Towards bloodless cystectomy: a 10‐year experience of intra‐operative cell salvage during radical cystectomy

Abstract

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Guidance from the UK National Institute for Health and Clinical Excellence (NICE) on the use of intraoperative cell savage (ICS) has been in place for over 3 years and recommends its routine usage in all patients undergoing radical pelvic urological surgery. The current series describes the contribution of ICS to contemporary blood conservation strategies and the goal of ‘bloodless’ cystectomy. OBJECTIVE To describe a 10‐year experience of intra‐operative cell salvage (ICS) during radical cystectomy at a regional cancer centre. PATIENTS AND METHODS Between 1st January 2001 and 31st December 2010, 213 consecutive patients underwent radical cystectomy and pelvic lymphadenectomy for bladder cancer, with an ICS suction device used in theatre. Surgery was performed by one of three consultant surgeons using an open technique with lymph node clearance to the iliac bifurcation. Orthotopic bladder substitution was performed in 25% of patients overall. ICS data were collected prospectively on an electronic database and the institutional database was then cross‐referenced with a complete review of patients' medical records, laboratory results and radiological investigations retrospectively. Data collected included patient demographics, haemoglobin levels before and after surgery, the volume of ICS blood collected and re‐infused, complications related to ICS usage, the volume of allogeneic red blood cells (RBCs) transfused, length of stay and overall patient survival at 3 and 5 years after surgery. RESULTS In all 213 cases described, ICS was used without complication, with no recorded episodes of device failure and no complications related to the use of cell salvage. Overall, 91% of patients received ICS blood and 28% of patients avoided any further transfusion products. The median (range) follow‐up for the cohort was 24 (9–119) months. Seventy percent of the transfusion requirement for patients who underwent surgery in 2001 was met using allogeneic RBC transfusion but by 2010, as blood loss markedly reduced, ICS blood was able to provide ∼70% of overall transfusion requirements. As a consequence, the percentage of patients avoiding an allogeneic RBC transfusion significantly increased during the 10‐year period, such that 70% of patients avoided allogeneic RBC transfusion in 2010 compared with only 10–20% in the period 2001–2003 The overall survival rate at 3 and 5 years was 58% and 49%, respectively. CONCLUSIONS In conclusion, the use of ICS during radical cystectomy is safe; it is capable of meeting the majority of or, in some cases, the total blood product requirement for individual patients. As a result, it decreases the need for allogeneic RBC transfusion and hence the associated risks. Current follow‐up shows no apparent risk of decreased long‐term survival from an oncological perspective. The authors advocate routine availability of ICS for all major urological oncology cases.

Management of severe perioperative bleeding

“…185 More recent non-randomised studies in urological cancer surgery and metastatic spinal surgery have shown ICS to decrease the need for allogeneic RBC transfusion with no apparent risk of decreased long-term survival from an oncological perspective. [186][187][188] Contamination of the surgical field (e.g. bowel surgery, penetrating abdominal trauma or infected wounds) has typically been considered as a contraindication for ICS.…”

Effect of Intraoperative Red Blood Cell Transfusion on Postoperative Complications After Open Radical Cystectomy: Old Versus Fresh Stored Blood

“…24 Therefore, it is reasonable to decrease the number of intraoperative blood transfusions. Various strategies, such as a combining epidural with general anesthesia, 25 new technical apparatuses for hemostasis, 26,27 autotransfusion using intraoperative cell salvage, 28 and meticulous surgical performance may help reduce blood loss, the need for …”

Implementation of the Exeter Enhanced Recovery Programme for patients undergoing radical cystectomy

“…This technique allows the patient's own blood, which is otherwise discarded, to be collected intraoperatively and then re‐infused as washed red blood cells. The aim is to reduce the need for allogenic blood transfusion and thereby reduce the associated risks as described in our earlier publication .…”