Stesura Seveso 379Archivio Italiano di Urologia e Andrologia 2021; 93, 4 ORIGINAL PAPER No conflict of interest declared. owing to provides the best cancer-specific survival in muscle-invasive patients (3, 4). RC provides excellent local control with a local recurrence rate of 4% in patients with lymph node-negative (5). RC is associated with significant complications, including death, with wide variability in reported postoperative morbidity and mortality rates. In a study of 1142 patients managed by Shabsigh et al., the serious complication rate was 13% and the mortality rate within 30 days was 1.5% (6). Although the mortality rate has decreased over the past decade, early morbidity rates have remained at rang- ing from 11 to 68% (3, 7, 8). Whether the disease is organ-confined to the or not and the patient's comorbidity status (age-adjusted Charlson comorbidity index - ACCI) are defined indicators of mor- tality and complications after radical cystectomy (9). Putting forth a marker that can predict complications can be a prominent attempt to reduce mortality and morbid- ity. In line with this goal, and hence that there is no prospective study on this subject in the literature, we aimed to examine the usability of serum albümin. Simultaneously, we also examined hematocrit values, age- dependent Charlson comorbidity index (ACCI), BMI, and operation time. MATERIALS AND METHODS All patients scheduled to view radical cystectomy for BC between 2015 and 2016 in the urology clinic of Kartal Lütfi Kırdar City Hospital were examined prospectively. A total of 60 patients underwent radical cystectomy oper- ation, and since five patients were out of follow-up, 55 cases, six females and 49 males were included in the study. Ethics Committee Approval was obtained from our hospital's ethics committee for our study, and all subjects signed an informed consent form (IRB number 514/65/4). Patient's age, BMI, ACCI score, preoperative serum albu- min, hematocrit (HCT), urea-creatinine values, operation time, pre-and post-cystectomy pathological stages, diver- sion type, amount of blood transfusion, type of complica- tions, intestinal functions (gas-stool output time), the transition time to oral nutrition, total parenteral nutrition (TPN) time, the length of hospital stay, the duration of drainage catheter and reoperations, patients' mortality Objective: To evaluate the relationship between serum albumin, hematocrit (HTC), age-dependent Charlson comorbidity index, body mass index (BMI), and deleted operation time in predicting mortality and complications associated with radical cystectomy. Materials and methods: All patients planned for radical cystec- tomy owing to bladder cancer were investigated prospectively between 2015 and 2016 in our clinic. A total of 55 cases were included in the study. Patients' characteristics, preoperative serum albumin values, hematocrit level, age-dependent Charlson comorbidity index (CCI), body mass index and deleted operation time, drainage catheter time, gas-stool expulsion time were recorded. The patients were followed up for 90 days. Results: Age of cases, Charlson comorbidity index scores, and HCT were not different in patients with or without complica- tions (overall) or severe complications nor in patients who died or survived after the procedure. The albumin value of the cases with observed mortality and complications was significantly lower than that of the cases with no mortality and complica- tions. In multivariate and univariate analysis, low albumin level was established to be meaningful in predicting mortality and serious complications. The cut-off point for albumin, according to mortality, was found to be 4.1. Mortality within 90 days was 16.3% (n = 9). Conclusions: We have evaluated albumin as a marker that could indicate both mortality and the presence