Development of a nomogram to predict achievement of trifecta outcomes in patients receving robot-assisted radical cystectomy with intracorporeal orthotopic neobladder

INTRODUCTION AND OBJECTIVE: Robot-assisted radical cystectomy (RARC) with orthotopic neobladder (ON) is associated with heterogeneous surgical, functional and oncological outcomes. We propose a combination of three standardized and reproducible postoperative criteria (Trifecta) to optimize outcomes reporting after RARC with ON and we developed a nomogram to predict probability of achieving trifecta. METHODS: We defined the "trifecta" as the combination of daily urinary continence, no reoperations (meaning neither post-operative complications Clavien-Dindo ≥ 3 nor other surgical interventions related to RARC/ON, after discharge) and recurrence-free status, all assessed at one year. A total of 137 consecutive patients who underwent RARC with intracorporeal ON for bladder cancer were used to generate a nomogram predicting probability of achieving trifecta outcomes. The discrimination accuracy was measured by concordance index (CI). Calibration plot was generated with 200 bootstrap resampling. A decision curve analysis was performed to assess the net benefit of the model. RESULTS: Overall, 137 patients were included in the analysis (Table 1). The trifecta was achieved by 72 (53%) patients. On multivariable logistic regression analysis, age, ASA score, body mass index and neoadjuvant chemotherapy were significant predictors of trifecta achievement. The developed nomogram had a 0.71 CI (Figure 1A) and was well calibrated (Figure 1B); on decision curve analysis, the net benefit of using the model was evident for probabilities ranging between 25% and 70% (Figure 1C). The small sample size and the lack of external validation are the main limitations of this study. CONCLUSIONS: This newly defined trifecta is the first standardized and reproducible system specifically designed to provide a comprehensive summary of global results after RARC-iN. The developed nomogram is an easy clinical tool to predict probability of trifecta achievement at 12-mo follow-up evaluation.