Comparison of Hemodynamic Management by Hypotension Prediction Index or Goal-Directed Therapy in Radical Cystectomies: A Prospective Observational Study

<b>Background:</b> Hypotensive events may occur during surgical interventions and are associated with major postoperative complications, depending on their duration and severity. Intraoperative hemodynamic goal-directed therapy can reduce postoperative complications and mortality in high-risk surgeries and high-risk patients. The study hypothesis was that a proactive approach by hypotension predictive index (HPI) is more effective than a reactive goal-directed therapy (GDT) in reducing the number of hypotensive events during radical cystectomy and that this is associated with improved postoperative outcomes. <b>Methods:</b> The study was a single-center prospective observational study conducted at Galliera Hospital, from November 2019 to February 2025, with a before-after population of sixty-seven patients with reactive approach (GDT group) and sixty-five patients with a proactive approach (HPI group) undergoing radical cystectomy, managed with a standardized ERAS protocol and invasive or non-invasive hemodynamic monitoring. The aim of the study was to compare the incidence, duration, and severity of intraoperative hypotensive episodes between a proactive approach guided by the Hypotension Prediction Index (HPI) and a reactive goal-directed therapy (GDT) strategy guided by an advanced hemodynamic monitoring system. <b>Results:</b> The HPI group had a 65% reduction in hypotensive events (225 vs. 633, <i>p</i> < 0.001), with a 72% reduction in their duration (14 vs. 49 min, <i>p</i> < 0.001) and an 85% reduction in their severity (time-weighted average MAP < 65 mmHg 0.11 vs. 0.76, <i>p</i> < 0.001) compared to the GDT group. The HPI-guided group showed a reduction in postoperative infectious complications (10 vs. 26) and in-hospital length of stay (8 ± 4 versus 13 ± 8 days). <b>Conclusions:</b> A proactive approach may allow attenuating the occurrence and severity of hypotensive events more than a reactive goal-directed approach during radical cystectomy.