Title: Analysis of radical cystectomy complications in patients previously treated by pelvic radiotherapy.
Allasia M(*), Soria F(*), Gonella A(*), Battaglia A(*), Marson F(*), Palazzetti A(*), Melloni G(*), Alessandria E(*), Garzino E(*), Bosio
A(*), Destefanis P(*), Gontero P(*), Frea B(*).
(*)
A.O. Città della Salute e della Scienza - Sede Molinette - Dipartimento di Scienze Chirurgiche e Specialistiche - Divisione di
Urologia
Introduction:
Radical cystectomy in patients with a history of pelvic radiation therapy is often a challenging and high risk
surgical procedure. We retrospectively evaluated data from patients underwent radical cystectomy and
urinary diversion in our Centre. We focused on the management and early complication rates in those who
previously received high dose pelvic radiation for any cause.
Materials and Methods
Patient medical records were retrospectively reviewed. Any patients that underwent a radical or salvage
cystectomy for any diagnosis has been included in the study. The following parameters were collected:
indication to surgery, previous pelvic radiation therapy (for any pelvic caner), intra and post-operative
complication, hospital stay, blood losses, post-discharge follow-up. The complications were graded using the
Clavien - Dindo classification.
Results
Between 2005 and 2012 we collected 330 patients who underwent radical cystectomy, among these 17
(5.2%) were previously treated with pelvic radiotherapy (PRT). Median age was 72 years (59-88). Median
follow-up was 45 months (1-102). PRT was performed as primary RT for prostate cancer (5 patients
external, 1 patient brachitherapy), as adjuvant therapy following radical prostatectomy (3 patients), as
multimodal therapy for muscle-invasive bladder cancer (chemo-radioteraphy, 3 patients), as treatment for
gynecological malignancy (4 patients) and, in one case, as adjuvant treatment following surgery in rectal
cancer. Radical cystectomy was performed in 9 cases for muscle-invasive bladder cancer, in 3 cases for local
progression of primary pelvic disease and in 5 cases for radiation induced cystitis. Urinary diversions
performed were ileal conduit in 12 patients (70.6%) and cutaneous ureterostomy in 5 patients (29.4%). A
total of 11 (65%) complications were identified: grade 1 in 5.9%, grade 2 in 23.5%, grade 3 in 29.4%, grade
4 in 0% and grade 5 in 5.9%. No complication was seen in 35% of the patients. Complication rate (ClavienDindo score 1-5) of radical cystectomy performed in patients (313) without PRT history was 30% with a
statistical significant difference (P=0,02). Urinary diversion type was not related with occurence of
complications.
Discussion
The early complication rate using a standardized reporting system in patients undergoing radical cystectomy
after radiation therapy is higher than previously published in nonirradiated subjects. In this selected serie
65% of patients experienced complications.
Conclusion
This revision shows as RC in PRT is still afflicted by an high rate of surgical complications and has to be
done in selected and well informed patients. Patients should be also well informed before undergoing
radiation therapy (especially for bladder cancer), that a subsequent salvage cystectomy would be a procedure
with a high risk of complications.