Characteristics and Associated Factors of Postoperative Pulmonary Complications in Patients Undergoing Radical Cystectomy for Bladder Cancer: A National Surgical Quality Improvement Program Study

Accepted Manuscript Characteristics and Associated Factors of Postoperative Pulmonary Complications in Patients Undergoing Radical Cystectomy for Bladder Cancer: A National Surgical Quality Improvement Program Study Leilei Xia, Benjamin L. Taylor, Thomas J. Guzzo PII:

S1558-7673(17)30093-9

DOI:

10.1016/j.clgc.2017.04.009

Reference:

CLGC 822

To appear in:

Clinical Genitourinary Cancer

Received Date: 3 February 2017 Revised Date:

27 March 2017

Accepted Date: 4 April 2017

Please cite this article as: Xia L, Taylor BL, Guzzo TJ, Characteristics and Associated Factors of Postoperative Pulmonary Complications in Patients Undergoing Radical Cystectomy for Bladder Cancer: A National Surgical Quality Improvement Program Study, Clinical Genitourinary Cancer (2017), doi: 10.1016/j.clgc.2017.04.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Title Page

Characteristics and Associated Factors of Postoperative Pulmonary Complications in

Improvement Program Study

Authors

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Leilei Xia, Benjamin L. Taylor, Thomas J. Guzzo

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Patients Undergoing Radical Cystectomy for Bladder Cancer: A National Surgical Quality

Affiliations

Division of Urology, Department of Surgery,

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University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

Correspondence

Thomas J. Guzzo, M.D., M.P.H.

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Perelman Center for Advanced Medicine, West Pavilion, 3rd Floor, 3400 Civic Center Boulevard Philadelphia, PA 19104

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Telephone: +1-215-662-2891; Fax: +1-215-662-3955 E-mail: [email protected]

Running Head: Pulmonary Complications after Radical Cystectomy

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Conflict of Interest Page

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All authors confirm that there is no conflict of interest.

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MicroAbstract Data regarding postoperative pulmonary complications after radical cystectomy are still limited. By analyzing National Surgical Quality Improvement Program database, our study showed that

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approximately 5.6% of patients undergoing radical cystectomy have at least one postoperative pulmonary complication. Several preoperative associated factors for postoperative pulmonary complications were identified and should be helpful for risk stratification, patient counseling, and

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perioperative care.

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Abstract Objective: To summarize the characteristics and identify associated factors of postoperative

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pulmonary complications (PPCs) in patients undergoing radical cystectomy (RC).

Materials and Methods: The National Surgical Quality Improvement Project (NSQIP) database (2005 - 2014) was used to identify patients who underwent RC for bladder cancer. PPCs were

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defined as pneumonia, unplanned re-intubation, and ventilator support > 48 h within 30 days of RC. Incidence, timing, and outcomes of PPCs were described and analyzed. Multivariable

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logistic regression was used to evaluate associated factors of PPCs.

Results: Among 3,790 patients included, 213 (5.6%) had at least one PPC. Patients with PPCs had a significantly higher 30-day mortality (17.4% vs. 0.7%, P < 0.001) and longer hospital stay (13 d vs. 8 d, P < 0.001). Logistic regression showed that Age ≥ 75 y (OR = 2.07, P = 0.001),

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body mass index (BMI) < 18.5 kg/m2 (OR = 2.48, P = 0.017), BMI ≥ 30 kg/m2 (OR = 1.71, P = 0.009), dependent functional status (OR = 2.77, P = 0.006), current smoker (OR = 1.57, P = 0.011), chronic obstructive pulmonary disease (OR = 1.70, P = 0.018), insulin-treated diabetes

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(OR = 1.70, P = 0.042), and albumin < 3.5 g/dL (OR = 1.72, P = 0.015) were associated with increased risk of overall PPCs.

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Conclusions: Approximately 5.6% of patients have at least one PPC within 30 days of RC. Several preoperative associated factors for PPCs were identified, which should be helpful for risk stratification, patient counseling, and perioperative care.

Keywords: cystectomy; pneumonia; complications; risk factors

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Introduction Muscle-invasive bladder cancer, which is a highly aggressive malignancy, is diagnosed predominantly in an elderly comorbid population in the 7th decade of life 1. While there are

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different management strategies that factor in patient comorbidities, tolerance of treatment, and patient preference, the standard of care is to offer neoadjuvant chemotherapy with radical cystectomy (RC) and pelvic lymph node dissection. Despite the improvements in surgical

significant morbidity and mortality

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techniques and perioperative patient care, RC with urinary diversion is still associated with . It has been reported that RC has perioperative

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complication rates up to 60% and mortality rates up to 3% 2, 4.

Among the adverse events, postoperative pulmonary complications (PPCs) is one of the most significant factors associated with poor patient outcomes 5. PPCs can lead to increased mortality, 5, 6

. Given the

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longer hospital stay, more frequent readmission, and higher overall cost

complexity of RC and serious consequences of PPCs, identifying potential preoperative associated factors for PPCs in RC patients would be very meaningful for patient counseling, risk

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stratification, perioperative care, early intervention, and outcome improvement.

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Although the incidence and associated factors of PPCs in patients undergoing surgery have been reported in the literature, most of those studies came from anesthesia or general surgery literature limiting applicability to a specific urologic patient population 5, 7, 8. Data regarding the incidence of PPCs after RC are still limited and often from single centers

2, 9

. Moreover, preoperative

associated factors for PPCs after RC are poorly studied and understood. To better define the scope of the problem and identify potential avenues to reduce pulmonary morbidity, we used the

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up-to-date American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database to identify clinical factors associated with patients’ risk of PPCs within

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30 days of RC.

Materials and Methods Data Source and Study Cohort

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The ACS-NSQIP Participant Use Data Files (PUF) from 2005 to 2014 were requested and used to generate the final study cohort. ACS-NSQIP prospectively maintains a national database of

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patients undergoing various surgical procedures in the United States. ACS-NSQIP PUF provides data regarding the postoperative 30-days morbidity and mortality outcomes. Detailed information about the ACS-NSQIP PUF, including variables and their definitions, can be found

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at the official website and user guide file 10.

The original files were merged into an Excel spreadsheet, and the built-in “filter” function was used to select the patient cohort for final inclusion. First, only radical cystectomy (Current

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Procedural Terminology [CPT] codes 51570, 51575, 51580, 51585, 51590, 51595, 51596, 51597) and only postoperative diagnosis of bladder cancer (ICD-9 codes 188, 188.1, 188.2, 188.3, 188.4,

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188.5, 188.6, 188.7, 188.8, 188.9, 233.7, 239.4) were included. Then any cases with other procedures (performed by the same surgical team of RC) that are not relevant to RC were excluded. Any cases with concurrent procedures (performed by a different surgical team or surgeon from that of the RC) were excluded. To restrict heterogeneity of our study, cases with additional procedures that suggest laparoscopic approach were also excluded. Also, considering the primary outcome of interest, patients with known preoperative systemic infection and

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patients that were ventilator dependent before RC were excluded. Finally, 3,790 cases of RC remained in our study cohort. Figure 1 shows the flow diagram of cohort selection and details of

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the process are provided in Supplementary Text File S1.

