{"paper_id":"28b0c1a5-e2b3-48a2-a7e5-2c6c1b9f7e06","body_text":"Clinical Utility of a Novel Perioperative Quality Assessment Metric, Trifecta, for Radical Cystectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Utility of a Novel Perioperative Quality Assessment Metric, Trifecta, for Radical Cystectomy Mahito Atsuta, Fumihiko Urabe, Kosuke Iwatani, Masataka Kubo, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5987355/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Jul, 2025 Read the published version in International Journal of Clinical Oncology → Version 1 posted 5 You are reading this latest preprint version Abstract Background: Assessing the quality of surgical procedures is crucial for improving outcomes in radical cystectomy (RC). While the “Pentafecta” metric has been used, its reliance on the absence of local recurrence within 1 year delays postoperative assessment. For timely clinical decision-making, a new metric that facilitates earlier evaluation is needed. We propose such a metric, named Trifecta. We evaluated its impact on prognosis and identified predictors for achieving it. Methods: The Trifecta metric was defined as meeting three criteria: adequate lymphadenectomy (≥10 nodes), negative surgical margins, and absence of Clavien-Dindo grade 3–5 complications within 30 days after surgery. This retrospective study analyzed data from patients who underwent RC and lymphadenectomy between April 2014 and June 2024. Kaplan-Meier analysis was used to assess oncological outcomes, including intrapelvic recurrence-free survival (RFS), metastatic-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). Cox proportional hazards models were used to examine the association between Trifecta and these outcomes, while logistic regression was used to identify predictors for failing to achieve Trifecta. Results: Of the 196 patients included, 121 (61.7%) achieved Trifecta and this was significantly associated with improved intrapelvic RFS, CSS, and OS but not MFS. Low serum levels of albumin were identified as a significant predictor for not achieving Trifecta. Conclusion: Achieving Trifecta was associated with improved survival outcomes, and low serum levels of albumin predicted a higher likelihood of failure to achieve it. The Trifecta metric enables early and clinically relevant evaluation of surgical quality, offering a practical alternative to traditional metrics. bladder carcinoma trifecta Radical cystectomy Figures Figure 1 Introduction Radical cystectomy (RC) is recommended for patients with T2–T4a, N0M0 disease, very high-risk NMIBC, BCG-refractory, BCG-relapsing, and BCG-unresponsive NMIBC, as well as extensive papillary disease that cannot be managed with TURBT and intravesical chemotherapy/immunotherapy alone 1 . The peri-operative mortality following RC has been reported as 2.1–3.2% at 30 days and 3.4–8.0% at 90 days. 2,3 Therefore, surgeons must strive to provide high-quality surgical care and closely monitor patients for peri-operative changes. Particularly, the quality of surgery would have a significant impact on prognosis and complications. The history of surgical quality assessment began with the \"Pentafecta\" proposed by Aziz et al., which comprised a negative surgical margin for soft tissue, adequate lymphadenectomy, and no Clavien-Dindo grade 3-5 complications within 90 days post-radical cystectomy, along with a treatment-free interval following TUR-BT within three months and no local recurrence in the pelvic region within 12 months. 4 Subsequently, Cacciamani et al. proposed a revised version of the” Pentafecta”, which included Aziz’s original trifecta along with the absence of local pelvic recurrence, distant metastasis, upper tract recurrence at 12 months, and no urinary diversion-related sequelae at 12 months. 5 A recent validation study has reported that cases achieving the revised “Pentafecta” had improved recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) 6 . However, these composite metrics require a one-year period before assessment. There is a need for a means to evaluate the quality of surgery at an early stage, which can act as a benchmark for guiding future treatment strategies. Additionally, early assessment can facilitate a timely review of surgical practices and contribute to achieving better surgical quality. Thus, we propose a novel quality assessment metric, \"Trifecta,\" which includes three factors: adequate lymphadenectomy, negative surgical margins, and the absence of significant complications within 30 days post-surgery. This metric allows for the quality of surgery to be assessed within 30 days after RC. In this study, we evaluate the clinical utility of the “Trifecta” model in patients who underwent RC. Additionally, we also investigated the types of patients who might face challenges in achieving Trifecta, emphasizing those who need careful preoperative planning and consideration. Patients and Methods Patient cohort This retrospective, single-center study included patients diagnosed with bladder cancer who had RC and lymphadenectomy. The extent of lymphadenectomy was at the surgeon's discretion. The type of urinary diversion was determined based on tumor characteristics, the patient’s performance status, and a shared decision-making process between the patient and the attending physician. Data were collected between April 2014, and June 2024. The following patients were excluded: distant metastasis already existed; RC was initiated but couldn’t be completed; and lymphadenectomy wasn’t performed. Method We evaluated three components of the “Trifecta” outcomes composite: adequate lymphadenectomy, negative surgical margin, and absence of significant complications within 30 days. Adequate lymphadenectomy was defined as yielding ≥ 10 lymph nodes. A negative surgical margin was defined as a soft tissue margin, ureter margin, and urethra margin, which were all negative. The absence of major complications was defined as the absence of Clavien–Dindo grade 3-5 complications. In the concept of 'Pentafecta,' the absence of local recurrence within one year is included as a criterion 4,5 . However, to facilitate early postoperative treatment planning, we excluded this criterion from the definition of 'Trifecta.' Therefore, we also evaluated the difference in the incidence of early pelvic recurrence within one year after RC between the group that achieved 'Trifecta' and the group that did not. The primary endpoint is to assess intrapelvic RFS stratified by trifecta achievement and identify the predictive factor for achieving trifecta. The secondary endpoints are MFS, CSS, and OS, which are stratified by trifecta achievement. Additionally, intrapelvic RFS at one year were assessed. The albumin data was collected at the earliest available time, prior to neoadjuvant chemotherapy (NAC) or RC, whichever came first. Albumin value was categorized as a categorical variable with a cutoff value of 3.8 based on the Youden index (Supplementary Figure 1). Statistical analysis Continuous parametric variables are expressed as medians accompanied by interquartile ranges (IQR). Mann-Whitney U tests were utilized to compare the medians of continuous variables, such as age. In contrast, chi-square tests were employed to compare the proportions of categorical variables, including sex, across different groups. The durations of intrapelvic RFS, MFS, CSS, and OS from the day of RC were computed using the Kaplan–Meier method; log-rank tests were conducted for intrapelvic RFS, MFS, CSS, and OS stratified by the achievement of “Trifecta” outcomes. Additionally, Cox proportional hazards regression analysis was performed, and the independent variables selected for this analysis included age 7 , sex 8 , ≥ pT3 9 , ≥ pN1 9 , NAC and trifecta achievement. Furthermore, logistic regression was applied to identify predictive factors associated with achievement of “Trifecta”. The independent variables analyzed in this context included age 5,6 , sex, body mass index (BMI) 6 , albumin, urinary diversion 5,10 , and the administration of NAC 11 . All statistical tests were two-sided, and statistical significance was defined as a p-value of less than 0.05. Statistical analysis was conducted using EZR software, version 1.68 12 . Results Patient demographics Two hundred thirty cases were collected; however, we excluded patients: one patient for metastasis at the point of cystectomy, one patient for dissemination, for which cystectomy was not performed, so only urinary diversion was performed, and 32 patients for no lymphadenectomy. Finally, 196 cases were analyzed. The median age was 71.5 years (IQR: 66.0-77.0 years). The median follow-up duration was 31.7 months (range: 10.6-55.0 months). Lymph node dissection was performed in all patients; 30 cases (20.4%) had lymph node involvement. NAC was prescribed for 131 patients (66.8%) prior to radical cystectomy. The clinicopathological characteristics of patients with bladder cancer achieving “Trifecta” and not are shown in Table 1. Of all patients, 61.7% were patients for achieving “Trifecta”. Table 1 also compares the clinicopathological characteristics of patients who were and were not achieving “Trifecta”. The group that achieved \"Trifecta\" had a median follow-up period of 37.6 months (IQR: 13.6-61.5 months), which was longer compared to 22.9 months (IQR: 6.0-48.1 months) in the group that did not achieve it (P = 0.003). Regarding urinary diversion, there was a trend toward orthotopic neobladder being selected more frequently in the group that achieved “Trifecta” (P = 0.024). No other significant factors outside the components constituting “Trifecta” were identified. Oncological outcomes During the follow-up period, we observed 37 cases of intrapelvic recurrence and 48 cases of distant metastasis. A total of 74 patients died, of whom 59 deaths were attributed to bladder cancer. The 3-year intrapelvic RFS, MFS, CSS, and OS rates were 78.1%, 70.1%, 70.7%, and 67.4%, respectively. The Kaplan–Meier curves revealed significantly inferior intrapelvic RFS, CSS, and OS in patients not achieving “Trifecta” (P < 0.001, P = 0.027, and P = 0.010, respectively) (Fig. 1a-c). In contrast, the MFS did not differ significantly between patients achieving “Trifecta” and those who did not. (Fig. 1d). In the multivariate analysis, “Trifecta” achievement (HR, 0.42; P = 0.014) and ≥ pT3 stage (HR, 7.47; P < 0.001) were significant for intrapelvic RFS (Table 2). Significant factors for CSS and OS included “Trifecta” achievement (HR, 0.56; P = 0.032, HR, 0.57; P = 0.02, respectively ), ≥ pT3 (HR, 2.83; P < 0.001, HR, 2.97; P < 0.001, respectively ), age (HR, 1.04; P = 0.013, HR, 1.05; P < 0.001, respectively ), and ≥ pN1 stage (HR, 2.90; P < 0.001, HR 2.44: P = 0.0014, respectively ). Notably, trifecta achievement was not associated with MFS (HR, 0.85; P = 0.62), while ≥ pT3 (HR, 2.2; P = 0.024) and ≥ pN1(HR, 3.59; P < 0.001) were significant predictors (Table 2). Next, to assess the impact of achieving 'Trifecta' on local recurrence within one year after RC, we conducted an analysis including 162 cases: 140 cases with a follow-up period of 12 months or longer and 22 cases with follow-up periods shorter than 12 months but with documented pelvic recurrence within 12 months. The rate of pelvic recurrence within 12 months was compared between the group achieving 'Trifecta' and the group that did not. Notably, among the 'Trifecta' group, the recurrence rate within 12 months was 10.7% (11/103), significantly lower than the 28.8% (17/59) observed in the non-'Trifecta' group (p=0.003) (Supplementary Table 1). Predicting factor for “Trifecta” achievement From the analysis so far, it has become evident that “Trifecta” has a significant impact on local recurrence and subsequent prognosis. Therefore, we next examined preoperative factors to identify cases where achieving “Trifecta” may be challenging. In the multivariate analysis examining preoperative factors associated with not achieving “Trifecta,” low albumin (serum Alb < 3.8 g/dL) was found to be the only significant correlating factor (OR, 2.06; P = 0.021). Furthermore, when we deconstructed the non-achievement of “Trifecta” into its components—incomplete lymphadenectomy, positive surgical margins, and significant complications within 30 days post-surgery—to determine which factor low albumin most strongly correlated with, interestingly, no significant correlation was observed with any individual component (P = 0.17, 0.25, and 0.31, respectively; Table 3). Discussion In this retrospective analysis of patients treated with RC for bladder cancer, we examined the association between “Trifecta” achievement and prognosis and investigated preoperative factors associated with not achieving “Trifecta.” Our study revealed that achieving Trifecta was significantly associated with better intrapelvic RFS, CSS, and OS, but not with MFS. Additionally, we found that patients with low serum albumin levels were less likely to achieve “Trifecta.” Aziz et al. initially proposed “Pentafecta” as a metric for ensuring surgical quality in RC 4 , and later, Cacciamani et al. revised this metric 5 . However, since recurrence within 12 months is included as a criterion in these composites, it is not possible to determine whether the surgery met the “Pentafecta” standard until 12 months postoperatively. Furthermore, while early recurrence within 12 months indicates insufficient surgical quality according to Aziz’s and Cacciamani’s “Pentafecta” criteria 4,5 , a substantial number of patients with bladder cancer tend to recur early. This means that even if the surgery itself was performed successfully, these patients cannot achieve the “Pentafecta.” In this context, our “Trifecta” metric has novelty, as it does not exclude early recurrence and can be assessed within just 30 days post-surgery. Actually, achieving 'Trifecta' resulted in approximately 90% of cases without intrapelvic recurrence within one year following RC. This finding suggests that our definition of 'Trifecta' serves as a reasonable and effective metric for assessing the quality of surgical outcomes. Additionally, our study showed that achieving “Trifecta” led to favorable intrapelvic RFS, even after adjusting for confounding factors in multivariate analysis. Previous studies have also used “Pentafecta” to assess its potential as a prognostic predictor and demonstrated improved oncological outcomes 6,13 . However, careful interpretation of these results is necessary because patients with early recurrences were categorized as not achieving “Pentafecta,” which may impact the overall assessment. In this regard, we believe that our “Trifecta” provides a relatively fair evaluation of prognosis. Interestingly, in our analysis, achieving “Trifecta” was still significantly associated with prolonged intrapelvic RFS but did not lead to an extension in MFS. This result can be understood when considering that cases with systemic metastasis likely had micrometastases already present at surgery. If dormant metastatic cells that existed preoperatively become reactivated post-surgery, it would explain why MFS was not extended regardless of surgical quality. Additionally, the association between achieving “Trifecta” and extended CSS and OS indicates that high-quality surgery can indeed contribute to improved prognosis. The only predicting factor for not achieving “Trifecta” was low serum albumin levels. Hypoalbuminemia is known to reflect inflammatory and nutritional states, which can interfere with appropriate responses to treatments such as surgery and chemotherapy, potentially hindering therapeutic efficacy 14 . Previous studies have demonstrated that hypoalbuminemia increases the incidence of postoperative complications following RC in patients with bladder cancer 15,16 . In the present study, we define the “Trifecta” as achieving adequate lymphadenectomy (≥10 nodes), negative surgical margins, and absence of Clavien-Dindo grade 3-5 complications within 30 days post-surgery. Notably, the rates of positive surgical margins and the number of lymph nodes removed are largely influenced by the surgeon’s skill and the tumor's location and stage, limiting direct evidence linking hypoalbuminemia with these outcomes. Conversely, an association between hypoalbuminemia and Clavien-Dindo grade 3-5 complications within 30 days post-surgery may be more readily explained. Interestingly, our findings did not reveal a significant correlation between hypoalbuminemia and any each component of the “Trifecta.” This underscores the importance of recognizing the “Trifecta” as an integrated measure for assessing surgical quality rather than evaluating its components in isolation. While previous reports have indicated that low albumin levels are associated with oncological outcomes following RC 17 , our study is the first to consider the potential impact of hypoalbuminemia on the quality of surgery provided. Reflecting on why hypoalbuminemia may hinder the achievement of the “Trifecta,” it might be plausible that the underlying condition represented by hypoalbuminemia contributes to tissue fragility, potentially impairing precise recognition and dissection of membrane structures during surgery. Moving forward, studies with larger sample sizes are warranted, and additional research should be conducted further to investigate the tissue characteristics of patients with hypoalbuminemia. Our study has several limitations. Firstly, the sample size is relatively small, which may impact the generalizability of the findings. Additionally, the study design is retrospective, which may introduce inherent biases. Since the study period includes the era when treatments such as pembrolizumab and enfortumab vedotin became available, these therapies might have influenced CSS and OS. Furthermore, this study is based on data from a single institution, which may limit the generalizability of the findings. A multi-center research could help validate these results across diverse healthcare settings. Finally, as a retrospective study, there may be incomplete data or missing records, which could affect the comprehensiveness of our analysis. Conclusion In this study, we proposed “Trifecta” as a metric for assessing the quality of RC and examined its impact on postoperative outcomes. Our findings indicated that while achieving “Trifecta” did not extend MFS, it was associated with extended pelvic RFS, CSS, and OS, confirming its utility as an indicator for evaluating the success of optimal curative treatment. Additionally, the correlation between low serum albumin and failure to achieve “Trifecta” suggests that recognizing such cases preoperatively is meaningful for providing optimal perioperative treatment centered around RC. Declarations Acknowledgments The authors express their gratitude for the expert English language editing provided by Textcheck Inc. Conflicts of Interest The authors declare that there is no conflict of interest. Data Availability Statement The data supporting the findings of this study are available upon reasonable request from the corresponding author. Ethics Approval The institutional review board approved the study protocol 36-005(12104). Study Registration Not applicable. Animal Studies Not applicable. References Alfred Witjes J, Max Bruins H, Carrión A, et al. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2023 Guidelines. Eur Urol. 2024;85(1):17-31. doi:10.1016/j.eururo.2023.08.016 Mossanen M, Krasnow RE, Zlatev DV, et al. Examining the relationship between complications and perioperative mortality following radical cystectomy: a population-based analysis. BJU Int. 2019;124(1):40-46. doi:10.1111/bju.14636 Bochner BH, Dalbagni G, Sjoberg DD, et al. Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial. Eur Urol. 2015;67(6):1042-1050. doi:10.1016/j.eururo.2014.11.043 Aziz A, Gierth M, Rink M, et al. Optimizing outcome reporting after radical cystectomy for organ-confined urothelial carcinoma of the bladder using oncological trifecta and pentafecta. World J Urol. 2015;33(12):1945-1950. doi:10.1007/s00345-015-1572-x Cacciamani GE, Winter M, Medina LG, et al. Radical cystectomy pentafecta: a proposal for standardisation of outcomes reporting following robot-assisted radical cystectomy. BJU Int. 2020;125(1):64-72. doi:10.1111/bju.14861 Laymon M, Mosbah A, Hashem A, et al. Predictors and survival benefit of achieving pentafecta in a contemporary series of open radical cystectomy. Minerva Urol Nephrol. 2022;74(4):428-436. doi:10.23736/S2724-6051.21.04230-0 Fairey AS, Kassouf W, Aprikian AG, et al. Age ≥ 80 years is independently associated with survival outcomes after radical cystectomy: results from the Canadian Bladder Cancer Network Database. Urol Oncol. 2012;30(6):825-832. doi:10.1016/j.urolonc.2011.07.014 Uhlig A, Seif Amir Hosseini A, Simon J, et al. Gender Specific Differences in Disease-Free, Cancer Specific and Overall Survival after Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis. J Urol. 2018;200(1):48-60. doi:10.1016/j.juro.2017.11.150 Hara S, Miyake H, Fujisawa M, et al. Prognostic variables in patients who have undergone radical cystectomy for transitional cell carcinoma of the bladder. Jpn J Clin Oncol. 