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To evaluate the risk of different in-hospital complications for patients undergoing a radical cystectomy RC , as limited nationwide population data on short- and long-term complications after RC is available, despite it being the standard treatment for localised muscle-invasive urinary bladder cancer UBC. There was a higher risk of urinary tract infection among patients who had a continent cutaneous reservoir HR: 1. Similarly, continent cutaneous reservoir and orthotopic neobladder were associated with increased risks for wound and abdominal wall hernias, stones in the urinary tract, hydronephrosis and nephrostomy tube treatment, and kidney failure. In contrast, risk of bowel obstruction was lower among those with orthotopic neobladder than those with ileal conduit HR: 0. In-hospital complications after RC are numerous and continue to accumulate for many years after surgery, indicating the need for life-long follow-up of these patients. Comparison between different types of diversion should, however, be made with care because of potential confounding by indication.

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To evaluate the risk of different in-hospital complications for patients undergoing a radical cystectomy RC , as limited nationwide population data on short- and long-term complications after RC is available, despite it being the standard treatment for localised muscle-invasive urinary bladder cancer UBC.

There was a higher risk of urinary tract infection among patients who had a continent cutaneous reservoir HR: 1. Similarly, continent cutaneous reservoir and orthotopic neobladder were associated with increased risks for wound and abdominal wall hernias, stones in the urinary tract, hydronephrosis and nephrostomy tube treatment, and kidney failure. In contrast, risk of bowel obstruction was lower among those with orthotopic neobladder than those with ileal conduit HR: 0.

In-hospital complications after RC are numerous and continue to accumulate for many years after surgery, indicating the need for life-long follow-up of these patients. Comparison between different types of diversion should, however, be made with care because of potential confounding by indication. Radical cystectomy RC for localised muscle-invasive urinary bladder cancer UBC 1 is a complex and multifaceted surgical procedure and the short- and long-term complications are well studied in single-centre series 2 — However, limited information is available from population-wide samples providing an estimate for the general population Another study focusing on long-term complications based on 75 patients who underwent RC and orthotopic ileal neobladder substitution showed that complications occurred in 23 patients and three died from pulmonary embolism 8.

To our knowledge there are only few nationwide reports on complications published to date. In-hospital mortality was also unchanged from 2. To assess the occurrence of hospitalisation due to complications after RC, we selected all men and women who underwent RC due to UBC in Sweden between and patients.

The latter register was also used to collect details on pre-specified complications. In addition, we obtained information on cause of death from the National Cause of Death Register.

Information from these three registers was linked using the unique personal identity numbers. Record linkage by means of the personal identity number ensures that each tumour is only registered once 19 — The National Patient Register includes information about in-patient care since in different Swedish regions. The number of participating counties increased over time and the Register became nationwide in Each observation contains information on dates of admission and discharge, hospital department, codes for surgical procedures performed during the stay, and main and contributory discharge diagnoses coded according to International Classification of Diseases ICD Since , the National Board of Health and Welfare has kept a database containing cause of death data The patients who underwent RC were subdivided based on the specific urinary diversion used: ileal conduit, continent cutaneous reservoir or orthotopic neobladder.

It is important to note that, especially in the beginning of the study period, ileal conduit was the most common procedure so that diversion type was often not recorded. Frequencies by diversion type are reported for the entire study period, but all analyses were based on those RCs performed as of to allow for comparisons between procedures conducted according to a similar surgical practice.

All complications were defined by using standardised surgical codes and the ICD, including both primary and secondary diagnoses, using in-hospital data so that we could not use the Clavien score, which focuses on short-term complications to which our data are not sensitive.

Finally, we also assessed all-cause mortality. For statistical analyses, frequency counts by diversion type were given for the entire study period, but all the following analyses were only performed for those RCs performed as of We calculated the incidence per person-years py for each complication after all RCs combined, as well as for the different types of urinary diversion. These incidences are thus defined by person-years for the at risk RC population.

The risk of developing each of these complications was modelled using multivariate Cox-proportional hazards models in which we adjusted for age, sex, and lymph node dissection LND. Risks were also estimated for the different types of urinary diversions used and by sex. Follow-up time was defined from the time of RC until date of complication, death, or end of study 31 December , whichever came first. In summary, all frequency counts involved all adverse events for every person, whether Cox proportional hazards models were always estimated by using the first event of the studied outcome for every person.

Follow-up thus varied per person depending on type of complication studied. As the choice of type of urinary diversion is associated with UBC severity, competing risks may be involved in the analysis of complications after RC. Patients with severe disease are more likely to die early of their UBC, so that they never develop potential long-term complications.

We therefore repeated the above described Cox proportional hazards models using Fine and Gray's analysis This analysis takes into account that a patient is at risk of more than one mutually exclusive event, such as death from UBC, which may then prevent any other event i.

Finally, the risk of developing different types of complications after RC was also shown using cumulative incidence graphs. The median range follow-up was 3. Three quarters of the RCs were performed on men and the mean age at surgery was 66 years. Baseline characteristics of the study population by year in which the RC was performed.

At the beginning of the series the patients were younger with a mean age of The number of patients with continent cutaneous reservoir slightly decreased from Hospitalisation for kidney failure and bowel obstruction were the second most common complications, with the highest incidence for bowel obstruction in patients with an ileal conduit Frequency and incidence of complications after RC and urinary diversion, — When studying the risk of different in-hospital complications by type of diversion we found a higher risk of UTI among patients who had an orthotopic neobladder hazard ratio [HR] 1.

