Regional differences in total hospital costs for radical cystectomy in the United States

Perioperative Complications and In-hospital Mortality After Cystectomy for Nonbladder Cancer Conditions Versus Radical Cystectomy for Bladder Cancer

OBJECTIVE

This study was designed to test for perioperative complications, mortality, and length of stay after cystectomy for nonbladder cancer (non-BCa) v radical cystectomy (RC) for bladder cancer (BCa).

METHODS

Patients were identified within the National Inpatient Sample (2000-2019). Multivariable logistic and Poisson regression models were fitted.

RESULTS

Of 26,721 cystectomy patients, 1314 (5%) harbored non-BCa diagnosis: 515 (39%) neurogenic bladder; 379 (29%) radiation cystitis; 238 (18%) interstitial cystitis; 181 (14%) bladder fistula. Relative to RC for BCa, cystectomy for neurogenic bladder, radiation cystitis and bladder fistula resulted in higher genitourinary (22-39 vs. 14%; multivariable odds ratios [MOR] 1.7-3.8), infectious (7-8 vs. 4%; MOR 1.5-2.3), and wound (9 vs. 5%; MOR 1.5-2.0) complications rates. Only cystectomy for neurogenic bladder resulted in higher pulmonary complications (15 vs. 11%; MOR 1.8). Additionally, cystectomy for neurogenic bladder and bladder fistula independently predicted 1.5-fold higher rate of critical care therapy (CCT) use, but only cystectomy for neurogenic bladder exhibited 2.4-fold higher in-hospital mortality rate. Finally, cystectomy for neurogenic bladder, radiation cystitis, and bladder fistula resulted in higher rates of hospital stay ≥ 75th percentile (33-47 vs. 27%; MOR 1.7-2.8).

CONCLUSIONS

Relative to RC for BCa, cystectomy for three of four non-BCa conditions resulted in higher rates of four of 12 in-hospital adverse outcomes. Additionally, cystectomy for two of four non-BCa conditions resulted in higher CCT use, but only cystectomy for neurogenic bladder predicted higher rate of in-hospital mortality.

Total hospital cost of robot-assisted approach in major urological cancer surgeries

BACKGROUND

The aim of this study was to test for differences in total hospital cost (THC) between robot-assisted vs. open partial nephrectomy (PN), radical cystectomy (RC), radical prostatectomy (RP) and radical nephroureterectomy (NU).

METHODS

Within the National Inpatient Sample (2010-2019), we identified all robot-assisted vs. open PN, RC, RP and NU patients. Multivariable Poisson regression models were fitted.

RESULTS

Of all surgeries, 22,572 (56%) were robot-assisted PN (RPN), 5114 (24%) were robot-assisted RC (RARC), 99,134 (70%) were robot-assisted RP (RARP), and 1138 (24%) patients were robot-assisted NU (RNU). Relative to open surgery, RARC (115,511 vs. 103,531$), RNU (64,761 vs. 54,768$), RARP (49,629 vs. 40,850$) and RPN (56,288 vs. 50,875$) were associated with higher THC (all P<0.001). After multivariable adjustment, RARP (risk ratio [RR]: 1.25), RNU (RR: 1.13), RPN (RR: 1.11) as well as RARC (RR: 1.10) independently predicted higher THC (all P<0.001). Additionally, Charlson Comorbidity Index ≥2 (RR: from 1.07 to 1.08), large bed size hospitals (RR: from 1.03 to 1.08), length of stay (RR: from 1.02 to 1.06), and overall complications (RR: from 1.09 to 1.19) invariably predicted higher THC.

CONCLUSIONS

THC is invariably higher when robot-assisted approach is applied instead of open approach in PN, RC, RP and NU patients. This THC disadvantage of robot-assisted approach requires consideration in the light of other benefits of robot-assisted surgery that could not be addressed in the current analyses.

Effect of Race/Ethnicity on In-hospital Outcomes After Radical Cystectomy

OBJECTIVE

Previously, African American race/ethnicity predisposed to higher rate of adverse in-hospital outcomes after radical cystectomy (RC). We tested whether this association applies to contemporary RC patients.

