cystectomy and Urinary Diversion and Development of a Nomogram: An Observational Cohort Study

Open radical cystectomy is associated with a substantial rate of perioperative blood transfusion. Early detection of potentially modifiable perioperative factors could reduce the need for perioperative blood transfusion and thus positively impact the outcome. We conducted an observational, single-center cohort study of 1168 patients undergoing cystectomy. Perioperative blood transfusion was defined as the need for packed red blood cells and/or fresh frozen plasma units within the first 24 h after the initiation of surgery. Multiple logistic regression analysis was performed to model the association between risk factors and blood transfusion, and a nomogram was developed. Blood transfusion occurred in 370/1168 patients (31.7%). Significant predictors were age (OR: 1.678, (95% CI: 1.379–2.042); p < 0.001), blood loss ratio (6.572, (4.878–8.853); p < 0.001), preoperative hemoglobin (0.316, (0.255–0.391); p < 0.001), tumor stage (2.067, (1.317–3.244); p = 0.002), use of oral anticoagulants (2.70, (1.163–6.270), p = 0.021), and interaction between female sex and blood loss ratio (1.344, (1.011–1.787); p = 0.042). Of the major predictors found to affect perioperative blood transfusion, two can be influenced: blood loss ratio by meticulous surgery and hemoglobin by preoperative optimization. Others such as age or advanced disease are not modifiable. This emphasizes the importance of optimal management of patients prior to surgery.

Patterns and timing of perioperative blood transfusion and association with outcomes after radical cystectomy

BACKGROUND

Perioperative blood transfusion (PBT) has been associated with worse outcomes across tumor types, including bladder cancer. We report our institutional experience with PBT utilization in the setting of radical cystectomy (RC) for patients with bladder cancer, exploring whether timing of PBT receipt influences perioperative and oncologic outcomes.

METHODS

Consecutive patients with bladder cancer treated with RC were identified. PBT was defined as red blood cell transfusion during RC or the postoperative admission. Clinicopathologic and peri and/or postoperative parameters were extracted and compared between patients who did and did not receive PBT using Mann Whitney U Test, chi-square, and log-rank test. Overall (OS) and recurrence-free survival (RFS) were estimated with the Kaplan Meier method. Univariate/multivariate logistic and Cox proportional hazards regression were used to identify variables associated with postoperative and oncologic outcomes, respectively.

RESULTS

The cohort consisted of 747 patients (77% men; median age 67 years). Median follow-up was 61.5 months (95% CI 55.8-67.2) At least one postoperative complication (90-day morbidity) occurred in 394 (53%) patients. Median OS and RFS were 91.8 months (95% CI: 76.0-107.6) and 66.0 months (95% CI: 48.3-83.7), respectively. On multivariate analysis, intraoperative, but not postoperative, BT was independently associated with shorter OS (HR: 1.74, 95% CI: 1.32-2.29) and RFS (HR: 1.55, 95%CI: 1.20-2.01), after adjusting for relevant clinicopathologic variables. PBT (intra- or post- operative) was significantly associated with prolonged postoperative hospitalization ≥10 days.

CONCLUSIONS

Intraoperative BT was associated with inferior OS and RFS, and PBT overall was associated with prolonged hospitalization following RC. Further studies are needed to validate this finding and explore potential causes for this observation.

Clinical markers of morbidity, mortality and survival in bladder cancer patients treated with radical cystectomy. A systematic review

Context: Radical cystectomy and pelvic lymph node dissection (RC and PLND) are an essential part of the treatment paradigm in high risk bladder cancer. However, these patients have high rates of morbidity and mortality related both to the treatment and to the disease.Objective: To provide overview of current literature about clinical markers that can be used to predict and improve BC-patient outcomes at the time of RC and PLND and to study if they are properly validated.Evidence acquisition: A systematic literature search was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria between January 1990 and October 2018 to identify English written original and review articles relevant to this topic. Prospective and retrospective studies were included.Evidence synthesis: There are several risk factors identified from non-randomised trials that can be improved before surgery to reduce perioperative mortality and morbidity. These include poor nutritional status, anaemia, renal function and smoking. Preoperative nomograms have also been developed to help decision-making and to inform patients about the risks of surgery. They can be used to estimate risk of postoperative mortality after RC and PLND with accuracy varying from 70 to 86%. These nomograms are largely based on retrospective data. Likewise, nomograms developed to calculate estimates about patient's overall and cancer specific survival have the same limitations.Conclusion: Clinical markers to predict morbidity, mortality and survival in patients with bladder cancer treated with RC and PLND may help to improve patient outcomes and treatment decision-making, but available data come from small retrospective trials and have not been properly validated. Prospective, multi-centre studies are needed to implement and disseminate predictive clinical markers and nomograms such that they can be utilised in treatment decision-making in daily practice.

