Comparison of Major Complications at 30 and 90 Days Following Radical Cystectomy

Perioperative factors and 30-day major complications following radical cystectomy: A single-center study in Thailand

Objective

This study aims to evaluate the prevalence of early postoperative complications of radical cystectomy, using standardized reporting methodology to assess perioperative characteristics and determine risk factors for major complications.

Materials and methods

A retrospective study included 254 consecutive bladder cancer patients undergoing RC between 2012 and 2020 at a urological cancer referral center. Postoperative complications within 30 days were recorded and graded according to the Clavien-Dindo classification (CDC). The study examined risk factors, including novel inflammatory-nutrition biomarkers and perioperative serum chloride.

Results

Total complications were observed in 135 (53 %). Of these, 47 (18.5 %) were high grade (CDC ≥ 3). Wound dehiscence was the most common complication, occurring in 14 (5.5 %) patients. Independent risk factors for major complications included an age-adjusted Charlson comorbidity index (ACCI) > 4 and thrombocytopenia (odds ratio [OR] 3.67 and OR 8.69). Preoperative platelet counts < 220,000/μL and albumin < 3 mg/dL were independent risk factors for wound dehiscence (OR 3.91 and OR 4.72). Additionally, postoperative hypochloremia was a risk factor for major complications (OR 13.71), while novel serum biomarkers such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic inflammatory response index (SIRI), and prognostic nutritional index (PNI) were not associated with early major complications.

Conclusion

Patients who have multiple comorbidities are at a greater risk of developing major complications after undergoing RC. Our result suggests that preoperative platelet counts and serum albumin levels are associated with wound dehiscence.

The Association Between Duration of Antibiotics and Infectious Complications Following Radical Cystectomy: Analysis of the 2019-2021 NSQIP Database

OBJECTIVES

To identify the impact of the duration of peri-operative antibiotics on infectious complications following radical cystectomy.

METHODS

The National Surgical Quality Improvement Project (NSQIP) targeted database was queried for patients undergoing radical cystectomy from 2019 to 2021. Baseline patient characteristics were collected. Antibiotic duration was classified as <24 hours (short), 24-72 hours (intermediate) or >72 hours (long). Infectious complication data were collected including surgical site infection (SSI), urinary tract infection (UTI), organ space infection, pneumonia, sepsis, and clostridium difficile infection up to 30 days after surgery. Univariate and multivariable analyses were performed to compare duration of antibiotic therapy to infectious outcomes.

RESULTS

Of the 4363 patients who underwent radical cystectomy, 3250 (74%), 827 (19%) and 286 (6.6%) received short, intermediate, and long duration of peri-operative antibiotics, respectively. Infectious complication occurred in 954 (22%) patients, including 227 (5.2%) SSI, 280 (6.4%) UTI, 268(6.1%) organ space infection, 87 (2%) pneumonia, and 378 (8.7%) sepsis. Clostridium difficile infection occurred in 89 (2%) patients. On multivariable analysis, there was no significant difference in overall infectious complication rates with long-duration antibiotics. However, intermediate duration of antibiotics in open surgery was associated with a decreased risk of SSI (OR 0.58; 95%CI 0.37-0.91) compared to those treated with short-term antibiotics.

CONCLUSION

Despite guideline recommendations, 26% of patients in this database received >24 hours of peri-operative antibiotics without decreased risk of overall infectious complication. An intermediate course of antibiotics decreased risk of SSI in open surgery compared to the guideline recommend <24-hour course. Greater education regarding antibiotic stewardship and further studies investigating infectious complications are warranted.

The impact of venous thromboembolism before open or minimally-invasive radical cystectomy in the USA: insurance claims data on perioperative outcomes and healthcare costs

BACKGROUND

The relationship between venous thromboembolism (VTE) and solid malignancy has been established over the decades. With rising projected rates of bladder cancer (BCa) worldwide as well as increasing number of patients experiencing BCa and VTE, our aim is to assess the impact of a preoperative VTE diagnosis on perioperative outcomes and health-care costs in BCa cases undergoing radical cystectomy (RC).

METHODS

Patients ≥18 years of age with BCa diagnosis and undergoing open or minimally invasive (MIS) RC were identified in the Merative™ Marketscan® Research Databases between 2007 and 2021. The association of previous VTE history with 90-day complication rates, postoperative VTE events, rehospitalization, and total hospital costs (2021 USA dollars) was determined by multivariable logistic regression modeling adjusted for patient and perioperative confounders. Sensitivity analysis on VTE degree of severity (i.e., pulmonary embolism [PE] and/or peripheral deep venous thrombosis [DVT]) was also examined.