of severe complications after radical cystectomy and urinary diversion. KEY WORDS: Albumin; Bladder cancer; Complications; Cystectomy; Mortality. Submitted Submitted 28 July 2021; Accepted 9 September 2021 INTRODUCTION Bladder cancer (BC) is the 7th most commonly diagnosed cancer in males, while it degrades to 11th when both gen- ders are taken into account (1); 75% of patients with BC present with disease non-muscle invasive bladder cancer at the first consult. Patients with muscle-invasive bladder tumors often present with progressed disease and approx- imately 20% of them are patients who progress from lower stages (2). The cancer-specific mortality rate of muscle-invasive bladder cancer (MIBC) can be predicted to increase up to 85% if left untreated (2). Radical cystectomy (RC) and pelvic lymph node dissection (PLND) is the standard treatment for localized MIBC Is it possible to reduce the complications and mortality of patients undergoing radical cystectomy? Effectiveness of pre-operative parameters. A prospective study Övünç Kavukoglu, Alper Coskun, Kubilay Sabuncu, Emre Çamur, Gökhan Faydaci Department of Urology, University of Health Sciences, Kartal Dr. Lutfi Kırdar City Hospital, Istanbul, Turkey. DOI: 10.4081/aiua.2021.4.379 Summary gastrointestinal system (GIS) with a 47.3% rate (n = 26). Second most frequent complications with a 36.4% rate (n = 20) were infectiouscomplications; wound/skin-relat- ed complications followed with 14.5% rate (n = 8). In the relationship between the variety of complications and albumin value, the rate of wound/skin and neurolog- ical complications in patients with albumin below 3.5 was significantly higher than in those with a value over 3.5 (p = 0.019, p = 0.002) (Table 2). According to Clavien complication status and severity, age, Charlson comorbidity index, operation times, HCT values, gas-stool output times did not show a statistically significant difference (p > 0.05). Likewise, when the albu- min values were examined according to the complication status and severity, no albumin value of 3.5 or less was observed in any of the cases without complications and with mild complication severity. Besides, the albumin value of the patients with complications was found to be significantly lower than the cases without complications (p = 0.013; p < 0.05) (Table 3). While there is no statistically significant difference between age, Charlson comorbidity index, BMI, opera- tion time, HCT value, gas-stool output time and mortali- ty, the same is not current for albumin. In fact, 55.6% of the cases with mortality had an albumin value of 3.5 and below, and 8.7% of the cases with no mortality had an albumin value below 3.5 (Table 4). The cut-off point for albumin considering mortality was found to be 4. Accordingly, it is significant that the albu- min value of the cases with mortality is 4.1 and below. This cut-off value's sensitivity is 100%, the specificity is 52.17%, the positive predictive value is 29 and the nega- tive predictive value is 100. The area under the ROC curve was 82% for the standard error of the area 6.7% (Figure 1). Archivio Italiano di Urologia e Andrologia 2021; 93, 4 Ö. Kavukoglu, A. Coskun, K. Sabuncu, E. Çamur, G. Faydaci 380 and morbidity until the postoperative 90th day and their application for any reason to the hospital, were recorded for each patient. Also, they routinely were called for fol- low-up visits in the postoperative first and third months. We preferred a well-described method, as Clavien Dindo classification system (CCS), for evaluation of postoperative complications (10, 11). Statistical analysis was conducted using NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA). The quantitative and qualitative variables were analyzed with Student's t-test, Mann Whitney U test, Pearson chi-square test, Fisher's