Predictors of postoperative complications of radical cystectomy

Radical cystectomy (RCC) is the standard treatment for muscle-invasive bladder cancer (BCC). In addition, RCE is performed for muscle-noninvasive bladder cancer with a high risk of progression and for other tumors of the pelvic organs with invasion of the bladder [1–4].

Improvements in the surgical technique of RCE and methods of perioperative management of patients have manifested themselves in a significant improvement in the results of radical cystectomy [5]. However, the proportion of complications associated with this operation still remains high - more than 64% [6], with the proportion of severe complications reaching 41% [7] and mortality -1.6-3.9% [7,8]. According to various authors [7, 9—12], the most common categories of complications are gastrointestinal (22.7%) and infectious (33%), which in most cases are the cause of repeated hospitalizations. In this regard, research in the field of etiology and pathogenesis of complications of RCE and the search for effective ways to prevent them are relevant.

The purpose of the study was to study the structure and frequency of early 30-day complications of RCE and to determine the most significant predictors influencing their development.

Material and methods

This study is based on an analysis of the results of treatment of 182 patients (152 (83.5%) men and 30 (16.5%) women, the age of the patients ranged from 31 to 84 years (mean age 62.3±0.7 years), underwent RCE from September 2014 to December 2021. All operations were performed at the Privolzhsky District Medical Center of the Federal Medical and Biological Agency of Russia by one team of surgeons (Fig. 1).

Rice. 1. Distribution of patients by age. The indication for RCE in 169 (92.9%) cases was bladder cancer: muscle-noninvasive in 38, muscle-invasive in 131 (T2a - 33 (18.1%), T2b - 42 (23.1%), T3a - 11 (6%), T3b - 16 (8.8%), T4a - 29 (16%)), other pelvic tumors in 9 (4.9%), microcystis in 4 (2.2%). 36 (19.8%) patients had primary multiple cancer. Locally advanced bladder cancer was detected in 38 (20.9%) cases, metastatic lesions of the lymph nodes were detected in 39 (21.4%).

At the time of hospitalization, 172 patients had complications of bladder cancer of various categories: gross hematuria - 84.6%, anemia - 21.4%, ureterohydronephrosis - 22.4%. Due to the predominance of patients in the older age group, the proportion of comorbidities associated with age was quite high. The most common diseases were diseases of the cardiovascular system - 69.8%, gastrointestinal tract - 34%, chronic obstructive pulmonary disease - 18.1%, obesity - 24.7%, diabetes mellitus - 13.7%.

Antibiotic prophylaxis (ABP) was carried out 30-60 minutes before surgery. When choosing an antibiotic, we were guided by risk factors for the development of infectious complications, epidemiological data on the resistance of microorganisms in the hospital, the results of bacteriological urine cultures, anamnestic data on previous infection and therapy, individual patient tolerance of the drug and the availability of a particular drug in the clinic. Depending on the drug used for ALD, three groups were formed (Table 1).

Table 1. Characteristics of patients in the study groups Group 1 included 82 patients who received protected penicillins (amoxicillin clavulanate or amoxicillin sulbactam), group 2 included 62 patients who were prescribed 3rd generation fluoroquinolones (levofloxacin) , group 3 included 33 patients who received carbapenems.
The remaining 6 patients received protected 3rd generation cephalosporins (cefoperazonesulbactam). Due to the small sample, we believe it is necessary to analyze a larger number of patients receiving protected 3rd generation cephalosporins to obtain more accurate data. The majority of patients in all three groups were men. The main indication for surgery was bladder cancer. In terms of body mass index ( p
= 0.657), type of urine diversion (
p
= 0.802), and comorbidity index (
p
= 0.761), the groups were equivalent.

The stages of the operation included extended lymphadenectomy, standard stages of radical cystectomy, anterior or total pelvic evisceration, depending on the gender of the patient and the extent of the tumor. The next stage of the operation was the implementation of the most favorable method of urine diversion for the patient, depending on the clinical situation. In the majority of patients, in 138 (75.8%) cases, a more complex orthotopic reconstruction of the bladder was performed, in 38 (20.9%) cases, Bricker surgery was performed, other methods of derivation accounted for 6 (3.3%) cases.

