EAU 2018: Bladder Cancer: Immediate and Late Complications Open Radical Cystectomy
RC is known to be a procedure that has many risks. Radical cystectomy in the 1960s, for example, had dismal morbidity and mortality rates. As techniques improved, these rates have decreased dramatically; and current estimates for mortality after RC is about 2-3%. Nonetheless, about 2/3 of patients have at least one complication within 90 postoperative days. These complications are usually related to the urinary diversion, followed by GI complications, then followed by infectious and pulmonary complications.
Diversion-related complications are often technique-related, but vigilance is important to diagnose and manage these complications early.
6% of patients develop postoperative pulmonary complications, usually pneumonia. The consequences in this patient population for such complications can be severe, especially if it puts them in an ICU setting. Interestingly, growing evidence in the Anesthesiology literature suggests that there may be some intraoperative Anesthesia maneuvers that can help prevent postoperative complications during open abdominal surgery, such as the use of low tidal volumes and low PEEP. Urologists should discuss these maneuvers with their Anesthesiologist before starting a case.
Notably, 2-10% of patients get a DVT after surgery. These patients are at high risk in general, and 14% of them develop thromboembolic events during neoadjuvant chemotherapy. Therefore, aggressive anticoagulation is necessary, as thromboembolic complications can quickly be deadly. Emerging consensus on standard of care involves the use of 4 weeks of postoperative low molecular weight heparin (LMWH), which has been shown to reduce DVT risks by 70% with a low risk of delayed bleeding. Some compelling evidence even indicates that LMWH should be administered during chemotherapy.
Several randomized trials for RC have been conducted that are instructive. The open vs. robotic RC trial in New York demonstrated that there is no significant difference in complication rates between surgical approaches. Another study found that there was no difference in complications or bleeding between the use of Ligasure vs. stapler for control of the pedicles. One study found that, as has been shown in general surgical procedures, patients who are managed intraoperatively with norepinephrine and restricted IVF use tend to have lower blood loss and improved outcomes.
Gastrointestinal complications can significantly prolong hospitalization. As the age of the population continues to rise, it is important to note that up to 80% of elderly patients getting RC develop a GI complication. Dr. Gakis argues that ureterocutaneostomy may be making a resurgence, especially given data that ureterocutaneostomy has less major complications (11% vs. 25% for bowel diversion) and better mortality rates in the elderly.
ERAS pathways are growing in use, especially at academic centers. ERAS should really be standard of care for patients undergoing RC, as the use of early feeding, non-narcotic pain management, and functional GI support have all been proven to positively impact patient recovery.
Dr. Gakis concluded with a call for everyone to report on their rates of complications after RC. He also implored everyone to remember that these patients have a high risk for postoperative thromboembolism, and to make sure chemoprophylaxis is always used. Lastly, avoidance of urinary extravasation is important because it can lead to ureteral anastomotic strictures and chemical GI ileus. Keeping these technicalities in mind can greatly improve the outcomes for patients undergoing RC.
In general, these recommendations are straightforward; and anyone practicing RC should strongly familiarize themselves with the best practices in this field. RC is a very technical surgery, and many complications can be prevented with diligent attention to detail.
Presented by: Georgios Gakis, MD, Würzburg, Germany
Written by: Shreyas Joshi, MD, Fox Chase Cancer Center, Philadelphia, PA at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark