Discussion
bladder cancer
SYSTEMIC DISEASE, POSTOPERATIVE COMPLICATIONS, COMPLICATION, BLADDER CANCER, COMPLICATIONS
This study investigated the effect of intraoperative GDHT on postoperative complications in patients who underwent open radical cystectomy. The intervention and control groups showed no significant difference in the incidence of overall complications during the hospital stay. There were also no significant differences in the incidence of each of the seven complications, duration of hospital stays, and the grade of complications. Changes in postoperative eGFR, serum creatinine, and CRP were comparable between the two groups.Radical cystectomy is the standard therapy for localized bladder cancer with muscle invasion [In the present study, GDHT did not lead to improved postoperative outcomes. Several reasons might explain this result. First, the two groups had no significant difference in the amount of fluid administered during surgery. Although the amount of fluid administration during surgery was low in the GDHT group, the difference between the groups was not statistically significant. The changes in the trends for administering less fluid during surgery and improvements in perioperative care due to the adoption of the enhanced recovery after surgery (ERAS) protocol may have affected these results [Previous studies have reported a U-shaped association between fluid administration during surgery and mortality, indicating that too much or too little intraoperative fluid administration may harm the patients [Our study had some limitations that need to be addressed. First, the sample size was calculated based on the total complication rate of 40% calculated in the preliminary investigation, but the actual complication rate in our study was much higher. This discrepancy may be attributed to the retrospective nature of the pilot study, which likely had missing data on postoperative complications. Second, since the accuracy and reliability of SVI and CI, used as indicators of the patient’s hemodynamic status in the GDHT protocol and obtained by arterial pulse contour analysis, are limited, this limitation might have influenced our results. Third, we did not include an assessment of baseline hemodynamic status at the awake state, which may raise uncertainty about the accuracy of post-induction assessment reflecting the individual patient’s baseline requirement. Fourth, we excluded patients with severe systemic diseases to minimize their potential influence on the effect of GDHT. However, these exclusion criteria also led to the omission of high-risk patients, thereby limiting the generalizability of our study. Hence, further large-scale randomized controlled trials are needed to confirm the benefits of individualized hemodynamic management in high-risk patients undergoing radical cystectomy. Fifth, due to an overly optimistic setting of the effects of GDHT on reducing postoperative complications, our study could be underpowered to detect a significant difference in the primary outcome. Sixth, the involvement of multiple surgeons and changes in anesthesia practice during the study period may have introduced confounding factors to our results. Lastly, we chose a per-protocol analysis to gauge the efficacy of GDHT more accurately. However, we acknowledge that this analysis could introduce biases and may not represent real-world practice despite aligning with the intention-to-treat analysis.