Defining radical cystectomy using the ICD-10 procedure coding system

Metformin intake and risk of metabolic acidosis after radical cystectomy with urinary diversion: A comparative study using data from the TriNetX research network

PURPOSE

To investigate the association of diabetes mellitus and metformin use with metabolic acidosis risk after radical cystectomy (RC) and urinary diversion for bladder cancer.

MATERIALS AND METHODS

This retrospective cohort study used TriNetX Research Network data. Patients undergoing RC with continent diversion or ileal conduit for bladder cancer were identified using International Classification of Diseases, 10th Revision (ICD-10) and ICD-10 Procedure Coding System (ICD-10-PCS) codes. The primary outcome was acidosis between 1 month and 3 years postsurgery. Risk ratios (RR) and odds ratios (OR) were calculated based on diabetes and metformin use, stratified by diversion type and chronic kidney disease stage. Propensity score matching balanced potential confounders.

RESULTS

We identified 1,986 patients who underwent continent diversion and 11,184 who underwent ileal conduit reconstruction. In matched analyses, diabetes patients had higher acidosis risk (continent diversion: RR 1.87, 95% confidence interval [CI] 1.39-2.51; ileal conduit: RR 1.94, 95% CI 1.66-2.27). The risk was highest for diabetes patients with metformin prescription (continent diversion: RR 2.06, 95% CI 1.63-2.61; ileal conduit: RR 2.13, 95% CI 1.84-2.47). However, among patients with diabetes, metformin use did not significantly affect acidosis rates in most analyses. Continent diversion patients had higher acidosis risk than ileal conduit patients (RR 1.89, 95% CI 1.58-2.26).

CONCLUSION

Diabetes significantly increases metabolic acidosis risk after RC with urinary diversion, especially in continent diversion patients. While metformin may contribute to metabolic acidosis risk, its impact appears less significant than that of diabetes. Careful monitoring and appropriate metformin adjustments are crucial in this population.

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.

Real-World Economic Burden and Healthcare Resource Utilization of Radical Cystectomy and Trimodal Therapy for Bladder Cancer in the United States

OBJECTIVE

To leverage contemporary real-world data to offer a comprehensive and longitudinal assessment of cost and healthcare resource utilization in patients with bladder cancer who underwent radical cystectomy (RC) or trimodal therapy (TMT).

METHODS

Claims data between October 01, 2015, and April 24, 2023, were assessed to determine patient characteristics, costs, and healthcare resource utilization. Patients were followed from 90-days up to 5-years of follow-up. Costs and healthcare utilization were further broken down by place of service and specific cost drivers, and subgroups were assessed to explore aspects of treatment recommended guidelines.

RESULTS

Of 1323 patients, 839 underwent RC (median age 71 years; 26.2% female), and 484 received trimodal therapy (median age 75; 26.2% female). Median [IQR] per-patient costs were $70,671 [$55,878-$106,812] for the RC cohort at 90-days follow-up and rose to $211,671 [$138,597-$346,389] by 5-years post-index. For trimodal therapy, total costs were $34,612 [$16,705-$64,263] at 90-days and increased to $274,462 [$186,337-$421,534] by 5-years. At 90-days, median overall visits (inpatient, outpatient, emergency room, or other) were 26 [16-39] for RC and 19 [12-33] for trimodal therapy; overall visits were 163 [119-218] and 186 [144-238] by 5-years, respectively.

CONCLUSION

This analysis reveals that RC costs were primarily driven by inpatient services, particularly inpatient facility costs. For trimodal therapy, outpatient costs predominated, driven by drugs administered and outpatient radiology facilities. The considerable costs and utilization associated with these treatments underscore the need for value-based therapeutic approaches aimed at enhancing patient outcomes.

The effect of chronic kidney disease on adverse in-hospital outcomes after radical cystectomy with ileal conduit urinary diversion

PURPOSE

Chronic kidney disease (CKD) is frequent in bladder cancer patients undergoing radical cystectomy (RC) with ileal conduit. However, the effect of CKD on adverse in-hospital outcomes after ileal conduit RC is not well known.

