Fracture risk rose after radical cystectomy with diversion, especially in women

Design

Nationwide register-based matched cohort

Population

2,908 patients after radical cystectomy with urinary diversion and 13,669 matched population referents, Sweden

Primary outcome

Femoral fracture, any fracture and initiation of bone-specific drug therapy

Effect

Women: any fracture HR 2.06 (95% CI 1.54 to 2.76); men: HR 1.51 (1.22 to 1.88); no increase in bone drug initiation

This nationwide Swedish register study compared 2,908 patients who had radical cystectomy with urinary diversion between 2011 and 2019 with 13,669 matched people from the general population, accounting for competing risks of death.

After cystectomy, women had about twice the risk of femoral fracture (HR 1.97, 95% CI 1.25 to 3.10) and of any fracture (HR 2.06, 1.54 to 2.76). Men had a 51% higher risk of any fracture (HR 1.51, 1.22 to 1.88). Despite this, starting bone-protective drug treatment was no more common than in the comparison group. In a smaller group treated with curative radiotherapy instead, men also had more fractures.

Urinary diversion through bowel can cause metabolic acidosis and malabsorption, which plausibly weaken bone, but the study cannot separate these from the effects of cancer, age and frailty. What it shows clearly is a higher fracture risk that is not being acted on. A bone health check is a simple addition to cystectomy follow-up.

• Assess bone health after radical cystectomy with urinary diversion, particularly in women.
• Check for metabolic acidosis and vitamin B12 and vitamin D status in patients with a bowel-based diversion.
• Consider fracture risk assessment and bone density testing where available.
• Discuss falls prevention, calcium and vitamin D intake, and treatment of osteoporosis when indicated.
• Share fracture risk information with the patient's primary care doctor.

Why it matters

Fracture risk rose after cystectomy, but bone treatment did not, which marks a gap in survivorship care.

Don't overread it

This is an observational registry study; it cannot say whether the diversion, the cancer or patient factors cause the extra fractures.

The statistics, in plain English

A hazard ratio of 2.06 means women after cystectomy had about twice the rate of any fracture compared with similar women in the population. The intervals exclude no effect in both sexes.

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