RESULTS

Out of 8759 RC procedures, 743 (8.48%) had a previous positive history for any VTE including 245 (32.97%) PE, 339 (45.63%) DVT and 159 (21.40%) superficial VTE. Overall, history of VTE before RC was strongly associated with almost any worse postoperative outcomes including higher risk for any and apparatus-specific 90-days postoperative complications (odds ratio [OR]: 1.21, 95% CI, 1.02-1.44). Subsequent incidence of new VTE events (OR: 7.02, 95% CI: 5.93-8.31), rehospitalization (OR: 1.25, 95% CI: 1.06-1.48), other than home/self-care discharge status (OR: 1.53, 95% CI: 1.28-1.82), and higher health-care costs related to the RC procedure (OR: 1.43, 95% CI: 1.22-1.68) were significantly associated with a history of VTE.

CONCLUSIONS

Preoperative VTE in patients undergoing RC significantly increases morbidity, post-procedure VTE events, hospital length of stay, rehospitalizations, and increased hospital costs. These findings may help during the BCa counseling on risks of surgery and hopefully improve our ability to mitigate such risks.

Preoperative smoking and robot-assisted radical cystectomy outcomes & complications in multicenter KORARC database

To investigate the influence of preoperative smoking history on the survival outcomes and complications in a cohort from a large multicenter database. Many patients who undergo radical cystectomy (RC) have a history of smoking; however, the direct association between preoperative smoking history and survival outcomes and complications in patients with muscle-invasive bladder cancer (MIBC) who undergo robot-assisted radical cystectomy (RARC) remains unexplored. We conducted a retrospective analysis using data from 749 patients in the Korean Robot-Assisted Radical Cystectomy Study Group (KORARC) database, with an average follow-up duration of 30.8 months. The cohort was divided into two groups: smokers (n = 351) and non-smokers (n = 398). Propensity score matching was employed to address differences in sample size and baseline demographics between the two groups (n = 274, each). Comparative analyses included assessments of oncological outcomes and complications. After matching, smoking did not significantly affect the overall complication rate (p = 0.121). Preoperative smoking did not significantly increase the occurrence of complications based on complication type (p = 0.322), nor did it increase the readmission rate (p = 0.076). There were no perioperative death in either group. Furthermore, preoperative smoking history showed no significant impact on overall survival (OS) [hazard ratio (HR) = 0.87, interquartile range (IQR): 0.54-1.42; p = 0.589] and recurrence-free survival (RFS) (HR = 1.12, IQR: 0.83-1.53; p = 0.458) following RARC for MIBC. The extent of preoperative smoking (≤ 10, 10-30, and ≥ 30 pack-years) had no significant influence on OS and RFS in any of the categories (all p > 0.05). Preoperative smoking history did not significantly affect OS, RFS, or complications in patients with MIBC undergoing RARC.

Modified GLIM Status as a Predictor of Morbidity and Mortality After Radical Cystectomy: A Propensity Matched Analysis

INTRODUCTION

To assess the modified Global Leadership Initiative on Malnutrition (mGLIM) status as a predictor of postoperative mortality and morbidity in patients undergoing Radical Cystectomy (RC).

METHODS AND MATERIALS

The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to select patients who underwent RC between the years 2011 to 2020. A positive mGLIM status includes patients with preoperative albumin levels < 3.5 g/L or patients with ≥ 10% weight loss over 6 months or BMI ≤ 21 kg/m2. We compared prolonged length of stay, mortality, major morbidity and Clavien-Dindo complications between mGLIM positive and negative patients. A multivariable logistic regression model was also performed to control for possible confounders. Furthermore, a sensitivity analysis was performed by propensity score matching.

RESULTS

Our cohort consisted of 12,760 patients who underwent RC. The matched cohort yielded 4864 matched patients. After propensity score matching, patients with a positive mGLIM status had higher odds of prolonged length of stay (OR = 1.99, 95%CI [1.75, 2.27]), mortality (OR 1.56, 95%CI [1.08, 2.26]), major morbidity (OR = 1.69, 95%CI [1.51, 1.90]), Clavien-Dindo class I and II (OR = 1.77, 95%CI [1.58, 1.99]), and lower odds of Clavien-Dindo class III (OR = 0.72, 95%CI [0.57, 0.92]) as compared to those with a negative mGLIM status (P < .018).

CONCLUSION

A positive mGLIM status is associated with prolonged hospital stay, morbidity, and mortality following RC. This indicates that the mGLIM criteria could serve as an independent predictor of morbidity and mortality in an attempt to optimize patient counseling and preoperative care.