METHODS

Patients were identified within the National Inpatient Sample (NIS 2000-2019). Multivariable logistic and Poisson regression models were fitted.

RESULTS

Of 19,370 RC patients, 1,089 (5.6%) were African American, while 18,281 (94.4%) were Caucasian. Relative to Caucasians, African Americans were younger (median age 66 vs. 70 years; p < 0.001), more frequently female (33.8 vs. 18.5%; p < 0.001) and more frequently in the lowest income quartile (46.8 vs. 18.6%; p < 0.001). Relative to Caucasians, after RC, African Americans exhibited higher rates of postoperative complications (61.3 vs. 58.3%; multivariable odds ratio [MOR] 1.2; p = 0.009). Specifically, African Americans exhibited higher rates of blood transfusions (30.2 vs. 24.1%; MOR 1.3; p < 0.001), gastrointestinal (26.7 vs. 24.1%; MOR 1.2; p = 0.003), and infectious (6.2 vs. 4.2%; MOR 1.5; p = 0.001) complications, as well as deep vein thrombosis (3.1 vs. 1.7%; MOR 1.9; p < 0.001). Additionally, after RC, African Americans exhibited higher rates of critical care therapy use (CCT; 13.9 vs. 12.2%; MOR 1.3; p = 0.002) and in-hospital mortality (2.8 vs. 1.7%; MOR 1.8; p = 0.002). Finally, African Americans exhibited higher rates of length of stay ≥ 75th percentile (40.9 vs. 31.2%; MOR 1.6; p < 0.001).

CONCLUSIONS

In contemporary RC patients, African American race/ethnicity predisposes to less favorable in-hospital outcomes, including higher in-hospital mortality and longer hospital stay. Unfortunately, these race/ethnicity disadvantages have not been improved upon relative to the previous report.

Urinary Diversion Versus Adverse In-Hospital Outcomes After Radical Cystectomy

OBJECTIVE

This study aimed to compare adverse in-hospital outcomes in ileal conduit versus neobladder urinary diversion type after radical cystectomy (RC) in contemporary versus historical patients.

METHODS

Patients were identified within the National Inpatient Sample (NIS 2000-2019). Propensity score matching (PSM; 1:2 ratio) and multivariable logistic regression models (LRMs) were used.

RESULTS

Of 10,533 contemporary (2011-2019) patients, 943 (9.0%) underwent neobladder urinary diversion, while 9590 (91.0%) underwent ileal conduit urinary diversion. Furthermore, of 9742 historical (2010-2019) patients, 932 (9.6%) underwent neobladder urinary diversion and 8810 (90.4%) underwent ileal conduit urinary diversion. After 1:2 PSM, within the contemporary cohort, 943/943 (100%) neobladder versus 1886/9590 (19.6%) ileal conduit patients were included. Similarly, within the historical cohort, 932/932 (100%) neobladder versus 1864/8810 (21.1%) ileal conduit patients were included after PSM. In multivariable LRMs, relative to contemporary neobladder patients, contemporary ileal conduit patients exhibited higher rates of overall postoperative (49.0 vs. 43.6%; multivariable odds ratio [MOR] 1.2), wound (4.2 vs. 2.7%; MOR 1.6), and genitourinary (13.1% vs. 10.0%; MOR 1.3) complications as well as blood transfusions (19.0 vs. 15.6%; MOR 1.3). Conversely, in multivariable LRMs within the historical cohort, no differences were recorded between ileal conduit and neobladder patients.

CONCLUSIONS

Unlike historical comparisons between ileal conduit and neobladder patients, where no differences in adverse in-hospital outcomes were recorded, analyses relying on a contemporary patient cohort subject to PSM and multivariable adjustment revealed higher rates of adverse in-hospital outcomes in 4/13 examined categories. This observation should be considered at informed consent.

Perioperative Complications and In-Hospital Mortality in Paraplegic Radical Cystectomy Patients

OBJECTIVE

The aim of this study was to test for the association between paraplegia and perioperative complications as well as in-hospital mortality after radical cystectomy (RC) for non-metastatic bladder cancer.