2001;31(8):399-402. doi:10.1093/jjco/hye086 Zapała Ł, Ślusarczyk A, Korczak B, et al. The View Outside of the Box: Reporting Outcomes Following Radical Cystectomy Using Pentafecta From a Multicenter Retrospective Analysis. Front Oncol. 2022;12:841852. doi:10.3389/fonc.2022.841852 Petrelli F, Coinu A, Cabiddu M, Ghilardi M, Vavassori I, Barni S. Correlation of pathologic complete response with survival after neoadjuvant chemotherapy in bladder cancer treated with cystectomy: a meta-analysis. Eur Urol. 2014;65(2):350-357. doi:10.1016/j.eururo.2013.06.049 Kanda Y. Investigation of the freely available easy-to-use software “EZR” for medical statistics. Bone Marrow Transplant. 2013;48(3):452-458. doi:10.1038/bmt.2012.244 Piazza P, Bravi CA, Puliatti S, et al. Assessing pentafecta achievement after robot-assisted radical cystectomy and its association with surgical experience: Results from a high-volume institution. Urol Oncol. 2022;40(6):272.e11-272.e20. doi:10.1016/j.urolonc.2022.01.001 Soeters PB, Wolfe RR, Shenkin A. Hypoalbuminemia: Pathogenesis and Clinical Significance. JPEN J Parenter Enteral Nutr. 2019;43(2):181-193. doi:10.1002/jpen.1451 Ornaghi PI, Afferi L, Antonelli A, et al. The impact of preoperative nutritional status on post-surgical complication and mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review of the literature. World J Urol. 2021;39(4):1045-1081. doi:10.1007/s00345-020-03291-z Li J, Cheng Y, Liu G, Ji Z. 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Patient characteristics Variable Total, n=196 Trifecta not achieved (n=75) Trifecta achieved (n=121) P value* Age, year [IQR] 71.5 [66.0, 77.0] 72.00 [67.0, 77.0] 71.0 [66.0, 76.0] 0.69 Follow-up, month [IQR] 31.7 [10.6, 55.0] 22.9 [6.0, 48.1] 37.6 [13.6, 61.5] 0.003 Sex, n (%) female 33 (16.8) 11 (14.7) 22 (18.2) 0.56 male 163 (83.2) 64 (85.3) 99 (81.8) BMI, kg/m 2 [IQR] 21.3 [19.4, 23.8] 21.4 [20.1, 24.0] 21.1 [19.1, 23.6] 0.36 unknown 5 (2.6) 0 (0.0) 5 (4.1) ECOG.PS (%) 0 177 (90.3) 70 (93.3) 107 (88.4) 0.325 1 19 (9.7) 5 (6.7) 14 (11.6) Diabetes (%) 54 (27.6) 16 (21.3) 38 (31.4) 0.141 Alb, g/dl [IQR] 3.8 [3.5, 4.1] 3.8 [3.5, 4.0] 3.9 [3.6, 4.1] 0.062 Creatinine, mg/dl [IQR] 0.97 [0.82, 1.21] 1.02 [0.83, 1.25] 0.95 [0.81, 1.19] 0.27 Clinical T stage (pre-NAC), n (%) Tis, Ta, T1 39 (19.9) 17 (22.7) 22 (18.2) 0.45 T2 97 (49.5) 35 (46.7) 62 (51.3) T3 38 (19.4) 12 (16.0) 26 (21.5) T4 22 (11.2) 11 (14.6) 11 (9.2) Clinical N stage (pre-NAC), n (%) N0 171 (87.2) 64 (85.3) 107 (88.4) 0.54 N1 16 (8.2) 6 (8.0) 10 (8.3) N2 6 (3.1) 4 (5.3) 2 (1.7) N3 3 (1.5) 1 (1.3) 2 (1.7) Neoadjuvant chemotherapy, n (%) 131 (66.8) 52 (69.3) 79 (65.3) 0.78 Surgical approach, n (%) open 9 (4.6) 3 (4.0) 6 (5.0) 0.51 laparoscopic 153 (78.1) 56 (74.7) 97 (80.2) robot-assisted 34 (17.3) 16 (21.3) 18 (14.9) Urinary diversion, n (%) 0.024 ileal conduit 121 (61.7) 50 (66.7) 71 (58.7) orthotopic neobladder 54 (27.6) 14 (18.7) 40 (33.1) ureterostomy 18 (9.2) 8 (10.7) 10 (8.3) none 3 (1.5) 3 (4.0) 0 (0.0) Variant Histology, n (%) present 17 (8.6) 7 (9.3) 10 (8.3) 0.064 Pathological T stage, n (%) pT0 33 (16.8) 9 (12.0) 24 (19.8) 0.038 pTis, pTa, pT1 70 (35.7) 25 (33.4) 48 (39.7) pT2 29 (14.7) 9 (12.0) 20 (16.5) pT3 47 (24.0) 25 (33.3) 22 (18.2) pT4a 17 (8.7) 10 (13.3) 7 (5.8) Pathological N stage, n (%) pN0 156 (79.6) 58 (77.3) 98 (81.0) 0.71 pN1 20 (10.2) 7 (9.3) 13 (10.7) pN2 16 (8.2) 8 (10.7) 8 (6.6) pN3 4 (2.0) 2 (2.7) 2 (1.7) Major Clavien–Dindo complication absent, n (%) 162 (82.7) 41 (54.7) 121 (100.0) <0.001 Number of lymph nodes removed, median [IQR] 15.5 [10.0, 23.0] 9.0 [6.5, 17.0] 17.0 [14.0, 25.0] <0.001 Surgical margin negative, n (%) 184 (93.9) 63 (84.0) 121 (100.0) <0.001 soft tissue margin negative 187 (95.4) 66 (88.0) 121 (100.0) <0.001 ureter margin negative 192 (98.0) 71 (94.7) 121 (100.0) 0.02 urethra margin negative 195 (99.5) 74 (98.7) 121 (100.0) 0.38 Adjuvant chemotherapy, n (%) 9 (4.6) 3 (4.0) 6 (5.0) 1.00 BMI: body mass index; UC: urothelial carcinoma; NAC: neoadjuvant chemotherapy; IQR: interquartile range *Trifecta not achieved vs Trifecta achieved Table 2. Multivariate analysis for oncological outcomes intrapelvic RFS CSS OS MFS Covariant Reference HR 95% CI p value HR 95% CI p value HR 95% CI p value HR 95% CI p value Age (Continuous) 1.01 0.97-1.05 0.6 1.04 1.01-1.08 0.013 1.05 1.02-1.08 <0.001 1.01 0.98-1.05 0.41 Sex Male Female 0.6 0.28-1.32 0.2 0.72 0.38-1.34 0.3 0.82 0.46-1.45 0.49 0.64 0.32-1.27 0.2 pathological T stage pT≥ 3 ≤pT2 7.47 3.24-17.24 <0.001 2.83 1.54-5.21 <0.001 2.97 1.72-5.13 <0.001 2.2 1.11-4.38 0.024 Pathological N stage pN (+) pN (-) 1.67 0.79-3.53 0.18 2.9 1.57-5.33 <0.001 2.44 1.41-4.22 0.001 3.59 1.82-7.11 <0.001 Trifecta Achievement Non-achievement 0.42 0.21-0.84 0.014 0.56 0.32-0.95 0.032 0.57 0.35-0.91 0.02 0.85 0.46-1.58 0.62 Neoadjuvant chemotherapy Present Absent 0.88 0.45-1.73 0.71 0.88 0.51-1.49 0.63 0.79 0.49-1.26 0.32 0.88 0.49-1.58 0.66 HR: hazard ratio; RFS: recurrence-free survival; CSS: cancer-specific survival; OS: overall survival; MFS: metastatic-free survival Table 3. Multivariate analysis for not achieving Trifecta and each component of Trifecta No Trifecta achievement Incomplete LND Positive surgical margins Grade 3-5 complications Covariant Reference OR 95% CI p value OR 95% CI p value OR 95% CI p value OR 95% CI p value Age, (continuous) 1 0.96-1.04 0.87 1.03 0.98-1.07 0.28 0.99 0.91-1.06 0.7 0.99 0.94-1.04 0.68 BMI, (continuous) 1.03 0.95-1.13 0.45 1.05 0.94-1.16 0.4 1.1 0.92-1.31 0.28 1.01 0.90-1.12 0.93 Sex Male Female 1.29 0.56-2.94 0.55 1.92 0.66-5.53 0.23 0.87 0.17-4.42 0.87 1.54 0.49-4.85 0.46 Clinical stage ≥cT3 or cN(+) ≤cT2 and cN(-) 0.88 0.47-1.66 0.7 1.59 0.76-3.31 0.22 1.89 0.57-6.21 0.29 0.54 0.23-1.29 0.16 Neoadjuvant chemotherapy Present Absent 1.17 0.60-2.28 0.65 0.59 0.27-1.28 0.18 1.89 0.38-9.44 0.44 1.55 0.63-3.82 0.34 Urinary diversion intestinal use Non-intestinal use 0.53 0.20-1.38 0.19 0.44 0.16-1.24 0.12 0.96 0.11-8.41 0.97 0.75 0.22-2.52 0.64 Serum alb (g/dl) <3.8 ≥3.8 2.06 1.11-3.80 0.021 1.67 0.81-3.48 0.17 2.05 0.60-6.98 0.25 1.5 0.69-3.26 0.31 BMI: body mass index; CI: confidence interval; OR: odds ratio; LND: lymph node dissection Supplementary Files R1SupplementaryFigure1.tiff R1SupplementaryFigure2.tiff R1SupplementaryTable1.docx R1SupplementaryTable2.docx R1SupplementaryTable3.docx R1SupplemtntaryTable4.docx Cite Share Download PDF Status: Published Journal Publication published 09 Jul, 2025 Read the published version in International Journal of Clinical Oncology → Version 1 posted Editorial decision: Accept 14 May, 2025 Reviewers agreed at journal 22 Apr, 2025 Reviewers invited by journal 21 Apr, 2025 Editor assigned by journal 19 Apr, 2025 First submitted to journal 18 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5987355\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":445965235,\"identity\":\"1a4cfd39-9fa7-4123-abe4-d386553fd8a4\",\"order_by\":0,\"name\":\"Mahito 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11:13:02\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-5987355/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5987355/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1007/s10147-025-02791-5\",\"type\":\"published\",\"date\":\"2025-07-09T15:57:05+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":81545842,\"identity\":\"b3420bd4-aec5-4c37-a8aa-6dc0d1b1a79c\",\"added_by\":\"auto\",\"created_at\":\"2025-04-28 11:46:33\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":52046,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eTrifecta achievement was associated better (a) Intrapelvic pelvis recurrence-free survival, (b) Cancer specific survival, and (c) overall survival after radical cystectomy, but not (d) metastatic free survival.\\u003c/p\\u003e\\n\\u003cp\\u003eTrifecta was defined as adequate lymphadenectomy 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11:38:33\",\"extension\":\"docx\",\"order_by\":17,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":20235,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"R1SupplementaryTable3.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5987355/v1/1324288f8544d3115f5b0f42.docx\"},{\"id\":81544455,\"identity\":\"1492be43-82da-4245-bdfc-cd5854ed18ec\",\"added_by\":\"auto\",\"created_at\":\"2025-04-28 11:30:33\",\"extension\":\"docx\",\"order_by\":18,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":15791,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"R1SupplemtntaryTable4.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5987355/v1/15ef12b46b24016427055104.docx\"}],\"financialInterests\":\"\",\"formattedTitle\":\"Clinical Utility of a Novel Perioperative Quality Assessment Metric, Trifecta, for Radical Cystectomy\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eRadical cystectomy (RC) is recommended for patients with T2–T4a, N0M0 disease, very high-risk NMIBC, BCG-refractory, BCG-relapsing, and BCG-unresponsive NMIBC, as well as extensive papillary disease that cannot be managed with TURBT and intravesical chemotherapy/immunotherapy alone\\u0026nbsp;\\u003csup\\u003e1\\u003c/sup\\u003e. The peri-operative mortality following RC has been reported as 2.1–3.2% at 30 days and 3.4–8.0% at 90 days.\\u0026nbsp;\\u003csup\\u003e2,3\\u003c/sup\\u003e Therefore, surgeons must strive to provide high-quality surgical care and closely monitor patients for peri-operative changes. Particularly, the quality of surgery would have a significant impact on prognosis and complications.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe history of surgical quality assessment began with the \\\"Pentafecta\\\" proposed by Aziz et al., which comprised a negative surgical margin for soft tissue, adequate lymphadenectomy, and no Clavien-Dindo grade 3-5 complications within 90 days post-radical cystectomy, along with a treatment-free interval following TUR-BT within three months and no local recurrence in the pelvic region within 12 months.\\u003csup\\u003e4\\u003c/sup\\u003e Subsequently, Cacciamani et al. proposed a revised version of the” Pentafecta”, which included Aziz’s original trifecta along with the absence of local pelvic recurrence, distant metastasis, upper tract recurrence at 12 months, and no urinary diversion-related sequelae at 12 months.