Clinical utility of a novel perioperative quality assessment metric, trifecta, for radical cystectomy

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.

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 and Cox proportional hazards models were used to assess oncological outcomes, while logistic regression was used to identify predictors for failing to achieve "Trifecta" .

Of the 196 patients included, 121 (61.7%) achieved "Trifecta" and this was significantly associated with improved intrapelvic RFS (HR 0.42; P = 0.014), CSS (HR 0.56; P = 0.032), and OS (HR 0.57; P = 0.020) but not MFS (HR 0.85; P = 0.620). Low serum levels of albumin were significantly associated with "Trifecta" failure (OR 2.06; P = 0.021), but not with survival outcomes.

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.