Exact Test, and Fisher Freeman Halton test. A p value < 0.05 was considered to indicate statistical significance. RESULTS The mean age of the patients was 65.27 ± 9.38, BMI 26.21 ± 4.17 kg/m2, HCT 37.90 ± 5.37, albumin values ranged from 2.2 to 4.9, with an average of 4.03 ± 0.55. Operation times averaged 273.15 ± 74.30 minutes and gas-stool output time 3.92 ± 1.60 days. The patients' demographic characteristics, preoperative laboratory val- ues, postoperative results, Charlson scores, Clavien com- plication scores were outlined in Table 1. The majority of postoperative complications are related to Table 1. Patients characteristics findings. Pre-operative parameters Min-max (median) Mean ± Ss Age (years) 38-85 (65) 65.27 ± 9.38 n % BMI (kg /m2) Normal 45.50 Overweight 34.50 Obese 20.00 Gender Female 6 10.9 Male 49 89.1 Hemoglobin 9.2-16 (12.1) 12.45 ± 1.80 Hematocrit 27.7-48.8 (37.6) 37.90 ± 5.37 Albumin 2.2-4.9 (4.1) 4.03 ± 0.55 Urea 12-135 (39) 44.65 ± 20.77 Creatinine 0.6-4.7 (1.1) 1.33 ± 0.87 Neoadjuvant chemotherapy radiotherapy/ 0-4 (0) Abdominal surgery No 40 72.7 Yes 15 27.3 Charlson score ≤ 2 9 16.4 3-4 28 50.9 ≥ 5 18 32.7 Clavien Dindo (n=39) 2 15 38.5 3 11 28.2 4 4 10.3 5 9 23.1 Peri-operative parameters Positive No 41 75.9 Surgical margin Yes 14 24.1 Operation time (min) 160-540 (257.5) 273.15 ± 74.30 Postoperative parameters Re-operation No 44 80.0 Yes 11 20.0 Intensive care unit time (day) 0-31 (1) 2.42 ± 5.43 Gas output time (day) 1-8 (3) 2.88 ± 1.45 Stool output time (day) 1-9 (4) 3.92 ± 1.60 Transition time to oral nutrition (day) 1-11 (4) 4.00 ± 1.79 TPN time (day) 0-10 (4) 4.10 ± 2.35 Drainage catheter staying time (day) 4-19 (8.5) 9.74 ± 3.53 Length of Hospital stay (day) 2-46 (10) 12.78 ± 9.65 Table 2. The type of complications and comparing with albumin. Pre-operative parameters Albumin Test value > 3.5 ≤ 3.5 P n (%) n (%) Gastrointestinal system No 26 (56.5) 3 (33.3) χ2 = 1.624 Yes 20 (43.5) 6 (66.7) 0.281b Infection No 32 (69.6) 3 (33.3) χ2 = 4.270 Yes 14 (30.4) 6 (66.7) 0.059 b Genitourinary system No 43 (93.5) 8 (88.9) χ2 = 0.235 Yes 3 (6.5) 1 (11.1) b0.522 b Hematological/vascular No 42 (91.3) 8 (88.9) χ2 = 0.053 Yes 4 (8.7) 1 (11.1) 1.000 b Cardiac No 44 (95.7) 8 (88.9) χ2 = 0.668 Yes 2 (4.3) 1 (11.1) b0.421 b Wound/skin No 42 (91.3) 5 (55.6) χ2 = 7.739 Yes 4 (8.7) 4 (44.4) 0.019 b * Pulmonary No 41 (89.1) 7 (77.8) χ2 = 0.873 Yes 5 (10.9) 2 (22.2) 0.321 b Neurological No 43 (93.5) 5 (55.6) χ2 = 9.746 Yes 3 (6.5) 4 (44.4) 0.002 b ** Metabolic No 41 (89.1) 8 (88.9) χ2 = 0.000 Yes 5 (10.9) 1 (11.1) 1.000 b Musculoskeletal system No 45 (97.8) 9 (100.0) χ2 = 0.199 Yes 1 (2.2) 0 (0.0) 1.000 b b Fisher’s Exact Test; *p < 0.05; **p < 0.01. 381Archivio Italiano di Urologia e Andrologia 2021; 93, 4 Complications of radical cystectomy lished. The sensitivity of these models (model 1, 2) for the cases with mortality was 44.4% and 79.2% and the speci- ficity rate was 66.7% and 93.5%, overall accuracy was 85% and 74.4%, respectively. Additionally, albumin's one- Table 3. Comparison of operation time, BMI and albumin values according to the presence of complications and their severity. Figure 1. Diagnostic screening tests and ROC curve outcomes of albumin by mortality. Overall complications Test value Complication severity Test value No (n = 16) Yes (n = 39) P Mild (n = 15) Severe (n = 24) P Age (years) Min-max (median) 51-77 (63) 38-85 (67) t = 0.864 38-81 (75) 53-85 (66) t = 0.053 Mean ± Ss 63.56 ± 7.76 65.97 ± 9.98 0.392 d 65.87 ± 11.78 66.04 ± 8.94 0.958 d BMI (kg/m2) Min-max (median) 22-34.1 (25.5) 17.6-36.3 (25.4) t = -0.288 17.6-34.0 (23) 22.1-36.3 (25.8) t = 2.215 Mean ± Ss 26.46 ± 3.92 26.10 ± 4.31 0.774 d 24.26 ± 4.21 27.25 ± 4.04 0.033 d * Charlson score Min-max (median) 2-6 (3.5) 0-8 (4) Z = -1.641 0-5 (4) 2-8 (4) Z = -0.944 Mean ± Ss 3.62 ± 1.20 4.10 ± 1.70 0.101 a 3.60 ± 1.40 4.42 ± 1.81 0.345 a Operasyon time Min-max (median) 180-450 (255) 160-540 (257.5) t = -0.539 180-540 (250) 160-390 (270) t = -0.468 Mean ± Ss 264.69 ± 69.84 276.71 ± 76.72 0.592 d 284.00 ± 97.43 271.96 ± 61.62 0.643 d Hematocrit Min-max (median) 33.4-46.5 (40) 27.7-48.8 (37.5) t = 1.548 31.6-47.0 (37.6) 27.7-48.8 (36.45) t = -0.930 Mean ± Ss 39.63 ± 4.32 37.19 ± 5.64 0.128 d 38.25 ± 4.99 36.53 ± 6.01 0.359 d BMI (n%) Normal 7 (43.8) 18 (46.2) χ2 = 0.367 9 (60.0) 9 (37.5) χ2 = 2.611 Overweight 5 (31.3) 14 (35.9) 0.832 e 5 (33.3) 9 (37.5) 0.283 c Obese 4 (25.0) 7 (17.9) 1 (6.7) 6 (25.0) Charlson score ≤ 2 3 (18.8) 6 (15.4) χ2 = 0.706 3 (20.0) 3 (12.5) χ2 = 1.115 3-4 9 (56.3) 19 (48.7) 0.716 c 8 (53.3) 11 (45.8) 0.675 c ≥ 5 4 (25.0) 14 (35.9) 4 (26.7) 10 (41.7) Albumin Min-max (median) 3.7-4.8 (4.25) 2.2-4.9 (4) t = 2.563 3.-4.9 (4.2) 2.2-4.8 (4) t = -2.499 Mean ± Ss 4.26 ± 0.31 3.94 ± 0.60 0.013 d* 4.23 ± 0.35 3.76 ± 0.66 0.007 d ** Albumin > 3.5 16 (100.0) 30 (76.9) χ2 = 4.415 15 (100.0) 15 (62.5) χ2 = 7.313 ≤ 3.5 0 (0.0) 9 (23.1) 0.046 b * 0 (0.0) 9 (37.5) 0.007 b ** a Mann WhitneyUTest; b Fisher’sExact Test; c Fisher Freeman Halton Test; d Student-tTest; e Pearson Chi-SquareTest; *p < 0.05; **p < 0.01. To examine factors that affect the severity of complica- tions and mortality, two separate logistic regression mod- els derived from age, BMI, albumin value, preoperative HCT value and Charlson index variables were estab- Archivio Italiano di Urologia e Andrologia 2021; 93, 4 Ö. Kavukoglu, A. Coskun, K. Sabuncu, E. Çamur, G. Faydaci 382 point rising could decrease the prospect of mortality by 0.014 (1/71) times and of serious complications by 0.057 (1/17) times. Similarly, it was found that a one-unit decrease in HCT value would increase the likelihood of mortality by 1.273 times, while a one-unit increase in BMI value would increase the likelihood of severe complica- tions by 1.4 times. b coefficients obtained in the logistic regression models (model 1, 2) are shown in Table 5. DISCUSSION Radical cystectomy (RC) is the primary treatment modality for patients with muscle-invasive urothelial cancer of the bladder (1). Increasing patient age, female gender, more than two comorbidities, having undergone previous pelvic surgery, stage of the disease (extravesical disease) and obesity are factors that will increase complications and mortality (6, 7, 12-14). Also, the experience of the surgeon, perioperative blood loss and operation time are important items. Assessment of comorbidities of patients is of great signif- icance in predicting mortality and morbidity. The American Society of Anesthesiologists (ASA) score is fre- quently used for this goal. However, we used the Charlson comorbidity index (CCI) in our study (15). Considering their comorbidity index, we divided the patients into three groups: 2 mild, 3-4 moderate, and ≥ 5 severe. We observed that patients with 5 and above have serious complications. In the study by Koppie et al., overall sur- vival was demonstrated decreasing in patients with high comorbidity considering the comorbidity index, but recurrence-free survival was not affected. Again Maffezini et al. In his study, a CCI of more than 3 was found to be associated with survival (16). It is also noteworthy that patients with high comorbidities had been performed less lymph node dissection and less post- operative chemotherapy (9). The complication percentage of our study is 70.9%. This value is higher than the literature obviously. (6, 15, 18- 20). Whereas these literature values included 30-day morbidity and mortality, we analyzed 90-day. Although most of the complications come into being were com- plaints that would not be classified as serious complica- tions, we found the serious complication rate (Clavien- Dindo: 3-5) 43.6% (n: 24), severe