After completion of the main stages of the operation, the abdominal cavity was washed with sterile liquid to evacuate blood clots and fragments of adipose tissue. In this case, lavage fluid was collected from the abdominal cavity twice for microbiological analysis (before and after lavage). To collect the material, a sealed sterile set of a plastic probe with a cotton swab at the end was used, which was subsequently placed in a test tube with ready-to-use Amies medium with charcoal. Next, the abdominal cavity was drained with two drains. The abdominal wall wound was sutured layer by layer, and in case of deficiency of abdominal wall tissue and in obese patients, the anterior abdominal wall was strengthened with a synthetic mesh implant [13].

To analyze and stratify surgical complications, the classification of surgical complications according to the Clavien-Dindo system was used [14]. Statistical analysis of the material was carried out on a personal computer using the IBM SPSS Statistics Version 14.0.1 license package (license S1401CDL-0306R). The Kruskal-Wallace method was used to calculate equality of data between groups. Subsequently, if there was a statistically significant difference, the groups were compared in pairs, for this purpose contingency tables were used, Pearson's test of goodness of fit χ2 and χ2 were calculated with Yates' correction for four-field tables with the number of observations in individual cells less than 10 and using the Mann-Whitney test. For statistical analysis of qualitative characteristics expressed in the ranking scale, the method of calculating the correlation coefficient and 95% confidence intervals according to Spearman was used.

Magazine archive /
2018 /

Intraoperative complications of radical cystectomy with various options for urine diversion

DOI: https://dx.doi.org/10.18565/urology.2018.4.102-105

T.N. Musaev, F.A. Guliyev
National Oncology Center; Azerbaijan, Baku

Goal of the work. To study the frequency, nature and risk factors for the development of intraoperative complications in patients with bladder cancer who underwent radical cystectomy with various options for urinary diversion. Materials and methods. The study included 257 patients who underwent radical cystectomy. Of these, 241 (93.8%) were men, 16 (6.2%) were women. The average age of the patients was 58.5 (37–81) years. The volume of intraoperative blood loss, the frequency of injuries to blood vessels, the rectum and the obturator nerve, the duration of surgery, the average volume of blood loss and blood transfusion were assessed depending on the method of urinary diversion and removal of the bladder, the nature of the operations, the stage of the tumor process - pT and pN, mass index body, as well as the total number of radical cystectomies performed by the surgical team. Results. Intraoperative mortality was 0.4%. Intraoperative complications were recorded in 34 (13.2%) patients. The average volume of blood loss was 597 (100–2500) ml, the average volume of intra- and perioperative blood transfusion was 950 and 310 ml, respectively. Statistically significant predictors of intraoperative blood loss were body mass index (p=0.001), surgeon experience (p=0.004) and the presence of metastatic lymph nodes - N+ (p=0.033). A significant factor influencing the incidence of rectal injuries is the stage of the disease pT4 (p = 0.028). Analysis of the frequency of obturator nerve injuries from the above factors did not show a statistically significant difference (p>0.05). Conclusion. Patients with locally advanced bladder cancer and a high body mass index should be operated on by highly qualified surgeons with experience in performing at least 50 radical cystectomies per year.

Key words: rectal trauma, intraoperative complications, radical cystectomy

The full text of the article is available in the Doctor's Library

Literature

1. Witijes J., Comperat E., Cowan N. et al. Muscle invasive and metastatic bladder cancer. EAU Guidelines. 2021.

2. Veliev EI, Loran OB The problem of urinary diversion after radical cystectomy and modern approaches to its resolution. Prakticheskaja onkologija. 2003;4:231–234. Russian (Veliev E.I., Laurent O.B. The problem of urinary diversion after radical cystectomy and modern approaches to its solution. Practical Oncology. 2003;4:231–234).

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4. Krasnyi SA Sukonko OG, Polyakov SL An original technique for the formation of a continent heterotopic reservoir after cystectomy. Reset. 2005;3:88–89. Russian (Krasny S.A. Sukonko O.G., Polyakov S.L. Original method of forming a continental heterotopic reservoir after cystectomy. Recipe. 2005;3:88–89).

5. Managadze LG, Rodionov. A., Gotsadze D. Methods of retropubic urinary diversion and cystoplasty. Urology and nephrology. Urologiya and nephrologiya. 1994;3:45–49. Russian (Managadze L.G., Rodionov A., Gotsadze D. Methods of supravesical urine diversion and cystoplasty. Urology and Nephrology. 1994;3:45–49).

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7. Lawrentschuk N., Colombo R., Hakenberg OW, Lerner SP, Månsson W., Sagalowsky A., Wirth MP Prevention and Management of Complications following Radical Cystectomy for Bladder Cancer. Eur Urol. 2010;57:991–1001.

