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124
Ó. R. Faba et al.
Preoperative Workup
All candidates should be discussed in multidisciplinary committee with the same work-up for
muscle-invasive bladder cancer. This comprises a
complete blood test, a CT scan of the abdomen
and pelvis with intravenous contrast, and thoracic
CT.If there is any suspicious for bone metastasis,
then a bone scan should also be indicated.
Random bladder biopsies should also be performed priory to surgery to exclude multifocal
disease and/or CIS. Moreover, a cystoscopy
might be part of the preoperative workup to
assess the location of the tumor and the bladder
capacity.
Special consideration should be taken in the
diagnosis and management of urachal tumors as
it can be difcult to distinguish between urachal
and nonurachal bladder adenocarcinomas. While
various criteria have been established to rule-out
in this differentiation, a practical approach was
reported by Johnson etal. The clinic and pathologic characteristics required for a diagnosis
include an enteric-type adenocarcinoma in the
midline of the bladder, location within the bladder wall, sharp demarcation between tumor and
normal urothelium, and exclusion of a primary
adenocarcinoma located elsewhere that has
spread secondarily to the bladder [6]. Urachal
cancers may express detectable serum levels of
tumor markers as carcinoembryonic antigen
(CEA), cancer antigen (CA) 125, and cancer
antigen (CA) 19-9, especially in the setting of
locally advanced or peritoneal carcinomatosis
[7, 8].
Surgical Technique
The surgical technique for an open PC has been
well-described in the literature over the years by
different authors [3]. A lower midline incision is
made from the pubic symphysis to the level of the
umbilicus. PC may be performed either transperitoneally or extraperitoneally. Dissection progresses down through the fascia, after which the
peritoneum and the Retzius space are opened. To
open the surgical eld, the vascular pedicles
might be divided on one side. The colon is partially mobilized on each side to partially expose
the retroperitoneum. The ureters are carefully
identied and swept medially. A surgical retractor of the surgeon’s choice is recommended to be
placed at this point. The pelvic lymph nodes
should be removed from the obturator fossa to
the common iliac vessels. After the lymphadenectomy, the bladder tumor is resected. The bladder is opened away from the site of the tumor,
preferably on the anterior bladder wall. The
tumor is identied intravesically and then excised
with a 1–2-cm margin. Alternatively, a exible
cystoscope can be inserted to identify the location of the tumor or perform rst step endoscopic
approach to delineate endoscopically the location
of the tumor. Next, the bladder is closed in two
layers and lled to conrm that the closure is
watertight. A closed suction drain is placed, and
the abdominal incision is closed [9].
Robotic surgery has some advantages over
open and laparoscopic surgery. It provides the
surgeon with superior optics with threedimensional visualization of the surgical eld as
well as improved dexterity that allows for precise
intracorporeal suturing. Furthermore, patients
who undergo robot-assisted PC (RAPC) could
potentially benet from earlier postoperative
recovery, improved postoperative cosmesis, and
reduced postoperative pain [10]. But it has been
reported the increased risk of cell seeding and
implantation in urothelial cell carcinoma [11].
Partial Cystectomy forUrachal
Tumors
The open surgical approach for urachal adenocarcinoma proceeds in much the same way as it
does for urothelial carcinoma. However, because
the urachus may be involved with the tumor anywhere along its course, an “en bloc” resection of
the entire urachus as well as umbilicus is required.
There is not much evidence on how to manage
urachal tumors in an adult population. When a
urachal mass is detected incidence of malignancy
12 Partial Cystectomy
ranges from 51 to 64% [12]. The surgical technique for treating a symptomatic urachal remnant
includes excision of the urachus and its tract,
including the portion that is attached to the bladder dome. Open partial cystectomy is the most
widely used technique for urachal disease.
Robotic partial cystectomy has been described
for the management of both pediatric and adult
urachal disease with good results [13].
The advantage of complete excision of the
urachal tract, including umbilectomy to achieve
a negative surgical margin, has been described
to be an important oncological aspect. The failure to perform umbilectomy is an independent
predictor of increased cancer-specic mortality
[14]. In other reports, the authors did not nd
umbilectomy to be a statistically signicant factor associated with survival [15] (Figs.12.1 and
12.2).