An International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery (TOLS)

OBJECTIVE

To reach global expert consensus on the definition of TOLS in minimally invasive and open liver resection among renowned international expert liver surgeons using a modified Delphi method.

BACKGROUND

Textbook outcome is a novel composite measure combining the most desirable postoperative outcomes into one single measure and representing the ideal postoperative course. Despite a recently developed international definition of Textbook Outcome in Liver Surgery (TOLS), a standardized and expert consensus-based definition is lacking.

METHODS

This international, consensus-based, qualitative study used a Delphi process to achieve consensus on the definition of TOLS. The survey comprised 6 surgical domains with a total of 26 questions on individual surgical outcome variables. The process included 4 rounds of online questionnaires. Consensus was achieved when a threshold of at least 80% agreement was reached. The results from the Delphi rounds were used to establish an international definition of TOLS.

RESULTS

In total, 44 expert liver surgeons from 22 countries and all 3 major international hepato-pancreato-biliary associations completed round 1. Forty-two (96%), 41 (98%), and 41 (98%) of the experts participated in round 2, 3, and 4, respectively. The TOLS definition derived from the consensus process included the absence of intraoperative grade ≥2 incidents, postoperative bile leakage grade B/C, postoperative liver failure grade B/C, 90-day major postoperative complications, 90-day readmission due to surgery-related major complications, 90-day/in-hospital mortality, and the presence of R0 resection margin.

CONCLUSIONS

This is the first study providing an international expert consensus-based definition of TOLS for minimally invasive and open liver resections by the use of a formal Delphi consensus approach. TOLS may be useful in assessing patient-level hospital performance and carrying out international comparisons between centers with different clinical practices to further improve patient outcomes.

Timing of Adverse Events Within 90 Days of Hip Fracture Surgery: A Database Study

INTRODUCTION

Hip fracture surgery is associated with notable morbidity. Understanding the timing of adverse events can inform strategies for prevention and management. Owing to database limitations, many studies have limited postoperative follow-up to 30 days. However, adverse events may not have plateaued by this time. This study evaluated adverse events after hip fracture surgery out to 90 days.

METHODS

Hip fracture surgeries in patients 65 years or older were identified in the 2010 to 2020 Q3 M91Ortho PearlDiver data set using administrative codes. The 90-day incidence and time of diagnosis of 10 common adverse events were determined and used to calculate median, interquartile range, and middle 80% for time of diagnosis. The number of events occurring before and after 30 days was also determined.

RESULTS

A total of 258,834 hip fracture surgery patients were identified. On average, 70% of adverse events occurred in postoperative days 0 to 30 and 30% occurred in days 31 to 90. The percentage of events in days 31 to 90 ranged from 8% (transfusion) to 42% (wound dehiscence). Compared with patients with a 0- to 30-day adverse event, those with 31- to 90-day adverse events had higher average Elixhauser Comorbidity Index scores (8.6 vs. 7.8, P < 0.001) and a slightly greater proportion of men (31.5% vs. 30.2%, P < 0.001).For specific adverse events, the time of diagnosis (median; interquartile range; middle 80%) were as follows: transfusion (2 days; 1 to 4 days; 1 to 24 days), acute kidney injury (5; 2 to 26; 1 to 55), cardiac event (9; 3 to 35; 1 to 64), urinary tract infection (13; 3 to 39; 1 to 65), hematoma (14; 6 to 28; 3 to 52), pneumonia (15; 5 to 39; 2 to 66), venous thromboembolism (16; 5 to 40; 2 to 64), surgical site infection (23; 14 to 37; 7 to 56), sepsis (24; 9 to 48; 3 to 71), and wound dehiscence (26; 15 to 41; 7 to 64).

DISCUSSION

Nearly one-third of 90-day adverse events after hip fracture surgery were found to occur after postoperative day 30. An understanding of the timing of adverse events is important for improving patient counseling and optimizing patient care.

Effect of a Smoking and Alcohol Cessation Intervention Initiated Shortly Before Radical Cystectomy-the STOP-OP Study: A Randomised Clinical Trial

BACKGROUND

Evidence concerning the reduction of postoperative complications due to smoking and alcohol drinking in patients undergoing radical cystectomy is incomplete.

OBJECTIVE

To evaluate the efficacy of a 6-wk smoking and/or alcohol cessation intervention, initiated shortly before surgery and continued until 4 wk after, in reducing complications.

DESIGN, SETTING, AND PARTICIPANTS

Between 2014 and 2018, we enrolled 104 patients with high-risk bladder cancer who were daily smokers or consuming at least 3 units of alcohol daily in a multicentre randomised clinical trial.

