Factors That Influence Selectionof Urinary Diversion Among Bladder Cancer Patients in 3 Community-based Integrated Health Care Systems

Abstract

Objectives: To assess the relative contributions of patient and surgeon factors for predicting selection of ileal conduit (IC), neobladder (NB), or continent pouch (CP) urinary diversions (UD) for patients diagnosed with muscle-invasive/high-risk non-muscle invasive bladder cancer. This information is needed to enhance research comparing cancer survivors' outcomes across different surgical treatment options.Methods: Bladder cancer patients age ≥21 years with cystectomy/UD performed from 1/2010 to 6/2015 in three Kaiser Permanente regions were included. All patient and surgeon data were obtained from electronic health records. A mixed effects logistic regression model was used treating surgeon as a random effect and region as a fixed effect.Results: Of 991 eligible patients, 794 (80%) received IC. 169 surgeons performed the surgeries and accounted for a sizeable proportion of the variability in patient receipt of UD (ICC=.26). The multilevel model with only patient factors showed good fit (AUC=.93, Hosmer-Lemeshow test p=. 44), and older age, female sex, eGFR<45, 4+ comorbidity index score, and stage III/IV tumors were associated with higher odds of receiving an IC vs. NB/CP. However, including surgeon factors (annual cystectomy volume, specialty training, clinical tenure) had no association (p=.29). Conclusions:In this community setting, patient factors were major predictors of UD received. Surgeons also played a substantial role, yet clinical training and experience were not major predictors. Surgeon factors such as beliefs about UD options and outcomes should be explored.

What is the Urinary Diversion of Choice after Cystectomy in 2020?

“…The International Consultation on Bladder Cancer-European Association of Urology (ICUD-EAU) strongly recommends that the realization of radical cystectomy with urinary diversion should be carried out in hospitals where at least 40 to 50 interventions per year are carried out, of which half of these procedures will be performed. by one or two surgeons, in order to guarantee their expertise, the availability of a well-trained staff and minimum of long-term complications [5,[15][16][17]. In addition, procedures performed at a non-university hospital center have more readmission rates of patients within 30 days after surgery [4].…”