A Simplified Frailty Index to Predict Outcomes After Radical Cystectomy

Maximizing efficiency and ensuring safety: Exploring the outcomes of 2 consecutive open radical cystectomies by the same team within a single surgical day

BACKGROUND

The purpose of this study was to evaluate the outcomes of performing 2 consecutive open radical cystectomies (RCs) within 1 day by the same surgical team.

PATIENTS AND METHODS

A retrospective analysis was conducted on data from patients who underwent RC at a single tertiary care center from January 2015 to February 2023. Patient characteristics, perioperative outcomes and endpoints were analyzed. Univariable and multivariable logistic regression models were created to predict major complications.

RESULTS

A total of 657 patients were included in the final cohort, containing 64 paired RCs (32 RC1 and 32 RC2) and 593 single RCs. Major complications occurred in 24.7% of the entire cohort, with no significant differences between single RC vs. RC1 and RC2. Paired RCs showed significantly shorter operative time (OT; p = 0.001) and length of stay (LOS; p = 0.047) compared to single RCs. There were no significant differences in transfusion rates, 30-day readmission, 30-day mortality, or histopathological results between paired and single RCs. Multivariable analysis identified patient characteristics such as age (OR = 1.67, p = 0.03), sex (OR = 0.45, p = 0.008), BMI (OR = 1.98, p = 0.007), ASA-score (OR = 1.61, p = 0.04), and OT (OR = 1.87, p = 0.008) as independent predictors of major complications.

CONCLUSION

Performing 2 consecutive open RCs within 1 day by the same surgical team is a safe approach in experienced hands. This strategy optimizes the utilization of surgical resources and addresses the growing demand for urologic care while maintaining high-quality patient care. Preoperative planning should consider patient-specific factors to minimize risks associated with major complications.

MICRO ABSTRACT

This study evaluates the outcomes of performing 2 consecutive open radical cystectomies (RC) in a single day by the same surgical team. Data from 657 patients who underwent RC at a single tertiary medical center proved that this approach is safe, with no significant differences in major complications. Preoperative planning should consider patient-specific factors for efficient utilization of surgical resources.

Transurethral Resection of Bladder Tumor Outcomes Are Predicted by a 5-Item Frailty Index

OBJECTIVE

To evaluate the mFI-5 as a predictor of postoperative outcomes following transurethral resection of bladder tumor (TURBT).

METHODS

The National Surgical Quality Improvement Program database was queried for TURBT cases from 2015-2019. mFI-5 scores were calculated by assigning a point to chronic obstructive pulmonary disease, congestive heart failure, dependent functional status, hypertension, and diabetes. Patients were stratified by mFI-5 scores. Demographics and 30-day outcomes including Clavien-Dindo (CD) complications, mortality, and increased healthcare resource utilization (HCRU) were compared. HCRU outcomes included prolonged length of stay, unplanned readmission, and discharge to continued care. Multivariate regression assessed the predictive value of mFI-5 scores on outcomes.

RESULTS

40,278 TURBT cases were identified (mFI-5 =0: 12,400, mFI-5 =1: 17,328, mFI-5 =2: 9225, mFI-5 ≥3: 1416). Patients with higher mFI-5 scores were more likely to be older, male, White, and have larger tumors, all P < .05. Increasing mFI-5 scores resulted in increased frequency of all adverse outcomes, all P < .001. On multivariate analysis, mFI-5 ≥ 3 classification was a predictor of CD I/II (OR=1.280), CD IV (OR=2.539), mortality (OR=2.202), HCRU (OR=2.094), prolonged length of stay (OR=2.136), discharge to continued care (OR=3.401), and unplanned readmission (OR=1.705), all P < .05. A mFI-5 ≥ 3 demonstrated a sensitivity ranging from 6.0%-13.5% and a specificity ranging from 96.6%-97.0% for all outcomes.

CONCLUSION

The mFI-5 is an easily ascertainable preoperative risk assessment tool that is a predictor of adverse clinical and HCRU outcomes following TURBT.

Preoperative Frailty Scores Predict the Early Postoperative Complications of Holmium Laser Enucleation of Prostate

Background: Frailty is a recent multidimensional concept of a contemporary growing interest for understanding the complex health status of elderly population. We aimed to assess the impact of frailty scores on the outcome and complication rate of holmium laser enucleation of prostate (HoLEP). Methods: A 7-year data of HoLEP patients in a single tertiary referral center were reviewed. The preoperative, operative, early, and late postoperative outcome data were collected and compared according to the preoperative frailty scores. Frailty was assessed preoperatively using the Modified Hopkins frailty score. Results: The study included 837 patients categorized into two groups: group I included 533 nonfrail patients (frailty score = 0), whereas group II included 304 frail patients (frailty score ≥1). The median (interquartile range) age was 70 (11) and 75 (11) years for groups I and II, respectively (<0.001). The 30-day perioperative complication rate (p = 0.005), blood transfusion (p = 0.013), failed voiding trial (p = 0.0015), and 30-day postoperative readmission (p = 0.0363) rates were significantly higher in frail patients of group II. The two groups were statistically comparable regarding postoperative international prostate symptom score (p = 0.6886, 0.6308, 0.9781), incontinence rate (p = 0.475, 0.592, 0.1546), postvoid residual (p = 0.5801, 0.1819, 0.593) at 6 weeks and 3 months, and 1-year follow-up intervals, respectively. Conclusion: In elderly patients undergoing HoLEP, the preoperative frailty scores strongly correlate with the risk of perioperative complications. Frail patients should be counseled regarding their relative higher risk of early perioperative complications although they gain the same functional profit of HoLEP as nonfrail patients.

A simplified frailty index and nomogram to predict the postoperative complications and survival in older patients with upper urinary tract urothelial carcinoma

Purpose

This study was designed to investigate the clinical value of a simplified five-item frailty index (sFI) for predicting short- and long-term outcomes in older patients with upper urinary tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU).

Method

This retrospective study included 333 patients (aged ≥65 years) with UTUC. Patients were classified into five groups: 0, 1, 2, 3, and 3+, according to sFI score. The variable importance and minimum depth methods were used to screen for significant variables, and univariable and multivariable logistic regression models applied to investigated the relationships between significant variables and postoperative complications. Survival differences between groups were analyzed using Kaplan-Meier plots and log-rank tests. Cox proportional hazards regression was used to evaluate risk factors associated with overall survival (OS) and cancer-specific survival (CSS). Further, we developed a nomogram based on clinicopathological features and the sFI. The area under the curve (AUC), Harrel's concordance index (C-index), calibration curve, and decision curve analysis (DCA) were used to evaluate the nomogram.