The PT2D-Score: a novel tool to predict complications and economic outcome after radical cystectomy

BACKGROUND

Radical cystectomy (RC) has a high morbidity and leads to a significant socio-economic burden. We aimed to investigate pre-, intra-, and post-operative variables to create a novel score predicting both post-operative clinical (complications) and economic (length of hospital stay) outcome after RC.

METHODS

We retrospectively evaluated clinical and histopathological data of 317 patients after RC. We performed univariate and multivariate logistic regression analyses to identify variables associated with post-operative clinical (30-day morbidity according to Clavien-Dindo complications) and economic (length of hospital stay) outcome.

RESULTS

In multivariate analysis, a high number of intraoperative transfusions (T) of packed red blood cells predicted major complications (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.10-2.58, p = 0.017), preoperative potassium (P) level predicted three or more complications (OR for high preoperative potassium 0.71, 95% CI 0.52-0.98, p = 0.037), and high drain (D) loss on post-operative day 1 predicted a longer hospital stay ≥ 22 days (OR 1.57, 95% CI 1.04-2.35, p = 0.003). The PT₂D-Score was able to predict three or more complications (area under the curve: 0.70, 95% CI 0.61-0.78, p < 0.001) and a hospital stay of ≥ 22 days in patients after radical cystectomy (area under the curve: 0.63, 95% confidence interval 0.53-0.72, p = 0.012).

CONCLUSIONS

The novel PT₂D-Score combines preoperative potassium level, intraoperative blood transfusion, and post-operative drain loss to predict both clinical (30-day morbidity) and economic (length of hospital stay) outcome for patients undergoing RC. After validation in a larger cohort, the novel PT₂D-Score might serve as an additional criterion to identify patients for intensified monitoring after RC.

Anesthetic considerations for urologic surgeries

Urologic surgeries are widely performed, and the cases have increased owing to the fact that the elderly population is growing. The narrow and limited surgical space is a challenge in performing most urologic surgeries. Additionally, the elderly population is exposed to the risk of perioperative complications; therefore, a comprehensive understanding and approach are required to provide optimized anesthesia during surgery. We have searched the literature on anesthesia for urologic surgeries and summarized the anesthetic considerations for urologic surgeries.

Preoperative anemia and extensive transfusion during stay-in-hospital are critical for patient`s mortality: A retrospective multicenter cohort study of oncological patients undergoing radical cystectomy

BACKGROUND

Preoperative anemia and allogeneic blood transfusions (ABTs) may affect outcomes in cancer surgery. The prevalence of anemia, the use of ABTs, the risks of transfusions, lengths of stay and mortality of oncological patients undergoing radical cystectomy were investigated in three University Hospitals in Germany.

PATIENTS AND METHODS

Hospital records of 220 consecutive patients undergoing radical cystectomy from 2010 to 2012 were retrospectively analyzed for independent risk factors of ABT and unfavorable outcomes (readmission, increased length of stay (LOS) or death) using multivariate regression analysis.

RESULTS

Preoperative anemia was present in 40%. 70% of patients received blood transfusions. Low preoperative and intraoperative nadir hemoglobin levels were associated with receipt of ABT (OR 1.33, P = 0.04 and OR 2.94, P < 0.001 respectively). Transfusion of ten or more red blood cell units (RBCs) during the entire hospital stay was a predictor of an increased LOS (P < 0.001) and death (OR 52, 95%CI [5.9, 461.3], P < 0.001), compared to non-transfused patients. Preoperative ABT and ASA scores were associated with ≥10RBCs.

CONCLUSION

Anemic patients undergoing radical cystectomy had a high risk to receive ABTs. Preoperative transfusions and transfusion of ≥10RBCs during the entire hospital stay may increase patient`s mortality. Prospective, randomized controlled studies have to follow this study.

Impact of Packed Red Blood Cells and Fresh Frozen Plasma Given During Radical Cystectomy and Urinary Diversion on Cancer-related Outcome and Survival: An Observational Cohort Study

BACKGROUND

The relationship between blood transfusion and cancer-related outcome and mortality is controversial.

OBJECTIVE

To assess if perioperative administration of packed red blood cell (PRBC) and fresh frozen plasma (FFP) units affects disease progression and survival after radical cystectomy for bladder cancer.

