One-stage radical cystectomy for bladder carcinoma: operative mortality, cost/benefit analysis

Costs of radical cystectomy

OBJECTIVE

The total costs of radical cystectomy comprise a significant part of the total costs of bladder cancer treatment. The aims of this study were to determine the costs of cystectomy, with and without complications, and to investigate related prognostic factors.

MATERIAL AND METHODS

The clinical records and relevant economic files of 70 consecutive patients operated on between 1994 and 1998 were studied. Uni- and multivariate analyses were performed on 22 variables of possible prognostic significance to high total costs.

RESULTS

The total (median) costs for 53 uncomplicated and 17 complicated cystectomies were 181,096 and 290,625 SEK, respectively. The preoperative variables (patient characteristics) had no or minimal prognostic significance for high total costs. High peri-operative blood loss was the most important factor associated with high total hospital costs for radical cystectomy.

CONCLUSIONS

Total costs may be very high for a cystectomy with complications. Peri-operative blood loss was the most important factor associated with high total hospital costs for radical cystectomy due to bladder cancer. If the amount of bleeding can be influenced then substantial reductions in the total costs of cystectomy would seem possible.

Identifying risk factors for potentially avoidable complications following radical cystectomy

PURPOSE

Morbidity after radical cystectomy is common and associated with increased health care resource use. Accurate characterization of complications after cystectomy, associated patient specific risk factors, and perioperative processes of care are essential to directing changes in perioperative management that will reduce morbidity and improve the quality of patient care.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program (NSQIP) is a prospective quality management initiative of 123 Veterans Affairs Medical Centers nationwide. The NSQIP collects clinical information, intraoperative data and outcomes on a wide variety of surgical procedures from multiple surgical disciplines. Since 1991, 2,538 radical cystectomy procedures have been captured by the NSQIP. Modeling using logistic regression was performed to identify patient specific risk factors and perioperative process measures associated with postoperative morbidity.

RESULTS

Of the 2,538 subjects at least 1 postoperative complication developed in 774 (30.5%). The most frequent complication was ileus (10%). Several factors were associated with the development of a complication, including age, dependent functional status, preoperative dyspnea, preoperative acute renal failure, chronic steroid use, preoperative alcohol consumption, American Society of Anesthesiology score, use of general anesthetic, operative time, intraoperative blood requirement and surgeon level of training.

CONCLUSIONS

Morbidity remains high after cystectomy with 30.5% of subjects experiencing at least 1 complication. Measurable patient specific risk factors and perioperative processes associated with postoperative morbidity following cystectomy are now delineated which allows for improved risk stratification, patient counseling, and the development of novel processes that may incrementally reduce risk and improve outcomes.

The health economics of bladder cancer: a comprehensive review of the published literature

The aim of this paper was to conduct a critical systematic review of the available literature on the clinical and economic burden of bladder cancer in developed countries, with a focus on the cost effectiveness of interventions aimed at reducing that burden.Forty-four economic studies were included in the review. Because of long- term survival and the need for lifelong routine monitoring and treatment, the cost per patient of bladder cancer from diagnosis to death is the highest of all cancers, ranging from 96000-187000 US dollars (2001 values) in the US. Overall, bladder cancer is the fifth most expensive cancer in terms of total medical care expenditures, accounting for almost 3.7 billion US dollars (2001 values) in direct costs in the US. Screening for bladder cancer in the general population is currently not recommended. The economic value of relatively new and less expensive urine assays and molecular urinary tumour markers has not been assessed. However, the literature suggests that screening patients suspected of having bladder cancer and using less invasive diagnostic procedures is cost effective. Very few cost-effectiveness studies have evaluated intravesical therapies such as bacillus Calmette-Guérin and mitomycin in the management of superficial disease and no robust recommendations can be drawn. Economic analyses suggest that non-surgical treatment strategies for the management of invasive disease aiming at bladder preservation may not be cost effective, because they have not consistently demonstrated survival benefits and do not eliminate the need for subsequent radical cystectomy. The literature suggests that the current conventional frequent follow-up and monitoring of patients can be cost effectively replaced by less frequent and less invasive monitoring, and should rely more heavily on intravesical chemotherapy to reduce the need for cystoscopies. Bladder cancer is a fairly common and costly malignancy. Nevertheless, the existing literature only contributes marginally to our knowledge concerning the burden of bladder cancer and the economic value of various interventions. The limited value of the literature in this area may be attributed to (i) being published as abstracts rather than full peer-reviewed evaluations; (ii) employing questionable methodologies; and (iii) being in many cases nearly obsolete, rendering them less relevant to, if not in conflict with, current clinical practice. Consequently, opportunities exist to conduct meaningful economic research in all areas of the management of bladder cancer, including screening, diagnosis, follow-up and treatment, especially with respect to new and innovative pharmaceutical and other technologies.