Result

Of 333 cases identified, 31.2% experienced a Clavien-Dindo grade of 2 or greater complication. Random forest-logistic regression modeling showed that sFI significantly influenced the incidence of postoperative complications in older patients (AUC= 0.756). Compared with patients with low sFI score, those with high sFI scores had significantly lower OS and CSS (p < 0.001). Across all patients, the random survival forest-Cox regression model revealed that sFI score was an independent prognostic factor for OS and CSS, with AUC values of 0.815 and 0.823 for predicting 3-year OS and CSS, respectively. The nomogram developed was clinically valuable and had good ability to discriminate abilities for high-risk patients. Further, we developed a survival risk classification system that divided all patients into high-, moderate-, and low-risk groups based on total nomogram points for each patient.

Conclusion

A simple five-item frailty index may be considered a prognostic factor for the prognosis and postoperative complications of UTUC following RNU. By using this predictive model, clinicians may increase their accuracy in predicting complications and prognosis and improve preoperative decision-making.

The 5-factor frailty index for radical nephrectomy: Simplifying personalized preoperative risk-stratification

Radical nephrectomy is the gold standard treatment for large renal cell carcinoma. Given the rising incidence of renal cell carcinoma and higher prevalence of geriatric patients in the population, readily identifying patients preoperatively that are at risk for a more complicated postoperative course is critical. The 5-factor modified frailty index (5-IFi) is a scoring system that assigns 1 point for each of the following comorbidities: dependent functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients with higher 5-IFi scores have been shown to be at significant risk for increased postoperative morbidity and mortality in many cohorts, including patients that undergo radical nephrectomy. This simplified comorbidity index with only 5 components is much more clinically pragmatic than its predecessors. As we encounter an increasing volume of patients with renal cell carcinoma and geriatric surgical candidates, readily risk stratifying patients on a personalized basis may be informative for shared clinical and surgical-decision making.

Relationship between lower urinary tract symptoms and frailty

OBJECTIVE

To elucidate the relationship between frailty and lower urinary tract symptoms (LUTS).

METHODS

We longitudinally evaluated the temporal changes and the relationships between frailty and LUTS in 247 community-dwelling adults (45 years or older) at baseline and at a 5-year follow-up. We used the Fried phenotype (phenotype-based frailty), 5-item modified frailty index (5i-mFI; comorbidity-based frailty), and frailty discriminant score (comprehensive frailty assessment) to evaluate frailty. LUTS were evaluated using the international prostate symptom score (IPSS) and overactive bladder symptom score (OABSS).

RESULTS

We analyzed 247 participants with a median age of 60 years. The median IPSS and OABSS were significantly increased over the 5 years. The proportion of frail individuals did not increase significantly over the 5 years. Of the three frailty assessment tools, the 5i-mFI score significantly increased between 2014 and 2019. Multiple linear regression analyses showed that the 5i-mFI score was significantly associated with the severity of LUTS in 2014 to 5i-mFI in 2019 but not with 5i-mFI in 2014 to the severity of LUTS in 2019.

CONCLUSION

The effect of LUTS on frailty might be greater than the effect of frailty on LUTS. Further large-scale studies are needed to elucidate the relationship between LUTS and frailty.

The 5-item frailty index predicts 30-day morbidity and mortality in radical nephrectomy patients: A propensity matched analysis

PURPOSE

To assess the ability of the 5-item frailty index (5-IFi) score to predict 30-day morbidity and mortality post-radical nephrectomy (RN).

METHODS

ACS-NSQIP database was used to select patients who underwent RN from 2011 to 2020. 5-IFi score was calculated by assigning a point for each of the following comorbidities: chronic obstructive pulmonary disease or pneumonia, congestive heart failure, dependent functional status, hypertension, and diabetes. Patients were divided into 3 frailty groups 0, 1, and ≥2. Patient demographics, medical comorbidities, prolonged length of stay, and prolonged operative time were compared between different groups; mortality and morbidity using the Clavien-Dindo classification (CVD). Multivariable logistic regression models and propensity score matching were performed as a sensitivity analysis to control for possible confounders.

RESULTS

Cohort consisted of 36,682 patients whereby 5-IFi class 0, 1, and ≥2 included 11,564 (31.5%), 16,571 (45.2%), and 8,547 (25.3%) patients respectively. A multivariable analysis and propensity score matching revealed that patients with 5-IFi classes 1 and ≥ 2 were more likely to have a prolonged length of stay (OR = 1.11, 1.3, respectively) and to mortality (OR = 1.85 for frailty class ≥2); in addition to CVD class 1 & 2 (OR = 1.51, OR = 1.13, respectively), and CVD ≥ 4 (OR = 1.41, 1.86, respectively) as compared to 5-IFi class 0 (P < 0.001).

CONCLUSION

The 5-IFi score was found to be an independent predictor of prolonged length of stay, morbidity, and mortality after RN. This tool can play a major role in preoperative risk assessment and patient counseling based on individualized risks.

Preoperative predictors of prolonged length of stay in radical cystectomy: a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Program Dataset

Background

Radical cystectomy (RC) is considered a complex procedure that entails significant morbidity and mortality.

Objectives

We aimed to determine pre-operative patient characteristics that help predict a prolonged length of hospital stay (PLOS) following RC.

Design and Methods

The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to select patients who underwent RC between the years 2011 and 2020. Prolonged length of stay was defined as a hospital stay ⩾9 days. We compared patient demographics, pre-operative labs, surgical characteristics, and medical history between patients with or without PLOS. Multivariable logistic regression models controlling for pre-operative characteristics and propensity score matching for post-operative complications were conducted to control for possible confounders.

Results

The analysis yielded details of 19,158 RC patients of which 6007 (31%) patients had a PLOS. Patients with PLOS were more likely to have post-operative complications that could serve as predictors for the PLOS rather than their pre-operative characteristics. Hence, we matched our cohort for these complications. After matching, patient pre-operative characteristics that predict PLOS included female gender (Odds Ratio (OR) = 5.91), 10-year increase in age (OR = 1.15), non-White race (OR = 1.98), partially or totally dependent functional health status (OR = 2.86), bleeding disorders (OR = 4.67), congestive heart failure (OR = 1.59), pre-operative transfusion (OR = 3.03), and a 20-min increase in operative time (OR = 1.01) (p < 0.046).