INTERVENTION

Patients were randomised to a 6-wk intensive smoking and/or alcohol cessation intervention or treatment as usual.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was the number of patients developing any postoperative complication, or death, within 30 d after surgery. The secondary endpoints were successful quitters, health-related quality of life, length of stay, time back to habitual activity, and mortality. An intention-to-treat analysis was applied to evaluate treatment effect.

RESULTS AND LIMITATIONS

There were some differences in baseline demographic and lifestyle characteristics. Postoperatively, 64% in the intervention group versus 70% in the control group (risk ratio [RR] 0.91, confidence interval [CI] 0.68-1.21, p = 0.51) developed complications. Significantly fewer patients developed three or more complications after 30 d (RR 0.39; CI 0.18-0.84, p = 0.01). The rates of successful quitting were 51% in the intervention group and 27% in the control group (RR 2, CI 1.14-3.51, p = 0.01). The external validity of this trial may be limited because 53% of eligible patients refused participation.

CONCLUSIONS

Despite a significant effect on the quit rate at completion of the intervention, this multimodal prehabilitation did not show a significant difference regarding our primary outcome postoperative complications.

PATIENT SUMMARY

A 6-wk smoking and alcohol cessation intervention in relation to bladder cancer surgery did not reduce postoperative complications, but it was effective in supporting people to quit in the short term.

Adverse Events After Posterior Lumbar Fusion Are Not Sufficiently Characterized With 30-day Follow-up: A Database Study

INTRODUCTION

Many studies track outcomes after procedures, such as posterior lumbar fusion (PLF), for only 30 days because of database limitations. However, adverse events may not have plateaued by this time. Thus, this study used an alternate database to evaluate the timing of adverse events for 90 days after PLF.

METHODS

Adult PLF patients were identified from the 2010 to 2020 Q2 M53Ortho PearlDiver administrative data set. Ninety-day rates of multiple adverse events were determined. The time of diagnosis for each event in the 90-day postoperative period was determined. Data were dichotomized by occurrence in days 0 to 30 and 31 to 90. Median, interquartile range, and middle 80% for the time of diagnosis were determined for each adverse event.

RESULTS

Of 51,915 patients undergoing PLF, 7,141 (13.8%) had an adverse event within 90 days of PLF. Of these, 5,174 (72.5%) experienced an event within 30 days and 2,544 (35.6%) after 30 days. For individual adverse outcomes studied, the percent that occurred 31 to 90 days after surgery ranged from 9% to 42%. The time of diagnosis (median; interquartile range; middle 80%) for each adverse event was as follows: transfusion (2 days; 2 to 5 days; 1 to 26 days), acute kidney injury (9; 2 to 29; 1 to 60), hematoma (9; 4 to 20; 3 to 39), cardiac event (11; 3 to 43; 1 to 71), pneumonia (12; 4 to 38; 2 to 68), venous thromboembolism (15; 6 to 33; 3 to 62), sepsis (19; 9 to 39; 4 to 63), surgical site infection (21; 14 to 34; 8 to 48), urinary tract infection (22; 8 to 49; 4 to 72), and wound dehiscence (27; 17 to 39; 9 to 54).

DISCUSSION

This study highlights the importance of looking past the 30-day mark for adverse events after PLF because approximately one-third of adverse events in this study were diagnosed 31 to 90 days after surgery. This can affect research studies, patient counseling about the incidence of specific adverse events, and the development of mechanisms for surveillance at key time points.

Predicting factor analysis of postoperative complications after robot-assisted radical cystectomy: Multicenter KORARC database study

OBJECTIVES

To evaluate postoperative complications following robot-assisted radical cystectomy in patients diagnosed with bladder cancer and reveal if there are predictors for postoperative complications.

METHODS

Prospectively collected medical records of 730 robot-assisted radical cystectomy patients between 2007/04 and 2019/05 in 13 tertiary referral centers were reviewed. Perioperative outcomes were compared between two groups by postoperative complications (complication vs non-complication). We assessed recurrence-free survival, cancer-specific survival, and overall survival between groups. Regression analyses were implemented to identify factors associated with postoperative complications.

