Race and postoperative complications following urologic cancer surgery: An ACS-NSQIP analysis
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Aims: To describe healthcare utilization and cost associated with the short-term and long-term complications of cystectomy among commercially insured bladder cancer patients in the United States.Materials and methods: This retrospective, observational cohort study evaluated adults with bladder cancer receiving a transurethral resection of bladder tumor followed by a partial or radical cystectomy procedure using U.S. administrative claims from the 2005-2015 IBM MarketScan Commercial and Medicare Supplemental databases. Bladder cancer patients were classified into two cohorts: partial cystectomy or radical cystectomy. Cystectomy complications were identified during the cystectomy admission, short-term period, and long-term period. Complication-related utilization and cost outcomes were reported in aggregate during the cystectomy admission and per patient per month (PPPM) during the short-term and long-term follow-up periods.Results: Of 5136 patients who received a cystectomy, 488 (9.5%) received partial cystectomy and 4648 (90.5%) received radical cystectomy. The mean (SD) costs of complications during the cystectomy admission were $11,728 ($43,380) for radical cystectomy and $4657 ($25,668) for partial cystectomy. In the short-term period, PPPM complication-related healthcare costs were $638 [$3793] for partial cystectomy and $2681 [$14,705] for radical cystectomy. In the long-term period, PPPM complication-related healthcare costs were $544 [$2580] for partial cystectomy and $1619 [$7874] for radical cystectomy.Conclusions: Cystectomy-related complications, especially with radical cystectomy, present a substantial financial burden to patients and payers immediately after surgery as well as in the long term. Targeted interventions which improve clinical outcomes but reduce substantial costs associated with cystectomy for bladder cancer are needed.
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Lymphadenectomy
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Analysis of 86 patients who underwent salvage cystectomy following a radical course of radiotherapy for bladder cancer and 37 patients who underwent primary cystectomy has shown a greater survival for women than men. The following factors were associated with a significant deterioration in survival: 1. Age at time of cystectomy: post-operative mortality and tumour recurrence are greater over the age of 70. 2. Non-function of one kidney on IVU. 3. Grade 3 tumour on cystectomy specimen. 4. pT3 or pT4 tumour on cystectomy specimen.
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The confluence of disease burden, advanced age and comorbidities of patients, and an inherently morbid operation make patients undergoing radical cystectomy (RC) for bladder cancer particularly vulnerable. In a recent study by Mossanen et al . (1), the authors explore the effect of complications on mortality following radical cystectomy. The study uses the Premier Hospital Database, a hospital discharge database, to identify patients who underwent radical cystectomy for bladder cancer and concludes that the timing, quantity, and nature of complications affect mortality following surgery.
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Radical prostatectomy is associated with excellent long-term disease control for localized prostate cancer. Prior studies have suggested an increased risk of short-term complications among older men who underwent radical prostatectomy, but these studies did not adjust for comorbidity.We examined mortality and complications occurring within 30 days following radical prostatectomy among all 11,010 men who underwent this surgery in Ontario, Canada, between 1990 and 1999 using multivariable logistic regression modeling. We adjusted for comorbidity using two common comorbidity indices. Statistical tests were two-sided.Overall, 53 men (0.5%) died, and 2195 [corrected] (19.9%[corrected]) had one or more complications within 30 days of radical prostatectomy. In models adjusted for comorbidity and year of surgery, age was associated with an increased risk of 30-day mortality (odds ratio = 2.04 per decade of age, 95% confidence interval [CI] = 1.23 to 3.39). However, the absolute 30-day mortality risk was low, even in older men, at 0.66% (95% CI = 0.2 to 1.1%) for men aged 70-79 years. In adjusted models, age was associated with an increased risk of cardiac (Ptrend < .001), respiratory (Ptrend = .01), and miscellaneous medical (Ptrend = .058) complications. Similarly, increasing comorbidity was associated with a higher risk of all categories of complications.Increasing comorbidity is a stronger predictor than age of almost all categories of early complications after radical prostatectomy. The risk of postoperative mortality after radical prostatectomy is relatively low for otherwise healthy older men up to age 79.
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The importance of comorbidity on the survival outcomes of any major surgery cannot be understated. Furthermore, the impact of one or more significant medical comorbidities on an inherently morbid procedure such as radical cystectomy is all but obvious.
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In the U.S., radical cystectomy has long been considered the standard of care for patients with muscle-invasive bladder cancer. However, radical cystectomy (with or without the creation of an orthotopic diversion) is a complex surgical procedure requiring intensive perioperative support services, and most patients with muscle-invasive disease are older than 70. During the past 2 decades, patients treated at academic centers have …
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Urinary diversion
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