Page 6 - World Journal of Laparoscopic Surgery

Reva Sergey et al
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results include lower intraoperative blood loss, earlier and 2 according to Clavien system. The results of
return to bowel function, less pain, and quicker our study suggest benefits of the minimally invasive
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postoperative convalescence. However, complication approach.
reports may be limited by reporting and selection bias for Several studies showed survival impairment after
healthier patients. Moreover, the difficulty in obtaining intraoperative blood transfusion. Thus, the transfusion
data on complications results from a lack of consistency rate could be potentially important for patients due to its
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in reporting complications. 19 hypothetically immunosuppressive effect. According
One of the limiting factors of laparoscopic cystectomy to the literature, blood loss in open, laparoscopic, and
is its labor intensity and duration. Indeed, recent data robotic RC is about 700 to 1500, 250 to 790, and 22 to
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show an increased treatment time compared to open 460 respectively. The same authors showed lower
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surgery. In our study, the duration of LRC was 1.6 times blood transfusion rate for minimally invasive RC [5 to
greater than ORC. However, when analyzing the entire 20% and 1 to 4% in LRC and robot-assisted RC (RARC)
series of laparoscopic surgery, a significant decrease respectively] compared to the open procedure (14 to
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was found in this indicator up to 1.3 times in the last 40%). Our study showed higher (compared to the
10 transactions compared to the first 10, which means literature data) blood loss during ORC, probably due to
that we gain experience. In other words, we find that a lower number of patients. However, in the literature
LRC takes longer to do than open procedure but results we found similar results with blood loss reduction due
in better functional outcomes with reduced blood loss, to reducing invasiveness of intervention. 25
transfusion rate, shorter length of stay in hospital, Another significant problem related to radical bladder
and fewer complication rates. According to the recent surgery consists in gastrointestinal complications.
literature, nearly 40% of this patient cohort experienced Intraoperative rectal wall damage occurred at a relatively
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at least one readmission within 90 days following RC. No low rate – about 0.2% (up to 4% according to some data).
differences in age, gender, race, or stage were observed The same rate (0.2 to 2%) was noted for large blood vessels
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between patients who did vs did not undergo the ER. damaging both in LRC and ORC. Such intraoperative
Gastrointestinal, wound, and deep vein thrombosis adverse events (Table 2) were associated with locally
complications were most commonly documented with advanced tumors and did not depend on the type of
readmission within 30 days. Genitourinary, neurologic, surgery (ORC or LRC).
and cardiac complications were more common in those With the minimally invasive approach, patients with
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with later readmissions. Stimson et al showed that ileal conduit urinary diversion had a decreased risk of
the readmission rates were as high as 27%, with bowel, complications compared to continent urinary diversions.
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urinary, and infectious complications being the most Totally, the 90-day perioperative mortality rate was 5.3%.
common reasons. The transfusion rate in one series According to our data, the most clinically significant event
was appr. 66%, with an average estimated blood loss (in terms of hospital and ICU readmission rates, repeated
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of 1 l for 1,142 consecutive ORCs. Our experience surgery) was gastrointestinal complications, particularly,
shows that in accordance with the mentioned studies, ileus. This event has the greatest differences among the
when comparing LRC and ORC, the results favor the patients after LRC (14.2%) and ORC (47.6%). Recent stud-
use of the laparoscopic approach. Other important ies showed that postoperative ileus happened in 23, 3,
characteristics are the number of days in ICU and and 8% of patients after open, laparoscopic, and robotic
duration of hospitalization. There was no significant cystectomy respectively. 15,27 However, many studies used
difference between these items (p = 0.53). different definition of this event. Ramirez et al in the
According to the Clivlend’s clinic data, which has recent review found 21 articles with a clear definition of
the greatest experience in minimally invasive RC with postoperative ileus. The most frequent one was absence
intracorporeal urinary diversion, this technique of of flatulence, stool on the 5th or 6th postoperative day;
intestinal substitution is significantly better than the postoperative nausea and vomiting which required to
extracorporeal one in terms of better intestinal function stop enteral feeding and to start intravenous feeding
recovery. Other complication rates were comparable and/or nasogastrointestinal intubation on the 5th or 6th
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between both groups. Totally, despite significant postoperative day; absence of intestinal movement on the
improvements in armamentarium and surgical 5th postoperative day; intestinal movement impairment
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technique, the complication rate after minimally which lead to prolonged hospitalization. Recovery of the
invasive RC remains high. In the largest series, the bowel function and/or removal of the gastric tube and/
30-day complication rate is about 60 to 65%, and in 90 or inability of oral food intake after 5 postoperative days
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days complications occurred in nearly 80%. Among were the criteria for establishment of dynamic intestinal
all patients with 90-day complications, 80% had grade 1 obstruction (ileus) in our study. According to these, we
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