Introduction:
Open radical cystectomy (ORC) is associated with significant amount of blood loss (600-1000ml) and also a high incidence of perioperative blood transfusions of around 30%. Strategies to decrease the amount of blood loss are thus needed to improve the perioperative outcome following this procedure. We evaluated the efficacy of a novel intraoperative strategy of using topical norepinephrine, tranexamic acid and endo cutter staplers for reducing blood loss in patients undergoing open radical cystectomy.
Methods:
We performed a prospective non randomized control trial with 50 subjects of urothelial carcinoma bladder who underwent open radical cystectomy at our center. The interventional arm included 25 patients wherein intra operatively topical norepinephrine and tranexamic acid soaked gauze pieces along with endo cutter staplers for controlling posterolateral vascular pedicles were used. The control arm included 25 patients of ORC without the use of above mentioned intraoperative adjuncts. Evaluation of blood loss was done by measuring intraoperative blood loss, fall in hematocrit at 36 hours post op and number of perioperative blood transfusions needed before discharge.
Results:
The baseline demographic data was comparable in both the arms (Table 1). The mean intraoperative blood loss in intervention arm was significantly lesser than the control arm (282.00±121.74 ml vs 502.00±184.54 ml; p < 0.001). Similarly, the mean fall in hematocrit was also significantly less in the intervention arm as compared to the control arm (4.81±2.91% vs 7.56±3.27%; p 0.003). The mean number of total blood units transfused in intervention and control arms were 0.24±0.52 and 1.32 ±0.94 respectively (p 0.000). Even the mean operative times (2.89±0.604 hours vs 5.36±1.295 hours; p 0.000) and postoperative hospital stay (10.16±2.39 days vs 18.32±8.38 days; p 0.000) was significantly less in the intervention arm (Table 2). No untoward side effects were observed related to the use of above agents intra operatively.
Conclusion:
Intraoperative use of topical norepinephrine, topical tranexamic acid and endocutter staplers during ORC results in significant reduction in intraoperative blood loss and the need for blood transfusion. This strategy helps in reducing operative time and also enhances postoperative recovery.
S No
|
Variable
|
Interventional arm (n=25)
|
Control arm
(n=25)
|
P value
|
1.
|
Mean Age (years)
|
58.96±9.51
|
58.12±12.46
|
0.790
|
2.
|
Sex
Males
Females
|
22 (88%)
3 (12%)
|
23 (92%)
2 (8%)
|
0.637
|
3.
|
Comorbidities
Diabetes Mellitus
Hypertension
|
4 (16%)
4 (16%)
|
5 (20%)
2 (8%)
|
0.713
0.384
|
4.
|
Neoadjuvant Chemothearpy
Given
Not Given
|
7 (28%)
18 (72%)
|
7 (28%)
18 (72%)
|
1.000
|
5.
|
Histopathology
T Stage
NMIBC
Ta
T0
T1
MIBC
T2a
T2b
T3a
T3b
T4a
T4b
N Stage
N0
N1
N2
N3
|
0 (0%)
0 (0%)
4 (16%)
1 (4%)
13 (52%)
1 (4%)
2 (8%)
3 (12%)
1 (4%)
23 (92%)
1 (4%)
0 (0%)
1 (4%)
|
0 (0%)
0 (0%)
6 (24%)
2 (8%)
13 (52%)
2 (8%)
2 (8%)
0 (0%)
0 (0%)
22 (88%)
3 (12%)
0 (0%)
0 (0%)
|
0.535
0.637
0.466
|
Table 1: Baseline demographic data in both the arms; NMIBC- Non muscle invasive bladder cancer; MIBC- Muscle invasive bladder cancer
1.
|
Mean OT Time (Hours)
|
2.89±0.604
|
5.36±1.295
|
0.000
|
2.
|
Mean Intraoperative Blood Loss (ml)
|
282.00±121.749
|
502.00±184.549
|
0.000
|
3.
|
Mean Fall In Hematocrit (%)
|
4.81±2.91
|
7.56±3.27
|
0.003
|
4.
|
Mean no. Of Blood Units Transfused
Intra-op
Post-op
Total
|
0.16±0.374
0.08±0.277
0.24±0.522
|
0.76±0.663
0.56±0.651
1.32±0.945
|
0.000
0.002
0.000
|
5.
|
Mean postoperative hospital stay (days)
|
10.16±2.392
|
18.32±8.380
|
0.000
|
Table 2: Comparative data on various perioperative parameters in both the arms