RESULTS

Any total and high-grade complication (Clavien-Dindo grade ≥3) rates were 57.8% and 21.1%, respectively. Patients in complication group had significantly higher proportion of diabetes mellitus (P = 0.048), chronic kidney disease (P = 0.011), dyslipidemia (P < 0.001), longer operation time (P = 0.001), more estimated blood loss (P = 0.001), and larger intraoperative fluid volume (P < 0.001). There was a significant difference in cancer-specific survival (log-rank P = 0.038, median cancer-specific survival: both groups not reached). Dyslipidemia (odds ratio 2.59, P = 0.002) and intraoperative fluid volume (odds ratio 1.0002, P = 0.040) were significantly associated with high-grade postoperative complications. Diabetes mellitus (odds ratio 1.97, P = 0.028), chronic kidney disease (odds ratio 1.89, P = 0.046), dyslipidemia (odds ratio 5.94, P = 0.007), and intraoperative fluid volume (odds ratio 1.0002, P = 0.009) were significantly associated with any postoperative complications.

CONCLUSIONS

Patients with diabetes mellitus, chronic kidney disease, dyslipidemia, or a relatively large intraoperatively infused fluid volume are more likely to develop postoperative complications. Patients with postoperative complications might have a possibility of lower cancer-specific survival rate.

Organ-Sparing Strategies in Muscle-Invasive Bladder Cancer

Radical cystectomy (RC) is the treatment of choice and is strongly recommended for patients with pT2-4aN0M0 bladder cancer in both the European Association of Urology (EAU) and American Urological Association (AUA) muscle-invasive bladder cancer (MIBC) guidelines. RC is a challenging operation, with significant perioperative and postoperative morbidity and mortality, having short-term complication rates between 14.4% and 21.7%, and long-term oncological survival rates ranging from 60% after 5 years to 43% after 10 years. The impact on quality of life (QoL) in patients after treatment for bladder cancer is significantly worse than in other pelvic cancers. Although RC is strongly recommended as the gold standard, there is a need for bladder-sparing options in MIBC. Attempts to improve mortality and morbidity rates after RC have been made by implementing Enhanced Recovery After Surgery (ERAS), robot-assisted RC, and sexual function-preserving techniques. None of these significantly improves QoL or functional outcome. Because of the invasiveness of RC, other therapeutic options have been evaluated. Transurethral resection of the bladder tumor (TURB) plays an important role in the diagnostic evaluation of MIBC and has also been reviewed as a curative option, although the oncological results appear inferior to RC. Furthermore, improved radiotherapy (RT) and widely used chemotherapy, both as monotherapeutic options in bladder cancer, are not as effective as radical surgery, with lower survival rates. Trimodality treatment (TMT) in bladder cancer combines TURB with chemotherapy and RT. The goal of TMT is preserving the bladder and QoL without compromising oncological outcome. A 2018 review showed no difference in overall survival rates between RC and TMT (30.9% vs 35.1%), with lower survival rates after RC than TMT in the first year of follow-up, probably due to higher postoperative mortality. For a selected group of patients, TMT is to be recommended, and it is the most favorable option out of the organ-sparing strategies in MIBC.

Single-Port Robotic Radical Cystectomy with Intracorporeal Bowel Diversion: Initial Experience and Review of Surgical Outcomes

INTRODUCTION & OBJECTIVE

Scant literature is available on surgical outcomes of radical cystectomies on the new single-port (SP) system. This study compares short term outcomes in patients undergoing radical cystectomy with intracorporeal urinary diversion (ICUD) on the multi-port (MP) vs. SP platform.

METHODS

This IRB approved study used a prospective cystectomy database and non-parametric testing including Chi-Squared, Mann-Whitney U, and Fisher Exact tests to analyze all variables stratified by surgical approach.

RESULTS

34 patients underwent radical cystectomy with ICUD from 9/1/2019 to 2/8/2021. 20 patients were in the MP cohort, while 14 were in the SP group. Table 1 presents the demographics of both groups and shows no statistically significant differences. Intra- and post-operative as well as pathology data is shown in Table 2. Patients in the SP group had less narcotic use (MP: 25 MME vs. SP: 11.5 MME, p=0.047) and shorter return of bowel function (MP: 3 days vs. SP: 2 days, p=0.032). Operative times were similar between both groups despite having fewer patients undergoing ileal conduit (MP: 85% vs. SP: 50%, p=0.027) in the SP group. In table 3, we list the early short term post-operative follow up data for each group which showed no significant differences between the two groups with an average follow up of 4.9 months for MP and 4.4 months for SP.

CONCLUSIONS

Our initial experience with SP robotic cystectomy and ICUD appears to be safe and an effective alternative to MP cystectomies. A learning curve was involved but the overall transition from MP to SP was smooth. Operative times were similar despite fewer patients undergoing ileal diversion, shorter return of bowel function, and less narcotic use in the SP group. Further studies including longer follow ups with multi-institutional data are underway.