METHODS

Perioperative complications and in-hospital mortality were tabulated in RC patients with or without paraplegia in the National Inpatient Sample (2000-2019).

RESULTS

Of 25,527 RC patients, 185 (0.7%) were paraplegic. Paraplegic RC patients were younger (≤70 years of age; 75 vs. 53%), more frequently female (28 vs. 19%), and more frequently harbored Charlson Comorbidity Index ≥3 (56 vs. 18%). Of paraplegic vs. non-paraplegic RC patients, 141 versus 15,112 (76 vs. 60%) experienced overall complications, 38 versus 2794 (21 vs. 11%) pulmonary complications, 36 versus 3525 (19 vs. 14%) genitourinary complications, 33 versus 3087 (18 vs. 12%) intraoperative complications, 21 versus 1035 (11 vs. 4%) infections, and 17 versus 1343 (9 vs. 5%) wound complications, while 62 versus 6267 (34 vs. 25%) received blood transfusions, 47 versus 3044 (25 vs. 12%) received critical care therapy (CCT), and intrahospital mortality was recorded in 13 versus 456 (7.0 vs. 1.8%) patients. In multivariable logistic regression models, paraplegic status independently predicted higher overall CCT use (odds ratio [OR] 2.1, p < 0.001) as well as fourfold higher in-hospital mortality (p < 0.001), higher infection rate (OR 2.5, p < 0.001), higher blood transfusion rate (OR 1.45, p = 0.009), and higher intraoperative (OR 1.56, p = 0.02), wound (OR 1.89, p = 0.01), and pulmonary (OR 1.72, p = 0.004) complication rates.

CONCLUSION

Paraplegic patients contemplating RC should be counseled about fourfold higher risk of in-hospital mortality and higher rates of other untoward effects.

An assessment of the direct and indirect costs of bladder cancer preceding and following a cystectomy: a real-world evidence study

INTRODUCTION

To estimate the direct and indirect costs of bladder cancer prior to and following cystectomy in a U.S. sample of patients.

METHODS

This retrospective, observational analysis of de-identified patients with bladder cancer utilized the MarketScan Commercial Claims & Encounters and Health & Productivity Management databases. Adult patients with bladder cancer plus ≥ 1 claim for partial or radical cystectomy between 1 October 2015 and 31 December 2020 (date of the cystectomy = index date) and who were continuously enrolled for 6 months pre- (baseline) and post-index (follow-up) were included in the sample. All-cause total healthcare costs and indirect costs associated with short-term and long-term disability (STD and LTD) employer claims were assessed during each of the 6-month baseline and follow-up periods.

RESULTS

The study included N = 142 patients; mean age 56 ± 6 years, 76% (male), and 42% had a baseline Deyo-Charlson Comorbidity Index ≥ 2. Baseline mean total all-cause direct healthcare costs were $51,473 ± $48,560 (median: $36,202), and $99,524 ± 86,839 (median: $75,444) during follow-up. At baseline, 32% of patients had ≥ 1 STD claim, equating to a mean 134 ± 303 h lost and $2,353 ± $6,445 in total payments per patient. Follow up STD claims increased 23.4% equating to a mean 218 ± 324 h lost and $3,679 ± $7,795 per patient. Patient LTD claims increased from baseline to follow-up (1-3%), with post-cystectomy LTD claims resulting in 574 ± 490 h lost, and $1,636 ± $1,429 in total payments. Over 85% of the population had a cystectomy related complication, the most common were genitourinary-related (47.9%) and infection/sepsis (33.1%).

CONCLUSIONS

Cystectomy was associated with complications and decreased work productivity post-surgery. Findings may aid to inform decisions regarding cystectomy vs. bladder preservation approaches, and underscores an ongoing need to further develop bladder preservation therapies within the bladder cancer treatment landscape.

