Introduction:

Cystectomy is recommended by the National Comprehensive Cancer Network and American Urological Association guidelines as a first-line treatment for muscle invasive bladder cancer. Cystectomy with urinary diversion (regardless if with conduit or continent diversion) is a highly complex procedure, carrying significant operative risks. The complication rate within the first 90 postoperative days has been quoted to be as high as 50-60%. Postoperative complications are likely to result in increased use of healthcare resource utilization (HRU) such as longer hospitalization duration, increased use of continued care facilities following hospital discharge, and a higher number of unplanned readmissions within 30 days of surgery. The aim of this study was to identify modifiable risk factors that may lead to increased HRU. We hypothesize that operative duration (OD) is an independent risk factor of increased postoperative HRU in cystectomy. 

Methods:

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was filtered for cystectomy procedures from years 2012-2018. Both incontinent and continent diversions were identified. Patient characteristics including sex, age, BMI, race, smoking status, ASA class, and presence of comorbid conditions were recorded. HRU was also identified for each patient. HRU was defined as prolonged length of stay, unplanned readmission within 30 days of surgery, and discharge destination other than home.

For categorical variables, frequencies and column percentages were reported and p-values were calculated using Pearson’s Chi-Square test. Given the large dataset size, deciles were used to more accurately describe meaningful findings in the data. The first decile of OD included cases shorter than 3.3 hours; the last decile lasted longer than 8.5 hours. Patient characteristics and HRU outcomes were compared against OD deciles. Independent predictors of HRU were then identified through multivariate analyses.

Results:

A total of 12,451 cystectomies were recorded. Any HRU increased linearly with OD with 42.1% of patients in the first decile of OD using HRU and 57% of patients in the last decile (p<0.001). Discharge to continued care was the most commonly used HRU for the first decile of OD (31.1%, p<0.001), while prolonged hospitalization was the most common in the last decile (30.2%, p<0.001).  Unplanned readmission rates increased linearly with OD, ranging 17-28%.

Mutltivariable analysis identified independent predictors of HRU. ASA class of IV-V and age >75 years were independent predictors of increased HRU (OR 1.80 and OR 1.76, respectively; p<0.001). COPD increased HRU by 51% (p<0.001). BMI was a modest predictor of HRU (OR 1.02, p<0.001). Surgeries >6 hours introduced an increased postoperative HRU (OR 1.35, p<0.03) with the last decile demonstrating a more than 2-fold increased use of HRU postoperatively (OR 2.13, p<0.001).

Conclusion:

Operative duration during cystectomy is a significant independent predictor of increased post-operative heathcare resource utilization irrespective of patient comorbidities. Operative duration was also the most profound predictor of healthcare resource utilization as compared to any other patient characteristic evaluated in this study. Patients in surgery longer than 8.5 hours have a more than 2-fold increased risk of healtchare resource utilization. 

Funding: N/A