Association between Preoperative Albumin Levels and Length of Stay after Radical Cystectomy

Purpose: Using contemporary population based epidemiological data we measured the relationship between the preoperative serum albumin level and hospital length of stay after cystectomy and urinary diversion. Materials and Methods: Data were acquired from the 2014 to 2015 NSQIP (R) (National Surgical Quality Improvement Program (R)) database. We identified 1,582 adults who underwent cystectomy between January 1, 2014 and December 31, 2015, and had a documented preoperative serum albumin level. The primary outcome was time to hospital discharge and the primary exposure was preoperative serum albumin. We fit a Cox proportional hazards model to assess associations with adjustment for a set of predefined confounders. We allowed for all continuous variables to have a nonlinear relationship with the primary outcome using a restricted cubic spline with 3 knots. Results: Preoperative serum albumin was independently associated with hospital length of stay after cystectomy. Increasing preoperative serum albumin below a threshold of 4 gm/dl was associated with decreased length of stay (HR 1.05, 95% CI 1.01-1.09, p < 0.004). Other significant predictors associated with longer length of stay included patient age (HR 0.84, 95% CI 0.77e0.91, p < 0.001), nonCaucasian race (HR 0.81, 95% CI 0.70-0.93, p = 0.003) and American College of Surgeons classification 4 (class 4 vs 3 HR 0.78, 95% CI 0.62-0.97, p = 0.008). Minimally invasive cystectomy was associated with a shorter length of stay (HR 1.23, 95% CI 1.07-1.42, p = 0.004). Conclusions: This study provides evidence that nutritional optimization prior to cystectomy shortens the length of stay after surgery but there are diminishing returns above a threshold of 4 gm/dl.