Surgical Quality and Survival After Radical Cystectomy: Clinical Determinants and Prognostic Value of Tetrafecta Achievement.

INTRODUCTION

To identify independent predictors of tetrafecta achievement after radical cystectomy (RC) and to assess its prognostic value for survival outcomes.

PATIENTS AND

METHODS

We queried a prospectively maintained single-center database of consecutive patients undergoing RC for nonmetastatic bladder cancer (2014-2025). Tetrafecta achievement was defined as: lymph node yield ≥16, negative soft tissue surgical margins, no intraoperative blood transfusion, and no 90-day major (Clavien-Dindo ≥III) complications. Predictors of tetrafecta achievement were analyzed using multivariable logistic regression. Time-to-event outcomes (overall survival [OS], cancer-specific survival [CSS], disease-free survival [DFS], local DFS [LDFS], metastasis-free survival [MFS]) were evaluated with Kaplan-Meier estimates and multivariable Cox regression adjusting for age, delayed RC (>90 days), locally advanced disease (≥pT3), nodal involvement, and neoadjuvant chemotherapy.

RESULTS

Of 330 eligible patients, 144 (43.6%) achieved tetrafecta. Compared with nonachievers, tetrafecta achievers were younger (median 67 vs. 72 years; P < .001), had lower age-adjusted Charlson Comorbidity Index (5 vs. 6; P = .02), more often had Eastern Cooperative Oncology Group 0 (70.8% vs. 59.1%; P = .028), and less frequently had preoperative hydronephrosis (23.6% vs. 38.7%; P = .004). They more commonly underwent robot-assisted RC (41.7% vs. 22.0%; P < .001) and orthotopic neobladder diversion (P < .001). On multivariable logistic regression, older age (odds ratio [OR] 0.96 [95% CI, 0.94-0.99]; P = .005), hydronephrosis (OR 0.55 [95% CI, 0.33-0.94]; P = .029), and cutaneous ureterostomy (OR 0.15 [95% CI, 0.04-0.53]; P = .003) independently reduced tetrafecta odds. With median follow-up of 34 months, OS was higher among tetrafecta achievers on Kaplan-Meier analysis (log-rank P = .012), whereas CSS, DFS, LDFS, and MFS did not differ (all P > .05). Tetrafecta achievement was not independently associated with any survival endpoint on multivariable Cox models.

CONCLUSION

Tetrafecta achievement after RC is primarily influenced by patient fitness and perioperative course and does not independently predict oncologic outcomes, which remain driven by pathological stage and nodal status.