8. Chang S., Smith J., Cookson M. Decreasing blood loss in patients treated with radical cystectomy: a prospective randomizes trial using a new stapling device. J Urol. 2003;169:951–954.

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12. Shabsigh A., Korets R., Vora KC, Brooks CM, Cronin AM, Savage C., Raj G., Bochner BH, Dalbagni G., Herr HW, Donat SM Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol. 2009;55:164–176.

13. Novara G., De Marco V., Aragona M., Boscolo-Berto R., Cavalleri S., Artibani W., Ficarra V. Complications and mortality after radical cystectomy for bladder transitional cell cancer. J Urol. 2009;182(3):914–921.

14. Boström PJ, Kössi J., Laato M., Nurmi M. Risk factors for mortality and morbidity related to radical cystectomy. BJU Int. 2009;103(2):191–196.

15. Lowrance WT, Rumohr JA, Chang SS, Clark PE, Smith JA Jr, Cookson MS Contemporary open radical cystectomy: analysis of perioperative outcomes. J Urol. 2008;179(4):1313–1318.

16. Cochetti G., Barillaro F., Boni A. Immediate Radical Cystectomy for Massive Bleeding of Bladder Cancer. J. Biomed Res Int. 2015;2015:154392.

17. Lee C., Dunn L., Chen B. Impact of body mass index on radical cystectomy. J Urol. 2004;172:1281–1285.

18. Hendrickson J., Hillyer C. Noninfectious serious hazards of transfusion. Anesth Analg. 2009;108:759–769.

19. Nosov A., Reva S., Dzhalilov I., Petrov S. Radical cystectomy in bladder cancer: comparison of early surgical complications in laparoscopic, open and video-assisted surgery. Onkourologiya. 2015;3:71–78. Russian (Nosov A., Reva S., Jalilov I., Petrov S. Radical cystectomy for bladder cancer: comparison of early surgical complications in laparoscopic, open and video-assisted surgery. Oncourology. 2015;3:71–78).

20. Huang J., Lin T., Liu H. et al. Laparoscopic radical cystectomy with orthotopoic ileal neobladder for bladder cancer: oncologic result of 171 cases with a median 3-year follow-up. Eur Urol 2010;58(3):442–449.

21. Ng CK, Kauffman EC, Lee MM, Otto BJ, Portnoff A., Ehrlich JR, Schwartz MJ, Wang GJ, Scherr DS A comparison of postoperative complications in open versus robotic cystectomy. Eur Urol. 2010;57(2):274–281.

22. Redondo C., Rozet F., Velilla G. Complications of radical prostatectomy. J.Arch. Esp. Urol. 2017;70(9):766–776.

23. Takenaka A., Leung RA, Fujisawa M., Tewari AK Anatomy of autonomic nerve component in the male pelvis: the new concept from a perspective for robotic nerve sparing radical prostatectomy. World J Urol. 2006;24:136–143.

24. Shabsigh A., Korets R., Vora KC et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol. 2009;55:164–176.

25. Castillo OA, Peacock L., Vitagliano G., Pinto I., Portalier P. Laparoscopic repair of an iliac artery injury during radical cystoprostatectomy. J. Surg. Laparosc. Endosc. Percutan. Tech. 2008;18(3):315–318.

26. Kozminski M., Konnak J., Grossman H. Management of rectal injuries during radical cystectomy. J Urol. 1989;142(5):1204–1205.

27. Zhvania G., Mshvildadze Sh., Managadze G. Results of radical cystectomy with Mainz pouch II diversion (single institution experience). Georgian Med News. 2012;211:7–13.

28. Sugihara T., Yasunaga H., Horiguchi H., Matsuda S., Fushimi K., Kattan MW, Homma Y. Does mechanical bowel preparation ameliorate damage from rectal injury in radicalprostatectomy? Analysis of 151 rectal injury cases. Int. J. Urol. 2014;21(6):566–570.

29. Castiñeiras Fernández J., Martínez A., Romero A., Moyano JL, Paublete MC, García Cabanillas MJ, Juárez A. Rectal injury during radical surgery of bladder and/or prostate. J Actas Urol Esp 1998;22(7):571–574.

About the authors / For correspondence

AUTHORIZATION: T. N. Musaev – candidate of medical sciences, oncologist of the department of oncourology of the National Oncology Center of the Ministry of Health of the Azerbaijan Republic, Baku, Azerbaijan; e-mail

results

According to the results of microbiological analysis, in 69 (41.8%) patients, various multidrug-resistant microflora were identified in preoperative urine cultures (Fig. 2).

