Defining a “High Volume” Radical Cystectomy Hospital: Where Do We Draw the Line?

National Surgical Quality Improvement Program audit of contemporary perioperative care for radical cystectomy

OBJECTIVE

To examine the impact of increased compliance to contemporary perioperative care measures, as outlined by enhanced recover after surgery (ERAS) guidelines, among patients undergoing radical cystectomy (RC).

PATIENTS AND METHODS

From the National Surgical Quality Improvement Program database we captured patients undergoing RC between 2019 and 2021. We identified five perioperative care measures: regional anaesthesia block, thromboembolism prophylaxis, ≤24 h perioperative antibiotic administration, absence of bowel preparation, and early oral diet. We stratified patients by the number of measures utilised (one to five). Statistical endpoints included 30-day complications, hospital length of stay (LOS), readmissions, and optimal RC outcome. Optimal RC outcome was defined as absence of any postoperative complication, re-operation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable regressions with Bonferroni correction were performed to assess the association between use of contemporary perioperative care measures and outcomes.

RESULTS

Of the 3702 patients who underwent RC, 73 (2%), 417 (11%), 1010 (27%), 1454 (39%), and 748 (20%) received one, two, three, four, and five interventions, respectively. On multivariable analysis, increased perioperative care measures were associated with lower odds of any complication (odds ratio [OR] 0.66, 99% confidence interval [CI] 0.6-0.73), and shorter LOS (β -0.82, 99% CI -0.99 to -0.65). Furthermore, patients with increased compliance to contemporary care measures had increased odds of an optimal outcome (OR 1.38, 99% CI 1.26-1.51).

CONCLUSIONS

Among the measures we assessed, greater adherence yielded improved postoperative outcomes among patients undergoing RC. Our work supports the efficacy of ERAS protocols in reducing the morbidity associated with RC.

Management of patients with muscle-invasive bladder cancer with clinical evidence of pelvic lymph node metastases

Identification of clinically positive pelvic lymph node metastases (cN+) in patients with muscle-invasive bladder cancer is currently challenging, as the diagnostic accuracy of available imaging modalities is limited. Conventional CT is still considered the gold-standard approach to diagnose lymph node metastases in these patients. The development of innovative diagnostic methods including radiomics, artificial intelligence-based models and molecular biomarkers might offer new perspectives for the diagnosis of cN+ disease. With regard to the treatment of these patients, multimodal strategies are likely to provide the best oncological outcomes, especially using induction chemotherapy followed by radical cystectomy and pelvic lymph node dissection in responders to chemotherapy. Additionally, the use of adjuvant nivolumab has been shown to decrease the risk of recurrence in patients who still harbour ypT2-T4a and/or ypN+ disease after surgery. Alternatively, the use of avelumab maintenance therapy can be offered to patients with unresectable cN+ tumours who have at least stable disease after induction chemotherapy alone. Lastly, patients with cN+ tumours who are not responding to induction chemotherapy are potential candidates for receiving second-line treatment with pembrolizumab.

Maximizing efficiency and ensuring safety: Exploring the outcomes of 2 consecutive open radical cystectomies by the same team within a single surgical day

BACKGROUND

The purpose of this study was to evaluate the outcomes of performing 2 consecutive open radical cystectomies (RCs) within 1 day by the same surgical team.

PATIENTS AND METHODS

A retrospective analysis was conducted on data from patients who underwent RC at a single tertiary care center from January 2015 to February 2023. Patient characteristics, perioperative outcomes and endpoints were analyzed. Univariable and multivariable logistic regression models were created to predict major complications.

RESULTS

A total of 657 patients were included in the final cohort, containing 64 paired RCs (32 RC1 and 32 RC2) and 593 single RCs. Major complications occurred in 24.7% of the entire cohort, with no significant differences between single RC vs. RC1 and RC2. Paired RCs showed significantly shorter operative time (OT; p = 0.001) and length of stay (LOS; p = 0.047) compared to single RCs. There were no significant differences in transfusion rates, 30-day readmission, 30-day mortality, or histopathological results between paired and single RCs. Multivariable analysis identified patient characteristics such as age (OR = 1.67, p = 0.03), sex (OR = 0.45, p = 0.008), BMI (OR = 1.98, p = 0.007), ASA-score (OR = 1.61, p = 0.04), and OT (OR = 1.87, p = 0.008) as independent predictors of major complications.

