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Page 8 of 11 Cicione et al. Mini-invasive Surg 2021;5:47 https://dx.doi.org/10.20517/2574-1225.2021.52

Table 3. Studies on complications after salvage radical cystectomy
N of patients
Ref. Findings
undergone to SRC
[35]
Iwai et al. 87 40 Gy administered. Retrospective in nature comparing 87 SRC vs. 106 RC
Urinary anastomosis-related complications and major gastrointestinal complications, most of
which were Grade 3 ileus, were more frequent in the SRC respectively: 11% vs. 2%, P = 0.007
and 14% vs. 4%, P = 0.002
[5]
Eswara et al. 91 Induction RT dose 40 Gy + 25 Gy consolidation in case of positive initial response
Major complications, CCS ≥ 3, occurred in 15 patients (16%). The overall 90-day complication
rate was 69%. Perioperative mortality rate within 90 days was 2.2%
[36]
Eisenberg et al. 148 Radiotherapy by 70 Gy. 90-day overall complication rate was 77%. Among them, 44.6% were
low grade and 32.4% high-grade. The type of urinary diversion was not related to complication
occurence
Gontero et al. [37] 682 Retrospective in nature from SRCs carried out in 25 high volume centers (more than 30
procedures per year). Overall rate of complications was 75.1%; CCS ≥ 3 in 29.6% and CCS = 5
in 2.9% of patients. 27% of patients received RT for bladder cancer. Mean RT dose was 63 Gy
(51-70)
RC: Radical cystectomy; SRC: salvage radical cystectomy; RT: radiotherapy; CCS: Clavien Classification System.

Table 4. Reported range of complications graded by Clavien-Dindo System
Grade ≥ 3 Grade < 3
Infection (wound, urinary tract, others) 3-7 4-43
Gastrointestinal (ileus, bowel perforation) 8-14 10-17
Urinary anastomosis-related (leakage, stricture) 2-5 3-7

According to the authors, these complications would result, at least in part, from compromised blood
supply to the tissue because of previous RT. Most patients (84%) received an ileal conduit as a urinary
diversion, while the others received orthotopic ileal neobladder (6%), Indiana pouch (3%), or
ureterocutaneostomy (7%). When univariate analysis was carried out to identify risk factors associated with
urinary and bowel complications, the type of urinary diversions was not a predictor.

Eisenberg et al. reviewed clinical data of RCs performed in their tertiary referral care center. In 148
[36]
patients who underwent SRC, they computed a 32.4% rate of high-grade complications (CCS ≥ 3). Again,
ileal conduit was the most used urinary diversion (43.9%), and this was not related to the occurrence of
complications, while ASA score and patients age were predictors.

Finally, in the study by Eswara et al. , which included 192 SRCs, major complications, Grades 3-5, occurred
[5]
in 15 patients (16%) for a total of 23 events. The perioperative mortality rate within 90 days was 2.2%. Ileal
conduit was the only used urinary diversion. However, the main finding of their study was to stratify
complications occurrence by the date of SRC. Although there were no significant differences in the number
of total complications, tissue healing-related complications occurred nearly three times more frequently
(35% vs. 12%, P = 0.05) in the case of late SRC, namely disease recurrence after a mean of 10.3 months
(range 2.1-178 months) from TMT termination. This group of complications included wound infection,
ureteral stricture, anastomotic stricture, and stoma/loop requiring revision. Again, the authors explained
this finding by assuming the higher dose (mean 64.7 Gy vs. 39.9 Gy) of radiation received.

All these studies reported occurrence of urinary anastomosis-related complications and major
gastrointestinal complications more likely in the case of a previous radiotherapy that presumably caused an
endarteritis process with subsequent ischemia delaying wound healing .
[40]