125
Fig. 12.1 Partial cystectomy for urachal tumor
Fig. 12.2 Partial cystectomy for urachal tumor
Complications
Apart from oncological issues (recurrence, progression), the complication rate of PC ranges
from 11–29% [1]. It is important to consider that
lower complication and mortality rates have been
reported at high-volume centers. Specically, no
cases of intrahospital mortality were identied
among hospitals performing at least ve PC procedures in a year [5]. Kates etal. [5] analyzed
more than 10, 000 patients who underwent PC
for BC (2002–2008). PC represented 13.9% of
all cystectomies performed. The complications
rate was 15.8%, with a mortality rate of 1.8%.
Results revealed that patients who died had
higher comorbidity status and were signicantly
older when compared to patients undergoing radical cystectomy (74.1 vs. 70.4years; P<0.001),
and therefore likely represent a population. It is
important to consider that a complication rate of
126
Ó. R. Faba et al.
15.8% is markedly decreased when compared to
that of radical cystectomy; 67% of radical cystectomy patients experienced an in-hospital complication and 13% had Clavien grade 3–5
complications [16].
Common complications of partial cystectomy
include bleeding, infection, reduction of bladder
capacity, and urinary stula. Less commonly,
some patients develop stulas (vesicocutaneous,
vesicovaginal, colovesical). Other complications
include those that are possible in any major surgery: myocardial infarction, pulmonary embolus,
congestive heart failure, upper gastrointestinal
hemorrhage, and death [3].
The implementation of laparoscopic and
robotic surgical approaches to PC represents a
signicant advancement and promises to further
reduce the length of hospital stay, surgical morbidity, and complication rates [17]. Robotic PC
results have been reported in small, single-center
studies, including a heterogenous patient population. Global results report a median hospital
length of stay of 1 day and an overall 90-day
complication rate of 24.1% (all Clavien grades
I–II) [1, 18]. Complications of robotic PC for
muscle-invasive BC have been explained in detail
in a retrospective series of 35 patients. Any grade
complications (ileus, pneumonia, and urethral
stricture) were reported in 4 patients. After 1year,
seven patients presented with recurrence; ve of
those patients died of their disease, and the other
two died of unrelated causes [10].
Oncological Outcomes
There are not randomized trials comparing radical and partial cystectomy in the contemporary
literature. Nevertheless, the retrospective data
report that in selected patients who t the prole,
PC may be a good alternative.
Capitanio et al. analyzed PC and RC after
matching at a ratio of 1:4 for tumor grade, pT
stage, pN stage, age, race, and year of surgery. A
second matched analysis was performed after
adding the number of removed lymph nodes to
the matching criteria. In the rst analysis, the
overall survival (OS) and cause-specic survival
(CSS) estimates at 5 years were 57.2% and
76.4%, respectively, for PC patients and 50.2%
and 65.8%, respectively, for RC patients
(P<0.001). In the second analysis, the OS and
CSS estimates were 56.0% and 73.5%, respectively, for PC patients and 50.9% and 67.5%,
respectively, for RC patients (P = 0.03 and
P<0.001 for both). When the number of removed
lymph nodes was included in the third analysis,
the 5-year OS and CSS estimates were 57.2%
and 70.3%, respectively, for PC patients and
54.6% and 69.2%, respectively, for RC patients
[19].
To assess the role of neoadjuvant chemotherapy in this eld, 60 patients who achieved cT0
after receiving MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) chemotherapy
followed by transurethral resection of a bladder
tumor (TURBT) were studied. Fifteen of these
patients subsequently underwent PC and 17
underwent RC.The 10-year metastasis-free survival (MFS) was 73% for those who underwent
PC and 65% for those who underwent
RC. Furthermore, 53% of patients in the PC
group had intact bladders [20]. Knoedler et al.
performed a matched-control analysis to compare RC with PC.Patients submitted to PC had a
single tumor without CIS. They were matched
based on age, gender, pathological stage, and
neoadjuvant chemotherapy. The results revealed
that patients undergoing PC were less likely to
have multifocal bladder tumors on the nal
pathology as compared to those undergoing RC
(15.1% vs. 32.9%). In all, 38% of patients who
underwent PC developed intravesical recurrence.
Five percent of PC patients experienced pelvic
recurrence. At a mean follow-up of 6.2 years,
81% of patients maintained an intact bladder.
Most signicantly, no differences existed between
PC and RC with regard to 10-year MFS (61% vs.