Variables and Outcomes of Interest

Preoperative patient and procedure characteristics including age, sex, race, body mass index

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(BMI), transfer status, elective surgery status, diversion type (continent vs. incontinent), functional status (independent vs. dependent), current steroid use, disseminated cancer status,

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weight loss, current smoker within 1 year, chronic obstructive pulmonary disease (COPD), dyspnea, diabetes, hypertension, bleeding disorders, preoperative transfusion, operative time, anemia status, and albumin level (≥ 3.5 g/dL vs. < 3.5 g/dL) were collected. For the purpose of analysis, age was categorized into 3 groups (< 65 y, 65-74 y, and ≥ 75 y), BMI was categorized

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into 4 groups (< 18.5 kg/m2, 18.5 -< 25 kg/m2, 25 -< 30 kg/m2, and ≥ 30 kg/m2), and operative time was categorized into 4 groups (< 240 min, 240 - < 360 min, 360 - < 480 min, and ≥ 480 min). Transfer status was designated as “no” if the patient was admitted from home. Weight loss

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was designated as “yes” if the patient had a greater than 10% decrease in body weight in the 6-month interval immediately preceding surgery. Bleeding disorders were any chronic, persistent,

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active condition that places the patient at risk for excessive bleeding. Preoperative transfusion was defined as received ≥ 1 unit of whole/packed red blood cells within 72 hours before surgery. Anemia in this study was defined using the following criteria of hematocrit: < 38% for female and < 42% for male. Variables were selected based on clinical relevance and availability within the database 10.

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The primary outcome of interest was PPCs, which were defined as postoperative pneumonia, unplanned re-intubation, and (cumulative) ventilator support > 48 h within 30 days of RC. PPCs were predefined in accordance with previously published literature in the field of general surgery . Secondary outcomes were 30-day mortality and length of hospital stay. Detailed definitions

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of the individual PPCs used by ACS-NSQIP are shown in Supplementary Text File S2.

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Statistical Analysis

Categorical variables were compared using Fisher's exact test and continuous variables using

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Mann–Whitney U test. Multivariable logistic regression accounting for related variables was performed for overall PPCs and individual PPCs to identify potential predictive factors. Cases with missing values of each variable were analyzed as a separate group in the logistic regression. All P values reported in our study were from 2-sided tests, with P < 0.05 considered significant.

Results

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Incidence of PPCs

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Statistical analyses were performed using STATA 14 (StataCorp LP, College Station, TX).

After the selection process, a total of 3,790 patients who underwent RC were included for

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analysis. Demographic data, preoperative patient characteristics, and procedure characteristics are shown in Table 1. Within 30 days of RC, 116 (3.06%) patients had pneumonia, 109 (2.88%) patients had unplanned re-intubation, and 80 (2.11%) patients had ventilator support > 48 h. Among the patients who had pneumonia, re-intubation, and ventilator support > 48 h, 0, 9 (8.3%), and 1 (1.3%) patient had multiple occurrences of the event, respectively. Overall, 213 (5.6%) patients had at least one PPC, including 73 (34.3%) patients had only pneumonia, 48 (22.5%)

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patients had only unplanned re-intubation, 25 (11.7%) patients had only ventilator support > 48 h, 12 (5.6%) patients had both pneumonia and unplanned re-intubation, 6 (2.8%) patients had both pneumonia and ventilator support > 48 h, 24 (11.3%) patients had both unplanned re-intubation

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and ventilator support > 48 h, and another 25 (11.7%) patients had all three PPCs (Figure 2).

Timing of PPCs

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Timing distribution of individual PPC events during the 30-day period in the cohort is shown in Figure 2. Median time from RC to pneumonia diagnosis was 7.5 d (IQR 4-13.75), median time

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from RC to have unplanned re-intubation was 7 d (IQR 2-13.75), and the median time from RC to have ventilator support > 48 h (cumulative ventilation time > 48 h) was 9 d (IQR 4-14).

Outcomes of PPCs

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As shown in Table 1, patients with PPCs had a significantly higher 30-day mortality compared with patients without any PPCs (17.4% vs. 0.7%, P < 0.001). Also, patients with PPCs had longer median LOS than those without PPCs (13 d vs. 8 d, P < 0.001). Fisher's exact tests showed that

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patients with one individual PPC (e.g. pneumonia) had significantly higher incidences of the remaining two individual PPCs (e.g. unplanned re-intubation and ventilator support > 48 h) than

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patients without that PPC (e.g. pneumonia), with all P values < 0.001.

Factors associated with PPCs Multivariable logistic regression (n = 3,780) for any PPC is shown in Table 2 (full model is shown in Supplementary Table S1). Age ≥ 75 y (odds ratio [OR] = 2.07, 95% confidence interval [CI] = 1.36-3.15, P = 0.001), BMI < 18.5 kg/m2 (OR = 2.48, 95% CI = 1.18-5.22, P =

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0.017), BMI ≥ 30 kg/m2 (OR = 1.71, 95% CI = 1.15-2.54, P = 0.009), dependent functional status (OR = 2.77, 95% CI = 1.34-5.71, P = 0.006), current smoker (OR = 1.57, 95% CI = 1.11-2.21, P = 0.011), COPD (OR = 1.70, 95% CI = 1.10-2.63, P = 0.018), insulin-treated

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diabetes (OR = 1.70, 95% CI = 1.02-2.84, P = 0.042), and albumin < 3.5 g/dL (OR = 1.72, 95% CI = 1.11-2.67, P = 0.015) were associated with increased risk of PPCs.

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Multivariable logistic regressions (n = 3,721 for pneumonia, n = 3,769 for unplanned re-intubation, and n = 3,592 for ventilator support > 48 h, respectively) for individual PPCs are

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shown in Table 3 (full model is shown in Supplementary Table S2). BMI < 18.5 kg/m2 (OR = 2.82, 95% CI = 1.24-6.42, P = 0.013), current smoker (OR = 1.71, 95% CI = 1.10-2.66, P = 0.016), COPD (OR = 2.03, 95% CI = 1.16-3.53, P = 0.013), insulin-treated diabetes (OR = 2.00, 95% CI = 1.01-3.94, P = 0.046), and albumin < 3.5 g/dL (OR = 2.22, 95% CI = 1.27-3.85, P =

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0.005) were found to be associated with increased risk of pneumonia. BMI < 18.5 kg/m2, BMI ≥ 30 kg/m2, and dependent functional status were associated with increased risk of both unplanned re-intubation and ventilator support > 48 h. However, age ≥ 75 was only associated with

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re-intubation.