METHODS

Descriptive analyses, propensity score matching (PSM), and multivariable logistic and Poisson regression models were used to address National Inpatient Sample patients treated with ileal conduit RC between 2006 and 2019. CKD severity was stratified as mild (stage II) vs. moderate (stage III) vs. severe (stage IV/V).

RESULTS

Of 13,359 patients treated with RC with ileal conduit, 1973 (14.8%) had CKD. Of those, 956 (48.5%), 802 (40.6%), and 215 (10.9%) were classified as mild, moderate, or severe CKD, respectively. CKD rate increased from 4.1 to 21.9% (2006-2019, EAPC: +8.9%, p < 0.001). CKD RC patients exhibited higher rates of adverse in-hospital outcomes in 11 of 15 categories. The absolute differences were largest for overall complications (+ 13.2%), prolonged length of stay (+ 7.0%), blood transfusions (+ 6.0%, all p < 0.001). After detailed multivariable adjustment, CKD was an independent predictor of 11 of 15 adverse in-hospital outcomes' categories. The detrimental effect of CKD was most pronounced for dialysis (OR 7.09), overall complications (OR 1.84), and neurological complications (OR 1.61, all p < 0.001). Finally, a dose-response effect according to CKD severity on adverse in-hospital outcomes was observed in eight of 15 categories.

CONCLUSIONS

CKD RC patients invariably exhibited higher rates of adverse in-hospital outcomes after RC with ileal conduit. In consequence this patient group should receive particularly strong consideration for preoperative optimization.

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.

Perioperative complications and in-hospital mortality in radical cystectomy patients with heart-valve replacement

PURPOSE

To assess in-hospital mortality and complication rates after radical cystectomy (RC) in patients with history of heart-valve replacement.

MATERIALS AND METHODS

Using the National Inpatient Sample (2000-2019), non-metastatic bladder cancer patients undergoing RC were stratified according to history of heart-valve replacement. Regression models (RM) predicted hospital outcomes.

RESULTS

Of 25,535 RC patients, 250 (1.0%) harbored history of heart-valve replacement. Heart-valve replacement patients were older (median 74 vs. 70 years), more frequently male (87.2 vs. 80.6%), and more frequently had Charlson comorbidity index ≥3 (26.8 vs. 18.9%). In RC patients with history of heart-valve replacement vs. others, 62 vs. 2634 (24.8 vs. 10.4%) experienced cardiac complications, 28 vs. 3092 (11.2 vs. 12.2%) intraoperative complications, 11 vs. 1046 (4.4 vs. 4.1%) infections, <11 vs. 594 (<4.4 vs. 2.3%) perioperative bleeding, <11 vs. 699 (<4.4 vs. 2.8%) vascular complications, 74 vs. 6225 (29.6 vs. 24.7%) received blood transfusions, 37 vs. 3054 (14.8 vs. 12.1%) critical care therapy (CCT), and in-hospital mortality was recorded in <11 vs. 463 (<4.4 vs. 1.8%) patients. In multivariable RM, history of heart-valve replacement independently predicted cardiac complications (odds ratio 2.20, 95% confidence interval 1.62-2.99; p < 0.001). Conversely, no statically significant association was recorded between history of heart-valve replacement and length of stay, estimated hospital cost, intraoperative complications, perioperative bleeding, vascular complications, infections, blood transfusions, CCT use, and in-hospital mortality.

CONCLUSIONS

Radical cystectomy patients with history of heart-valve replacement exhibited a 2.2-fold higher risk of cardiac complications, but no other complications, including no significantly higher in-hospital mortality.

Development of the multivariate administrative data cystectomy model and its impact on misclassification bias

BACKGROUND

Misclassification bias (MB) is the deviation of measured from true values due to incorrect case assignment. This study compared MB when cystectomy status was determined using administrative database codes vs. predicted cystectomy probability.

