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Keywords:

  • radical cystectomy;
  • mortality;
  • morbidity;
  • complications;
  • lymphadenectomy

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

OBJECTIVE

To report the events during and after radical cystectomy and urinary diversion for bladder cancer, in terms of major and minor complications, comparing a minimal with an extended lymphadenectomy, as more lymph nodes obtained during radical cystectomy may improve staging and thus the outcome.

PATIENTS AND METHODS

We reviewed 92 consecutive patients who underwent radical cystectomy from March 1998 to February 2002; 46 had a minimal (group A) and 46 an extended lymphadenectomy (group B). Cases were selected according to the American Society of Anesthesiologists classification, only including those graded 2 or 3. We specifically evaluated the incidence and type of complications within 30 days after surgery.

RESULTS

Because of extending the lymphadenectomy the operative duration was a median of 63 min longer in group B (P < 0.01). Complications requiring surgical interventions occurred in four (9%) patients in group A and five (11%) in group B (P = 0.28). Complications requiring no surgical intervention were also similar in both groups. Three patients died, two in group A and one in group B (P = 0.57).

CONCLUSION

Extended lymphadenectomy in radical cystectomy does not increase the morbidity within 30 days of surgery.


Abbreviations
ASA

American Society of Anesthesiologists.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

The increasing age of the general population will lead to a higher incidence of muscle-invasive bladder cancer. Radical cystectomy is the treatment of choice for invasive bladder cancer [1], but to date there is no standard procedure for radical cystectomy, and even less so for lymphadenectomy. There is evidence that a wide resection of perivesical soft tissue can decrease the frequency of local tumour recurrence. Pelvic lymphadenectomy during radical cystectomy improves information about the spread of the cancer. Recent studies show that removing more lymph nodes could increase the number of positive lymph nodes detected [2,3]. There is an important divergence of opinion about how the lymphadenectomy should be carried out and about the minimum number of nodes that should be removed. However, this has an influence on further therapeutic strategies. Herr et al.[2] emphasized that at least nine lymph nodes should be removed to increase the likelihood of proper staging and a better outcome. It was further established that removing more lymph nodes might even cure some patients with positive lymph nodes [4,5] and this is therefore a reason for using an extended lymphadenectomy. However, most patients undergoing radical cystectomy are elderly, have significant comorbidity and are deemed unfit for the extended surgery resulting from extensive lymphadenectomy. Thus the goal of the present study was to evaluate whether an extended lymphadenectomy would cause greater morbidity in patients undergoing radical cystectomy.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Between March 1998 to February 2002, 98 consecutive patients underwent radical cystectomy in two European hospitals; they were all American Society of Anesthesiologists (ASA) grade 1–4. We selected 92 patients with an ASA grade of 2 or 3; 46 patients had surgery in the Oberwart (group A), Austria, and 46 in Bolzano/Bozen (group B), Italy. An external urinary diversion (ileal conduit in 58) and ileal neobladder (Studer in 30 and Gonheim in four) was created. The patients underwent radical cystectomy by two urologists in group A and by one urologist in group B; the mean (range) age of patients in groups A and B was 68.2 (51–83) and 66.3 (46–81) years, respectively.

The operation consisted of radical cystoprostatectomy in men and anterior pelvectomy removing the adnexes, uterus and anterior vagina in women. All patients in group B had an extended lymphadenectomy, including the perivesical, hypogastric, obturator, external iliac, common iliac and aortal lymph nodes, into the region of the inferior mesenteric artery. This in group A had a ‘minimal’ lymphadenectomy, including the perivesical lymph nodes and the lymphatic tissue of the obturator fossa, being confined laterally by the external iliac vein and medial by the obturator nerve. Lymph nodes in both groups were removed as packets. To avoid (or minimize) morbidity from lymph-node dissection, particularly lymphoceles, in both groups the lymphatic vessels were ligated at their distal end when they were severed. When removing lymph nodes from the iliac vessels only bipolar coagulation was used. Patient selection for an ileal conduit or an orthotopic neobladder depended on age and patient compliance. Patients were monitored in the intensive care unit after surgery. For this study, postoperative morbidity (or death) was defined as that within 30 days after surgery.

Before surgery CT of the abdomen and chest, and a bone scan, were used to exclude gross metastasis, and the patients evaluated for cardiovascular, pulmonary, renal, hepatic and metabolic status. Patients had a routine blood count, electrocardiography and, if indicated, spirometry, echocardiography and coronary angiography. Before cystectomy all patients were ASA graded; the commonest comorbidities are listed in Table 1. Patients were admitted to the hospital 2 days before surgery for intravenous fluid hydration and/or blood supply for anaemia and the day before surgery all patients had their bowel prepared. To minimize the risk of thrombosis, low molecular weight heparin was started 1 day before surgery, combined with compression stockings. Broad-spectrum antibiotic coverage was started with the premedication. The operative duration, blood replacement and intraoperative complications were reviewed.

Table 1.  The ASA grade, the pathological staging of the cystectomy specimen, and the characteristics of the complications within 30 days after radical cystectomy in the two groups
VariableGroup, n (%)
ABTotal
  • *

    P   =  0.02.