Conclusion

Patient demographics and pre-operative factors can help predict PLOS in RC patients. These predictors could serve as tools for patient counseling and risk stratification.

Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).

Bladder cancer, inflammageing and microbiomes

Ageing is correlated with elevated bladder cancer incidence, morbidity and mortality. Advanced age is also associated with elevated markers of chronic inflammation and perturbations in gut and urinary tract microbiota. One reason for the increased incidence and mortality of bladder cancer in the elderly might be that age-associated changes in multiple microbiomes induce systemic metabolic changes that contribute to immune dysregulation with potentially tumorigenic effects. The gut and urinary microbiomes could be dysregulated in bladder cancer, although the effect of these changes is poorly understood. Each of these domains - the immune system, gut microbiome and urinary microbiome - might also influence the response of patients with bladder cancer to treatment. Improved understanding of age-related alterations to the immune system and gut and urinary microbiomes could provide possible insight into the risk of bladder cancer development and progression in the elderly. In patients with bladder cancer, improved understanding of microbiota might also provide potential targets for therapeutic intervention.

Updates on enhanced recovery after surgery for radical cystectomy

Enhanced Recovery after Surgery (ERAS) is a multimodal pathway that provides evidence-based guidance for improving perioperative care and outcomes in patients undergoing surgery. In 2013, the ERAS society released its original guidelines for radical cystectomy (RC) for bladder cancer (BC), adopting much of its supporting data from colorectal literature. In the last decade, growing interest in ERAS has increased RC-specific ERAS research, including prospective randomized controlled trials (RCTs). Collective data suggest ERAS contributes to improved complication rates, decreased hospital length-of-stay, and/or time to bowel recovery. Various institutions have adopted modified versions of the ERAS pathway, yet there remains a lack of consensus on the efficacy of specific ERAS items and standardization of the protocol. In this review, we summarize updated evidence and practice patterns of ERAS pathways for RC since the introduction of the original 2013 guidelines. Novel target interventions, including use of immunonutrition, prehabilitation, alvimopan, and methods of local analgesia are reviewed. Finally, we discuss barriers to implementing and future steps in advancing the ERAS movement.

Adrenalectomy outcomes predicted by a 5-item frailty index (5-iFI) in the ACS-NSQIP database

BACKGROUND

Frailty has been shown to be a predictor of adverse postoperative outcomes. This study aims to evaluate a 5-item frailty index (5-iFI) as a predictor of complications as well as healthcare resource utilization (HCRU) following adrenalectomy.

METHODS

All adrenalectomy cases recorded in the ACS-NSQIP database from 2015 to 2018 were analyzed. Primary outcomes of interest were Clavien-Dindo [CD] I/II or CD IV complications and HCRU. HCRU outcomes were prolonged length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmission (UR).

RESULTS

4358 patients were included. Higher 5-iFI scores were associated with higher rates of CDI/II, CDIV, and increased HCRU (p < 0.05). On multivariate analysis, 5-iFI scores were found to be independent predictors of adverse clinical and HCRU outcomes.

CONCLUSIONS

Frailty tools like the 5i-FI can be useful in preoperative risk-benefit analysis, patient counseling, and planning prehabilitation interventions.

Frailty as a Predictor of Adverse Outcomes After Peripheral Vascular Surgery in Patients With End-Stage Renal Disease

BACKGROUND

Frailty and end-stage renal disease (ESRD) are each independently associated with adverse outcomes in patients who undergo lower extremity vascular bypass operations (LEOs). It is not known whether frailty imparts additional risk to patients with ESRD having LEO.

METHODS

The study was a retrospective cohort study of 29 203 patients without ESRD and 1718 with ESRD who had LEO surgery between the years 2014 and 2018 extracted from the American College of Surgeons National Surgical Quality Improvement Program database. Preoperative frailty was assessed using a simplified frailty index based on a history of diabetes, heart failure, chronic obstructive pulmonary disease, hypertension, and functional status. Adverse outcomes measured were 30-day mortality, surgical complications, reoperation, length of stay, readmission, discharge destination, and any ("composite") adverse outcome. Odds ratios (ORs) for adverse outcomes were calculated with logistic regression.

RESULTS

Among patients with ESRD, the OR for having the composite adverse outcome was greater for frailty than for any of the other preoperative risk factors studied (OR 2.191, CI 1.569-3.061, P < .001). Adverse outcomes occurred in 84.3% of frail patients with ESRD, but in only 39.6% of the non-frail patients without ESRD.

CONCLUSIONS

Frailty imparts additional risk for adverse outcomes to patients with ESRD undergoing LEO.

5-Item Modified Frailty Index as a Preoperative Predictor of Morbidity Following Minimally Invasive Partial Nephrectomy

OBJECTIVE

To apply the modified frailty index-5 (mFI-5) to those patients undergoing minimally invasive partial nephrectomy (MIPN) to examine the relationship between frailty and postoperative outcomes.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, data were retrospectively reviewed between 2012 and 2018 for cases coded for MIPN. The mFI-5 score was defined on a scale of 1 to 5, with each patient receiving one point per each of the following comorbidities: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes mellitus, hypertension that requires medication and functional health status of partial or total dependence prior to surgery. Complications were examined within the first 30 days postoperatively. Using univariate and multivariate logistic regression, postoperative outcomes were obtained and stratified based on frailty score.

RESULTS

Of the 18,904 cases identified between 2012 and 2018, mFI-5 score was 0 for 38.0% of patients, 1 for 42.8%, ≥2 for 19.2%. With increasing mFI-5 score, a significant increase in multiple postoperative morbidities were identified (P <0.05). 11.2% of patients with mFI-5 ≥2 had complications vs 5.3% with mFI-5 of 0 and 7.8% mFI-5 of 1, P <0.05. Multivariate analysis revealed nearly 50% increase in the odds of having an overall complication for patients with mFI-5 score ≥2 (OR = 1.48, 95% CI 1.22 - 1.80, P <0.001).

