The impact of perioperative risk factors on long-term survival after radical cystectomy: a prospective, high-volume cohort study.

ABSTRACT

INTRODUCTION: Radical cystectomy (RC) is the gold standard for muscle-invasive bladder cancer. Nevertheless, RC is associated with substantial perioperative morbidity and mortality. We aimed to evaluate the role of important perioperative risk factors in predicting long-term survival after RC. METHODS: An analysis of the prospective cohort of patients undergoing open RC from 2004 to 2023 at our center was performed. Patients who died within one month after RC were excluded from the study. A univariate and multivariable Cox regression analysis was performed to assess the role of sex, age, urinary diversion, preoperative values of creatinine and hemoglobin, first-day postoperative values of CRP, leucocytes, and thrombocytes, perioperative Clavien-Dindo complications, perioperative chemotherapy, admission to the intensive or intermediate care unit, as well as type of histology, pathologic T-stage, positive lymph nodes, and positive surgical margins on predicting the long-term overall survival after RC. For all analyses hazard ratios (HRs) with the corresponding 95% confidence intervals (CIs) were estimated. RESULTS: A total of 1,750 patients with a median age of 70 years (IQR 62-76) were included. Of them, 1,069 (61%) received ileal conduit and 650 (37%) neobladder. Overall, 1,016 (58%) perioperative complications occurred. At a median follow-up of 31 months (IQR 12-71), 884 (51%) deaths were recorded. In the multivariable Cox regression analysis, increasing age (HR 1.03, 95%CI 1.02-1.04, p < 0.001), higher preoperative creatinine values (HR 1.27, 95%CI 1.12-1.44, p < 0.001), lower preoperative hemoglobin values (HR 0.93, 95%CI 0.89-0.97, p = 0.002), higher postoperative thrombocyte values (HR 1.01, 95%CI 1.01-1.02, p = 0.02), Clavien-Dindo 1-2 complications (HR 1.26, 95%CI 1.03-1.53, p = 0.02), Clavien-Dindo 3-4 complications (HR 1.55, 95%CI 1.22-1.96, p < 0.001), locally advanced bladder cancer (HR 1.29, 95%CI 1.06-1.55, p = 0.009), positive lymph nodes (HR 1.74, 95%CI 1.45-2.11, p < 0.001), and positive surgical margins (HR 1.61, 95%CI 1.29-2.01, p < 0.001) negatively affected long-term survival. CONCLUSION: Beside increased age and worse oncological status, impaired renal function, lower preoperative hemoglobin values, higher postoperative thrombocyte values, and perioperative complications are independent risk factors for mortality in the long term in patients undergoing open RC.