Comparing direct medical care costs of patients with bladder cancer who received an ileal conduit vs. neobladder in the year following cystectomy

Abstract

Purpose

Bladder cancer is 1 of the most costly cancers, however there is limited research on medical care costs by type of urinary diversion. The objective of our study was to compare medical care costs of the 2 most common urinary diversions in the year following radical cystectomy.

Methods:

The Bladder Cancer Quality of Life Study included patients diagnosed with bladder cancer who underwent radical cystectomy and received an ileal conduit (IC, n = 821) or neobladder (NB, n = 181) in 3 integrated health systems. Medical care costs per patient per quarter were estimated for the year following cystectomy. Multivariable generalized linear models with a gamma distribution and log link were used to estimate mean monthly medical care costs (2022 USD$), adjusted for patient demographic and clinical characteristics.

Results:

In multivariable analysis, mean monthly costs per quarter were not significantly different between IC and NB patients in the 12 months following cystectomy. Overall, mean monthly costs in IC and NB patients were highest during the first quarter and decreased thereafter. Factors associated with higher mean costs across all quarters included presence of any complications and advanced tumor stage at cystectomy (all P < 0.001).

Conclusion:

Our study addresses an important knowledge gap by quantifying the medical costs of bladder cancer patients by urinary diversion type and comparing costs of different treatment approaches. Studies that assess patient-reported outcomes and out-of-pocket costs, by urinary diversion type, are warranted to inform treatment decision-making and cost conversations.

1. Introduction

Bladder cancer imposes significant health impacts, with approximately 81,180 new diagnoses and 17,100 deaths expected in the United States (US) in 2022 [1]. It is also among the most costly cancers, with total annual national expenditures in the US projected to reach $11.6 billion by 2030 [2]. For patients with advanced disease, treatment often involves removal of the bladder (radical cystectomy). Patients who have a radical cystectomy undergo urinary system reconstruction through urinary diversion (UD), among which the majority receive either an ileal conduit or neobladder [3]. These treatment approaches are characterized by periods of high healthcare service use, with high risk of complications and readmission, and estimated 90-day direct hospital costs of nearly $40,000 (in US Dollars [USD]) [3–6].

Previous research on medical costs of bladder cancer patients following radical cystectomy has largely focused on identifying drivers of high costs [7]. Few studies having assessed medical care costs by UD type [6,8–12], most of which were based on medical care claims data. Nevertheless, understanding the direct medical costs associated with different UD types is important for comparative effectiveness analyses, as well as to inform cost containment efforts and guide treatment decision-making.

The Bladder Cancer Quality of Life (BCQOL) Study was a large mixed-method, comparative effectiveness study developed to compare costs, complications, and patient- and family-centered outcomes among bladder cancer patients undergoing cystectomy with a UD. The objective of the current analysis was to compare total medical care costs in the year following radical cystectomy between ileal conduit and neobladder patients, in addition to identifying potential drivers of cost. We hypothesized that medical care costs would differ by UD type.

2. Materials and methods

2.1. Study population

We included data on 1,002 adult (ages ≥ 21 years) patients who were members of one of three integrated health care systems who were diagnosed with bladder cancer between 01/01/2010–05/30/2015 and who underwent radical cystectomy with urinary diversion [13]. The integrated health systems included three Kaiser Permanente (KP) regions—KP Northwest (Oregon and southwest Washington state), KP Northern California, and KP Southern California – serving a total of approximately 9.8 million members. For the current analysis, we included patients who received ileal conduit (n = 821) or neobladder (n = 181) UDs and excluded patients who received a continent pouch UD (n = 30). The study received institutional review board approval from all 3 health systems.

2.2. Data sources

Data for this study were obtained from clinical and administrative data systems at the three participating sites, and included: demographic variables – age at cystectomy, sex, race, and Hispanic ethnicity; study site; health insurance type; clinical variables – year of cystectomy, UD type, Charlson-Deyo Comorbidity Index [18], American Joint Committee on Cancer (AJCC) stage at cystectomy, presence of any complications in the year following cystectomy, vital status, robot-assisted surgery, and months since cystectomy. We extracted utilization data from hospital discharge abstracts; claims; hospital, emergency room, same-day surgical, and medical office ambulatory care encounters. Data were standardized across the participating sites according to specifications established by the Health Care System Research Network's Virtual Data Warehouse [14].