CONCLUSION

The mFI-5 is a well defined and easily ascertainable predictor of postoperative outcomes in those undergoing MIPN and could be used preoperatively to identify and counsel those at increased risk for morbidity.

A Systematic Review and Meta-Analysis of Preoperative Frailty Instruments Derived From Electronic Health Data

BACKGROUND

Frailty is a strong predictor of adverse outcomes in the perioperative period. Given the increasing availability of electronic medical data, we performed a systematic review and meta-analysis with primary objectives of describing available frailty instruments applied to electronic data and synthesizing their prognostic value. Our secondary objectives were to assess the construct validity of frailty instruments that have been applied to perioperative electronic data and the feasibility of electronic frailty assessment.

METHODS

Following protocol registration, a peer-reviewed search strategy was applied to Medline, Excerpta Medica dataBASE (EMBASE), Cochrane databases, and the Comprehensive Index to Nursing and Allied Health literature from inception to December 31, 2019. All stages of the review were completed in duplicate. The primary outcome was mortality; secondary outcomes included nonhome discharge, health care costs, and length of stay. Effect estimates adjusted for baseline illness, sex, age, procedure, and urgency were of primary interest; unadjusted and adjusted estimates were pooled using random-effects models where appropriate or narratively synthesized. Risk of bias was assessed.

RESULTS

Ninety studies were included; 83 contributed to the meta-analysis. Frailty was defined using 22 different instruments. In adjusted data, frailty identified from electronic data using any instrument was associated with a 3.57-fold increase in the odds of mortality (95% confidence interval [CI], 2.68-4.75), increased odds of institutional discharge (odds ratio [OR], 2.40; 95% CI, 1.99-2.89), and increased costs (ratio of means, 1.54; 95% CI, 1.46-1.63). Most instruments were not multidimensional, head-to-head comparisons were lacking, and no feasibility data were reported.

CONCLUSIONS

Frailty status derived from electronic data provides prognostic value as it is associated with adverse outcomes, even after adjustment for typical risk factors. However, future research is required to evaluate multidimensional instruments and their head-to-head performance and to assess their feasibility and clinical impact.

Relationship of frailty with treatment modality selection in patients with muscle-invasive bladder cancer (FRART-BC study)

Background

We aimed to investigate the association of frailty with treatment selection in patients with muscle-invasive bladder cancer (MIBC) as frailty is one of the key factors for modality selection.

Methods

We retrospectively evaluated frailty in 169 patients with MIBC from January 2014 to September 2020 using the Fried phenotype, modified frailty index, and frailty discriminant score. The primary purpose was comparing the frailty between the patients who underwent radical cystectomy (RC) with those who had trimodal therapy (TMT) for bladder preservation. Secondary purposes were comparing the frailty between the groups and the effect of TMT on overall survival adjusting the frailty by multivariate Cox proportional hazards analysis using inverse probability of treatment weighting (IPTW)-adjusted model.

Results

Of 169 patients, 96 and 73 were classified into the RC and the TMT groups, respectively. The median age of the TMT group was significantly higher than that of the RC group (80 vs. 69 years). Frailty levels and prevalence in the Fried phenotype, modified frailty index, and frailty discriminant score were significantly higher in the TMT group than those in the RC group. Logistic regression analysis showed that frailty was significantly associated with the TMT selection. Overall survival was significantly shorter in the TMT group by the IPTW-adjusted Cox regression analysis (hazard ratio 2.48, P=0.043).

Conclusions

Frailty was significantly different between the RC and TMT in patients with MIBC and might be one of the key factors for treatment selection.

The Potential of Prehabilitation in Radical Cystectomy Pathways: Where Are We Now?

OBJECTIVE

The growing recognition of prehabilitation has caused an emerging paradigm shift in surgical cancer care and an integrated component of the cancer care continuum. This narrative review aims to update and inform the urological community of the potential of prehabilitation before radical cystectomy.

DATA SOURCES

A nonsystematic narrative review was performed through a database search in PubMed, and CINAHL using the following search terms: enhanced recovery after surgery (ERAS); Frailty; Prehabilitation and/or Rehabilitation; Physical Activity and/or exercises; Nutrition; Nutritional Care; Smoking cessation; Alcohol cessation; Prevention; Supportive Care; and combined with Radical Cystectomy.

CONCLUSION

A multimodal and multi-professional approach during the preoperative period may offer an opportunity to preserve or enhance physiological integrity and optimize surgical recovery. Studies indicate a positive effect of prehabilitation on postoperative functional capacity and earlier return to daily activities and health related quality of life. Meaningful outcomes that reflect recovery from a patient's perspective and clinical outcome measures, as well as validating metrics, are necessary to establish whether prehabilitation diminish the risk of developing long-term disability in high-risk patients.

IMPLICATIONS FOR NURSING PRACTICE

Uro-oncology nurses are at the forefront in every ERAS program and vital in screening patients ahead of surgery for common risk factors, current impairments, and limitations that can compromise baseline functional capacity. The growing movement to standardize clinical implementation of prehabilitation, indicate there is a clear need for further investigation, optimization of a multimodal approach and an open discussion between health care providers from different areas of expertise who might best support and promote these initiatives.

Oncologic and patient-reported outcomes after robot-assisted radical prostatectomy in men aged ≥75 years

OBJECTIVE

The present study aimed to evaluate oncologic outcomes, patient-reported outcomes (PROs), and frailty in older adult patients aged ≥75 years who underwent robot-assisted radical prostatectomy (RARP).

MATERIALS AND METHODS

This retrospective study reviewed the medical records of 752 patients who underwent RARP from July 2011 to May 2020. The PROs were evaluated by Expanded Prostate Cancer Index Composite questionnaire at baseline and 1 year after RARP. Patients were divided into 3 groups according to age at RARP: <70, 70-74, and ≥75 years. Oncologic outcomes and PROs were compared between the ≥75 and 70-74 years groups and between the ≥75 and <70 years groups.

RESULTS

Median follow up was 47 months. Of the 752 patients, 469, 216, and 74 were classified into the <70, 70-74, and ≥75 years groups, respectively. No significant differences were observed in the biochemical recurrence-free survival, cancer-specific survival, and overall survival among the groups. No significant differences were observed in the PROs and pad-free rates at baseline and 1 year after RARP among the groups. The full satisfaction (Expanded Prostate Cancer Index Composite score = 100) at 12 months after RARP was significantly higher in the ≥75 years group (27%) than in the <70 years group (15%, P = 0.045).