METHODS

We identified every primary cystectomy-diversion type at a single hospital 2009-2019. We linked to claims data to measure true association of cystectomy with 30 patient and hospitalization factors. Associations were also measured when cystectomy status was assigned using billing codes and by cystectomy probability from multivariate logistic regression model with covariates from administrative data. MB was the difference between measured and true associations.

RESULTS

500 people underwent cystectomy (0.12% of 428 677 hospitalizations). Sensitivity and positive predictive values for cystectomy codes were 97.1% and 58.6% for incontinent diversions and 100.0% and 48.4% for continent diversions, respectively. The model accurately predicted cystectomy-incontinent diversion (c-statistic [C] 0.999, Integrated Calibration Index [ICI] 0.000) and cystectomy-continent diversion (C:1.000, ICI 0.000) probabilities. MB was significantly lower when model-based predictions was used to impute cystectomy-diversion type status using for both incontinent cystectomy (F = 12.75; p < .0001) and continent cystectomy (F = 11.25; p < .0001).

CONCLUSIONS

A model using administrative data accurately returned the probability that cystectomy by diversion type occurred during a hospitalization. Using this model to impute cystectomy status minimized MB. Accuracy of administrative database research can be increased by using probabilistic imputation to determine case status instead of individual codes.

Features associated with travel distance for radical cystectomy in Florida: Implications for access to care

INTRODUCTION

Characteristics associated with travel distance for radical cystectomy (RC) remain incompletely defined but are needed to inform efforts to bridge gaps in care. Therefore, we assessed features associated with travel distance for RC in a statewide dataset.

METHODS

We identified RC patients in the Florida Inpatient Discharge dataset from 2013 to 2019. Travel distance was estimated using zip code centroids. The primary outcome was travel >50 miles for RC. Secondary outcomes included inpatient mortality, nonhome discharge, and inpatient complications. U.S. County Health Rankings were included as model covariates. Mixed effects logistic regression models accounting for clustering within hospitals were utilized.

RESULTS

We identified 4,209 patients, of whom 2,284 (54%) traveled <25 miles, 654 (16%) traveled 25 to 50 miles, and 1271 (30%) traveled >50 miles. Patients who traveled >50 miles primarily lived in central and southwest Florida. Following multivariable adjustment, patients traveling >50 miles were less likely to be Hispanic/Latino (odds ratio [OR] 0.35, 95% CI: 0.23-0.51), and more likely to reside in a county with the lowest health behavior (OR 6.48, 95% CI: 3.81-11.2) and lowest socioeconomic (OR 7.63, 95% CI: 5.30-11.1) rankings compared to those traveling <25 miles (all P < 0.01). Travel distance >50 miles was associated with treatment at a high-volume center and significantly lower risks of inpatient mortality, nonhome discharge, and postoperative complications (all P < 0.02).

CONCLUSION

These data identify characteristics of patients and communities in the state of Florida with potentially impaired access to RC care and can be used to guide outreach efforts designed to improve access to care.

Outcomes of robotic-assisted versus open radical cystectomy in a large-scale, contemporary cohort of bladder cancer patients

BACKGROUND AND OBJECTIVES

To test for differences in perioperative outcomes and total hospital costs (THC) in nonmetastatic bladder cancer patients undergoing open (ORC) versus robotic-assisted radical cystectomy (RARC).

METHODS

We relied on the National Inpatient Sample database (2016-2019). Statistics consisted of trend analyses, multivariable logistic, Poisson, and linear regression models.