2.3. Medical care cost estimates

Medical care costs were calculated by applying cost coefficients to monthly counts of the following utilization categories: inpatient days, same-day surgeries, hospital ambulatory encounters, emergency room visits, and outpatient clinic visits. Outpatient visit counts were further divided into the following groups: primary care, oncology, nephrology, urology, cardiology, and other specialty visits. Cost coefficients were based on average cost per visit per utilization category, using a hybrid methodology from Medicare fee schedules (e.g., inpatient day, hospital ambulatory, same-day surgery) [15] and administrative data from KP (i.e., medical care costs for services provided both in network and out of network. Cost coefficients used in the analysis are shown in Supplementary Table 1. Monthly medical care costs per patient were estimated from the month of radical cystectomy (month 0) through the 11 months following cystectomy, then averaged across quarters: Quarter 1 (Q1) = month 0 through month 2; Quarter 2 (Q2)=month 3 through month 5; Quarter 3 (Q3) = month 6 through month 8; and Quarter 4 (Q4) = month 9 through month 11. Costs of the initial surgery were included as part of the first quarter cost estimates. Costs were adjusted for inflation using the Consumer Price Index for Medical Care in 2022 [16].

2.4. Statistical analysis

We calculated descriptive statistics for patients with each UD type, including frequencies, means, proportions, and standard deviation (SD), for patient demographic and clinical characteristics [17]. We present the mean and SDs for unadjusted monthly medical care utilization rates, by quarter and UD type, for the following service categories: inpatient stays and days, emergency department (ED) visits, primary care (PC) visits, and specialist visits.

To account for confounders, we developed a propensity score using logistic regression that included race, Hispanic ethnicity, health insurance type, sex, receipt of neoadjuvant therapy, body mass index and study site as predictors. The variables included in the propensity score were considered potential confounders based on prior research [13]. To check the performance of the propensity score in achieving balance, we calculated standardized differences between the ileal conduit and neobladder patients before and after adjustment for the propensity score. The largest standardized difference prior to propensity score adjustment was .46 (for site 1) whereas after adjustment all values were near zero, with the largest difference being .015 for sex; well below the .10 cutoff proposed by Normand et al. [18] and the 0.25 cutoff by Rubin [19].

We used generalized linear models with a gamma distribution and log link [20] to estimate mean monthly medical care costs per quarter, adjusting for UD type, age at cystectomy, Charlson-Deyo Comorbidity Index, presence of any complications, stage at cystectomy, year of cystectomy, robot-assisted surgery, death in quarter, and the propensity score. Adjustment variables were selected based on prior literature on medical costs of bladder cancer [7]. Few studies having assessed medical care costs by UD type [6,8–12] Cost estimates and 95% confidence intervals (95% CI) for UD type, tumor stage at cystectomy, presence of any complications, surgical approach, and death in quarter were obtained from the multivariable model. In this complete-case study, SAS [version 9.1] and STATA [version 15] were used for all statistical analyses.

3. Results

3.1. Patient demographics

Study population characteristics by UD type are presented in Table 1. Patients who received a neobladder were more likely to be younger (age at cystectomy ≤ 64 years, 59% vs. 22%, P < 0.001), female (90% vs. 76%, P < 0.001), have a lower comorbidity burden (Charlson-Deyo Comorbidity Index ≤ 2, 48% vs. 27%, P < 0.001), have lower tumor stage (AJCC stage at cystectomy 0 or 1, 30% vs. 21%, P < 0.001), and have undergone robotic surgery (22% vs. 8%, P <0.001) than patients who received an ileal conduit. Patients who received a neobladder were less likely than those who received an ileal conduit to die within the first year of surgery (13% vs. 25%, P < 0.001).

Table 1.