Rice.
2. Microflora in preoperative urine cultures. The most common causative agents of urinary tract infections were Enterococcus
spp. - 28.9%,
Escherichia coli
- 27.5%,
Klebsiella
spp.
– 20.3%. Moreover, in 10.1% of cases, the identified microorganisms produced extended spectrum beta-lactamases. In addition, Pseudomonas aeruginosa
. Multidrug-resistant nosocomial infection was recorded in patients who had previously been operated on and were repeatedly hospitalized in various hospitals and who received various antibacterial drugs for a long time. Quite often, in this category of patients, microflora was cultured that remained sensitive only to reserve antibiotics, which created difficulties in choosing an antibiotic for ALD.

When inoculating lavage fluid from the abdominal cavity, various types of microorganisms were identified in 99 (54.4%) patients (Fig. 3),

Rice.
3. Microflora in cultures of fluid from the abdominal cavity. the most common were Escherichia coli
- 42.4%,
Enterobacter
spp.
— 21.2%, Enterococcus
spp.
- 26.3%. Washing the abdominal cavity at the end of the operation significantly reduced the titer of microbial contamination in 46 (45.1%) of 102 infected patients ( t
= 3.975;
p
< 0.001). Thus, bacteriological monitoring data demonstrated a high level of infection in both preoperative urine (41.8%) and the abdominal cavity (54.4%).

The high perioperative infection of patients is additional confirmation of the fact that RCE refers to contaminated and “dirty” operations. Therefore, the prescription of antibiotics should be regarded not as prevention, but as therapy and carried out with broad-spectrum antibacterial drugs, in accordance with the principles of rational antibiotic therapy.

Analysis of the reasons for the development of 30-day complications of RCE

There were no complications recorded in 84 (46.2%) patients after RCE. In the remaining 98 (53.8%) patients, undesirable deviations of varying severity were recorded in the postoperative period (Table 2).

Table 2. 30-day complications of RCE (total 182 patients; there were 98 patients with complications; a total of 148 complications) In 7.4% of cases, grade I complications were identified, which did not require any additional treatment. The most common complications were grade II - 64.9%. To correct this category of complications, additional drug therapy was necessary. Grade III complications requiring surgical intervention amounted to 20.2%: 8.1% under local anesthesia (IIIa), 12.1% under general anesthesia (IIIb). Life-threatening complications of grade IV, which required transfer of the patient to the intensive care unit, developed in 5.4%. Complications of grade V, which caused deaths, amounted to 2% (in the structure of complications). The cause of death in 2 cases was pulmonary embolism and in 1 case - acute infarction complicated by cardiogenic shock; The 30-day postoperative mortality rate was 1.64%. Thus, among the complications of RCE, the most common were complications of degrees I-II - 72.3%, and severe conditions amounted to 27.6%.

Gastrointestinal and infectious complications prevailed in the structure of complications (Table 3).

Table 3. Categories and types of complications of radical cystectomy

To search for the most significant predictors of the development of complications within 30 days after surgery, single- and multivariate regression analyzes were performed (Tables 4, 5).

Table 4. Predictors of complications (univariate analysis)

Table 5. Predictors of complications (multivariate analysis) Multivariate analysis found that the most significant independent predictors influencing the incidence of complications after RCE are low body mass index (
p
= 0.008), anemia before surgery (Hb less than 90 g/l) (
p
=0.034), degree of blood loss (more than 600 ml) (
p
=0.003) and infection of the abdominal cavity (
p
<0.001).
It was also found that predictors influencing the development of severe Clavien-Dindo grade III-V complications are preoperative hemoglobin level less than 90 g/l ( p
= 0.021), degree of intraoperative blood loss more than 600 ml (
p
= 0.019) and intra-abdominal titer infection (
p
=0.007).

When conducting a correlation analysis, a statistically significant correlation was revealed between the number of species sown from the washout before sanitation of microbes (mixed infection) and the severity of the developed complication (Spearman correlation 0.216, p

=0.001), i.e., the presence of two or more strains in the patient’s abdominal fluid is an independent predictor of the development of complications in the postoperative period.
Moreover, in a categorical analysis, the development of complications in patients who have a “positive” wash with one strain is 2.4 times more ( p
= 0.007), and in patients with mixed infection is 3.5 times more (
p
= 0.026) compared with patients whose washes were sterile (
p
= 0.007).

When comparing the titer of microbes taken intraoperatively from the abdominal cavity before and after sanitation, it was revealed that the titer of microbes after sanitation decreased statistically significantly ( t

=3,975;
R
<0,001).