complication Clavien Dindo 4-5 23.6%. The mortality rate within 90 days post- operatively is 16.3% (n = 9). We did not find a significant relationship between mor- tality and complication rates with BMI, Charlson comor- bidity index, preoperative hematocrit values and opera- tion time in univariate analysis. As for the multivariate analysis, we observed that the hematocrit value is strong- ly related to predicting mortality and BMI is also signifi- cant in the presence of severe complications. However, it would not be wrong to say that we found the most sig- nificant results in our study when we analyzed the albu- min values. Albumin is an important marker to predict mortality and severe complication in both univariate and multivariate analyses. In addition, Our results showed us that wound/skin and neurological complications were significantly higher if albumin values are low. Undernourishment is a well-known risk factor for compli- cations (21-23). Serum albumin has been shown that is a determinant of nutritional status and is a prominent mark- er of prognosis and progression in many types of cancer in previous studies (24, 25). In the study by Gregg at al., they have categorized patients with preoperative albumin value of 3.5 and below, those with BMI < 18.5 and patients with pre-operative weight loss of more than 5% were as patients with malnutrition (23). In another study that had been done with similar logic, the preoperative albumin value was found to be significant in predicting complica- Table 4. Charlson comorbidity index, BMI, HCT, and albumin values by mortality. Mortality Test value Yes (n = 46) No (n = 9) P Age (years) Min-max (median) 38-84 (65) 57-85 (70) Z = -1.162 Mean ± Ss 64.63 ± 9.45 68.56 ± 8.80 0.245 a BMI (kg/m2) Min-max (median) 17.6-36.3 (25.4) 22.1-32 (24.8) Z = -0.228 Mean ± Ss 26.28 ± 4.30 25.83 ± 3.64 0.820 a Charlson Score Min-max (median) 0-8 (4) 2-7 (5) Z = -0.995 Mean ± Ss 3.80 ± 1.51 4.78 ± 1.71 0.320 a Hematocrit Min-max (median) 27.7-48.0 (37.7) 30.0-48.8 (37.5) Z = -0.262 Mean ± Ss 37.94 ± 5.27 37.71 ± 6.20 0.794 a BMI (n %) Normal 20 (43.5) 5 (55.6) χ2 = 0.835 Overweight 17 (37.0) 2 (22.2) 0.725 c Obese 9 (19.6) 2 (22.2) Charlson score ≤ 2 8 (17.4) 1 (11.1) χ2 = 2.341 3-4 25 (54.3) 3 (33.3) 0.343 c ≥ 5 13 (28.3) 5 (55.6) Albumin (n %) > 3.5 42 (91.3) 4 (44.4) χ2 = 12.077 ≤ 3.5 4 (8.7) 5 (55.6) 0.003 b ** Albumin g/dl Min-max (median) 2.7-4.9 (4.2) 2.2-4.1 (3.3) Z = -3.028 Ort ± Ss 4.15 ± 0.45 3.44 ± 0.66 0.002 a ** Albumin Cut-Off > 4.1 24 (52.2) 0 (0.0) χ2 = 8.331 ≤ 4.1 22 (47.8) 9 (100.0) 0.003 b ** a Mann WhitneyUTest; b Fisher’sExact Test; c Fisher Freeman Halton Test; *p < 0.05; **p < 0.01. Operation time was excluded. Table 5. Logistic regression models for factors affecting mortality and complication severity. β P Odds ratio Confidence interval (OR) for OR Low High Model 1. Mortality Age -0.079 0.412 0.924 0.766 1.116 BMI -0.039 0.792 0.961 0.717 1.289 Albumin -4.294 0.005 0.014 0.001 0.272 Hematocrit 0.242 0.036 1.273 1.016 1.595 Charlson score 0.457 Charlson (2-5) -0.192 0.919 0.825 0.020 34.123 Charlson (> 5) 1.140 0.569 3.128 0.062 158.545 Constant 11.709 0.230 121625.915 Model 2. Complication severity Age 0.021 0.736 1.022 0.902 1.158 BMI 0.337 0.027 * 1.400 1.039 1.887 Albumin -2.857 0.025 * 0.057 0.005 0.704 Hematocrit -0.010 0.917 0.991 0.828 1.184 Charlson score 0.822 Charlson (2-5) -0.978 0.531 0.376 0.018 8.040 Charlson (> 5) -0.956 0.603 0.384 0.011 14.063 Constant 3.135 0.661 22.993 *p < 0.05. 