EUROPEAN UROLOGY 57 (2010) 983–1001

available at www.sciencedirect.com
journal homepage: www.europeanurology.com

Collaborative Review – Bladder Cancer

Prevention and Management of Complications Following Radical

Cystectomy for Bladder Cancer

Nathan Lawrentschuk a,*, Renzo Colombo b, Oliver W. Hakenberg c, Seth P. Lerner d,

Wiking Månsson e, Arthur Sagalowsky f, Manfred P. Wirth g
a
Division of Urology, Department of Surgical Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Canada
b
Department of Urology, University ‘‘Vita-Salute’’ - San Raffaele Hospital, Milan, Italy
c
Department of Urology, Rostock University, Rostock, Germany
d
Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA
e
Department of Urology, Skåne University Hospital, Lund, Sweden
f
Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
g
Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany

Article info Abstract

Article history: Context: This review focuses on the prevention and management of complications
Accepted February 17, 2010 following radical cystectomy (RC) for bladder cancer (BCa).
Published online ahead of Objective: We review the current literature and perform an analysis of the fre-
print on February 26, 2010 quency, treatment, and prevention of complications related to RC for BCa.
Evidence acquisition: A Medline search was conducted to identify original articles,
Keywords: reviews, and editorials addressing the relationship between RC and short- and
Bladder carcinoma long-term complications. Series examined were published within the past decade.
Cystectomy Large series reported on multiple occasions (Lee [1], Meyer [2], and Chang and
Adverse effects Cookson [3]) with the same cohorts are recorded only once. Quality of life (QoL) and
Urology sexual function were excluded.
Surgery Evidence synthesis: The literature regarding prophylaxis, prevention, and treatment
Review of complications of RC in general is retrospective, not standardised. In general, it is of
poor quality when it comes to evidence and is thus difficult to synthesise.
Conclusions: Progress has been made in reducing mortality and preventing com-
plications of RC. Postoperative morbidity remains high, partly because of the
complexity of the procedures. The issues of surgical volume and standardised
prospective reporting of RC morbidity to create evidence-based guidelines are
essential for further reducing morbidity and improving patients’ QoL.
# 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. University of Toronto, Surgical Oncology, 610 University Ave, Ste 3-130,
Princess Margaret Hospital, Toronto, M5G2M9 Canada.
E-mail address: lawrentschuk@gmail.com (N. Lawrentschuk).

1. Introduction treatment, with 10-yr recurrence-free survival rates of

50–59% and overall survival rates of around 45% [2,4].
Radical cystectomy (RC) with pelvic lymph node dissection RC with urinary diversion (UD) is a procedure in which
provides the best cancer-specific survival for muscle- reduction of morbidity, rapid postoperative rehabilitation,
invasive urothelial cancer [2,3] and is the standard limited length of hospital stay, and cost containment are
0302-2838/$ – see back matter # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2010.02.024
984 EUROPEAN UROLOGY 57 (2010) 983–1001

Table 1 – Large series of radical cystectomy with reported early postoperative complications (2008–2009)

Series (past decade, Summary Shabsigh Novara, Boström Meyer Nieuwenhuijzen

around 100 patients) et al, 2009 [13] 2009 [16] et al, 2009 et al, et al, 2008 [46]
[123] 2009 [2]

Patients 96–6577 1142 358 258 104 281

Study period 1995–2005 2002–2006 1986–2005 1994–2003 1990–2005
Centres Single Single Single Multi (3) Single
Mortality at 30 d 0.3–3.9 1.5 3.0* 3.9 1 2.8
Minor complications 18.6–58 58 36 26 – 19
Major complications 4.9–25.5 9 13 11 – 24
One postoperative complication or more 19–57 64 (67 in hospital, 49 34 24 44
58% postdischarge)
Operating time, h 4.9–6.4 6.4 5 3.8 (IC), 4.6 5 –
(neo), 5.6 (CCD)
EBL 600–1700 1000 600 1700 1500 –
Intraoperative transfusion rate (U) 1–66 66 15* 2.9 2 (in 82%) –
and perioperative*

Medical
DVT 0–5.3 5.3 4 1.2 – 1.4
PE 0–6 3.2 – 0.8 2 2.5
Septicaemia 0–9.6 6.6 – 1.2 – 9.6
Acute respiratory distress 0–3.8 3.5 1 – – 1.1
Pneumonia 0–7.8 3.9 4 1.9 4 7.8
Failure to wean from ventilator/on 0–2.6 – – – – –
ventilator >48 h postoperatively
PE; clinical evidence of PE 0–1.9 – – – – –
Reintubation for arrest; unplanned intubation 0–1.9 – – – – –
for cardiac or pulmonary arrest
Cardiac (general) 0–13 2.3 4 – – –
MI 0–4 1.3 1.5 1.9 – 2.1
Dysrhythmia; postoperative 0–7.2 7.2 2 1.9 – –
cardiac arrhythmia
Cardiac arrest; initiation of 0–1.3 – – – – –
advanced cardiac life support
Enterocolitis/persistent diarrhoea 0–8 3.4 – – – –
Acute renal failure; worsening renal function 0–7 – – – – –
requiring dialysis or ultrafiltration
UTI 0–12.8 9.9 – 5 1 12.8
Pyelonephritis 0–7.4 2.5 1 3.5 – –
Metabolic imbalance (severe)/delirium 0–4 2 0.3 0.8 – 0.7
Skin ulcer/pressure sore 0–0.6 0.4 – – – 0.4
PEG leakage 0–0.4 – – – – 0.4
Stroke (neurologic) 0–1.4 0.5 0.5 – 1 –

Surgical
Perioperative blood transfusion rate 0–2.3 – – – – –
Postoperative haemorrhage; transfusion 0–9 9 – – 1 1.4
>4 U after operation 72 h postop
Subileus (paralytic) 0–22.7 16 – 4 – 2.8
Constipation 0–12 2.6 12 – – –
GI (eg, emesis, gastritis, ulcer) 0–16.1 1.4 3 – – –
Small bowel obstruction 0–7 7 – 0.8 4 –
Enteroanastomosis leak 0–8.7 0.9 2 0.4 – 0.7
Required TPN 0–9 100y – – – –
GI bleed 0–1.3 1.3 – – – –
Pyrexia of unknown origin 0–7.0 4.8 7 – – –
Pelvic lymphocoele with intervention 0–3.5 1.3
Pelvic lymphocoele (no intervention) 0–5.4 – – – – –
Percutaneous drainage 0–2.7 – – – – –
Peritonitis 0–0.8
Wound infection, including 0–15 9.3 – 0.8 4 8
superficial (incisional)

Deep (fascial/muscle) wound infections

Wound dehiscence 0–9 4.6 5 – 3 5
Secondary healing 0–8 – 3 – – –
With revision 0–5 – 2 – – –
Pelvic haematoma 0–2 – 1 – – –
Pelvic/abdominal abscess 0–4.4 4.4 – – – 1.1
Without revision 0–0.4 0.4 – – – –
With revision 0–0.4 – – – – –
Diversion related 0–16 – – – – –
 EUROPEAN UROLOGY 57 (2010) 983–1001 985

Table 1 (Continued )
Series (past decade, Summary Shabsigh Novara, Boström Meyer Nieuwenhuijzen
around 100 patients) et al, 2009 [13] 2009 [16] et al, 2009 et al, et al, 2008 [46]
[123] 2009 [2]

Urine leak/pouch leak/other 0–7.7 2.6 1 – 3 –

urine related
Stomal necrosis/stricture 0–1.7 0.4 – – – 0.7
Diversion necrosis 0–0.7 – – – – 0.7
Rectal injury 0–1.7 – – – – 0.7
Fistula 0–4 – 0.5 – – 0.4
Reoperation rate 0–17 3 10 8 8 –
Other 0–14.5 4 8.3 5 1 –

IC = EBL = estimated blood loss; DVT = deep vein thrombosis; PE = pulmonary embolism; MI = myocardial infarction; UTI = urinary tract infection;
PEG = percutaneous endoscopic gastrostomy; GI = gastrointestinal; TPN = total parenteral nutrition.
*
90-d morbidity and mortality.
y
Given to all participants as protocol.

difficult to achieve [5]. Prior to 1990, large series (100
patients) reported mortality of 2.4–15% and early morbidity
of 28–42% [6–10]. In the past decade, mortality has been
reduced to 0–3.9%, while early morbidity remains at
11–68% (Tables 1–4). Reported late complications in
contemporary series are 19–58% (Table 5). The difficulties
with comparing morbidity across series and time periods
are manifold. The reduction in perioperative mortality
probably reflects improvements in multidisciplinary man-
agement as well as in the management of early complica-
tions.
1.1. Large series of radical cystectomy reporting on
complications
When considering large series (100 patients) of RC that
report on short- and long-term complications, one must state
at the outset that the patients form an extremely heteroge-
neous group. Reporting of complications is not standardised,
few series are prospective, differing surgical techniques are
utilised, patients selection is not uniform, length of follow-up
is inconsistent, classification of complications varies (eg,
early vs late, at least four different definitions exist for ileus),
and the metachronous nature of the series makes comparison
extremely difficult. Clearly, larger prospective series with
longer follow-up are need to be published. Because of the
aforementioned limitations, this review can only provide
suggestions based on everyday clinical practice rather than
recommendations based on evidence-based medicine unless
otherwise indicated in the text.
1.2. Reporting of complications for cystectomy
Donat argues that the disparity in the quality of surgical
complication reporting in urologic oncology makes it
impossible to compare the morbidity of surgical techniques
and outcomes [11]. Terms such as major and minor
complication have little meaning, particularly if not clearly
defined or consistent. The lack of standardisation is
hampering the progress of improving morbidity and
mortality associated with RC [4,12–14]. Attempts have
been made to correct these deficiencies in urologic oncology
reporting in prospective studies.
First, Hollenbeck et al [15] accessed the Veterans Affairs
National Surgical Quality Improvement Program (NSQIP)
data set, which has the advantages of a large sample size,
multi-institutional participation, prospective explicit data
collection by trained nurse reviewers, and a reliable
assessment of 30-d postoperative follow-up. It should be
highlighted that in their series, they specifically did not
report on complications with an incidence of < 0.5%. Second,
Shabsigh et al [13] and Novara et al [16] have utilised
complication grading systems based on the Clavien system in
order to assist in standardising complication reporting in
solid organ transplants [17]. Such methodology identifies 11
specific categories, and five grades and may be adapted to any
urologic oncology procedure [11]. Ultimately, standard
guidelines for accruing and reporting surgical morbidity
data as well as defining procedure-specific complications
with minimal follow-up of reconstructions and severity
grading need to be established for RC [11,14,18].
2. Patient selection and its influence on
complications and outcome
2.1. Patient selection and timing of cystectomy
2.1.1. Patient comorbidities
Increasing age and being female affect morbidity [13,19–21].
However, the old adage that definitive therapy based on
physiologic age as opposed to chronologic age remains true
[22], with the key being patient selection in addition to
adequate preoperative counselling and risk balancing [20].
Disappointingly, many large series of RC do not
comprehensively report on patient comorbidities (eg, only
providing the American Society of Anaesthesiologists score)
[13]. Where reported, having more than two comorbidities
appears detrimental [23]. In general, although RC after
pelvic radiation therapy (RT) is associated with acceptable
morbidity, the risk of complications requiring invasive
intervention is increased (eg, pelvic collections) [24].
Conversely, others have indicated that postirradiation
complications do not increase [25]. Although prior RT
should not be a significant factor in bowel segment
selection, it is still a factor and at minimum, a careful
visual inspection of the bowel is required [26].
986 EUROPEAN UROLOGY 57 (2010) 983–1001

