Variations in reconstruction after radical cystectomy

Abstract

Background-Most urologists specializing in the management of patients with bladder cancer consider continent urinary diversion the reconstructive technique that affords the best quality of life after radical cystectomy. We sought to evaluate factors that predict reconstructive technique following radical cystectomy. Methods-Using linked data from Medicare and the National Cancer Institute (NCI)'s Surveillance, Epidemiology, and End Results (SEER)-program, we identified 3,980 subjects who underwent radical cystectomy for bladder cancer diagnosed between 1991 and 2000, of whom 776 (19.5%) underwent continent and 3,204 (80.5%) underwent incontinent urinary diversion. We used multivariate logistic regression modeling to identify factors independently associated with utilization of continent reconstruction following radical cystectomy, incorporating patient and provider variables. Results-In multivariate analysis, the likelihood of continent diversion was inversely associated with African American race (OR 0.54, p=0.03) and higher Charlson comorbidity score (OR 0.66, p=0.01), and directly associated with older age (OR 0.92, p<0.001) and education level (OR 1.01, p=0.01). Treatment at academic (OR 1.48, p=0.002) and NCI-designated cancer centers (OR 4.01, p<0.001) and by high volume providers (OR 1.56, p<0.001) was independently associated with continent reconstruction. Conclusions-Disparities in the utilization of continent urinary diversion following radical cystectomy suggest that demographic, socioeconomic, provider-based, and clinical variables predict the likelihood that those undergoing radical cystectomy will receive continent reconstruction. Regionalization of bladder cancer care may ameliorate many of the disparities noted but must be balanced against the risk imposed by a delay in care.

Does Robot-Assisted Approach to Radical Cystectomy Influence Surgeon Choice for Urinary Diversion?

“…However, the past decade has witnessed a significant change in the paradigm for the acceptable criteria for CUD which proved to be feasible among patients with the aforementioned factors. Although the majority of patients presenting for RC are likely reasonable candidates for CUD, less than 25% of patients actually received it [4,10,11]. The major cause for under-…”

Candidate quality of care indicators for localized bladder cancer

“…Although many experts consider orthotopic neobladder to be the optimal diversion in terms of functional and cosmetic outcomes for appropriately selected patients [32], the decision on type of diversion ultimately should be driven by patient factors: personal preferences as well as functional status and biology. Appropriately tailoring the type of diversion to the patient's desires and physiology may be regarded as an indicator of high quality care, albeit one that may be difficult to measure.…”

Intestinal adenocarcinoma arising in urinary conduits

“…Ureters are implanted and the pouch is either connected to the native urethra (orthotopic neobladder) or a catheterizable stoma is created. Today, in young patients without major comorbid conditions, the orthotopic neobladder is the most commonly utilized form of urinary diversion and allows for a good quality of life (28,29).…”

“…However, it is now also clear that patients with ileal conduits and continent diversions of various types (e.g., continent conduits and orthotopic neobladders) are at risk for second primary cancers. About 13,000 individuals receive a cystectomy for bladder carcinoma in the US each year, and~17% undergo continent diversion (28,29). Based on these statistics, we estimate that about 11,000 patients receive an ileal conduit and >2,000 receive a neobladder each year in the US.…”