Study Population Characteristics

	Urinary Diversion Type
	Ileal Conduit (n = 821)		Neobladder (n =181)
	n	%	n	%
Age group at Cystectomy a
< 55 years	26	3.2	37	20.4
55–64 years	157	19.1	69	38.1
65–74 years	296	36.1	59	32.6
≥ 75 years	342	41.7	16	8.8
Sex a
Male	627	76.4	162	89.5
Female	194	23.6	19	10.5
Race
White	686	83.6	147	81.2
Non-White	135	16.4	34	18.8
Hispanic Ethnicity
Hispanic	79	9.6	20	11.1
Non-Hispanic	742	90.4	161	89.0
Charlson Comorbidity Index a
≤ 2	218	26.6	86	47.5
3	161	19.6	35	19.3
4	132	16.1	22	12.2
≥ 5	310	37.8	38	21.0
AJCC Stage at Cystectomy a
0 or I	171	20.8	55	30.4
II	194	23.6	64	35.4
III or IV	456	55.5	62	34.3
Body Mass Index (BMI)
Normal	249	30.3	57	31.5
Overweight	349	42.5	72	39.8
Obese	223	27.2	52	28.7
Surgical Approach a
Robotic	67	8.2	40	22.1
Open	754	91.8	141	77.9
Any complications in the year following cystectomy
Yes	624	76.0	150	82.9
No	197	24.0	31	18.1
Died within year after surgery a	202	24.6	23	12.7
Follow-up Time, months a
Mean (SD)	10.4 (3.1)		11.2 (2.3)
Median (IQR)	12.0 (8.3, 12.5)		12.0 (9.6,12.8)

IQR = Interquartile Range; SD = Standard Deviation. Values are based on data from n = 1002 patients with non-missing data on the characteristics presented. Due to rounding, percentages may not add to 100%. Differences between urinary diversion groups assessed by t-test for continuous variables and by chi-square for categorical variables.

^aP < 0.001.

3.2. Medical care utilization by UD type

Unadjusted monthly utilization rates per quarter by UD type are presented in Table 2. Ileal conduit patients had longer mean hospitalization length of stay than neobladder patients across all quarters: Quarter 1 (mean = 5.48 days, SD = 4.40 vs. 5.12 days, SD = 3.55; P < 0.001); Quarter 2 (mean = 0.93 days, SD = 3.65 vs. 0.51 days, SD = 1.74; P < 0.001); Quarter 3 (mean = 0.68 days, SD=2.51 vs. 0.52 days, SD=2.05; P < 0.001); and Quarter 4 (mean = 0.37 days, SD = 2.00 vs. 0.35 days, SD = 1.26; P < 0.001). In general, most notable differences in utilization were observed in Quarter 4, ileal conduit patients had more hospitalizations than neobladder patients (mean = 0.06, SD = 0.19 vs. 0.04, SD = 0.14, P < 0.001) and more ED visits than neobladder patients (mean = 0.12, SD = 0.30 vs. 0.08 SD = 0.22, P < 0.001). Furthermore, ileal conduit patients had fewer specialist visits (mean = 1.09, SD = 1.80 vs. 1.17, SD = 1.45, P < 0.001) and fewer outpatient visits (mean = 1.42, SD = 1.92 vs. 1.48, SD = 1.66, P < 0.01) than neobladder patients. Other utilization rates were not significantly different between IC and NB patients across quarters.

Table 2.

Mean Monthly Medical Care Utilization Per Patient, by Quarter following Surgery

Service Type	Quarter 1		Quarter 2		Quarter 3		Quarter 4
	Ileal Conduit (n = 821) Mean (SD)	Neobladder (n = 181) Mean (SD)	Ileal Conduit (n = 758) Mean (SD)	Neobladder (n = 174) Mean (SD)	Ileal Conduit (703) Mean (SD)	Neobladder (n= 169) Mean (SD)	Ileal Conduit (n=648) Mean (SD)	Neobladder (n=162) Mean (SD)
Hospitalizations	0.54 (0.34)	0.60 (0.37)	0.11 (0.29)	0.08 (0.24)b	0.09 (0.25)	0.07 (0.23)	0.06 (0.19)	0.04 (0.14)c
Length of stay	5.48 (4.40)	5.12 (3.55)c	0.93 (3.65)	0.51 (1.74)c	0.68 (2.51)	0.52 (2.05)b	0.37 (2.00)	0.35 (1.26)c
Emergency Department Visits	0.33 (0.46)	0.44 (0.54)b	0.19 (0.38)	0.16 (0.36)	0.14 (0.35)	0.14 (0.32)	0.12 (0.30)	0.08 (0.22)c
Primary Care Visits	0.49 (0.67)	0.41 (0.61)	0.45 (0.70)	0.31 (0.60)a	0.39 (0.72)	0.34 (0.61)b	0.34 (0.49)	0.30 (0.54)
Specialist Visits	2.05 (1.50)	2.40 (1.60)	1.63 (1.86)	1.64 (1.90)	1.21 (1.80)	1.48 (1.88)	1.09 (1.80)	1.17 (1.45)c
Outpatient Visits	2.54 (1.78)	2.81 (1.75)	2.07 (2.15)	1.95 (2.10)	1.60 (2.11)	1.83 (2.11)	1.42 (1.92)	1.48 (1.66)a

