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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 29  |  Issue : 1  |  Page : 20-24

Performing laparoscopic radical cystectomy is feasible for the elderly with marginal cardiopulmonary function


1 Division of Urology, Chang-Gung Memorial Hospital at Chia-Yi, Taoyuan, Taiwan
2 Chang-Gung Memorial Hospital at Chia-Yi, Taoyuan, Taiwan
3 Division of Urology, Chang-Gung Memorial Hospital at Chia-Yi; Chang Gung University of Science and Technology, Chia-Yi; Department of Medicine, Chang Gung University, Taoyuan, Taiwan

Date of Web Publication23-Feb-2018

Correspondence Address:
Wei Yu Lin
Division of Urology, Chang-Gung Memorial Hospital, Chiayi Park, Road West, No 6, Putz City, Chiayi County
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_9_17

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  Abstract 

Purpose: The purpose of this study was to report the feasibility, safety, and benefits of laparoscopic radical cystectomy (LRC) for patients with bladder cancer (BC) who are older than 75 years and with marginal cardiopulmonary function in a regional teaching hospital. Materials and Methods: The charts of thirty patients who underwent LRC between 2013 and 2016 in a community teaching hospital were reviewed. The patients were subgrouped into the age groups ≥75 years and <75 years. Data extracted from the charts included patient demographics, American Society of Anesthesiologists (ASA) Score, Charlson Comorbidity Index (CCI) Score, cardiopulmonary function test result, pathological results, conversion rate, operative time, Intensive Care Unit days, and postoperative recovery time. Results: A significant difference was observed in the data of the group ≥75 years group compared with the <75 years group, with a higher ASA score (P = 0.0007) and higher rate of marginal cardiopulmonary function (80% vs. 26.7%, P = 0.0092). No significant difference was observed in sex, CCI score (3.93 vs. 3.27), body mass index (24.8 vs. 24.4), ejection fraction (69% vs. 70.97%), operation time (473 vs. 465 min), blood loss (503 vs. 380 mL), urinary diversion type, Intensive Care Unit care (1.13 vs. 0.6 days), interval to ambulation (2 vs. 1.8 days), interval to oral food intake (3.2 vs. 2.6 days), interval to normal bowel function (4.6 vs. 3.6 days), postoperative hospitalization (15.67 vs. 11.67 days), and blood transfusion rate (33.3% vs. 26.7%) between the two groups. No conversion to open surgery or mortality was observed. Surgical complications occurred in 15 patients, with a complication rate of 50%. No surgical mortality was noted in 30 or 90 days. Most pathological cases revealed urothelial carcinoma. Conclusions: LRC is a safe option with favorable outcomes in BC patients older than 75 years with marginal cardiopulmonary function in a regional teaching hospital.

Keywords: Elderly, laparoscopic radical cystectomy, marginal cardiopulmonary function


How to cite this article:
Lin JH, Chiu KH, Ho DR, Huang YC, Huang KT, Chen CS, Lin WY. Performing laparoscopic radical cystectomy is feasible for the elderly with marginal cardiopulmonary function. Urol Sci 2018;29:20-4

How to cite this URL:
Lin JH, Chiu KH, Ho DR, Huang YC, Huang KT, Chen CS, Lin WY. Performing laparoscopic radical cystectomy is feasible for the elderly with marginal cardiopulmonary function. Urol Sci [serial online] 2018 [cited 2018 Sep 23];29:20-4. Available from: http://www.e-urol-sci.com/text.asp?2018/29/1/20/226034


  Introduction Top


Urothelial carcinoma is the fourth most common tumor,[1],[2] and bladder cancer (BC) is the most common urinary tract cancer.[3] The prevalence of BC increases with age and a high prevalence is observed in the elderly population.[4] Men have a higher risk of BC [4] and the most common pathological outcome of BC is transitional (urothelial) cell carcinoma, which constitutes more than 90% of BCs.[5] A high incidence of BC was observed on the Southwest coast of Taiwan,[6] and the rate of aging in Taiwan was reported to be two times that in European countries and the United States.[7] However, a greater risk of perioperative morbidity and mortality in elderly people undergoing radical cystectomy (RC) was observed.[8]

RC with pelvic lymph node dissection is the standard operation for nonmetastatic muscle-invasive bladder urothelial cancer or recurrent high-grade bladder urothelial cancer. Although laparoscopic RC (LRC) has been demonstrated to be feasible in elderly patients[9] because of advances in surgical techniques, patient care, and medical instrumentations, the use of this technique is still associated with higher morbidity and mortality rates (14%).[9] In a systematic review and cumulative analysis, irrespective of the age of the patients undergoing robot-assisted RC, the perioperative mortality rate was 3% and the 90-day complication rate was 59%.[10] Typically, patients older than 75 years with BC do not receive the same operations as do younger patients because of the age-related health status and anesthesia risk.

