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Comparison of radical cystectomy in patients with and without prior pelvic irradiation
Spencer I. Kozinn, MD1, Niall J. Harty, MD1, Jessica M. DeLong, MD1, Yoojin Lee, MS, MPH2, Karim Hamawy, MD1, David Canes, MD1, Jason Gee, MD1, John A. Libertino, MD1, Andrea Sorcini, MD1, Alireza Moinzadeh, MD1.
1Lahey Clinic Medical Center, Burlington, MA, USA, 2Tufts Medical Center, Boston, MA, USA.

BACKGROUND: A portion of patients undergoing radical cystectomy (RC) at our institution have had prior pelvic radiation. We hypothesized that patients with prior pelvic radiation undergoing RC would have higher complication rates as compared to patients without prior pelvic radiation. In this study we assessed Clavien classification for complication rates and oncologic outcomes of patients undergoing radical cystectomy with and without prior pelvic radiation.
METHODS: We performed a retrospective review of all patients who underwent RC at our institution between January 2000 and January 2010. Patients were stratified into two groups, those having received pelvic radiation prior to surgery (RPS) and an age/stage-matched control group without prior pelvic irradiation. Patient demographics, perioperative data, and oncologic outcomes were recorded for all patients. Complications within 90 days of surgery were graded using the Clavien classification. Data were compared using Student’s T-test, Fisher’s exact test, and chi square test as appropriate. Group specific overall survival was determined using Kaplan-Meier analysis.
RESULTS: Five hundred and fifteen RC’s were performed over the 10-year period, of which 50 (9.7%) patients had received prior pelvic radiation (42 for prostate cancer, 4 for bladder cancer, and 4 for other malignancies). These 50 patients were compared to 50 age/stage matched controls. There were no demographic differences between the two groups (Table 1). There was no significant difference in preoperative T stage, with the majority of each group having T2 disease (60.0% vs. 61.2%, p=0.274). The RPS group, however, had a significantly higher requirement for blood transfusion, at a rate of 79% compared with 45% in the control group (p=0.001). Postoperative complications as classified by the Clavien system did not differ between the groups, with a rate of 86% in the RPS group vs. 81.6% in the controls (p=0.777) (Table 2). Final pathology revealed a trend towards a higher rate of T4 lesions in the RPS group (31.3% vs 16.3%), but this value was not statistically significant (p=0.08). Rates of progression to metastatic disease were equivalent (57.1% vs. 55.8%, p=1). There was no significant difference in overall survival rates (1061 and 737 days, p=0.89) at a median follow up of 19.6 and 23.9 months (Figure 1).
CONCLUSIONS: The majority of patients have a complication after RC. Prior pelvic radiation did not appear to significantly increase intraoperative or postoperative complication rates as graded by the Clavien classification system. Blood transfusion rate was higher in the radiated group as compared to the non-radiated group.

Demographic and Perioperative Data
Prior RadiationControlp-value
Mean age (years)72.1±1.869.1±1.20.082
BMI27.9±0.728.7±0.70.433
Charlson Comorbidity Index Score5.9±0.25.7±0.30.342
Mean operative time (mins)392±16376±130.448
EBL (mL)1160±1101101±960.691
Intraop complication rates10%12.2%0.722
Transfusion rate78.6%44.7%0.001
Length of stay (days)9.8±0.611.2±0.70.166
Readmission within 90 days34%27%0.419

Postoperative Complications
Clavien ClassificationPrior RadiationControl
014.0%18.4%
I10.0%16.3%
II38.0%34.7%
IIIa12.0%8.2%
IIIb8.0%8.2%
IVa14.0%10.2%
IVb4.0%2.0%
V0.0%2.0%


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