Table 2 – Large series of radical cystectomy with reported early postoperative complications (2007–2008)

Series (past decade, around 100 patients) Summary Maffezzini Arumainayagamet Pycha Lowrance Novotny
et al, 2008 [5] et al, 2008 [25] et al, 2008 et al, et al, 2007
[124] 2008 [125] [126]

Patients 96–6577 107 112 130 553 516

Study period – 2003–2006 N/A 2000–2007 2000–2005 1993–2005
Centres – Single Single Single Single Single
Mortality at 30 d 0.3–3.9 3.7 1.8 – 1.7 0.8
Minor complications 18.6–58 18.6 – – 38 –
Major complications 4.9–25.5 7.5 – – 7.4 –
One postoperative complication or more 19–57 26.1 46 24 45.4 27
Operating time, h 4.9–6.4 5.5 – – – 6.1
EBL 600–1700 – – – 600 (median) 1208
Intraoperative transfusion rate, U 1–66 – 38* – 38* N/A

Medical
DVT 0–5.3 1 2 – 2.5 4.7
PE 0–6 – 6 – 1.2 1.7
Septicaemia 0–9.6 3 – – 0.9 1.4
Acute respiratory distress 0–3.8 – – – 1.4 1.6
Pneumonia 0–7.8 – – – 1.4 –
Failure to wean from ventilator/on 0–2.6 – – – – –
ventilator >48 h postoperatively
PE; clinical evidence of PE 0–1.9 – – – – –
Reintubation for arrest; unplanned 0–1.9 – – – – –
intubation for cardiac or pulmonary arrest
Cardiac (general) 0–13 – 2 – – –
MI 0–4 4 2 – 2 0.4
Dysrhythmia; postoperative cardiac arrhythmia 0–7.2 – – – 2 –
Cardiac arrest; initiation of 0–1.3 – – – – –
advanced cardiac life support
Enterocolitis/persistent diarrhoea 0–8 4 8 – – 0.9
Acute renal failure; worsening renal 0–7 – 2 – – –
function requiring dialysis or ultrafiltration
UTI 0–12.8 – – – 10 –
Pyelonephritis 0–7.4 – 2 – –
Metabolic imbalance (severe)/delirium 0–4 4 – – 0.7 –
Skin ulcer/pressure sore 0–0.6 – – – – –
PEG leakage 0–0.4 – – – – –
Stroke (neurologic) 0–1.4 – – – 1.4 –

Surgical
Perioperative blood transfusion rate 0–2.3 – – – – 2.3
Postoperative haemorrhage; 0–9 – – – – –
transfusion >4 U after operation 72 h postop
Subileus (paralytic) 0–22.7 – – – 22 3.9
Constipation 0–12 – – – – –
GI (eg, emesis, gastritis, ulcer) 0–16.1 – – – – –
Small bowel obstruction 0–7 2 1 – 0.3 0.8
Enteroanastomosis leak 0–8.7 – – – 0.9 –
Required TPN 0–9 – – – 9 –
GI bleed 0–1.3 – – – – –
Pyrexia of unknown origin 0–7.0 – – – – –
Pelvic lymphocoele with intervention 0–3.5 – – – 0.5 –
Pelvic lymphocoele (no intervention) 0–5.4 – – – – 5.4
Percutaneous drainage 0–2.7 – – – – 2.7
Peritonitis 0–0.8 – – – – 0.8
Wound infection, including superficial (incisional) 0–15 – 1 – 7.5 –

Deep (fascial/muscle) wound infections

Wound dehiscence 0–9 4 9 – 0.5 –
Secondary healing 0–8 – – – – 3.9
With revision 0–5 – – – – 5
Pelvic haematoma 0–2 2 – – – –
Pelvic/abdominal abscess 0–4.4 – 3 – 1.1 –
Without revision 0–0.4 – – – – 0.4
With revision 0–0.4 – – – – 0.4
Diversion related 0–16 – – – – –
Urine leak/pouch leak/other urine related 0–7.7 2 – – 1.1 –
Stomal necrosis/stricture 0–1.7 – – – – –
Diversion necrosis 0–0.7 – – – – –
Rectal injury 0–1.7 – – – – –
Fistula 0–4 3 4 – – –
 EUROPEAN UROLOGY 57 (2010) 983–1001 987

Table 2 (Continued )
Series (past decade, around 100 patients) Summary Maffezzini Arumainayagamet Pycha Lowrance Novotny
et al, 2008 [5] et al, 2008 [25] et al, 2008 et al, et al, 2007
[124] 2008 [125] [126]

Reoperation rate 0–17 14 7 – 2 6.2

Other 0–14.5 2 2 – 1.1 –

N/A = not applicable; EBL = estimated blood loss; DVT = deep vein thrombosis; PE = pulmonary embolism; MI = myocardial infarction; UTI = urinary tract
infection; PEG = percutaneous endoscopic gastrostomy; GI = gastrointestinal; TPN = total parenteral nutrition.
*
Perioperative.

Table 3 – Large series of radical cystectomy with reported early postoperative complications (2004–2007)

Series (past decade, Summary Studer et al, Konety et al, Hollenbeck Clark et al, Knap Lee et al,
around 100 patients) 2006 [117] 2006 [127] et al, 2005 2005 [22] et al, 2004 2004 [1]
[19] [128]

Patients 96–6577 482 6577 2538 1054 268 498

Study period – 1985–2005 1998–2002 1991–2002 1971–1997 1992–1998 1990–2002
Centres – Single Multiple/ Multi (123) Single Single Single
population
based
Mortality at 30 d 0.3–3.9 – 2.6 – 2.5 2.2 –
Minor complications 18.6–58 – – – – – 40
Major complications 4.9–25.5 – – – – – 5
One postoperative complication or more 19–57 19 28.4 31 28.4 57 45
Operating time, h 4.9–6.4 – – 6.1 – – 5.7
EBL 600–1700 – – – – – –
Intraoperative transfusion rate, U 1–66 – – 1.7 – – –

Medical
DVT 0–5.3 – – 1.1 – – –
PE 0–6 – – < 0.5 4.1 – 1
Septicaemia 0–9.6 3.5 – 3.4 4.7 – –
Acute respiratory distress 0–3.8 – 3.8 N/A 1.1 – 2
Pneumonia 0–7.8 – – 3.9 – – 1
Failure to wean from ventilator/on 0–2.6 – – 2.6 – – –
ventilator >48 h postoperatively
PE; clinical evidence of PE 0–1.9 – – 1.9 – – –
Reintubation for arrest; unplanned intubation 0–1.9 – – 1.9 – – –
for cardiac or pulmonary arrest

Cardiac (general) 0–13 – 4.1 – 2.2 – 13

MI 0–4 – – 0.8 – – –
Dysrhythmia; postoperative cardiac arrhythmia 0–7.2 – – 1.3 – – –
Cardiac arrest; initiation of 0–1.3 – – 1.3 – – –
advanced cardiac life support
Enterocolitis/persistent diarrhoea 0–8 – – 0.6 – – –
Acute renal failure; worsening renal function 0–7 – – 0.8 2.3 – –
requiring dialysis or ultrafiltration
UTI 0–12.8 – – 7.8 – – –
Pyelonephritis 0–7.4 5.8 – – – – –
Metabolic imbalance (severe)/delirium 0–4 6.2 – – 4.2 – –
Skin ulcer/pressure sore 0–0.6 – – – – – –
PEG leakage 0–0.4 – – – – – –
Stroke (neurologic) 0–1.4 – – – 1.42 – –

Surgical
Perioperative blood transfusion rate 0–2.3 – – – – – –
Postoperative haemorrhage; 0–9 – – 1.8 – – –
transfusion >4 U after
operation 72 h postop
Subileus (paralytic) 0–22.7 – – 9.7 – – 11
Constipation 0–12 – – – – – –
GI (eg, emesis, gastritis, ulcer) 0–16.1 – 16.1 – 3.3 – –
Small bowel obstruction 0–7 – – (Included – – –
with ileus)
Enteroanastomosis leak 0–8.7 – – – – – –
Required TPN 0–9 2.1 – – – – –
GI bleed 0–1.3 – – – – – –
Pyrexia of unknown origin 0–7.0 – – – – – –
Pelvic lymphocoele with intervention 0–3.5 – – – – – –
Pelvic lymphocoele (no intervention) 0–5.4 – – – – – –
Percutaneous drainage 0–2.7 – – – – – –
988 EUROPEAN UROLOGY 57 (2010) 983–1001

Table 3 (Continued )
Series (past decade, Summary Studer et al, Konety et al, Hollenbeck Clark et al, Knap Lee et al,
around 100 patients) 2006 [117] 2006 [127] et al, 2005 2005 [22] et al, 2004 2004 [1]
[19] [128]

Peritonitis 0–0.8 – – – – – –
Wound infection, including 0–15 – – – – – 8
superficial (incisional)

Deep (fascial/muscle) wound infections

Wound dehiscence 0–9 – 4.3 5.5 – 2.1 2
Secondary healing 0–8 – – 3 – 1.7 8
With revision 0–5 – – – – 0.4 1
Pelvic haematoma 0–2 – 1 – – 1.3 –
Pelvic/abdominal abscess 0–4.4 – – – – – –
Without revision 0–0.4 – – – – – –
With revision 0–0.4 – – – – – –
Diversion related 0–16 – – – – 16 –
Urine leak/pouch leak/other urine related 0–7.7 – 2.9 2.8 – – –
Stomal necrosis/stricture 0–1.7 – – – – – –
Diversion necrosis 0–0.7 – – – – – –
Rectal injury 0–1.7 – – – – – –
Fistula 0–4 0.2 0.5 – – – –
Reoperation rate 0–17 – – – – – –
Other 0–14.5 14.5 – – – 0.7 –

EBL = estimated blood loss; DVT = deep vein thrombosis; PE = pulmonary embolism; N/A = not applicable; MI = myocardial infarction; UTI = urinary tract
infection; PEG = percutaneous endoscopic gastrostomy; GI = gastrointestinal; TPN = total parenteral nutrition.