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ventilator support > 48 h and preoperative transfusion was only associated with unplanned

Discussion

In this NSQIP database study of 3,790 patients who underwent RC, a total of 5.6% had PPCs within 30 days of surgery. We also identified several preoperative associated factors for PPCs, including advanced age, underweight, obesity, dependent functional status, smoking, COPD, insulin-treated diabetes, and low albumin level. To our knowledge, this is the first cohort study

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using a validated national database to report the incidence, timing and associated factors of PPCs following RC.

PPCs after major surgery, some of which used ACS-NSQIP data

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There have been a growing number of studies reporting the incidence and associated factors of 5, 7, 12-14

. However, most of the

studies either did not include urologic surgery or did not specify the procedure 5, 7, 12-14. It is very

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likely different procedures have their own inherent risks and incidence of PPCs. In a study that only included major general abdominal surgery, the percentage difference between procedures

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with the highest incidence of PPCs versus the lowest incidence of PPCs was about 20% 12. Given the large sample size and contemporary data set (2005-2014), this study adds to the limited urologic literature regarding the scope and implications of PPCs among patients who undergo

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RC.

Our results showed that pneumonia was most commonly diagnosed between postoperative day (POD) 2 and POD 9, which is consistent with the general surgery literature

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study

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median time of 7.5 days (IQR 4-13.75) after surgery is longer than 5 days (IQR 2-9) noted in that . The timing distribution of pneumonia may give providers some diagnostic

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discrimination when assessing a postoperative fever after RC. As for the timing of unplanned re-intubation, POD 0 (procedure day) had the largest number of events, which is surprisingly different from a cardiac surgery cohort

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. Beverly et al.

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showed that most unplanned

re-intubations for cardiac surgery occurred on POD 2 (15%) where only 4% were re-intubated on POD 0. The discrepancy might result from the difference of extubation indications between cardiac surgery and RC. For example, ventilator support > 48 h had the largest number of events

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in POD 2, which is similar to unplanned re-intubation since the definition of ventilator support > 48 h is cumulative.

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We analyzed both the associated factors of overall PPCs and of individual PPCs for several reasons. It is intuitive that the individual PPCs may place patients at additional risk for subsequent pulmonary events. Our results and prior studies have confirmed the connection

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among pneumonia, unplanned re-intubation, and ventilator support > 48 h

5, 16

. Analyzing

individual PPCs allows us to identify and validate potential associated factors for overall PPCs.

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Only preoperative transfusion, which was an associated factor for unplanned re-intubation, was not identified as the associated factor for overall PPCs. When compared to unplanned re-intubation and ventilator support > 48 h, pneumonia had more statistically significant

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associated factors on multivariate analysis.

Unsurprisingly, smoking and COPD were associated factors for developing PPCs, and this is consistent with studies from the general surgery literature

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. The reason why there are no

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associations between smoking and unplanned re-intubation/ventilator support > 48 h could be because of unmeasured confounding factors. It appears that smoking cessation at least 1 year

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before major surgery offsets the increased risk of PPCs

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. Although the duration of abstinence

from smoking necessary for a reduction in PPCs has not been fully established, preoperative cessation of smoking should always be encouraged to reduce short-term perioperative morbidity and long-term mortality for muscle-invasive bladder cancer 18.

Compared with normal BMI, BMI ≥ 30 kg/m2 is an associated factor for both unplanned

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re-intubation and ventilator support > 48 h. The association is possibly related to the reduced lung volume, altered ventilation pattern, and comorbid conditions in obese patients

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. Obesity

has long been recognized as a risk factor for various perioperative morbidities of RC

20-22

. A

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recent NSQIP study showed that BMI ≥ 30 kg/m2 is associated with increased risk of infection after RC, including urinary tract infection, surgical site infection, and sepsis/septic shock 21. We failed to identify the association between obesity and pneumonia, which is partially supported by

performed by Phung et al.

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the previous literature. A recent comprehensive meta-analysis of epidemiologic studies showed that obesity does not increase the risk of developing

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community-acquired pneumonia and nosocomial pneumonia. Based on a NSQIP study in general surgery, obesity conferred a slight protective factor against postoperative pneumonia 12. However, there is always the possibility that unmeasured confounding variables account for the

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insignificant association between obesity and pneumonia.

Among all the associated factors identified in our study, BMI < 18.5 kg/m2 is the most consistent and the strongest predictor of all PPCs. Previous studies using NSQIP RC database tend to not

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subcategorize patients with BMI < 25 kg/m2 or BMI < 30 kg/m2 and focus more on the effects of overweight or obesity 21-23. But for patients with muscle-invasive bladder cancer, we believe it is

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necessary to consider BMI < 18.5 kg/m2 as a separate entity considering the aggressive nature of the disease and low BMI being a possible indicator of patients’ suboptimal nutritional status. Although BMI < 18.5 kg/m2 is not a contradiction for surgery, it should be taken into account when making the decision of RC given its strong association with PPCs.

Another significant predictor of overall PPCs and pneumonia is low albumin level (< 3.5 g/dL),

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although only 2,376 patients were available for analysis. Several single-institutional studies have shown that there appears to be an association between hypoalbuminemia and overall postoperative complications of RC 24-26. More recently, Johnson et al. 27 analyzed the NSQIP data

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and concluded that poor nutritional status measured by serum albumin is predictive of an increased rate of surgical complications following RC. As for specific complications, Garg et al. 25

reported that neurologic and wound complications were more frequently seen in patients with

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decreased preoperative serum albumin, while “pulmonary complications” were not. However, the authors did not break down types of pulmonary complications nor did they evaluate the

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overall risk of developing specific complications 25. On the contrary, our study showed a strong association between preoperative hypoalbuminemia and increased risk of postoperative pneumonia after RC. The discrepancy might result from different definitions of pulmonary

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complications and different cutoff value of hypoalbuminemia.

Lastly, insulin-treated diabetes was associated with pneumonia, preoperative transfusion and dependent functional status were associated with unplanned re-intubation, age ≥ 75 years and

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dependent functional status were associated with ventilator support > 48 h. While some factors are potentially not modifiable, at a minimum they should help the urologist risk stratify patients

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preoperatively and postoperatively to direct counseling and resources that will optimize outcomes. Some of the associated factors are potentially modifiable, such as low body weight and low albumin level. However, it remains unclear how much measurable improvement can be expected in surgical outcomes when certain variables are optimized 25, 27-29.

