Open radical cystectomy (ORC) continues to carry a high overall complication rate, and wound infections are a major contributor to this morbidity. Post-operative surgical site infections (SSI) often times subject patients to more time in the hospital, delays in recovery (and subsequently the start of adjuvant therapies), and financial toxicity. In an effort to optimize perioperative outcomes for this medically complex and comorbid population, our institution began selectively utilizing incisional negative pressure wound therapy (iNPWT) prophylactically at the time of ORC. We recently analyzed our experience with this technique and published the subsequent findings in Urologic Oncology: Seminars and Original Investigations.
The utilization of iNPWT has previously gained traction in other surgical specialties, particularly general surgery and plastic surgery. The technique of applying sub atmospheric pressure to a surgical incision is thought to foster favorable wound healing by improving perfusion, minimizing lateral tension, and reducing dead space, fluid accumulation, and bacterial contamination. Prior to our study, this intervention was investigated in the ORC setting in one other series, published by Joice et al. in 2020 (EU Focus). These authors found a significant reduction in a composite outcome of wound complications in patients who received iNPWT after ORC. In our study, we sought to build on this work through a more rigorous evaluation of iNPWT in this same clinical context.
We performed a retrospective analysis of over 2,300 patients who underwent ORC at the Mayo Clinic over a 23-year span, drawing from our prospectively maintained cystectomy registry. At our institution, prophylactic iNPWT was selectively applied at the discretion of the operative team, most often in patients considered at higher risk for wound complications (e.g., smokers, obese patients, immunocompromised individuals, and those with prior radiation therapy). We compared outcomes between patients who received the intervention and those who were managed with standard dressings. Multivariable logistic regression was used to adjust for key baseline variables such as body mass index, diabetes, and overall comorbidity burden.
The results were compelling. On adjusted analyses, patients in the iNPWT group had a nearly 50% reduction in postoperative SSI compared to those who did not receive iNPWT. Although other complications, such as wound dehiscence and seroma did not show statistically significant reductions, the direction of effect favored iNPWT. Patients who received iNPWT also had a shorter length of stay in the hospital, though it was unclear if this was specifically due to a reduction in wound infections.
Admittedly, these data do not unequivocally support universal adoption of this intervention; however, the low cost and low risk nature of postoperative iNPWT suggest that implementation in specific populations is helpful, while broad application should be considered. In this vein, our study underscores the need for prospective trials to confirm these findings and to refine patient selection criteria. Additionally, cost-effectiveness analyses will be valuable to quantify the potential economic benefits of this intervention.
Surgical site infection after open radical cystectomy remains a major source of morbidity. Our work demonstrates that prophylactic iNPWT can substantially reduce the risk of infection in this high-risk population. While future prospective studies are warranted, we believe these findings support the consideration of iNPWT as a valuable adjunct in cystectomy care, offering a practical means of improving outcomes for our bladder cancer patients.Written by: Daniel Roberson, MD, and Vidit Sharma, MD
- Department of Urology, Mayo Clinic, Rochester, MN