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Login to My HealthEarly Complications After Cystectomy Following High Dose Pelvic Radiation
Authors: Manuel S. Eisenberg, Ryan P. Dorin, Georg Bartsch, Jie Cai, Gus Miranda, Eila C. Skinner
USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
PURPOSE: Radical cystectomyCystectomysurgical removal of all (radical) or part (partial) of the urinary bladder in patients with a history of pelvic radiation therapy (RT) is an often challenging and morbid procedure. We report early complication rates in patients undergoing cystectomy and urinary diversion (UD) after high dose pelvic radiation.
MATERIALS AND METHODS: From 1983 to 2008, 2629 patients underwent cystectomy with UD at a single institution. Of these, 148 received ≥60 Gy pelvic RT prior to surgery. Each patient's medical record was retrospectively reviewed and any complication within 90 days of surgery was graded using the Clavien-Dindo system.
RESULTS: The median age was 74 years old, with a median ASA score of 3. Patients received a median 70 Gy pelvic RT a median 2.3 years prior to surgery. UD performed were ileal conduit in 65 (43.9%), continent cutaneous pouch in 35 (23.6%), and orthotopic neobladder in 48 (32.4%). A total of 335 early complications were identified. The highest grade complication was: none in 23%, grade 1 in 12.2%, grade 2 in 32.4%, grade 3 in 18.9%, grade 4 in 7.4%, and grade 5 in 6.1%. Age >65 and ASA were statistically significant predictors of postoperative complications (p=0.0264 and p=0.0252, respectively). Type of UD did not significantly affect the grade distribution or number of early complications per patient (p=0.7444 and p=0.1807, respectively).
CONCLUSIONS: The early complication rate using a standardized reporting system in patients undergoing post-RT radical cystectomy is higher than previously published in non-irradiated subjects. Age and ASA, but not urinary diversion type, are associated with early complications in this population.
Table 2: Patient clinical characteristics
| Characteristic | Median (% or IQR) |
| n | 148 |
| Age, years | 74 (69-78) |
| Male | 120 (81.1%) |
| ASA (n=122) | 3 (3-3) |
| Radiation to surgery interval (years) | 2.3 (1-9) |
| Total radiation dose | 70 (65-100) |
| Indication for radiation therapy | |
| bladder cancer | 79 (53.4%) |
| prostate cancer | 55 (37.2%) |
| other* | 14 (9.5%) |
| Previous abdominal or pelvic surgery (n=147) | 95 (64.6%) |
| Preoperative systemic chemotherapy | 39 (26.4%) |
| IQR, inter-quartile range; ASA, American Society of Anesthesiologists score
*other indications for radiation therapy include cervical cancer, endometrial cancer, lymphoma, and carcinoma not otherwise specified |
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Table 6: Complication categories and types
| Category | Complication type (incidence*) | n* | % of total |
| Gastrointestinal | Ileus† (29), dehydration (22), diarrhea (13), fistula / anastamotic bowel leak (9), failure to thrive (9), gastrointestinal bleeding (6), liver insufficiency/elevated LFT’s (4), emesis (3), dysphagia (3), small bowel obstruction (2) constipation‡ (2), large bowel obstruction (1) | 103 | 30.7% |
| Infectious | Sepsis (15), urinary tract infection (11), fever of unknown origin (7), urosepsis (6), C. difficile infection (5), abscess (4), oral candidiasis (2), cholecystitis (1), pyelonephritis (1) | 51 | 15.2% |
| Bleeding | Anemia requiring transfusion (28), internal hemorrhage (3), hematoma (2) | 33 | 9.9% |