383Archivio Italiano di Urologia e Andrologia 2021; 93, 4 Complications of radical cystectomy tions and mortality after radical cystectomy. It was pre- dicted that better postoperative outcomes could be achieved with preoperative nutritional support (26). The study by Djaladat et al. investigated the relationship between ASA score and albumin with survival; they established that a high ASA score was associated with increased complication rates and low serum albumin with recurrence-free overall survival. As a result of albumin being so vital, the idea of albumin supplementation to patients had come into question, but studies have shown that it does not cause better results and may cause undesirable effects (26, 27). Similarly, when the patients who were given TPN (total parenteral nutrition) and not given were investigated, no difference was obtained in the complication rates and infectious complications (such as intraabdominal abscess and peri- tonitis) increased in patients who received TPN (28). We can indicate the study's limitations as follows; it is a single-center study, the number of patients is insufficient, a single surgeon did not perform operations, complica- tions, mortality and was not calculated according to the pathological stages of the patients, our follow-up period is short. We thought that it would cause us to have diffi- culty in distinguishing cancer-specific survival from post- operative mortality in a more extended follow-up period. Therefore, we considered that the 3-month period is opti- mal duration. The fact that our results are similar to the literature may bring a criticism that the study does not contribute to lit- erature at first. Although accepting this as a self-criticism, our research was designed prospectively, point that it is different from existing studies. Another subject of criti- cism is that the patients' postoperative albumin values were not compared with the preoperative values. Frankly, we believe that this may be the subject of a different study. It is valuable that albumin gives such significant statisti- cal results with a small patient population. However, it would not explain the high mortality and complications with only preoperative data-besides, the lack of patient outcomes who underwent laparoscopic and robotic sur- gery acceptable an issue of criticism. Our results are gen- erally concordant with the literature. We believe that the fact that these supportive data were obtained prospective- ly will make our study privileged. CONCLUSIONS Finding a marker that predict the mortality and compli- cations that may occur after radical cystectomy may be help to prepare the patient before surgery and manage the patient after surgery. As a result, albumin was found to be meaningful in predicting both mortality and the presence of serious complications. We believe that our results will give an opinion for future randomized controlled multi- center studies. Thus, it may be possible to minimize com- plications and mortality. REFERENCES 1. Babjuk M, Böhle A, Burger M, et al. EAU Guidelines on non-mus- cle-invasive urothelial carcinoma of the bladder: update 2016. Eur Urol. 2017; 71:447-461. 2. Prout GR, Marshall VF. The prognosis with untreated bladder tumors. Cancer. 1956; 9:551-558. 3. Lawrentschuk N, Colombo R, Hakenberg OW, et al. Prevention and management of complications following radical cystectomy for bladder cancer. Eur Urol. 2010; 57:983-1001. 4. Meyer JP, Blick C, Arumainayagam N, et al. A three-centre expe- rience of orthotopic neobladder reconstruction after radical cystecto- my: revisiting the initial experience, and results in 104 patients. BJU Int. 2009; 103:680-683. 5. Morris DS, Weizer AZ, Ye Z, et al. Understanding bladder cancer death: tumor biology versus physician practice. Cancer. 2009; 115:1011-1020. 6. Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a stan- dardized reporting methodology. Eur Urol. 2009; 55:164-74. 7. Novara G, Marco VD, Aragona M, et al. Complications and mor- tality after radical cystectomy for bladder transitional cell cancer. J Urol. 2009; 182:914-921. 