CONCLUSION

The oncologic outcomes and PROs in select patients with prostate cancer aged ≥75 years were feasible and acceptable with RARP.

Implementation of frailty preoperative assessment to predict outcome in patients undergoing urological surgery: a systematic review and meta-analysis

BACKGROUND

A common limit of the widely used risk scores for preoperative assessment is the lack of information about aspects linked to frailty that may affect outcome, especially in the setting of elderly patients undergoing urological surgery. Frailty has recently been introduced as an additional characteristic to be assessed for better identifying patients at risk of negative outcomes.

OBJECTIVE

To examine the evidence for recent advances in preoperative assessment in patients undergoing urological surgery focussing on the detrimental effect of frailty on outcome, including major (mPCs) and total postoperative complications (tPCs), discharge to a facility, and mortality. The secondary aim was to establish which cut-off scores of the modified Frailty Index (mFI, 11 items) and/or simplified FI (sFI, five items) predicted PCs.

METHODS

We searched PubMed, the Excerpta Medica database (EMBASE), Cochrane Library and clinicaltrial.gov from inception to 31 May 2020. Studies reporting relationships between the investigated outcomes and patients' frailty were included. We estimated odds ratios (ORs) through a random effect model by using Revman 5.4.

RESULTS

Frailty, assessed by different tools, was associated with a significantly higher rate of 30-day (OR 1.73, 95% confidence interval [CI] 1.58-1.89) and 90-day (OR 2.09, 95% CI 1.14-3.82) mPCs and 30-day tPCs (OR 2.10, 95% CI 1.76-2.52). A mFI of ≥2 was associated with a higher rate of 30-day mPCs (OR 1.79, 95% CI 1.69-1.89) and greater 30-day mortality (OR 3.46, 95% CI 2.10-5.49). A pre-planned post hoc analysis also revealed that a sFI of ≥3 was predictive of mPCs (OR 3.30, 95% CI 2.12-5.12).

CONCLUSIONS

Frailty assessment may help to predict PCs and mortality in patients undergoing major urological surgery. Either a mFi of ≥2 or sFI of ≥3 should be considered potential 'red flags' for preoperative risk assessment and decision-making. There is not enough evidence to confirm the necessity to perform frailty assessment in minor urological surgery.

Predicting morbidity and mortality after radical cystectomy using risk calculators: A comprehensive review of the literature

INTRODUCTION

Radical cystectomy (RC) with urinary diversion is associated with significant perioperative morbidity and mortality, varying between 30% and 70% and between 0.3% and 10.6%, respectively. Risk calculators have been extensively studied in the general surgery literature to predict 30- and 90-day postoperative morbidity and mortality but have not been widely accepted in the RC literature.

MATERIALS AND METHODS

We performed a search of MEDLINE and Embase databases during May 2020 to identify all relevant studies using the following keywords: radical cystectomy, surgical complication predictive model, surgical complication predictive equation, surgical complication predictive nomogram, surgical risk calculator, morbidity, and mortality. We determined the existing surgical predictive nomograms, calculators, and indices and their accuracy in predicting morbidity, mortality, and major complications after RC.

RESULTS

National Surgical Quality Improvement Program had poor accuracy at predicting 30-day morbidity at mortality (AUC 0.5-0.6). LACE index showed good discrimination at predicting 90-day mortality (AUC 0.7). The various frailty and sarcopenia indices have shown poor to fair accuracy at predicting (AUC 0.5-0.7). The Isbarn and Aziz nomograms have equivalent accuracy at predicting 90-day mortality (AUC 0.7) but are limited by inclusion of tumor histology and presence of metastatic disease as variables. POSSUM and P-POSSUM have poor ability at predicting morbidity and mortality (AUC 0.5) and are cumbersome calculators. The surgical Apgar score has been able to predict 30-day morbidity and mortality but can only be used in the postoperative setting.

DISCUSSION

The currently available surgical risk calculators have either poor accuracy at predicting post-RC morbidity and mortality or are limited by types of variables included. An ideal risk calculator would be comprised of preoperative factors only and have a high accuracy to serve as a tool for preoperative patient counseling prior to surgery.

CONCLUSION

There exists a strong need to develop a comprehensive and accurate preoperative risk calculator that predicts morbidity and mortality after RC.

Frailty impact on postoperative complications and early mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review

Objective: To assess the prevalence of frailty, a status of vulnerability to stressors leading to adverse health events, in bladder cancer patients undergoing radical cystectomy (RC), and test the impact of frailty measurements on postoperative adverse outcomes.

Methods: A systematic review of English-language articles published up to April 2020 was performed. Electronic databases were searched to quantify the frailty prevalence in RC patients and assess the predictive ability of frailty indexes on RC-related outcomes as postoperative complications, early mortality, hospitalization length (LOS), costs, discharge dispositions, readmission rate.

Results: Eleven studies were selected. Patients’ frailty was identified by Johns Hopkins indicator (JHI) in two studies, 11-item modified Frailty Index (mFI) in four, 5-item simplified FI (sFI) in three, 15-point mFI in one, Fried Frailty Criteria in one. Considering all the frailty measurements applied, 8% and 31% of patients were frail or pre-frail, respectively. Frail (43%) and pre-frail patients (35%) were more at risk of major complications compared to non-frail (27%) using sFI; with JHI the percentages of frail and non-frail were 53% versus 19%. According to JHI and mFI frailty was related to longer LOS and higher costs. JHI identified that 3% of frail patients experience in-hospital mortality versus 1.5% of non-frail. Finally, using sFI, frail (28%), and pre-frail (19%) were more likely to be discharged non-home compared to non-frail patients (8%) and had a higher risk of 30-day mortality (4% and 2% versus 1%).

Conclusions: Almost half of RC patients were frail or pre-frail, conditions significantly related to an increased risk of postoperative adverse events with higher rates of major complications and early mortality. The most-used frailty index was mFI, while JHI and sFI resulted the most reliable to predict early postoperative RC-related adverse outcomes and should be routinely included in clinical practice after better standardization throughout prospective comparative studies.