A special subset includes patients previously treated
with RT and/or radical prostatectomy (RP), who may have a
greater level of morbidity than previously reported [27].
Prior abdominal or pelvic surgery is also considered a risk
factor for complications [13]. Finally, extravesical disease,
which occurs in many large series in around 25% of cases
[15] as well as cystectomy with palliative intent [28,29] or
salvage situation [30] are risk factors for morbidity.
Increased body mass index is also associated with an
increased risk of wound infection and dehiscence as well as
hernias [16,25]. In general, one should not consider obesity
or previous pelvic RT a contraindication for RC. The
construction of a diversion or orthotopic bladder substitu-
tion is, however, not that easy in the very obese. We suggest
that only experienced urologists perform RC in such
patients because the additional risks for bleeding, urinary
tract infection (UTI), and reliability of UD.
2.1.2. Timing of cystectomy and perioperative chemotherapy
Although the timing of RC generally relates to oncologic
outcome only [31], data on morbidity and the use of
multimodal therapy are becoming relevant. For example, it
is advisable to leave the catheter during chemotherapy with
continent diversions in order to reduce toxicity from the
reabsorption of the drugs [32]. The impact of early
morbidity from RC in potentially delaying receipt of
adjuvant chemotherapy in 30% of patients has recently
been reported [33]. Conversely, data from RC series with
neoadjuvant chemotherapy suggest that it does not
increase postoperative morbidity [13,25].
volume is emerging [34–37]. Both the mortality [34–36]
and morbidity [38] of RC are reduced in higher-volume
centres [37]. Individual surgeon volume is also a significant
predictive factor for complications [39]. However, some
smaller centres (<13 RC/yr) believe that they can still
achieve acceptable results [23].
The Calman-Hine report requires that patients have
access to a uniformly high quality of care for maximal
possible cure rates and quality of life [40]. Bladder cancer
treatment should therefore be completed in reference
centres with expertise in major urologic oncology with
appropriate intensive care and interventional radiolo-
gists. As several retrospective studies have clearly
demonstrated a relationship among complications, mor-
tality, and surgical volume [37,41], it is in our opinion
inevitable that the urologic community should ultimately
agree on a recommendation for a minimum surgical
volume for RC and do so before health care providers take
this issue out of our hands. Clearly, this is a complex issue
that depends not only on the surgeon’s personal experi-
ence but also on many other factors. In our opinion,
an annual rate of 10 RC procedures per hospital seems
adequate, with patients scheduled to undergo continent
reconstruction, such as orthotopic bladder substitution or
continent cutaneous diversion, being referred to large units.
3. Surgical technique and complications
3.1. Patient preparation: preoperative factors, fast-track
surgery, and technique

2.2. Surgical relationship of morbidity to surgeon and hospital
volume
A whole body of literature concerning the surgical learning
curve and the personal as well as institutional surgical
3.1.1. Preoperative factors
Preoperative renal failure is a significant risk factor and
should be corrected prior to RC [19], occasionally necessi-
tating preoperative nephrostomy. Surgical morbidity is
not increased if the serum creatinine <2.5 mg/dl [33].
Table 4 – Large series of radical cystectomy with reported early postoperative complications (1999–2003)

Series (past decade, around Summary Kulkarni Chahal et al, Cookson et al, Malavaud Dahm, Rosario Hautmann
100 patients) et al, 2003[129] 2003 [130] 2003 [3] et al, 2001 [131] et al, 2001 [54] et al, 2000 [132] et al, 1999 [133]

Patients 96–6577 102 96 293 161 115 101 363

Study period – 1998 1993–1996 1995–2000 N/A 1996–1998 1992–1997 1986–1997
Centres – Single Multicentre Single Multi (2) Single 101, single centre Single centre
Mortality at 30 d 0.3–3.9 3.9 3.1 0.3 – – 2* 3y
Minor complications 18.6–58 – – 30.4 – – N/A –
Major complications 4.9–25.5 – – 4.9 25.5 – N/A –
One postoperative complication or more 19–57 31 28 22 39
Operating time, h 4.9–6.4 – – 5 – – N/A –
EBL 600–1700 – – 696–758 – – N/A –
Intraoperative transfusion rate, U 1–66 – – 1 – – 4z –

Medical – – – – – – –
DVT 0–5.3 – 5.2 (includes PE) 0.6 – – 4 3
PE 0–6 – – 0.7 1.2 – 2 1.1

EUROPEAN UROLOGY 57 (2010) 983–1001

Septicaemia 0–9.6 – – – 3.7 – 8 –
Acute respiratory distress 0–3.8 – 1.7 1 – – 1 1.4
Pneumonia 0–7.8 – – 1.9 – – – 4.6
Failure to wean from ventilator/on ventilator 0–2.6 – – – – – – –
>48 h postoperatively
PE; clinical evidence of PE 0–1.9 – – – – – – –
Reintubation for arrest; unplanned intubation 0–1.9 – – – – – – –
for cardiac or pulmonary arrest

Cardiac (general) 0–13 – 3.5 – – – – –

MI 0–4 2 – 0.3 – – – 0.3
Dysrhythmia; postoperative cardiac arrhythmia 0–7.2 – – – – – – 3.8
Cardiac arrest; initiation of advanced 0–1.3 – – – – – – –
cardiac life support
Enterocolitis/persistent diarrhoea 0–8 – – 0.3 1.2 – – –
Acute renal failure; worsening renal function 0–7 – 7 0.9 – – – –
requiring dialysis or ultrafiltration
UTI 0–12.8 – – – – – – –
Pyelonephritis 0–7.4 – – 1.6 – – – 7.4
Metabolic imbalance (severe)/delirium 0–4 – – – – – – –
Skin ulcer/pressure sore 0–0.6 – – 0.6 – – – –
PEG leakage 0–0.4 – – – – – – –
Stroke (neurologic) 0–1.4 – – 0.7 – – – –

Surgical
Perioperative blood transfusion rate 0–2.3 – – – – – – –
Postoperative haemorrhage; transfusion 0–9 – – – – – – –
>4 U after operation 72 h postop
Subileus (paralytic) 0–22.7 3.5 22.7 2.5 – 3 10.6
Constipation 0–12 – – – – – – –
GI (eg, emesis, gastritis, ulcer) 0–16.1 – – – – – – –
Small bowel obstruction 0–7 1 5.2 – – – – –
Enteroanastomosis leak 0–8.7 3 8.7 0.3 1 1.1
Required TPN 0–9 – – – – – – 3
GI bleed 0–1.3 – – – – – – –

989
Pyrexia of unknown origin 0–7.0 – – – – – – –
 990
Table 4 (Continued )
Series (past decade, around Summary Kulkarni Chahal et al, Cookson et al, Malavaud Dahm, Rosario Hautmann
100 patients) et al, 2003[129] 2003 [130] 2003 [3] et al, 2001 [131] et al, 2001 [54] et al, 2000 [132] et al, 1999 [133]

Pelvic lymphocoele with intervention 0–3.5 – – – – – – 3.5

Pelvic lymphocoele (no intervention) 0–5.4 – – – – – – –
Percutaneous drainage 0–2.7 – – – – – – –
Peritonitis 0–0.8 – – – 0.6 – – –
Wound infection, including superficial (incisional) 0–15 15 – 2.9 – – – 5.8

Deep (fascial/muscle) wound infections

EUROPEAN UROLOGY 57 (2010) 983–1001

Wound dehiscence 0–9 4 3.5 – 3.7 – – –
Secondary healing 0–8 – – – – – – –
With revision 0–5 – – – – – – –
Pelvic haematoma 0–2 – – – – – – 0.3
Pelvic/abdominal abscess 0–4.4 1 3.5 – – – – –
Without revision 0–0.4 – – – – – – –
With revision 0–0.4 – – – – – – –
Diversion related 0–16 – – – – – – –
Urine leak/pouch leak/other urine related 0–7.7 6 3.5 – – – – 7.7
Stomal necrosis/stricture 0–1.7 – 1.7 0.3 – – – –
Diversion necrosis 0–0.7 – – – – – – –
Rectal injury 0–1.7 – 1.7 0.3 – – – –
Fistula 0–4 – – – – – – –
Reoperation rate 0–17 9 – 2.4 8.7 – 4 4.4
Other 0–14.5 – – 0.9 – – 4 6.3

N/A = not applicable; EBL = estimated blood loss; DVT = deep vein thrombosis; PE = pulmonary embolism; N/A = not applicable; MI = myocardial infarction; UTI = urinary tract infection; PEG = percutaneous endoscopic
gastrostomy; GI = gastrointestinal; TPN = total parenteral nutrition.
*
60-d morbidity and mortality.
y
90-d morbidity and mortality.
z
Perioperative.
Table 5 – Large series of radical cystectomy with reported late operative complications

Summary Nieuwenhuijzen Meyer et al, Studer et al, Clark et al, Madersbacher Chahal et al, Kulkarni et al, Hautmann
et al, 2008 [46] 2008 [2] 2006 [117] 2005 [27] et al, 2003 [109] 2003 [130] 2003 [129] et al, 1999 [134]

Late complications >30 d >30 d >30 d >90 d >90 d >90 d N/A >90 d
Patients 96–1054 281 104 482 1054 507 96 103 363
Follow-up, yr 3.8–10.2 N/A 7.3 Single 10.2 3.8 N/A 6.1 5.7
Complication rate 21–66 51 31 34 29 66 21 30 32

Surgery related
Conversion to conduit 0–3 – 3 – – – – – –
UTI 0–32.8 32.8 1 – – 23 – – –
Reservoir related 0–6.4 – – 6.4 – – – – –
Diversion related (unspecified) 0–14 – – – 26.2 14 – – –
Incisional hernia 0–14 8.5 13 4.6 14 – 5 5 3.8
Pouch stones 0–5 – 1 – – – – 5 0.5
Pyelonephritis 0–6.3 – – 3.9 – – – – 6.3
Dehydration 0–1.8 1.8 – – 0.9 – – – –

EUROPEAN UROLOGY 57 (2010) 983–1001

Intestinal obstruction 0–1 – 1 – – – – – –
Parastomal hernia 0–5.2 5.2 – – – – – – –
Stomal stenosis 0–14 3.3 – – – 14 – – –
Stomal hernia 0–6 – – – – 6 – – –
Stomal other 0–4 – – – – 4 – – –
Ureteroileal/ureteroenteric stenosis 0–14 10.7 2 2.7 – 14 1 9 9.3
Enterourethral stricture/urethral stricture 0–9 4.4 2 3.5 – – – 9 2.2
Lymphocoele 0–1.5 1.5 – – 3.2 – – – –
Enteric fistula 0–5 3.7 – 0.6 – 5 – – 1.8
Abscess 0–0.3 – – – – – – – 0.3
Pelvic abscess 0–1 – – – – – – – 0.6
Vaginal prolapse/cystocoele 0–1 0.7 1 – – – – – –
Severe hydronephrosis/ureteric reflux 0–3.3 0.4 3 – – – – – 3.3
Urolithiasis 0–9 – – – – 9 1 – 2.2
Metabolic, including vitamin B12 deficiency 0–3 – 2 – – 1.5 3 3 1.1
Bowel obstruction (conservative) 0–7.4 7.4 – – – 6 3 – 2.1
Bowel obstruction (surgery) 0–6 – – – – 6 – – 1.1

Not surgery related

GI (general) 0–8 0.7 – – 7.4 8 – – 3.8
Renal insufficiency 0.3–27 – – – 16* 27 3 – –
Diarrhoea 0–0.3 – – – – – – – 0.3
Infectious 0–8.4 – – – 8.4 – – – –
Neurologic 0–0.2 – – – 0.5 – – – –
Pulmonary 0–1 – 1 – – – – – –
Haematologic 0–0.4 – – – 1.2 – – – –
Cardiovascular 0–0.4 – – – 0.9 – – – –
Other 0–24 0.4 – 9.6 6.3 24 – – –

N/A = not applicable; UTI = urinary

tract infection; GI = gastrointestinal.
*
Renal related.

