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JU INSIGHT: Obesity and Complication Risk From Radical Cystectomy: Identifying a Body Mass Index Threshold

By: Louise Catherine McLoughlin, MB, BCH, BAO; Wassim Kassouf, MD; Rodney H. Breau, MD; Adrian Fairey, MD; Ramanakumar Agnihotram V, PhD; Afsar Salimi, MSc; Eric Hyndman, MD; Darrel E. Drachenberg, MD; Jonathan Izawa, MD; Bobby Shayegan, MD; Jean-Baptiste Lattouf, MD; Michele Lodde, MD; Ricardo Rendon, MD; D. Robert Siemens, MD; Claudio Jeldres, MD; Peter C. Black, MD; Girish S. Kulkarni, MD | Posted on: 17 Jan 2023

McLoughlin LC, Kassouf W, Breau RH, et al. Obesity and complication risk from radical cystectomy: identifying a body mass index threshold. J Urol. 2023;209(1):111-120.

Figure. Restricted cubic spline plot demonstrating the association between body mass index and complications. Predicted risk estimates (y-axis) with associated 95% confidence intervals (shaded gray area) are plotted. Restricted cubic splines were produced with 4 knots at 21, 26, 30, and 38, corresponding with the 5th, 35th, 65th, and 95th percentile BMI values. The data have been restricted to BMI of 18.5-45 kg/m2 (n = 576). Analyses were adjusted for age, sex, smoking status, blood loss, Charlson score, clinical T and N stage, and previous abdominal or pelvic surgery or radiotherapy.

Study Need and Importance

Surgical morbidity after radical cystectomy (RC) is significant, and obesity is associated with increased complication risk. However, it is unknown if a BMI threshold exists above which complication risk is considerably increased. Such a threshold could be helpful in preoperative counseling for RC-associated complication risk. A BMI threshold could also inform weight loss strategies during prehabilitation to potentially reduce complication risk.

What We Found

We found that obesity was independently associated with the risk of developing any complications after RC, and the risk increased as the BMI value increased (OR 1.04 95% CI 1.01, 10.7).We also identified a BMI threshold of 34 kg/m2 as the predicted complication risk began to rise consistently above this level (see Figure).

Limitations

This retrospective study was limited to the 90-day follow-up of registry data from academic centres and may not fully reflect real-world practice. It included a higher than average number of patients operated on for nonmuscle-invasive bladder cancer, with a high proportion of smokers in the overweight and obese patient categories. These factors have associated unmeasurable confounders that could impact complication risk. Furthermore, although we suggest a BMI threshold below which complication risk may be reduced, this was not an intervention study. The impact of individual change in BMI on outcomes is speculative based on our data.

Interpretation for Patient Care

The results from this study will aid in preoperative counseling about the increased risk of complications in obese patients. Furthermore, this study hypothesizes that complication risk may be reduced by lowering the preoperative BMI of obese patients below a threshold of 34 kg/m2. This BMI target could inform weight loss strategies undertaken as part of a multimodal prehabilitation program before RC.

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