Clinical Utility of a Novel Perioperative Quality Assessment Metric, Trifecta, for Radical Cystectomy

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.