Original article
Assessing trends in urinary diversion after radical cystectomy for bladder cancer in the United States

https://doi.org/10.1016/j.urolonc.2018.11.003Get rights and content

Highlights

  • Continent diversion (CD) rates have been steadily declining across the United States.

  • High-volume hospitals perform more open than robotic CD.

  • Academic and high-volume centers are positively correlated with performing CD.

Abstract

Objectives

We assessed recent trends in both urinary diversion after radical cystectomy for bladder cancer in the United States and patient- and hospital-related characteristics. We also identified variables associated with undergoing continent diversion.

Materials and methods

We queried the National Cancer Database and identified 27,170 patients who underwent radical cystectomy with urinary diversion from 2004 to 2013. Patient demographics, socioeconomic variables, and hospital-related factors were compared between incontinent and continent diversion and trended over time. Multivariable logistic regression was used to identify variables associated with undergoing continent diversion.

Results

Overall, 23,224 (85.5%) and 3,946 (14.5%) patients underwent incontinent and continent diversion, respectively. Continent diversion declined from 17.2% in 2004 to 2006 to 12.1% in 2010 to 2013 (P < 0.01). When analyzing high-volume facilities, those performing ≥75% minimally invasive radical cystectomy had fewer continent diversions (10.2%) compared to centers with higher rate of open approach (19.7%), P < 0.01. Higher income, facility located in the West, academic programs, high-volume facilities, and patients traveling >60 miles for care were significantly associated with undergoing continent diversion. Rate of continent diversion has declined in most patient- and hospital-related subgroups. Compared to 2004 to 2006, patients in 2010 to 2013 were more likely to be older, have more comorbidities, and be operated on at a high-volume academic facility.

Conclusion

The rate of continent diversion has declined to 12.1% in the United States. Hospital volume and type, patient income, distance traveled for care, and geography are significantly associated with undergoing continent diversion. Even among high-volume and academic centers, the rate of continent diversion is declining.

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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Disclosure: Nothing to disclose.

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