Population-based trends in urinary diversion among patients undergoing radical cystectomy for bladder cancer

Abstract

What's known on the subject? and what does the study add?: Variations in the type of urinary diversion exist for patients undergoing radical cystectomy. Although its use has been increasing from 2001 to 2008, patients who are older, female, and primary insured by Medicaid are less likely to receive continent diversions. Furthermore, patients treated surgically at high-volume and teaching hospitals are more likely to receive continent diversions.

Objective: To describe the contemporary trends in urinary diversion among patients undergoing radical cystectomy (RC) for bladder cancer; and elucidate whether socioeconomic disparities persist in the type of diversion performed in the USA from a population-based cohort.

Patients and methods: Using the Nationwide Inpatient Sample, we identified patients who underwent RC for bladder cancer between 2001 and 2008. Multivariable regression models were used to identify patient and hospital covariates associated with continent urinary diversion and enumerate predicted probabilities for statistically significant variables over time.

Results: Overall, 55635 (92%) patients undergoing RC for bladder cancer received incontinent urinary diversion, while 4552 (8%) patients received continent diversion from 2001 to 2008. Receipt of continent urinary diversion increased from 6.6% in 2001-2002 to 9.4% in 2007-2008 (P < 0.001 for trend). Patients who were older (odds ratio [OR] 0.93; P < 0.001), female (OR 0.52; P < 0.001) and insured by Medicaid (OR 0.54; P = 0.002) were less likely to receive continent urinary diversion. However, patients treated at teaching (OR 2.14; P < 0.001) and high-volume hospitals (OR 2.39; P = 0.04) had higher odds of continent urinary diversion. Predicted probabilities of continent diversion remained lower for female patients, Medicaid insurance status, and non-teaching and medium/low-volume hospitals over time.

Conclusions: In this nationally representative sample of hospitals from 2001 to 2008, the use of continent diversion in RC gradually increased. Although variations in urinary diversion exist by hospital teaching status, case volume, patient gender and primary health insurance, increased attention in expanding the use of continent diversions may help reduce these disparities for patients undergoing RC for bladder cancer.

Keywords: bladder cancer; disparities; outcomes; radical cystectomy; urinary diversion.