Long‐term renal function in patients with chronic kidney disease following radical cystectomy and orthotopic neobladder

Abstract

To evaluate long-term renal function in patients with chronic kidney disease (CKD) Stage IIIa who underwent radical cystectomy and orthotopic neobladder (RC/ONB) compared to matched controls. Patients and MethodsUsing our Institutional Review Board-approved institutional database, patients with a glomerular filtration rate (GFR) of 45-59.9 mL/min/1.73 m 2 who underwent RC/ONB were identified. A control group of patients with a GFR of ≥60 mL/min/1.73 m 2 was selected. Groups were matched based on age, baseline hypertension/diabetes mellitus, perioperative chemotherapy, and preoperative hydronephrosis. A decrease in GFR of >10 mL/min/1.73 m 2 during the follow-up was considered significant. A multivariate Cox regression analysis was performed to identify predictors of GFR decline in each group. ResultsOf 1237 patients who underwent RC/ONB, 508 patients were included (254 per group). The mean preoperative GFR was 53.3 mL/min/1.73 m 2 in the study group and 78.8 mL/min/1.73 m 2 in controls. The median follow-up was 3.7 years. During follow-up, GFR stayed at or above baseline in 51% of the study patients compared to 46% of the controls (P = 0.5). The mean time to a significant GFR decline in the study patients was significantly longer compared to the controls (5.6 vs 2 years, respectively; P < 0.001). In multivariate analysis, neoadjuvant chemotherapy was found to be the strongest predictor of a significant GFR decline as well as GFR decline below baseline (hazard ratio [HR] 2.15, 95% confidence interval [CI] 1.4-3.29, P = 0.004; and HR 2.15, 95% CI 1.4-3.29, P < 0.001, respectively). ConclusionPatients with CKD Stage IIIa who undergo ONB appear to have comparable long-term renal function to those with a GFR of ≥60 mL/min/1.73 m 2 . An ONB reconstruction is a safe option for patients with CKD Stage IIIa desiring a continent diversion.

Comparative performance of the different orthotopic urinary diversions

“…A meta-analysis did not show significant difference in serum creatinine between patients with sigmoid and ileal neobladder, and the renal function was well maintained within the normal range in those with normal renal functions prior to surgery [26]. A recent study from our center even demonstrated that patients with chronic kidney disease stage IIIa who undergo neobladder have comparable postoperative renal function to those with a GFR of 60 ml/min [55].…”

Renal function change after radical cystectomy for urothelial carcinoma patients with a solitary kidney may be independent of urinary diversion type

“…To determine renal function decline, our study referred to previous journals and combined various definitions using different values and ratios [ 13 16 17 18 19 20 21 22 23 24 ]. The follow-up duration and interval were different between previous studies; we followed up the renal function after cystectomy for 5 years.…”

“…The follow-up duration and interval were different between previous studies; we followed up the renal function after cystectomy for 5 years. Other studies defined the renal function decline by comparing the assessment and preoperative periods using only one episode [ 13 18 19 22 ]. We questioned this definition and determined that renal function decline should be used when there were two or more consecutive episodes.…”

“…Previous studies have reported a significant relationship between renal function decline and neoadjuvant chemotherapy [ 18 ], higher preoperative eGFR [ 20 ], and urinary tract obstruction (ureteroenteric or enterourethral stricture) [ 13 19 24 ]. Another study reported similar complications of NB and IC, which contrasts the popular view that IC is simple and safe [ 24 ].…”

“…To test the consistency of the change in renal function following RC, we used various methods to assess the renal function, including (i) serum creatinine level, (ii) eGFR (CKD-EPI and MDRD), (iii) eGFR difference value (preoperative value–follow-up value), and (iv) eGFR difference proportion (eGFR difference value/preoperative eGFR) at 1, 3, 6, 12, 24, 36, 48, and 60 months [ 16 17 18 19 ]. Furthermore, eGFR decline was assessed using various definitions: (i) 10 points decline in eGFR, (ii) 10% decline in eGFR, and (iii) 20% decline in eGFR [ 13 19 ].…”