66%), CSS (58% vs. 63%), and OS (36% vs.
36%) [21].
Koga etal. developed a much stricter protocol.
Patients received as rst step a debulking TURBT
with random biopsy and were subsequently considered for PC if they had intravesical circumscribed tumors ≤25% of the bladder area and no
involvement of the bladder neck or trigone. They
12 Partial Cystectomy
Table 12.1 Oncological outcomes PC
Author N (PC) F-U (months) Outcomes (y; %) Characteristics
Capitanio [19] 1573 64 DSS(5y): 76.4
OS(5y):57.2
Herr [20] 15 120 MFS (10y): 73 Neoadj MVAC
Knoedler [21] 86 74 MFS (10y):61
DSS (10y):58
OS (10y);36
Koga [22] 46 45 MFS (10y): 100
DSS(5y):100
Golombos [18] 29 37 RFS (5y): 68
OS (5y): 79
DSS Disease free survival, OS Overall Survival, RFS Recurrence free survival, MFS Metastasis free survival
SEER database
T1-4, N0-2, M0; RC vs.PC
RC vs. PC (T0)
RC vs.PC
Pior TURBT
Robotic
127
were then submitted to radiotherapy and two
cycles of cisplatin, before being restaged
4–6weeks later. To be included as a PC candidate, the restaged TURBT must show no evidence of disease or small residual
non-muscle-invasive disease. Of their initial
cohort of 183 patients, 65 met the criteria, of
which 46 underwent PC. Seven patients developed intravesical recurrence, all of which was
supercial. Five-year CSS for this cohort was
100% [22].
One of the largest robotic PC series included
29 patients who underwent robotic PC. With a
median follow-up of 37months, the 5-year OS
and recurrence-free survival (RFS) rates were
79% and 68%, respectively. Seven patients (24%)
had a recurrence, three of which were local and
four of which were regional or distant. Two local
recurrences were managed with TURBT because
there was no muscle invasion. The third local
recurrence was muscle-invasive and was thus
managed with a cystectomy [18] (Table12.1).
Conclusions
• Approximately 5.8–18.9% of patients with
muscle-invasive bladder cancer are suitable
candidates for partial cystectomy.
• PC is indicated in patients with a normally
functioning bladder with good capacity and a
solitary tumor located where a 1–2-cm resec-
tion margin is possible.
• For high-risk tumors, a multimodal approach
with neoadjuvant or adjuvant chemotherapy
and possible radiotherapy may be needed.
• Absolute contraindications include carcinoma
in situ (CIS) elsewhere in the bladder and multifocal tumors.
• After surgery, ongoing surveillance, including
imaging, cystoscopy, and cytology, is important because the local recurrence rate is high
(37–78%).
• Patients who have undergone partial cystectomy for bladder cancer should have cystoscopy and urinary cytological examination
every 3months for at least 2years. Regular
CT scans of the pelvis and abdomen are recommended in the rst several years of
follow-up.
• With proper patient selection, long-term,
bladder- sparing survival rates with partial cystectomy range from 35 to 70%.
References
1. Knoedler J, Frank I.Organ-sparing surgery in urology:
partial cystectomy. Curr Opin Urol. 2015;25:111–5.
2. Holzbeierlein JM, Lopez-Corona E, Bochner BH,
Herr HW, Donat SM, Russo P, et al. Partial cystectomy: a contemporary review of the Memorial
Sloan-Kettering Cancer Center experience and
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5. Kates M, Gorin MA, Deibert CM, Pierorazio PM,
Schoenberg MP, McKiernan JM, et al. In-hospital
death and hospital-acquired complications among
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2014;32(53):e9–14.
6. Johnson DE, Hodge GB, Abdul-Karim FW, Ayala
AG.Urachal carcinoma. Urology. 1985;26:218–21.
7. Kikuno N, Urakami S, Shigeno K, Shiina H, Igawa
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N. Adenocarcinoma of the urachus associated with
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10. Alanee S, El-Zawahry A.Robotic-assisted partial cystectomy for muscle invasive bladder cancer: contemporary experience. Int J Med Robot. 2022;18:e2390.