A previous study demonstrated that laparoscopic surgery improved the overall morbidity and mortality.[11] The benefits of laparoscopic surgery are likely relatively less blood loss, a quicker return to normal bowel function, and shorter hospital stay. Therefore, we evaluated the safety and efficacy of LRC in older patients, particularly those aged ≥75 years by determining marginal cardiopulmonary function, in regular clinical treatment. This study evaluated the perioperative and postoperative outcomes of LRC for BC in elder patients with marginal cardiopulmonary function at our hospital.


  Materials and Methods Top


This study was approved by the Institutional Review Board (IRB) of our hospital (IRB case number: 201700016B0). The charts of thirty patients who underwent LRC between 2014 and 2016 at our hospital were reviewed. Data extracted from the charts included patients' demographics, clinical stages, cardiopulmonary function, pathological results and procedures, conversion rate, operative time, postoperative recovery time, and complications. The thirty patients were subgrouped into the age groups ≥75 years and <75 years. The main indication for surgery included muscle-invasive BC (MIBC) after transurethral bladder biopsy and non-MIBC (NMIBC) refractory to conservative treatment (intravesical chemotherapy or immunotherapy, recurrent after treatment) or intractable hematuria with hemorrhagic cystitis after radiation therapy. All patients underwent routine preoperative imaging evaluation for distant metastases, including computed tomography of the abdomen and bone scan in selected patients. The preoperative evaluation included a complete blood count, complete biochemical profile, chest X-ray, cardiac echography, and pulmonary functional tests.

LRC or laparoscopic radical cystoprostatectomy with bilateral pelvis lymph node dissection was performed through four or five laparoscopic ports after positioning the patient in the supine and Trendelenburg position. The final specimen was removed through a small infraumbilical median incision, and ureteral reconstruction and anastomosis were performed extracorporeally through the infraumbilical incision. The type of urinary diversion depended on the patient and surgeon preference; however, the neobladder type was not suitable for patients with BC with urethra invasion or previous bowel operations.

Postoperative care included nasogastric tube removal as soon as possible after bowel gas passage, early patient ambulation, and early diet intake. In addition, peripheral parenteral nutrition was prescribed for the patients undergoing a neobladder or ileal conduit operation. Postoperative ileus was defined as a period of 7 days to normalization of bowel function. Complications were graded on the basis of the Clavien-Dindo Classification of Surgical Complications (Grades 1–5). Minor complications in this study were categorized as Grades 1–2, and major complications were categorized as Grades 3–5.

The primary preoperative parameters evaluated in this study were patient age, body mass index (BMI), sex, ASA score, Charlson Comorbidity Index (CCI) Score, cardiopulmonary function, and marginal cardiopulmonary function. Marginal cardiopulmonary function is defined as one of the following: moderate or severe restrictive ventilatory impairment, moderate or severe obstructive ventilatory impairment, ejection fraction <50%, atrial fibrillation, moderate or severe valve regurgitation, left ventricular dysfunction or dilatation, moderate or severe pericardial effusion, and moderate or severe pulmonary hypertension revealed through pulmonary function test or cardiac echography.

The intraoperative parameters included the total operative time instead of LRC duration, as well as intraoperative blood loss, number and type of intraoperative complications, and transfusion rate. The postoperative parameters included serum albumin levels, duration of stay in the Intensive Care Unit, duration of hospital stay, complications, transfusion rate, and interval to normal bowel function.

We used the GraphPad Prism 7 software, GraphPad Software, Inc for statistical analysis. A t-test was used for analyzing continuous variants with normal distribution, and Chi-square test or Fisher's exact test was used for analyzing discontinuous variants with nonnormal distributions.


