Many previous studies investigating this topic have lacked standardized collection methods consistent with European Association of Urology (EAU) guidelines and have reported complications only within 3 months post-surgery.1,2 At our institution, we maintain meticulous follow-up of all RARC patients at a dedicated outpatient clinic. This approach allows us to comprehensively capture data on complications and oncological outcomes, extending beyond the three-month mark post-surgery.
We relied on a population of 246 patients who underwent RARC with intracorporal urinary diversion at our center, with a postoperative follow-up of ≥1 year for survival. Our analysis revealed that approximately 91% of patients experienced at least one complication, with around 52% of patients experiencing severe complications (Clavien-Dindo grade ≥3). This translated into a readmission rate of 61%. The most common complications were infectious, genitourinary, and gastrointestinal experienced by 72%, 41%, and 33% of patients, respectively. Looking at the time to complications, 52% of complications occurred within the first 10 days from surgery.
However, 13% of complications and 28% of severe complications occurred after 3 months from surgery. This resulted in a median time to first readmission of 87 days. The earliest complications were fever of unknown origins and paralytic ileus (median time-to-complication [mTTC]: 4 days), the latest complications were urinary tract infection (mTTC: 40days) and hydronephrosis/ureteral obstruction (mTTC: 70days).
While our observed rate of complications may appear high, it is consistent with findings from other studies investigating complications post-radical cystectomy and utilizing similar standardized data collection systems.3 These findings suggest that RARC should be performed by experienced surgeons in high-volume tertiary centers where there are multidisciplinary resources and expertise to manage the complex postoperative course of these patients. A major difference from previous studies on this topic is the use of a long post-operative follow-up (≥1 year). This approach enabled us to demonstrate that a consistent proportion of complications occur late after surgery, and using a short follow-up may lead to overlooking a considerable number of them. This is particularly true, for some types of complications such as UTI, hydronephrosis/ureteral obstruction, and wound complications.
Despite several strengths, our analyses are not devoid of limitations. These included the use of a relatively small cohort of patients from a single center, where all procedures were conducted by experienced surgeons. Additionally, the selection of a specific urinary diversion over others was influenced by individual surgical decisions. Finally, since preoperative counseling in preparation for surgery was provided to all patients, we cannot test whether this approach was associated with complications.
Written by:
- Pietro Scilipoti, MD, Department of Urology and Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Francesco Pellegrino, MD, Department of Urology and Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Marco Moschini, MD, Urologist, Department of Urology and Division of Experimental Oncology/Unit of Urology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Mitropoulos D, Artibani W, Graefen M, Remzi M, Rouprêt M, Truss M. Reporting and Grading of Complications After Urologic Surgical Procedures: An ad hoc EAU Guidelines Panel Assessment and Recommendations. European Urology. 2012;61(2):341-349.
- Piazza P, Luca Sarchi, Stefano Puliatti, Carlo Andrea Bravi, Knipper S, Alexandre Mottrie. The Unsolved Issue of Reporting of Late Complications in Urology. European Urology. 2021;80(5):527-528.
- Klemm J, Rink M, Markus von Deimling, et al. Time-to-complication Patterns After Radical Cystectomy: A Secondary Analysis of a 30-day Morbidity Assessment Using the European Association of Urology Quality Criteria for Standardized Reporting. European urology focus. 2023;9(6):1072-1076.