Critical care therapy and in-hospital mortality after radical nephroureterectomy for nonmetastatic upper urinary tract carcinoma
Francesco Di Bello, Carolin Siech, Mario de Angelis, Natali Rodriguez Peñaranda, Zhe Tian, Jordan A. Goyal, Claudia Collà Ruvolo, Gianluigi Califano, Massimiliano Creta, Fred Saad, Shahrokh F. Shariat, Alberto Briganti, Felix K.‐H. Chun, Stefano Puliatti, Nicola Longo, Pierre I. Karakiewicz
Abstract
BACKGROUND: Use of critical care therapies (CCT), that include invasive mechanical ventilation (IMV), total parenteral nutrition (TPN) and other modalities are unknown after radical nephroureterectomy (RNU) for upper urinary tract carcinoma (UUTC). Their relationship with in-hospital mortality is also unknown. METHODS: Within the National Inpatient Sample (2008-2019), we identified non-metastatic UUTC patients treated with RNU. Multivariable logistic regression models were used. RESULTS: Of 8,995 patients, 375 (4.2%) received CCT and 82 (0.9%) experienced in-hospital mortality. Of CCT modalities, 215 (2.4%) received IMV and 139 (1.5%) TPN. Temporal CCT, IMV, and TPN trends very closely followed in-hospital mortality trends. Relative to historical UUTC patients (2008-2013), contemporary (2014-2019) patients exhibited lower CCT (Δ = 2.2%, P value < 0.0001), lower IMV (Δ = 1.4%, P < 0.0001), lower TPN (Δ = 2.2%, P < 0.0001), and lower in-hospital mortality (Δ = 0.4%, P = 0.03) rates. Of in-hospital mortalities, 52 out of 82 received CCT but 30 of 82 did not. Median age (> 72 years; odds ratio [OR] 1.4; P = 0.002) and Charlson comorbidity index ≥ 3 (OR 4.1; P < 0.001) and ≥ 1-2 (OR 1.7; P = 0.001) independently predicted overall higher CCT, IMV, TPN, and in-hospital mortality. CONCLUSION: After RNU, CCT rates parallels in-hospital mortality rates. CCT represents a 5 to 6-fold multiple of in-hospital mortality rate. In RNU patients, CCT rates are higher in older and sicker individuals. Lower CCT rates that are paralleled by lower in-hospital mortality may be interpreted as an indicator of improved quality of care. Ideally all in-hospital mortalities should be predated by CCT exposure.