  Results Top


The general data of all 30 patients (mean age, 70 years) were collected [Table 1]. Of the patients, 24 were men and 6 were women, with a mean BMI of 24.6. The mean American Society of Anesthesiologists (ASA) score was 2.7 and the average ejection fraction was 69.86% according to M-mode echocardiography. The results of a pulmonary function test revealed that 13 patients had restrictive ventilatory impairment or obstructive ventilatory impairment. The average of CCI Score was 3.6, and there are 26 patients exhibited a positive finding of cardiac echography (cardiac echography revealed any grade of valve regurgitation, pulmonary hypertension, ventricular dysfunction, ventricular dilatation, or pericardial effusion). Sixteen patients exhibited marginal cardiopulmonary function. The intraoperative characteristics are listed in [Table 2]; the average operation time was 469 min. Fourteen patients received the ileal conduit and four received the neobladder procedures. Moreover, eight patients underwent ureterostomy and four did not receive urinary diversion procedures because of their end-stage renal disease status posthemodialysis or peritoneal dialysis.
Table 1: Preoperative characteristics

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Table 2: Intraoperative characteristics

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The average estimated blood loss was 442 cc and the average interval to ambulation was 1.9 days. No conversion to open surgery or mortality was observed during the perioperative or postoperative period [Table 3]. Surgical complications occurred in 15 patients, with a complication rate of 50%. According to the Clavien-Dindo Classification, 10, 3, and 1 patient(s) were classified under the complication Classes II, III, and IV, respectively. Four major complications were observed: acute left middle cerebral artery infarction, rectal perforation postreceiving primary repair and ileostomy, acute cholecystitis status postdrainage, and urine leakage status postdrainage. Most cases (29 patients) of pathology revealed urothelial carcinoma except one case of hemorrhagic cystitis. A higher rate of advanced bladder staging was observed with Stage IV (33.3%) (26.7% vs. 40%) in this study. Only one pathological finding revealed a positive margin, and it was due to distant metastasis with pelvic lymph node metastasis.
Table 3: Postoperative characteristics

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The 30 patients were subgrouped into two age groups: ≥75 years (average age, 77 years) and <75 years (average age, 62 years). A total of 15 patients were present in each group. No significant difference was observed in sex, CCI score (3.93 vs. 3.27), BMI (24.8 vs. 24.4), ejection fraction (69% vs. 70.97%), operation time (473 vs. 465 min), blood loss (503 vs. 380 mL), urinary diversion type, minor or major early complications rate, Intensive Care Unit care (1.13 vs. 0.6 days), interval to ambulation (2 vs. 1.8 days), interval to oral food intake (3.2 vs. 2.6 days), interval to normal bowel function (4.6 vs. 3.6 days), postoperative hospitalization (15.67 vs. 11.67 days), blood transfusion rate (33.3% vs. 26.7%), and albumin level (3 vs. 3.16 ng/dL) between the two groups.

However, the ≥75 years group exhibited a significantly higher ASA score (P = 0.0007) and higher rate of marginal cardiopulmonary function (80% vs. 26.7%, P = 0.0092) than did the other group. Three major complications were observed: acute left middle cerebral artery infarction, rectal perforation postreceiving primary repair and ileostomy, and acute cholecystitis status postdrainage. The two patients who exhibited major complications had atrial fibrillation with moderate obstructive or restrictive ventilatory impairment. No 30- or 90-day mortality was observed in both the groups.


  Discussion Top


RC is the gold standard for treating MIBC and recurrent high-grade NMIBC or refractory to BC-conserving regimens.[12] RC or radical cystoprostatectomy is a major surgical procedure with bilateral pelvic lymph node dissection with or without urinary diversion. According to the current relevant literature on urology, the morbidity rates vary widely from 19% to 67%,[13],[14] and mortality rates range from 0.8% to 8.3%.[15],[16]

LRC is considered safer than traditional open RC.[17] However, some elderly patients with more underlying diseases were skeptical about receiving the curative operations for advanced BC or recurrent BC. Because of their multiple diseases and poor cardiopulmonary functions, the elderly patients can choose to receive concurrent chemoradiotherapy (CCRT) for advanced BC; however, numerous patients have reported complications and residual BC after CCRT. The post-CCRT complications included postchemotherapy syndromes (neutropenia, nausea, or vomiting), lower urinary tract syndromes after radiation therapy, intractable gross hematuria postradiotherapy, urine retention, and fistulas between the bladder and intestine.