\\u003csup\\u003e5\\u003c/sup\\u003e A recent validation study has reported that cases achieving the revised “Pentafecta” had improved recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS)\\u0026nbsp;\\u003csup\\u003e6\\u003c/sup\\u003e. However, these composite metrics require a one-year period before assessment. There is a need for a means to evaluate the quality of surgery at an early stage, which can act as a benchmark for guiding future treatment strategies. Additionally, early assessment can facilitate a timely review of surgical practices and contribute to achieving better surgical quality.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThus, we propose a novel quality assessment metric, \\\"Trifecta,\\\" which includes three factors: adequate lymphadenectomy, negative surgical margins, and the absence of significant complications within 30 days post-surgery. This metric allows for the quality of surgery to be assessed within 30 days after RC. In this study, we evaluate the clinical utility of the “Trifecta” model in patients who underwent RC. Additionally, we also investigated the types of patients who might face challenges in achieving Trifecta, emphasizing those who need careful preoperative planning and consideration.\\u003c/p\\u003e\"},{\"header\":\"Patients and Methods\",\"content\":\"\\u003cp\\u003e\\u003cem\\u003ePatient cohort\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis retrospective, single-center study included patients diagnosed with bladder cancer who had RC and lymphadenectomy. The extent of lymphadenectomy was at the surgeon\\u0026apos;s discretion. The type of urinary diversion was determined based on tumor characteristics, the patient\\u0026rsquo;s performance status, and a shared decision-making process between the patient and the attending physician. Data were collected between April 2014, and June 2024. The following patients were excluded: distant metastasis already existed; RC was initiated but couldn\\u0026rsquo;t be completed; and lymphadenectomy wasn\\u0026rsquo;t performed.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eMethod\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe evaluated three components of the \\u0026ldquo;Trifecta\\u0026rdquo; outcomes composite: adequate lymphadenectomy, negative surgical margin, and absence of significant complications within 30 days. Adequate lymphadenectomy was defined as yielding \\u0026ge; 10 lymph nodes. A negative surgical margin was defined as a soft tissue margin, ureter margin, and urethra margin, which were all negative. The absence of major complications was defined as the absence of Clavien\\u0026ndash;Dindo grade 3-5 complications.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn the concept of \\u0026apos;Pentafecta,\\u0026apos; the absence of local recurrence within one year is included as a criterion\\u003csup\\u003e4,5\\u003c/sup\\u003e. However, to facilitate early postoperative treatment planning, we excluded this criterion from the definition of \\u0026apos;Trifecta.\\u0026apos; Therefore, we also evaluated the difference in the incidence of early pelvic recurrence within one year after RC between the group that achieved \\u0026apos;Trifecta\\u0026apos; and the group that did not.\\u003c/p\\u003e\\n\\u003cp\\u003eThe primary endpoint is to assess intrapelvic RFS stratified by trifecta achievement and identify the predictive factor for achieving trifecta. The secondary endpoints are MFS, CSS, and OS, which are stratified by trifecta achievement. Additionally, intrapelvic RFS at one year were assessed. The albumin data was collected at the earliest available time, prior to neoadjuvant chemotherapy (NAC) or RC, whichever came first. Albumin value was categorized as a categorical variable with a cutoff value of 3.8 based on the Youden index (Supplementary Figure 1).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eStatistical analysis\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eContinuous parametric variables are expressed as medians accompanied by interquartile ranges (IQR). Mann-Whitney U tests were utilized to compare the medians of continuous variables, such as age. In contrast, chi-square tests were employed to compare the proportions of categorical variables, including sex, across different groups. \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe durations of intrapelvic RFS, MFS, CSS, and OS from the day of RC were computed using the Kaplan\\u0026ndash;Meier method; log-rank tests were conducted for intrapelvic RFS, MFS, CSS, and OS stratified by the achievement of \\u0026ldquo;Trifecta\\u0026rdquo; outcomes. Additionally, Cox proportional hazards regression analysis was performed, and the independent variables selected for this analysis included age \\u003csup\\u003e7\\u003c/sup\\u003e, sex \\u003csup\\u003e8\\u003c/sup\\u003e, \\u0026ge; pT3 \\u003csup\\u003e9\\u003c/sup\\u003e, \\u0026ge; pN1 \\u003csup\\u003e9\\u003c/sup\\u003e, NAC and trifecta achievement. Furthermore, logistic regression was applied to identify predictive factors associated with achievement of \\u0026ldquo;Trifecta\\u0026rdquo;. The independent variables analyzed in this context included age \\u003csup\\u003e5,6\\u003c/sup\\u003e , sex, body mass index (BMI) \\u003csup\\u003e6\\u003c/sup\\u003e, albumin, urinary diversion \\u003csup\\u003e5,10\\u003c/sup\\u003e, and the administration of NAC \\u003csup\\u003e11\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eAll statistical tests were two-sided, and statistical significance was defined as a p-value of less than 0.05. Statistical analysis was conducted using EZR software, version 1.68 \\u003csup\\u003e12\\u003c/sup\\u003e.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cem\\u003ePatient demographics\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTwo hundred thirty cases were collected; however, we excluded patients: one patient for metastasis at the point of cystectomy, one patient for dissemination, for which cystectomy was not performed, so only urinary diversion was performed, and 32 patients for no lymphadenectomy. Finally, 196 cases were analyzed. The median age was 71.5 years (IQR: 66.0-77.0 years). The median follow-up duration was 31.7 months (range: 10.6-55.0 months). Lymph node dissection was performed in all patients; 30 cases (20.4%) had lymph node involvement. NAC was prescribed for 131 patients (66.8%) prior to radical cystectomy. The clinicopathological characteristics of patients with bladder cancer achieving “Trifecta” and not are shown in Table 1. Of all patients, 61.7% were patients for achieving “Trifecta”. Table 1 also compares the clinicopathological characteristics of patients who were and were not achieving “Trifecta”. The group that achieved \\\"Trifecta\\\" had a median follow-up period of 37.6 months (IQR: 13.6-61.5 months), which was longer compared to 22.9 months (IQR: 6.0-48.1 months) in the group that did not achieve it (P = 0.003). Regarding urinary diversion, there was a trend toward orthotopic neobladder being selected more frequently in the group that achieved “Trifecta” (P = 0.024). No other significant factors outside the components constituting “Trifecta” were identified.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eOncological outcomes\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDuring the follow-up period, we observed 37 cases of intrapelvic recurrence and 48 cases of distant metastasis. A total of 74 patients died, of whom 59 deaths were attributed to bladder cancer. The 3-year intrapelvic RFS, MFS, CSS, and OS rates were 78.1%, 70.1%, 70.7%, and 67.4%, respectively. The Kaplan–Meier curves revealed significantly inferior intrapelvic RFS, CSS, and OS in patients not achieving “Trifecta” (P \\u0026lt; 0.001, P = 0.027, and P = 0.010, respectively) (Fig. 1a-c). In contrast, the MFS did not differ significantly between patients achieving “Trifecta” and those who did not. (Fig. 1d). In the multivariate analysis, “Trifecta” achievement (HR, 0.42; P = 0.014) and ≥ pT3 stage (HR, 7.47; P \\u0026lt; 0.001) were significant for intrapelvic RFS (Table 2). Significant factors for CSS and OS included “Trifecta” achievement (HR, 0.56; P = 0.032, HR, 0.57; P = 0.02, respectively ), ≥ pT3 (HR, 2.83; P \\u0026lt; 0.001, HR, 2.97; P \\u0026lt; 0.001, respectively ), age (HR, 1.04; P = 0.013, HR, 1.05; P \\u0026lt; 0.001, respectively ), and ≥ pN1 stage (HR, 2.90; P \\u0026lt; 0.001, HR 2.44: P = 0.0014, respectively ). Notably, trifecta achievement was not associated with MFS (HR, 0.85; P = 0.62), while ≥ pT3 (HR, 2.2; P = 0.024) and ≥ pN1(HR, 3.59; P \\u0026lt; 0.001) were significant predictors (Table 2).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eNext, to assess the impact of achieving 'Trifecta' on local recurrence within one year after RC, we conducted an analysis including 162 cases: 140 cases with a follow-up period of 12 months or longer and 22 cases with follow-up periods shorter than 12 months but with documented pelvic recurrence within 12 months. The rate of pelvic recurrence within 12 months was compared between the group achieving 'Trifecta' and the group that did not. Notably, among the 'Trifecta' group, the recurrence rate within 12 months was 10.7% (11/103), significantly lower than the 28.8% (17/59) observed in the non-'Trifecta' group (p=0.003) (Supplementary Table 1).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003ePredicting factor for “Trifecta” achievement\\u003c/em\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFrom the analysis so far, it has become evident that “Trifecta” has a significant impact on local recurrence and subsequent prognosis. Therefore, we next examined preoperative factors to identify cases where achieving “Trifecta” may be challenging. In the multivariate analysis examining preoperative factors associated with not achieving “Trifecta,” low albumin (serum Alb \\u0026lt; 3.8 g/dL) was found to be the only significant correlating factor (OR, 2.06; P = 0.021). Furthermore, when we deconstructed the non-achievement of “Trifecta” into its components—incomplete lymphadenectomy, positive surgical margins, and significant complications within 30 days post-surgery—to determine which factor low albumin most strongly correlated with, interestingly, no significant correlation was observed with any individual component (P = 0.17, 0.25, and 0.31, respectively; Table 3).\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eIn this retrospective analysis of patients treated with RC for bladder cancer, we examined the association between “Trifecta” achievement and prognosis and investigated preoperative factors associated with not achieving “Trifecta.” Our study revealed that achieving Trifecta was significantly associated with better intrapelvic RFS, CSS, and OS, but not with MFS. Additionally, we found that patients with low serum albumin levels were less likely to achieve “Trifecta.”