991
992 EUROPEAN UROLOGY 57 (2010) 983–1001
Patients with severe nutritional depletion may receive
hyperalimentation prior to RC to reduce complications
[42], but little supportive data exist [5].
3.1.2. Technical surgical considerations
Preoperative consideration for the type of UD is essential,
taking into account patient factors such as previous abdomi-
nal surgery, RT, and overall health and function [43]. The
neobladder as an orthotopic bladder substitute approaches
the ideal UD by providing a low-pressure, easily emptied
continent reservoir; it preserves the upper tracts and avoids
the body image issues of a stoma [44]. Caveats usually
imposed on patient selection for orthotopic bladder substitu-
tion include metastatic disease, tumour involvement at the
bladder neck or urethra in women, and prostate involvement
in men [45,46]. Additionally, an ileal conduit is generally
advised to all patients with compromised renal function or
electrolyte disturbance [43], elderly patients, those with
significant comorbidities or preexisting bowel disease, and
those who are unable to perform intermittent catheterisation
or have severe functional impairment, with consultation
between the urologist and enterostomal therapist being
essential [44,46–48]. Thus, ileal conduits remain the most
common form of diversion worldwide, with orthotopic
bladder diversions increasing each year.
The expected rate of complications according to
the different surgical solutions after RC are analysed in
Tables 1–5. We realise that the reporting is so variable
that it cannot be shown that one surgical solution
provides fewer complications than another other. From a
technical point of view, two major factors have positively
affected the postoperative complication rate: the improved
understanding of surgical anatomy of the pelvis (ie,
accurate control of the dorsal vein, helping to reduce blood
loss) [49] and the advances and implementations in surgical
instrumentation (ie, bipolar diathermy and staplers).
3.2. Anaesthesia and perioperative assistance
Anaesthesia and perioperative assistance are certainly
contributing factors to the overall reduction in mortality
during the past decade [50]. Preoperative anaesthetic
assessment clinics (eg, cardiac testing) with correction of
modifiable medical disease (eg, hypertension, cardiac
arrhythmias) have assisted in this regard [15,50,51]. Further,
the introduction of complementary epidural anaesthesia in
major surgery has favourably affected perioperative com-
plications. In a randomised series of 50 patients [52],
combined epidural and general anaesthesia was associated
with significantly lower intraoperative blood loss compared
to general anaesthesia alone. Also, mandatory surgical
intensive care unit admission is probably no longer necessary
[53,54], with adequate recovery room observation [34,55],
invasive blood pressure monitoring [51], and tailored fluid
replacement the key to reducing morbidity [56].
3.3. Fast-track surgery
Enhanced recovery protocols with standardised periopera-
tive plan of care or ‘‘fast-track’’ (FT) approaches have
emerged as tools to assist RC patients [5]. The general
principles of FT protocols in visceral surgery incorporate
innovative aspects of analgesia, bowel preparation, feeding,
and drainage management. In one study examining
traditional versus FT surgery, no increase in the amount
of complications—including digestive complications—could
be observed in the FT group. Moreover, the postoperative
stay in the intermediate care unit was significantly shorter
in the FT cohort, and feeding was completed significantly
earlier [57].
Controlled clinical trials are needed to further investigate
additional aspects of an FT regime for RC (eg, antibiotic
regimen, earlier removal of catheters). The use of bowel
preparation to reduce the incidence of postoperative ileus
has not been established [58,59]. Non-narcotic analgesics
and early institution of an oral diet appear to be promising
implementations of the FT approach and deserve to be
investigated in multicentre studies [60].
3.4. Bowel preparation
Bowel preparation may be used, particularly when the large
bowel is utilised for reconstruction to reduce contamination.
In general surgery, a recent trend has been for no preparation;
but in such cases, there is no urinary tract anastomosis to
bowel mucosa. If small bowel only is being used, there is
scant evidence to support bowel preparation [59].
3.5. Laparoscopic and robot-assisted techniques
Recently, there has been a rapid rise in the interest in and
application of minimally invasive techniques (laparoscopic
or robotic) RC [61–67]. However, the data are premature
and from comparatively small series.
3.6. Perioperative and postoperative complications
Postoperative complications and some suggestions for their
prevention and treatment according to the current litera-
ture are summarised for early and late complications.
3.6.1. Perioperative complications
3.6.1.1. Blood loss and transfusions. Acute blood loss is common
in RC, and predicting blood loss and transfusion require-
ments remains difficult. In RC, most blood loss occurs when
dealing with the bladder vasculature and pedicles. One
prospective, randomised trial of 70 patients found that the
estimated blood loss (523 ml vs 756 ml, on average) and
transfusion requirements were significantly reduced by
using a stapler device instead of the traditional suture-
ligation technique for the dissection of the bladder [68].
Meticulous intraoperative haemostasis is important, as is
refinement in surgical techniques in order to decrease blood
loss [23]. Certainly, the anatomical understanding of RP has
contributed to a reduction in blood loss (eg, dorsal venous
plexus ligation) [69]. Patient selection and combined
epidural and general anaesthesia may act to lower
transfusion rates, but larger studies are required [52]
(Table 6).
 EUROPEAN UROLOGY 57 (2010) 983–1001 993

Table 6 – Recommendations for prevention and treatment of blood loss and blood transfusion

Blood loss (mean loss: 600–1700 cm3) and blood transfusion (1–9%)

Recommendation for prevention Use meticulous technique/dissection.

Treatment recommendation
Use controlled hypotensive anaesthesia.
Take your time.
Use haemostatic surgery devices such as bipolar devices (eg, LigaSure), harmonic scalpel, or stapling devices.
Use oxidised cellulose (Surgicel) or absorbable gelatine sponge (Gelfoam) on raw surfaces.
Use adhesive/biologic tissue glue (Tisseel or FloSeal), if appropriate.
Ensure adequate intravascular filling with or without haemodilution.
Transfuse if haemoglobin is between 7 and 8 g/dl or if clinically indicated.

3.6.1.2. Urinary extravasation/reservoir leak. Prevention involves
leaving drains until the surgeon is satisfied that anasto-
motic integrity is ensured as well as avoiding self-
catheterisation or aggressive catheterisation. Catheters in
orthotopic bladder substitutes and pouches should be free
of mucous build-up [70], while urinary stents may be
irrigated if external [71]. Stents may be attached to the
Foley catheter with a nylon suture, facilitating a wet pouch
and ease of stent removal, with the Foley adequately fixed
to prevent dislodgement. The need for an additional
suprapubic catheter for orthotopic bladder substitutions
or pouch diversion in case the main catheter becomes
blocked is controversial, with little evidence available.
It is common practice to use urinary stents for 10 d with
no imaging unless clinically indicated prior to removal
[72]. In a randomised, controlled trial of 54 patients,
stenting of the ureteroileal anastomosis allowed for
significantly less frequent incidence of early postoperative
pelvicaliceal system dilatation, a quicker return of bowel
activity, and a reduced incidence of metabolic acidosis
[73].
Surgeon preference and experience will dictate how long
drains and catheters are left in place. For example, in
orthotopic bladder substitutes/continent diversion, the
transurethral catheter may be removed in 12–21 d without
a pouchogram if the drain output is minimal—say, 50 ml/d—
while others do routine pouchograms to detect a leak before
catheter removal [16,74]. Memorial Sloan-Kettering Cancer
Centre has even challenged the use of stents in RC
reconstructions (Table 7).
3.6.1.3. Sepsis, urinary tract infection, and pneumonia. Periopera-
tive antimicrobial prophylaxis (AMP) to prevent surgical
site infections (wound, peritoneum, urinary tract, bowel) for
RC patients has been routinely used for decades [75], but
there is no clear evidence that it is actually necessary, and
nor has the best schedule been defined [76,77]. AMP
(eg, cephalosporin and metronidazole) should be given prior
to opening the bowel. Evidence to support longer courses is
lacking, with a single AMP dose possibly being adequate [76].
Pulmonary physiotherapy with intensive spirometry
contributes to reducing postoperative pneumonia after
abdominal surgery. The value of optimised pain alleviation
and mobilisation should be evaluated in prospective
trials [78] (Table 8).
3.6.1.4. Deep vein thrombosis and pulmonary embolism. Risk factors
for deep vein thrombosis (DVT) include age >40 yr, obesity,
malignancy, recent surgery, prior history of pulmonary
embolism (PE) or DVT, and pelvic lymphocoeles or
haematomas [79]. Prophylactic treatment in patients
undergoing radical pelvic surgery can reduce the risk of
DVT from 30% to 10% and that of fatal PE from 5% to 0.4%
[80]. Low-molecular-weight heparins are currently the gold
standard prevention agent [81], with intermittent pneu-
matic compression stockings (IPCS) also being effective
[82]. Graduated compression stockings should be combined
with heparin/ICPS for prophylaxis [83] (Table 9).
3.6.1.5. Paralytic ileus. Ileus is a general term used to describe
intestine that ceases contracting for a brief period of time,
but there is no accepted or standard definition. Paralytic
ileus is a commonly observed within 3–5 d after major
abdominal surgery. Passing flatus signals the resolution of
the ileus. Shabsigh et al proposed the definition of ileus as
‘‘the inability to tolerate solid food by postoperative day
five, the need to place a nasogastric tube (NGT), or the need
to stop oral intake due to abdominal distension, nausea, or
emesis’’ [13].
Usually, recovery of small bowel motility and absorption
occurs within hours of surgery, whereas gastric and colonic
function requires 2–5 d [5]. Barring complications, the

Table 7 – Recommendations for prevention and treatment of urinary extravasation and reservoir leak

Urinary extravasation/reservoir leak (1.7–7.7%)

Recommendation for prevention Take your time.

Treatment recommendation
Use meticulous closure of conduit/pouch with seromuscular sutures.
Ensure good spatulation.
Always stent the ureterointestinal anastomosis.
Maintain drain/catheter placement until satisfied with integrity.
Make certain the pouch-draining catheter functions; if in doubt, change it under fluoroscopy.
Replace the transurethral catheter under fluoroscopy or vision, leaving it for at least 1 wk in case of leakage.
Divert urine with nephrostomies.
994 EUROPEAN UROLOGY 57 (2010) 983–1001

Table 8 – Recommendations for prevention and treatment of infections

Pneumonia (1–7.8%), sepsis (0.7–9.6%), and UTI (1–12.8%)

Recommendation for prevention Ensure early and intensive mobilisation.

Use respiratory exercise aids.
Encourage cessation of smoking preoperatively.
Use preoperative urine culture and treatment of infection.
Use intraoperative antibiotics.
Ensure adequate hydration.
Treatment recommendation Use incentive spirometry and mobility for atelectasis.
Use supportive therapy if sepsis: oxygenation, fluid replacement, change of infected catheters and lines.
Use appropriate culture, imaging, and antibiotics.

UTI = urinary tract infection.

Table 9 – Recommendations for prevention and treatment of deep vein thrombosis and pulmonary embolus

DVT (0.6–5.3%) and PE (0.7–6%)

Recommendation for prevention Use LMWH (up to 15 d after discharge).

Ensure early mobilisation.
Recommend intensive physiotherapy.
Use epidural analgesia.
Treatment recommendation Ensure early recognition with appropriate imaging and anticoagulation, if safe.

