Urologic Oncology: Seminars and Original Investigations
Original articleAssessing trends in urinary diversion after radical cystectomy for bladder cancer in the United States
Introduction
In the United States, bladder cancer will be diagnosed in an estimated 81,000 patients in 2018 [1]. Radical cystectomy (RC) with a thorough pelvic lymph node dissection is the treatment of choice for muscle-invasive bladder cancer [2], [3]. Following RC, reconstruction of the urinary system can be performed using a variety of techniques. The critical distinction of different diversion options is between incontinent diversions (ID) and continent diversions (CD), such as catheterizable continent cutaneous pouches and the most common form, the orthotopic neobladder.
Each type of diversion requires consideration of surgical technique, perioperative morbidity [4], [5], and long-term quality of life outcomes [6], [7], [8]. There continues to be controversy as to which diversion is best suited for patients. Approximately 75% of patients undergoing RC are candidates for CD [9], nonetheless, the rate of CD is highly variable, even when comparing between high-volume, tertiary care centers [2], [10]. A better understanding of trends in the performance of CD over time and critical patient- and facility-related factors driving the choice of urinary diversion (UD) is needed in order to optimize patient selection and outcomes.
The aim of this study was to analyze current trends in patterns of care for UD utilization after RC for bladder cancer in the United States. We examined trends over time in performance of CD, as well as changes in patient and facility characteristics that could be driving the evolution of practice patterns. Additionally, we assessed the relationship between minimally invasive surgery (MIS) and frequency of ID and CD. Finally, we sought to identify features associated with undergoing continent diversion using both patient- and facility-related variables.
Section snippets
Data source
The National Cancer Database (NCDB) is jointly sponsored by the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The database collects oncologic data on more than 70% of new cancer cases in the United States through more than 1,500 CoC-accredited cancer programs. Data are de-identified and submitted to the NCDB by each cancer program using standardized data and coding definitions defined by the CoC's Facility Oncology Registry Data Standards. The
Patient-related demographics
From 2004 to 2013, there were a total of 27,170 patients who underwent RC with UD of which 23,224 (85.5%) and 3,946 (14.5%) were ID and CD, respectively (Table 1). Those aged ≤80 years had a CD rate of 15.8% compared to CD rate of 3.9% for patients older than 80 years, P < 0.01. When comparing sex, males were more likely to undergo CD compared to females (15.2% vs. 10.1%, P < 0.01). Patients with ≥1 CCI were less likely to have CD compared to patients with no comorbidities (10.5% vs. 16.3%, P <
Discussion
In our analysis of the NCDB, we report a low and declining rate of continent diversion after RC for bladder cancer in the United States from 2004 to 2013. Multiple independent variables were identified as being positively and negatively associated with undergoing CD. The overall CD rate of 14.5% is similar to previous national database study estimates of 8% to 19% [11], [12], [13], [14]. While confirming prior studies that bladder cancer care is becoming increasingly centralized to high-volume
Conclusion
The rate of continent diversion after RC for bladder cancer in the United States has downtrended from 17.2% in 2004 to 2006 to 12.1% in 2010 to 2013. Higher income, facility geographic location in the West, academic program, high hospital volume, and traveling >60 miles for care were positively associated with receiving CD. Despite an overall national decline in CD, high-volume hospitals performing a larger proportion of open RCs had higher rates of CD compared to high-volume MIS facilities.
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Cited by (19)
Early and Midterm Complications of the Continent Catheterizable Indiana Pouch Urinary Diversion: A 7-year Experience
2022, UrologyCitation Excerpt :On multivariate logistic regression only hypertension was predictive of increased Clavien Grade III-V complications (OR 3.5, P = .03, Supplementary Table 5). The rates of continent urinary diversion have been decreasing over the decades with only 12% of patients undergoing continent diversion in 2013 compared to 17% in 2004.1 Furthermore, utilization of continent catheterizable IP urinary reservoir is utilized less often than NB.
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Disclosure: Nothing to disclose.