In the present study, the most common categories of complications were gastrointestinal and infectious. Taking this fact into account, we searched for predictors influencing their development. The incidence of gastrostasis and intestinal paresis is influenced by male gender ( p

=0.019) and infection of the abdominal cavity (
p
=0.004). Men developed intestinal paresis 5.9 times more often than women (OR=5.888). The development of intestinal paresis in patients with a “positive” abdominal wash is almost 3 times higher compared to patients whose washes were sterile (OR = 2.960).

The incidence of infectious complications is influenced by infection of the abdominal cavity ( p

=0.004).
The duration of anesthesia ( p
= 0.059) and surgery (
p
= 0.056) tends to develop infectious complications.
Interestingly, urine infection did not predict infectious complications ( p
= 0.134). This is explained by the fact that perioperative ABP was carried out according to urine cultures, promoting the etiotropic elimination of bacteria.

Taking into account the role of infection in the development of complications, we assessed the influence of the type of ALD on the development of complications in the 30-day period after RCE by comparing the groups with each other both in the frequency and severity of the onset of complications. When comparing all three groups with each other, significant differences were revealed in the incidence of complications ( p

=0.043).
In the groups receiving protected penicillins and fluoroquinolones, various complications were identified in patients in 59.8 and 58.1% of cases, respectively. In the carbapenem group, the incidence of complications was almost 2 times lower than in other groups and amounted to 31.3%. Comparison of the groups also revealed significant differences in the severity of complications that developed depending on the type of perioperative ABP performed ( p
= 0.009). In the group of patients receiving carbapenems (OR=0.306), complications of a more severe category developed 3 times less frequently than in the groups of patients receiving protected penicillins (OR=1) and 3rd generation fluoroquinolones (OR=0.932).

We analyzed the immediate clinical results of radical cystectomy in groups (Table 6).

Table 6. Results of radical cystectomy in groups The group of patients receiving carbapenems had the highest level of infection before surgery. As a rule, these were previously operated patients who were repeatedly hospitalized in various hospitals and received various antibacterial drugs for a long time. In this category of patients, multidrug-resistant microflora was cultured, which remained sensitive only to reserve antibiotics. The percentage of patients with “positive” cultures from the abdominal cavity in all three groups was almost the same. Complete restoration of gastrointestinal function occurred more quickly in patients receiving carbapenems. Long-term gastrostasis and intestinal paresis developed in 1/3 of patients from the groups of protected penicillins and fluoroquinolones. In the carbapenem group, paresis developed 5 times less often than in other groups. Moreover, in all cases of patients receiving carbapenems, paresis was managed conservatively. Severe Clavien-Dindo grade III-V complications were recorded in patients receiving protected penicillins and 3rd generation fluoroquinolones. Also in these groups there was a need to perform repeated operations. In the group of patients receiving carbapenems, the postoperative period was more favorable, without severe complications and reoperations. In the early stages after surgery, in the groups of protected penicillins (40.2%), 3rd generation fluoroquinolones (32.2%), there was often a need to change the antibiotic due to its clinical ineffectiveness.

Laparoscopic cystectomy

lasts

40,000 rubles.

Description of the operation: Laparoscopic cystectomy

Laparoscopic cystectomy is the removal of an ovarian cyst.

The operation is performed through four punctures (one in the navel and three in the lower abdomen).

The ovary is dissected over the cyst. All benign ovarian cysts have a clear capsule; the border between healthy ovarian tissue and the cyst capsule is clearly visible.

The ovarian cyst is desquamated (separated from healthy ovarian tissue). Bleeding from the cyst bed is stopped by coagulation of the bleeding vessels.

The cyst is removed from the abdominal cavity using a special plastic container.

Preparing for surgery

Before hospitalization, the patient must undergo a standard examination. If there are concomitant diseases that may affect the operation and postoperative period (diabetes mellitus, coronary heart disease, varicose veins of the lower extremities, etc.), it is necessary to undergo additional examinations and/or consultation with other specialists. A list of standard examinations is listed here.

What you need to take with you to the hospital: passport, compulsory medical insurance policy, tests, robe (or cotton suit), slippers, nightgown, pads (2-3 drops), hygiene items, stockings for the prevention of varicose veins of the lower extremities (1 degree of compression).

The patient is hospitalized on the day of the planned operation.

The day before going home, you need to shave your perineum and pubis. Preparation of the colon (cleansing enema or special laxatives) is necessary only before surgery for infiltrative endometriosis with suspected rectal involvement.