There are limitations with the present study involving the data source and methodology. Even

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though the ACS NSQIP database is well validated, highly standardized, and prospectively collected, it does not include all the detailed clinicopathologic and procedure related information. For example, patients undergoing neoadjuvant chemotherapy would appear to be at an increased

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risk for low body weight and albumin level, which in theory could translate into increased risk for PPCs. However, neoadjuvant chemotherapy status was not available in the dataset, which prevents us from identifying another potential independent predictor for PPCs. Also, congestive

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heart failure within 30 days prior to surgery and history of myocardial infarction 6 months prior to surgery were not included in our analyses because of the rarity of the events and NSQIP

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actually has stopped to collect the history of myocardial infarction. In addition, some variables, such as albumin, had a large proportion of missing values. The definition of pneumonia is based on radiology and signs/symptoms/laboratory results, so no specific causes or inductive factors can be identified in the database. Our study would be more informative if some subgroup of

Conclusions

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patients with specific pneumonia (such as aspiration pneumonia) can be analyzed separately.

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Approximately 5.6% of patients undergoing RC have at least one PPC within 30 days of surgery. We identified several preoperative risk factors for PPCs following RC, including advanced age,

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underweight, obesity, dependent functional status, smoking, COPD, insulin-treated diabetes, preoperative transfusion, and low albumin level. These results should be helpful for risk stratification, patient counseling, and perioperative care. Further studies are needed to validate these findings and examine the predictive nature of additional unmeasured variables in this population.

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Clinical Practice Points


Postoperative pulmonary complications is one of the most significant factors associated with poor patient outcomes. The incidence and associated factors of postoperative pulmonary complications in patients

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undergoing surgery have been reported, but most of those studies came from anesthesia or general surgery literature limiting applicability to a specific urologic patient population. Approximately 5.6% of patients undergoing radical cystectomy have at least one

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postoperative pulmonary complication within 30 days of surgery.

Several preoperative risk factors for postoperative pulmonary complication following radical

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cystectomy were identified, including advanced age, underweight, obesity, dependent functional status, smoking, COPD, insulin-treated diabetes, preoperative transfusion, and low albumin level.

Our results should be helpful for risk stratification, patient counseling, and perioperative care.

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Acknowledgement

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The American College of Surgeons National Surgical Quality Improvement Program (ACS

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NSQIP) and the hospitals participating in the ACS NSQIP are the sources of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

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Figure Legends Figure 1. Flow diagram of the cohort selection Figure 2. Incidence distributions of individual PPCs (A) and timing distributions of the

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pneumonia diagnosis (B), unplanned re-intubation (C), and ventilator support > 48 h (D)

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Table 1. Baseline patient and perioperative characteristics, stratified by PPC status

EP

TE D

M AN U

SC

RI PT

Total (n = 3,790) With PPCs (n = 213) Without PPCs (n = 3,577) P value 0.001 1,220 (32.2%) 50 (23.5%) 1,170 (32.7%) 1,357 (35.8%) 73 (34.3%) 1,284 (35.9%) 1,202 (31.7%) 88 (41.3%) 1,114 (31.1%) 11 (0.3%) 2 (0.9%) 9 (0.3%) 0.562 905 (23.9%) 55 (25.8%) 850 (23.8%) 2,883 (76.1%) 158 (74.2%) 2,725 (76.2%) 2 (0.05%) 0 2 (0.06%) 0.154 3,173 (83.7%) 172 (80.7%) 3,001 (83.9%) 149 (3.9%) 13 (6.1%) 136 (3.8%) 59 (1.6%) 1 (0.5%) 58 (1.6%) 409 (10.8%) 27 (12.7%) 382 (10.7%) 0.003 81 (2.1%) 11 (5.2%) 70 (2.0%) 984 (26.0%) 47 (22.1%) 937 (26.2%) 1,447 (38.2%) 69 (32.4%) 1,378 (38.5%) 1,278 (33.7%) 86 (40.4%) 1,192 (33.3%) 0.031 3,747 (98.9%) 207 (97.2%) 3,540 (99.0%) 43 (1.1%) 6 (2.8%) 37 (1.0%) 0.036 3,080 (81.3%) 159 (74.7%) 2,921 (81.7%) 236 (6.2%) 19 (8.9%) 217 (6.1%) 474 (12.5%) 35 (16.4%) 439 (12.3%) 0.179 2,374 (62.6%) 136 (63.8%) 2,238 (62.6%) 640 (16.9%) 27 (12.7%) 613 (17.1%)

AC C

Variable Age (y), n (%) < 65 65-74 ≥ 75 Unknown Sex, n (%) Female Male Unknown Race, n (%) White Black Other Unknown BMI (kg/m2), n (%) < 18.5 18.5 -< 25 25 -< 30 ≥ 30 Transferred, n (%) No Yes Elective surgery, n (%) Yes No Unknown Diversion type, n (%) Incontinent Continent

ACCEPTED MANUSCRIPT

776 (20.5%)

50 (23.5%)

726 (20.3%) 0.002

202 (94.8%) 11 (5.2%) 0 210 (98.6%) 3 (1.4%)

3,610 (95.3%) 180 (4.7%)

199 (93.4%) 14 (6.6%)

201 (94.4%) 12 (5.6%)

149 (70.0%) 64 (30.0%)

TE D

2,858 (75.4%) 932 (24.6%)

M AN U

3,682 (97.2%) 108 (2.8%)

3,470 (91.6%) 320 (8.4%)

179 (84.0%) 34 (16.0%)

0.186

3,411 (95.4%) 166 (4.6%) 0.019 3,481 (9.3%) 96 (2.7%) 0.060 2,709 (75.7%) 868 (24.3%) < 0.001 3,291 (92.0%) 286 (8.0%) < 0.001

3,418 (90.2%) 372 (9.8%)

175 (82.2%) 38 (17.8%)

3,243 (90.7%) 334 (9.3%)

3,063 (80.8%) 514 (13.6%) 213 (5.6%)

156 (73.2%) 37 (17.4%) 20 (9.4%)

2,907 (81.3%) 477 (13.3%) 193 (5.4%)

1,489 (39.3%) 2,301 (60.7%)

64 (30.0%) 149 (70.0%)

1,425 (39.8%) 2,152 (60.2%)

EP

0.159

3,459 (96.7%) 118 (3.3%)

SC

3,669 (96.8%) 121 (3.2%)

3,522 (98.5%) 51 (1.4%) 4 (0.1%)

RI PT

3,724 (98.3%) 62 (1.6%) 4 (0.1%)

AC C

Unknown Functional status, n (%) Independent Dependent Unknown Steroid use, n (%) No Yes Disseminated cancer, n (%) No Yes Weight loss, n (%) No Yes Current smoker, n (%) No Yes COPD, n (%) No Yes Dyspnea, n (%) No Yes Diabetes, n (%) No Oral medication Insulin Hypertension, n (%) No Yes Bleeding disorder, n (%) No

