A comparative analysis of complication rates in urinary diversions: Exploring the impact of contemporary surgical trends.
Authors: Pfail John , Fu Melinda , Passarelli Rachel , Kaldany Alain , Lichtbroun Benjamin , Golombos David , Jang Thomas L , Packiam Vignesh T. , Ghodoussipour Saum 
Published: February 2025

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Background:
Historically, outcomes have been similar among patients undergoing continent (CD) and incontinent diversion (ID) at time of radical cystectomy (RC), with no difference in complication rates. Given the decreasing rates of CD, we sought to examine postoperative complication rates based on type of diversion in a contemporary cohort.
Methods:
Data was extracted from the NSQIP database from 2019-2021 who underwent RC. Patients were stratified based on diversion type. Statistical endpoints included thirty-day complications, length of stay (LOS), and readmissions. Optimal RC outcome was defined as absence of any postoperative complication, reoperation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable analyses with Bonferroni correction were performed to assess the association between urinary diversion and postoperative outcomes.
Results:
A total of 4375 patients were identified, including 3780 (86.4%) who underwent ID and 595 (13.6%) who underwent CD. Compared to patients with CD, those with ID were more likely to be older, female, have higher ASA, worse renal function, robotic/lap approach, history of radiation or pelvic surgery, and higher stage (Table). On multivariable analysis, after Bonferroni adjustment, patients with CD had increased odds of high grade complications (OR 1.58; 99% CI [1.15-2.15]) and readmission (OR 1.7 [1.28-2.27]) as well as lower odds of an optimal outcome (OR 0.74 [0.58-0.95]) compared to incontinent diversion.
Conclusions:
In a contemporary cohort of patients undergoing RC, odds of adverse postoperative outcomes were increased among those undergoing CD compared to ID, despite more favorable baseline characteristics in this cohort.

Preoperative and operative characteristics for patients undergoing radical cystectomy procedures stratified by diversion type.

Incontinent
Continent
P-value

Characteristic
N=3780
N=595

 Age
72.0 [65.0;77.0]
63.0 [57.0;69.0]
<0.001

 Sex:

0.001

Female
734 (19.4%)
80 (13.4%)

Male
3046 (80.6%)
515 (86.6%)

Year of Surgery:

0.33

 2019
1450 (38.4%)
240 (40.3%)

 2020
1601 (42.4%)
255 (42.9%)

 2021
729 (19.3%)
100 (16.8%)

ASA:

<0.001

 <3
752 (19.9%)
185 (31.1%)

 ≥3
3028 (80.1%)
410 (68.9%)

eGFR
68.3 [51.8;87.3]
77.3 [62.7;92.8]
<0.001

BMI
27.8 [24.7;31.6]
27.5 [24.9;31.1]
0.704

Chemotherapy
1320 (34.9%)
276 (46.4%)
<0.001

Radiation
346 (9.15%)
22 (3.70%)
<0.001

Prior Pelvic Surgery
1863 (49.3%)
258 (43.4%)
0.008

Surgical Approach:

<0.001

 Open
2672 (70.7%)
467 (78.5%)

 Hybrid
185 (4.89%)
20 (3.36%)

 Lap/Robo
923 (24.4%)
108 (18.2%)

OR Time
312 [240;393]
369 [280;465]
<0.001

# Nodes
16.0 [10.0;25.0]
17.0 [11.0;26.5]
0.001

AJCC Stage:

<0.001

 0a-II
1833 (48.5%)
370 (62.2%)

 III-IV
1947 (51.5%)
225 (37.8%)

ASA: American Society of Anesthesiologist classification. BMI: body mass index. OR: operating room. AJCC: American Joint Committee on Cancer. # of nodes: median, [IQR].