Hypoalbuminemia is associated with increased 30-day complications following rectourethral fistula repair: A NSQIP study
M. Ryan Farrell, MD, MPH, Alex J. Vanni, MD.
Lahey Hospital and Medical Center, Burlington, MA, USA.
BACKGROUND: Surgical management of rectourethral fistula (RUF) is complex and can include bowel and urinary diversion, bowel resection, cystectomy, or urethral reconstruction. Hypoalbuminemia is a marker of poor nutrition and has been associated with increased complications in other major surgical procedures including cystectomy and colorectal surgery. Yet, the limited prevalence of RUF makes it a challenging entity to study. We sought to utilize a large national database to describe the population of men undergoing RUF repair and to evaluate the effect of hypoalbuminemia on postoperative complications.
METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for all male patients who underwent RUF repair from 2006-2018. Postoperative 30 day complications included wound infection, organ space surgical site infection, wound dehiscence, urinary tract infection, sepsis, venous thromboembolism, pneumonia, mortality, and return to operating room.
RESULTS: A total of 250 patients were identified. At the time of RUF repair, 17.2% underwent concurrent bowel diversion and 13.6% underwent bowel resection. Additional concurrent procedures included cystectomy (8.0%) and urethroplasty (14.8%). A muscle, myocutaneous, or fasciocutaneous flap was used in 75.7% of those undergoing urethroplasty. Overall, median age was 66.0 years (IQR 59.0-72.0), BMI 26.6 kg/m2 (IQR 23.7-29.5), and 98.8% were functionally independent. Comorbidities included hypertension on medication (56.0%), smoking (22.0%), diabetes (6.8%), COPD (4.4%), and CHF (0.4%). Hypoalbuminemia (<3.5 g/dL) was present in 19.8%. Overall, 20.4% of patients experienced a complication within 30 days of surgery including wound infection (5.6%), sepsis (5.2%), organ space infection (4.4%), urinary tract infection (3.2%), and venous thromboembolism (3.2%). Hypoalbuminemia was associated with increased odds of an adverse event (OR 3.1, p=0.02). Median hospital length of stay was 5.0 days (IQR 3.0-8.0), and was significantly longer among patients undergoing cystectomy (8.0 days, IQR 6.0-13.0; p<0.01). Overall 30-day mortality was 2.0% and did not differ by concurrent procedures.
CONCLUSIONS: Patients who underwent surgical repair of RUF were often functionally independent with limited major comorbidities. Hypoalbuminemia was associated with increased odds of an adverse postoperative event, thereby suggesting a role for nutritional optimization prior to RUF repair.
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