DESIGN, SETTING, AND PARTICIPANTS

We conducted an observational single-centre cohort study of a consecutive series of 885 bladder cancer patients, between 2000 and 2015. Perioperative blood transfusion was defined as need for PRBCs and FFP transfusion within the first 24h after the beginning of surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Disease recurrence-free, cancer-specific, and overall survival were estimated using the Kaplan-Meier technique and log-rank test.

RESULTS AND LIMITATIONS

A total of 267/885 patients (23%) were transfused; 187/267 patients (70%) received only PRBCs (median 2 units [interquartile range: 1-2]) and 80/267 patients (30%) received PRBCs (2 [2-3]) plus FFP (2 [2-2]). Receipt of PRBCs or PRBCs+FFP was associated with a higher 90 d mortality (7.0% vs 7.5% vs 2.9%; p=0.016), inferior 5 yr recurrence-free survival (no transfusion 92%, PRBCs 74%, p=0.005; PRBCs+FFP 49%, p=0.002), 5 yr cancer-specific survival (no transfusion 74%, PRBCs 60%, PRBCs+FFP 49%, all p<0.001), and 5 yr overall survival (no transfusion 90%, PRBCs 70%, PRBCs+FFP 34%, all p<0.001). In multivariate analysis, blood transfusion was predictive for all-cause mortality (PRBCs [hazard ratio; HR 1.610; p<0.001] and PRBCs+FFP [HR 1.640; p=0.003]) and cancer-specific mortality (PRBCs [HR 1.467; p=0.010] and PRBCs+FFP [HR 1.901; p=0.021]). Limitations include selection bias and lack of standardised transfusion criteria.

CONCLUSIONS

Administration of PRBCs and FFP was associated with significantly inferior cancer-specific and overall survival. Relevant preoperative factors for receiving blood transfusion were neoadjuvant chemotherapy, preoperative anaemia, older age, and American Society of Anesthesiologists score ≥3, and these factors emphasise the importance of preoperative optimisation of patients undergoing cystectomy.

PATIENT SUMMARY

Blood transfusion during radical cystectomy was associated with inferior survival.

The Preoperative Assessment and Optimization of Patients Undergoing Major Urological Surgery

PURPOSE OF REVIEW

Improving patient outcomes from major urological surgery requires not only advancement in surgical technique and technology, but also the practice of patient-centered, multidisciplinary, and integrated medical care of these patients from the moment of contemplation of surgery until full recovery. This review examines the evidence for recent developments in preoperative assessment and optimization that is of relevance to major urological surgery.

RECENT FINDINGS

Current perioperative medicine recommendations aim to improve the short-term safety and long-term effectiveness of surgical treatments by the delivery of multidisciplinary integrated medical care. New strategies to deliver this aim include preoperative risk stratification using a frailty index and cardiopulmonary exercise testing for patients undergoing intra-abdominal surgery (including radical cystectomy), preoperative management of iron deficiency and anemia, and preoperative exercise intervention. Proof of the utility and validity for improving surgical outcomes through advances in preoperative care is still evolving. Evidence-based developments in this field are likely to benefit patients undergoing major urological surgery, but further research targeted at high-risk patients undergoing specific urological operations is required.

Red blood cell transfusion in surgical cancer patients: Targets, risks, mechanistic understanding and further therapeutic opportunities

Anemia is present in more than half of cancer patients and appears to be an independent prognostic factor of short- and long-term adverse outcomes. It increases in the advanced period of cancer and perioperatively, in patients with solid tumors who undergo surgery. As a result, allogeneic red blood cell (RBC) transfusion is an indispensable treatment in cancer. However, its safety remains controversial, based on several laboratory and clinical data reporting a linkage with increased risk for cancer recurrence, infection and cancer-related mortality. Immunological, inflammatory and thrombotic reactions mediated by the residual leukocytes and platelets, the stored RBCs per se, the biological response modifiers and the plasticizer of the unit may underlie infection and tumor-promoting effects. Although the causality between transfusion and infection has been established, the effects of transfusion on cancer recurrence remain confusing; this is mainly due to the extreme biological heterogeneity that characterizes RBC donations and cancer context. In fact, the functional interplay between donation-associated factors and recipient characteristics, including tumor biology per se, inflammation, infection, coagulation and immune activation state and competence may synergistically and individually define the clinical impact of each transfusion in any given cancer patient. Our understanding of how the potential risk is mediated is important to make RBC transfusion safer and to pave the way for novel, promising and highly personalized strategies for the treatment of anemia in surgical cancer patients.