8. Bostrom PJ, Mirtti T, Kössi J, et al. Twenty-year experience of rad- ical cystectomy for bladder cancer in a medium-volume centre. Scand J Urol Nephrol Suppl. 2009; 43:357-364. 9. Koppie TM, Serio AM, Vickers AJ, et al. Age-adjusted Charlson comorbidity score is associated with treatment decisions and clinical outcomes for patients undergoing radical cystectomy for bladder can- cer. Cancer. 2008; 112:2384-2392. 10. Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992; 111:518-526. 11. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240:205-213. 12. Kim HL, Steinberg GD. Complications of cystectomy in patients with a history of pelvic radiation. Urology. 2001; 58:557-560. 13. Mastroeni F, Aragona M, Caldarera E, et al. Deep venous throm- bosis in patients undergoing salvage radical cystectomy. Arch Esp Urol. 2001; 54:839-841. 14. Arumainayagam N, McGrath J, Jefferson KP, Gillat DA. Introduction of an enhanced recovery protocol for radical cystectomy. BJU Int. 2008; 101:698-701. 15. Charlson ME, Pompei P, Ales KL, MacKenzie CR. J Chronic Dis. 1987; 40:373-383. 16. Maffezzini M, Fontana V, Pacchetti A, et al. Age above 70 years and Charlson Comorbidity Index higher than 3 are associated with reduced survival probabilities after radical cystectomy for bladder cancer. Data from a contemporary series of 334 consecutive patients. Arch Ital Urol Androl. 2021; 93:15-20. 17. Frazier HA, Robertson JE, Paulson DF. Complications of radical cystectomy and urinary diversion: a retrospective review of 675 cases in 2 decades. J Urol. 1992; 148:1401-1405. 18. Konety BR, Allareddy V, Herr H. Complications after radical cys- tectomy: analysis of population-based data. Urology. 2006; 68:58- 64. 19. Brannan W, Fuselier HA, Ochsner M, Randrup ER. Critical eval- uation of 1-stage cystectomy--reducing morbidity and mortality. J Urol. 1981; 125:640-642. 20. Skinner DG, Crawford ED, Kaufman JJ. Complications of radical cystectomy for carcinoma of the bladder. J Urol. 1980; 123:640-643. Archivio Italiano di Urologia e Andrologia 2021; 93, 4 Ö. Kavukoglu, A. Coskun, K. Sabuncu, E. Çamur, G. Faydaci 384 21. Gibbs J, Cull W, Henderson W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134:36-42. 22. Djaladat H, Bruins HM, Miranda G, et al. The association of pre- operative serum albumin level and American Society of Anesthesiologists (ASA) score on early complications and survival of patients undergoing radical cystectomy for urothelial bladder cancer. BJU Int. 2014; 113:887-893. 23. Gregg JR, Cookson MS, Phillips S, et al. Effect of preoperative nutritional deficiency on mortality after radical cystectomy for blad- der cancer. J Urol. 2011; 185:90-96. 24. Liu J, Dai Y, Zhou F, et al. The prognostic role of preoperative serum albumin/globulin ratio in patients with bladder urothelial carcinoma undergoing radical cystectomy. Urol Oncol. 2016; 34:484 e1-484e8. 25. Gupta D, Lis CG. Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J. 2010; 9:69. 26. Garg T, Chen LY, Donat M. Preoperative serum albumin is asso- ciated with mortality and complications after radical cystectomy. BJU Int. 2014; 113:918-923. 27. Gore JL, Lai J, Setodji CM, et al. Mortality increases when radi- cal cystectomy is delayed more than 12 weeks: results from a Surveillance, Epidemiology, and End Results-Medicare analysis. Cancer. 2009; 115:988-996. 28. Brennan MF, Pisters PW, Posner M, et al. A prospective random- ized trial of total parenteral nutrition after major pancreatic resec- tion for malignancy. Ann Surg. 1994; 220:436-444. Correspondence Övünç Kavukoglu, MD ovunckavukoglu@hotmail.com Alper Coskun, MD (Corresponding Author) alpercoskun62@yahoo.com Kubilay Sabuncu, MD kubilaysabuncu@yahoo.com Emre Çamur, MD emre.camur@outlook.com Gökhan Faydaci, MD faydacig@yahoo.com Department of Urology, University of Health Sciences, Kartal Dr. Lutfi Kırdar City Hospital, Istanbul (Turkey)