The clinical aspects of peritonitis developing after cystectomy

Background. Surgical morbidities of radical cystectomy, which are, as a rule, complicated intraabdominal infections, appear to be the main causes of repeated surgeries and fatal outcomes. The elimination of the infection Indus and an-timicrobic therapy are the currently accepted standard of treatment for postoperative peritonitis in cancer urology, as well as in general surgery hospital.

Objective: defining the most reasonable option of surgical aid for peritonitis developing after cystectomy.

Materials and methods. In the time period from 2000 through 2014, 58 cancer patients with postoperative peritonitis developing after cystectomy received indoor treatment at N.N. Alexandrov Republican Research and Practical Center for Oncology and Medical Radiology. Their mean age was 64.9 years, the range 44-90 years, 53 (91.4 %) of them being male. Primary urinary bladder cancer was present in 51 (87.9 %) patients. Peritoneal infection was microbiologically verified in 57 (98.3 %) patients. Each case of fatal outcome was associated with ineffective treatment of peritonitis. Depending on the intraoperative findings (presence or absence of a hollow organ defect) and the surgical approach undertaken (obstructive resection or operation maintaining the continuity of the intestinal and/or urinary tract), the patients were stratified into three groups: group 1 (n = 28), group 2 (n = 20) and group 3 (n = 10). There were no significant differences in the basic parameters specifying peritoneal infection severity between the patients of groups 1 and 2 vs group 3 (p >0.05).

Results. Overall mortality amounted to 25.9 %, 15 patients died. Among the 28 (48.3 %) patients (group 1) who underwent obstructive elimination of the peritonitis focus by means of urointestinal reservoir ablation, resection of small or large intestine with ileo- or colostomy, 6 patients died, mortality 21.4 %. In the 10 (17.2 %) patients (group 3) who succeeded in preserving the urinary conduit or continuity of the bowels by anastomosis defect closure, resection of enteroentero-anastomosis or urointestinal reservoir with repeated anastomosing or defect closure, mortality was higher (60 %) (p = 0.045); 6 patients died.

Conclusion. The most effective option of surgical treatment of postoperative peritonitis developing after cystectomy is obstructive reoperation on the bowels and urinary tracts: compared with the intervention consisting in preserving the urinary conduit and/or continuity of the intestinal tract, this type of surgery caused a 2.8-fold lower mortality.

1. Hautmann R.E., Hautmann S.H., Hautmann O. Complications associated with urinary diversion. Nat Rev Urol 2011; 8(12):667–77. DOI: 10.1038/nrurol.2011.147. PMID: 22045349.

2. Malkowicz S.B., van Poppel H., Mickisch G. et al. Muscle-invasive urothelial carcinoma of the bladder. Urology. 2007; 69 (Suppl 1):3–16. DOI: 10.1016/j.urology.2006.10.040. PMID: 17280906.

3. Villalba J.A.M., Jabaloyas J.M.M., Hernández F.P. et al. Radical cystectomy as a muscle-invasive bladder cancer treatment in elderly patients. Actas Urol Esp 2008; 32(7):696–704. doi: 10.1016/s0210-4806(08)73917-2. PMID: 18788485.

4. Lawrentschuk N., Colombo R., Hakenberg O.W. et al. Prevention and management of complications following radical cystectomy for bladder cancer. Eur Urol 2010; 57(6):983–1001. PMID: 20227172. DOI: 10.1016/j.eururo.2010.02.024.

5. Falconi M., Pederzoli P. The relevance of gastrointestinal fistulae in clinical practice: a review. Gut 2001;49 Suppl 4(Suppl 4):iv2–10. DOI: 10.1136/gut.49.suppl_4.iv2. PMID: 11878790.

6. Farnham S.B., Cookson M.S. Surgical complications of urinary diversion. World Journal of Urology 2004; 22(3):157–167 DOI: 10.1007/s00345-004-0429-5. PMID: 15316737.

7. Colombo R., Naspro R. Ileal conduit as the standard for urinary diversion after radical cystectomy for bladder cancer. Eur Urol Suppl 2010; 9(10):736–44. DOI: 10.1016 / j.eursup.2010.09.001.

8. Novara G., De Marco V., Aragona M. et al. Complications and mortality after radical cystectomy for bladder transitional cell cancer. J Urol 2009; 182 (3): 914–21. DOI: 10.1016/j.juro.2009.05.032. PMID: 19616246.

9. Froehner M., Brausi M.A., Herr H.W. et al. Complications following radical cystectomy for bladder cancer in the elderly. Eur Urol 2009; 56(3):443–54. DOI: 10.1016/j.eururo.2009.05.008. PMID: 19481861.

10. Shabsigh A., Korets R., Vora K.C. et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol. 2009;55(1):164–74. DOI: 10.1016/j.eururo.2008.07.031. PMID: 18675501.

11. Villalba J.A.M., Jabaloyas J.M.M., Hernández F.P. et al. Radical cystectomy as a muscle-invasive bladder cancer treatment in elderly patients. Actas Urol Esp 2008;32(7):696–704. DOI: 10.1016/s0210-4806(08)73917-2. PMID: 18788485.

12. Serra C.A., Narbón S.E., Briones R.J. et al. Is radical cystectomy justified in patients over 75 years old? Actas Urol Esp 2008;32(3):288–96. DOI: 10.1016/s0210-4806(08)73833-6. PMID: 18512385.

13. Clark P.E., Stein J.P., Groshen S.G. et al. Radical cystectomy in the elderly: comparison of clinical outcomes between younger and older patients. Cancer 2005; 104(1):36–43. DOI: 10.1002/cncr.21126. PMID: 15912515.

14. Boström P.J, Kössi J., Laato M., Nurmi M. Risk factors for mortality and morbidity related to radical cystectomy. BJU Int 2009; 103(2):191–6. DOI: 10.1111/j.1464-410X.2008.07889.x. PMID: 18671789.

15. Zebic N., Weinknecht S., Kroepfl D. Radical cystectomy in patients aged > or = 75 years: an updated review of patients treated with curative and palliative intent. BJU Int 2005; 95(9):1211–4. DOI: 10.1111/j.1464-410X.2005.05507.x. PMID: 15892803.

16. Mendiola F.P., Zorn K.C., Gofrit O.N. et al. Cystectomy in the ninth decade: operative results and long-term survival outcomes. Can J Urol 2007;4(4):3628–34. PMID: 17784983.

17. Deliveliotis C., Papatsoris A., Chrisofos M. et al. Urinary diversion in high-risk elderly patients: modified cutaneous ureterostomy or ileal conduit? Urology 2005; 66(2):299–304. DOI: 10.1016/j.urology.2005.03.031. PMID: 16040096.