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Cicione et al. Mini-invasive Surg 2021;5:47 https://dx.doi.org/10.20517/2574-1225.2021.52 Page 7 of 11

estimate the patient’s vulnerability to stress factors such as surgery. It has been recently developed in the
context of bladder cancer because of the patient’s median age at diagnosis, which makes the presence of
[28]
several comorbidities highly probable . Although a variety of methods are available to measure frailty, a
poor score has usually been associated with worse postoperative outcomes in patients who undergo urologic
surgery including RC .
[28]
When SRC is not possible due to the patient’s elevated frailty status or the patient’s refusal, several
alternatives to a radical treatment have been proposed.

Since 1960, low-dose RT has been adopted to control hematuria. Regarding treatment outcomes, at 2 weeks,
the rate of efficacy in arresting bladder bleedings has been reported as 60%-69%, while the risk of recurrence
at 6 months has been computed as 33%-69% [29-31] .

Selective angiography for bladder embolization showed a high success rate (82%-100%) with complete
cessation of hematuria within 48 h and a bleeding recurrence risk of 28%-50% within 16 months .
[32]
However, this option is not free from complications. Ischemic pain, bladder necrosis, bladder infarction,
and even inadvertent occlusion of uninvolved vessels by refluxed embolic material have been reported .
[33]

Finally, several endovesical agents have been used to stop bladder bleeding such as 1% silver nitrate or 1%-
2% alum and formalin (2.5%-4% for 30 min) with response rates of 71%-100% and 5%-100%, respectively.
However, the treatment lasted 1-5 days, and in all cases anesthesia was required.

Salvage radical cystectomy: morbidity and mortality
SRC is thought to be difficult because of previous radiotherapy. Pelvic RT results in tissue damage that can
also affect surrounding organs and lead to desmoplastic reaction, obliterating the tissue plane. This makes it
[34]
difficult to identify and dissect surgical structures .
By researching studies only using Clavien-Dindo system to grade complications, we found three single-
institution studies [5,35,36] which assessed complications of SRC after RT for MIBC and one multicenter
[37]
study where SRC was carried out after RT for further diseases [Tables 3 and 4].
Gontero et al. retrospectively analyzed data from 25 large-volume institutions, defined as more than 30
[37]
cystectomies per year. Although only 27% of patients previously received RT for bladder cancer, the authors
showed that the SRC is associated with a high risk of morbidity (75% risk of a single complication and a 33%
risk of a major complication) and a 3.1% mortality rate at 90 days after surgery. Only large-volume centers
participated in this study. Surgeon volume had a greater impact on outcomes in RC when compared with
other surgeries such as lung resection for cancer, abdominal aortic aneurysm repair, and coronary artery
[38]
bypass . Furthermore, it has been computed that more than 20 RCs per year positively affected the
complication rates when compared to a lower number .
[39]

Iwai et al. compared complication rates in patients with and without previous TMT using the
[35]
standardized Clavien-Dindo grade. Data analysis showed that previous chemoradiotherapy increases the
risk of urinary anastomosis-related complications (such as stricture and urinary leakage) and is associated
with gastrointestinal complications (such as bowel perforation and Grade 3 ileus).