title: Orthotopic neobladder following radical cystectomy in patients with high perioperative risk and co-morbid medical conditions.
abstract: OBJECTIVE
  A significant number of patients requiring radical cystectomy for bladder cancer have substantial co-morbidity. Nonetheless, these patients often prefer orthotopic neobladder reconstruction to avoid an abdominal stoma. We performed a retrospective study to determine perioperative morbidity in this group of patients.
  
  
  METHODS
  We used the American Society of Anesthesiologists physical status classification to assign perioperative risk. Of 250 patients undergoing orthotopic neobladder reconstruction after radical cystectomy during a 5-year period we identified 84 with an American Society of Anesthesiologists score of 3 or greater. Charts were available for review for all patients and none was lost to followup.
  
  
  RESULTS
  Median operative time (calculated from anesthesia ready time to completion of surgery and application of a dressing) was 256 minutes. In 14 patients (16.6%) transfusion of a median of 2 units of allogeneic blood was required. A total of 79 patients (94%) were transferred directly from the recovery room to the general urology floor without a need for postoperative cardiac monitoring. Median hospital stay was 7 days. One patient (1.1%) died on postopera-tive day 9 of a presumed pulmonary embolus after having been discharged home on postoperative day 6. Minor complications occurred in 16 patients (19%). Only 1 patient required a return to the operating room for endoscopic removal of a retained stent fragment.
  
  
  CONCLUSIONS
  In experienced hands radical cystectomy and orthotopic neobladder can be offered to patients with co-morbid conditions. Expeditious performance of the surgical procedure, minimization of blood loss, restricting the surgical incision to an infraumbilical location, and avoidance of intraoperative complications all contribute to decreasing morbidity and mortality. Although orthotopic reconstruction is more complex than performance of an ileal conduit, there is no apparent increase in perioperative morbidity or mortality. Therefore, orthotopic reconstruction can be offered to patients who want to avoid an abdominal stoma even in the face of significant co-morbid conditions.
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee, USA.
authors.forename: Dipen J
authors.initials: DJ
authors.lastname: Parekh
authors.forename: Travis
authors.initials: T
authors.lastname: Clark
authors.forename: Jeffrey
authors.initials: J
authors.lastname: O'Connor
authors.forename: Charlie
authors.initials: C
authors.lastname: Jung
authors.forename: Sam S
authors.initials: SS
authors.lastname: Chang
authors.forename: Michael
authors.initials: M
authors.lastname: Cookson
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Smith
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002278:Carcinoma in Situ / Q000601:surgery; D002295:Carcinoma, Transitional Cell / Q000601:surgery; D015897:Comorbidity; D015653:Cystectomy / Q000534:rehabilitation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D012307:Risk Factors; D001749:Urinary Bladder Neoplasms / Q000601:surgery*; D016476:Urinary Reservoirs, Continent