0.010

0.005

0.694 3,663 (96.6%)

205 (96.2%)

3458 (96.7%)

ACCEPTED MANUSCRIPT

127 (3.4%)

8 (3.8%)

119 (3.3%) 0.012

775 (20.4%) 1,572 (41.5%) 1,004 (26.5%) 435 (11.5%) 4 (0.1%)

47 (22.1%) 93 (43.7%) 51 (30.0%) 22 (10.3%) 0

57 (26.8%) 152 (71.4%) 4 (1.9%)

3,727 (98.3%) 63 (1.7%) 8 (6-11)

0.784

728 (20.4%) 1,479 (41.3%) 953 (26.7%) 413 (11.5%) 4 (0.1%) 0.154

1,180 (33.0%) 2,326 (65.0%) 71 (2.0%) < 0.001

101 (47.4%) 37 (17.4%) 75 (35.2%)

1,946 (54.4%) 291 (8.1%) 1,340 (37.5%)

176 (82.6%) 37 (17.4%) 13 (9-28)

3551 (99.3%) 26 (0.7%) 8 (6-10)

TE D

2,047 (54.0%) 328 (8.7%) 1,415 (37.3%)

M AN U

1,237 (32.6%) 2,478 (65.4%) 75 (2.0%)

3,529 (98.7%) 48 (1.3%)

RI PT

205 (96.2%) 8 (3.8%)

SC

3,734 (98.5%) 56 (1.5%)

EP

Yes Preoperative transfusion, n (%) No Yes Operative time (min) < 240 240 - < 360 360- < 480 ≥ 480 Unknown Anemia, n (%) No Yes Unknown Albumin (g/dL), n (%) ≥ 3.5 < 3.5 Unknown 30-day mortality, n (%) Alive Dead Median length of stay (IQR) (d) ¶

< 0.001 < 0.001

AC C

¶ 5 missing values, 1 in with PPCs, 4 in without PPCs. PPC = postoperative pulmonary complication, BMI = body mass index, COPD = chronic obstructive pulmonary disease, IQR = interquartile range

ACCEPTED MANUSCRIPT

Table 2. Multivariable logistic regression analysis for risk of overall PPCs within 30 days of RC 95% CI

P value

RI PT

OR

1.35 0.91-2.00 0.133 2.07 1.36-3.15 0.001

SC

2.48 1.18-5.22 0.017 1.12 0.76-1.67 0.560 1.71 1.15-2.54 0.009 2.77 1.34-5.71 0.006 1.57 1.11-2.21 0.011 1.70 1.10-2.63 0.018

TE D

M AN U

Variable Age (y) (ref. < 65) 65-74 ≥ 75 BMI (kg/m2) (ref. 18.5 -< 25) < 18.5 25-<30 ≥ 30 Functional status (ref. independent) Dependent Current smoker COPD Diabetes (ref. no) Oral medication Insulin Albumin (g/dL) (ref. ≥ 3.5) < 3.5

1.33 0.90-1.96 0.157 1.70 1.02-2.84 0.042 1.72 1.11-2.67 0.015

AC C

EP

PPC = postoperative pulmonary complication, BMI = body mass index, COPD = chronic obstructive pulmonary disease. Significant results are shown in bold.

ACCEPTED MANUSCRIPT

Table 3. Multivariable logistic regression analyses for risk of individual PPCs within 30 days of RC

OR

Unplanned re-intubation 95% CI P value

1.13 1.45

0.68-1.87 0.84-2.51

0.639 0.183

1.26 1.58

0.75-2.12 0.90-2.77

0.387 0.114

1.44 2.02

0.77-2.68 1.04-3.94

0.252 0.038

2.82 0.96 0.91

1.24-6.42 0.59-1.55 0.53-1.55

0.013 0.858 0.727

3.08 1.16 2.20

1.14-8.30 0.65-2.08 1.23-3.86

0.026 0.615 0.006

4.00 1.61 2.84

1.26-12.67 0.79-3.29 1.40-5.74

0.018 0.193 0.004

1.63 1.71 2.03

0.59-4.48 1.10-2.66 1.16-3.53

0.346 0.016 0.013

2.81 1.10 1.88

1.09-7.28 0.68-1.78 1.05-3.36

0.033 0.709 0.035

3.49 1.37 1.48

1.28-9.47 0.78-2.40 0.71-3.06

0.014 0.270 0.296

1.30 2.00 0.97

0.74-2.27 1.01-3.94 0.27-3.49

0.358 0.046 0.959

1.36 1.55 2.81

0.80-2.30 0.76-3.13 1.02-7.72

0.252 0.226 0.045

1.46 1.32 2.06

0.81-2.65 0.56-3.08 0.67-6.31

0.289 0.524 0.208

2.22

1.27-3. 85

0.005

1.38

0.75-2.55

0.306

1.81

0.91-3.62

0.092

M AN U

SC

RI PT

Pneumonia 95% CI P value

TE D

Age (y) (ref. < 65) 65-74 ≥ 75 BMI (kg/m2) (ref. 18.5 -< 25) < 18.5 25 -< 30 ≥ 30 Functional status (ref. independent) Dependent Current smoker COPD Diabetes (ref. no) Oral medication Insulin Preoperative transfusion Albumin (g/dL) (ref. ≥ 3.5) < 3.5

OR

EP

Variable

OR

Ventilator support > 48 h 95% CI P value

AC C

PPC = postoperative pulmonary complication, BMI = body mass index, COPD = chronic obstructive pulmonary disease. Significant results are shown in bold.

ACCEPTED MANUSCRIPT RC in NSQIP, 2005-2014 (Based on CPT codes) (n=5,994)

SC

M AN U

RC for bladder cancer (Based on ICD-9 codes) (n=5,115)

RI PT

Not bladder cancer (n=879)

TE D

Additional/concurrent unrelated procedures and laparoscopic approach (n=1,283)

AC C

EP

Preliminary included cohort (n= 3,832)

Final study cohort (n= 3,790)

Preoperative systemic infection and ventilator dependent (n=42)

A

B

Pneumonia

ACCEPTED MANUSCRIPT 15

Pneumonia 73 (34.3%)

24 (11.3%)

Ventilator support > 48 h 25 (11.7%)

48 (22.5%)

0

C

TE D

Unplanned re-intubation

1

2

3

4

5

6

7

8

9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 28 29 30

Postoperative day

Ventilator support > 48 h

15

10

Counts

AC C

Counts

15

0

D

EP

20

10

RI PT

5

SC

Unplanned re-intubation

Counts

25 (11.7%)

6 (2.8%)

M AN U

12 (5.6%)