CONCLUSION

Performing 2 consecutive open RCs within 1 day by the same surgical team is a safe approach in experienced hands. This strategy optimizes the utilization of surgical resources and addresses the growing demand for urologic care while maintaining high-quality patient care. Preoperative planning should consider patient-specific factors to minimize risks associated with major complications.

MICRO ABSTRACT

This study evaluates the outcomes of performing 2 consecutive open radical cystectomies (RC) in a single day by the same surgical team. Data from 657 patients who underwent RC at a single tertiary medical center proved that this approach is safe, with no significant differences in major complications. Preoperative planning should consider patient-specific factors for efficient utilization of surgical resources.

The effect of hospital caseload on perioperative mortality, morbidity and costs in bladder cancer patients undergoing radical cystectomy: results of the German nationwide inpatient data

OBJECTIVES

To determine a data-based optimal annual radical cystectomy (RC) hospital volume threshold and evaluate its clinical significance regarding perioperative mortality, complications, length of hospital stay, and hospital revenues.

MATERIAL AND METHODS

We used the German Nationwide inpatient Data, provided by the Research Data Center of the Federal Bureau of Statistics (2005-2020). 95,841 patients undergoing RC were included. Based on ROC analyses, the optimal RC threshold to reduce mortality, ileus, sepsis, transfusion, hospital stay, and costs is 54, 50, 44, 44, 71 and 76 cases/year, respectively. Therefore, we defined an optimal annual hospital threshold of 50 RCs/year, and we also used the threshold of 20 RCs/year proposed by the EAU guidelines to perform multiple patient-level analyses.

RESULTS

28,291 (29.5%) patients were operated in low- (< 20 RC/year), 49,616 (51.8%) in intermediate- (20-49 RC/year), and 17,934 (18.7%) in high-volume (≥ 50 RC/year) centers. After adjusting for major risk factors, high-volume centers were associated with lower inpatient mortality (OR 0.72, 95% CI 0.64-0.8, p < 0.001), shorter length of hospital stay (2.7 days, 95% CI 2.4-2.9, p < 0.001) and lower costs (457 Euros, 95% CI 207-707, p < 0.001) compared to low-volume centers. Patients operated in low-volume centers developed more perioperative complications such as transfusion, sepsis, and ileus.

CONCLUSIONS

Centralization of RC not only improves inpatient morbidity and mortality but also reduces hospital stay and costs. We propose a threshold of 50 RCs/year for optimal outcomes.

Features associated with travel distance for radical cystectomy in Florida: Implications for access to care

INTRODUCTION

Characteristics associated with travel distance for radical cystectomy (RC) remain incompletely defined but are needed to inform efforts to bridge gaps in care. Therefore, we assessed features associated with travel distance for RC in a statewide dataset.

METHODS

We identified RC patients in the Florida Inpatient Discharge dataset from 2013 to 2019. Travel distance was estimated using zip code centroids. The primary outcome was travel >50 miles for RC. Secondary outcomes included inpatient mortality, nonhome discharge, and inpatient complications. U.S. County Health Rankings were included as model covariates. Mixed effects logistic regression models accounting for clustering within hospitals were utilized.

RESULTS

We identified 4,209 patients, of whom 2,284 (54%) traveled <25 miles, 654 (16%) traveled 25 to 50 miles, and 1271 (30%) traveled >50 miles. Patients who traveled >50 miles primarily lived in central and southwest Florida. Following multivariable adjustment, patients traveling >50 miles were less likely to be Hispanic/Latino (odds ratio [OR] 0.35, 95% CI: 0.23-0.51), and more likely to reside in a county with the lowest health behavior (OR 6.48, 95% CI: 3.81-11.2) and lowest socioeconomic (OR 7.63, 95% CI: 5.30-11.1) rankings compared to those traveling <25 miles (all P < 0.01). Travel distance >50 miles was associated with treatment at a high-volume center and significantly lower risks of inpatient mortality, nonhome discharge, and postoperative complications (all P < 0.02).