ASA 22018 
ASA 32628 
Comorbidity
Cardiovascular30 (67)25 (55) 
Coronary disease  11 (24)  9 (19) 
Severe atherosclerotic peripheral  disease  5 (10)  4 (9) 
Pulmonary disease24 (53)20 (44) 
Chronic kidney failure  9 (19)12 (26) 
Diabetes mellitus  6 (14)  8 (17) 
Pathological stage
pT1  6 (14)  4 (9)10 (11)
pT2–3a18 (39)24 (52)42 (46)
pT3b–T422 (47)18 (39)40 (43)
N+10 (22)18 (39)28 (30)
Complications
Pulmonary embolus  2 (4.3)  1 (2.2) 
Pneumonia  7 (15)  2 (4.3)* 
Cardiac (infarction, arrhythmia)  4 (9)  2 (4.3) 
Prolonged ileus (>6 days)  2 (4.3)  1 (2.2) 
Hydronephrosis  6 (13)  3 (6.5) 
Pyelonephritis  4 (9)  4 (9) 
Acute renal failure  0 (0)  1 (2.2) 
Transient cerebrovascular accident  1 (2.2)  3 (6.5) 

The results were analysed statistically using commercial software, with comparisons by Fisher's (two-sided) exact test, with differences considered significant at P < 0.05.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

There were complications during surgery in 17 (37%) patients in group A and in 20 (43%) in group B (P = 0.08), but they were only medical disturbances like transient hyper- and/or hypotension and transient sinus bradycardia and/or tachycardia. Cardiac arrhythmia occurred in three (6.5%) patients in group A and in five (11%) in group B (Table 1; P = 0.16). The median (range) operative duration was 277 (205–300) min in group A and 330 (225–410) min in group B (P < 0.01); thus extended lymphadenectomy increased the duration by 63 min. Groups A and B received a median (range) of 1.15 (0–8) and 0.8 (0–4) blood units (P = 0.37). The pathological staging of the cystectomy specimens is shown in Table 1.

All patients were monitored in the intensive care unit after surgery until 20.00 hours on the same day and then, if conditions allowed, transferred to the regular care unit. In group A the median intensive care unit stay was 5.1 (1–25) days and the median hospital stay 14.2 (11–32) days; the respective values for group B were 4.5 (1–14) and 16.3 (10–27) days.

There were complications requiring surgical intervention within 30 days after surgery in four patients (9%) in group A (two dehiscences of the intestinal small bowel and one of the surgical wound, and one severe bleeding) and in five (11%) in group B (one small bowel obstruction, one ureteric necrosis, two leakages of the ureter-neobladder anastomosis and one dehiscence of the surgical wound; P = 0.28).

Complications not requiring surgical intervention within 30 days after cystectomy are listed in Table 1; there were no lymphoceles on clinical exploration. The mean number of blood units transfused within 30 days in group A 3.2 (0–19) and in group B, 0.7 (0–3) (P = 0.067).

Three patients died (3.3%), two in group A and one in group B (P = 0.57). A 70-year-old woman and an 81-year-old women died in group A because of pneumonia caused by pre-existing chronic obstructive lung disease. In group B a 72-year-old man died from a pulmonary embolus 3 days after surgery.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

The main aim of all cancer surgery is definitive therapy for the primary tumour and preservation of the quality of life. A series of studies published in the last decade emphasize the importance of pelvic lymph node dissection during cystectomy for invasive bladder cancer. Most investigators advocate lymph node dissection as an integral part of the curative intent of radical surgery of invasive bladder cancer, and not only as a staging procedure [3,6,7].

In a recent study [2] patients in whom nine or more lymph nodes were removed had significantly better survival than those with fewer lymph nodes removed. Although there is clearly no absolute threshold the study implied that nine lymph nodes should be the minimum removed. Removing more lymph nodes should improve survival and ensure that the surgery is optimal. However, pelvic lymphadenectomy during radical cystectomy provides important pathological information for predicting the prognosis. It identifies patients who require adjuvant chemotherapy because of a high risk of relapse after surgery [8,9], and extended lymphadenectomy may cure some patients with positive lymph nodes.

Although it was not the (primary) goal of the present study to compare the number of positive lymph nodes in both groups, there were significantly more patients with positive lymph nodes in group B (Table 1). The pathological evaluation of the lymphatic tissues was not detailed enough to provide the exact number and/or location of negative and positive lymph nodes in each case. Therefore, the only information was whether the patients were lymph node-positive or -negative.

The aim of the present study was to determine whether any improvement in outcome from extending the lymphadenectomy was at the price of more complications during and after surgery. The only surgical complication which was significantly more common in group A was pneumonia; although we have no clear explanation, we suggest this might be a result of the higher proportion of cigarette smokers in group A than B.

In this study ileal conduits and continent urinary reconstructions were included, because a recent study [10] showed that perioperative morbidity and mortality did not depend on the kind of urinary diversion. The present re-operation rate was 9.8%, compared with 4.1%, 8.7% and 25% in other studies [11,12].

Despite the careful selection of patients, attention to perioperative details and immediate postoperative care, radical cystoprostatectomy in the present series still resulted in three deaths (3%) within 30 days of surgery, compared with 2.5%[13] and 2.8%[14] in other series. However, these (slightly) lower death rates were in studies with more patients (404 and 675, respectively) than in the present series (92), and therefore more likely to be representative. The present rate of severe complications was 23%, compared with 32%, 25–32% (depending on age) and 28% in other series [13–15].

In conclusion, most investigators advocate lymph node dissection as an integral part of the curative intent of radical surgery for invasive bladder cancer, and not only as a staging procedure. The present study suggests that, despite prolonging the operation, extended lymphadenectomy causes no increase in complications during and after surgery.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  • 1
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