A total of 1,883 patients underwent open RC at our institution for oncological reasons. Of them, 123 patients (6.5%) patients died within one month after RC. Thus, 1,750 patients were included in the present analysis. Their median age was 70 years (IQR: 62–76), their median BMI was 26 kg/m2 (IQR: 23–29) and 1,283 (73%) patients were male. A total of 826 (55%) patients were smokers, 1,073 (62%) had hypertension, and 678 (39%) had diabetes. Of them, 1,069 (61%) received an ileal conduit and 650 (37%) an orthotopic ileal neobladder. The operative time of RC was 229 min (IQR: 186–279), the intraoperative blood loss 500 ml (IQR: 300–963), and the median length of hospital stay was 20 days (IQR: 16–24). Of note, 134 (7.7%) patients presented variant histology, 947 (63%) locally advanced bladder cancer (≥ pT3), 358 (27%) positive lymph nodes (pN +) and 224 (15%) positive surgical margins at the time of open RC. The median preoperative and first-day postoperative creatinine values were 1.1 mg/dl (IQR: 0.9–1.3). Despite worse oncological findings in the present cohort, only 515 (29%) patients underwent perioperative (neoadjuvant or adjuvant) chemotherapy within three months from the operation.

Overall, 1,016 (58%) patients experienced at least one perioperative complication during hospital stay. Based on the Clavien-Dindo classification, most complications were grade 1 or 2 (609, 66%). Moreover, 534 (31%) patients required transfusion with a median number of 2 blood units (IQR: 1–3), and 915 (53%) were admitted postoperatively to the intensive or intermediate care unit for a median duration of 2 days (IQR: 2–3). Other common complications included urinary and surgical wound infections, ileus, and cardiopulmonary complications. As expected, patients experiencing perioperative complications were older (p < 0.001), underwent urinary diversion with orthotopic ileal neobladder less frequently (p < 0.001), had worse ASA score (p < 0.001), had more often diabetes (p < 0.001), hypertension (p < 0.001) and heart disease (p < 0.001), whereas their operation lasted longer (p < 0.001) with more blood loss (p < 0.001) and worse histological findings (p < 0.001). Accordingly, patients with perioperative complications presented a statistically significantly worse preoperative and first-day creatinine, CRP, hemoglobin, leucocyte, and thrombocyte values. The baseline characteristics of the whole study cohort based on the occurrence of at least one perioperative complication during hospital stay are available in Table 1.

At a median follow-up of 31 months (IQR: 12–71), 884 (51%) deaths occurred. Of them, 598 (59%) were reported in the group with perioperative complications and 286 (39%) in the group with no perioperative complications (p < 0.001). In the univariate Cox regression analysis, all assessed major perioperative risk factors (except for first-day postoperative leucocyte values) were associated with statistically significant worse long-term survival. Subsequently, the effect of these risk factors on survival was assessed through a multivariable Cox regression analysis.

In the multivariable Cox regression analysis, increased age (HR: 1.03, 95% CI: 1.02 to 1.04, p < 0.001), higher preoperative creatinine values (HR: 1.27, 95% CI: 1.12 to 1.44, p < 0.001), lower preoperative hemoglobin values (HR: 0.93, 95% CI: 0.89 to 0.97, p = 0.002), higher postoperative thrombocyte values (HR: 1.01, 95% CI: 1.01 to 1.02, p = 0.02), Clavien-Dindo 1–2 complications (HR: 1.26, 95% CI: 1.03 to 1.53, p = 0.024), Clavien-Dindo 3–4 complications (HR: 1.55, 95% CI: 1.22 to 1.96, p < 0.001), locally advanced bladder cancer (HR: 1.29, 95% CI: 1.06 to 1.55, p = 0.009), positive lymph nodes (HR: 1.74, 95% CI: 1.45 to 2.11, p < 0.001), perioperative chemotherapy (HR: 1.32, 95% CI: 1.09 to 1.59, p = 0.004) and positive surgical margins (HR: 1.61, 95% CI: 1.29 to 2.01, p < 0.001) displayed a negative effect on long-term survival. On the contrary, patients undergoing neobladder presented better long-term survival compared to ileal conduit (HR: 0.78, 95% CI: 0.64 to 0.95, p = 0.014). The univariate and multivariable Cox regression analysis is presented in Table 2. In patients who required chemotherapy, the administration of chemotherapy was associated with better overall survival in the multivariate analysis (HR: 0.86, 95% CI: 0.71 to 0.95, p = 0.008) compared to omission of chemotherapy.

Given that the median preoperative and first-day creatinine values of the study cohort were 1.1 mg/dl, we evaluated whether patients with increased creatinine values before RC and on the first day after RC presented worse long-term overall survival. Based on the log-rank test and the corresponding Kaplan–Meier curves, impaired preoperative and fist-day postoperative renal function was independently associated with worse overall survival (p < 0.01). The corresponding Kaplan–Meier curves are depicted in Fig. 1.

A Kaplan-Maier curve for overall survival in patients undergoing radical cystectomy based on preoperative renal function. B Kaplan-Maier curve for overall survival in patients undergoing radical cystectomy based on first-day postoperative renal function