CONCLUSION

These data identify characteristics of patients and communities in the state of Florida with potentially impaired access to RC care and can be used to guide outreach efforts designed to improve access to care.

Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer

Importance

The value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear.

Objectives

To compare the cost-effectiveness of iRARC with that of ORC.

Design, Setting, and Participants

This economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023.

Interventions

Patients were randomized to receive either iRARC (n = 169) or ORC (n = 169).

Main Outcomes and Measures

Costs of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion.

Results

A total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, -£576 to £2824 [US $1622 (95% CI, -$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status.

Conclusions and Relevance

In this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective.

Trial Registration

ClinicalTrials.gov Identifier: NCT03049410.

Impact of preexisting opioid dependence on morbidity, length of stay, and inpatient cost of urological oncological surgery

OBJECTIVES

To determine the incidence of preexisting opioid dependence in patients undergoing elective urological oncological surgery. In addition, to quantify the impact of preexisting opioid dependence on outcomes and cost of common urologic oncological procedures at a national level in the USA.

METHODS

We used the National Inpatient Sample (NIS) to study 1,609,948 admissions for elective partial/radical nephrectomy, radical prostatectomy, and cystectomy procedures. Trends of preexisting opioid dependence were studied over 2003-2014. We use multivariable-adjusted analysis to compare opioid-dependent patients to those without opioid dependence (reference group) in terms of outcomes, namely major complications, length of stay (LOS), and total cost.

RESULTS

The incidence of opioid dependence steadily increased from 0.6 per 1000 patients in 2003 to 2 per 1000 in 2014. Opioid-dependent patients had a significantly higher rate of major complications (18 vs 10%; p < 0.001) and longer LOS (4 days (IQR 2-7) vs 2 days (IQR 1-4); p < 0.001), when compared to the non-opioid-dependent counterparts. Opioid dependence also increased the overall cost by 48% (adjusted median cost $18,290 [IQR 12,549-27,715] vs. $12,383 [IQR 9225-17,494] in non-opioid-dependent, p < 0.001). Multivariable analysis confirmed the independent association of preexisting opioid dependence with major complications, length of stay in 4th quartile, and total cost in 4th quartile.

CONCLUSIONS

The incidence of preexisting opioid dependence before elective urological oncology is increasing and is associated with adverse outcomes after surgery. There is a need to further understand the challenges associated with opioid dependence before surgery and identify and optimize these patients to improve outcomes.

Effect of Robot-Assisted Radical Cystectomy With Intracorporeal Urinary Diversion vs Open Radical Cystectomy on 90-Day Morbidity and Mortality Among Patients With Bladder Cancer: A Randomized Clinical Trial

IMPORTANCE

Robot-assisted radical cystectomy is being performed with increasing frequency, but it is unclear whether total intracorporeal surgery improves recovery compared with open radical cystectomy for bladder cancer.

OBJECTIVES

To compare recovery and morbidity after robot-assisted radical cystectomy with intracorporeal reconstruction vs open radical cystectomy.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial of patients with nonmetastatic bladder cancer recruited at 9 sites in the UK, from March 2017-March 2020. Follow-up was conducted at 90 days, 6 months, and 12 months, with final follow-up on September 23, 2021.

INTERVENTIONS

Participants were randomized to receive robot-assisted radical cystectomy with intracorporeal reconstruction (n = 169) or open radical cystectomy (n = 169).

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of days alive and out of the hospital within 90 days of surgery. There were 20 secondary outcomes, including complications, quality of life, disability, stamina, activity levels, and survival. Analyses were adjusted for the type of diversion and center.

