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AUA 2018

AUA 2018: Comprehensive Characterization of Returns to the Operating Room following Radical Cystectomy

San Francisco, CA (UroToday.com) As part of the American College of Surgeons National Surgical Quality Improvement Program, several metrics are measured for improving patient safety and quality of care [1]. One important metric for major abdominal surgery is an “unplanned return to the operating room” within 30 days of the original procedure. Certainly, radical cystectomy fits this criterion and is an inherently morbid procedure, however there is a paucity of data assessing predictors of unplanned returns to the operating room. As such, the group from the Mayo Clinic lead by Dr. Lyon presented their institutional results assessing predictors of return to the operating room following radical cystectomy at the invasive bladder cancer session at the 2018 AUA.  


For this study, the authors queried the robust and granular Mayo Clinic radical cystectomy registry to identify 1968 patients who underwent radical cystectomy from 2000-2016 to assess those that had a return to the operating room within 90 days of radical cystectomy. The authors defined a return to the operating room as a return to a surgical operating room, and did not include gastrointestinal endoscopy or interventional radiology procedures. Missing albumin data for 23% of patients was imputed. Multivariable logistic regression was used to examine associations between patient features and return to the operating room. Overall survival was modeled using the Kaplan-Meier method and compared with the log rank test, and Cox proportional hazards models were used to identify features associated with survival. 

Among the 1968 patients included in the study, 112 (5.7%) patients underwent 125 reoperations within 90 days of radical cystectomy. Of these returns to the operating room, 99 (83%) had their first reoperation within 30 days of the original procedure. The most common reasons for primary return to the operating room were facial dehiscence (29%), bowel obstruction (21%), enteric anastomotic leak (9%), neobladder leak (5%) and uncontrolled hemorrhage (4%). On multivariable analysis, variables significantly associated with an increased odds of return to the operating room included:  

Screen Shot 2018 05 18 at 7.29.38 PM

Median follow-up among patients alive at last contact was 5.4 years (IQR 2.2-9.6). There were 1,047 deaths due to any cause, and 687 deaths secondary to bladder cancer. Importantly, patients returning to the operating room had significantly decreased 5-year overall survival (42% vs 55%, p=0.003), and a return to the operating room was found to be independently associated with all-cause mortality (HR 1.33, 95% CI 1.04-1.74, p=0.04).  

The strengths of this study include the ability to assess 90-day returns to the operating room, as well as long-term follow-up allowing assessment of how these events relate to down-stream mortality outcomes. Both of these outcomes are not assessable through the NSQIP database. Possible limitations include the fact that because this is an institutional, tertiary referral center analysis, these results may not necessarily be generalizable to the other centers. Dr. Lyon concluded with several take home points: 

  • Although a morbid procedure, radical cystectomy results in uncommon returns to the operating room within 90 days (~6%) 
  • The most common reasons for return to the operating room were related to fascial closure and bowel complications 
  • Returns to the operating room after radical cystectomy is associated with overall survival and appears to be a valid quality measure 
Presented By: Timothy Lyon, Mayo Clinic, Rochester, MN 
Co-Authors: Stephen Boorjian, Paras Shah, Robert Tarrell, Prabin Thapa, John Cheville, Igor Frank, R. Jeffrey Karnes, R. Houston Thompson, Matthew Tollefson, Rochester, MN 

References: 
1. ACS NSQIP User Guide for the 2012 ACS NSQIP Participant Use Data File. Available at: https://www.facs.org/~/media/files/quality%20programs/nsqip/ug12.ash  

Written by:  Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre Twitter: @zklaassen_md at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA