Original article
Female radical cystectomy patients have a higher risk of surgical site infections

https://doi.org/10.1016/j.urolonc.2018.05.023Get rights and content

Highlights

  • Female sex increases the odds of surgical site infections after cystectomy by 21%.

  • Females with surgical site infections are at higher risk of other adverse events.

  • More studies are needed to prescribe the best measures to prevent infection.

Abstract

Introduction

Surgical site infections (SSI) are common after radical cystectomy. The objectives of this study were to evaluate if female sex is associated with postoperative SSI and if experiencing an SSI was associated with subsequent adverse events.

Methods

This was a historical cohort study of radical cystectomy patients from the American College of Surgeons’ National Surgical Quality Improvement Program database between 2006 and 2016. The primary outcome was development of a SSI (superficial, deep, or organ/abdominal space) within 30 days of surgery. Multivariable logistic regression analyses were performed to determine the association between sex and other patient/procedural factors with SSI. Female patients with SSI were also compared to those without SSI to determine risk of subsequent adverse events.

Results

A total of 9,275 radical cystectomy patients met the inclusion criteria. SSI occurred in 1,277(13.7%) patients, 308 (16.4%) females and 969 (13.1%) males (odds ratio = 1.27; 95% confidence interval 1.10–1.47; P = 0.009). Infections were superficial in 150 (8.0%) females versus 410 (5.5%) males (P < 0.0001), deep in 40 (2.1%) females versus 114 (1.5%) males (P = 0.07), and organ/abdominal space in 118 (6.2%) females versus 445 (6.0%) males (P = 0.66). On multivariable analysis, female sex was independently associated with SSI (odds ratio = 1.21 confidence interval 1.01–1.43 P = 0.03). Females who experience SSI had higher probability of developing other complications including wound dehiscence, septic shock, and need for reoperation (all P < 0.05).

Conclusions

Female sex is an independent risk factor for SSI following radical cystectomy. More detailed study of patient factors, pathogenic microbes, and treatment factors are needed to prescribe the best measures for infection prophylaxis.

Introduction

Radical cystectomy is associated with frequent and often severe adverse events. As systems for recording patient outcomes have become more sensitive and comprehensive over time, the reported risk of adverse events has increased from 20% to 30% in early 1980s to upward of 80% in recent publications [1], [2], [3], [4], [5], [6], [7], [8]. Higher quality data pertaining to adverse events have allowed for more accurate patient counseling and have identified specific complications that may be targeted for improvement with interventions.

One relatively common complications of radical cystectomy is surgical site infection (SSI). SSI have negative impacts on a patient's quality of life, are expensive to the health care system, and may also delay adjuvant treatments [2], [7], [8], [9], [10], [11], [12]. Hence, several investigators have studied risk factors for SSI after radical cystectomy [13], [14], [15], [16], [17], [18], [19]. Characterizing risk factors for SSI is important as they identify patients at highest risk and may help determine why some of these infections occur.

It is reasonable to suggest that sex may be a risk factor for SSI following radical cystectomy because males and females have different pelvic anatomy. Furthermore, even in anatomical regions where anatomy does not differ, such as orthopedic surgery [20], [21], neurosurgery [22], and cardiac surgery [23], [24], female sex has been associated with a higher infection rate. Previous studies of SSI in cystectomy have not included sex in multivariable analysis [16], [17], [18], [19] or were underpowered [13], [14] to detect clinically meaningful differences. The purpose of this study was to evaluate the association between sex and SSI after cystectomy in a large prospective cohort.

Section snippets

Methods

The Ottawa Health Science Network Research Ethics Board approved this study. De-identified and anonymized patient data from the American College of Surgeons’ National Surgical Quality Improvement Program was reviewed from 2006 to 2016. NSQIP data is prospectively derived from over 500 hospitals, mostly in North America. The database is populated through a combination of automated collection and input from trained surgical clinical reviewers. All participating centers capture data for eligible

Results

Between 2006 and 2016, a total of 9,275 radical cystectomy patients (1,877 female and 7,398 male) met inclusion criteria. Baseline characteristics are presented in Table 1. Postoperative SSI occurred in 1,277(13.8%) patients; 308 (16.4%) females and 969 (13.1%) males (odds ratio [OR] = 1.27; 95% confidence interval [CI] 1.10–1.47; P = 0.009). Infections were superficial in 150 (8.0%) females versus 410 (5.5%) males; P < 0.0001), deep in 40 (2.1%) females versus 114 (1.5%) males; P = 0.07), and

Discussion

In this study, we reviewed the incidence of SSI following radical cystectomy. We found that female sex independently increased the odds of SSI by 21%. Furthermore, females that suffered an SSI had a longer length of hospital stay and other complications compared to those who did not.

The incidence of SSI in this cohort is similar to previous studies where the infection risk has been reported between 9% and 32% [2], [14], [16], [17], [18], [19]. It is likely that the range of reported risks

Conclusions

Using a large and contemporary cohort of patients, we found that female sex is an independent risk factor for SSI after cystectomy. Females who experience SSI have higher probability of developing other complications including wound dehiscence, septic shock, and return to the operating room. More detailed information about the incident infections may help determine the reason why females have a higher risk of SSI. Until more information is available, careful vaginal preparation and prophylactic

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