Influence of previous pelvic radiation therapy in the outcome of radical cystectomy.

im: To describe perioperative morbidity of radical cystectomy comparing patients with past medical history (PMH) of extravesical pelvic radiation therapy with patients never undergone radiation therapy. We particularly wanted to find pre- operative factors determining worse prognosis in radiotreated patients. Patients and Methods: We retrospectively collected data of any patients undergone radical or salvage cystectomy between January 2010 and January 2013. We analyzed the same parameters in both groups, radiotreated and not: indication to surgery, peri-operative complications according to Clavien- Dindo Classification of Surgical Complications (CDCSC), hospitalization time, bleeding and transfusions. We compared these parameters using Student t-test. Results: Between January 2010 and January 2013, 104 patients underwent radical cystectomy; first group of patients (GR 1) was made of naïfs patients for radiation therapy (n=89, 85.5%), second group (GR 2) was made of previously irradiated patients (n=15, 14.4%). Reasons for cystectomy in irradiated patients were: radiation cystitis (n= 3/15, 20%), bladder cancer (n=6/15, 40%), anal cancer (n=2/15, 13.3%), uterus cancer (n=2/15, 13.3%), prostate cancer (n=1/15, 6.6%), rectal cancer (n=1/15, 6.6%). We analyzed data separately for both groups. GR 1 showed mean age 72.19 (Standard Deviation, SD, 8.16), 75 males (84.27%) and 14 females (15, 73). Preoperative comorbidity according to Charlson Classification Index showed a mean score of 6.29 (SD 2.91). Urinary diversion was cutaneous ureterostomy (UCS) for 17 patients (19.10%), ileal conduit for 62 patients (69.66%), ileal neobladder (Y neobladder, Camey or Hautmann according to surgeon’s preference) for 10 patients (11.24%). Mean preoperative Hemoglobin was 11,99 mg/dL (SD 1.72), mean hospitalization was 17.87 days (SD 13.87), mean number of blood sack transfusion was 2,27 (SD 2.58), mean day of return of normal bowel function was 5,79 (SD 2.32). GR 2 showed mean age 71,87 (SD, 9.2), 12 males (80%) and 3 females (20%). Preoperative comorbidity according to Charlston Classification Index showed mean score of 7.13 (SD 2.88). Urinary diversion was UCS for 5 patients (33.3%), ileal conduit for 10 patients (66.6%). No patient received ileal neobladder. Mean preoperative Hemoglobin was 10.9 mg/dL (SD 1.49), mean hospitalization was 29.87 days (SD 22.4), mean number of blood sack transfusion was 5.27 (SD 3.39), mean day of return of normal bowel function was 6.47 (SD 0.99). Surgical omplicances, according to CDCSC, are reported in Table I for both groups. Preoperative comorbidities were assessed using Charlston Comorbidity Index: t-Student test showed no significant differences between two groups (p=0.3); non significant was also the mean day of return to normal bowel function (p=0.28). We found statistically significant mean preoperative level of hemoglobin (p=0.02), mean hospitalization (p=0.01) and mean tranfusions (p=0). Discussion and Conclusion: Higher surgical complications arising from previous radiation therapy are well known by urologists; considering that Charlston Morbidity Index did not show statistical significancy between two groups, the only radiation therapy seems to represent an independent factor of worse prognosis. Lower initial hemoglobin level and higher transfusion needing suggests the necessity to check blood parameters every day after cystectomy; previous radiation therapy does not affect the time of return to normal bowel function. Among 15 radiotreated patients, 6 patients (40%) developed de novo transitional carcinoma: in these cases radiation therapy could have played a significant pathogenetic factor for bladder cancer.