Complicaciones posquirúrgicas en cistectomías radicales a 30 días: factores relacionados y uso de la escala de APGAR quirúrgico para su predicción
Palabras clave:Cáncer de vejiga, cistectomía radical, escala APGAR
Objective: Bladder cancer represents the seventh most common cancer with highly variable morbidity and mortality due to detection, treatment and follow-up strategies, with radical cystectomy (RC) being the treatment that offers the best oncological control. A morbidity rate between 30-93% has been reported at 30 days, and mortality greater than 8%. This variability is due to the scarcity of standardized reports using scales such as Clavien-Dindo (CD). Due to the little evidence of publications on complications associated with RC, we decided to make a standardized report of these, using the CD scale of the RCs performed in our hospital, with the goal of finding out the incidence and real severity of these.
Materials and methods: A retrospective analysis was made of a prospectively maintained database of RCs performed in our center between 1994 and 2019. All patients over 18 years of age who underwent RC during the study period were included, and all patients with incomplete documentation of the immediate 30 day-postoperative were excluded. Descriptive statistics were used for data presentation. The Kolmogorov-Smirnov test was used to determine the data distribution. An inferential mean comparison analysis was performed using the Student's t-test for variables with normal distribution, and non-parametric tests (Mann–Whitney U-test) for those with non-normal distribution.
Results: The mean age of the study population was 61.16 years (SD 10.1). Patients without major complications had a BMI 2.45 kg/m2 lower compared to patients with major complications (95% CI -4.7 to -0.18). Bleeding and surgical time, as well as type of derivation, were not significantly associated with major complications.
Study limitations: It was a retrospective study, so the SAS could not be calculated for the entire population. Also, it was a small cohort of patients in a tertiary care center with a restricted number of hospital beds, which considerably reduces the statistical power of the study to find low-frequency events (mortality). Extending the follow-up to more than 30 days could modify the incidence of complications.
Originality: Our series is the first to use a standardized system (Clavien-Dindo scale) to report postoperative complications in patients undergoing RC in Mexico.
Conclusions: RC continues to be one of the surgeries with the highest morbidity. The use of standardized scales for reporting complications associated with RC would allow us to establish prevention strategies and establish homogeneous surveillance criteria with other specialties.
International Agency for Research on Cancer. Cancer Today. Estimated number of new cases in 2020, worlwide, both sexes, all ages. 2021.2022. World Health Organization; 2020. Available from: https://gco.iarc.fr/today/online-analysis-table
Schiavina R, Borghesi M, Guidi M, Vagnoni V, Zukerman Z, Pultrone C, et al. Perioperative complications and mortality after radical cystectomy when using a standardized reporting methodology. Clin Genitourin Cancer. 2013;11(2):189–97. doi: https://doi.org/10.1016/j.clgc.2012.12.003
Chang SS, Bochner BH, Chou R, Dreicer R, Kamat AM, Lerner SP, et al. Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline. J Urol. 2017;198(3):552–9. doi: https://doi.org/10.1016/j.juro.2017.04.086}
Olasveengen TM, Semeraro F, Ristagno G, Castren M, Handley A, Kuzovlev A, et al. European Resuscitation Council Guidelines 2021: Basic Life Support. Resuscitation. 2021 Apr;161:98–114. doi: https://doi.org/10.1016/j.resuscitation.2021.02.009
Patel HD, Ball MW, Cohen JE, Kates M, Pierorazio PM, Allaf ME. Morbidity of Urologic Surgical Procedures: An Analysis of Rates, Risk Factors, and Outcomes. Urology. 2015;85(3):552–60. doi:https://doi.org/10.1016/j.urology.2014.11.034
Hirobe M, Tanaka T, Shindo T, Ichihara K, Hotta H, Takahashi A, et al. Complications within 90 days after radical cystectomy for bladder cancer: results of a multicenter prospective study in Japan. Int J Clin Oncol. 2018;23(4):734–41. doi: https://doi.org/10.1007/s10147-018-1245-z
Moschini M, Simone G, Stenzl A, Gill IS, Catto J. Critical Review of Outcomes from Radical Cystectomy: Can Complications from Radical Cystectomy Be Reduced by Surgical Volume and Robotic Surgery? Eur Urol Focus. 2016;2(1):19–29. doi: https://doi.org/10.1016/j.euf.2016.03.001
Yuh BE, Nazmy M, Ruel NH, Jankowski JT, Menchaca AR, Torrey RR, et al. Standardized analysis of frequency and severity of complications after robot-assisted radical cystectomy. Eur Urol. 2012;62(5):806–13. doi:https://doi.org/10.1016/j.eururo.2012.06.007
Canales R R, Iturriaga V C, Canales S O, Guamán O R, Michael L P, Susaeta S R, et al. Cistectomía radical por cáncer vesical en un hospital docente-asistencial: análisis de resultados perioperatorios. Revista chilena de cirugía. 2014;66(4):351–8. doi: http://dx.doi.org/10.4067/S0718-40262014000400010
Álvarez Ardura M, Llorente Abarca C, Studer UE. Manejo perioperatorio y resultados en pacientes con neovejiga ileal ortotópica. Actas Urológicas Españolas. 2008;32(3):297–306. doi: https://doi.org/10.1016/S0210-4806(08)73834-8
Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13. doi: https://doi.org/10.1097/01.sla.0000133083.54934.ae
Martínez-Cornelio A, Hernández-Toriz N, Quintero-Becerra J, Flores-López D, Moreno-Palacios J, Vázquez-Martínez E. Trece años de experiencia en el manejo de cáncer vesical con neovejiga ortotópica de Studer. Cir Cir. 2009;77(6):443–50.