RESULTS

Among 338 randomized participants, 317 underwent radical cystectomy (mean age, 69 years; 67 women [21%]; 107 [34%] received neoadjuvant chemotherapy; 282 [89%] underwent ileal conduit reconstruction); the primary outcome was analyzed in 305 (96%). The median number of days alive and out of the hospital within 90 days of surgery was 82 (IQR, 76-84) for patients undergoing robotic surgery vs 80 (IQR, 72-83) for open surgery (adjusted difference, 2.2 days [95% CI, 0.50-3.85]; P = .01). Thromboembolic complications (1.9% vs 8.3%; difference, -6.5% [95% CI, -11.4% to -1.4%]) and wound complications (5.6% vs 16.0%; difference, -11.7% [95% CI, -18.6% to -4.6%]) were less common with robotic surgery than open surgery. Participants undergoing open surgery reported worse quality of life vs robotic surgery at 5 weeks (difference in mean European Quality of Life 5-Dimension, 5-Level instrument scores, -0.07 [95% CI, -0.11 to -0.03]; P = .003) and greater disability at 5 weeks (difference in World Health Organization Disability Assessment Schedule 2.0 scores, 0.48 [95% CI, 0.15-0.73]; P = .003) and at 12 weeks (difference in WHODAS 2.0 scores, 0.38 [95% CI, 0.09-0.68]; P = .01); the differences were not significant after 12 weeks. There were no statistically significant differences in cancer recurrence (29/161 [18%] vs 25/156 [16%] after robotic and open surgery, respectively) and overall mortality (23/161 [14.3%] vs 23/156 [14.7%]), respectively) at median follow-up of 18.4 months (IQR, 12.8-21.1).

CONCLUSIONS AND RELEVANCE

Among patients with nonmetastatic bladder cancer undergoing radical cystectomy, treatment with robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy resulted in a statistically significant increase in days alive and out of the hospital over 90 days. However, the clinical importance of these findings remains uncertain.

TRIAL REGISTRATION

ISRCTN Identifier: ISRCTN13680280; ClinicalTrials.gov Identifier: NCT03049410.

Defining radical cystectomy using the ICD-10 procedure coding system

INTRODUCTION

The International Classification of Diseases-10-Procedure Coding System (ICD-10-PCS) is markedly more complex than the preceding ICD-9 system, which has increased the difficulty of identifying radical cystectomy (RC) in administrative datasets. Given the absence of a consensus code definition for RC, we sought to develop and internally validate a list of ICD-10-PCS codes for RC.

MATERIALS AND METHODS

All RCs performed from January 2019 to December 2020 were identified from our prospectively maintained registries and split into training (2019) and validation (2020) cohorts. A list of candidate ICD-10-PCS codes to identify RC were compiled using an online ICD-9 to ICD-10 converter. Codes were used to identify RCs from hospital billing data and referenced against registry cases in the training cohort; when discrepancies were found, the working ICD-10 code definition was iteratively revised. Accuracy of the consensus code list was verified in the validation cohort.

RESULTS

We identified 459 RCs over the study period, including 225 in 2019 and 234 in 2020. In the training cohort, our codes identified 241 procedures, including 222 of 225 (99%) RCs performed for bladder cancer. Misidentified cases included 15 (6.2%) RCs for benign disease or nonurologic cancers and 4 (1.7%) non-RC cases. In the validation cohort we identified 239 cases, including 227 of 234 (97%) RCs for bladder cancer and 12 (5%) RCs for benign disease or nonurologic cancers.

CONCLUSION

Given high fidelity to actual procedures performed, this list of ICD-10-PCS codes may be useful for researchers seeking to identify RC within administrative datasets.

Hospital volume is associated with postoperative mortality after radical cystectomy for treatment of bladder cancer

Objective

To contribute to the debate regarding the minimum volume of radical cystectomies (RCs) that a hospital should perform by evaluating the association between hospital volume (HV) and postoperative mortality.