On the day of surgery, do not drink or eat anything in the morning. Before the operation, the patient is examined by an anesthesiologist.

List of examinations required for hospitalization:

You can download the exact list of tests and examinations in PDF

Rehabilitation

Depending on the severity of the operation, the patient is in a horizontal position from several hours until the next morning. You can drink 2 hours after surgery. As a rule, in the evening you can get up and eat. The next day or one day after the operation, the patient is discharged home. There is no special diet. For two weeks, refrain from aggressive foods (fried, smoked, spicy, salty, fast food.)

Physical rest for 2 weeks after surgery.

Limiting physical activity means:

do not exercise
don't lift weights
Don't push on the toilet. Normal (ordinary) straining is acceptable. To maintain normal stool, follow a diet and, if necessary, use laxatives

Sexual rest for 2 weeks.

This operation corresponds to:

Diseases Ovarian cyst

Anatomy

Ovaries

Discussion

RCE still remains an operation with a high risk of postoperative complications. The incidence and severity of postoperative complications of RCE are influenced by many factors, such as the experience of the surgeon and the specialization of the institution where these operations are performed [6, 8, 15]. Thus, an analysis of an earlier series of 174 RCE performed in 2008–2011 revealed the development of complications in 71.8%, mortality was 6.3% within 30 days after surgery [16]. In patients in this series of studies, early complications were recorded in 53.8%, and mortality in 1.64%. According to publications over the past 10 years, 30-day complications after RCE are about 58%, and mortality reaches 3.9% [8, 16-22].

The development of complications and deaths after RCE depends not only on the neglect of the underlying disease and the severity of surgical treatment [7, 23, 24], but is also directly related to the presence of serious concomitant pathology [8, 17, 25]. Thus, a high level of complications is observed in patients with chronic cardiopulmonary, neurological and autoimmune diseases, chronic renal failure and some intestinal diseases [26]. In this study, univariate regression analysis did not reveal a statistically significant relationship between the development of complications and concomitant diseases and the Charlson comorbidity index ( p

=0.68). We explain this by the fact that patients underwent correction of identified concomitant pathology before surgery and prevention of decompensation in the postoperative period.

In the structure of RCE complications, according to various authors, gastrointestinal and infectious complications prevail, which is explained by the high traumatic nature of RCE and massive microbial contamination of the surgical field [7, 10—12]. Paresis of the stomach and intestines occurs in 22.7% of patients, and small intestinal obstruction is diagnosed in 8.7% [7-9]. Complications of an infectious nature reach 33% [6, 10—12]. In most cases, these categories of complications are the reason for repeated operations and hospitalizations. According to A. Haraz et al. [12], among 1000 patients analyzed who underwent RCE, the most common causes of readmission were upper urinary tract obstruction, urinary tract infection, intestinal obstruction, and metabolic disorders. Even after laparoscopic and robotic cystectomies, complications of an infectious nature are the cause of re-hospitalization in approximately 41% of cases [27]. In turn, infection of tissues and organs in a surgical wound by a diverse microflora can lead to severe dysfunction of various organs and systems, for example, paresis of the stomach and intestines. Confirmation of the above is that in the study the most significant predictor of the development of frequent and especially severe categories of complications was intraoperative infection of the abdominal cavity.

Other predictors influencing the frequency and severity of RCE complications were preoperative anemia (Hb less than 90 g/l), body mass deficiency (Quetelet's BMI less than 18.5 kg/m2) and intraoperative blood loss (more than 600 ml). All of these factors are interconnected. Prolonged bleeding (hematuria) before surgery and intraoperative blood loss associated with RCE lead to anemia in patients [7, 8]. As a result, underweight and anemia lead to a deficiency in the level of lymphocytes, hypoalbuminemia, hypercatabolism and negative energy balance, which causes a weakening of the body’s immune defense and a decrease in the regenerative capacity of tissues after surgery [28–30]. The barrier function of the intestinal mucosa is also lost and the motor-evacuation function slows down, which may cause the translocation of toxins and bacteria into the blood circulation system. This further increases the risks of developing gastrointestinal and infectious complications, and in severe cases leads to multiple organ failure [7, 29]. All of these factors can explain the revealed dependence of the frequency and severity of postoperative complications on the degree of intraoperative infection of the abdominal cavity. Therefore, to reduce the risk of developing postoperative complications before RCE, it is recommended, along with treatment of identified concomitant pathology, to correct anemia and hypoproteinemia [30].