Abbreviations: ACG: Adjusted Clinical Groups; ACS: American College Surgeons; AUC: area under the curve; BCa: bladder cancer; CCI: Charlson Comorbidity Index; CSHA-FI: Canadian Study of Health and Aging Frailty Index; CCS: Clavien-Dindo Classification Score; ERAS: Enhanced Recovery After Surgery; FFC: Fried Frailty Criteria; (e)(m)(s)FI: (extended) (modified) (simplified) Frailty Index; ICU: intensive care unit; IQR: interquartile range; (p)LOS: (prolonged) length of hospital stay; NSQIP: National Surgical Quality Improvement Program; OR: odds ratio; (O)PN: (open) partial nephrectomy; PRISMA: Preferred Reporting Items for Systematic reviews and Meta-Analyses; (O)(RA)RC: (open)(robot-assisted) radical cystectomy; (O)RN: (open) radical nephrectomy; ROC: receiver operating characteristic; RNU: radical nephroureterectomy; (R)RP: (retropubic) radical prostatectomy; RR: relative risk; THCs: total hospital charges; nephrectomy; UD: urinary diversion

Perioperative considerations in nonagenarians

OBJECTIVE

The nation's aging population presents novel perioperative challenges. Potential benefits of operative interventions must be scrutinized in relation to recoverable quality of life. The purpose of this study is to evaluate common risk calculators used for medical decision making in a nonagenarian patient population.

METHODS

Retrospective medical record review was performed on patients 90 years or older who underwent operative interventions requiring anesthesia at a large academic medical center between January 1, 2013, and December 31, 2017. GraphPad 8.2.1 was used for statistical analysis.

RESULTS

Significant differences were found when data were stratified by age for elective versus emergent cases (P value < .0001), ability to return to baseline function (P value  = .0062), and mortality (P value < .0001). Significant differences were found in emergent and elective cases, ability to return to baseline function, readmissions, and mortality (all P values < .0001) when stratified by American Society of Anesthesiologists score. Ability of patients to return to baseline functionality after intervention was influenced by their preintervention level of functionality (P value = .0008). American College of Surgeons and Portsmouth Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity risk calculators underestimated the need for rehabilitation and overestimated mortality for this population (all P values < .0001).

CONCLUSION

Perioperative cares of the extreme geriatric population are complex and should be approached collaboratively. Rehabilitation and postoperative assistance resources should be assessed and used fully. Input from palliative care teams should be sought appropriately. End-of-life and escalation-of-care discussions should ideally be organized prior to emergent interventions. Frailty and risk calculators should be used and considered for formal implementation into the preoperative workflow.

Frailty assessment and postoperative complications in urologic oncology operations

Major urologic oncology procedures such as radical cystectomy (RC), radical prostatectomy (RP), radical nephroureterectomy (RNU) and radical or partial nephrectomy are the gold standard operations for the treatment of urological malignancies not suitable to be dealt with using minimal invasive procedures such as transurethral resection or other conservative approaches. However, these surgical procedures carry significant risk of complications, especially in elderly and frail patients. The purpose of this review is to highlight the use of a wide variety of preoperative frailty and health status indexes and calculators. Recent data from large population based studies confirm that these calculators can assist physicians and urologists to predict the postoperative morbidity of patients undergoing major operations. Moreover, these frailty calculators can help urologists choose the most suitable and safe treatment for every individual patient. However, the absence of widely accepted specific urologic oncology calculators to predict the association between frailty and postoperative complications emphasizes the necessity for the use of a combination of calculators.

Robtic-assisted radical cystectomy: Literature review

Radical cystectomy (RC) with pelvic lymph node dissection (PLND) is the standard treatment for localized muscle-invasive bladder cancer (MIBC) and non-muscle-invasive bladder cancer (NMIBC) with recurrence or high risk of progression. Also, the robotic approach to this type of surgery is well established in the literature. Our objective is to summarize in this manuscript the most relevant articles related to the robotic-assisted radical cystectomy for prostate cancer. We performed a literature review of articles describing the robotic approach to RC in patients with bladder cancer. Also, we described the procedure since the patient selection until the bladder removal. The reconstructive techniques were not included in this review. Twenty-five articles were used to divide our manuscript into key points such as preoperative patient selection and protocols, surgical technique, pathology report, oncological outcomes, complication rates, and quality of life after the procedure. Robotic-assisted radical cystectomy is feasible and safe with satisfactory oncological outcomes. The robotic approach is related to lower blood loss and fewer transfusion rates. However, when compared to open surgery, the use of this technology increases the operative time.

Frailty is significantly associated with the type of urinary diversion in patients with muscle-invasive bladder cancer

OBJECTIVES

To investigate the effect of frailty on the type of urinary diversion after radical cystectomy in patients with muscle-invasive bladder cancer.

METHODS

Between January 2014 and January 2020, we prospectively evaluated frailty in 88 patients with localized muscle-invasive bladder cancer, who had received radical cystectomy and urinary diversion. The selection of the type of urinary diversion was determined by the operating surgeon based on performance status, comorbidities, tumor status and the patient's preference. The frailty evaluation included the Fried phenotype criteria, the modified frailty index and the frailty discriminant score. We investigated the association between frailty and type of urinary diversion, the effect of frailty on postoperative complications and the effect of frailty on overall survival.

RESULTS

The median age of the selected participants was 68 years. The number of patients with an orthotopic neobladder and any postoperative complications was 54 (61%) and 46 (52%), respectively. Of the frailty assessment tools that were used, Fried phenotype criteria and frailty discriminant score were significantly associated with the selection of non-orthotopic neobladder urinary diversion. Occurrences of postoperative complications in participants were significantly associated with modified frailty index, but not with Fried phenotype criteria and frailty discriminant score. Multivariate Cox regression analysis showed that a higher frailty discriminant score was significantly associated with poor overall survival, whereas higher Fried phenotype criteria and modified frailty index were not.

CONCLUSION

Frailty is significantly associated with the type of urinary diversion, and it should be considered for the selection of urinary diversion in muscle-invasive bladder cancer patients undergoing radical cystectomy.

Frailty is a predictor of moderate to severe pain after robot‐assisted laparoscopic prostatectomy: A case‐control study (FRAP study)

Objective

To investigate the association of pain with frailty in patients with localized prostate cancer (PC) who underwent robot‐assisted laparoscopic radical prostatectomy (RARP).