| Cardiac | Arrhythmia (17), angina (4), myocardial infarction (3), congestive heart failure (3), hypertension (3), hypotension (1) | 31 | 9.3% |
| Genitourinary (GU) / Diversion | Urinary leak (7), renal insufficiency (4), urinary fistula (3), stomal incontinence (3), stomal ischemia/necrosis (3), acute tubular necrosis (2), ureteral obstruction (1), hematuria (1), renal failure (1), low urine output (1) | 26 | 7.8% |
| Miscellaneous | Edema (4), depression (4), electrolyte abnormality (3), rash (3), decubitus ulcer (2), other rare complications (10) | 26 | 7.8% |
| Neurologic | Altered mental status (18), neuropraxia (4), neuropathy (1), loss of consciousness (1) | 24 | 7.2% |
| Pulmonary | Respiratory distress (8), respiratory failure (6), atelectasis (4), pneumonia (2) | 20 | 6.0% |
| Wound | Seroma (10), superficial infection (6), fascial dehiscence (2) | 18 | 5.4% |
| Thromboembolic | Deep venous thrombosis (2), pulmonary embolus (1) | 3 | 0.9% |
| LFTs, Liver function tests
*Patients experiencing multiple complications are counted more than once †Ileus is defined as post-operative nausea or vomiting requiring the cessation of oral intake and/or nasogastric tube placement, or the intolerance of any oral intake by postoperative day 5. ‡Constipation is defined as the inability to have a bowel movement by postoperative day 5 without signs of ileus or bowel obstruction |
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Table 7: Complication categories by grade
| Low Grade (n = 264) | High Grade (n = 71) | ||
| Category | n (%) | Category | n (%) |
| Gastrointestinal | 81 (30.7%)
|
Gastrointestinal | 22 (31.0%) |
| Infectious | 43 (16.3%) | GU / Diversion | 16 (22.5%) |
| Bleeding | 30 (11.4%) | Pulmonary | 10 (14.1%) |
| Cardiac | 26 (9.8%) | Infectious | 8 (11.3%) |
| Neurologic | 23 (8.7%) | Cardiac | 5 (7.0%) |
| Miscellaneous | 23 (8.7%) | Bleeding | 3 (4.2%) |
| Wound | 16 (6.1%) | Miscellaneous | 3 (4.2%) |
| GU / Diversion | 10 (3.8%) | Wound | 2 (2.8%) |
| Pulmonary | 10 (3.8% | Thromboembolic | 1 (1.4%) |
| Thromboembolic | 2 (0.8%) | Neurologic | 1 (1.4%) |
Table 8: Statistical analysis of early complications (≤ 90days)
| Univariate variable | No Complications | Any Grade 1-5 complication | P value |
| n | 34 | 114 | |
| Male | 25 (73.5%) | 95 (83.3%) | 0.2002 |
| Age >65yrs | 24 (70.6%) | 99 (86.8%) | 0.0264 |
| ASA (n=122) | 0.0252 | ||
| 1 | 2 (7.1%) | 0 (0%) | |
| 2 | 5 (17.9%) | 17 (18.1%) | |
| 3 | 20 (71.4%) | 62 (66.0%) | |
| 4 | 1 (3.6%) | 15 (16.0%) | |
| RT to RC interval (yrs, median) (IQR) | 2 (1-10) | 2 (1-8) | 0.7035 |
| RT dose (Gy, median) (IQR) | 71 (65-100) | 70 (65-136) | 0.8925 |
| Indication for XRT | 0.8587 | ||
| bladder cancer | 17 (50.0%) | 62 (54.4%) | |
| prostate cancer | 14 (41.2%) | 41 (36.0%) | |
| Other | 3 (8.8%) | 11 (9.6%) | |
| Prior abdominal or pelvic sugery (n=147) | 22 (66.7%) | 73 (64.0%) | 0.7807 |
| Prior neoadjuvant chemotherapy | 9 (26.5%) | 30 (26.3%) | 0.9857 |
| Extent of lymphadenectomy | 0.3129 | ||
| Not performed | 14 (41.2%) | 35 (30.7%) | |
| <15 | 6 (17.7%) | 34 (29.8%) | |
| ≥15 | 14 (41.2%) | 45 (39.5%) | |
| Diversion type | 0.5681 | ||
| Ileal conduit | 15 (44.1%) | 50 (43.9%) | |
| Continent cutaneous | 6 (17.7%) | 29 (25.4%) | |
| Orthotopic neobladder | 13 (38.2%) | 35 (30.7%) | |
| Operative time (hr, median) (IQR) | 5 (5.0-6.0) | 6 (5.0-7.0) | 0.3238 |
| EBL (ml, median) (IQR) | 700 (600-1200) | 1000 (700-1500) | 0.1796 |