DVT = deep vein thrombosis; PE = pulmonary embolism; LMWH = low-molecular-weight heparin.

duration of postoperative ileus is one of the most important
determinants of the length of hospitalisation [84]. Type of
preoperative bowel preparation, fasting before surgery,
intraoperative pain control, hypovolaemia, postoperative
pain control, long-term NGT, administration of large
amounts of saline, and postoperative fasting until recovery
of bowel function are well-defined conditioning factors for
ileus [5]. Studies examining gum chewing to hasten bowel
functional recovery have been supported in a meta-analysis
of colorectal surgery [85] and also one study after RC and
diversion [86].
Routine NGT use is not required following RC, as the time
of NGT use does not affect ileus resolution [58,60,87].
Similarly, postoperative artificial nutrition does not appear
to affect the return of bowel function [88]. Some have
advocated gastrostomy, but there is no evidence supporting
this approach [87]. Data from gastrointestinal FT
approaches support the early administration of oral fluids
(day 1) and, if successful, the early restoration of oral
feeding. Small bowel obstruction may be treated with NGT,
intravenous fluids, and bowel rest but may require surgical
correction (Table 10).
3.6.1.6. Intestinal anastomotic leakage/fistulae. Whether or not a
stapled anastomosis is superior to hand-sewn anastomosis
has not been specifically examined in the urology literature.
Only in gastrointestinal surgery have studies favoured
shorter operative times using stapled rather than hand-
sewn anastomoses, but no difference was detected in length
of stay. A significant difference between stapled and hand-
sewn ileostomy closures could not be found in the urologic
literature [89]. Using an omental buttress in previously
operated or irradiated intestine may also be beneficial [90]
(Table 11).
Fistulae may develop between the intestine and recon-
structed urinary tract and from either of these to the skin or
even other organs. Most commonly for urinary tract
fistulae, the primary treatment is nutrition, diversion/
drainage, and treatment of any sepsis [91]. Reconstruction
may be required in the longer term. A similar concept

Table 10 – Recommendations for prevention and treatment of paralytic ileus and small bowel obstruction

Paralytic ileus (2.5–22.7%) and small bowel obstruction (0.3–7%)

Recommendation for prevention
Treatment recommendation
Ensure as little surgical trauma to the bowel as possible.
FT protocols may be of importance.
Reduce analgesic requirements.
Where possible, remove the NGT with extubation (this will be dictated by the type of patient, the extent of
surgery, and the bowel segment used).
Begin oral fluids on day 1.
Start oral feeding as soon as possible after removal of the NGT.
Rest the bowel.
Ensure intravenous fluids.
Exclude a true obstruction requiring surgical intervention.
Order TPN if no oral intake by 3–7 d.

FT = fast track; NGT = nasogastric tube; TPN = total parenteral nutrition.

 EUROPEAN UROLOGY 57 (2010) 983–1001 995

Table 11 – Recommendations for prevention and treatment of intestinal leakage and fistulae

Intestinal anastomotic leakage/fistulae (0.3–8.7%)

Recommendation for prevention Adhere to anastomotic principles, and take your time.
Minimise surgical trauma to the bowel and mesenterium.
Use meticulous hand-sewn or stapled anastomoses.
Maintain adequate perioperative nutrition either orally or with parenteral support, if appropriate.
Consider using the large intestine if prior to RT to the abdomen/pelvis or small bowel disease.
Treatment recommendation Early recognition and reoperation with or without diversion if fistula; consider vacuum dressing.
Consider TPN.

RT = radiation therapy; TPN = total parenteral nutrition.

applies for intestinal fistulae, but innovative devices such as
vacuum dressings are gaining favour [92]. If severe sepsis
occurs, percutaneous drainage of collections or open
revision is essential.
3.6.1.7. Wound dehiscence. Interrupted closures were replaced
in favour of continuous nonabsorbable sutures for closing
laparotomy incisions to spread tension and reduce dehis-
cence [93]. However, a recent meta-analysis suggests
interrupted closures with nonabsorbable sutures may
significantly reduce wound dehiscence [94]. Surgeon
factors are important, and attention to opposing fascia
and correct tension on the suture cannot be overempha-
sised, although it is unclear if preemptive tension sutures
assist [95]. Significant factors contributing to dehiscence
include age >65 yr, wound infection, pulmonary disease,
haemodynamic instability, and ostomies in the incision
[96]. Treatment of dehiscence involves treatment of sepsis
and early repair. Unless the defect is too large, interrupted
sutures are preferred over mesh, which should be avoided if
any infection is present [97]. Similar risk factors were
identified for wound dehiscence as for incisional hernias
(Table 12).
3.6.1.8. Lymphocoele. In recent years, the extent of
lymphadenectomy has increased [98,99] but with minimal
morbidity [100]. Lymphocoeles remain an issue, with
salvage cystectomy patients at higher risk [30,101]. Small
lymphocoeles will be resorbed, while large or symptomatic
lymphocoeles require percutaneous drainage, with open
surgery rarely required (Table 13).
3.6.2. Late postoperative complications
3.6.2.1. Ureterointestinal and urethrointestinal anastomotic stricture-
s. Obstruction may be benign or malignant (a second
primary site or a recurrence at the ureterointestinal
anastomosis). Benign strictures commonly occur during
postoperative year 1 and are usually asymptomatic because
they develop slowly. Early diagnosis and prompt drainage
(usually with a nephrostomy) are required to prevent
consequent renal parenchymal loss and infectious compli-
cations [102]. Although endoscopic and percutaneous
management procedures are viable treatment options
[103], open surgical revision may need to be the long-term
definitive treatment, particularly if the stricture occurs after
6 mo [46,104].
The type of ureteroileal anastomosis (Bricker vs Wallace)
does not affect the stricture incidence [104,105]. Meticulous
handling and preparation of the distal ureter are essential to
minimising the risk of urine leak and postoperative
stricture. The importance of ensuring good vascular supply,
limiting the dissection, adequate calibre ureteroenteric
anastomosis, complete excision of pathologic lesions, good
drainage, and a wide spatulated and tension-free anasto-
mosis of mucosa to mucosa remain paramount [106,107].
Tunnelling techniques for antireflux mechanisms carried
a higher risk of stenosis in a randomised trial [108]
(Table 14).

Table 12 – Recommendations for prevention and treatment of wound dehiscence

Wound dehiscence (0.5–9%)

Recommendation for prevention Use meticulous fascial closure (1-cm bites, 1 cm along).
Use extra interrupted sutures and/or tension sutures in obese, higher-risk patients.
Treatment recommendation Ensure early recognition and immediate open repair if there is fascial dehiscence.
Use interrupted sutures with or without treatment for sepsis.

Table 13 – Recommendations for prevention and treatment of lymphocoele

Lymphocoele (0.5–3.5%)

Recommendation for prevention Pay attention to surgical technique.

Identify and ligate (or clip) the distal and proximal lymphatic vessels during lymphadenectomy.
Leave adequate peritoneal opening for drainage of lymphatic fluid.
Treatment recommendation Recognise early with imaging.
Use percutaneous management with or without open drainage (rare).
996 EUROPEAN UROLOGY 57 (2010) 983–1001

Table 14 – Recommendations for prevention and treatment of anastomotic strictures

Anastomotic strictures (7–14%)

Recommendation for prevention Adhere to anastomotic principles (eg, minimal ureteric dissection, watertight, well vascularised).
Leak test to ensure that there are no major leaks.
Leave the ureteral blood supply as intact as possible, especially minimal dissection of the left ureter.
Use copious spatulation.
Ensure careful placement of sutures at the apex, generally at least two interrupted sutures.
Treatment recommendation Ensure early recognition and reoperation with or without diversion of urine.

3.7. Ureteric reflux and deterioration of renal function
The importance of refluxing ureterointestinal anastomoses
stems largely from UD in children with neurogenic bladder
disorders. In RC patients, this issue is of minor importance,
as is now increasingly being recognised. Undoubtedly,
severe reflux can cause or contribute to a deterioration of
renal function and therefore remains a concern with any
UD. With a follow-up of 15 yr, up to 50% of patients will
have upper urinary tract changes, but only 12% will
demonstrate such changes at 5 yr [109]. It should be
recognised that the causes for such changes are likely to be
multifactorial, and in our opinion, obstruction with
ureterointestinal anastomotic stenosis is more likely to
contribute to a slowly progressive postoperative deteriora-
tion of renal function in RC patients.
Although techniques using antirefluxing mechanisms are
still used for ureterosigmoidostomy or continent reservoirs
with a catheterisable abdominal stoma resulting from higher
pressures, the evidence for use in orthotopic bladder
substitutes is equivocal. For ileal conduits—considered
low-pressure diversions—antirefluxing techniques for the
ureteral anastomoses are not useful [110] (Table 15).
3.7.1. Stones
The incidence of upper tract stones is low at around 1%
[111], but if patients are followed for a decade, rates >30%
have been reported [109]. Stones can occur for three reasons:
malabsorption resulting in oxalate nephropathy; reabsorp-
tion of urine solutes from the reservoir, inducing an acidosis;
and chronic infections with urease-producing bacteria [111].
Prevention can be aided by preserving the most distal 10–
25 cm of ileum and—postoperatively—by encouraging fre-
quent voiding with minimal residual volumes. Treatment of
bacteriuria until the urine is sterile is controversial [111,112],
because about 40% of patients with an orthotopic bladder will
have persistent bacteriuria and may have other adverse
affects, such as resistant organisms.
Pouch stones are related to poor emptying and foreign
bodies in the reservoir or (rarely) in a conduit. Exposed
metallic staple lines and mesh are at a higher risk of stone
formation and should be avoided [113] (Table 16).
3.8. Chronic/recurrent pyelonephritis
A positive urine culture is a common finding in patients
with UD, but this does not translate to symptomatic
infection [112]. However, symptomatic UTI (including
pyelonephritis) may develop in almost a quarter of patients
[109]. Symptomatic UTIs must be treated expeditiously
with appropriate antibiotics and—in cases of sepsis—
supportive therapy [114]. Pouchitis is a soft tissue infection
occurring almost exclusively in the first few months but
rarely in a mature pouch, but few data are available.

Table 15 – Recommendations for prevention and treatment of ureteric reflux and deterioration of renal function

Ureteric reflux (1–12%) and deterioration of renal function (0.3–27%)

Recommendation for prevention Do not use antireflux techniques with ureteroileal anastomoses, only with colon.
Treat reflux only if it is associated with clinical problems (recurrent infections).
Monitor serum creatinine every 3–6 mo for the first 2 yr, and then annually.
Monitor upper urinary tracts at 3–4 mo, and then annually.
Treatment recommendation Consider the age and life expectancy of the patient.
Recommend ureteric reimplantation with consideration for reflux protection.

Table 16 – Recommendations for prevention and treatment of stones

Stones (3.9–9%)

Recommendation for prevention Ensure adequate reservoir size.

Ensure adequate emptying of the reservoir (angulation of conduit; ISC in
orthotopic bladder substitutes with residual, frequent checking of adequate pouch evacuation).
Minimise UTI and bacteriuria.
Ensure hydration.
Treatment recommendation Ensure early recognition of obstructions.
Use ISC, if required; use a minimally invasive technique to treat calculi.

ISC = intermittent self-catheterisation; UTI = urinary tract infection.