10

5 5

0

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Postoperative day

16

17

18

19

21

22

25

27

28

29

0

0

2

3

4

5

6

8

9

10

11

12

13

14

Postoperative day

16

17

18

19

20

23

26

29

ACCEPTED MANUSCRIPT

Supplementary Table S1. Multivariable logistic regression analysis for risk of overall PPCs within 30 days of RC (full model) OR

95% CI

P value

RI PT

Reference 1.35 0.91-2.00 0.133 2.07 1.36-3.15 0.001 Reference 0.95 0.66-1.35 0.756

M AN U

SC

Reference 1.43 0.77-2.67 0.260 0.34 0.05-2.51 0.288 Reference 2.48 1.18-5.22 0.017 1.12 0.76-1.67 0.560 1.71 1.15-2.54 0.009

Reference 1.54 0.59-4.04 0.375 Reference 0.98 0.56-1.72 0.943

AC C

EP

TE D

Variable Age (y) < 65 65-74 ≥ 75 Sex Female Male Race White Black Other BMI (kg/m2) 18.5 -< 25 < 18.5 25-<30 ≥ 30 Transferred No Yes Elective surgery Yes No Diversion type Incontinent Continent Functional status Independent Dependent Steroid use No Yes Disseminated cancer No Yes Weight loss No Yes Current smoker No Yes COPD

Reference 1.07 0.68-1.69 0.758 Reference 2.77 1.34-5.71 0.006

Reference 0.34 0.10-1.12 0.076 Reference 1.25 0.69-2.27 0.456 Reference 1.40 0.72-2.72 0.316 Reference 1.57 1.11-2.21 0.011

ACCEPTED MANUSCRIPT

Reference 1.70 1.10-2.63 0.018 Reference 1.43 0.95-2.15 0.088

RI PT

Reference 1.33 0.90-1.96 0.157 1.70 1.02-2.84 0.042

SC

Reference 1.23 0.89-1.70 0.218 Reference 1.04 0.49-2.21 0.913

M AN U

No Yes Dyspnea No Yes Diabetes No Oral medication Insulin Hypertension No Yes Bleeding disorder No Yes Preoperative transfusion No Yes Operative time (min) < 240 240 - < 360 360 - < 480 ≥ 480 Anemia No Yes Albumin (g/dL) ≥ 3.5 < 3.5

Reference 1.62 0.69-3.83 0.270 Reference 1.09 0.75-1.60 0.653 0.89 0.57-1.37 0.592 0.99 0.57-1.73 0.972

AC C

EP

TE D

Reference 1.17 0.84-1.64 0.351 Reference 1.72 1.11-2.67 0.015

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

PPC = postoperative pulmonary complication, BMI = body mass index, COPD = chronic obstructive pulmonary disease. Significant results are shown in bold.

ACCEPTED MANUSCRIPT

Supplementary Table S2. Multivariable logistic regression analyses for risk of individual PPCs within 30 days of RC (full model)

P value

OR

Unplanned re-intubation 95% CI P value

0.68-1.87 0.84-2.51

0.639 0.183

Reference 1.26 1.58

Reference 0.91

0.57-1.46

0.698

Reference 1.23

0.54-3.11

1.24-6.42 0.59-1.55 0.53-1.55

Reference 1.86

0.59-5.91

Reference 0.91 Reference 1.05 Reference 1.63

0.74-2.04

0.72-3.77 0.10-5.99

OR

Ventilator support > 48 h 95% CI P value

0.387 0.114

Reference 1.44 2.02

0.77-2.68 1.04-3.94

0.252 0.038

0.429

Reference 0.77

0.45-1.31

0.333

0.242 0.819

Reference 1.15 NA

0.43-3.11

0.780

1.26-12.67 0.79-3.29 1.40-5.74

0.018 0.193 0.004

Reference 3.08 1.16 2.20

1.14-8.30 0.65-2.08 1.23-3.86

0.026 0.615 0.006

Reference 4.00 1.61 2.84

0.293

Reference 1.55

0.42-5.69

0.508

Reference 2.80

0.84-9.31

0.094

0.804

Reference 0.94

0.881

Reference 1.28

0.56-2.92

0.558

0.59-1.89

0.860

Reference 1.00

0.54-1.87

1.000

Reference 1.04

0.50-2.17

0.919

0.59-4.48

0.346

Reference 2.81

1.09-7.28

0.033

Reference 3.49

1.28-9.47

0.014

0.013 0.858 0.727

EP

Reference 2.82 0.96 0.91

0.564

Reference 1.64 0.79

TE D

Reference 1.30 NA

0.75-2.12 0.90-2.77

M AN U

Reference 1.13 1.45

AC C

Age (y) < 65 65-74 ≥ 75 Sex Female Male Race White Black Other BMI (kg/m2) 18.5 -< 25 < 18.5 25 -< 30 ≥ 30 Transferred No Yes Elective surgery Yes No Diversion type Incontinent Continent Functional status Independent Dependent

Pneumonia 95% CI

RI PT

OR

SC

Variable

0.44-1.90

0.43-2.06

ACCEPTED MANUSCRIPT

Reference 1.17

0.51-2.65

0.275

0.03-1.67

0.713

Reference 0.70

0.27-1.84

0.48- 2.86

0.737

Reference 1.37

Reference 1.71

1.10-2.66

0.016

Reference 1.10

1.16-3.53

0.63-1.98

Reference 1.30 2.00

0.74-2.27 1.01-3.94

Reference 1.07

0.70-1.62

Reference 0.68 Reference 0.97

1.05-3.36

0.475

Reference 1.99

0.89-4.46

0.093

0.494

Reference 2.21

0.92-5.27

0.075

0.709

Reference 1.37

0.78-2.40

0.270

0.035

Reference 1.48

0.71-3.06

0.296

0.54-2.11

0.855

Reference 1.54

0.89-2.67

0.126

Reference 1.07

0.358 0.046

Reference 1.36 1.55

0.80-2.30 0.76-3.13

0.252 0.226

Reference 1.46 1.32

0.81-2.65 0.56-3.08

0.211 0.524

0.763

Reference 1.12

0.72-1.75

0.624

Reference 1.49

0.86-2.58

0.155

0.21-2.24

0.529

Reference 1.33

0.51- 3.43

0.557

Reference 1.55

0.54-4.45

0.416

0.27-3.49

0.959

Reference 2.81

1.02-7.72

0.045

Reference 2.06

0.67-6.31

0.208

0.718

TE D

Reference 1.11

0.013

Reference 1.88

0.68-1.78

Reference NA

EP

Reference 2.03

0.55-3.39

M AN U

Reference 1.17

0.145

RI PT

0.11-1.89

Reference 0.23

SC

Reference 0.45

AC C

Steroid use No Yes Disseminated cancer No Yes Weight loss No Yes Current smoker No Yes COPD No Yes Dyspnea No Yes Diabetes No Oral medication Insulin Hypertension No Yes Bleeding disorder No Yes Preoperative transfusion No Yes Operative time (min)