Estimates are unadjusted mean counts of medical care utilization per patient, for each service type, by urinary diversion type and by quarter following surgery. Quarter 1 = month of radical cystectomy (month 0) through month 2 following cystectomy; Quarter 2 = months 3–5 following cystectomy; Quarter 3 = months 6–8 following cystectomy; Quarter 4 = months 9–11 following cystectomy. Differences between urinary diversion groups assessed by t-test.

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

3.3. Medical care costs by UD type

We found no significant differences in mean monthly costs between ileal conduit and neobladder patients across all 4 quarters in the 12 months following cystectomy in adjusted analysis (Table 3). Overall, mean monthly costs ranged from Quarter 1 (mean ileal conduit = $39,792, 95% CI [$38,405, $41,231] vs. neobladder patients $43,695, 95% CI [$40,198, $47,495]), Quarter 2 (mean ileal conduit = $5,686, 95% CI[$5,073, $6,375]vs. neobladder patients$4,269, 95% CI [$3,256, $5,599],Quarter 3 (mean ileal conduit = $4,280, 95% CI [$3,769, $4,860] vs. neobladder patients = $3,558, 95% CI [$2,657, $4,763],Quarter 4 (mean ileal conduit = $3,015, 95% CI [$2,632, $3,453]vs. neobladder patients = $2,903, 95% CI [$2,135, $3,946].

Table 3.

Adjusted Mean Monthly Medical Care Costs, Per Quarter^a

Characteristic	Quarter 1 (n =1002)	Quarter 2 (n = 932)	Quarter 3 (n = 872)	Quarter 4 (n = 810)
Urinary Diversion Type	Mean [95% CI]	Mean [95% CI]	[l]Mean [95% CI]	Mean [95% CI]
Ileal Conduit	$39,792 [$38,405, $41,231]	$5,686 [$5,073, $6,375]	$4,280 [$3,769, $4,860]	$3,015 [$2,632, $3,453]
Neobladder	$43,695 [$40,198, $47,495]	$4,269 [$3,256, $5,599]	$3,558 [$2,657, $4,763]	$2,903 [$2,135, $3,946]
Tumor Stage at Cystectomy
0 or I	$38,224 [$35,764, $40,855]	$3,515d [$2,854, $4,328]	$2,759d [$2,194, $3,471]	$2,226b [$1,763, $2,812]
II	$39,599 [$37,222, $42,128]	$4,226 [$3,473, $5,139]	$3,931 [$3,157, $4,893]	$3,091 [$2,477, $3,859]
III or IV	$41,961 [$40,159, $43,842]	$7,502 [$6,501, $8,657]	$5,258 [$4,464, $6,196]	$3,497 [$2,924, $4,183]
Presence of Any Complications
Yes	$44,385d [$42,827, $45,998]	$6,558d [$5,883, $7,309]	$5,025d [$4,466, $5,654]	$3,361d [$2,976, $3,796]
No	$29,846 [$27,954, $31,867]	$2,010 [$1,566, $2,582]	$1,135 [$831, $1,550]	$1,098 [$758, $1,589]
Surgical Approach
Robotic	$39,034 [$35,275, $43,194]	$6,246 [$4,501, $8,669]	$2,387c [$1,655, $3,444]	$2,234 [$1,517, $3,291]
Open	$40,651 [$39,322, $42,023]	$5,289 [$4,760, $5,877]	$4,422 [$3,931, $4,974]	$3,108 [$2,744, $3,520]
Died in Quarter
Yes	$80,355d [$69,487, $92,923]	$30,108d [$18,106, $50,069]	$19,797d [$11,376, $34,448]	$10,016d [$5,243, $19,133]
No	$39,111 [$37,881, $40,381]	$5,011 [$4,531, $5,541]	$3,855 [$3,447, $4,312]	$2,867 [$2,551, $3,223]

Cost estimates are based on multivariable generalized linear models (GLM), adjusted for tumor stage at cystectomy, age at cystectomy, Charlson Comorbidity Index, presence of any complications, body mass index, year of cystectomy, robotic surgery, death in quarter, and the propensity score. Separate models were conducted for each quarter, using the same variables. P-value based on Wald Test for a difference between groups, as presented in the table, obtained from the adjusted GLM for each quarter.