 EUROPEAN UROLOGY 57 (2010) 983–1001
Table 17 – Recommendations for prevention and treatment of
pyelonephritis
Chronic/recurrent pyelonephritis (3.1–6.3%)
Recommendation Check regularly to exclude obstruction.
for prevention Exclude stagnation of urine in the conduit
and residual urine in orthotopic bladder
substitutes.
Ensure adequate and constant diuresis.
Treatment Employ early culture and treatment,
recommendation if symptomatic.
Avoid overtreating and cultivating
resistant organisms.
Recurrent symptomatic UTI not related to ureteral
obstruction or reflux requires fluoroscopy of the reservoir
or conduit to determine whether there is poor emptying of
the reservoir and to identify stenotic areas [115].
In orthotopic bladder substitutes, stagnant urine with
incomplete emptying because of stricture at the urethral
anastomosis or voiding dysfunction should be considered.
In summary, the presence of small bowel intestine
appears to promote asymptomatic bacterial colonisation,
but urosepsis rarely occurs unless the patient has recurrent
symptomatic UTI. Prophylactic antibiotics are recom-
mended only for patients with recurring symptomatic
UTI, but treating a positive urinary culture in the absence of
specific voiding symptoms is not advocated in this patient
population [116] (Table 17).
3.9. Metabolic disorders
Metabolic consequences relate to reabsorption and vitamin
deficiencies [117]. Patients with preexisting renal disease
are less able to compensate for metabolic changes resulting
from UD [43]. For ileum and colon, the most common
metabolic disturbance is hyperchloraemic metabolic acido-
sis. Rare occurrences of total body potassium depletion and
other effects, such as hypocalcaemia, hypomagnesaemia,
and hyperamonaemia, are possible. The presenting symp-
toms are fatigue, anorexia, and diarrhoea. Treatment in the
short term involves intravenous hydration and monitoring
of electrolytes plus bicarbonate. Metabolic imbalances
usually respond promptly to an adaptation of the substitu-
tion therapy [23,38].
Malabsorptive vitamin B12 deficiency may be a concern
and a relatively common problem [39]. Distal terminal
ileum preservation is essential, and it may take 3–4 yr to
deplete vitamin B12 stores. Parenteral or oral replacement
should be initiated prior to symptoms [43,46] (Table 18).
3.10. Miscellaneous
3.10.1. Orthotopic bladder substitute retention and rupture
A variable number of patients will have problems with
incomplete orthotopic bladder substitute emptying, al-
though the incidence of this functional problem is not
known. It may be severe and rarely leads to reservoir rupture
with minor trauma [118]. What defines retention is
contentious but probably between 100 ml and 200 ml
997
Table 18 – Recommendations for prevention and treatment of
metabolic disorders
Metabolic disorders (0–3%)
Recommendation Preserve the distal ileum.
for prevention Monitor vitamin B12, pH bicarbonate, and
electrolytes.
Use generous replacement of vitamin B12,
if required.
Ensure adequate positioning of conduits
for rapid emptying.
Ensure adequate emptying of the pouch,
conduits, and the orthotopic bladder substitute.
Check adequate emptying.
Start oral bicarbonate early.
Treatment Use early correction as appropriate.
recommendation Ensure adequate management of orthotopic
bladder substitution.
depending on the type and size of the reservoir. Chronic
retention in orthotopic bladder substitutes may be related to
the initial capacity and configuration of the orthotopic
bladder substitute pouch at the time of surgery. Education
and the patient’s ability to void the bladder regularly,
excessive mucous formation, decompensation of the ortho-
topic bladder substitute, and angulation just proximal to the
urethral anastomosis are important. Successful conservative
management may require attempts to reduce mucous
accumulation (eg, N-acetyl-L-cysteine), prevention of infec-
tion, and/or intermittent self-catheterisation. Orthotopic
bladder substitute rupture is rare and may not always
require surgical repair [119,120]. Whether surgical tech-
nique of orthotopic bladder substitute formation plays a role
in facilitating rupture is unknown; in women, the use of a
supportive hammock has been advocated to prevent this
complication [121] (Table 19).
3.10.2. Stomal hernia and stenosis
Hernias may occur in the wound or adjacent to stomas and
may require revision, often without disrupting the whole
conduit or reservoir. Mesh may be used to reinforce
weakened fascial planes around stomas [122]. However,
relocation of the stoma to the contralateral side is an
important consideration because of the high rate of
recurrence without stoma relocation. Stomal stenosis,
Table 19 – Recommendations for prevention and treatment of
orthotopic bladder substitute retention and rupture
Orthotopic bladder substitute
retention (>1.5%) and rupture (rare)
Recommendation Encourage patient education with a
for prevention stomal therapist.
Ensure adequate emptying.
Reduce mucus.
Use ISC in patients with high residual urine.
Treatment Use ISC or cystoscopic drainage.
recommendation Use a transurethral catheter.
Reduce mucous formation.
Consider open surgical repair.
ISC = intermittent self-catheterisation.
998 EUROPEAN UROLOGY 57 (2010) 983–1001
usually secondary to insufficient blood supply to the bowel,
results from successive shrinkage of the bowel and/or is
secondary to narrowing of the skin. Obvious narrowing
and/or catheterisation difficulty requires a retrograde
study to define possible anatomical abnormalities (eg,
false passage, conduit elongation). Revision is usually
necessary after the obstruction is relieved and sepsis
resolved [115].
4. Conclusions
There is no doubt that progress has been made in the
surgical art of RC and UD. Compared to historical series,
mortality has been markedly reduced. Postoperative mor-
bidity remains high and is partly the result of the complexity
of the procedures. A variety of UD techniques have been
developed and can be offered to the patient—if the patient’s
surgeon is sufficiently experienced with different techniques.
Otherwise, the surgeon should refer the patient to someone
who has that experience. RC remains a highly complex
procedure, especially with complex UDs. Thus, two issues are
paramount if outcomes are to be further improved. One is
related to surgical volume, and it concerns all aspects of RC
(surgeons, anaesthetists, intensive care, stomal therapist,
physiotherapist, nutrition). The other is to reduce long-term
postoperative morbidity, an issue that is increasingly being
recognised.
Ultimately, it is the urologic oncology community that
will move the important area of prevention of RC
complications forward. We must do a better job with
evidence-based medicine, which should also include the
participation of medical journals, national medical socie-
ties, and government authorities. Outcome methods and
methods of combining those outcomes (ie, blending of
subjective and objective results to establish definitions of
cured and failed) should be standardised. In particular, we
need standard definitions of complications, standard
follow-up, and prospectively collected data if we want to
improve long-term RC outcomes.
Author contributions: Nathan Lawrentschuk had full access to all the
data in the study and takes responsibility for the integrity of the data and
the accuracy of the data analysis.
Study concept and design: Lawrentschuk, Colombo, Hakenberg, Lerner,
Månsson, Sagalowsky, Wirth.
Acquisition of data: Lawrentschuk.
Analysis and interpretation of data: Lawrentschuk, Colombo, Hakenberg,
Lerner, Månsson, Sagalowsky, Wirth.
Drafting of the manuscript: Lawrentschuk, Colombo, Hakenberg, Lerner,
Månsson, Sagalowsky, Wirth.
Critical revision of the manuscript for important intellectual content:
Lawrentschuk, Colombo, Hakenberg, Lerner, Månsson, Sagalowsky,
Wirth.
Statistical analysis: Lawrentschuk.
Obtaining funding: None.
Administrative, technical, or material support: Lawrentschuk, Colombo,
Hakenberg, Lerner, Månsson, Sagalowsky, Wirth.
Supervision: Colombo, Hakenberg, Lerner, Månsson, Sagalowsky, Wirth.
Other (specify): None.
Financial disclosures: I certify that all conflicts of interest, including
specific financial interests and relationships and affiliations relevant to
the subject matter or materials discussed in the manuscript (eg,
employment/affiliation, grants or funding, consultancies, honoraria,
stock ownership or options, expert testimony, royalties, or patents filed,
received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.
References
[1] Lee CT, Dunn RL, Chen BT, Joshi DP, Sheffield J, Montie JE. Impact of
body mass index on radical cystectomy. J Urol 2004;172:1281–5.
[2] Meyer JP, Blick C, Arumainayagam N, et al. A three-centre experi-
ence of orthotopic neobladder reconstruction after radical cystec-
tomy: revisiting the initial experience, and results in 104 patients.
BJU Int 2009;103:680–3.
[3] Cookson MS, Chang SS, Wells N, Parekh DJ, Smith Jr JA. Complica-
tions of radical cystectomy for nonmuscle invasive disease:
comparison with muscle invasive disease. J Urol 2003;169:101–4.
[4] Colombo R. Editorial comment on: defining early morbidity of
radical cystectomy for patients with bladder cancer using a stan-
dardized reporting methodology. Eur Urol 2009;55:175–6.
[5] Maffezzini M, Campodonico F, Canepa G, Gerbi G, Parodi D. Current
perioperative management of radical cystectomy with intestinal
urinary reconstruction for muscle-invasive bladder cancer and
reduction of the incidence of postoperative ileus. Surg Oncol
2008;17:41–8.
[6] Charbit L, Beurton D, Cukier J. Mortality and morbidity after total
cystectomy for cancer [in French]. J Urol (Paris) 1984;90:39–46.
[7] Johnson DE, Lamy SM. Complications of a single stage radical
cystectomy and ileal conduit diversion: review of 214 cases. J
Urol 1977;117:171–3.
[8] Skinner DG, Crawford ED, Kaufman JJ. Complications of radical
cystectomy for carcinoma of the bladder. J Urol 1980;123:640–3.
[9] Thomas DM, Riddle PR. Morbidity and mortality in 100 consecu-
tive radical cystectomies. Br J Urol 1982;54:716–9.
[10] Sullivan JW, Grabstald H, Whitmore Jr WF. Complications of
ureteroileal conduit with radical cystectomy: review of 336 cases.
J Urol 1980;124:797–801.
[11] Donat SM. Standards for surgical complication reporting in uro-
logic oncology: time for a change. Urology 2007;69:221–5.
[12] Hautmann RE. Editorial comment on: defining early morbidity of
radical cystectomy for patients with bladder cancer using a stan-