Hyperbilirubinemia after single-stage radical cystectomy and ileal loop diversion

One hundred ninety-two patients underwent single-stage radical cystectomy and ileal loop diversion over a three-year period. Postoperative hyperbilirubinemia occurred in 21 patients (10.9%) within the first ten days. Early hyperbilirubinemia occurred in 11 patients by postoperative day 5, accounting for 52 percent of the hyperbilirubinemic patients and 5.7 percent of the study population. Elevation persisted into the six to ten-day postoperative period for 9 at which time a total of 18 patients had bilirubin levels elevated above their presurgical values (P less than 0.001). This clinical observation appears to be benign and worthy of further investigation.

Management of rectal injuries during radical cystectomy

We reviewed the incidence and management of intraoperative rectal injuries in patients who underwent radical cystectomy from January 1980 through July 1988 to assess the role of primary repair without diverting colostomy as definitive therapy. During this interval 163 radical cystectomies were performed and 125 charts were available for review. The incidence of rectal injuries was 9.6% (12 of 125 patients). The rate of rectal injury in patients who had previously received definitive pelvic radiation was 27% (3 of 11). The incidence of injury in patients who received 2,000 rad preoperative radiation (11%, 2 of 17) was similar to that noted in individuals who were not irradiated (7%, 7 of 97). Of the 12 patients with rectal injury 9 underwent primary closure without diverting colostomy. The remainder were treated with an initial colostomy. Only 1 patient who had not received prior radiation required a colostomy after initial treatment with primary closure. The 8 successful primary rectal closures were done in 2 patients who underwent definitive pelvic radiation, 2 who had received 2,000 rad preoperatively and 4 who had not been irradiated.

Morbidity and mortality of radical cystectomy (1971-78 and 1978-85)

The mortality after radical cystectomy with urinary diversion has been reduced from 11% in 53 patients operated on during 1971-78, to 2.5% in a similar group of 120 patients operated on during 1978-85. Amongst the latter, mortality varied from 0 amongst 32 non-irradiated patients, to 1 (3%) of 33 after planned preoperative radiotherapy and 2 (3.6%) of 55 after previous radical radiotherapy. The improvement in results appears to be due to a number of factors including routine intensive care in the early postoperative phase, with epidural analgesia, and meticulous attention to haemostasis and the technical details of construction of the ileal conduit.

Complications of radical cystectomy and correlation with nutritional assessment

Single stage radical cystectomy and ileal conduit remains the procedure of choice for invasive bladder cancer and is a formidable operation performed on an elderly population. A retrospective review of 69 radical cystectomies was done to evaluate not only operative mortality and complication rate, but also the nutritional status of the patients and its relationship to the frequency of complications. Preoperative nutritional status was assessed by total lymphocyte count and serum albumin. There was an operative mortality rate of 2.9 per cent and early complication rate of 41 per cent. The findings suggest that patients with severe nutritional depletion should receive hyperalimentation prior to cystectomy to reduce serious postoperative complications.

Cost-benefit and cost-effective analysis in surgery

Cost-benefit analysis and cost-effective analysis are formal analytical methods to provide a rational, objective means of comparing total costs with total benefits or of comparing effects in the selection of competing programs for financial support. The use of these techniques in the medical field is a relatively recent development and can aid in future cost containment.