Health Related Quality of Life in Patients with Bladder Cancer Receiving a Radical Cystectomy

Radical Cystectomy (RC) and Urinary Diversion (UD) is a complex surgery associated with a significant impact on health-related quality of life (HRQoL). However, HRQoL assessment is too often overlooked, with survival and complications being the most commonly investigated outcomes. This study aimed to identify the most impaired HRQoL features in patients receiving RC, compared to a healthy population (HP) control, as well as patients' recovery after surgery, differentiating between patients receiving ORC and RARC. Patients with Bca, who were candidates for RC with curative intent, were enrolled in the "BCa cohort". HRQoL outcomes were collected with an EORTC QLQ-C30 questionnaire. These were collected at baseline, and then at 6-, 12- and 24 mo after surgery in the BCa cohorts, and at baseline in the HP cohort. A 1:1 propensity score matched (PSM)-analysis, adjusted for age, Charlson Comorbidity Index (CCI) and smoking history, was performed. Between January 2018 and February 2023, a total of 418 patients were enrolled in the study, 116 and 302 in the BCa and HP cohorts, respectively. After applying the 1:1 propensity scored match (PSM) analysis, two homogeneous cohorts were selected, including 85 patients in each group. Baseline HRQoL assessment showed a significant impairment in terms of emotional and cognitive functioning, appetite loss and financial difficulties for the BCa cohort. Among secondary outcomes, we investigated patients' recovery after RC and UD, comparing HRQoL outcome questionnaires between the HP and BCa cohorts at 6-, 12- and 24 mo after surgery, and a subgroup analysis was performed differentiating between patients receiving ORC and RARC with totally intracorporeal UD. Interestingly, ORC compared to RARC provided a major impact on HRQoL recovery across the early, mid and long term. In particular, the ORC cohort experienced a major impairment in terms of symptoms scales items such as fatigue, nausea and vomiting, pain and appetite loss. Consequently, comparing ORC and RARC vs. HP reported a major HRQoL impairment in the ORC cohort, possibly defining a benefit of RARC in early, mid- and long-term recovery. To conclude, this study confirmed the undeniable impact of RC on HRQoL. Interestingly, we highlighted the benefit of RARC in early, mid- and long-term recovery, expressed as less impairment of symptoms scales.

Comparison of peri- and intraoperative outcomes of open vs robotic-assisted partial nephrectomy for renal cell carcinoma: a propensity-matched analysis

BACKGROUND

Partial nephrectomy (PN) is the gold standard surgical treatment for resectable renal cell carcinoma (RCC) tumors. However, the decision whether a robotic (RAPN) or open PN (OPN) approach is chosen is often based on the surgeon's individual experience and preference. To overcome the inherent selection bias when comparing peri- and postoperative outcomes of RAPN vs. OPN, a strict statistical methodology is needed.

MATERIALS AND METHODS

We relied on an institutional tertiary-care database to identify RCC patients treated with RAPN and OPN between January 2003 and January 2021. Study endpoints were estimated blood loss (EBL), length of stay (LOS), rate of intraoperative and postoperative complications, and trifecta. In the first step of analyses, descriptive statistics and multivariable regression models (MVA) were applied. In the second step of analyses, to validate initial findings, MVA were applied after 2:1 propensity-score matching (PSM).

RESULTS

Of 615 RCC patients, 481 (78%) underwent OPN vs 134 (22%) RAPN. RAPN patients were younger and presented with a smaller tumor diameter and lower RENAL-Score sum, respectively. Median EBL was comparable, whereas LOS was shorter in RAPN vs. OPN. Both intraoperative (27 vs 6%) and Clavien-Dindo > 2 complications (11 vs 3%) were higher in OPN (both < 0.05), whereas achievement of trifecta was higher in RAPN (65 vs 54%; p = 0.028). In MVA, RAPN was a significant predictor for shorter LOS, lower rates of intraoperative and postoperative complications as well as higher trifecta rates. After 2:1 PSM with subsequent MVA, RAPN remained a statistical and clinical predictor for lower rates of intraoperative and postoperative complications and higher rates of trifecta achievement but not LOS.

CONCLUSIONS

Differences in baseline and outcome characteristics exist between RAPN vs. OPN, probably due to selection bias. However, after applying two sets of statistical analyses, RAPN seems to be associated with more favorable outcomes regarding complications and trifecta rates.