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Mateu L, Musquera M, et al. Intraoperative prognostic factors and atypical patterns of recurrence in
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12. Ashley RA, Inman BA, Routh JC, Rohlinger AL,
Husmann DA, Kramer SA.Urachal anomalies: a longitudinal study of urachal remnants in children and
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13. Kim DK, Lee JW, Park SY, Kim YT, Park HY, Lee
TY. Initial experience with robotic-assisted laparoscopic partial cystectomy in urachal diseases. Korean
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14. Ashley RA, Inman BA, Sebo TJ, Leibovich BC, Blute
ML, Kwon ED, etal. Urachal carcinoma: clinicopath-
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15. Siefker-Radtke AO, Gee J, Shen Y, Wen S, Daliani
D, Millikan RE, etal. Multimodality management of
urachal carcinoma: the M.D. Anderson cancer center
experience. J Urol. 2003;169:1295–8.
16. Shabsigh A, Korets R, Vora KC, Brooks CM, Cronin
AM, Savage C, etal. Dening early morbidity of radical cystectomy for patients with bladder cancer using
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Knoedler JJ.Perioperative outcomes of robot-assisted
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Saad F, etal. Partial cystectomy does not undermine
cancer control in appropriately selected patients with
urothelial carcinoma of the bladder: a populationbased matched analysist. Urology. 2009;74:858–64.
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P, Tarrell RF, etal. Does partial cystectomy compromise oncologic outcomes for patients with bladder
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Masuda H, et al. Selective bladder-sparing protocol
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Complications ofRadical
Cystectomy
KellyR.Pekala andBernardH.Bochner
13
Introduction
Radical cystectomy in women (with hysterectomy, bilateral salpingectomy, +/− oophorectomy, +/− anterior vaginectomy and urethral
excision) and pelvic lymphadenectomy with subsequent urinary diversion are the gold-standard
operation for women with invasive bladder cancer [1]. When performed for bladder cancer the
average age of women undergoing cystectomy is
68years, with two thirds having a prior history of
extensive smoking. Owing to advanced age, multiple comorbidities, and the extent of the procedure, complications are common. In a series of
1142 radical cystectomy patients at a large cancer
center, in which complications were recorded
prospectively, 64% of patients were observed to
have a complication of any grade (1–5) at
90-days. Approximately two thirds experienced a
complication during the initial hospital admission and 58% following postoperative discharge.
Importantly, of these complications, only 13%
were of high grade (grades 3–5) with a 30-day
mortality rate of 1.5% [2]. These are consistent
with more contemporary series, in which the rate
of grade 3–5 complications was 14.4% at 30days
and 21.7% at 90days [3].
K. R. Pekala · B. H. Bochner (*)
Urology Service, Department of Surgery, Memorial
Sloan Kettering Cancer Center, New York, NY, USA
e-mail: bochnerb@mskcc.org
There is retrospective evidence that women
undergoing radical cystectomy may experience
more complications than men in patients undergoing radical cystectomy for reasons other than
bladder cancer. In one analysis of the National
Surgical Quality Improvement Program Database, after propensity matching, there was an
increased risk of readmission, supercial surgical
wound infection, and transfusion in women compared with men. The addition of organ sparing to
radical cystectomy in women did not increase the
complication rates [4].
Herein, we review the common complications
following radical cystectomy.
Surgical Approach
Historically, the majority of radical cystectomy
series encompassed patients undergoing open
surgery. The use of robotic cystectomy, with
intra- or extracorporeal diversion, is increasing,
with a recent analysis of the national cancer database revealing that 40.6% of cystectomies were
performed robotically in 2015 [5]. There have
been several randomized controlled trials (RCTs)
comparing robotic with open cystectomy. The
MSKCC trial was the initial RCT, with a primary
endpoint of 90-day complication rates of open
versus robotic techniques. The robotic group
underwent robotic extirpative surgery and the
diversion was performed as open surgery. Overall
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_13
129
130
K. R. Pekala and B. H. Bochner
complications of 62% and 66% were observed in
the robot-assisted radical cystectomy (RARC)
and open radical cystectomy (ORC) patients
respectively (p=0.7). Operative time was longer
with RARC but resulted in a lower intraoperative
blood loss. The RAZOR trial had a primary endpoint of 3-year cancer recurrence. Similar to the
MSKCC study, it compared open and robotic
approaches with extracorporeal diversion and
found no difference in rates of overall complications or rates of major grade 3–5 complications.
