Comprehensive Characterization of the Real-World Perioperative Morbidity of Radical Cystectomy in Older Adults
John Ernandez, Jr., BA1, Sumedh Kaul, MS2, Aaron Fleishman, MPH2, Ruslan Korets, MD3, Peter Chang, MD, MPH3, Andrew Wagner, MD3, Simon Kim, MD4, Joaquim Bellmunt, MD, PhD5, Nima Aghdam, MD6, Aria Olumi, MD3, Dae Kim, MD, MPH, ScD7, Ellen McCarthy, PhD, MPH8, Boris Gershman, MD3.
1Harvard Medical School, Cambridge, MA, USA, 2Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA, 3Division of Urologic Surgery, Beth Israel Deaconess Medical CenterSchool, Boston, MA, USA, 4Division of Urology, University of Colorado Anschutz Medical Center, Aurora, CO, USA, 5Department of Medicine, Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA, 6Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA, 7Marcus Institute for Aging Research, Hebrew SeniorLife; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA, 8Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA.
INTRODUCTION: The perioperative morbidity of radical cystectomy (RC) is a critical factor for optimal decision-making in older adults with bladder cancer (BC). However, existing literature on the morbidity of RC is dated, does not focus on older adults, and predominantly reflects the experience of academic medical centers. Herein, we examine the real-world, perioperative morbidity of RC in a national, contemporary cohort of older adults with BC.
MATERIALS & METHODS: Using SEER-Medicare, we identified patients 66-89 years diagnosed from 2000 to 2017 with Tany Nany cM0 bladder cancer who underwent RC. We examined rates of perioperative blood transfusion, healthy days at home (HDAH) within 90 days post-RC, postoperative complications, emergency room (ER) utilization, and hospital readmission using Medicare claims. The associations between baseline characteristics and 90-day complications and hospital readmission were evaluated using logistic regression.
RESULTS: A total of 5,916 patients were included. Median age was 74 (IQR 70-79) years. The median LOS was 9 days (IQR 8-13), and the median number of HDAH was 78 (IQR 65-82) days. Perioperative blood transfusion occurred in 1,366 (23%) patients, while 90-day complications occurred in 3,786 (64%) patients (Figure 1), with 2,067 (35%) patients experiencing a post-discharge complication requiring care in the ER or hospital. A total of 1,745 (29%) of patients required ER evaluation within 90 days of RC, while 2,598 (44%) were readmitted to the hospital under observation or inpatient status. On multivariable analysis, higher Charlson comorbidity index (CCI), higher census tract poverty level, and lower census tract education level were associated with increased risk of 90-day inpatient readmission, while older age, Black race, higher CCI, current/former smoker status, and lower annual hospital RC volume were associated with increased risk of 90-day complications.
CONCLUSIONS: The real-world perioperative morbidity of RC in older adults is substantial and even greater than reported in prior institutional studies, with 44% of patients requiring hospital-based care within 90 days of surgery. These observations should inform the counseling of older adults with bladder cancer considering RC and encourage interventions to reduce morbidity in at-risk patient populations. 
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