Urology

Background: Open radical cystectomy (ORC) is associated with substantial blood loss and a high incidence of perioperative blood transfusions. Strategies to reduce blood loss and blood transfusion are warranted. Objective: To determine whether continuous norepinephrine administration combined with intraoperative restrictive hydration with Ringer's maleate solution can reduce blood loss and the need for blood transfusion. Design, setting, and participants: This was a double-blind, randomised, parallel-group, single-centre trial including 166 consecutive patients undergoing ORC with urinary diversion (UD). Exclusion criteria were severe hepatic or renal dysfunction, congestive heart failure, and contraindications to epidural analgesia. Intervention: Patients were randomly allocated to continuous norepinephrine administration starting with 2 mg/kg per hour combined with 1 ml/kg per hour until the bladder was removed, then to 3 ml/kg per hour of Ringer's maleate solution (norepinephrine/low-volume group) or 6 ml/kg per hour of Ringer's maleate solution throughout surgery (control group). Outcome measurements and statistical analysis: Intraoperative blood loss and the percentage of patients requiring blood transfusions perioperatively were assessed. Data were analysed using nonparametric statistical models. Results and limitations: Total median blood loss was 800 ml (range: 300-1700) in the norepinephrine/low-volume group versus 1200 ml (range: 400-2800) in the control group ( p < 0.0001). In the norepinephrine/low-volume group, 27 of 83 patients (33%) required an average of 1.8 U (AE0.8) of packed red blood cells (PRBCs). In the control group, 50 of 83 patients (60%) required an average of 2.9 U (AE2.1) of PRBCs during hospitalisation (relative risk: 0.54; 95% confidence interval [CI], 0.38-0.77; p = 0.0006). The absolute reduction in transfusion rate throughout hospitalisation was 28% (95% CI, 12-45). In this study, surgery was performed by three high-volume surgeons using a standardised technique, so whether these significant results are reproducible in other centres needs to be shown. Conclusions: Continuous norepinephrine administration combined with restrictive hydration significantly reduces intraoperative blood loss, the rate of blood transfusions, and the number of PRBC units required per patient undergoing ORC with UD.

We prospectively assessed the role of nerve sparing surgery on urinary continence after open radical retropubic prostatectomy. Materials and Methods: We evaluated a consecutive series of 536 patients who underwent open radical retropubic prostatectomy with attempted bilateral, unilateral or no nerve sparing, as defined by the surgeon, without prior radiotherapy at a minimum followup of 1 year with documented assessment of urinary continence status. Because outlet obstruction may influence continence rates, its incidence and management was also evaluated. Results: One year after surgery 505 of 536 patients (94.2%) were continent, 27 (5%) had grade I stress incontinence and 4 (0.8%) had grade II stress incontinence. Incontinence was found in 1 of 75 (1.3%), 11 of 322 (3.4%) and 19 of 139 patients (13.7%) with attempted bilateral, attempted unilateral and without attempted nerve sparing, respectively. The proportional differences were highly significant, favoring a nerve sparing technique (p Ͻ0.0001). On multiple logistic regression analysis attempted nerve sparing was the only statistically significant factor influencing urinary continence after open radical retropubic prostatectomy (OR 4.77, 95% CI 2.18 to 10.44, p ϭ 0.0001). Outlet obstruction at the anastomotic site in 33 of the 536 men (6.2%) developed at a median of 8 weeks (IQR 4 to 12) and was managed by dilation or an endoscopic procedure. Conclusions: The incidence of incontinence after open radical retropubic prostatectomy is low and continence is highly associated with a nerve sparing technique. Therefore, nerve sparing should be attempted in all patients if the principles of oncological surgery are not compromised.