How to lower postoperative complications after radical cystectomy - a review

Increased One-Year Mortality Among Elderly Patients After Radical Cystectomy for Muscle-Invasive Bladder Cancer: A Retrospective, Observational Comparative Study

Introduction

Muscle invasive bladder cancer (MIBC) is a common malignancy amongst elderly. Increasing life expectancy, prevalence of smoking, lifelong exposure to environmental pollutants and immunosenescence contribute to growing number of cases. Traditionally, radical cystectomy (RC) with pelvic lymph node dissection (PLND) constituted the mainstay of treatment for MIBC, but despite proven feasibility in elderly population, it has been associated with significant burden of morbidity, mortality, and complications.

Study Objective

We aimed to re-evaluate the safety and efficacy of RC amongst the elderly patients with MIBC.

Material and Methods

This single-center, retrospective, observational comparative study was conducted among 568 patients who underwent RC due to MIBC between 2003 and 2021. We evaluated the influence of chronological age (<70 vs ≥70 years) on clinical, demographic, and pathological variables related to MIBC and RC.

Results

Elderly patients had similar clinical and pathological features of disease compared to their younger counterparts; nonetheless, they more often received simplified urinary diversion, ie ureterostomy (60.25% vs 39.33%, p<0.001) and had no PLND (15.76% vs 8.5%, p=0.01) during RC. Furthermore, more elderly patients were treated for secondary MIBCs and fewer had history of smoking. Severe complication and 90-day mortality rates were comparable between groups; however, the elderly had significantly higher all-cause mortality at one year post RC (46.67% vs 33.25%, p=0.003). On multivariate analysis, one-year mortality risk was independently associated with elderly age (HR=2.119, 95% CI: 1.227–3.660, p=0.007), rural residency (HR=1.760, 95% CI: 1.043–2.968, p=0.034), extravesical extension of tumor (HR=2.109, 95% CI: 1.155–3.850, p=0.015), lymph node metastasis (HR=2.268, 95% CI: 1.290–3.987, p=0.004) and omission of PLND (HR=6.064, 95% CI: 2.926–12.568, p<0.001).

Conclusion

Radical cystectomy in elderly patients is associated with significant one-year mortality. Our study emphasizes the unmet need for considerate planning of treatment for MIBC in potentially vulnerable groups of elderly patients. Efforts are needed to reliably identify those unlikely to benefit from surgery and facilitate patient-centered choice of alternative therapies.

Can we lower the rates of cystectomy complications by modifying risk factors? A review of the literature

Introduction

Radical cystectomy (RC), beyond its therapeutic effect, is associated with significant rates of complications, hospital readmissions and mortality. In recent years much research has been made in order to clarify the main reasons of these events. This article, based on a literature review, presents the impact of risk factors on RC complications and highlights possible modifications of these factors to reach better RC outcome.

Material and methods

PubMed, Science Direct, Google Scholar databases were searched using key-words to identify studies about risk factors and RC complications between 2010 and 2021. A total of 96 articles were retrieved and studied as full-text versions. The most significant data was targeted, analysed and categorized according to the article's design.

Results

All the most valuable risk factors of RC complications were grouped in patient-related, treatment-related risk factors and subgrouped in nonmodifiable, modifiable and potentially modifiable categories. All the modifiable and potentially modifiable risk factors were found to have considerable value, as their adjustment lowers the rates of morbidity and mortality.

Conclusions

Proper identification and adjustment of the risk factors present the possibility of better RC results. Although, in advanced disease and highly morbid cases, complications are not fully omit-table. Management of bladder cancer (BC) in high-volume centres using new technologies offers lower rates of complications. To sum up, rigorous interdisciplinary presurgical patient preparation should be implemented in BC management.

Value of evaluating procalcitonin kinetics in diagnosis of infections in patients undergoing laparoscopic radical cystectomy

Postsurgery infection is a common complication after laparoscopic radical cystectomy (LRC) followed by urinary diversion. White blood cell (WBC) values and C-reactive protein (CRP) are routinely used as markers for infection, but lack of specificity and their elevation is often delayed in clinically significant events. In this study, we aimed to investigate the value of procalcitonin (PCT) kinetics in assisting early diagnosis of infection in patients undergoing LRC.The patients' medical records between May 2013 and May 2016 were reviewed retrospectively. WBC, CRP, and PCT plasma levels as well as clinical symptoms were registered in 306 patients preoperatively (day 0), and 5 consecutive days postoperatively. Based on microbiological and clinical data, patients were grouped into noninfection- (NI-) and infection- (I-) groups. The day of new onset infection was observed were defined as day t0 and the day after that as day t1. For the NI-group, the day on which PCT was at the peak was defined as day t1 and the previous day as day t0.Of the 306 patients, 46 (15.03%) have proven infection. PCT levels were analogous at day t0:NI-group [median (interquartile range)]: 0.69(1.99) vs I-group [median (interquartile range)]: 1.0[0.75], P = .1. PCT levels were significantly increased at day t1 in the I-group[median (interquartile range)]:2.9(1.3) vs NI-group[median (interquartile range)]: 1.3(1.5), P < .01. The area under the curve for the prediction of infection was 0.72 [95% confidence interval (CI) = 0.63-0.81] for the absolute value of PCT; and for delta PCT:0.88 (95% CI = 0.81-0.94), P < .01. The optimal cut-off value was 0.79 ng/mL with the highest Youden index of 0.80 for delta-PCT to indicate infection. Neither absolute values nor changes in CRP, or WBC could predict infection better. The "delta" was considered as the changes in the absolute values (subtracting day t0 from day t1) of PCT, CRP, and WBC.This study suggest that early elevation of PCT within the first 24 hours of new onset infection, interpreted with clinical results, appears to be a promising indicator for the diagnosis of infections following LRC.