The impact of smoking on radical cystectomy complications increases in elderly patients

Background Smoking, the most common risk factor for bladder cancer (BC), is associated with increased complications after radical cystectomy (RC), poorer oncologic outcomes, and higher mortality. The authors hypothesized that the effect of smoking on the probability of major complications increases with increasing age among patients who undergo RC. Methods The authors analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2011‐2017), identified all patients undergoing RC using Current Procedural Terminology codes, and formed two groups according to smoking status (active smoker and nonsmoker [included former and never‐smokers]). Patient characteristics and 30‐day postoperative complications using the Clavien‐Dindo Classification (CDC) were assessed. A multivariable logistic regression model was constructed that included age, sex, race, body mass index, operative time, comorbidities, chemotherapy status, and type of diversion with major complications (CDC ≥III) as the outcome variable, and explored the interaction between age and smoking status. Results A total of 10,528 patients underwent RC, including 22.8% who were active smokers. The authors identified an interaction between age and smoking status (P = .045). Older patients were found to experience a stronger smoking effect than younger patients with regard to the probability of major complications. The risk of a major complication was the same for 50‐year‐old nonsmokers and smokers, but it increased from 17.8% to 21.7% for 70‐year‐old nonsmokers and smokers, respectively (P < .001). Conclusions Up to 20% of patients who undergo RC are active smokers, and these individuals have an increased risk of major complications. The effect of smoking is stronger with increasing age; the difference with regard to complications for smokers versus nonsmokers was found to increase substantially, wherein older smokers are at an especially high risk of complications. The impact of smoking on the probability of major complications after radical cystectomy increases with increasing age. By encouraging smoking cessation, especially among younger patients with bladder cancer, there is a valuable opportunity to reduce smoking‐related morbidity for patients undergoing radical cystectomy.