Evaluation of surgical complications incidence after radical cystectomy

Objective: to study the frequency of surgical complications and postoperative mortality after radical cystectomy (RCE).

Material and methods. In study included 107 patients who underwent RCE by one surgeon. Starting in 2015, the protocol for accelerated recovery of patients after surgery, ERAS was applied in all patients undergoing RCE. The frequency of complications and mortality was studied depending on the age of the patients and the ERAS protocol. There were 84 male (78.5 %) and 23female (21.5 %) in this study. All patients were divided into 2 groups: 1st group — 89 (83.0 %) people younger 75 years and 2nd group — 18 (17.0 %) people from 75 years and older. Depending on the application of the ERAS protocol, patients in each group were divided into 2 subgroups. Group 1st consists of subgroups: 1(A) — 40 (45.0 %) patients with ERAS protocol, 1(B) — 49 (55.0 %) patients without ERAS protocol. Group 2nd also consists of subgroups: 2(A) — 8 (44.4 %) patients with ERAS protocol, 2(B) — 10 (55.6 %) patients without ERAS protocol. The average age of the patients was 65.5 (32—85) years.

Results. Totally, over the 90-day period after the operation, 55 cases (51.4 %) of complications were recorded: Clavien—Dindo I—II in 1st group — 27 (30.3 %), in 2nd group — 8 (44.4 %). Complications of Clavien—Dindo III—IV in the 1st group — 15 (16.8 %), in the 2nd group — 5 (27.7 %). The overall 90-day mortality was 10 cases (9.3 %): in 1st group — 8 (9.0 %) patients, in 2ndgroup — 2 (11.1 %) patients. According to the comparative study of the use of the ERAS protocol in subgroup 1(A), the incidence of complications of the Clavien—Dindo I—II category was noted in 11 (27.5 %) patients, and in subgroup 1(B) in 16 (32.6 %) patients. Complications of Clavien—Dindo Ш—IV in subgroup 1(A) were observed in 5 (12.5 %) patients and in subgroup 1(B) — in 10 (20.4 %) patients; in subgroup 2(A), the incidence of Clavien—Dindo I—II complications was noted in 3 (37.5 %) patients, and in subgroup 2(B) — in 5 (50.0 %) patients. Complications of Clavien— Dindo III—IV in subgroup 2(A) were observed in 2 (25.0 %) patients and in subgroup 2(B) — in 3 (30.0 %) patients. Thus, the ERAS protocol decreased the number of complications in the subgroup 1(A) compared to the subgroup 1(B) (z = 1.44; p = 0.08) and between the subgroup 2(A) and 2(B) (z = 1.39; p = 0.09). Also there was an increase in the number of complications in older subgroups: in subgroup 2(B) compared with subgroup 1(B) (z = 1.86; p = 0.068).

The 90-day mortality in subgroup 1(A) was in 3 (7.5 %) cases, 1(B) — 5 (10.2 %) cases. The 90-day mortality in subgroups 2(A) was in 1 (12.5 %) case, in subgroup 2(B) was 1 (10.0 %) cases. Repeated hospitalization for the first 90 days was 14 (13.0 %) cases, with differences in the frequency of rehospitalization depending on age and application of the ERAS protocol.

Conclusion. RCE is an acceptable method of treatment in patients of the older age group and should be performed in hospitals with experience of regular treatment of this nosology. Application of the ERAS protocol (accelerated recovery after surgery) in patients undergoing RCE allows, regardless of age, to reduce the incidence of early postoperative surgical complications and mortality.

1. Witjes J.A., Comperat E., Cowan N.C. et al. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. European Association of Urology, 2016. Pp. 3-4.

2. Malignant tumors in Russia in 2016 (morbidity and mortality). Eds.: A.D. Kaprin, VV Starinskiy, G.V. Petrova. Moscow: MNIOI im. P.A. Gertsena - filial FGBU “NMIRTS” Minzdrava Rossii, 2018. 250 p. (In Russ.).

3. Loran O.B., Seregin I.V., Khachatryan A.L., Guspanov R.I. 10-year experience of using direct uretero-intestinal anastomoses in intestinal urine derivation after radical and simple cystectomy. Urologiya = Urology 2015;(4):48—51. (In Russ.).

4. Darenkov S.P, Kotov S.V., Proskokov A.A. et al. The importance of the program “rapid recovery surgery” in the surgical treatment of bladder tumors. Urologiya = Urology 2015;(2):109—15. (In Russ.).

5. Aziz A., May M., Burger M. et al. Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Eur Urol 2014;66(1):156—63. DOI: 10.1016/j.eururo.2013.12.018.

6. 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.

7. Darenkov S.P., Krivoborodov G.G., Kotov S.V. et al. Postoperative complications of radical cystectomy with ortho- and heterotopic intestinal plasticity (review). Vestnik Rossiyskogo gosudarstvennogo universiteta = Bulletin of the Russian State Medical University 2013;(4):49—53. (In Russ.).

8. Harraz A.M., Osman Y., El-Halwagy S. et al. Risk factors of hospital readmission after radical cystectomy and urinary diversion: analysis of a large contemporary series BJU Int 2015;115(1):94—100. DOI: 10.1111/bju.12830. PMID: 24905239.

9. Stimson C.J., Chang S.S., Barocas D.A. et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol 2010;184(4):1296—300. DOI: 10.1016/j.juro.2010.06.007. PMID: 20723939.

10. Perepechai V.A., Vasilyev O.N., Spitsyn I.M., Kogan M.I. Predictors for morbidity of radical cystectomy and different types of urine derivation: 20-year experience of a surgery center. Onkourologiya = Cancer Urology 2016;12(1):42—57. (In Russ.).

11. Cerantola Y., Valerio M., Persson B. et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS) society recommendations. Clin Nutr 2013;32(6):879—87. DOI: 10.1016/jclnu.2013.09.014. PMID: 24189391.

12. Tyson M.D., Chang S.S. enhanced recovery pathways versus standard care after cystectomy: a meta-analysis of the effect on perioperative outcomes. Eur Urol 2016;70(6):995—1003. DOI: 10.1016/j.eururo.2016.05.031. PMID: 27297680.