In contrast, these patients had a lower risk of bowel obstruction compared to those with ileal conduit HR 0. Patients with a cutaneous reservoir were at higher risk of hydronephrosis, wound hernia, and stones than those with ileal conduit e. HR wound hernia 1. Also those with an orthotopic neobladder were at increased risk of hydronephrosis than those with ileal conduits HR 1. HR orthotopic neobladder 0. The analysis is restricted to procedures performed in onwards.

All models are adjusted for age, gender, and LND. The year cumulative incidence curves for complications after RC by type of urinary diversion indicate that most complications continue to accumulate during the entire period of follow-up Fig. Cumulative incidence of different complications after different types of RC in Sweden, — It therefore enabled us to provide a general picture of complications after RC, including both low- and high-volume centres, without the risk of loss to follow-up when evaluation long-term adverse events.

Ileal conduit was the type of urinary diversion associated with the lowest frequency of complications but also with the highest incidence of death. Apart from the increased risk of postoperative bowel obstruction, the present data show a more preferable risk profile for ileal conduit over continent cutaneous reservoir or orthotopic neobladder.

This positive risk profile is of interest given that the typical patient selection for this procedure would predict the opposite risk profile. In contrast to those undergoing the latter two procedures, patients undergoing a RC with ileal conduit are less exposed to residual urine or repeated catheterisations as a consequence of retention of urine inside the body.

Patients with an orthotopic neobladder had less bowel obstruction than patients with an ileal conduit, which may be attributed to the presence of an intestinal stoma through the abdominal wall in the latter patients. The surgically created passage of intestine through the abdominal wall is a well-known site of herniation and rotation causing bowel obstruction.

Moreover, a higher rate of locally advanced disease may contribute to the higher incidence of bowel obstruction among patients who underwent a RC with ileal conduit. A slightly increased risk of complications among patients with continent urinary diversions could be outweighed by a better health-related quality of life. In contrast to an ileal conduit, an orthotopic neobladder replicates the physiological voiding function and may seem intuitively attractive to both the surgeon and the patient.

However, studies of quality-of-life outcomes have consistently failed to show any clear advantages of an orthotopic neobladder 22 — Nevertheless, preoperative expectations may differ and the interpretation of data is complex, while randomised studies equalising the baseline characteristics are lacking.

We conclude that the present findings underscore how the intuitive attractiveness of an orthotopic neobladder could be deceiving and that it is crucial for patients to be carefully informed before the type of diversion is chosen. The proportion of patients undergoing a LND was surprisingly low. As RCs historically have been decentralised to many low-volume hospitals, it is, however, expected that the number of lymphadenectomies is low compared with reports of case series from single centres of excellence.

The unique infrastructure of nationwide registers in Sweden enabled us to follow a large population-based cohort of patients for up to almost 40 years. These patients represent the entire population, thus avoiding selection bias.

The validity of the Patient Register is known to be high for specific diagnoses such as septicaemia and hernia However, it should be noted that because we based the present study on inpatient data, we only estimated the incidence of complications based on the records of those admitted to hospital, so that the incidence of several conditions, e. Another limitation is the lack of detailed information on clinical characteristics, e. Therefore, we cannot evaluate the use of specific devices, e.

Comparing different urinary diversions in terms of in-hospital complications is complex because the choice of diversion may be influenced by the perceived baseline risk of such outcomes, a phenomenon known as confounding by indication. Ileal conduit, for instance, is preferred among the elderly, those with more advanced disease stage and more comorbidity. Despite the likely higher baseline risk of complications among patients with ileal conduit, we found that ileal conduits were negatively associated with several complications.

Moreover, Fine and Gray analyses indicated that competing risks did not play a major role in these analyses. Whereas oncological surveillance can be terminated 5 years after RC 27 , these data thus underscore the need for a continuing follow-up of functional outcomes and complications. At present, the European Association of Urology guidelines recommend that such surveillance may be stopped after 15 years, but the present data as well as others 28 do not indicate any time point beyond which complications do not continue to accumulate.

We therefore suggest that functional follow-up of these patients be lifelong In particular, surveillance of renal function seems warranted, and a liberal use of imaging techniques on demand to perhaps prevent the development of kidney failure in a proportion of the patients. In conclusion, overall the present data show that complications after RC and urinary diversion are numerous and continue to accumulate for many years after surgery, suggesting that follow-up of these patients should be lifelong.

When comparing the frequency of complications between different types of urinary diversion, ileal conduit was associated with more events of bowel obstruction, but fewer instances of other complications, e.

National Center for Biotechnology Information , U. Bju International. BJU Int. Published online Jul Author information Copyright and License information Disclaimer. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

This article has been cited by other articles in PMC. Abstract Objective To evaluate the risk of different in-hospital complications for patients undergoing a radical cystectomy RC , as limited nationwide population data on short- and long-term complications after RC is available, despite it being the standard treatment for localised muscle-invasive urinary bladder cancer UBC.

Conclusions In-hospital complications after RC are numerous and continue to accumulate for many years after surgery, indicating the need for life-long follow-up of these patients. Keywords: bladder cancer, cystectomy, complication. Introduction Radical cystectomy RC for localised muscle-invasive urinary bladder cancer UBC 1 is a complex and multifaceted surgical procedure and the short- and long-term complications are well studied in single-centre series 2 — Patients and Methods To assess the occurrence of hospitalisation due to complications after RC, we selected all men and women who underwent RC due to UBC in Sweden between and patients.

Appendix 1 Surgical and inpatient code for different complications studied.

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