ACCEPTED MANUSCRIPT

0.55-1.45 0.50-1.51 0.17-1.06

0.654 0.627 0.066

Reference 1.13 1.08 1.08

Reference 1.00

0.65-1.56

0.984

Reference 1.26

Reference 2.22

1.27-3. 85

0.005

Reference 1.38

0.66-1.94 0.60-1.96 0.51-2.32

0.650 0.793 0.838

Reference 1.35 1.32 1.96

0.69-2.66 0.63-2.75 0.84-4.60

0.381 0.456 0.120

0.325

Reference 1.10

0.64-1.89

0.722

0.306

Reference 1.81

0.91-3.62

0.092

RI PT

Reference 0.89 0.87 0.42

0.79-2.01

SC

< 240 240 - < 360 360 - < 480 ≥ 480 Anemia No Yes Albumin (g/dL) ≥ 3.5 < 3.5

0.75-2.55

AC C

EP

TE D

M AN U

PPC = postoperative pulmonary complication, BMI = body mass index, COPD = chronic obstructive pulmonary disease, NA = not available. Significant results are shown in bold.

ACCEPTED MANUSCRIPT

Supplementary Text File S1. Selection process of the included RC cases

1

Variable name Description Included Remaining in the PUF used cases for filtering Include RC (Principal Operative CPT The CPT 51570; 51575; 51580; 51585; 5994 Procedure) codes for RC 51590; 51595; 51596; 51597 Include only bladder cancer

PODIAG

3

Include only additional surgical OTHERCPT1procedures that are considered OTHERCPT10 necessary for RC or related to RC. Exclude any potential surgery that suggest laparoscopic approach. (Performed by the same surgical team, under the same anesthetic which has a CPT code different from that of the Principal Operative Procedure.)

ICD-9-CM codes for bladder cancer CPT codes

M AN U

TE D

EP AC C

188; 188.0; 188.1; 188.2; 188.3; 5115 188.4; 188.5; 188.6; 188.7; 188.8; 188.9; 233.7; 239.4

SC

2

RI PT

Steps Purpose

38500; 38770; 44120; 44140; 44146; 44320; 44661; 49900; 50600; 50688; 50727; 50782; 50820; 50951; 51050; 51550; 51585; 51597; 51880; 52224; 52276;

38562; 38780; 44121; 44141; 44151; 44602; 44800; 49904; 50605; 50700; 50760; 50800; 50825; 50970; 51102; 51570; 51590; 51702; 51900; 52234; 52281;

38564; 44005; 44125; 44143; 44160; 44604; 49000; 49905; 50650; 50715; 50770; 50810; 50830; 51040; 51525; 51575; 51595; 51705; 51960; 52235; 52282;

38747; 4219 44005; 44139; 44145; 44310; 44620; 49010; 49906; 50660; 50725; 50780; 50815; 50860; 51045; 51530; 51580; 51596; 51720; 52204; 52240; 52310;

ACCEPTED MANUSCRIPT

6

TE D

Exclude preoperative dependent

EP

5

Exclude concurrent procedure. CONCPT1(Performed by a different surgical CONCPT10 team or surgeon and under the same anesthetic which have CPT codes different from that of the Principal Operative Procedure) Exclude preoperative systemic PRSEPIS infection ventilator VENTILAT

AC C

4

M AN U

SC

RI PT

52315; 52332; 52351; 52354; 53020; 53210; 53215; 53400; 55801; 55810; 55812; 55815; 55821; 55831; 55840; 55842; 55845; 55865; 56800; 57106; 57107; 57109; 57110; 57120; 57200; 57240; 57280; 57283; 57284; 57288; 57292; 57295; 57335; 58150; 58180; 58200; 58210; 58240; 58260; 58262; 58291; 58700; 58720; 58740; 58925; 58940; 58943; 58953; 58954; 58956; NULL (= No Procedure) NULL (= No Procedure) 3832

ICD-9 codes for bladder cancer 188 Malignant neoplasm of bladder 188.0 Malignant neoplasm of trigone of urinary bladder 188.1 Malignant neoplasm of dome of urinary bladder

CPT codes

SIRS; Sepsis; None; NULL (= Unknown) Septic Shock; None Yes; No No

3791

3790

SC

188.2 Malignant neoplasm of lateral wall of urinary bladder 188.3 Malignant neoplasm of anterior wall of urinary bladder 188.4 Malignant neoplasm of posterior wall of urinary bladder 188.5 Malignant neoplasm of bladder neck 188.6 Malignant neoplasm of ureteric orifice 188.7 Malignant neoplasm of urachus 188.8 Malignant neoplasm of other specified sites of bladder 188.9 Malignant neoplasm of bladder, part unspecified 233.7 Carcinoma in situ of bladder 239.4 Neoplasm of unspecified nature of bladder

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

CPT codes for radical cystectomy (principal operative procedure) 51570 Cystectomy, complete; (separate procedure) 51575 Cystectomy, complete; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes 51580 Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations 51585 Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes 51590 Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; 51595 Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes 51596 Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder 51597 Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination CPT codes for procedures that are considered necessary or related to radical cystectomy 38500 Biopsy/removal, lymph nodes 38562 Removal, pelvic lymph nodes 38564 Removal, abdomen lymph nodes 44005 Freeing of bowel adhesion 44120 Removal of small intestine 44121 Removal of small intestine

SC M AN U TE D EP

AC C

44125 Removal of small intestine 44139 Mobilization of colon 44140 Partial removal of colon 44141 Partial removal of colon 44143 Partial removal of colon 44145 Partial removal of colon 44146 Partial removal of colon 44151 Removal of colon/ileostomy 44160 Removal of colon 44602 Suture, small intestine 44604 Suture, large intestine 44620 Repair bowel opening 44661 Repair bowel-bladder fistula 44800 Excision of bowel pouch 49000 Exploration of abdomen 49010 Exploration behind abdomen 49900 Repair of abdominal wall 49904 Omental flap, extra-abdom 49905 Omental flap, intra-abdom 49906 Free omental flap, microvasc 50600 Exploration of ureter 50605 Insert ureteral support 50650 Removal of ureter 50660 Removal of ureter 50688 Change of ureter tube/stent 50700 Revision of ureter 50715 Release of ureter 50725 Release/revise ureter 50727 Revise ureter 50760 Fusion of ureters 50770 Splicing of ureters 50780 Reimplant ureter in bladder 50782 Reimplant ureter in bladder

