Outcomes following radical cystectomy: a population‐based study from Queensland, Australia

Abstract

Background: Radical cystectomy (RC) is a complex uro-oncology surgical procedure with high surgical morbidity. We report on outcomes following RC for bladder cancer using a population-based cohort of patients. Methods: Patients receiving an RC from 2002 to 2016 were included and linked to their cancer-related surgical procedures. Hospitals were categorized as high (>7 RCs/year) and low (≤7 RCs/year). Outcomes included 30-and 90-day mortalities and 2-year overall survival (OS). Multivariable logistic regression models were used to examine factors associated with the outcomes of interest. OS was estimated using the Kaplan-Meier survival function. Results: During the 15-year study period, 1230 patients underwent an RC for invasive bladder cancer. In-hospital mortality was 1.1%, and 30-and 90-day mortality was 1.4% and 2.9%, respectively. Both 30-and 90-day mortalities were significantly higher for older versus younger patients (P = 0.01 and P < 0.001, respectively), and lymph node involvement was significantly associated with 90-day mortality (P = 0.002). Patients treated more recently were about 80% less likely to die within 90 days. The 2-year OS was 71.5%, with significant improvements observed over time (P < 0.001). While we found no evidence of a hospital-volume relationship for post-operative mortality or survival, patients treated in lowvolume compared to high-volume hospitals were more likely to have surgical margin involvement (10.9% versus 7.1%, respectively, P = 0.03). Conclusion: We observed low post-operative mortality rates overall, with rates decreasing significantly over time. Some subgroups of patients experience poorer post-operative outcomes. Reporting on post-operative outcomes, and survival over time helps monitor clinical progress and identify areas for improvement.

Factors predicting early mortality after radical cystectomy for urothelial carcinoma in a contemporary cohort of patients

“…The baseline characteristics of our study population who underwent RC were consistent with current literature, which demonstrates that patients who are younger, have fewer comorbidities, and localized disease are more likely to undergo RC for management of their bladder cancer. [8][9][10][11][12][13][20][21][22][23][24][25] Our study also found that increased age, advanced clinical stage, increased comorbidity, and decreased hospital volume were significantly associated with increased mortality as indicated in Table 3. Interestingly, we identified a significantly decreased mortality among patients receiving neoadjuvant chemotherapy (NAC) prior to RC at both 30and 90-days after RC.…”

“…Variations exist in published early mortality rates, which have been estimated to be up to 20% in early studies, down to 1.1-2.7% in more recent literature, with an overall complication rate of approximately 34%. [3][4][5][6] As life expectancy increases, the number of RCs offered is predicted to increase, particularly in elderly patients. 7 Given the high risk of morbidity and mortality associated with RC, it is important to gain a more granular understanding of postoperative mortality to inform patients.…”

Does the introduction of pre‐operative cardiopulmonary exercise testing in radical cystectomy delay or alter surgical care?

“… 13 , 15 Our 24‐ to 35‐month survival rate calculated is also comparable to other studies (52–71%), but further longer term studies and specific subgroup analysis with tumour staging, grading, and variant pathology would be beneficial in considering the impact of CPET and prehabilitation options on outcomes. 16 , 17 , 18 …”

“…13,15 Our 24-to 35-month survival rate calculated is also comparable to other studies (52-71%), but further longer term studies and specific subgroup analysis with tumour staging, grading, and variant pathology would be beneficial in considering the impact of CPET and prehabilitation options on outcomes. [16][17][18] Anaerobic threshold is considered the optimal predictor of outcome in intra-abdominal surgery, with <10-11 ml/kg/min considered high risk. 2,5,19 We certainly found this to be consistent with our post-operative morbidity and mortality outcomes showing higher complication rates and mortality rates with patients who had AT <11 ml/kg/min.…”

Why a robot took my bladder

“…5 In Queensland, from 2002 to 2016, there were 1230 radical cystectomy operations performed, average 80/year. 6 It seems timely, stimulated by this excellent and provocative paper, to have a discussion around centralization of cystectomy surgery, be it open or robotic. Intuitively, it seems inevitable that all major urological surgeries will be performed robotically.…”