^aSample sizes in each quarter were as follows: Quarter 1 – Illeal Conduit (n = 821), Neobladder (n = 181); Quarter 2 – Illeal Conduit (n = 758), Neobladder (n = 174); Quarter 1 – Illeal Conduit (n = 703), Neobladder (n = 169); Quarter 1 – Illeal Conduit (n = 648), Neobladder (n = 162).

^bP < 0.05.

^cP < 0.01.

^dP < 0.001. Make a footnote about change in sample size due to death or loss of membership eligibility, which could be loss of enrollment or insurance coverage, move out of coverage area.

3.4. Medical care costs by risk factors

Patients with any complications had significantly higher mean monthly costs per quarter than those without complications (Table 3; all P < 0.001): Quarter 1 (any complications = $44,385, 95% CI [$42,827, $45,998] vs. no complications = $29,84695% CI [$27,954, $31,867]); Quarter 2 (any complications = $6,558, 95% CI [$5,883, $7,309] vs. no complications = $2,010, 95% CI [$1,566, $2,582]); Quarter 3 (any complications = $5,025, 95% CI [$4,466, $5,654] vs. no complications = $1,135, 95% CI [$831, $1,550]); and Quarter 4 (any complications = $3,361, 95% CI [$2,976, $3,796] vs. no complications = $1,098, 95% CI [$758, $1,589]). Compared to patients who underwent robotic surgery, patients who underwent open surgery had no significant difference in mean monthly costs in Quarter 1 (mean robotic = $39,034, 95% CI [$35,275, $43,194] vs. open = $40,651, 95% CI [$39,322, $42,023]) and Quarter 2 (mean robotic = $6,246, 95% CI [$4,501, $8,669] vs. Open = $5,289, 95% CI [$4,760, $5,877]. However, mean monthly costs for patients with robotic surgery were lower in Quarter 3 $2,387, 95% CI [$1,655, $3,444]) than for those with open surgery ($4,422, 95% CI [$3,931, $4,974]), but were not significantly lower in Quarter 4 (robotic = $2,234, 95% CI [$1,517, $3,291] vs. Open = $3,108, 95% CI [$2,744, $3,520]). Patients with a lower tumor stage at cystectomy (stage 0 or 1) had lower mean monthly costs than patients with a higher tumor stage (stage 3 and stage 4) in Quarters 2 through 4 (P < 0.05). Mean monthly costs for patients who died in a quarter were higher in that quarter than costs for those who did not die, across all quarters (P < 0.001).

4. Discussion

We found that, despite differences in service use, mean medical care costs in the year following radical cystectomy were similar between bladder cancer patients who received an ileal conduit and those who received a neobladder. As expected, mean monthly costs were highest during the first quarter and decreased thereafter. We highlight important medical care costs drivers, including the finding that patients who experienced any complications had higher costs than patients without such complications, a mean of over $14,000 higher in Quarter 1 to over $2,000 higher in Quarter 4 of the year following cystectomy. Patients with advanced tumor stage at cystectomy had higher costs across all quarters than those with early tumor stage at diagnosis. Likewise, patients who died during Quarter 1 three months had more than 2-fold higher costs in that quarter, which are likely associated with more intense utilization towards the end-of-life.

