Identifying risk factors for potentially avoidable complications following radical cystectomy

Purpose: Morbidity after radical cystectomy is common and associated with increased health care resource use. Accurate characterization of complications after cystectomy, associated patient specific risk factors, and perioperative processes of care are essential to directing changes in perioperative management that will reduce morbidity and improve the quality of patient care. Materials and Methods: The National Surgical Quality Improvement Program (NSQIP) is a prospective quality management initiative of 123 Veterans Affairs Medical Centers nationwide. The NSQIP collects clinical information, intraoperative data and outcomes on a wide variety of surgical procedures from multiple surgical disciplines. Since 1991, 2,538 radical cystectomy procedures have been captured by the NSQIP. Modeling using logistic regression was performed to identify patient specific risk factors and perioperative process measures associated with postoperative morbidity. Results: Of the 2,538 subjects at least 1 postoperative complication developed in 774 (30.5%). The most frequent complication was ileus (10%). Several factors were associated with the development of a complication, including age, dependent functional status, preoperative dyspnea, preoperative acute renal failure, chronic steroid use, preoperative alcohol consumption, American Society of Anesthesiology score, use of general anesthetic, operative time, intraoperative blood requirement and surgeon level of training. Conclusions: Morbidity remains high after cystectomy with 30.5% of subjects experiencing at least 1 complication. Measurable patient specific risk factors and perioperative processes associated with postoperative morbidity following cystectomy are now delineated which allows for improved risk stratification, patient counseling, and the development of novel processes that may incrementally reduce risk and improve outcomes.