Materials and Methods

Between January 2017 and June 2019, we prospectively evaluated the geriatric 8 (G8) score, simplified frailty index (sFI), and numerical rating scale (NRS) of 154 patients with localized PC who underwent RARP at our institution. NRS was measured on preoperative day 0, postoperative days 1, 2, 3, and at discharge. Moderate to severe pain was defined as NRS ≥ 5, whereas frailty was defined as G8 ≤ 14. The primary objectives of this study were to investigate the effects of moderate to severe pain (NRS ≥ 5) on frailty, postoperative complications, and the use of analgesics after RARP. Our secondary objectives were the effect of frailty on postoperative complications and the use of analgesics.

Results

The median age of participants was 69 years. Of 154 patients, 37 (24%) and 61 (40%) were classified to have NRS ≥ 5 and G8 ≤ 14, respectively. Patients with NRS > 5 presented significantly association with G8 < 14, whereas they did not show the association with sFI, complication, or analgesics. Multivariate logistic regression analysis showed that G8 ≤ 14 was significantly associated with NRS ≥ 5. Frailty was not significantly associated with postoperative complications and analgesics.

Conclusions

Frailty was significantly associated with moderate to severe pain after RARP, and might be a potential predictor of postoperative pain. Frail patients require individual care to avoid painful experiences.

Frailty assessment in older urological patients prior to surgery: a systematic review and narrative synthesis

Background:

Radical cystectomy (RC) and urinary diversion are the recommended treatment for patients with muscle invasive bladder cancer. This is complex surgery, associated with significant patient morbidity and mortality. Frailty has been shown to be an independent risk factor for adverse outcomes in several surgical populations. Preoperative assessment of frailty is advocated in current guidelines but is not yet standard clinical practice.

Aims:

This systematic review and narrative synthesis aims to examine whether patients undergoing RC are assessed for frailty, what tools are used, and whether an association is found between frailty and adverse outcomes in this population.

Results:

Nine studies, published within the last 4 years, describe the use of tools reporting to measure frailty in the RC population. All demonstrate increased risk of adverse postoperative outcomes with higher frailty levels. Only one study used a validated frailty tool. The majority of studies measure frailty using variations on a tool derived from a large database (ACS-NSQIP) effectively counting co-morbidities, rather than assessing the multidomain nature of the frailty syndrome.

Conclusion:

The recognition of frailty as an important consideration in the perioperative period is welcome. This systematic review and narrative synthesis demonstrates the need for collaboration in research and delivery of clinical care for older surgical patients. Such collaboration may provide clarity regarding terms such as frailty and multimorbidity, preventing the development of assessment tools inaccurately measuring these discreet syndromes interchangeably. More accurate assessment of patients in terms of frailty, multimorbidity and functional status may allow better modification and shared decision making leading to improved postoperative outcomes in older patients undergoing RC.

The Usefulness of the Modified Frailty Index for Muscle-Invasive Bladder Cancer Patients Treated with Radical Cystectomy

Background

Radical cystectomy is still the gold standard for muscle-invasive bladder carcinoma (MIBC) treatment. In order to reduce postoperative complications, multimodality bladder-sparing therapies could be a good alternative. Studies in various malignancies have shown that the modified Frailty Index (mFI) may be more useful for identifying high-risk patients.

Objectives

We investigated the possible correlation between the mFI in cystectomy patients with MIBC and serious complications 30 and 90 days postoperatively.

Methods

Analysis of a prospective database of 109 consecutive MIBC patients who underwent a cystectomy between January 2012 and August 2017 was performed. The mFI was added retrospectively. Differences between groups were tested with independent t-tests, Mann-Whitney U tests, ANOVA, Kruskal-Wallis test, or Chi square tests as appropriate. Univariate and multivariate logistic regression analysis were performed to analyse the relation between the mFI and complications.

Results

Patients with Clavien-Dindo ≥ 3 at 30 and 90 days postoperatively had a significantly higher mFI compared to patients with Clavien-Dindo < 3: the odds ratio of the mFI for serious complications within 30 days was 1.5 (95% confidence interval 1.1-2.1, p = 0.010) and for 90 days was 1.5 (95% confidence interval 1.1-2.1, p = 0.008).

Conclusions

We found an association between a high mFI and postoperative complications and mortality. The mFI is therefore useful when discussing treatment options with MIBC patients.

Risk stratification metrics for bladder cancer: Comprehensive Geriatric Assessments

Despite advances in surgical technique and perioperative care pathways, complication rates following radical cystectomy for bladder cancer remain high and perioperative outcomes for elderly patients are suboptimal. Furthermore, subjective risk assessments of patients with bladder cancer, with a high prevalence of complex comorbidity burden and risk of frailty, may result in undertreatment of patients assumed to be poor operative candidates. A critical component of preoperative patient counseling and treatment selection is accurate and objective preoperative risk appraisal. Comprehensive Geriatric Assessments are multi-domain evaluations of the medical, functional, and psychosocial aspects of health designed specifically for use in elderly patients with the objective of identifying vulnerabilities that may be targeted with interventions for improvement. While currently recommended by multiple guideline bodies for use in the preoperative evaluation of elderly patients with bladder cancer there is a paucity of data describing their use in contemporary clinical practice. Herein, then, we will describe the components of a Comprehensive Geriatric Assessments and propose strategies for their integration into the preoperative surgical workflow.

Anesthetic considerations for urologic surgeries

Urologic surgeries are widely performed, and the cases have increased owing to the fact that the elderly population is growing. The narrow and limited surgical space is a challenge in performing most urologic surgeries. Additionally, the elderly population is exposed to the risk of perioperative complications; therefore, a comprehensive understanding and approach are required to provide optimized anesthesia during surgery. We have searched the literature on anesthesia for urologic surgeries and summarized the anesthetic considerations for urologic surgeries.

Orthotopic Neobladder Reconstruction: Patient Selection And Perspectives

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure that may be performed in a patient with bladder cancer following a radical cystectomy. The selection of a patient for an ONB reconstruction is strict as not everyone may be suitable to undergo this complex surgery. Patients must be not only mentally competent but also physically dexterous enough to allow for appropriate neobladder training post-procedure, to achieve best urinary function. However, even with a carefully chosen patient population, various complications specific to ONB reconstruction may result. Metabolic acidosis may result from electrolyte shifts, resulting in secondary complications such as bone demineralization and urinary calculi. In addition, nutritional deficiencies may result from the use of a transposed intestinal segment for the fashioning of the reservoir. A widely used outcome measure when assessing for ONB reconstruction is continence. With a strict neobladder training regimen, daytime continence may be achieved in roughly 70% of patients post-ONB procedure. This number may increase over the course of several years, although may decrease in up to 20 years of follow-up. Similarly, quality of life (QoL) measures have been widely studied, and current literature suggests slightly better QoL achieved with ONB compared to other urinary diversion procedures. Of note, the tools used to assess continence and QoL vary between studies, limiting the interpretability of the summarized data. Nevertheless, ONB reconstruction is a procedure that is still evolving, with ongoing modifications that can reduce complications and improve patient urinary function.