Critical evaluation of 1-stage cystectomy--reducing morbidity and mortality

Although it is a major surgical effort removal of the bladder can be done with reasonable safety. In our opinion cystectomy and urinary diversion by an ileal conduit can be performed as a conjoined procedure without need for staging to reduce risks. Mortality up to 3 months postoperatively was 3.9 per cent and the major complication rate for surviving patients was 18.6 per cent. Minor complications occurred in 28.7 per cent of all patients but were treated easily. We did not note increased morbidity after radical cystectomy compared to other types of cystectomy. A higher complication rate was noted in patients who had undergone preoperative radiation treatment, and wound infection rate was higher in patients with neurogenic bladder dysfunction and chronic cystitis. The advantages of 1-stage compared to 2-stage cystectomy would include the fact that it eliminates the need for a second operation, saves considerable expense by virtue of shortened hospitalization and an earlier resumption of the patient's productivity, achieves early removal of the malignancy, decreases the chances of infection by avoiding a second laparotomy in the presence of a stoma and allows better exposure in the absence of previous ureteroileal anastomoses.

Case against routine 2-stage cystectomy for carcinoma of the bladder

A total of 25 patients with carcinoma of the bladder was subjected to urinary diversion, staged irradiation and total cystectomy. Of these 25 patients 1 died after cystectomy, for a mortality rate of 4 per cent. Complications occurred in 60 per cent of the patients. The projected 5-year survival rate is 49 per cent. We conclude that this protocol offers no advantages over radiation followed by cystectomy and diversion, and we believe that the procedure is unwarranted except in individualized instances.

Complications of ureteroileal conduit with radical cystectomy: review of 336 cases

Review of complications of the ileal conduit in patients undergoing radical cystectomy for bladder cancer showed a statistically significant increase in renal calculi, ureteral obstruction, acute and chronic pyelonephritis and deterioration of renal function by 60 months postoperatively. Ureteroileal fistulas occurred in 3.3 per cent, stomal stenosis in 5.1 per cent, intestinal fistulas in 5.4 per cent, severe intestinal obstruction in 6 per cent and abdominal wound infection or dehiscence in 20.2 per cent of the cases. The over-all operative mortality was 13.7 per cent, with 8 per cent of the deaths attributed to complications from the ileal conduit. Comparison of colonic conduits to ileal conduits as a means of urinary diversion with radical cystectomy for bladder cancer demonstrated no convincing evidence of its superiority.

Postdiversion precystectomy irradiation for cancer of the bladder

This is the first report of a 4-year prospective trial of integrated irradiation and cystectomy in the management of advanced bladder carcinoma. Patients are treated sequentially with staging laparotomy and urinary diversion, highdose preoperative irradiation (5,000 rad/30 treatments/42 days), and total cystectomy. Twenty-eight consecutive patients have been entered into the study; all had Grade III or IV tumor or clinical evidence of invasion (Jewett Stage B1-D1). Local control has been achieved in 21 of 22 patients, and the 4-year actuarial survival is 54%. The initial staging procedure not only defines inoperable patients, but also allows completion of urinary diversion prior to small bowel irradiation with fewer anastomotic problems. Acute and chronic complications have been minimal, and there have been no treatment-related deaths.

Perineal-abdominal cystourethrectomy with pelvic node dissection: a new 2-stage procedure for selected cases

An ileal conduit diversion followed 7 to 14 days later by cystourethrectomy with pelvic node dissection was done on 20 patients with carcinoma of the bladder. Two types of patients were selected for this operation: 1) those with an advanced stage of carcinoma involving the bladder neck, prostatic urethra or prostate, primarily cases suspected of having focal metastatic disease in the urethra, and 2) patients who had had a previous pelvic operation with resultant dense adhesions and scarring. The cystourethrectomy with pelvic node dissection is begun perineally. After the specimen, consisting of the urethra, part of the urogenital diaphragm, seminal vesicles, prostate and bladder is dissected, mobilized and, finally, pushed into the pelvis the perineum is closed and the operation is completed abdominanlly through a Pfannenstiel incision.