RI PT

ACCEPTED MANUSCRIPT

SC M AN U TE D EP

AC C

50800 Implant ureter in bowel 50810 Fusion of ureter & bowel 50815 Urine shunt to intestine 50820 Construct bowel bladder 50825 Construct bowel bladder 50830 Revise urine flow 50860 Transplant ureter to skin 50951 Endoscopy of ureter 50970 Ureter endoscopy 51040 Incise & drain bladder 51045 Incise bladder/drain ureter 51050 Removal of bladder stone 51102 Drain Bl W/Cath Insertion 51525 Removal of bladder lesion 51530 Removal of bladder lesion 51550 Partial removal of bladder 51702 Insert temp bladder cath 51705 Change of bladder tube 51720 Treatment of bladder lesion 51880 Revision of bladder/urethra 51900 Repair bladder/vagina lesion 51960 Revision of bladder & bowel 52000 Cystoscopy 52005 Cystoscopy & ureter catheter 52204 Cystoscopy w/biopsy(s) 52224 Cystoscopy and treatment 52234 Cystoscopy and treatment 52235 Cystoscopy and treatment 52240 Cystoscopy and treatment 52276 Cystoscopy and treatment 52281 Cystoscopy and treatment 52282 Cystoscopy, implant stent 52310 Cystoscopy and treatment

RI PT

ACCEPTED MANUSCRIPT

SC M AN U TE D EP

AC C

52315 Cystoscopy and treatment 52332 Cystoscopy and treatment 52351 Cystouretero & or pyeloscope 52354 Cystouretero w/biopsy 53020 Incision of urethra 53210 Removal of urethra 53215 Removal of urethra 53400 Revise urethra, stage 1 55801 Removal of prostate 55810 Extensive prostate surgery 55812 Extensive prostate surgery 55815 Extensive prostate surgery 55821 Removal of prostate 55831 Removal of prostate 55840 Extensive prostate surgery 55842 Extensive prostate surgery 55845 Extensive prostate surgery 55865 Extensive prostate surgery 56800 Repair of vagina 57106 Remove vagina wall, partial 57107 Remove vagina tissue, part 57109 Vaginectomy partial w/nodes 57110 Remove vagina wall, complete 57120 Closure of vagina 57200 Repair of vagina 57240 Repair bladder & vagina 57280 Suspension of vagina 57283 Colpopexy, intraperitoneal 57284 Repair paravag defect, open 57288 Repair bladder defect 57292 Construct vagina with graft 57295 Revise Vag Graft via Vagina 57335 Repair vagina

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58150 Total hysterectomy 58180 Partial hysterectomy 58200 Extensive hysterectomy 58210 Extensive hysterectomy 58240 Removal of pelvis contents 58260 Vaginal hysterectomy 58262 Vag hyst including t/o 58291 Vag hyst t/o & repair, compl 58700 Removal of fallopian tube 58720 Removal of ovary/tube(s) 58740 Adhesiolysis tube,ovary 58925 Removal of ovariancyst(s) 58940 Removal of ovary(s) 58943 Removal of ovary(s) 58953 TAH, rad dissect for debulk 58954 TAH rad debulk/lymph remove 58956 BSO, omentectomy w/ta

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Supplementary Text File S2. Definitions of PPCs in NSQIP

Pneumonia: Patients

with

pneumonia

must

meet

criteria

from

Radiology

and

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Signs/Symptoms/Laboratory sections listed as follows:

both

Radiology:

New or progressive and persistent infiltrate




Consolidation or opacity




Cavitation

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One definitive chest radiological exam (x-ray or CT)* with at least one of the following:

Note: In patients with underlying pulmonary or cardiac disease (e.g. respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease), two or more serial chest radiological exams (x-ray or CT) are required. [Serial radiological exams should be taken no less than 12 hours apart, but not more than 7 days apart. The occurrence should be assigned on the date the patient first met all of the criteria of the

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definition (i.e, if the patient meets all PNA criteria on the day of the first x-ray, assign this date to the occurrence). Do not assign the date of the occurrence to when the second serial x-ray was performed].

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Signs/Symptoms/Laboratory:

For any patient, at least one of the following: Fever (>38 C or >100.4 F) with no other recognized cause




Leukopenia (<4000 WBC/mm3) or leukocytosis(≥12,000 WBC/mm3)




For adults ≥70 years old, altered mental status with no other recognized cause

AND

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At least one of the following:


5% Bronchoalveolar lavage (BAL) -obtained cells contain intracellular bacteria on direct microscopic exam (e.g., Gram stain)




Positive growth in blood culture not related to another source of infection




Positive growth in culture of pleural fluid

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Positive quantitative culture from minimally contaminated lower respiratory tract (LRT) specimen (e.g. BAL or protected specimen brushing)

OR At least two of the following: New onset of purulent sputum, or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements

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New onset or worsening cough, or dyspnea, or tachypnea




Rales or rhonchi




Worsening gas exchange (e.g. O2 desaturations (e.g., PaO2/FiO2 ≤240), increased oxygen

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requirements, or increased ventilator demand)

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Unplanned re-intubation:

Patient required placement of an endotracheal tube or other similar breathing tube [Laryngeal Mask Airway (LMA), nasotracheal tube, etc] and ventilator support intraoperatively or within 30 days following surgery which was not intended or planned.


The variable intent is to capture all-cause unplanned intubations, including but not limited to

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unplanned intubations for refractory hypotension, cardiac arrest, inability to protect airway.


Accidental self extubations requiring reintubation would be assigned.




Emergency tracheostomy would be assigned. Patients with a chronic/long-term tracheostomy who are on and off the ventilator would not be assigned, unless the

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tracheostomy tube itself is removed and the patient requires reintubation (endotracheal or a new tracheostomy tube) or an emergency tracheostomy. Patients undergoing time off the ventilator during weaning trials and who fail the trail and

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are placed back on the ventilator would not be assigned.


Intubations for an unplanned return to the OR would not be assigned, as the intubation is planned, it is the return to the OR which is unplanned.




In patients who were intubated for a return to the OR for a surgical procedure unplanned intubation occurs after they have been extubated after surgery. In patients who were not intubated for a return to the OR, intubation at any time after their surgery is complete is considered unplanned.




Intraoperative conversion from local or MAC anesthesia to general anesthesia, during the

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Principal Operative Procedure, with placement of a breathing tube and ventilator support, secondary to the patient not tolerating local or MAC anesthesia, in the absence of an emergency, would not be assigned. If patients required placement of an endotracheal tube or other similar breathing tube and refused

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placement of the tube would not be assigned.

Ventilator support > 48 h:

Total duration of ventilator-assisted respirations during postoperative hospitalization was greater

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than 48 hours. This can occur at any time during the 30-day period postoperatively. This time assessment is CUMULATIVE, not necessarily consecutive. Ventilator-assisted respirations can

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be via endotracheal tube, nasotracheal tube, or tracheostomy tube.