Introduction: A significant decline in renal function following radical cystectomy has been documented in numerous settings and with a variety of urinary diversions. Implications of poor post-operative renal function include the need for renal replacement therapy and exclusion from adjuvant therapies. In the present study, we seek to better characterize two groups of particular interest: those with pre-operative renal impairment (PORI) who improve post-operatively and those with normal renal function who subsequently develop chronic renal insufficiency after surgery.
Methods: A prospectively maintained, single-institutional database retrospectively identified 367 patients who underwent radical cystectomy between 2013 and 2021. Patients were stratified by the presence of PORI, defined as having Stage III CKD (CKD3) or worse (n=142, 38.7%). Variables included the presence of ureteral obstruction before surgery and within one year post-operatively, diabetes, neoadjuvant chemotherapy, age, and rates of major complications.
Results: Compared to those with PORI, those with better renal function had a lower incidence of diabetes (33.1% vs. 20.4%, p= 0.007). Rates of major complications after cystectomy were not significantly different between those with PORI vs. normal renal function (15.5% vs. 13.8%, p = 0.649). Of those with PORI, 21 (23.3%) experienced renal function improvement to GFR >59 mL/min/1.73m2 at 12 months post-operatively. Of these improved patients, 12 (57.1%) initially presented with ureteral obstruction. Within the remaining 225 patients without PORI, 49 patients (36.3%) developed CKD3 at 12 months post-operatively. Among these patients with renal function decline, 16 (32.7%) had ureteral obstruction within one year after surgery. Presence of diabetes, age >70, history of neoadjuvant chemotherapy, and type of diversion were not significantly different between the above groups.
Conclusions: While 36.3% of patients with normal pre-operative renal function experienced a decline to CKD3 at one year, 23.3% of patients with PORI had resolution of CKD3 at one year. Ureteral obstruction appears to play a significant role in changes in long-term renal function.