Prevalence and Prognostic Significance of Preoperative Anemia in Radical Cystectomy Patients: A Multicenter Retrospective Observational Study

Ernest Kaufmann¹, Luca Antonelli^{1

2}, Luca Afferi¹, Vincenzo Asero², Francesco Prata³, Silvia Rebuffo^{4

5}, Alessandro Veccia⁶, Meftun Culpan⁷, Karl Tully⁸, Luis Ribeiro⁹, Thierry Roumeguere¹⁰, Kees Hendricksen¹¹, Luca Lambertini¹², Renate Pichler¹³, Nicola Pavan¹⁴, Jeremy Yuen-Chun Teoh^{15

16

17}, Mathieu Roumiguié¹⁸, Gerald Bastian Schulz¹⁹, Francesco Soria²⁰, Aamer AlGhamlas²¹, Pierre-Emmanuel Desprez²², Luca Orecchia²³, Cedric Poyet²⁴, Majed Alrumayyan²⁵, Michael Rink²⁶, Stefania Zamboni²⁷, Maria Riaza Montes²⁸, Steven Okoye²⁹, Mattia Lo Re³⁰, Wojciech Krajewski³¹, Luke Lavallee³², Marian Severin Wettstein³³, Marco Moschini³⁴, Christian Daniel Fankhauser¹

Affiliations

¹ Department of Urology, Luzerner Kantonsspital, University of Lucerne, Lucerne, Switzerland.
² Department of Urology, Sapienza University of Rome, Rome, Italy.
³ Department of Urology, Fondazione Policlinico Universitario Campus BIo-Medico of Rome, Rome, Italy.
⁴ IRCCS Ospedale Policlinico S. Martino, Genoa, Italy.
⁵ Department of Surgical and Diagnostic Integrated Sciences, University of Genoa, Genoa, Italy.
⁶ Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
⁷ Department of Urology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey.
⁸ Department of Urology and Neurourology, Marien Hospital Herne, Ruhr University Bochum, Bochum, Germany.
⁹ St. George's University Hospital, London, UK.
¹⁰ Service d'Urologie, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Bruxelles, Belgium.
¹¹ Department of urology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
¹² Unit of Oncologic Minimally Invasive Urology and Andrology - Careggi Hospital, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy.
¹³ Department of Urology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁴ Urology Clinic, Department of Precision Medicine in Medical, Surgical and Critical Care, University of Palermo, Palermo, Italy.
¹⁵ S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China.
¹⁶ Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China.
¹⁷ Department of Urology, Medical University of Vienna, Vienna, Austria.
¹⁸ Department of Urology, CHU-IUCT, Toulouse, France.
¹⁹ Department of Urology, LMU Munich, Munich, Germany.
²⁰ Division of Urology, Department of Surgical Sciences, AOU città della Salute e della Scienza di Torino, Torino School of Medicine, Torino, Italy.
²¹ Urology, GRC 5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, Sorbonne University, Paris, France.
²² Urology Department, Claude Huriez Hospital, CHU Lille, Lille, France.
²³ Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, Rome, Italy.
²⁴ Department of Urology, Stadtspital Zürich Triemli, Zürich, Switzerland.
²⁵ Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
²⁶ Department of Urology, Marienkrankenhaus Hamburg, Hamburg, Germany.
²⁷ Unit of Urology, Department of Medical and Surgical Specialities, Radiological Science and Public Health, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy.
²⁸ Galdakao-Usansolo Hospital, Vizcaya, Spain.
²⁹ Department of Urology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
³⁰ Unit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy.
³¹ Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, Wrocław, Poland.
³² Division of Urology, Department of Surgery, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada.
³³ Department of Uro-Oncology, University of Toronto, Toronto, ON, Canada.
³⁴ Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele, Milan, Italy.

PMID: 40524687
PMCID: PMC12169704
DOI: 10.1016/j.euros.2025.05.002

Prevalence and Prognostic Significance of Preoperative Anemia in Radical Cystectomy Patients: A Multicenter Retrospective Observational Study

Ernest Kaufmann et al. Eur Urol Open Sci. 2025.

. 2025 Jun 4:77:10-18.

doi: 10.1016/j.euros.2025.05.002. eCollection 2025 Jul.

