The association between prior pelvic radiotherapy for cancer and surgical outcomes in patients undergoing radical cystectomy for bladder cancer: An analysis of national surgical quality improvement program targeted cystectomy database.

Introduction: Patients undergoing radical cystectomy (RC) for bladder cancer (BCa) may have previously received pelvic radiotherapy (pRT), which is both a risk factor for BCa and is independently associated with an increased risk of intraoperative and postoperative complications. We sought to quantify this risk at the population level and to assess rates of granular, cystectomy-specific and general surgical outcomes of patients undergoing RC who received pRT for any pelvic malignancy any time prior using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Cystectomy database.

Methods: We conducted a retrospective cohort study using the ACS-NSQIP targeted cystectomy dataset of patients 18-90 years old who underwent RC for BCa from 2019 to 2022. The primary outcomes included rates of cystectomy-specific outcomes potentially related to pRT (e.g., rectal injury) and 30-day major postoperative outcomes: mortality, reoperation, cardiovascular events, and readmission rates. Secondary outcomes included general surgical complications such as rates of sepsis, surgical-site infections (SSIs), length of hospital stay (LOS) and surgery duration. We balanced for potential confounders by propensity score matching (PSM) with a 1:5 ratio between pRT and no-pRT groups with a caliper of 0.009.

Results: We identified 5,058 patients of whom 403 (7.97%) had pRT prior to RC. After PSM, the analytical cohort consisted of 1,901 RC patients and 387 RC + pRT patients. Prior pRT was associated with significantly higher odds of rectal injury (OR 3.17, 95% CI: 1.59-6.33). Additionally, prior pRT was associated with infectious complications, including SSI (OR 1.48, 95% CI: 1.08-2.39), organ-site infection (OR 1.61, 95% CI: 1.08-2.39). Subgroup analyses suggested the association between prior pRT, and rectal injury was statistically significant among patients with age ≥ 65 years, BMI 25-29.9, open approach for RC and norreceipt of neoadjuvant chemotherapy.

Conclusions: In a contemporary real-world, multicenter cohort, patients undergoing RC after pRT were associated with 3-fold higher odds of rectal injury, and higher odds of multiple infectious complications. These data provide a framework to assist in patient counseling and optimizing selection.