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Neoadjuvant Chemotherapy and Perioperative Morbidity in Patients Undergoing Radical Cystectomy
Antonio Cusano, B.S., Peter Haddock, Ph.D., Ilene Staff, Ph.D., Peter Renehan, M.D., Fernando Abarzua-Cabezas, M.D., Jeffrey Kamradt, M.D., Joseph Wagner, M.D., Anoop Meraney, M.D..
Hartford Hospital, Hartford, CT, USA.

Objective: Neoadjuvant chemotherapy prior to radical cystectomy (RC) provides improved survival. This has been demonstrated in randomized control trials, and as a result neoadjuvant chemotherapy is considered the standard of care. Potential disadvantages of this approach, however, include a delay in definitive local therapy and exposing patients, many of whom have several preexisting comorbid conditions, to excessive levels of cytotoxic agents prior to surgery. In our current study, we assessed the relationship between chemotherapy exposure and perioperative morbidity and surgical outcomes at our large, urban clinical urology center.
Methods: We undertook a retrospective review of our IRB-approved database and identified 266 patients who underwent radical cystectomy (RC) between January 2003 and December 2013, for management of their bladder cancer. Patient demographics, pathologic stage, perioperative complications and their associated Clavien grading were assessed and compared in those who received RC alone versus those with RC following neoadjuvant chemotherapy. Statistical analysis was performed using MedCalc Version 12.7.7.0, and the level of significance was accepted to be p<0.05.
Results: Of the 266 patients initially identified as having received RC, 241 had complete data that included demographics, perioperative morbidity and complications, as well as long-term follow-up. Patients were stratified based on whether they received open or robotic surgery. For open RC, the mean age, mean Charlson Comorbidity Index (CCI) score, and median length of stay for patients with or without neoadjuvant therapy were 66.5±75.5 and 68.9±10.3 years; 3.8±1.5 and 4.3±1.9; and 9.0±3.3 and 9.0±8.9, respectively. There was no difference in rates of perioperative complications between the two groups (p=0.878). A qualitatively similar pattern was observed between minor (Clavien 1-2) complication rates (p=0.943) and major (Clavien 3-5) complication rates(p=0.427). For robotic RC with and without neoadjuvant chemotherapy, the mean age, mean CCI score, and median length of stay were 63.1±9.10 and 67.9±10.6 years; 3.5±1.4 and 4.3±1.8; and 8.0±8.2 and 8.0±8.8 days, respectively. There was no statistical difference between overall complication rates (p= 0.067), or between the incidence of minor (p=0.704) and major (p=0.879) complication rates within both groups.
Conclusions: Our data suggests that patients are not at an elevated risk for perioperative complications and higher morbidity when using neoadjuvant chemotherapy prior to RC.
Neoadjuvant chemotherapy versus Perioperative Complications: Open Radical Cystectomy
Open RC AloneOpen RC + NeoaduvantP-Value
No. of Patients8825-
Mean Age: Years (Range)68.9±10.3 (38-84)66.5±75.5 (50-79)0.35
Mean CCI (Range)4.3±1.9 (0-10)3.8±1.5 (1-7)0.383
Median LOS: Days (Range)9.0±8.9 (4-56)9.0±3.3 (4-17)0.207
No. of Complications113120.878
Minor Complications (Clavien 1-2)
(n; % of all complications)
84 (74.3)9 (75)0.943
Major Complications (Clavien 3-5)
(n; % of all complications)
29 (25.7)3 (25)0.427

Neoadjuvant chemotherapy versus Perioperative Complications: Robotic Radical Cystectomy
Robotic RC AloneRobotic RC + NeoadjuvantP-Value
No. of Patients8939-
Mean Age: Years (Range)67.9±10.6 (38-86)63.1±9.1 (43-78)0.029
Mean CCI (Range)4.3±1.8 (0-9)3.5±1.4 (1-7)0.035
Median LOS: Days(Range)8.0±8.8 (5-49)8.0±8.2 (5-52)0.91
No. of Complications77280.067
Minor Complications (Clavien 1-2)
(n; % of all complications)
52 (67.5)21 (75)0.704
Major Complications (Clavien 3-5)
(n; % of all complications)
25 (32.5)7 (25)0.879


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