BC is an age-related disease, and the management of MIBC in older patients is challenging because of the concerns regarding anesthesia administration in elders with marginal cardiopulmonary function. In some studies, elderly patients were defined as being 65–80 years old, and a cut-off age of 75 years was used by most researches.[18],[19] Thus, we performed LRC in a sample of 30 elderlies classified into two groups (≥75 years and <75 years of age). The ASA score of the older group was higher (3.0 vs. 2.4, P = 0.0007) than that of the younger group, as expected. The elderly groups exhibited a higher risk of marginal cardiopulmonary function (80% vs. 26.7%, P = 0.0092). The marginal cardiopulmonary function was defined as one of the following: moderate or severe restrictive ventilatory impairment, moderate or severe obstructive ventilatory impairment (possibly leading to postanesthesia prolonged respiratory failure), ejection fraction <50%, atrial fibrillation, moderate or severe valve regurgitation, left ventricular dysfunction or dilatation, moderate or severe pericardial effusion, and moderate or severe pulmonary hypertension revealed through cardiac echography. These cardiac echography findings indicated the risk of postanesthesia arrhythmia and heart failure. Arrhythmia causes cerebral vascular accidents and acute myocardial infarction. During heart failure, sufficient blood cannot be supplied to the organs and tissue, which leads to organ function problems or even organ failure.

We use the CCI score to evaluate mortality in patients with comorbid conditions. No significant difference was observed in the CCI score between the two groups (3.93 vs. 3.27). The more critical heart function in the elderly group exhibited a lower ejection fraction (25%), and a patient with poor liver function and child C liver cirrhosis was present in the older subgroup. Four patients in these groups had severe obstructive or restrictive pulmonary function. However, despite the aforementioned poor cardiopulmonary function, the older subgroup did not exhibit any significant difference in operation time (473 vs. 465 min), blood loss (503 vs. 380 mL), early minor complications rate (40% vs. 33.33%, P = 0.427), early major complications (20% vs. 6.67%, P = 0.598), Intensive Care Unit care (1.13 vs. 0.6 days), interval to ambulation (2 vs. 1.8 days), interval to oral food intake (3.2 vs. 2.6 days), interval to normal bowel function (4.6 vs. 3.6 days), postoperative hospitalization (15.67 vs. 11.67 days), and blood transfusion rate (33.3% vs. 26.7%) compared with the younger group.

LRC was performed under pneumoperitoneal conditions, which causes a high intra-abdominal pressure and pressure on the diaphragm, leading to reduced venous return, which can worsen during change in position during surgery. This consequence can be prevented by adjusting the intra-abdominal pressure to <12 mmHg and through appropriate preoperative hydration.[20] LRC generally requires the patient to be in the Trendelenburg position to prevent the intestine from blocking the vision during operation. The Trendelenburg position typically results in reduced functional residual capacity and hypoxemia. This consequence can be prevented by increasing the frequency of mechanical ventilation with mild positive end-expiratory pressure.[20] Furthermore, in elderly groups with marginal cardiopulmonary function, these consequences must be prevented during anesthesia and laparoscopic surgery. However, cardiopulmonary-compromised patients should not be contraindicated for laparoscopic surgery.

In our study, the older subgroup with marginal cardiopulmonary function did not present with poor perioperative or postoperative outcomes compared with the younger patients. Most recent studies have demonstrated no relationship between age at RC and perioperative complication rates and mortality. In our study, the morbidity rates in the elderly and younger patients were 60% and 40%, respectively. Most complications were minor and included postoperative blood transfusion and ileus. The laparoscopic technique has been demonstrated to have several benefits, including reduced blood loss and postoperative painkiller use, rapid oral intake, and faster return to normal bowel functions. In our study, we observed a quicker recovery and shorter hospital stay in both groups (15.67 vs. 11.67 days).

Specifically, the major cardiac problem is atrial fibrillation, and the decreased venous return after LRC leads to more complications. Two major complications occurred in our study: acute left middle cerebral artery infarction and acute cholecystitis status postdrainage. The two patients who presented these major complications had atrial fibrillation. Before the operation, the atrial fibrillation needed to be controlled with medication and adequate hydration was also required to reduce major complications.

Our studies are limited to retrospective study bias and a relatively small cohort of patients. However, our study suggests that LRC is feasible for the elderly patients with marginal cardiopulmonary function according to our clinical experience.


  Conclusions Top


Our preliminary result revealed that LRC with or without urinary diversion is a safe option with favorable outcomes for patients with BC with marginal cardiopulmonary function older than 75 years in a regional teaching hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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