More recently, perioperative BT has also been linked to an increased risk of death after several oncological surgeries, including open radical cystectomy. The exact mechanism through which BT might affect survival after cancer surgery remains unclear, but one proposed theory has been the immunosuppressive effect of transfusion exposing the host to circulating tumor cells during and after surgery.
In the present study, we wanted to find the impact of perioperative BT on patients treated with robot assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD). The study is part of a project launched by the European Association of Urology - Young Academic Urologists (EAU-YAU), Urothelial carcinoma working group in October 2020 that includes patients undergoing RARC with ICUD from 15 European centers. It is also the first study on the oncological impact of BT in robotic cystectomy. Our main finding was that the timing of transfusion appears to have an impact on oncological outcomes: patients that received intraoperative BT had a higher risk of cancer recurrence. This was not observed with post-operative BT and could be explained by intraoperative transfusion-related immunosuppression combined with cancer cell release during tumor manipulation.
These results call for the importance of reducing perioperative blood transfusions during radical cystectomy. However, intraoperative blood transfusions are often necessary and sometimes lifesaving during radical cystectomy. So can we really reduce them? Based on the latest evidence, the answer is yes. Results from the iROC trial (RARC+ICUD vs open radical cystectomy) show a significantly lower transfusion rate with the robotic approach (22% vs 41%, p=0.046). Switching to a robotic approach lowers BT. In our study, only 14.9% of patients received perioperative BT.
Second, we should always keep in mind that we are dealing with an old and fragile population, where neoadjuvant chemotherapy is increasingly prescribed. Preoperative anemia should be systematically searched for at least one month before surgery, and treated when needed.
Last but not least, we highlight in our article the importance of involving the anesthesia team and discuss peri-operative strategies that could minimize transfusions.
Urothelial carcinoma is an extremely aggressive disease: surgeons performing cystectomy should apply all possible approaches to improve oncologic outcomes. Our study shed the light on one possible negative factor, blood transfusions, and the strategy to minimize them.
Written by: Julien Sarkis, MD1,2 Thierry Roumeguere, MD1 & Simone Albisinni, MD1,3
- Department of Urology, University Clinics of Brussels, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Department of Urology, AP-HP, Hopital Henri Mondor, Creteil, France
- Unit of Urology, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, Rome, Italy.
Read the Abstract