dardized reporting methodology. Eur Urol 2009;55:174.
[13] Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of
radical cystectomy for patients with bladder cancer using a stan-
dardized reporting methodology. Eur Urol 2009;55:164–76.
[14] Dmochowski R, Scarpero H. Surgical outcomes reporting—closer
to reality. Eur Urol 2007;52:1306–8.
[15] Hollenbeck BK, Miller DC, Taub D, et al. Identifying risk factors for
potentially avoidable complications following radical cystectomy.
J Urol 2005;174:1231–7, discussion 1237.
[16] Novara G, De Marco V, Aragona M, et al. Complications and
mortality after radical cystectomy for bladder transitional cell
cancer. J Urol 2009;182:914–21.
[17] Clavien PA, Camargo Jr CA, Croxford R, Langer B, Levy GA, Greig PD.
Definition and classification of negative outcomes in solid organ
transplantation. Application in liver transplantation. Ann Surg
1994;220:109–20.
[18] Rhoads KF, Konety BM, Dudley RA. Performance measurement,
public reporting, and pay-for-performance. Urol Clin North Am
2009;36:37–48.
 EUROPEAN UROLOGY 57 (2010) 983–1001
[19] Hollenbeck BK, Taub DA, Miller DC, Dunn RL, Montie JE, Wei JT. The
regionalization of radical cystectomy to specific medical centers. J
Urol 2005;174:1385–9, discussion 1389.
[20] Gamé X, Soulié M, Seguin P, et al. Radical cystectomy in patients
older than 75 years: assessment of morbidity and mortality. Eur
Urol 2001;39:525–9.
[21] Lee KL, Freiha F, Presti Jr JC, Gill HS. Gender differences in radical
cystectomy: complications and blood loss. Urology 2004;63:
1095–9.
[22] Clark PE, Stein JP, Groshen SG, et al. Radical cystectomy in the
elderly: comparison of clinical outcomes between younger and
older patients. Cancer 2005;104:36–43.
[23] Bostrom PJ, Kössi J, Laato M, Nurmi M. Risk factors for mortality and
morbidity related to radical cystectomy. BJU Int 2009;103:191–6.
[24] Kim HL, Steinberg GD. Complications of cystectomy in patients
with a history of pelvic radiation. Urology 2001;58:557–60.
[25] Arumainayagam N, McGrath J, Jefferson KP, Gillatt DA. Introduc-
tion of an enhanced recovery protocol for radical cystectomy. BJU
Int 2008;101:698–701.
[26] Hautmann RE, de Petriconi R, Volkmer BG. Neobladder formation
after pelvic irradiation. World J Urol 2009;27:57–62.
[27] Tolhurst SR, Rapp DE, O’Connor RC, Lyon MB, Orvieto MA, Stein-
berg GD. Complications after cystectomy and urinary diversion in
patients previously treated for localized prostate cancer. Urology
2005;66:824–9.
[28] Nagele U, Anastasiadis AG, Merseburger AS, et al. The rationale for
radical cystectomy as primary therapy for T4 bladder cancer.
World J Urol 2007;25:401–5.
[29] Shahin O, Thalmann GN, Rentsch C, Mazzucchelli L, Studer UE. A
retrospective analysis of 153 patients treated with or without
intravesical bacillus Calmette-Guerin for primary stage T1 grade 3
bladder cancer: recurrence, progression and survival. J Urol
2003;169:96–100, discussion 100.
[30] Mastroeni F, Aragona M, Caldarera E, et al. Deep venous thrombo-
sis in patients undergoing salvage radical cystectomy. Arch Esp
Urol 2001;54:839–41.
[31] Weight CJ, Garcia JA, Hansel DE, et al. Lack of pathologic down-
staging with neoadjuvant chemotherapy for muscle-invasive
urothelial carcinoma of the bladder: a contemporary series. Can-
cer 2009;115:792–9.
[32] Manoharan M, Reyes MA, Kava BR, Singal R, Kim SS, Soloway MS. Is
adjuvant chemotherapy for bladder cancer safer in patients with
an ileal conduit than a neobladder? BJU Int 2005;96:1286–9.
[33] Donat SM, Shabsigh A, Savage C, et al. Potential impact of postoper-
ative early complications on the timing of adjuvant chemotherapy
in patients undergoing radical cystectomy: a high-volume tertiary
cancer center experience. Eur Urol 2009;55:177–86.
[34] Konety BR, Allareddy V, Modak S, Smith B. Mortality after major
surgery for urologic cancers in specialized urology hospitals: are
they any better? J Clin Oncol 2006;24:2006–12.
[35] Hollenbeck BK, Dunn RL, Miller DC, Daignault S, Taub DA, Wei JT.
Volume-based referral for cancer surgery: informing the debate. J
Clin Oncol 2007;25:91–6.
[36] Imkamp F, Herrmann TR, Rassweiler J, et al. Laparoscopy in
German urology: changing acceptance among urologists. Eur Urol
2009;56:1074–81.
[37] McCabe JE, Jibawi A, Javle PM. Radical cystectomy: defining the
threshold for a surgeon to achieve optimum outcomes. Postgrad
Med J 2007;83:556–60.
[38] Barbieri CE, Lee B, Cookson MS, et al. Association of procedure
volume with radical cystectomy outcomes in a nationwide data-
base. J Urol 2007;178:1418–21, discussion 1421–2.
[39] Fairey A, Chetner M, Metcalfe J, et al. Associations among age,
comorbidity and clinical outcomes after radical cystectomy:
999
results from the Alberta Urology Institute radical cystectomy
database. J Urol 2008;180:128–34, discussion 134.
[40] Guidance on Cancer Services: Improving Outcomes in Urological
Cancers. London: National Institute for Clinical Excellence; 2002.
[41] Froehner M, Brausi MA, Herr HW, Muto G, Studer UE. Complica-
tions following radical cystectomy for bladder cancer in the
elderly. Eur Urol 2009;56:443–54.
[42] Terry WJ, Bueschen AJ. Complications of radical cystectomy and
correlation with nutritional assessment. Urology 1986;27:229–32.
[43] Mills RD, Studer UE. Metabolic consequences of continent urinary
diversion. J Urol 1999;161:1057–66.
[44] Flohr P, Hefty R, Paiss T, Hautmann R. The ileal neobladder—updated
experience with 306 patients. World J Urol 1996;14:22–6.
[45] Stein JP, Penson DF, Wu SD, Skinner DG. Pathological guidelines for
orthotopic urinary diversion in women with bladder cancer: a
review of the literature. J Urol 2007;178:756–60.
[46] Nieuwenhuijzen JA, de Vries RR, Bex A, et al. Urinary diversions
after cystectomy: the association of clinical factors, complications
and functional results of four different diversions. Eur Urol
2008;53:834–44, discussion 842–4.
[47] Parekh DJ, Gilbert WB, Koch MO, Smith Jr JA. Continent urinary
reconstruction versus ileal conduit: a contemporary single-insti-
tution comparison of perioperative morbidity and mortality. Urol-
ogy 2000;55:852–5.
[48] Lerner SP, Bochner B, Kibel AS. The use and abuse of data: nomo-
grams and talking to patients about clinical medicine. Urol Oncol
2007;25:333–7.
[49] Stenzl A, Nagele U, Kuczyk M, et al. Cystectomy – technical
considerations in male and female patients. EAU Update Series
2005;3:138–46.
[50] Holt NF, Silverman DG, Prasad R, Dziura J, Ruskin KJ. Preanesthesia
clinics, information management, and operating room delays:
results of a survey of practicing anesthesiologists. Anesth Analg
2007;104:615–8.
[51] Hollenbeck BK, Wei Y, Birkmeyer JD. Volume, process of care, and
operative mortality for cystectomy for bladder cancer. Urology
2007;69:871–5.
[52] Ozyuvaci E, Altan A, Karadeniz T, Topsakal M, Besisik A, Yucel M.
General anesthesia versus epidural and general anesthesia in
radical cystectomy. Urol Int 2005;74:62–7.
[53] Chang SS, Alberts G, Cookson MS, Smith Jr JA. Radical cystectomy
is safe in elderly patients at high risk. J Urol 2001;166:938–41.
[54] Dahm P, Tuttle-Newhall JE, Nimjee SM, Byrne RR, Yowell CW, Price
DT. Indications for admission to the surgical intensive care unit
after radical cystectomy and urinary diversion. J Urol 2001;166:
189–93.
[55] Leung AK, Tan IK. Critical care and the urologic patient. Crit Care
Clin 2003;19:1–10.
[56] Yeager MP, Spence BC. Perioperative fluid management: current
consensus and controversies. Semin Dial 2006;19:472–9.
[57] Olbert PJ, Baumann L, Hegele A, Schrader AJ, Hofmann R. Fast-track
concepts in the perioperative management of patients undergoing
radical cystectomy and urinary diversion: review of the literature
and research results [in German]. Urologe A 2009;48:137–42.
[58] Park HK, Kwak C, Byun SS, Lee E, Lee SE. Early removal of naso-
gastric tube after cystectomy with urinary diversion: does post-
operative ileus risk increase? Urology 2005;65:905–8.
[59] Tabibi A, Simforoosh N, Basiri A, Ezzatnejad M, Abdi H, Farrokhi F.
Bowel preparation versus no preparation before ileal urinary
diversion. Urology 2007;70:654–8.
[60] Pruthi RS, Chun J, Richman M. Reducing time to oral diet and
hospital discharge in patients undergoing radical cystectomy
using a perioperative care plan. Urology 2003;62:661–5, discus-
sion 665–6.
1000 EUROPEAN UROLOGY 57 (2010) 983–1001
[61] Simonato A, Gregori A. Re: Georges-Pascal Haber, Sebastien Crouzet,
Inderbir S. Gill. Laparoscopic and robotic-assisted radical cystec-
tomy for bladder cancer: a critical analysis. Eur Urol 2009;55:e13–4.
[62] Herr HW. Editorial comment on: robotic-assisted laparoscopic
radical cystectomy with extracorporeal urinary diversion: initial
experience. Eur Urol 2008;54:579.
[63] Murphy DG, Challacombe BJ, Elhage O, et al. Robotic-assisted
laparoscopic radical cystectomy with extracorporeal urinary
diversion: initial experience. Eur Urol 2008;54:570–80.
[64] Naspro R. Editorial comment on: robotic-assisted laparoscopic
radical cystectomy with extracorporeal urinary diversion: initial
experience. Eur Urol 2008;54:578.
[65] Soloway MS. Editorial comment on: robotic-assisted laparoscopic
radical cystectomy with extracorporeal urinary diversion: initial
experience. Eur Urol 2008;54:580.
[66] Haber G-P, Crouzet S, Gill IS. Laparoscopic and robotic assisted
radical cystectomy for bladder cancer: a critical analysis. Eur Urol
2008;54:54–64.
[67] Karam JA, Sagalowsky AI. Minimally invasive radical cystectomy
for bladder cancer? Lancet Oncol 2008;9:317–8.
[68] Chang SS, Smith Jr JA, Cookson MS. Decreasing blood loss in
patients treated with radical cystectomy: a prospective rando-
mizes trial using a new stapling device. J Urol 2003;169:951–4.
[69] Stolzenburg J-U, Schwalenberg T, Horn L-C, Neuhaus J, Constan-
tinides C, Liatsikos EN. Anatomical landmarks of radical prosta-
tectomy. Eur Urol 2007;51:629–39.
[70] Stein RG. Continent urinary diversion and the ileal cecal pouch
with appendostomy: a review with nursing care. J Wound Ostomy
Continence Nurs 1995;22:51–7.
[71] Micali S, De Carli P, Miano R, O’Sullivan D, Lamanna L, Micali F.
Double-J ureteral stents: an alternative to external urinary stents
in orthotopic bladder substitution. Eur Urol 2001;39:575–9.
[72] Touma N, Spodek J, Kuan J, Shepherd RR, Hayman WP, Chin JL.
Confirming routine stentograms after cystectomy is unnecessary.
Can Urol Assoc J 2007;1:103–5.
[73] Mattei A, Birkhaeuser FD, Baermann C, Warncke SH, Studer UE. To
stent or not to stent perioperatively the ureteroileal anastomosis
