EAU18 – Open RC remains most effective treatment despite complications risks

Complications during or after radical cystectomy are frequent with delayed diagnosis and treatment resulting in severe chronic morbidity. Therefore, its management requires a high level of knowledge and experience as this surgical procedure may cause severe morbidity in fourth of the patients with mortality rates rapidly increasing with complications. This article summarizes recent studies with high level of evidence in this field.

Intraoperative blood loss

Open radical cystectomy is still the mainstay of treatment for muscle-invasive bladder cancer1. It has been consistently reported that open radical cystectomy, as a major surgical procedure, is associated with a higher estimated blood loss during surgery compared to robotic cystectomy2. Therefore, reducing blood loss has come to the focus of surgeons experienced in open techniques.

In a double-blind trial randomized trial, intraoperative blood loss was lower in patients with pelvic venous pressure less than 5 mm Hg. Low pelvic venous pressures were also more frequent in patients treated with a norepinephrine-low-volume strategy intraoperatively as compared to liberal use of intravenous fluid. Furthermore, pelvic venous pressure decreased significantly after removing abdominal packing and abdominal lifting at all time points during cystectomy. Of note, no correlation was reported between pelvic venous pressure and central venous pressur3. Continuous norepinephrine administration resulted in lower blood loss and rate of transfusions. Moreover, in patients with neobladder, restrictive intraoperative fluid management was associated with improved continence and potency results postoperatively.

Pulmonary complications

The occurence of pulmonary complications is often associated with patient risk factors. Approximately 6% of patients develop postoperative pulmonary complications after cystectomy. Risk factors for postoperative pulmonary complications were reported to be higher age (75 years and older), very low (<18.5) or very high (>=30) body mass index (BMI), smoking, chronic obstructive pulmonary disease, insulintreated diabetes and low albulin levels (<3.5g/dL).

Therefore, some efforts have been undertaken to reduce the risk of pulmonary complications postoperatively. One strategy that has been investigated was to compare the rate of complications using either a low vs. high positive end-exspiratory pressure and alveolar recruitment manoeuvres during surgery. Looking into the literature there is divergent data on whether this anesthesiologic strategy during surgery may have beneficial effects on pulmonary function postoperatively.

In the largest study, Hemmes et al. did not find a significant impact of this manoeuvre on outcomes after major abdomimal surgery. On the contrary, a trend towards improved outcomes was noted when a strategy with low tidal volume and low positive end-exspirary pressure without recruitment manoeuvres was used. In a meta-analysis, low tidal volume was also reported to be most protective against the development of postoperative acute respiratory distress syndrome8. The most widely accepted practice for ventilation during radical cystectomy is nowadays to avoid high end-exspiratory pressures and high tidal volumes during surgery whenever possible. Venous thromboembolism (VTE) Postoperative venous thromboembolism (VTE) occurs in 2.5-10% of all patients undergoing radical cystectomy for bladder cancer. The wide range in reported rates is possibly related to an under-reporting bias across different countries which, in turn, is likely due to under-registration of thromboemblic events after discharge in different health care systems. It is important to note that the majority of thromboembolic events occur after discharge of the patient10.

Risk factors for the development of VTE include a high BMI, positive surgical margins, type of urinary diversion and prolonged duration of hospitalization10 and non-O blood type11. Of the thromboembolic events 40% of cases relate to deep vein thrombosis and 60% to pulmonary embolism10. In various studies it was consistently reported that extended duration of thromboprophylaxis using low-molecular weight heparin derivates for four weeks after discharge reduces the relative risk of VTE by approximately 70% while the risk of delayed bleeding during extended treatment is low. Importantly, a recent study also revealed that thromboembolic events are more frequent in patients receiving neoadjuvant chemotherapy for muscle-invasive bladder cancer (17%) supporting the use of agents for thromboembolic prophylaxis during chemotherapy.

Gastrointestinal complications

The construction of urinary diversion is the main reason for postoperative complications after cystectomy. A lot of discussion currently focuses on the type of diversion in octogenarians, most of which often suffer from severe comorbities prior to surgery.

In this regard, avoiding the use of intestinal segments for reconstruction of the urinary route using, i.e. a ureterocutaneostomy, was shown to significantly reduce the rate of major complications (11% vs. 25%) and 30-/90 mortality rates (5.9%/6.9% vs. 7.7%/17.3%) in patients aged 75 years and older15. In this regard, protocols for enhanced recovery after surgery have nowadays been adopted in clinical practice and found to be associated with significantly improved perioperative gastrointestinal (GI) recovery and lower rates of GI complications.

In some studies additional benefits were reported with the adoption of ERAS protocols resulting in shorter time intervals on intensive care units, lower rates of wound healing disorders and VTE events.

Moreover, a randomized study revealed that total parenteral nutrition for the first five days after surgery resulted in higher number of postoperative complications which was mainly due to a higher rate of infectious complications.

Summary

Given the tumor aggressiveness of muscle-invasive bladder cancer open radical cystectomy is nowadays still the most effective treatment option for the treatment of muscle-invasive bladder cancer. The increasing use of neodjuvant and adjuvant treatment modalities mandates further attempts to reduce the rate and severity of perioperative complications.

In recent years an increasing number of randomized trials have addressed critical issues of perioperative care. Further well-designed trials are warranted in this major urological field of surgery to improve our understanding in refinements of perioperative care for improved functional and oncological outcomes after cystectomy.

Article by:
Prof. Georgios Gakis
Department of Urology and Pediatric Urology
Julius-Maximillians University of Würzburg (DE)

Prof. Georgios Gakis speaks at the Joint meeting of the EAU Section of Oncological Urology (ESOU), the EAU Robotic Urology Section (ERUS), the EAU Section of Uro-Technology (ESUT) and with the ESSO, ESTRO, EUOG, EORTC GUCG and SUO

Date: Saturday 17 March
Time: 10.15-15.30
Session: Complications in treatment of urological cancers