Our study findings add to a limited body of research by quantifying the magnitude of medical care cost for bladder cancer patients who receive an ileal conduit and those who receive a neobladder, addressing an important knowledge gap about cost patterns between different treatment approaches and yielding information that is important for understanding potential cost implications and cost reduction targets. While differences in study design and populations preclude direct comparison of cost estimates across studies, prior study findings underscore the range of costs associated with treating bladder cancer, research assessing medical care costs among patients with bladder cancer [6,8–11,21]. In a study of US adult bladder cancer patients who underwent radical cystectomy, Leow et al. [6] reported 90-day mean direct hospital costs of $39,651 (2016 USD) and mean postdischarge costs of $4,847 (2016 USD). Moreover, this study reported that, compared to patients who received an incontinent diversion (e.g., ileal conduit), those with a continent urinary diversion, which is most often a neobladder, had 1.56 times greater odds of having high costs (≥ $68,166 per cystectomy). Among studies using SEER-Medicare data, Williams et al. [11] reported mean 90-day total costs of $68,692 (2017 USD) for patients who underwent radical cystectomy, $109,078 (2017 USD) at 180-day and $148,757 (2017 USD) at 1-year after cystectomy. Sloan et al. [22] reported mean total costs in the 1-year post diagnosis of $23,201 (2018 USD) for localized disease, $51,840 (2018 USD) for regional disease and $59,919 (2018 USD) for distant disease. Whereas, Santos et al. [9] reported mean costs of approximately $18,979 (2014 CAD) per patient per year for radical cystectomy and approximately $4,770 (2014 CAD) per patient per year for postsurgery costs. Collectively, these findings underscore the range of costs associated with treating bladder cancer, particularly in the US where bladder cancer has the highest treatment costs per patient [10].

We found important factors that merit consideration with respect to drivers of medical care costs among patients who undergo radical cystectomy. Postcystectomy complications are an important driver of medical care costs for these patients. We also found that the proportion of patients with postcystectomy complications was 76% among ileal conduit patients and 83% among neobladder patients. Prior studies reported postcystectomy complications in up to 69% of patients [6,9,23]. Patients with complications had higher costs than patients without complications – ranging from approximately $5,703 to more than $15,000 – and may account for nearly 85% of total cost variation associated with cystectomy [6,9,10,21,23,24]. While we did not observe significantly lower costs among ileal conduit patients compared to neobladder patients, despite having lower complications, 1 potential explanation may be that ileal conduit patients had increased comorbidities, hospitalizations with longer lengths of stay, and were more likely to die in the year following cystectomy compared to neobladder patients; all of which are factors associated with higher medical care costs that may have counter-balanced the costs associated with complications. Nevertheless, focused evaluation and management of patients at high risk for complications following cystectomy is vital to cost containment. Patients at end of life had higher costs, with patients in our study who died within the first quarter following cystectomy having costs of over $80,000; similar results of higher costs have been reported in other studies [8]. As such, integration of palliative and end-of-life care as part of the management for patients with advanced bladder cancer and poor health status may be warranted; this accords with recent recommendations by leading professional societies [25]. Collectively, such strategies may lead to both improved patient outcomes [26], as well as supporting efforts to emphasize high-value care that aligns costs with outcomes.

There are important limitations to consider in regard to these findings. Cost estimates from our study reflect utilization patterns of bladder cancer patients diagnosed between 2010–2015, who underwent radical cystectomy and received a urinary diversion (ileal conduit or neobladder). Our estimates did not account for all costs associated with more contemporary treatments, such as equipment associated with robotic surgery, prescription drug costs, nor preoperative chemotherapy as data were not available from all study sites. Moreover, cost estimates presented in our study reflect costs based on summarized monthly utilization data (versus encounter-level utilization) on patients who received care in three large, integrated health systems in the US and may not reflect costs in other settings (i.e., fee-for-services). Further, we estimated quarterly costs, rather than annualized costs, given the prior literature on medical costs among bladder cancer patients following radical cystectomy that demonstrates distinct periods of decreasing costs (i.e., higher initial costs, such as month of initial hospitalization for cystectomy, followed by months of decreasing costs), which improved the generalizability of our study findings and produced cost estimates that can be used as inputs for program planning and in comparative effectiveness models. We did not have access to information on performance status or patient and physician preferences, and as such, selection bias may influence costs associated with care patterns [13]. Lastly, the results in this study are estimates of total payor or health system costs and do not capture patient cost liabilities (i.e., out of pocket costs), which may lead to substantial financial hardship for many patients and their families.

5. Conclusion

Our study provides valuable estimates of medical care costs for bladder cancer patients who receive an ileal conduit and a neobladder, addressing an important knowledge gap about cost patterns between different treatment approaches. We highlight potential costs drivers that may serve as valuable targets for future cost containment strategies. Future research should explore out-of-pocket costs and other financial impacts of cystectomy by UD type to provide additional valuable information that may be used in treatment decision-making and cost conversations.

Supplementary Material

Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j.urolonc.2024.09.031.

Data Sharing

De-identified data or summarized may be available upon request from the Dr. Carmit McMullen (Carmit.McMullen@kpchr.org).