# The Interplay of Cumulative Perioperative Morbidity and Health-related Quality of Life After Radical Cystectomy—Prospective Evidence from the COMPACT Registry

## TL;DR

Complications after bladder cancer surgery do not significantly affect quality of life six months later, with pre-existing health conditions being more influential.

## Contribution

This study provides prospective evidence that surgical complications have limited long-term impact on quality of life compared to pre-existing comorbidities.

## Key findings

- Most patients experienced complications, but these did not significantly affect HRQOL at 6 months.
- Pre-existing comorbidity was the only factor significantly associated with HRQOL.
- Neither major complications nor the Comprehensive Complication Index significantly influenced HRQOL.

## Abstract

Despite the high rate of complications after radical cystectomy, these complications do not significantly affect quality of life at 6 mo postoperatively. Pre-existing comorbidity, rather than surgical morbidity, appears to be the key driver of patient-reported recovery.

Radical cystectomy (RC) in bladder cancer patients is associated with considerable short-term morbidity. Although RC is known to impair health-related quality of life (HRQOL), the impact of complication severity on HRQOL in the long term remains unclear. The aim of this study is to investigate the relationship between perioperative cumulative complication burden and HRQOL after RC using data from a prospective registry, given the limited existing evidence.

The Comprehensive Outcome Measures and Perioperative Morbidity After CystecTomy (COMPACT) registry (DRKS00024929) prospectively collects standardized data on perioperative morbidity and longitudinal patient-reported outcome measures. The study includes patients undergoing open RC with pelvic lymph node dissection and urinary diversion for bladder cancer. According to the European Association of Urology guidelines, 90-d morbidity was assessed using both the Clavien-Dindo classification (CDC) and the Comprehensive Complication Index (CCI). HRQOL was measured at baseline and 3, 6, and 12 mo using the Functional Assessment of Cancer Therapy—Bladder—Cystectomy (FACT-BL-CYS) scores (range 0–168). Patients treated between 2020 and 2022 were included. Multivariable linear regression was used to evaluate the associations of 90-d CDC grade ≥IIIb (ie, “major complications”) and 90-d CCI with the 6-mo FACT-BL-CYS total score, adjusting for clinical and pathological confounders.

Among 82 patients, one (1.2%) had no complications, and 47 (57%) had CDC grade ≤II, 22 (27%) grade III, and 11 (13%) grade IV complications. The 90-d mortality rate was 1.2%. The median 90-d CCI was 35 (interquartile range [IQR] 26–45). The median 6-mo FACT-BL-CYS total score was 119 (IQR 90–142). Only comorbidity (age-adjusted Charlson index) was significantly associated with HRQOL (coefficient: –4.76, p = 0.02); neither CDC ≥IIIb (p = 0.7) nor CCI (p = 0.2) was significant. Limitations include uncertainty in effect sizes due to the low number of major complications.

Open RC is associated with a high rate of perioperative complications when assessed with standardized methods. However, our findings suggest that their impact on HRQOL at 6 mo is limited. HRQOL appears to be more closely related to age-adjusted comorbidity. These insights should inform preoperative counseling and guide individualized postoperative care planning.

We looked at whether complications after bladder removal surgery (radical cystectomy) affect patients’ quality of life. We found that most patients have complications, but these usually do not reduce quality of life 6 mo after surgery. Instead, pre-existing health conditions had a stronger impact on recovery.