Predictors for morbidity of radical cystectomy and different types of urine derivation: 20-year experience of a surgery center

Background. Most of serious complications of radical cystectomy (RCE) should be associated with the comorbidity of patients and the interintestinal anastomoses designed with urinary reservoirs rather than with RCE. It is relevant to identify and assess the role of predictors for morbidity of RCE and urine derivation.

Objective: to search for risk factors for complications after RCE with different types of urine derivation.

Subjects and methods. The immediate and late results of RCE and urine derivation were studied in 350 patients with bladder cancer. Sequential postoperative complications were additionally analyzed in chronological order in all the patients, including non-cancer ones (n = 43).

Results. 43.9% of the patients had postoperative complications, if a surgeon had sufficient surgical experience; there was a preponderance of patients with mild-to-moderate complications (Clavien-Dindo grade I-II, 37.8%) unassociated with urine derivation. The patients with severe postoperative complications were 16.3%; mortality was 3.1%, which significantly correlated with surgical experience. Late (3-18 month) postoperative complications were detected in 21.4% of the patients with a preponderance of those with urine derivation-related complications (19.4). The frequency of complications due to extraintestinal versus intestinal urine derivations was significantly higher (68.1 and 49.8% (p < 0.05). During two-step surgical treatment, the patients demonstrated higher morbidity and worse survival. Extraintestinal urine derivations, continuous urinary intestinal diversion determine a less favorable prognosis compared with one-stage ortho- and heterotopic procedures. The type of urine derivation and the experience of a surgeon performing RCE are valid predictors for postoperative morbidity and independent prognostic factors of overall and cancer-specific survival, respectively. 150 operations are needed for achieving optimal surgical experience. Discussion. It is appropriate to increase the time of research reports on the results of urine derivation up to 12-18 months of a postoperative follow-up.

In practice, the routine use of two-step RCE and final urine derivation and internal and/or external urine ones should be abandoned; preference should be, when possible, given to single-stage ortho- and/or heterotopic urine derivations rather than to the former.

Conclusion. Extraintestinal (percutaneous puncture nephrostomy, ureterocutaneostomy), and internal (ureterosigmoanastomosis, ureterosigmorectoanastomosis, Mainz pouch II) urine derivations, two-step surgical treatment, and a surgeon’s insufficient experience are predictors for high morbidity and poor prognostic factors for survival after RCE and urine derivation.