Operative duration and short term morbidity and mortality following radical cystectomy with urinary diversion

INTRODUCTION: To elucidate the association between operative duration (OD) and postoperative complications, which has been poorly studied in radical cystectomy. We hypothesize an increase in morbidity in radical cystectomy cases which have a longer OD. MATERIALS AND METHODS: Data from the National Surgical Quality Improvement Program (NSQIP) between the years 2012 and 2018 were reviewed for radical cystectomy with ileal conduit urinary diversion or continent diversion. Total operative time was divided into deciles and stratified comparisons were made using univariable and multivariable analysis. RESULTS: A total of 11,128 patients were examined. OD by minutes was stratified into the following deciles: 90-201, 202-237, 238-269, 270-299, 300-330, 331-361, 362-397, 398-442, 443-508, > 508. Operative times were shorter for patients with advanced age (p < 0.001), male gender (p < 0.001), low body mass index (BMI) (p < 0.001), bleeding diathesis (p = 0.019), COPD (p = 0.004), and advanced ASA class (p < 0.001). Complications significantly associated with prolonged OD included surgical site infection, urinary tract infection, sepsis/septic shock, renal failure and venous thromboembolism. On multivariate analysis, factors predictive of perioperative morbidity included presence of bleeding disorder (OR 1.70, 95% confidence intervals (CI) 1.37-2.12, p < 0.001), ASA Class IV-V compared to I-II (OR 2.26, 95% CI 1.89-2.72, p < 0.001), and prolonged operative time (tenth decile OR 3.05, 95% CI 2.55-3.66, ninth decile OR 2.11 95% CI 1.77-2.50, third decile OR 1.31, 95% CI 1.11-1.56, second decile OR 1.02, 95% CI 0.86-1.21 compared to first decile, p < 0.001) Conclusion: OD is an independent predictor of post-operative morbidity in patients undergoing radical cystectomy, even when adjusting for patient specific factors. Those patients within the longest decile had over 3-fold increase in the risk of morbidity compared to those with shorter OD.