\\u003c/p\\u003e\\n\\u003cp\\u003eAziz et al. initially proposed “Pentafecta” as a metric for ensuring surgical quality in RC\\u0026nbsp;\\u003csup\\u003e4\\u003c/sup\\u003e, and later, Cacciamani et al. revised this metric\\u0026nbsp;\\u003csup\\u003e5\\u003c/sup\\u003e. However, since recurrence within 12 months is included as a criterion in these composites, it is not possible to determine whether the surgery met the “Pentafecta” standard until 12 months postoperatively. Furthermore, while early recurrence within 12 months indicates insufficient surgical quality according to Aziz’s and Cacciamani’s “Pentafecta” criteria\\u0026nbsp;\\u003csup\\u003e4,5\\u003c/sup\\u003e, a substantial number of patients with bladder cancer tend to recur early. This means that even if the surgery itself was performed successfully, these patients cannot achieve the “Pentafecta.” In this context, our “Trifecta” metric has novelty, as it does not exclude early recurrence and can be assessed within just 30 days post-surgery. Actually, achieving 'Trifecta' resulted in approximately 90% of cases without intrapelvic recurrence within one year following RC. This finding suggests that our definition of 'Trifecta' serves as a reasonable and effective metric for assessing the quality of surgical outcomes. Additionally, our study showed that achieving “Trifecta” led to favorable intrapelvic RFS, even after adjusting for confounding factors in multivariate analysis.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003ePrevious studies have also used “Pentafecta” to assess its potential as a prognostic predictor and demonstrated improved oncological outcomes\\u0026nbsp;\\u003csup\\u003e6,13\\u003c/sup\\u003e. However, careful interpretation of these results is necessary because patients with early recurrences were categorized as not achieving “Pentafecta,” which may impact the overall assessment. In this regard, we believe that our “Trifecta” provides a relatively fair evaluation of prognosis. Interestingly, in our analysis, achieving “Trifecta” was still significantly associated with prolonged intrapelvic RFS but did not lead to an extension in MFS. This result can be understood when considering that cases with systemic metastasis likely had micrometastases already present at surgery. If dormant metastatic cells that existed preoperatively become reactivated post-surgery, it would explain why MFS was not extended regardless of surgical quality. Additionally, the association between achieving “Trifecta” and extended CSS and OS indicates that high-quality surgery can indeed contribute to improved prognosis.\\u003c/p\\u003e\\n\\u003cp\\u003eThe only predicting factor for not achieving “Trifecta” was low serum albumin levels. Hypoalbuminemia is known to reflect inflammatory and nutritional states, which can interfere with appropriate responses to treatments such as surgery and chemotherapy, potentially hindering therapeutic efficacy\\u0026nbsp;\\u003csup\\u003e14\\u003c/sup\\u003e. Previous studies have demonstrated that hypoalbuminemia increases the incidence of postoperative complications following RC in patients with bladder cancer\\u0026nbsp;\\u003csup\\u003e15,16\\u003c/sup\\u003e. In the present study, we define the “Trifecta” as achieving adequate lymphadenectomy (≥10 nodes), negative surgical margins, and absence of Clavien-Dindo grade 3-5 complications within 30 days post-surgery. Notably, the rates of positive surgical margins and the number of lymph nodes removed are largely influenced by the surgeon’s skill and the tumor's location and stage, limiting direct evidence linking hypoalbuminemia with these outcomes. Conversely, an association between hypoalbuminemia and Clavien-Dindo grade 3-5 complications within 30 days post-surgery may be more readily explained. Interestingly, our findings did not reveal a significant correlation between hypoalbuminemia and any each component of the “Trifecta.” This underscores the importance of recognizing the “Trifecta” as an integrated measure for assessing surgical quality rather than evaluating its components in isolation. While previous reports have indicated that low albumin levels are associated with oncological outcomes following RC\\u003csup\\u003e17\\u003c/sup\\u003e, our study is the first to consider the potential impact of hypoalbuminemia on the quality of surgery provided. Reflecting on why hypoalbuminemia may hinder the achievement of the “Trifecta,” it might be plausible that the underlying condition represented by hypoalbuminemia contributes to tissue fragility, potentially impairing precise recognition and dissection of membrane structures during surgery. Moving forward, studies with larger sample sizes are warranted, and additional research should be conducted further to investigate the tissue characteristics of patients with hypoalbuminemia.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOur study has several limitations. Firstly, the sample size is relatively small, which may impact the generalizability of the findings. Additionally, the study design is retrospective, which may introduce inherent biases. Since the study period includes the era when treatments such as pembrolizumab and enfortumab vedotin became available, these therapies might have influenced CSS and OS. Furthermore, this study is based on data from a single institution, which may limit the generalizability of the findings. A multi-center research could help validate these results across diverse healthcare settings. Finally, as a retrospective study, there may be incomplete data or missing records, which could affect the comprehensiveness of our analysis.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eIn this study, we proposed “Trifecta” as a metric for assessing the quality of RC and examined its impact on postoperative outcomes. Our findings indicated that while achieving “Trifecta” did not extend MFS, it was associated with extended pelvic RFS, CSS, and OS, confirming its utility as an indicator for evaluating the success of optimal curative treatment. Additionally, the correlation between low serum albumin and failure to achieve “Trifecta” suggests that recognizing such cases preoperatively is meaningful for providing optimal perioperative treatment centered around RC.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cbr\\u003e\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors express their gratitude for the expert English language editing provided by\\u0026nbsp;Textcheck Inc.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflicts of Interest\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that there is no conflict of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData Availability Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe data supporting the findings of this study are available upon reasonable request from the corresponding author.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics Approval\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe institutional review board approved the study protocol 36-005(12104).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStudy Registration\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAnimal Studies\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Alfred Witjes J, Max Bruins H, Carri\\u0026oacute;n A, et al. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2023 Guidelines. Eur Urol. 2024;85(1):17-31. doi:10.1016/j.eururo.2023.08.016\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Mossanen M, Krasnow RE, Zlatev DV, et al. Examining the relationship between complications and perioperative mortality following radical cystectomy: a population-based analysis. BJU Int. 2019;124(1):40-46. doi:10.1111/bju.14636\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Bochner BH, Dalbagni G, Sjoberg DD, et al. Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial. Eur Urol. 2015;67(6):1042-1050. doi:10.1016/j.eururo.2014.11.043\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Aziz A, Gierth M, Rink M, et al. Optimizing outcome reporting after radical cystectomy for organ-confined urothelial carcinoma of the bladder using oncological trifecta and pentafecta. World J Urol. 2015;33(12):1945-1950. doi:10.1007/s00345-015-1572-x\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Cacciamani GE, Winter M, Medina LG, et al. Radical cystectomy pentafecta: a proposal for standardisation of outcomes reporting following robot-assisted radical cystectomy. BJU Int. 2020;125(1):64-72. doi:10.1111/bju.14861\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Laymon M, Mosbah A, Hashem A, et al. Predictors and survival benefit of achieving pentafecta in a contemporary series of open radical cystectomy. Minerva Urol Nephrol. 2022;74(4):428-436. doi:10.23736/S2724-6051.21.04230-0\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Fairey AS, Kassouf W, Aprikian AG, et al. Age \\u0026ge; 80 years is independently associated with survival outcomes after radical cystectomy: results from the Canadian Bladder Cancer Network Database. Urol Oncol. 2012;30(6):825-832. doi:10.1016/j.urolonc.2011.07.014\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Uhlig A, Seif Amir Hosseini A, Simon J, et al. Gender Specific Differences in Disease-Free, Cancer Specific and Overall Survival after Radical Cystectomy for Bladder Cancer: A Systematic Review and Meta-Analysis. J Urol. 2018;200(1):48-60. doi:10.1016/j.juro.2017.11.150\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Hara S, Miyake H, Fujisawa M, et al. Prognostic variables in patients who have undergone radical cystectomy for transitional cell carcinoma of the bladder. Jpn J Clin Oncol. 2001;31(8):399-402. doi:10.1093/jjco/hye086\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Zapała Ł, Ślusarczyk A, Korczak B, et al. The View Outside of the Box: Reporting Outcomes Following Radical Cystectomy Using Pentafecta From a Multicenter Retrospective Analysis. Front Oncol. 2022;12:841852. doi:10.3389/fonc.2022.841852\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Petrelli F, Coinu A, Cabiddu M, Ghilardi M, Vavassori I, Barni S. Correlation of pathologic complete response with survival after neoadjuvant chemotherapy in bladder cancer treated with cystectomy: a meta-analysis. Eur Urol. 2014;65(2):350-357. doi:10.1016/j.eururo.2013.06.049\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Kanda Y. Investigation of the freely available easy-to-use software \\u0026ldquo;EZR\\u0026rdquo; for medical statistics. Bone Marrow Transplant. 