br Materials and methods We
Materials and methods: We queried the National Cancer Database and identified 27,170 patients who underwent radical cystectomy with urinary diversion from 2004 to 2013. Patient demographics, socioeconomic variables, and hospital-related factors were compared between incontinent and continent diversion and trended over time. Multivariable logistic regression was used to identify variables associ-ated with undergoing continent diversion.
Results: Overall, 23,224 (85.5%) and 3,946 (14.5%) patients underwent incontinent and continent diversion, respectively. Continent diversion declined from 17.2% in 2004 to 2006 to 12.1% in 2010 to 2013 (P < 0.01). When analyzing high-volume facilities, those perform-ing ≥75% minimally invasive radical cystectomy had fewer continent diversions (10.2%) compared to centers with higher rate of open approach (19.7%), P < 0.01. Higher income, facility located in the West, academic programs, high-volume facilities, and patients traveling >60 miles for care were significantly associated with undergoing continent diversion. Rate of continent diversion has declined in most patient- and hospital-related subgroups. Compared to 2004 to 2006, patients in 2010 to 2013 were more likely to be older, have more comor-bidities, and be operated on at a high-volume academic facility.
Conclusion: The rate of continent diversion has declined to 12.1% in the United States. Hospital volume and type, patient income, dis-tance traveled for care, and geography are significantly associated with undergoing continent diversion. Even among high-volume and aca-demic centers, the rate of continent diversion is declining. 2018 Elsevier Inc. All rights reserved.
Keywords: Bladder cancer; Radical cystectomy; Urinary diversion; Neobladder; Trends
In the United States, SQ109 cancer will be diagnosed in an estimated 81,000 patients in 2018 . Radical cystec-tomy (RC) with a thorough pelvic lymph node dissection is the treatment of choice for muscle-invasive bladder cancer [2,3]. Following RC, reconstruction of the urinary system
Disclosure: Nothing to disclose.
E-mail address: [email protected] (S. Daneshmand).
can be performed using a variety of techniques. The critical distinction of different diversion options is between inconti-nent diversions (ID) and continent diversions (CD), such as catheterizable continent cutaneous pouches and the most common form, the orthotopic neobladder.
Each type of diversion requires consideration of surgical technique, perioperative morbidity [4,5], and long-term quality of life outcomes [6−8]. There continues to be con-troversy as to which diversion is best suited for patients. Approximately 75% of patients undergoing RC are candi-dates for CD , nonetheless, the rate of CD is highly
variable, even when comparing between high-volume, ter-tiary care centers [2,10]. A better understanding of trends in the performance of CD over time and critical patient- and facility-related factors driving the choice of urinary diver-sion (UD) is needed in order to optimize patient selection and outcomes.
The aim of this study was to analyze current trends in patterns of care for UD utilization after RC for bladder can-cer in the United States. We examined trends over time in performance of CD, as well as changes in patient and facil-ity characteristics that could be driving the evolution of practice patterns. Additionally, we assessed the relationship between minimally invasive surgery (MIS) and frequency of ID and CD. Finally, we sought to identify features asso-ciated with undergoing continent diversion using both patient- and facility-related variables.
2. Materials and methods
The National Cancer Database (NCDB) is jointly spon-sored by the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The database collects oncologic data on more than 70% of new cancer cases in the United States through more than 1,500 CoC-accredited cancer programs. Data are de-identified and submitted to the NCDB by each cancer program using standardized data and coding definitions defined by the CoC’s Facility Oncology Registry Data Standards. The NCDB captures information about patient demographics and socioeconomic status, cancer staging, treatments, and outcomes. Institutional review board approval was not required as patient, physician, and hospital information is de-identified in the NCDB.
2.2. Study population
We identified 27,170 patients who were diagnosed with primary bladder cancer and underwent RC with UD between 2004 and 2013. Type of UD was identified using the Partici-pant User File bladder codes: 61 (ileal conduit), 62 (conti-nent cutaneous reservoir or pouch NOS), 63 (abdominal pouch [cutaneous]), and 64 (in situ pouch [orthotopic]). Patients were categorized into ID (61) or CD (62−64).