González Ávila G, Rodríguez Ovalle H, Rojas Barrera JA. Morbilidad y mortalidad en conducto ileal y su relación con nutrición parenteral total postoperatoria. Nutrición Hospitalaria. 2006;21(4):511–6.
Acosta-Garduño J, Sánchez-Puente JC, Aragón-Tovar AR, Torres-Medina E, Vilchis-Cárdenas MA, Urbina-Bernal LC, et al. Morbimortalidad asociada a la cistectomía radical; experiencia en la UMAE N° 25 del IMSS. Rev Mex Urol. 2010;70(4):224–7.
Djaladat H, Bruins HM, Miranda G, Cai J, Skinner EC, Daneshmand S. The association of preoperative serum albumin level and American Society of Anesthesiologists (ASA) score on early complications and survival of patients undergoing radical cystectomy for urothelial bladder cancer. BJU Int. 2014;113(6):887–93. doi: https://doi.org/10.1111/bju.12240
Arumainayagam N, McGrath J, Jefferson KP, Gillatt DA. Introduction of an enhanced recovery protocol for radical cystectomy. BJU International. 2008;101(6):698–701. doi: https://doi.org/10.1111/j.1464-410X.2007.07319.x
Hollenbeck BK, Miller DC, Taub D, Dunn RL, Khuri SF, Henderson WG, et al. Identifying risk factors for potentially avoidable complications following radical cystectomy. J Urol. 2005;174(4 Pt 1):1231–7; discussion 1237. doi: https://doi.org/10.1097/01.ju.0000173923.35338.99
Masago T, Morizane S, Honda M, Isoyama T, Koumi T, Ono K, et al. Estimation of mortality and morbidity risk of radical cystectomy using POSSUM and the Portsmouth predictor equation. Cent European J Urol. 2015;68(3):270–6. doi: https://doi.org/10.5173/ceju.2015.636
Gawande AA, Kwaan MR, Regenbogen SE, Lipsitz SA, Zinner MJ. An Apgar score for surgery. J Am Coll Surg. 2007;204(2):201–8. doi: https://doi.org/10.1016/j.jamcollsurg.2006.11.011
Baltazar GA, Darnauer T, Akella K, Kanitsch S, Shafey A, Chendrasekhar A. Surgical Apgar Score Predicts Postoperative Length of Stay Better Than American Society of Anesthesiologists Classification. The Internet Journal of Surgery. 2014;32(1). doi: http://ispub.com/doi/10.5580/IJS.22197
Baumeister P, Galioto D, Moschini M, Lonati C, Zamboni S, Afferi L, et al. Single staff cystectomy in a low-volume center: Oncological outcomes and complications. Canadian Urological Association Journal. 2021 May 11;15(11). doi: https://doi.org/10.5489/cuaj.7171
Arora S, Keeley J, Patel A, Eleswarapu SV, Bronkema C, Alanee S, et al. Defining a ‘High Volume’ Radical Cystectomy Hospital: Where Do We Draw the Line? Eur Urol Focus. 2020;6(5):975–81. doi: https://doi.org/10.1016/j.euf.2019.02.001
Waingankar N, Mallin K, Smaldone M, Egleston BL, Higgins A, Winchester DP, et al. Assessing the relative influence of hospital and surgeon volume on short-term mortality after radical cystectomy. BJU Int. 2017;120(2):239–45. doi: https://doi.org/10.1111/bju.13804
Vetterlein MW, Meyer CP, Leyh-Bannurah S-R, Mayr R, Gierth M, Fritsche H-M, et al. Effect of Hospital and Surgeon Case Volume on Perioperative Quality of Care and Short-term Outcomes After Radical Cystectomy for Muscle-invasive Bladder Cancer: Results From a European Tertiary Care Center Cohort. Clin Genitourin Cancer. 2017;15(5):e809–17. doi: https://doi.org/10.1016/j.clgc.2017.04.021
Grande P, Campi R, Rouprêt M. Relationship of surgeon/hospital volume with outcomes in uro-oncology surgery. Current Opinion in Urology. 2018;28(3):251–9. doi: https://doi.org/10.1097/mou.0000000000000490
Azhar RA, Bochner B, Catto J, Goh AC, Kelly J, Patel HD, et al. Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs. European Urology. 2016;70(1):176–87. doi:https://doi.org/10.1016/j.eururo.2016.02.051
Tyson MD, Chang SS. Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes. European Urology. 2016;70(6):995–1003. doi: https://doi.org/10.1016/j.eururo.2016.05.031