There were higher rates of urinary tract infection
(35% vs 26%) and similar rates of postoperative
ileus (22% vs 20%) in the robotic group versus
the open group [6]. The recently published iROC
study, a randomized controlled trial that compared robotic cystectomy plus intracorporeal
diversion with open radical cystectomy found no
differences in overall complications, or highgrade complications. Closer evaluation of specic categories of complications found that
wound complications (17.3% vs 5.6%) and
thromboembolic events (8.3% vs 1.9%) showed a
higher trend in the open surgical groups.
Readmission rates of 32% in the open and 22% in
the robotic cohort were observed; however, most
readmissions were short with a median readmission time of 0days [7].
Table 13.1 Early and overall complications within
90days following radical cystectomy and urinary diversion
30-day complications
(N=149)
GU 24% GU 28%
Infectious 20% Infectious 23%
Pulmonary 11% GI 9%
Cardiac 10% Cardiac 9%
DVT/PE 9% Pulmonary 9%
Reproduced with permission from Ref. [2]
GU genitourinary, GI gastrointestinal, DVT deep vein
thrombosis, PE pulmonary embolism
Overall complications within
90days (N=199)
leakage (4.3% vs 2.6%) amongst the robotic
group [7]. Renal failure occurred in 5–7% of
patients in the iROC study [7] and 11–13% in the
RAZOR trial [6]. However, these data contradict
rates of new renal failure or worsening of CKD,
which was noted to be ~3% in an MSKCC prospectively recorded database that included over
1100 patients [2]. Renal failure can be managed
expectantly postoperatively by assessment for the
presence or absence of hydronephrosis and subsequent placement of appropriate nephrostomy
tubes, with concomitant management of electrolyte disturbances.
Infection
Complications by Category
The most common complications by category
following radical cystectomy include genitourinary, infectious, gastrointestinal, cardiac, and
pulmonary complications (Table13.1).
Genitourinary
There is an 11% rate of genitourinary (GU) complications found in ORC and RARC patients
undergoing cystectomy [2, 7]. The most common
GU complications are typically urinary diversion
related and include ureteral obstruction, renal
failure, and urine leaks. The iROC study found
that there were higher rates of ureteroenteric
anastomotic strictures (2.5% vs 0.6%) and urine
Infectious complications are another major category of complications and are seen in one quarter
to one third of all patients undergoing ORC [2].
Randomized trial data demonstrated rates of
infection of 24–38% and 29–33% in the RARC
vs ORC cohorts in the iROC and MSKCC studies
[7, 8]. Rates of infection types were similar, with
the exception of wound infections, seen more frequently in the open cohorts of both trials [7, 8].
Common sources of infection are urinary (pyelonephritis, urosepsis, urinary tract infections),
abdominal uid collections, wound infections, or
rarer infections such as pulmonary, bowel leaks,
or osteomyelitis of the pubic bone.
Careful assessment and treatment of preoperative positive urine cultures and administration of antibiotics that cover likely organisms to
include skin ora, S. aureus, Gram-negative
13 Complications ofRadical Cystectomy
131
rods, possibly Enterococcus, and anaerobic
coverage is recommended by American Urological Association guidelines, depending on
the type of planned urinary diversion and use of
the small or large bowel [9].
Gastrointestinal
As radical cystectomy is accompanied by a urinary diversion using a segment of the gastrointestinal tract, gastrointestinal complications are a
common postoperative complication. The most
common gastrointestinal complications include
ileus or small bowel obstruction. Less common
gastrointestinal-associated complications include
anastomotic bowel leak and gastrointestinal
bleeding. In the randomized controlled trials of
open versus robotic cystectomy, the MSKCC trial
found 23% vs 29% gastrointestinal complications
in ORC versus RARC, whereas the iROC study
found similar rates of gastrointestinal complications within 90days of 28%, similar rates of ileus
of around 10%, and small bowel obstruction of
3% [7]. These ndings are echoed by smaller real
world series that report that ileus is the most common reason for readmission within 30days (11%),
whereas small bowel obstruction was a common
reason for readmissions within 90days (5%). [10]
There have been several efforts to improve on
gastrointestinal complications over the years.
The enhanced recovery after surgery (ERAS)
approach, originally designed for colorectal surgery, has been adopted for radical cystectomy
and is detailed in another chapter in this textbook.
