Background:Perioperative fluid management plays a critical role in optimizing recovery after radical cystectomy. Various strategies, such as restrictive fluid therapy, goal-directed fluid therapy (GDFT), and warmed fluids, have been studied for their impact on complications and outcomes. However, the optimal approach remains uncertain.Methods:We conducted a systematic review in accordance with PRISMA 2020 guidelines. A PubMed search was performed in January 2025. Eligible studies included randomized controlled trials (RCTs) and observational studies published in English that assessed perioperative fluid strategies in radical cystectomy. Two reviewers independently selected studies, with a third resolving discrepancies. Data were extracted on study characteristics, interventions, and outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Due to heterogeneity, narrative synthesis was used.Results:Seventeen studies (eight RCTs, nine observational; total n = 3519) were included. Three publications based on a single RCT (n = 167) showed that restrictive fluid therapy with norepinephrine significantly reduced blood loss (p< 0.0001), transfusions (p= 0.0006), complications (p= 0.006), and hospital stay (p= 0.02), with a trend toward fewer 90-day complications (p= 0.12). Six studies (four RCTs, two observational) evaluated GDFT. Doppler- and SVV-based GDFT reduced ileus, nausea, wound infections, and blood loss, although findings on renal function and length of stay were mixed. One RCT showed that warmed fluids reduced transfusion needs (p= 0.028) and hospital stay (p= 0.05). VBFI (Vascular Bed Filling Index)- and aVBFI (adjusted Vascular Bed Filling Index)-guided strategies may lower complications in ileal conduit patients, but evidence remains limited.Conclusions:Restrictive fluid therapy with norepinephrine appears to improve outcomes after radical cystectomy. GDFT and warmed fluids show potential benefits, but findings are inconsistent. Further high-quality trials are needed to define the optimal strategy.
背景：围手术期液体管理对优化根治性膀胱切除术后的康复至关重要。限制性液体疗法、目标导向液体疗法（GDFT）以及加温输液等多种策略对并发症及预后的影响已得到研究，但最佳方案仍不明确。 方法：我们依据PRISMA 2020指南进行了系统综述。于2025年1月检索了PubMed数据库。纳入标准为评估根治性膀胱切除术围手术期液体策略的英文随机对照试验（RCT）及观察性研究。由两名评审员独立筛选文献，分歧由第三人裁决。提取研究特征、干预措施及结局数据，并采用Cochrane偏倚风险评估工具进行质量评价。鉴于研究异质性，采用描述性综合法进行分析。 结果：共纳入17项研究（8项RCT，9项观察性研究；总样本量n=3519）。一项包含167例患者的RCT的三篇衍生文献显示，联合去甲肾上腺素的限制性液体疗法显著减少了失血量（p<0.0001）、输血需求（p=0.0006）、并发症（p=0.006）及住院时间（p=0.02），并在减少90天并发症方面呈现趋势（p=0.12）。六项研究（四项RCT，两项观察性研究）评估了GDFT。基于多普勒和每搏量变异度（SVV）的GDFT降低了肠梗阻、恶心、伤口感染和失血量，但对肾功能和住院时间的影响结果不一。一项RCT表明加温输液减少了输血需求（p=0.028）和住院时间（p=0.05）。血管床充盈指数（VBFI）及校正血管床充盈指数（aVBFI）引导的策略可能降低回肠通道术患者的并发症，但证据仍有限。 结论：联合去甲肾上腺素的限制性液体疗法似乎能改善根治性膀胱切除术后的预后。GDFT和加温输液显示出潜在益处，但研究结果不一致。需要进一步开展高质量试验以明确最佳策略。
Impact of Perioperative Fluid Strategies on Outcomes in Radical Cystectomy: A Systematic Review
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