Date Published: December 9, 2018
Author(s): Ajaydeep S. Sidhu, Eric Marten, Nikita Bodoukhin, George Wayne, Elizabeth Nagoda, Akshay Bhandari, Alan M. Nieder.
Surgical site infection rates remain a common postoperative problem that continues to affect patients undergoing urologic surgery. Our study seeks to evaluate the difference in surgical site infection rates in patients undergoing open radical cystectomy when comparing the Bookwalter vs. the Alexis wound retractors. After institutional review board approval, we performed a retrospective chart review from February 2010 through August 2017 of patients undergoing open radical cystectomy with urinary diversion for bladder cancer. We then stratified the groups according to whether or not the surgery was performed with the Alexis or standard Bookwalter retractor. Baseline characteristics and operative outcomes were then compared between the two groups, with the main measure being incidence of surgical site infection as defined by the CDC. We evaluated those presenting with surgical site infections within or greater than 30 postoperatively. Of 237 patients who underwent radical cystectomy with either the Alexis or Bookwalter retractor, 168 patients were eligible to be included in our analysis. There was no statistical difference noted regarding surgical site infections (SSIs) between the two groups; however, the trend was in favor of the Alexis (3%) vs. the Bookwalter (11%) at less than 30 days surgery. The Alexis wound retractor likely poses an advantage in reducing the incidence in surgical site infections in patients undergoing radical cystectomy; however, multicenter studies with larger sample sizes are suggested for further elucidation.
Self-retaining retractors fixed to the operating table have traditionally been used in major open operations. The Bookwalter retractor has been in use for several decades and is frequently used during major open operations, including open urologic surgery. More recently, combined wound-edge protectors and retractors are being used in operations at risk for surgical wound complications, including colorectal and gynecologic surgery [1, 2]. To our knowledge, the use of wound-edge protectors/retractors has not been studied in open urologic operations, though its feasibility was recently evaluated for robotic-assisted cystectomy .
After institutional review board approval, we performed a nonrandomized, retrospective chart review of 237 patients undergoing open radical cystectomy with a urinary diversion from February 2010 through August 2017. Of these, 168 patients were included in this study. Patients who underwent robotic cystectomy (15), simple cystectomy (11), and aborted cystectomies (11) were excluded from the analysis. In addition, 4 cases were excluded due to an intraoperative change to a different retractor. Finally, 28 cases were excluded due to insufficient data. The remaining 168 patients underwent radical cystectomy with a urinary diversion using either a Bookwalter or an Alexis wound retractor for the entirety of the operation. Different surgeons did indeed utilize the Alexis retractor in a nonrandomized fashion. Importantly, while the Bookwalter retractor was used predominantly in the first half of our radical cystectomy series, it was mostly utilized in our morbidly obese patients during the second half of the series when most of the surgeons had converted to the Alexis.
We identified 168 patients who were included in our study. 95 operations were performed entirely with the Alexis retractor and 73 with the Bookwalter. Besides average BMI, baseline characteristics were similar between the two groups with no statistically significant differences (Table 1).
In our single-center, retrospective study, we found that the Alexis provides appropriate exposure during radical cystectomy, with a decreased operative time and a possible trend towards reduced wound infection. The Alexis wound retractor/protector was developed in 2000 and combines wound retractor with wound barrier protection. It is comprised of two plastic rings with a plastic sleeve connecting the rings. The inner ring is placed underneath the body wall, and the outer ring is placed on top of skin. The plastic sleeve is rolled over the outer ring to retract the body wall circumferentially outward, theoretically applying equal force throughout the wound.
The Alexis retractor is a safe and effective tool for retraction and wound protection during open radical cystectomy and may potentially reduce wound-related complications, improve operative time, and lead to lower length of stay among patients. The Alexis retractor likely provides the benefit of lower surgical site infections compared to traditional retraction methods; however, further, larger, prospective multicenter trials should be initiated to confirm our findings.