PURPOSE: To investigate the association of diabetes mellitus and metformin use with metabolic acidosis risk after radical cystectomy (RC) and urinary diversion for bladder cancer. MATERIALS AND METHODS: This retrospective cohort study used TriNetX Research Network data. Patients undergoing RC with continent diversion or ileal conduit for bladder cancer were identified using International Classification of Diseases, 10th Revision (ICD-10) and ICD-10 Procedure Coding System (ICD-10-PCS) codes. The primary outcome was acidosis between 1 month and 3 years postsurgery. Risk ratios (RR) and odds ratios (OR) were calculated based on diabetes and metformin use, stratified by diversion type and chronic kidney disease stage. Propensity score matching balanced potential confounders. RESULTS: We identified 1,986 patients who underwent continent diversion and 11,184 who underwent ileal conduit reconstruction. In matched analyses, diabetes patients had higher acidosis risk (continent diversion: RR 1.87, 95% confidence interval [CI] 1.39-2.51; ileal conduit: RR 1.94, 95% CI 1.66-2.27). The risk was highest for diabetes patients with metformin prescription (continent diversion: RR 2.06, 95% CI 1.63-2.61; ileal conduit: RR 2.13, 95% CI 1.84-2.47). However, among patients with diabetes, metformin use did not significantly affect acidosis rates in most analyses. Continent diversion patients had higher acidosis risk than ileal conduit patients (RR 1.89, 95% CI 1.58-2.26). CONCLUSION: Diabetes significantly increases metabolic acidosis risk after RC with urinary diversion, especially in continent diversion patients. While metformin may contribute to metabolic acidosis risk, its impact appears less significant than that of diabetes. Careful monitoring and appropriate metformin adjustments are crucial in this population.

Department of Oncology The Sidney Kimmel Comprehensive Cancer Center Johns Hopkins University School of Medicine Baltimore MD

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria; Division of Urology Rabin Medical Center Petah Tikva Israel; Faculty of Medicine Tel Aviv University Israel; Institute for Urology and Reproductive Health 1 M Sechenov 1st Moscow State Medical University Moscow Russia

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria; Karl Landsteiner Institute of Urology and Andrology Vienna Austria; Department of Urology Weill Cornell Medical College New York NY; Department of Urology University of Texas Southwestern Dallas TX; Department of Urology 2nd Faculty of Medicine Charles University Prague Czech Republic; Division of Urology Department of Special Surgery Jordan University Hospital The University of Jordan Amman Jordan; Research Center for Evidence Medicine Urology Department Tabriz University of Medical Sciences Tabriz Iran

Department of Urology University Hospital Salzburg Paracelsus Medical University Salzburg Austria; The James Buchanan Brady Urological Institute and Department of Urology Johns Hopkins University School of Medicine Baltimore MD

The James Buchanan Brady Urological Institute and Department of Urology Johns Hopkins University School of Medicine Baltimore MD

The James Buchanan Brady Urological Institute and Department of Urology Johns Hopkins University School of Medicine Baltimore MD; Department of Oncology The Sidney Kimmel Comprehensive Cancer Center Johns Hopkins University School of Medicine Baltimore MD

The James Buchanan Brady Urological Institute and Department of Urology Johns Hopkins University School of Medicine Baltimore MD; Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria

The James Buchanan Brady Urological Institute and Department of Urology Johns Hopkins University School of Medicine Baltimore MD; Johns Hopkins Urologic Oncology at Sibley Memorial Hospital Washington DC

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