RESULTS

Of 5280 patients, 1876 (36%) versus 3200 (60%) underwent RARC versus ORC. RARC increased from 32% to 41% (estimated annual percentage change [EAPC]: + 8.6%; p = 0.02). Rates of transfusion (8% vs. 16%), intraoperative (2% vs. 3%), wound (6% vs. 10%), and pulmonary (6% vs. 10%) complications were lower in RARC patients (all p < 0.05). Moreover, median length of stay (LOS) was shorter in RARC (6 vs. 7days; p < 0.001). Conversely, median THC (31,486 vs. 27,162$; p < 0.001) were higher in RARC. Multivariable logistic regression-derived odds ratios addressing transfusion (0.49), intraoperative (0.53), wound (0.68), and pulmonary (0.71) complications favored RARC (all p < 0.01). In multivariable Poisson and linear regression models, RARC was associated with shorter LOS (Rate ratio:0.86; p < 0.001), yet higher THC (Coef.:5,859$; p < 0.001). RARC in-hospital mortality was lower (1% vs. 2%; p = 0.04).

CONCLUSIONS

RARC complications, LOS, and mortality appear more favorable than ORC, but result in higher THC. The favorable RARC profile contributes to its increasing popularity throughout the United States.

The Association Between Mood and Anxiety Disorders with Perioperative Outcomes Following Radical Cystectomy

OBJECTIVE

To identify associations between preoperative psychiatric diagnoses and perioperative outcomes after RC.

METHODS

The Florida Inpatient Data File was used to identify patients who underwent RC from 2013-2019. ICD-10 codes for a mood or anxiety disorder were identified and analyzed as a 3-level variable: neither, one of these, or both. Outcomes included inpatient mortality, non-home discharge, in-hospital complications, and length of stay. Mixed-effects logistic regression (accounting for clustering within hospitals) and negative binomial regression models were utilized.

RESULTS

We identified 4396 RC patients, including 306 (7.0%) with a mood disorder and 389 (8.8%) with an anxiety disorder. After multivariable adjustment, there was no significant association between mood and/or anxiety disorders with mortality or the presence or number of in-hospital complications. However, a mood or anxiety disorder was significantly associated with increased odds of non-home discharge (OR 1.60, 95% CI 1.20-2.14) and longer length of stay (IRR 1.13, 95% CI 1.07-1.19); these associations were also increased among patients with both mood and anxiety disorder diagnoses (non-home discharge OR 2.66, 95% CI 1.61-4.38; length of stay IRR 1.12, 95% CI 1.01-1.24).

CONCLUSION

Patients with mood and/or anxiety disorders undergoing RC had longer length of stay and increased odds of discharge to a non-home facility despite similar risks of perioperative complications. These data suggest an opportunity for perioperative intervention to address these disparities in postoperative outcomes. However, further work is needed to determine the underlying causes of these differences and to develop effective interventions.

Effect of Neoadjuvant Chemotherapy on Complications, in-Hospital Mortality, Length of Stay and Total Hospital Costs in Bladder Cancer Patients Undergoing Radical Cystectomy

Background: To test for differences in complication rates, in-hospital mortality, length of stay (LOS) and total hospital costs (THCs) in patients treated with neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC). Methods: Within the National (Nationwide) Inpatient Sample (NIS) database (2016−2019), we identified RC-treated, non-metastatic, lymph-node negative bladder cancer patients, stratified by NAC status. Trend analyses, multivariable logistic, multivariable Poisson and multivariable linear regression models were used. Results: We identified 4347 RC-treated bladder cancer patients. Of those, 805 (19%) received NAC prior to RC. Overall, complications rates did not differ (65 vs. 66%; p = 0.7). However, NAC patients harbored lower rates of surgical site (6 vs. 9%), cardiac (13 vs. 19%) and genitourinary (5.5 vs. 9.7%) complications. In-hospital mortality (<1.7 vs. 1.8%) and LOS (6 vs. 7 days) was lower in NAC patients (all p < 0.05). Moreover, NAC was an independent predictor of shorter LOS in multivariable Poisson regression models (Risk ratio: 0.86; p < 0.001) and an independent predictor for higher THCs in multivariable linear regression models (Odds ratio: 1474$; p = 0.02). Conclusion: NAC was not associated with higher complication rates and in-hospital mortality. Contrary, NAC was associated with shorter LOS, yet moderately higher THCs. The current analysis suggests no detriment from NAC in the context of RC.