2013;48(3):452-458. doi:10.1038/bmt.2012.244\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Piazza P, Bravi CA, Puliatti S, et al. Assessing pentafecta achievement after robot-assisted radical cystectomy and its association with surgical experience: Results from a high-volume institution. Urol Oncol. 2022;40(6):272.e11-272.e20. doi:10.1016/j.urolonc.2022.01.001\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Soeters PB, Wolfe RR, Shenkin A. Hypoalbuminemia: Pathogenesis and Clinical Significance. JPEN J Parenter Enteral Nutr. 2019;43(2):181-193. doi:10.1002/jpen.1451\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Ornaghi PI, Afferi L, Antonelli A, et al. The impact of preoperative nutritional status on post-surgical complication and mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review of the literature. World J Urol. 2021;39(4):1045-1081. doi:10.1007/s00345-020-03291-z\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Li J, Cheng Y, Liu G, Ji Z. The association of pretreatment serum albumin with outcomes in bladder cancer: a meta-analysis. Onco Targets Ther. 2018;11:3449-3459. doi:10.2147/OTT.S162066\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003cli\\u003e\\u003cstrong\\u003e Arora K, Hanson KT, Habermann EB, Tollefson MK, Psutka SP. Early Complications and Mortality following Radical Cystectomy: Associations with Malnutrition and Obesity. Bladder Cancer. 2018;4(4):377-388. doi:10.3233/BLC-180173\\u003c/strong\\u003e\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eTable 1. Patient characteristics\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eVariable\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTotal, n=196\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTrifecta not achieved\\u0026nbsp;\\u003cbr\\u003e\\u0026nbsp;(n=75)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTrifecta achieved\\u0026nbsp;\\u003cbr\\u003e\\u0026nbsp;(n=121)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eP value*\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAge, year [IQR]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e71.5 [66.0, 77.0]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e72.00 [67.0, 77.0]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e71.0 [66.0, 76.0]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.69\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eFollow-up, month [IQR]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e31.7 [10.6, 55.0]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e22.9 [6.0, 48.1]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e37.6 [13.6, 61.5]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.003\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSex, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; female\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e33 (16.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e11 (14.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e22 (18.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.56\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; male\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e163 (83.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e64 (85.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e99 (81.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eBMI, kg/m\\u003csup\\u003e2\\u003c/sup\\u003e [IQR]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e21.3 [19.4, 23.8]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e21.4 [20.1, 24.0]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e21.1 [19.1, 23.6]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.36\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; unknown\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e5 (2.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e0 (0.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e5 (4.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eECOG.PS (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp; 0\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e177 (90.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e70 (93.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e107 (88.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.325\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp; 1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e19 (9.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e5 (6.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e14 (11.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDiabetes (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e54 (27.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e16 (21.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e38 (31.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.141\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAlb, g/dl [IQR]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e3.8 [3.5, 4.1]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e3.8 [3.5, 4.0]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e3.9 [3.6, 4.1]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.062\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCreatinine, mg/dl [IQR]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e0.97 [0.82, 1.21]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e1.02 [0.83, 1.25]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e0.95 [0.81, 1.19]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.27\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eClinical T stage (pre-NAC), n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; Tis, Ta, T1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e39 (19.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e17 (22.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e22 (18.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; T2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e97 (49.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e35 (46.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e62 (51.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; T3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e38 (19.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e12 (16.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e26 (21.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; T4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e22 (11.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e11 (14.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e11 (9.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eClinical N stage (pre-NAC), n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; N0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e171 (87.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e64 (85.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e107 (88.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.54\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; N1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e16 (8.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e6 (8.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e10 (8.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; N2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e6 (3.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e4 (5.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e2 (1.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; N3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e3 (1.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e1 (1.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e2 (1.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNeoadjuvant chemotherapy, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e131 (66.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e52 (69.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e79 (65.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.78\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSurgical approach, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; open\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e9 (4.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e3 (4.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e6 (5.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.51\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; laparoscopic\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e153 (78.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e56 (74.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e97 (80.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; robot-assisted\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e34 (17.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e16 (21.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e18 (14.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eUrinary diversion, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.024\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; ileal conduit\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e121 (61.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e50 (66.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e71 (58.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; orthotopic neobladder\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e54 (27.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e14 (18.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e40 (33.1)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; ureterostomy\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e18 (9.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e8 (10.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e10 (8.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; none\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e3 (1.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e3 (4.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e0 (0.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eVariant Histology, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; present\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e17 (8.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e7 (9.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e10 (8.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.064\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePathological T stage, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; pT0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e33 (16.