Location of Metastatic Bladder Cancer as a Determinant of In-hospital Mortality After Radical Cystectomy

Background: A recent study of a highly select cohort suggested a survival benefit when local treatment is delivered in patients with metastatic bladder cancer (BCa). Objective: We examined in-hospital mortality (IHM) rates according to the presence, absence, and location of metastatic disease in a similar highly select cohort of BCa patients treated with radical cystectomy (RC). Design, setting, and participants: We used data for 25 004 BCa patients included in the National Inpatients Sample (NIS) database between 1998 and 2013. Intervention: Radical cystectomy. Outcome measurements and statistical analysis: We tested postoperative IHM rates according to the presence of metastases and the location of metastatic disease (exclusive nodal vs distant metastases). Multivariable logistic regression analyses were adjusted for age, gender, race, comorbidities, length of hospitalization, hospital location, teaching status, hospital surgical volume, and bed size. Results and limitations: Among 25 004 BCa patients treated with RC, 3830 (14.4%) had nonregional lymph node metastases (NRNM), 693 (2.8%) had distant metastases (DM), and 19 965 (79.8%) had nonmetastatic disease. Virtually all patients with metastatic BCa had a single metastatic focus (n = 4020; 93.7%). In multivariable logistic regression analyses, DM (odds ratio [OR] 2.31, 95% confidence interval [CI] 1.57–3.28; p < 0.001) but not NRNM (OR 0.88, 95% CI 0.66–1.15; p = 0.4) was associated with higher risk of IHM. The absence of information on preoperative chemotherapy and the retrospective study design may limit our findings. Conclusions: The risk of IHM for highly select individuals with NRNM treated with RC is similar to that for patients with nonmetastatic BCa. Conversely, patients with DM are at higher risk of IHM compared to patients with NRNM. Patient summary: According to existing data, radical cystectomy in the metastatic bladder cancer setting should be limited to patients with nonregional lymph node metastases, if at all indicated. In-hospital mortality (IHM) is significantly higher among patients harboring distant metastases in comparison to those without metastatic disease. Patients with nonregional lymph node metastases exhibited similar IHM to patients with nonmetastatic disease. Radical cystectomy in the metastatic setting should be limited to patients with nonregional lymph node metastatic tumor, in whom the procedure appears feasible.