ERAS typically consists of alterations to historical management in the preoperative phase (bowel
preparation, preoperative fasting), intraoperative
phase (intravenous uid management, alterations
to analgesia with minimization of opioids), and
postoperative phase (alteration of diet advancement and use of nasogastric tubes). There have
been three randomized controlled trials of ERAS
for cystectomy. Two trials found no difference in
30-day postoperative complications [11, 12],
with improved time to bowel function and length
of stay group in the ERAS group. One trial found
that patients who received alvimopan (Entereg)
had a statistically signicantly faster recovery of
bowel function than those who received placebo
(5.5days vs 6.8days), shorter length of stay (7.4
vs 10.1 days), and fewer postoperative ileusrelated morbidity (8.4% vs 29.1%) [13]. A systematic review and meta-analysis performed a
multivariable analysis of individual ERAS factors associated with length of stay and found that
omitting the nasogastric tube (−8.7days) and the
use of local anesthetic blocks (−3.29 days)
reduced the duration of hospital stay [14].
Cardiopulmonary
Cardiopulmonary complications such as cardiac
arrhythmia, congestive heart failure, hypertension, hypotension, myocardial infarction, atelectasis, pleural effusion, pneumothorax, and
pneumonia are relatively rare but certainly possible in patients with pre-existing comorbidities.
In these cases, postoperative cardiac monitoring
should be performed, at least in the initial perioperative setting, with early evaluation by
Cardiology as indicated. Pre- and postoperative
use of incentive spirometry and early ambulation
can reduce the risk of pulmonary complications.
Bleeding/Thromboembolic
Although bleeding is a common surgical risk for
radical cystectomy, prospective series demonstrate average intraoperative blood loss of 500 vs
680cc (MSKCC), 300 vs 700cc (RAZOR), 200
vs 550cc (iROC) for robotic versus open respectively [6–8]. Transfusion rates in large open series
of approximately 8% have been reported [2].
Open versus robotic comparisons have consistently noted a lower estimated blood loss (EBL) in
RARC-treated patients; however, this is not necessarily associated with a lower transfusion rate
of 12% vs 7% in the iROC study. Still, major
bleeding complications (0.6%), wound hematomas (0%), and postoperative bleeding (0%)
remain rare amongst both the open and robotic
cohorts. Other clinical characteristics associated
with increased EBL come from real- world data
132
K. R. Pekala and B. H. Bochner
using the NSQIP database. Propensity matching
and multivariable analysis note that women were
twice as likely to require postoperative blood
transfusion for anemia (53% vs 38%) [4].
In one, the largest radical cystectomy analysis
of complications, there was a 8% risk of thromboembolic events, with deep vein thrombosis (5%)
and pulmonary embolism (3%) the most common
events. This was conrmed by the RAZOR trial,
which found a 8% versus 5% thromboembolic
event rate (deep vein thrombosis, DVT) in open
versus robotic and similar rates of pulmonary
embolism (PE; 3%). These data contrast with the
iROC study, in which thromboembolic events
such as DVT (0.6% vs 0%), PE (7.1% vs 1.9%)
were higher in the open cohort [7].
Postoperative thromboembolic prevention is a
mainstay for patients undergoing major abdominal
and pelvic surgery, with a large Cochrane review
that demonstrated a reduction of thromboembolic
events from 13.2% to 5.3%, without an associated
increase in bleeding complications or mortality
[15]. In the cystectomy setting, it typically consists
of sequential compression devices, early ambulation, pre- and post-operative administration of
subcutaneous heparin during the perioperative
inpatient hospital stay and discharge with 30days
of anticoagulation (commonly subcutaneous
enoxaparin), with emerging evidence for the use
of oral anticoagulation with apixaban [16].
the MSKCC series and similar rates of delirium
of approximately 3% in both the open and robotic
cohorts in the iROC study [7]. Efforts to reduce
delirium, such as reduced night-time sleep disruptions for unnecessary vital signs, ensuring
adequate sunlight during the day, and efforts to
reorient patients, are recommended to reduce the
risk of hospital-induced delirium. There are also
low-risk pharmacological interventions, such as
melatonin or ramelteon, that can be used at night,
and in a recent systematic review of randomized
controlled trials signicantly reduced hospital
delirium by 49% in surgical patients [18].
Miscellaneous
Lymphocele
Pelvic lymph node dissection performed for radical cystectomy is associated with a risk of lymphocele of approximately 3% that has been
reported in randomized controlled trials [6].