of ileal orthotopic bladder substitutes and ileal conduits? Results
of a prospective randomized trial. J Urol 2008;179:582–6.
[74] Ankem MK, Han KR, Hartanto V, et al. Routine pouchograms are
not necessary after continent urinary diversion. Urology 2004;63:
435–7.
[75] Amin M. Antibacterial prophylaxis in urology: a review. Am J Med
1992;92:114S–7S.
[76] Hara N, Kitamura Y, Saito T, Komatsubara S, Nishiyama T, Taka-
hashi K. Perioperative antibiotics in radical cystectomy with ileal
conduit urinary diversion: efficacy and risk of antimicrobial pro-
phylaxis on the operation day alone. Int J Urol 2008;15:511–5.
[77] Yamamoto S, Shima H, Matsumoto T. Controversies in periopera-
tive management and antimicrobial prophylaxis in urologic sur-
gery. Int J Urol 2008;15:467–71.
[78] Lie C, Kehlet H, Rosenberg J. Lung physiotherapy as prophylaxis
against atelectasis and pneumonia after abdominal surgery [in
Danish]. Ugeskr Laeger 1998;160:3540–4.
[79] Heinzer H, Hammerer P, Graefen M, Huland H. Thromboembolic
complication rate after radical retropubic prostatectomy. Impact
of routine ultrasonography for the detection of pelvic lymphoceles
and hematomas. Eur Urol 1998;33:86–90.
[80] Kibel AS, Loughlin KR. Pathogenesis and prophylaxis of postoper-
ative thromboembolic disease in urological pelvic surgery. J Urol
1995;153:1763–74.
[81] Hunt BJ. The prevention of hospital-acquired venous thrombo-
embolism in the United Kingdom. Br J Haematol 2009;144:
642–52.
[82] Hansberry KL, Thompson Jr IM, Bauman J, Deppe S, Rodriguez FR.
A prospective comparison of thromboembolic stockings, external
sequential pneumatic compression stockings and heparin sodium/
dihydroergotamine mesylate for the prevention of thromboem-
bolic complications in urological surgery. J Urol 1991;145:1205–8.
[83] Koch MO, Seckin B, Smith Jr JA. Impact of a collaborative care
approach to radical cystectomy and urinary reconstruction. J Urol
1995;154:996–1001.
[84] Frazier HA, Robertson JE, Paulson DF. Complications of radical
cystectomy and urinary diversion: a retrospective review of 675
cases in 2 decades. J Urol 1992;148:1401–5.
[85] Purkayastha S, Tilney HS, Darzi AW, Tekkis PP. Meta-analysis of
randomized studies evaluating chewing gum to enhance postop-
erative recovery following colectomy. Arch Surg 2008;143:788–93.
[86] Kouba EJ, Wallen EM, Pruthi RS. Gum chewing stimulates bowel
motility in patients undergoing radical cystectomy with urinary
diversion. Urology 2007;70:1053–6.
[87] Figueroa AJ, Stein JP, Dickinson M, et al. Radical cystectomy for
elderly patients with bladder carcinoma: an updated experience
with 404 patients. Cancer 1998;83:141–7.
[88] Maffezzini M, Gerbi G, Campodonico F, Parodi D. A multimodal
perioperative plan for radical cystectomy and urinary intestinal
diversion: effects, limits and complications of early artificial
nutrition. J Urol 2006;176:945–8, discussion 948–9.
[89] Leung TT, MacLean AR, Buie WD, Dixon E. Comparison of
stapled versus handsewn loop ileostomy closure: a meta-analysis.
J Gastrointest Surg 2008;12:939–44.
[90] Enestvedt CK, Thompson SK, Chang EY, Jobe BA. Clinical review:
healing in gastrointestinal anastomoses, part II. Microsurgery
2006;26:137–43.
[91] Tunuguntla HS, Manoharan M, Gousse AE. Management of neo-
bladder-vaginal fistula and stress incontinence following radical
cystectomy in women: a review. World J Urol 2005;23:231–5.
[92] Wainstein DE, Fernandez E, Gonzalez D, Chara O, Berkowski D.
Treatment of high-output enterocutaneous fistulas with a vacu-
um-compaction device. A ten-year experience. World J Surg
2008;32:430–5.
[93] Rubio PA. Closure of abdominal wounds with continuous nonab-
sorbable sutures: experience in 1697 cases. Int Surg 1991;76:
159–60.
[94] Gupta H, Srivastava A, Menon GR, Agrawal CS, Chumber S, Kumar
S. Comparison of interrupted versus continuous closure in abdom-
inal wound repair: a meta-analysis of 23 trials. Asian J Surg
2008;31: 104–14.
[95] Eke N, Jebbin NJ. Abdominal wound dehiscence: a review. Int Surg
2006;91:276–87.
[96] Riou JP, Cohen JR, Johnson Jr H. Factors influencing wound dehis-
cence. Am J Surg 1992;163:324–30.
[97] van’t Riet M, de Vos van Steenwijk PJ, Bonjer HJ, Steyerberg EW,
Jeekel J. Mesh repair for postoperative wound dehiscence in the
presence of infection: is absorbable mesh safer than non-absorb-
able mesh? Hernia 2007;11:409–13.
[98] Dhar NB, Klein EA, Reuther AM, Thalmann GN, Madersbacher S,
Studer UE. Outcome after radical cystectomy with limited or
extended pelvic lymph node dissection. J Urol 2008;179:873–8,
discussion 878.
[99] Liedberg F, Månsson W. Lymph node metastasis in bladder cancer.
Eur Urol 2006;49:13–21.
[100] Buscarini M, Josephson DY, Stein JP. Lymphadenectomy in bladder
cancer: a review. Urol Int 2007;79:191–9.
[101] Lattouf J-B, Beri A, Jeschke S, Sega W, Leeb K, Janetschek G.
Laparoscopic extended pelvic lymph node dissection for prostate
cancer: description of the surgical technique and initial results.
Eur Urol 2007;52:1347–57.
 EUROPEAN UROLOGY 57 (2010) 983–1001
[102] Shokeir AA, Al Ansari AA. Iatrogenic infections in urological prac-
tice: concepts of pathogenesis, prevention and management.
Scand J Urol Nephrol 2006;40:89–97.
[103] Pappas P, Stravodimos KG, Kapetanakis T, et al. Ureterointestinal
strictures following Bricker ileal conduit: management via a
percutaneous approach. Int Urol Nephrol 2008;40:621–7.
[104] Kouba E, Sands M, Lentz A, Wallen E, Pruthi RS. A comparison of
the Bricker versus Wallace ureteroileal anastomosis in patients
undergoing urinary diversion for bladder cancer. J Urol 2007;178:
945–8, discussion 948–9.
[105] Pagano S, Ruggeri P, Rovellini P, Bottanelli A. The anterior ileal
conduit: results of 100 consecutive cases. J Urol 2005;174:959–62,
discussion 962.
[106] Nagele U, Sievert K-D, Merseburger AS, Anastasiadis AG, Stenzl A.
Urinary diversion following cystectomy. EAU Update Series
2005;3:129–37.
[107] Estape R, Mendez LE, Angioli R, Penalver M. Urinary diversion in
gynecologic oncology. Surg Clin North Am 2001;81:781–97.
[108] Shaaban AA, Abdel-Latif M, Mosbah A, et al. A randomized study
comparing an antireflux system with a direct ureteric anastomosis
in patients with orthotopic ileal neobladders. BJU Int 2006;97:
1057–62.
[109] Madersbacher S, Schmidt J, Eberle JM, et al. Long-term outcome of
ileal conduit diversion. J Urol 2003;169:985–90.
[110] Hautmann RE, Abol-Enein H, Hafez K, et al. World Health Organi-
zation (WHO) Consensus Conference on Bladder Cancer. Urinary
diversion. Urology 2007;69(Suppl 1):17–49.
[111] Dhar NB, Hernandez AV, Reinhardt K, et al. Prevalence of nephro-
lithiasis in patients with ileal bladder substitutes. Urology
2008;71:128–30.
[112] Suriano F, Gallucci M, Flammia GP, et al. Bacteriuria in patients
with an orthotopic ileal neobladder: urinary tract infection or
asymptomatic bacteriuria? BJU Int 2008;101:1576–9.
[113] Stoller M, Meng M. Urinary stone disease: the practical guide to
medical and surgical management. ed. 1 New York: Humana
Press; 2007.
[114] Wagenlehner FM, Weidner W, Naber KG. Optimal management of
urosepsis from the urological perspective. Int J Antimicrob Agents
2007;30:390–7.
[115] Ordorica RC, Masel J, Seigne J, Persky L, Lockhart JL. Evaluation and
management of mechanical dysfunction in continent colonic
urinary reservoirs. J Urol 2000;163:1679–84.
[116] Wood Jr DP, Bianco Jr FJ, Pontes JE, Heath MA, DaJusta D. Incidence
and significance of positive urine cultures in patients with an
orthotopic neobladder. J Urol 2003;169:2196–9.
[117] Studer UE, Burkhard FC, Schumacher M, et al. Twenty years
experience with an ileal orthotopic low pressure bladder substi-
tute—lessons to be learned. J Urol 2006;176:161–6.
[118] Mansson W, Bakke A, Bergmanet B, et al. Perforation of continent
urinary reservoirs. Scandinavian experience. Scand J Urol Nephrol
1997;31:529–32.
1001
[119] Baseman AG, Young Jr RR, Young AK, Lerner SP. Conservative
management of spontaneous rupture of Kock orthotopic ileal
reservoir. Urology 1997;49:629–31.
[120] Nippgen JB, Hakenberg OW, Manseck A, Wirth MP. Spontaneous
late rupture of orthotopic detubularized ileal neobladders: report
of five cases. Urology 2001;58:43–6.
[121] Puppo P, Introini C, Calvi P, Naselli A. Prevention of chronic urinary
retention in orthotopic bladder replacement in the female. Eur
Urol 2005;47:674–8, discussion 678.
[122] Guzman-Valdivia G, Guerrero TS, Laurrabaquio HV. Parastomal
hernia-repair using mesh and an open technique. World J Surg
2008;32:465–70.
[123] Boström PJ, Kössi J, Laato M, Nurmi M. Risk factors for mortality
and morbidity related to radical cystectomy. BJU Int 2009;103:
191–6.
[124] Pycha A, Comploj E, Martini T, et al. Comparison of complications
in three incontinent urinary diversions. Eur Urol 2008;54:825–34.
[125] Lowrance WT, Rumohr JA, Chang SS, Clark PE, Smith Jr JA, Cookson
MS. Contemporary open radical cystectomy: analysis of periop-
erative outcomes. J Urol 2008;179:1313–8, discussion 1318.
[126] Novotny V, Hakenberg OW, Wiessner D, et al. Perioperative
complications of radical cystectomy in a contemporary series.
Eur Urol 2007;51:397–402, discussion 401–2.
[127] Konety BR, Allareddy V, Herr H. Complications after radical
cystectomy: analysis of population-based data. Urology 2006;68:
58–64.
[128] Knap MM, Lundbeck F, Overgaard J. Early and late treatment-
related morbidity following radical cystectomy. Scand J Urol
Nephrol 2004;38:153–60.
[129] Kulkarni JN, Pramesh CS, Rathi S, Pantvaidya GH. Long-term
results of orthotopic neobladder reconstruction after radical cys-
tectomy. BJU Int 2003;91:485–8.
[130] Chahal R, Sundaram SK, Iddenden R, Forman DF, Weston PMT,
Harrison SCW. A study of the morbidity, mortality and long-term
survival following radical cystectomy and radical radiotherapy in
the treatment of invasive bladder cancer in Yorkshire. Eur Urol
2003;43:246–57.
[131] Malavaud B, Vaessen C, Mouzin M, Rischmann P, Sarramon JP,
Schulman C. Complications for radical cystectomy: impact of the
American Society of Anesthesiologists score. Eur Urol 2001;39:
79–84.
[132] Rosario DJ, Becker M, Anderson JB. The changing pattern of
mortality and morbidity from radical cystectomy. BJU Int 2000;
85:427–30.
[133] Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K,
Mattes R, Paiss T. The ileal neobladder: complications and func-
tional results in 363 patients after 11 years of followup. J Urol
1999;161:422–7, discussion 427–8.
[134] Hautmann RE, Miller K, Steiner U, Wenderoth U. The ileal neo-
bladder: 6 years of experience with more than 200 patients. J Urol
1993;150:40–5.