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e9 (12.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e24 (19.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.038\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; pTis, pTa, pT1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e70 (35.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e25 (33.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e48 (39.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; pT2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e29 (14.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e9 (12.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e20 (16.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; pT3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e47 (24.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e25 (33.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e22 (18.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; pT4a\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e17 (8.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e10 (13.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e7 (5.8)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePathological N stage, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; pN0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e156 (79.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e58 (77.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e98 (81.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.71\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; pN1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e20 (10.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e7 (9.3)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e13 (10.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; pN2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e16 (8.2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e8 (10.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e8 (6.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; pN3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e4 (2.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e2 (2.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e2 (1.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMajor Clavien\\u0026ndash;Dindo complication absent, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e162 (82.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e41 (54.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e121 (100.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNumber of lymph nodes removed, median [IQR]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e15.5 [10.0, 23.0]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e9.0 [6.5, 17.0]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e17.0 [14.0, 25.0]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSurgical margin negative, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e184 (93.9)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e63 (84.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e121 (100.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; soft tissue margin negative\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e187 (95.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e66 (88.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e121 (100.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; ureter margin negative\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e192 (98.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e71 (94.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e121 (100.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.02\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; urethra margin negative\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e195 (99.5)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e74 (98.7)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e121 (100.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e0.38\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 35.2488%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAdjuvant chemotherapy, n (%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 13.6679%;\\\"\\u003e\\n \\u003cp\\u003e9 (4.6)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 16.6652%;\\\"\\u003e\\n \\u003cp\\u003e3 (4.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 14.627%;\\\"\\u003e\\n \\u003cp\\u003e6 (5.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 6.9538%;\\\"\\u003e\\n \\u003cp\\u003e1.00\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\" valign=\\\"top\\\" style=\\\"width: 89.3209%;\\\"\\u003e\\n \\u003cp\\u003eBMI: body mass index; UC: urothelial carcinoma; NAC: neoadjuvant chemotherapy; IQR: interquartile range\\u003cbr\\u003e\\u0026nbsp;*Trifecta not achieved vs Trifecta achieved\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2. Multivariate analysis for oncological outcomes\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"1021\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 7.6997%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 6.4275%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 8.7709%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eintrapelvic RFS\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 8.637%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCSS\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 8.5031%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOS\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 8.5701%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMFS\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 7.6997%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCovariant\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 6.4275%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eReference\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.2764%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eHR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.879%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e95% CI\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.3434%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eHR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.6781%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e95% CI\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.2764%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eHR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.6781%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e95% CI\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.2764%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eHR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.6781%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e95% CI\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 7.6997%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAge (Continuous)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 6.4275%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.2764%;\\\"\\u003e\\n \\u003cp\\u003e1.01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.879%;\\\"\\u003e\\n \\u003cp\\u003e0.97-1.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e0.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.3434%;\\\"\\u003e\\n \\u003cp\\u003e1.04\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.6781%;\\\"\\u003e\\n \\u003cp\\u003e1.01-1.08\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e0.013\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.2764%;\\\"\\u003e\\n \\u003cp\\u003e1.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.6781%;\\\"\\u003e\\n \\u003cp\\u003e1.02-1.08\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.2764%;\\\"\\u003e\\n \\u003cp\\u003e1.01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.6781%;\\\"\\u003e\\n \\u003cp\\u003e0.98-1.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e0.41\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 7.6997%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSex\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 6.4275%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.2764%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.879%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 3.6155%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.3434%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.6781%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 3.6155%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd 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3.6155%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.3434%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.6781%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 3.6155%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.2764%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.6781%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 3.6155%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.2764%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.6781%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 3.6155%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 7.6997%;\\\"\\u003e\\n \\u003cp\\u003ePresent\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 6.4275%;\\\"\\u003e\\n \\u003cp\\u003eAbsent\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.2764%;\\\"\\u003e\\n \\u003cp\\u003e0.88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.879%;\\\"\\u003e\\n \\u003cp\\u003e0.45-1.73\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e0.71\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.3434%;\\\"\\u003e\\n \\u003cp\\u003e0.88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.6781%;\\\"\\u003e\\n \\u003cp\\u003e0.51-1.49\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e0.63\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.2764%;\\\"\\u003e\\n \\u003cp\\u003e0.79\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.6781%;\\\"\\u003e\\n \\u003cp\\u003e0.49-1.26\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e0.32\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.2764%;\\\"\\u003e\\n \\u003cp\\u003e0.88\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.6781%;\\\"\\u003e\\n \\u003cp\\u003e0.49-1.58\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.6155%;\\\"\\u003e\\n \\u003cp\\u003e0.66\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"14\\\" valign=\\\"bottom\\\" style=\\\"width: 49.8804%;\\\"\\u003e\\n \\u003cp\\u003eHR: hazard ratio; RFS: recurrence-free