Prolonged length of stay in illeal conduit compared to neobladder diversion in radical cystectomy patients for bladder cancer

Philadelphia, PA

Background:

Radical cystectomy and urinary diversion has become the standard treatment for invasive and complicated malignancies of the bladder, urethra, and ureters. [1] Robotic-assisted radical cystectomy (RARC), introduced in the last decade, has been associated with favorable perioperative outcomes when compared to open radical cystectomy. Yet little is known about how different urinary diversion types compare in regards to length of hospital stay, readmission rates, and perioperative course. This data analysis seeks to identify the statistically significant differences in postoperative course of ileal conduit versus neobladder among patients with staged bladder cancer.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a health insurance portability and accountability act (HIPAA) compliant data file containing cases from 706 participating hospitals. The data includes 275 HIPAA compliant variables on 902,968 cases in 2020 and 273 variables on 1,076,441 cases in 2019. ACS NSQIP includes all major cases as determined by Current Procedural Terminology (CPT) code. The goal of the program is to determine the quality of care after surgical procedures. The ACS NSQIP is deidentified and the study was exempted from the requirement for institutional review board approval. The primary outcomes were length of stay and readmission after radical cystectomy with either ileal conduit or neobladder. Wilcoxon signed-rank test was utilized for continuous variables as the data was not normally distributed. For categorical variables, Fisher’s exact test was performed and Chi-squared analysis where more than two categories were evaluated. Statistical significance was set at P-value < 0.05.

Results:

Data from a total of 6,103 patients in the NSQIP database were screened and 1,478 analyzed for all outcomes measures. There was no statistical significance in terms of mean length of stay between the ileal conduit and neobladder groups (7.85 vs. 7.44 days, p = 0.185) (Table 1). Additionally, there was not a statistically significant difference in mean days to discharge. Secondary endpoints that resulted in statistically significant differences include rates of readmission (21.5% vs 30%, p < 0.05), colonic anastomotic leak (6.3% vs 1.8%, p < 0.05), urinary anastomotic leak (3.1% vs 6.7%, p < 0.05) , and lymphocele/lymphatic leak (3.8% vs 8.5%, p < 0.05)( Table 1.) Multivariable analysis revealed additional differences between these groups. Prior pelvic radiotherapy ( p = 0.003) and a characterized bleeding disorder (p = 0.001) were associated with length of stay in the ileal conduit group (Table 2). Chemotherapy within 90 days (p = 0.004) and diabetes mellitus (p = 0.029) were predictors of length of stay in the neobladder group (Table 2).

Conclusion:

The conduit diversion cohort did not show a difference in length of stay compared to the neobladder cohort. However, secondary endpoints including rates of readmission, colonic anastomotic leak, urinary anastomotic leak, and lymphocele/lymphatic leak showed significant differences. Risk factors that influenced length of stay were prior pelvic radiation, a characterized bleeding disorder, chemotherapy within 90 days, and diabetes mellitus.