Patients and Methods

Patients who underwent RC for bladder cancer between 1 January 2008 and 31 December 2018 were retrospectively identified from the Netherlands Cancer Registry. To create a calendar‐year independent measure, the HV of RCs was calculated per patient by counting the RCs performed in the same hospital in the 12 months preceding surgery. The relationship of HV with 30‐ and 90‐day mortality was assessed by logistic regression with a non‐linear spline function for HV as a continuous variable, which was adjusted for age, tumour, node and metastasis (TNM) stage, and neoadjuvant treatment.

Results

The median (interquartile range; range) HV among the 9287 RC‐treated patients was 19 (12–27; 1–75). Of all the included patients, 208 (2.2%) and 518 (5.6%) died within 30 and 90 days after RC, respectively. After adjustment for age, TNM stage and neoadjuvant therapy, postoperative mortality slightly increased between an HV of 0 and an HV of 25 RCs and steadily decreased from an HV of 30 onwards. The lowest risks of postoperative mortality were observed for the highest volumes.

Conclusion

This paper, based on high‐quality data from a large nationwide population‐based cohort, suggests that increasing the RC volume criteria beyond 30 RCs annually could further decrease postoperative mortality. Based on these results, the volume criterion of 20 RCs annually, as recently recommended by the European Association of Urology Guideline Panel, might therefore be reconsidered.

Impact of hospital and surgeon volumes on short-term and long-term outcomes of radical cystectomy

PURPOSE OF REVIEW

There is heightened awareness and trends towards centralizing high-risk, complex surgeries such as radical cystectomy to minimize complications and improve survival. However, after nearly a decade of mandated and/or passive centralization of care, debate regarding its benefits and harms continues.

RECENT FINDINGS

During the past decade, mandated and passive centralization has led to an increase in radical cystectomies performed in high-volume hospitals (HVHs) and, perhaps by high-volume surgeons (HVS), in addition to efforts to increase the uptake of multidisciplinary strategies in the management of radical cystectomy patients. Consequently, 30 and 90-day mortality rates and overall survival have improved, and major complications and transfusion rates have decreased. Factors impacting surgical quality, such as negative surgical margin(s), pelvic lymphadenectomy and/or lymph node yield rates have increased. However, current studies have not demonstrated a coadditive impact of centralization on oncological outcomes (i.e. cancer-specific and recurrence-free survival). The benefits of centralization on oncologic survival of radical cystectomy remain unclear given the varied definitions of HVHs and HVSs across studies. In fact, centralization of radical cystectomy could lead to an increase in patient load in HVHs and for HVSs, thereby leading to longer surgery waiting times, a factor that is important in the management of muscle-invasive bladder cancer.

SUMMARY

The benefits of centralization of radical cystectomy with multidisciplinary management are shown increasingly and convincingly. More studies are necessary to prospectively test the benefits, risks and harms of centralization.

The Importance of Hospital and Surgeon Volume as Major Determinants of Morbidity and Mortality After Radical Cystectomy for Bladder Cancer: A Systematic Review and Recommendations by the European Association of Urology Muscle-invasive and Metastatic Bladder Cancer Guideline Panel

CONTEXT

In bladder cancer patients treated with radical cystectomy (RC), controversy exists regarding the impact of the annual hospital volume (HV) and/or surgeon volume (SV) on oncological outcomes and quality of care.

OBJECTIVE

A systematic review was performed to evaluate the impact of HV and SV on clinical outcomes. Primary outcomes included in-hospital, 30-d, and 90-d mortality. Secondary outcomes included complications, long-term survival, positive surgical margin rate, lymphadenectomy performance, length of hospital stay, neobladder performance, and blood loss/transfusion rate.

EVIDENCE ACQUISITION

Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched. Comparative studies published after the year of 2000 including patients who underwent RC for bladder cancer were eligible for inclusion. Partial cystectomy was an exclusion criterion. Risk of bias (RoB) assessment was performed according to the ROBINS-1 tool.