survival; CSS: cancer-specific survival; OS: overall survival; MFS: metastatic-free survival\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 3. Multivariate analysis for not achieving Trifecta and each component of Trifecta\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"1023\\\" style=\\\"margin-right: calc(0%); width: 100%;\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 8.4864%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 5.9191%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 8.629%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNo Trifecta achievement\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 8.629%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eIncomplete LND\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 8.629%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ePositive surgical margins\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"3\\\" style=\\\"width: 11.7668%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eGrade 3-5 complications\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 8.4864%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCovariant\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 5.9191%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eReference\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e95% CI\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e95% CI\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e95% CI\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2804%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOR\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 4.1362%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e95% CI\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.3502%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 8.4864%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAge, (continuous)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 5.9191%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.96-1.04\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.87\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e1.03\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.98-1.07\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e0.99\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.91-1.06\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2804%;\\\"\\u003e\\n \\u003cp\\u003e0.99\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.1362%;\\\"\\u003e\\n \\u003cp\\u003e0.94-1.04\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.3502%;\\\"\\u003e\\n \\u003cp\\u003e0.68\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 8.4864%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eBMI, (continuous)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 5.9191%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e1.03\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.95-1.13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e1.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.94-1.16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e1.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.92-1.31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.28\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2804%;\\\"\\u003e\\n \\u003cp\\u003e1.01\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.1362%;\\\"\\u003e\\n \\u003cp\\u003e0.90-1.12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.3502%;\\\"\\u003e\\n \\u003cp\\u003e0.93\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 8.4864%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSex\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 5.9191%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2804%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.1362%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.3502%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 8.4864%;\\\"\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 5.9191%;\\\"\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e1.29\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.56-2.94\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.55\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e1.92\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.66-5.53\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e0.87\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.17-4.42\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.87\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2804%;\\\"\\u003e\\n \\u003cp\\u003e1.54\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.1362%;\\\"\\u003e\\n \\u003cp\\u003e0.49-4.85\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.3502%;\\\"\\u003e\\n \\u003cp\\u003e0.46\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd style=\\\"width: 8.4864%;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eClinical stage\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 5.9191%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2804%;\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd 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\\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.496%;\\\"\\u003e\\n \\u003cp\\u003e2.05\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 2.9239%;\\\"\\u003e\\n \\u003cp\\u003e0.60-6.98\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2091%;\\\"\\u003e\\n \\u003cp\\u003e0.25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 3.2804%;\\\"\\u003e\\n \\u003cp\\u003e1.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.1362%;\\\"\\u003e\\n \\u003cp\\u003e0.69-3.26\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd style=\\\"width: 4.3502%;\\\"\\u003e\\n \\u003cp\\u003e0.31\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eBMI: body mass index; CI: confidence interval; OR: odds ratio; LND: lymph node dissection\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"international-journal-of-clinical-oncology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ijco\",\"sideBox\":\"Learn more about [International Journal of Clinical Oncology](http://link.springer.com/journal/10147)\",\"snPcode\":\"10147\",\"submissionUrl\":\"https://www.editorialmanager.com/ijco/default2.aspx\",\"title\":\"International Journal of Clinical Oncology\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"bladder carcinoma, trifecta, Radical cystectomy\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5987355/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5987355/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground:\\u003c/strong\\u003e Assessing the quality of surgical procedures is crucial for improving outcomes in radical cystectomy (RC). While the “Pentafecta” metric has been used, its reliance on the absence of local recurrence within 1 year delays postoperative assessment. For timely clinical decision-making, a new metric that facilitates earlier evaluation is needed. We propose such a metric, named Trifecta. We evaluated its impact on prognosis and identified predictors for achieving it.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e The Trifecta metric was defined as meeting three criteria: adequate lymphadenectomy (≥10 nodes), negative surgical margins, and absence of Clavien-Dindo grade 3–5 complications within 30 days after surgery. This retrospective study analyzed data from patients who underwent RC and lymphadenectomy between April 2014 and June 2024. Kaplan-Meier analysis was used to assess oncological outcomes, including intrapelvic recurrence-free survival (RFS), metastatic-free survival (MFS), cancer-specific survival (CSS), and overall survival (OS). Cox proportional hazards models were used to examine the association between Trifecta and these outcomes, while logistic regression was used to identify predictors for failing to achieve Trifecta.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e Of the 196 patients included, 121 (61.7%) achieved Trifecta and this was significantly associated with improved intrapelvic RFS, CSS, and OS but not MFS. Low serum levels of albumin were identified as a significant predictor for not achieving Trifecta.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion:\\u003c/strong\\u003e Achieving Trifecta was associated with improved survival outcomes, and low serum levels of albumin predicted a higher likelihood of failure to achieve it. The Trifecta metric enables early and clinically relevant evaluation of surgical quality, offering a practical alternative to traditional metrics.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Clinical Utility of a Novel Perioperative Quality Assessment Metric, Trifecta, for Radical Cystectomy\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-04-28 11:30:28\",\"doi\":\"10.21203/rs.3.rs-5987355/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Accept\",\"date\":\"2025-05-15T03:30:28+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2025-04-22T21:30:17+00:00\",\"index\":0,\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-04-21T23:27:24+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-04-19T05:30:52+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"International Journal of Clinical Oncology\",\"date\":\"2025-04-18T20:27:08+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"international-journal-of-clinical-oncology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ijco\",\"sideBox\":\"Learn more about [International Journal of Clinical Oncology](http://link.springer.com/journal/10147)\",\"snPcode\":\"10147\",\"submissionUrl\":\"https://www.editorialmanager.com/ijco/default2.aspx\",\"title\":\"International Journal of Clinical Oncology\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"019e4247-e647-494a-b4c5-082eed67b1e5\",\"owner\":[],\"postedDate\":\"April 28th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-07-14T15:59:24+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-5987355\",\"link\":\"https://doi.org/10.1007/s10147-025-02791-5\",\"journal\":{\"identity\":\"international-journal-of-clinical-oncology\",\"isVorOnly\":false,\"title\":\"International Journal of Clinical Oncology\"},\"publishedOn\":\"2025-07-09 15:57:05\",\"publishedOnDateReadable\":\"July 9th, 2025\"},\"versionCreatedAt\":\"2025-04-28 11:30:28\",\"video\":\"\",\"vorDoi\":\"10.1007/s10147-025-02791-5\",\"vorDoiUrl\":\"https://doi.org/10.1007/s10147-025-02791-5\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5987355\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5987355\",\"identity\":\"rs-5987355\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}