Perioperative complications of orthotopic neobladder after radical cystectomy for carcinoma of urinary bladder: A Retrospective Study

Background: The gold standard treatment for muscle-invasive bladder cancer is radical cystectomy (RC) with urinary diversion. Urinary diversion is performed in either as continent or incontinent forms. Orthotopic neobladder has the benefits of continent reservoir with voiding from the urethra. The mortality and morbidity rates ranged from 0 to 9.0% and 30 to 70%, respectively in various reports. For surgical outcome assessment, Clavien-Dindo classification is widely accepted for classification of complications of most of the surgical procedures. This study will be helpful to identify the potential complications and possibly minimize the morbidity and mortality of this surgery in the future. Materials and Methods: Data of 20 consecutively enrolled patients who underwent radical cystectomy and orthotopic neobladder form January 2023 to July 2024 at Urology unit of B.P. Koirala Memorial Cancer Hospital were taken for study from hospital medical records. The various demographic data and perioperative parameters were recorded. The early complications were defined as the complications during the period of hospitalization and up to 30 days of surgery, they were enlisted and then classified according to Clavein-Dindo Classification and the continence was reviewed at 1 month of surgery after catheter removal and after 3 months of surgery. Data was entered in SPSS 27 software and analyzed. Results: Complications were seen in 18 (90%) patients out of which 1 (5%) patients had Grade I complication, 12 (60%) patients had Grade II, 3 (15%) patients had grade IVA and 2(10%) had died. 5 (25%) patients developed high grade(≥ Grade III) complications. Mortality rate was 5%. Conclusion: Radical cystectomy with any forms of diversion is associated with high rate of morbidity and mortality. In order to identify and minimize the complications of this surgery in future, Clavein-Dindo classification is the standardized way of reporting the complications


Introduction:
Bladder cancer is the second most common urological malignancy, with transitional cell carcinoma making up nearly 90% of all primary bladder tumors. 1 The major risk factors for bladder cancer are environmental, tobacco smoking, exposure to toxic industrial chemicals and gases, bladder inflammation due to microbial and parasitic infections, as well as some adverse side-effects of medications. 2ladder cancer has been divided into Non muscle invasive (NMIBC) and Muscle invasive bladder cancer (MIBC) accounting for 75% and 25% of the bladder cancer as an initial presentation. 3egional therapy involves maximal transurethral resection of bladder tumor (TURBT) followed by treatments such as intravesical chemotherapy, intravesical immunotherapy, extirpative surgery, or chemoradiation.Pathologic staging and risk stratification are used to help guide further therapy. 4Radical cystectomy with pelvic lymph node dissection is by far considered the gold standard treatment for muscle invasive bladder cancer. 5The Indications of radical cystectomy are MIBC, and among NMIBC; very high risk category, BCG refractory, relapsing, unresponsive and intolerant, some variant histology. 6adical cystectomy has evolved from open radical cystectomy to laparoscopic to robot assisted radical cystectomy with comparable oncological outcomes as well as perioperative complications. 7Technical advances and the ability to use smaller incisions may ease recovery, limit complications, and decrease in-hospital recovery time.A more limited in-hospital length of stay (LOS) potentially may offset the additional equipment-related costs.The patients underwent pre-defined radical cystectomy and with standard pelvic lymph node dissection along with Ileal neo bladder of studers type under general anaesthesia.The operative time, intra-operative blood loss and length of abdominal incision were also recorded.The duration of ICU stay, requirements of antibiotics and its duration of use, use of analgesics and its type, proton pump inhibitors, prokinetics and diuretic agents were reviewed.Low molecular weight heparin and potassium in IV fluids were started on first post operative day or as per need.The daily drain and urine out puts and the post-operative day of drain removal, stent removal were recorded.All the complications that were observed during the period of recovery were recorded.Duration of hospital stay was noted.The complications related to neobladder like: unability to void after catheter removal, leakages were also recorded.The final histopathology report was reviewed and compared to previous histopathology reports of TURBT if available.Also noted the site, size, margin status, tumor grade, extension and lymph nodes status along with lympho-vascular and perineural extension were noted.All the patients were advised to do pelvic floor muscle training exercise by contracting and relaxing the pelvic floor muscles and anal sphincter in early post-operative days.The time/ days of foleys catheter removal was noted.The day time and night time incontinence episodes were reviewed at 1 month and 3 months follow ups.The postoperative complications are enlisted and then classified according to Clavein-Dindo Classification.Univariate analysis was done, using student's independent t-test for continuous variables and chi-square test for categorical variables.Data Analysis: Data are analyzed using SPSS 27 software.

Definition of Early Complication
Postoperative morbidity and mortality was defined as complications and death from any cause occurring during hospitalization or within 30 days of surgery. 12Postoperative complications during the hospital stay are recorded and classified according to Clavein-Dindo classification. 13

IVa
Single organ dysfunction (including dialysis)

Death of a patient
Surgical site infection which did not require any intervention were classified as Grade I. Patients with postoperative pneumonia, paralytic ileus, pyelonephritis and those requiring total parenteral nutrition (TPN) and Blood transfusion were classified as Grade II.Patients with bowel obstruction or peritonitis, wound dehiscence who needed surgery under general anesthesia were classified as Grade IIIB while those who did not require general anesthesia taken as Grade IIIA.Patient with single organ dysfunction or septic shock who needed inotropic support were classified as IVA while those with multiorgan dysfunction as Grade IVB.Death of the patient was taken as Grade V.
Postoperative blood transfusion was necessary in 16 (80%) patients.Postoperatively, the mean duration of ICU stay was 3.55 ± 2.66 days with range of 2-10 days.Inotropic support was required in 5 (25%) patients.

Complications
were classified according to Clavien-Dindo classification and complications were seen in 18 (90%) patients out of which 1 (5%) patients had Grade I complication, 11 (55%) patients had Grade II, 4 (20%) patients had grade IVA and 1(5%) mortality occurred in postoperative period due to MODS. 5 (25%) patients developed high grade (≥ Grade III) complications.Mean length of hospital stay was 19.1 ± 5.78 days with range of 14-35 days.After catheter removal after about 2 weeks, almost 90% patient had increased frequency.2 patients went into retention after catheter removal due to mucus and were re-catheterized again which was removed 5 days later.At 1 st month 50% patients were daytime continent and but were incontinent in night.At 3 months 75% of patients were daytime continent and 50% were night time continent.2017) concluded in his study that the daytime incidence of continence at the 6 th , 12 th , 24 th , 36 th , and 48 th months can reach 63%, 70%, 76%, 88%, and 92%, respectively.We observed in our study 50% patients were daytime continent and none were night time continent at 1 st month after ONB and 75% patients were daytime continent and 50% were nighttime continent at 3 rd month.The status of continence should be evaluated at 12 and 24 months after ONB before proceeding with any type of surgical intervention. 26The same group has observed and learned less complications in due course of learning curve and with stringent selection criteria. 27

Conclusion:
Radical cystectomy is a procedure with some higher rate of morbidity in urological surgical field.The majority of the complications are minor.However, morbidity and mortality can probably be decreased with careful patient selection, surgery performed by skilled surgeons, treatment at high volume canters and the application of an Enhanced Recovery After Surgery (ERAS) protocol.
Clavein-Dindo classification is the standardized way of reporting complications of radical cystectomy with orthotopic neobladder in bladder cancer.The idea behind this study is to identify the potential complications and possibly minimize the morbidity and mortality of this surgery in the future.

Table 2 :
Basic parameters

Table 3 :
Complications in CD classification