Predictors for Perioperative Blood Transfusion in Patients Undergoing Open Cystectomy and Urinary Diversion and Development of a Nomogram: An Observational Cohort Study

Abstract

Open radical cystectomy is associated with a substantial rate of perioperative blood transfusion. Early detection of potentially modifiable perioperative factors could reduce the need for perioperative blood transfusion and thus positively impact the outcome. We conducted an observational, single-center cohort study of 1168 patients undergoing cystectomy. Perioperative blood transfusion was defined as the need for packed red blood cells and/or fresh frozen plasma units within the first 24 h after the initiation of surgery. Multiple logistic regression analysis was performed to model the association between risk factors and blood transfusion, and a nomogram was developed. Blood transfusion occurred in 370/1168 patients (31.7%). Significant predictors were age (OR: 1.678, (95% CI: 1.379–2.042); p < 0.001), blood loss ratio (6.572, (4.878–8.853); p < 0.001), preoperative hemoglobin (0.316, (0.255–0.391); p < 0.001), tumor stage (2.067, (1.317–3.244); p = 0.002), use of oral anticoagulants (2.70, (1.163–6.270), p = 0.021), and interaction between female sex and blood loss ratio (1.344, (1.011–1.787); p = 0.042). Of the major predictors found to affect perioperative blood transfusion, two can be influenced: blood loss ratio by meticulous surgery and hemoglobin by preoperative optimization. Others such as age or advanced disease are not modifiable. This emphasizes the importance of optimal management of patients prior to surgery.

Perioperative Blood Transfusion Is Associated with Worse Survival in Patients Undergoing Radical Cystectomy after Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer

“…Female patients were more likely to require PBT in our series, which is consistent also with other cystectomy series [7,17]. This likely reflects anatomic differences.…”

“…This likely reflects anatomic differences. Advanced age is also a reproducible risk factor for needing PBT, as shown in our series and other reports [17]. All cases were performed in an open fashion in this series, but an increasing proportion of RC is being performed robotically today.…”

“…NAC adds one additional element to cause anemia in addition to patient-and disease-related factors that cause pre-operative anemia and intraoperative blood loss during cystectomy. It is expected that the additional anemia caused by NAC will increase the need for PBT [17]. We cannot draw any specific conclusions in this regard since the PBT rate in our series (64%) was similar to that reported in other studies in which patients had not received NAC [6,11].…”

Can we lower the rates of cystectomy complications by modifying risk factors? A review of the literature

“…Recently, there has been increasing interest in the role of anaemic status as a prognostic factor in surgical outcomes after RC. High circulating oxygen transport capacity has higher impact compared to other factors like duration of surgery, tumour stage, or oral anticoagulation for incidence of perioperative blood transfusion (PBT) [ 28 ]. A study by Pavone et al [ 29 ] showed that preoperative anaemia condition is very common in patients with MIBC and is proved to be a predictor of postoperative complications, but not of 90-day mortality.…”

Updates on enhanced recovery after surgery for radical cystectomy

“…Expectedly, preoperative anemia can be associated with increased PBT. 98 , 99 Thus, the effects of preoperative anemia on clinical outcomes have not been clearly delineated from those of PBT. Nevertheless, the correction of anemia, as highlighted in the 2013 ERAS guidelines, is an important component of medical optimization prior to surgery.…”