These can present with lower-extremity swelling,
DVT, or abdominal uid collections. Management
may consist of needle aspiration or drain placement in selected cases, depending on whether or
not there are signs of infection or other related
symptoms. Extending the pelvic lymphadenectomy to the level of the aortic bifurcation can
increase the risk of lymphocele formation [19].
Neurological
Cerebrovascular Accident/Stroke
Cerebrovascular accident/stroke are uncommon
complications following radical cystectomy
(<1%) [2], but are more common in older patients.
Octogenarians have a signicantly higher rate of
neurological complications than patients aged
<80years (10.3% vs 3.9%) [17].
Delirium/Agitation
As radical cystectomy patients have an average
age of 68years old and spend several days in the
hospital recovering, they are at particular risk of
hospital-induced delirium, with disturbed sleep/
wake cycles. There was a 2% rate of delirium in
Unique Complications forWomen
The concept of radical cystectomy for women has
evolved over time with uterus-, fallopian tube-,
ovary-, and vagina-sparing cystectomy entering
the treatment paradigm to maintain the oncological outcomes while attempting to preserve gynecological organs of importance to women for
endocrine and sexual function [20]. Patients must
be appropriately selected for pelvic organ sparing,
taking into consideration bimanual examination,
tumor location, gynecological history, and relevant cervical cancer screening, menopausal status, sexual function, and family history (BRCA 1
or 2 mutation or Lynch syndrome) [21].
13 Complications ofRadical Cystectomy
133
Organ-Sparing Cystectomy (Uterus-, Fallopian Tube-, Ovary-Sparing)
The rationale for organ-sparing approaches
includes the low incidence of involvement
of gynecological organs by direct extension, with a rate of 2.5–7.5%, improved
sexual function, reduction in neobladder–
vaginal fistula, and improved voiding for
the neobladder. [22] Series have demonstrated that in the well-selected patient,
there are equivalent oncological outcomes
and excellent urinary and sexual functional
outcomes [21].
Ovary Removal Risks (Bone Loss, Fracture Risk, Cardiac Events, Cognitive Decline, Mortality)
Bilateral oophorectomy has been based on the
risk of bladder cancer presence or recurrence
within the ovaries and risk of ovarian primary
malignancy. However, ovarian involvement of
cancer is rare, with one retrospective study that
found 4% ovarian involvement and 2.5% involvement of the fallopian tubes with urothelial carcinoma and no primary gynecological malignancies
[23]. After excluding patients with advanced disease, women with ≤pT2 had a 0% rate of ovarian
involvement.
There have been several large prospective
studies that have found that women who undergo
bilateral salpingo-oophorectomy as part of a
hysterectomy had a 13% increase in overall
mortality [24], particularly in women up to the
age of 50–65, where the risk of mortality related
to oophorectomy was similar to other competing risks [25, 26]. Even in the postmenopausal
setting, ovaries continue to secrete hormones,
which has a variety of benets, including cardiac, cognitive, bone, sexual, and health
[27–31]. Gynecologists recognizing the benets
of leaving the ovary in situ in younger women,
have adopted a practice of prophylactic bilateral
salpingectomies as there is evidence that most
ovarian cancers originate in the fallopian tubes
[32, 33].
Vaginal Complications
There are many possible vaginal complications
following removal of the anterior vaginal wall
and subsequent closure, including vaginal prolapse, stula, dyspareunia, cuff dehiscence, and
subsequent bowel evisceration. In a study that
evaluated SEER-Medicare, which includes
patients 65 and older including 481 women, there
was a 20% rate of vaginal complications within
2 years of radical cystectomy. They found that
cuff dehiscence was the most common vaginal
complication (10.2%), followed by stula (6.9%),
prolapse (4.5%), and dyspareunia (2.3%).
However, only 26% of these women went on to
have an intervention [34]. In a systematic review
that reviewed the same topic with an inclusive
cohort that included younger patients, a neobladder vaginal stula rate of 3–6% at high- volume
centers with risk factors for stula such as poor
vascularity, overlapping suture lines, prior radiation, and tumor recurrence [35]. There are several
techniques to counter the potential for neobladder vaginal stula including organ preservation
of the uterus and omental interposition.
References
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2. Shabsigh A, Korets R, Vora KC, etal. Dening early
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