Authors

Affiliations

¹ Department of Urology, Luzerner Kantonsspital, University of Lucerne, Lucerne, Switzerland.
² Department of Urology, Sapienza University of Rome, Rome, Italy.
³ Department of Urology, Fondazione Policlinico Universitario Campus BIo-Medico of Rome, Rome, Italy.
⁴ IRCCS Ospedale Policlinico S. Martino, Genoa, Italy.
⁵ Department of Surgical and Diagnostic Integrated Sciences, University of Genoa, Genoa, Italy.
⁶ Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
⁷ Department of Urology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey.
⁸ Department of Urology and Neurourology, Marien Hospital Herne, Ruhr University Bochum, Bochum, Germany.
⁹ St. George's University Hospital, London, UK.
¹⁰ Service d'Urologie, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Bruxelles, Belgium.
¹¹ Department of urology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
¹² Unit of Oncologic Minimally Invasive Urology and Andrology - Careggi Hospital, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy.
¹³ Department of Urology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁴ Urology Clinic, Department of Precision Medicine in Medical, Surgical and Critical Care, University of Palermo, Palermo, Italy.
¹⁵ S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China.
¹⁶ Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China.
¹⁷ Department of Urology, Medical University of Vienna, Vienna, Austria.
¹⁸ Department of Urology, CHU-IUCT, Toulouse, France.
¹⁹ Department of Urology, LMU Munich, Munich, Germany.
²⁰ Division of Urology, Department of Surgical Sciences, AOU città della Salute e della Scienza di Torino, Torino School of Medicine, Torino, Italy.
²¹ Urology, GRC 5 Predictive Onco-Uro, AP-HP, Pitie-Salpetriere Hospital, Sorbonne University, Paris, France.
²² Urology Department, Claude Huriez Hospital, CHU Lille, Lille, France.
²³ Urology Unit, Department of Surgical Sciences, Tor Vergata University Hospital, University of Rome Tor Vergata, Rome, Italy.
²⁴ Department of Urology, Stadtspital Zürich Triemli, Zürich, Switzerland.
²⁵ Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
²⁶ Department of Urology, Marienkrankenhaus Hamburg, Hamburg, Germany.
²⁷ Unit of Urology, Department of Medical and Surgical Specialities, Radiological Science and Public Health, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy.
²⁸ Galdakao-Usansolo Hospital, Vizcaya, Spain.
²⁹ Department of Urology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
³⁰ Unit of Urological Robotic Surgery and Renal Transplantation, University of Florence, Careggi Hospital, Florence, Italy.
³¹ Department of Minimally Invasive and Robotic Urology, Wrocław Medical University, Wrocław, Poland.
³² Division of Urology, Department of Surgery, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada.
³³ Department of Uro-Oncology, University of Toronto, Toronto, ON, Canada.
³⁴ Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele, Milan, Italy.

PMID: 40524687
PMCID: PMC12169704
DOI: 10.1016/j.euros.2025.05.002

Abstract

Background and objective: Preoperative anemia is common in patients undergoing radical cystectomy for bladder cancer, but its prevalence and impact on outcomes remain poorly characterized across different health care settings. This study aims to assess the prevalence of preoperative anemia, evaluate its current management practices, and determine its association with postoperative and oncological outcomes in patients undergoing radical cystectomy.

Methods: We retrospectively analyzed 4886 patients with nonmetastatic bladder cancer who underwent radical cystectomy across 28 centers in 13 countries. Multivariable regression models identified the predictors of preoperative hemoglobin levels and postoperative blood transfusions. Survival outcomes were assessed using Kaplan-Meier and Cox proportional hazards regression analyses.

Key findings and limitations: Preoperative anemia was present in 44% of women and 48% of men. Among anemic patients, 73% received no blood management interventions. Higher hemoglobin levels before transurethral resection of a bladder tumor correlated with higher levels before cystectomy and fewer postoperative blood transfusions (odds ratio: 0.98, 95% confidence interval [CI]: 0.97-0.99, p < 0.001). Higher preoperative hemoglobin levels were associated with lower 90-d mortality rates (hazard ratio: 0.98, 95% CI: 0.97-0.99, p < 0.001) and independently predicted reduced all-cause mortality, cancer-specific mortality, and disease relapse.

Conclusions and clinical implications: Preoperative anemia is prevalent and undertreated in patients undergoing radical cystectomy, and is independently associated with adverse perioperative and oncological outcomes. This highlights the need for further research regarding the potential benefits of implementing systematic preoperative anemia management.

Patient summary: This study found that low blood counts before bladder removal surgery are common, often untreated, and linked to worse outcomes. Early treatment of low blood counts before surgery could improve results for patients.

Keywords: Anemia; Bladder cancer; Hemoglobin; Patient blood management; Radical cystectomy; Survival outcomes.

PubMed Disclaimer

Figures

**Fig. 1**
Kaplan-Meyer curves for overall, cancer-specific, and recurrence-free survival in patients with hemoglobin values >130 g/l (blue) and <130 g/l (red), and log-rank tests for overall survival (p < 0.001), cancer-specific survival (p < 0.001), and recurrence-free survival (p < 0.001). Hb = hemoglobin.

See this image and copyright information in PMC

References

1. Gaspar B.L., Sharma P., Das R. Anemia in malignancies: pathogenetic and diagnostic considerations. Hematology. 2015;20:18–25. - PubMed
1. Ferran-Carpintero A., Domínguez-García A., Muñoz-Rodríguez J., et al. Impact of anemia on the survival of patients undergoing radical cystectomy for bladder cancer. Actas Urol Esp (Engl Ed) 2020;44:489–496. - PubMed
1. Carvalho F.L.F., Wang Y., Dall C.P., et al. Preoperative anemia is associated with increased radical cystectomy complications. Urol Oncol. 2022;40:382.e7–382.e13. - PubMed
1. Xia L., Guzzo T.J. Preoperative anemia and low hemoglobin level are associated with worse clinical outcomes in patients with bladder cancer undergoing radical cystectomy: a meta-analysis. Clin Genitourin Cancer. 2017;15:263–272.e4. - PubMed
1. Syan-Bhanvadia S., Drangsholt S., Shah S., et al. Restrictive transfusion in radical cystectomy is safe. Urol Oncol. 2017;35:528.e15–528.e21. - PubMed

LinkOut - more resources

Full Text Sources
- Elsevier Science
- PubMed Central

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Prevalence and Prognostic Significance of Preoperative Anemia in Radical Cystectomy Patients: A Multicenter Retrospective Observational Study

Affiliations

Prevalence and Prognostic Significance of Preoperative Anemia in Radical Cystectomy Patients: A Multicenter Retrospective Observational Study

Authors

Affiliations

Abstract

Figures

References

LinkOut - more resources

Full Text Sources