(UroToday.com) The joint session of the European Association of Urology and the Maghreb Union Countries included a presentation by Dr. Imad Ziouziou who discussed the preparation of patients for radical cystectomy. Dr. Ziouziou started by noting that radical cystectomy plus extended pelvic lymphadenectomy is the gold standard treatment for muscle invasive bladder cancer and for those with the highest risk non-muscle invasive bladder cancer. Perioperative management of radical cystectomy includes patient selection, assessment of operative risk, and fast recovery with fewer complications:
These aspects are important given the 30 days complication rates of 31.5-58% and the 90-day complication rates of 47-78% after radical cystectomy.
Patient selection for radical cystectomy is crucial, encompassing patient frailty defined as “clinical state characterized by an increased vulnerability of an organism to stressors, exposing individuals to negative health-related outcomes”. The Fried Frailty Criteria is defined as 3 or more of:
- Shrinking (unintentional weight loss of 4.5 kg or more in the last year)
- Weakness (low grip strength)
- Exhaustion (self-reported)
- Slowness (slow-walking speed)
- Low physical activity
Burg et al.1 assessed whether a prospective frailty assessment or traditional risk indices can identify patients undergoing radical cystectomy at risk for complications. Among 123 patients included in the study, 59 (48.0%) had ≥1 complication within 30 days and 72 (58.5%) within 90 days. Shrinking (OR 3.79, 95% CI 1.64-9.26, p = 0.0024) was significant for any 30-day complication, while physical activity was protective (OR 0.84, 95% CI 0.69-1.00, p = 0.072) for any 90-day complication. Furthermore, being intermediately frail or frail was associated with high-grade 30-day (OR 4.87, 95% CI 1.39-22.77, P = 0.022) and 90-day complications (OR 3.01, 95% CI 1.05-9.37, P = 0.045). According to Dr. Ziouziou, patient selection comes down to performance status, comorbidities, nutritional status, psychological status.
The conditions for radical cystectomy are an integrated relationship between the hospital, the surgeon, and the anesthesiologist. Hospital volume is likely associated with 30- and 90-day mortality, whereas surgeon volume has conflicting data. It is generally recommended that hospitals perform at least 10 radical cystectomies per year or refer the patient to a center that reaches this number. Jubber et al.2 previously looked at the impact of anesthetist volume on radical cystectomy outcomes, stratifying anesthetists as low (<10 cases) and high-volume (>=10 cases). Among 63 anesthetists, 56 (88.9%) were low volume and seven (11.1%) were high volume, providing coverage for 110 (25.6%) and 320 (74.4%) patients, respectively. When comparing high- versus low-volume anesthetists, there were shorter length of stay (median: 10 [IQR 6-14] vs 12 [IQR 7-19] days, p = 0.008), lower blood loss (median: 600 [IQR 384-1000] vs 800 [IQR 500-1275] ml, p<0.001), and lower transfusion rate (23/320, 7.2% vs 22/110, 20%; p < 0.001). There was no difference in disease-specific mortality, overall mortality, or readmission rates.
When deciding on proceeding with radical cystectomy, specifically a patient that is high-risk for complications, the decision revolves around finding an alternative treatment or prehabilitation prior to proceeding with radical cystectomy. Additionally, taking after the colorectal literature, enhanced recovery after surgery (ERAS) protocols have widely been adopted for patients undergoing radical cystectomy. Pang and colleagues3 reported their experience with prospective implementation of an ERAS program among 453 patients undergoing radical cystectomy, including 393 (87%) with ERAS. Length of stay was shorter with ERAS (median: 8 [IQR 6-13] days) than without (18 [13-25], p<0.001). Additionally, patients with ERAS had lower blood loss (ERAS: 600 [383-969] ml vs 1050 [900-1575] ml for non-ERAS, p<0.001), lower transfusion rates (ERAS: 8.1% vs 25%, p<0.001), and fewer readmissions (ERAS: 15% vs 25%, p=0.04) than those without.
Dr. Ziouziou concluded his presentation with the following take-home messages:
- We must check everything before taking the decision to proceed with radical cystectomy, including detecting frailty, anticipating surgical complications (inform the patient), anticipate general complications in collaboration with anesthetist and other colleagues, check that the environment (hospital) is appropriate, and implement ERAS
- The decision ultimately comes down to a shared decision-making process with the patient, oncologists, anesthetists, cardiologists, and perhaps other surgical colleagues
Presented by: Imad Ziouziou, MD, PhD, University Hospital of Agadir, Agadir, Morocco
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md on Twitter during the 2021 European Association of Urology, EAU 2021- Virtual Meeting, July 8-12, 2021.
References:
- Burg ML, Clifford TG, Bazargani ST, et al. Frailty as a predictor of complications after radical cystectomy: A prospective study of various preoperative assessments. Urol Oncol. 2019 Jan;37(1):40-47.
- Jubber I, Pang KH, Groves R, et al. Impact of anaesthetist volume on radical cystectomy outcomes. Eur Urol Focus. 2021 Jan;7(1):117-123.
- Pang KH, Groves R, Venugopal S, et al. Prospective implementation of enhanced recovery after surgery protocols to radical cystectomy. Eur Urol. 2018 Mar;73(3):363-371.