EVIDENCE SYNTHESIS

After screening of 1190 abstracts, 39 studies recruiting 549 542 patients were included. All studies were retrospective observation cohort studies (level of evidence 3). Twenty-two studies reported on HV only, six studies on SV only, and 12 on both. Higher HV, specifically an HV of >10, was associated with improved primary and secondary outcomes in most studies. In addition, there is some evidence that an HV of >20 improves outcomes. For SV, limited and conflicting data are reported. Most studies had moderate to high RoB. The results were synthesized narratively.

CONCLUSIONS

Acknowledging the lower level of evidence, HV is likely associated with in-hospital, 30- and 90-d mortality, as well as the secondary outcomes assessed. Based on this study, the European Association of Urology Muscle-invasive and Metastatic Bladder Cancer Guideline Panel recommends hospitals to perform at least 10, and preferably >20, RCs annually or refer the patient to a center that reaches this number. For SV, limited and conflicting data are available. The available evidence suggests HV rather than SV to be the main driver of perioperative outcomes.

PATIENT SUMMARY

Current literature suggests that the number of bladder removal operations per hospital per year is associated with postoperative survival as well as the quality of care provided.

Non-financial conflicts of interest: contribution to a surgical dilemma by the European Reference Networks for Rare Diseases

PURPOSE

Conflicts of interest can impede both research and medical treatment. The European Reference Networks require their members to deal with financial and non-financial conflicts according to an explicit protocol. In a literature review, we identified relevant interests in paediatric surgery, and drafted such a policy.

METHODS

We conducted a Pubmed query and identified additional publications based on the content of the papers.

RESULTS

58 titles were identified. According to their abstracts, 10 publications were studied in full text. A scientific taxonomy does not yet exist, but a variety of factors are mentioned. Non-financial conflicts of interest are addressed less accurately and less frequently than financial ones, especially regarding surgical treatment. Since the clinical effect of surgical volume was identified as being relevant, additional 29 respective publications were analysed. This volume-quality relationship causes conflicts of interest for the many surgeons treating a broad spectrum of rare conditions. We present a recommendation that may guide referral of patients requiring complex surgery to centres with a higher volume.

CONCLUSIONS

Non-financial conflicts of interest need to be dealt with more accuracy, especially with regard to surgery in rare, complex congenital conditions. The European Reference Networks offer a framework to mitigate these conflicts.

Charlson comorbidity score is associated with readmission to the index operative hospital after radical cystectomy and correlates with 90-day mortality risk

PURPOSE

Our objective was to determine perioperative variables associated with 30-day readmission to the index operative hospital after radical cystectomy for bladder cancer and subsequent survival outcomes.

METHODS

Retrospective cohort study utilizing the United States National Cancer Database from 2004-2015. All clinical stages undergoing radical cystectomy were analyzed. Exclusion criteria included clinical suspicion of nodal disease, metastasis, or preoperative radiation therapy. Multivariable logistic regression was used for 30-day readmission risk to the index hospital. Kaplan-Meier analysis and multivariable Cox regressions were used for survival outcomes.

RESULTS

31,147 patients were identified and stratified by 30-day readmission (n = 2628) or no readmission (n = 28,519). Thirty-day readmission to the index surgery hospital was 8.4%. Groups were comparable in terms of age, gender, race, income, facility type, insurance, length of hospital stay, and pathologic stage. There were significantly more patients with higher Charlson comorbidity score in the readmission cohort. On logistic regression analysis, increasing Charlson score was the only predictor of 30-day readmission (OR 1.39-1.73, p < 0.001). The 90-day mortality rate was 7.2% overall (7.0% no readmission vs 9.9% 30-day readmission, p < 0.001). Cox regression analysis for mortality revealed increasing age (HR 1.04), higher Charlson score (HR 1.42-1.85), readmission within 30 days (HR 1.38) and pathologic stage pT ≥ 2 (HR 1.88-7.09, all p < 0.001) as independent predictors of 90-day mortality.

CONCLUSIONS

Increasing comorbidity is a strong predictor of readmission to the index surgery hospital after radical cystectomy. Readmission is associated with worsened mortality at 90 days.