Comparison of Major Complications at 30 and 90 days Following Radical Cystectomy - Beyond the Abstract

Radical cystectomy is associated with some of the highest rates of morbidity and mortality in the field of urologic surgery. Despite this burden, there remains a lack of consensus as to when it is most useful to assess complications across the post-surgical recovery period. Our objective was to describe the time-course of major complications (Clavien grade III-V) after radical cystectomy and explore associations that exist with these events at early (30-day) and late (90-day) time points. 

In 969 patients undergoing radical cystectomy, 14.4% experienced a major complication at 30 days, compared to a rate of 21.7% at 90 days. Complications were categorized by type with genitourinary, gastrointestinal, and infectious complications occurring most frequently. Upon further stratification, ureteral obstruction, intra-abdominal abscess, and small bowel obstruction were the three most commonly experienced major complications. When comparing events at 30 and 90 days, the majority of deaths and genitourinary complications occurred in the late time period (30-90 days). Chronic obstructive pulmonary disease (COPD) (p=0.03), CCI (p=0.02), and Indiana pouch diversion (p=0.002) were significant predictors of early complication, while diabetes was the strongest predictor for late complication (odds ratio [OR]: 2.42; p = 0.01) and late genitourinary complication (OR 3.39; p=0.01). Smoking history was a significant predictor for late infectious complications (OR 3.61; p=0.01).

A highlight of this study was the finding that a significant number of major complications occurred after 30 days post-surgery, including the preponderance of deaths and genitourinary complications. This could potentially be explained by limiting early perioperative complications as a result of improved cystectomy experience overall. It is also possible that data-sharing between EMR platforms, such as EPIC’s Care Everywhere, allowed for a more complete recording of late complications that occurred outside the study institution. Whatever the cause, this finding challenges the idea that morbidity and mortality following radical cystectomy is limited to the immediate postoperative time period and further underscores the need for future studies to include assessment of 90-day outcomes.

Another highlight of this study focuses on the distribution of events in the postoperative period. Though the propensity for major complications decreases after 30 days, we observed a slow but steady rate of complication occurrences throughout the 30-90 day time period. Though future studies are needed, this finding may inform how we optimize post-cystectomy follow-up, suggesting extended utilization of in-person or virtual follow-up visits could help to identify early signs of complications, such as infection or ureteral obstruction, and mitigate progression to major complication or death.

While we identified associations between patient characteristics and major complications in this study, future work includes the creation of a risk calculator to better guide clinical decision making and to provide a more informed explanation of post-operative risk to patients when deciding to pursue surgery or alternative therapies.

Written by: Jacob M Knorr, Kyle J Ericson, Jj H Zhang, Prithvi Murthy, Amy S Nowacki, Carlos Munoz-Lopez, Lewis J Thomas, Georges-Pascal Haber, Byron Lee

Cleveland Clinic Lerner College of Medicine, 9501 Euclid Ave, Cleveland, Ohio, USA 44195. Electronic address: ., Cleveland Clinic Foundation, 9500 Euclid Ave. Cleveland, Ohio, USA 44195., Cleveland Clinic Lerner College of Medicine, 9501 Euclid Ave, Cleveland, Ohio, USA 44195.

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