Patients on hemodialysis (HD) who undergo radical cystectomy (RC) for bladder cancer experience significant perioperative and all-cause mortality, new study findings suggest.
The overall survival rate is less than 15% at 5 years. Older age and a history of diabetes or cerebrovascular disease are mortality risk factors, Scott C. Johnson, MD, of the Medical College of Wisconsin in Milwaukee, and colleagues reported online ahead of print in Urologic Oncology.
Using the US Renal Data System database, Dr Johnson’s team identified 985 patients on HD who underwent RC for bladder cancer from 1984 to 2013. Of these, 31.5% underwent urinary diversion. The median hospital length of stay was 10 days and 43.1% of patients experienced a complication. The 30-day mortality rate was 9.3%. All-cause mortality rates at 1, 3, and 5 years was 51.7%, 77.3%, and 87.9%, respectively. Each 1-year increment in age was associated with a significant 2% increased risk of death from any cause. Cerebrovascular disease and diabetes were associated with a significant 48% and 33% increased risk of all-cause mortality, respectively. Urinary diversion was associated with a significant 17% decreased risk of death.
Cancer-specific mortality (CSM) rates at 1, 3, and 5 years was 12.3%, 18.4%, and 19.7%, respectively. The only risk factor for CMS was active smoking. On multivariable analysis, active smoking was associated with a significant 70% increased risk for CSM.
To the investigators’ knowledge, their study is the largest to explore outcomes following RC among patients with end-stage renal disease (ESRD).
“Although we have reported sobering perioperative and long-term outcomes, we believe there remains a role for RC in carefully selected ESRD patients,” the authors wrote.
They stated that younger patients without diabetes or cerebrovascular disease represent a subgroup with the lowest risk of non-cancer mortality and may benefit most from RC. “In our opinion, when performing RC in this population, urinary diversion should not necessarily be avoided and concurrent nephrectomy is not mandatory.”
The authors said it is unclear why urinary diversion was associated with lower mortality, but selection bias could be a factor. It is possible that patients who underwent a urinary diversion were more likely to have substantial urine output and residual renal function (RRF), Dr Johnson and his colleagues pointed out. RRF in ESRD patients can have significant effects on cardiac function, small solute clearance, fluid balance, and mortality, they noted.
With respect to study limitations, the authors acknowledged that their study lacked a control group of patients who did not undergo RC, “so how RC actually impacted outcomes is not known.” In addition, the investigators noted that they did not have information available on staging and specific operative details such as receipt of lymphadenectomy, both of which may have had a significant effect on outcomes.
Johnson SC, Smith ZL, Golan S, et al. Perioperative and long-term outcomes after radical cystectomy in hemodialysis patients. Urol Oncol. 2018; published online ahead of print.