OPTIMIZING A POST-OPERATIVE PATHWAY IN RADICAL CYSTECTOMY PATIENTS REDUCES INFECTIOUS COMPLICATIONS

Abstract

Introduction

Radical Cystectomy (RC) is a morbid procedure with a known high risk of complications and readmissions. Our institution is the only academic center in a rural state and provides the majority of cystectomy care, leading to a robust bladder cancer program. Longitudinally, a series of peri-operative changes to our RC care pathway have been made with the aim of improving outcomes. After the introduction of ERAS in 2020, we did not observe a change in outcomes which prompted a change in our perioperative pathway. Furthermore, genitourinary (GU) infections represented the largest body of post-operative complications amongst our complications. We describe the introduction of a post-operative discharge pathway (PODP), incorporated in 2022, aimed to reduce low-grade complications and associated readmissions.

Methods

Data was extracted from a prospectively maintained database identifying 323 RC pts from 2015-2024. Complications were graded and classified by the Memorial Sloan Kettering Cancer Center system. A statewide health information exchange allows for record sharing across institutions. This allowed for capture of complete 90d follow-up. All 90d readmissions, complications, and GU infections after surgery were recorded and analyzed.

An antibiogram specific to our RC pts was previously created, leading to prophylaxis (ppx) with low dose Levaquin or Bactrim starting POD#4 until stent removal at 2 weeks. This began April 1, 2022, as part of a larger PODP that included increased post-operative education, a post-discharge day 2 and 5 phone call with an oncology RN, and oral 30d DVT ppx post-discharge. Chi-square and multivariable logistic regression analyses were performed to assess the association between antibiotic ppx and 30 and 90d readmissions due to GU infection.

Results

90d follow-up was available for all 323 pts. 462 complications were recorded pre-PODP. 75.4% and 24.6% occurred at 30d and 90d, respectively. Infectious (27.3%), gastrointestinal (17.7%), and genitourinary (12.6%) causes were the most common, predominantly due to GU infections, ileus, and renal failure (Table 1). The majority were grade 2 (35.5%, Table 1). 30d and 90d mortality was 2.7% and 5.0%, respectively. Post-PODP implementation, 93 complications were recorded. 66.7% and 33.3% occurred at 30d and 90d, respectively. Gastrointestinal (33.3%), infectious (19.4%), and genitourinary (16.1%) causes were the most common (Table 1). The majority were grade 1 (23.4%, Table 1).

After PODP implementation, 53/56 pts received antibiotic ppx. The 30d risk of GU infections decreased following antibiotic ppx from 84/172 (48.0%) to 3/24 (12.5%), (p=0.001, Table 2). Of 66 pts readmitted at 30d pre-ppx, 41/66 (62.1%) were due to a GU infection vs 1/10 (10%) post-ppx (p=0.002, Table 2).

Conclusions

Here we show complete capture of follow-up for RC pts still living at 90d between 2015-2024. Our complications and readmissions are consistent with prior reports in both class and grade. Introduction of an updated PODP, which included targeted low dose daily antibiotics, increased education, and closer outpatient follow-up, led to reduction of our readmission rate due to GU infections and overall post-RC GU infection rate. Overall readmission rate is not statistically different, but limited by sample size and expected to be significant as the cohort increases.