Multicenter prospective study validating the efficacy of a quantitative assessment tool for frailty in patients with urological cancers

We prospectively validate the efficacy of the frailty discriminant score (FDS) in individuals with urological cancers, as there has been growing importance in evaluating frailty in clinical practice. A prospective, multicenter study was conducted from February 2017 to April 2019. We enrolled 258 patients with urological cancers and 301 community-dwelling participants who were assessed for frailty. Frailty was assessed using FDS that includes ten items, such as physical, mental, and blood biochemical tests. The primary outcome was the non-inferiority (margin 5%) of FDS in discriminating patients with urological cancers from controls (Ctrl). The sensitivity, specificity, and area under the receiver operating characteristic (AUROC) curve for each predictive test were calculated. The secondary endpoints included the prediction of overall survival between patients with urological cancer who have high and low FDS. FDS was significantly higher in patients with urological cancers than that in the Ctrl. The AUROC curves for individuals with non-prostate cancers (such as bladder cancer, upper tract urothelial carcinoma, and renal cell carcinoma; 0.942) and those with prostate cancer (0.943) were within the non-inferior margin. The overall survival values were significantly lower in patients with higher FDS score than in those with lower FDS score. The study met its primary and secondary endpoints. The FDS is a reliable and valid tool for assessing frailty and prognosis in patients with urological cancers.

"A National Study Demonstrating the Need for Improved Frailty Indices for Preoperative Risk Assessment of Common Urologic Procedures"

OBJECTIVE

To compare the associations between frailty indices and postoperative complications among older adults undergoing common urologic procedures. Frailty is known to be strongly associated with poor postoperative complications; however, the optimal way to measure frailty remains unknown.

METHODS

We identified the 20 most common urologic procedures from 2013-2016 in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Frailty was measured using the NSQIP frailty index, simplified frailty index, and Risk Analysis Index. Multivariable logistic regression models were performed with each index and the American Society of Anesthesiologists (ASA) classification system with postoperative complications (any, major, or minor) as the outcomes. Statistical models were compared using the following fit parameters: area under the curve, Akaike information criterion, and Bayesian information criterion.

RESULTS

A total of 158,855 procedures were identified. All frailty indices (NSQIP frailty index, simplified frailty index, and Risk Analysis Index) and ASA were associated with increased odds for any, major, and minor complications (all P values <.001). ASA demonstrated stronger model fit parameters for any, major and minor complications compared to all other indices, with an area under the curve of 0.63, 0.64, and 0.64, respectively (all P values <.001). Adding ASA to each frailty index resulted in slight improvement of model fit parameters (P value <.001).

CONCLUSION

ASA slightly outperforms current frailty indices in predicting postoperative complications among individuals undergoing commonly performed urologic procedures. Our findings highlight the need for improved frailty measures for preoperative risk assessment.

Which comorbidity classification is best suited to identify patients at risk for 90-day and long-term non-bladder cancer mortality after radical cystectomy?

PURPOSE

There is no consensus on the best comorbidity measure in candidates for radical cystectomy. The aim of this study was to identify tool best suited to identify patients at risk for 90-day or premature long-term non-bladder cancer mortality.

METHODS

We studied 1268 patients who underwent radical cystectomy to identify patients at risk for 90-day and later-than-90-day mortality, respectively. Six classifications were investigated as possible predictors of both types of mortality. Multivariable models including age as continuous variable and each classification separately were calculated. A heuristic ranking was based on the evaluation of the hazard ratios, p values, Akaike's information criteria, and concerning the logit models also the areas under the curve.

RESULTS

The median follow-up was 5.7 years. Within 90 days after surgery, the mortality rate was 4.2%. The greatest independent contribution concerning the prediction of 90-day mortality was seen with the American Society of Anesthesiologists (ASA) physical status classification (classes 3-4 versus 1-2: hazard ratio 7.98, 95% confidence interval 3.54-18.01, p < 0.0001). In the longer term, countable diseases (Canadian Cardiovascular Society classification of angina pectoris, conditions contributing the Charlson score) were of greater importance. The results of heuristic ranking were confirmed by multivariate analyses including age and all classifications together.

CONCLUSIONS

Besides to chronological age, clinicians should pay particular attention to the ASA classification to identify patients at risk for 90-day mortality after radical cystectomy, whereas long-term mortality is more determined by countable comorbid diseases.

Frailty as a prognostic indicator in the radical cystectomy population: a review

Radical cystectomy and urinary diversion are the current gold standard of management for patients with muscle-invasive bladder cancer. While it is a common urologic procedure, it is associated with significant patient morbidity and mortality. Complications associated with the operation are often frequent, although minor, and significantly impact functional outcomes as well as patient quality of life. Frailty is emerging as a new preoperative prognostic indicator to help determine which patients are at greatest risk of poor outcomes and postoperative complications after treatment. In this review, we summarize the current known literature analyzing frailty as a significant prognostic risk factor of short-term and long-term outcomes after radical cystectomy and urinary diversion in the treatment of muscle-invasive bladder cancer.

Surgical High-risk Patients With ASA ≥ 3 Undergoing Radical Cystectomy: Morbidity, Mortality, and Predictors for Major Complications in a High-volume Tertiary Center

BACKGROUND

The purpose of this study was to investigate major complications and risk factors for adverse clinical outcome in surgical high-risk (American Society of Anesthesiologists [ASA] 3-4) patients undergoing radical cystectomy (RC) in a high-volume setting.

PATIENTS AND METHODS

A total of 1206 patients underwent RC between 2004 and 2017 in our institution and were included. We assessed complications graded by the Clavien-Dindo-Classification system (CDC) in addition to the 90-day mortality rate and stratified results by the ASA classification. In a multivariate analysis, risk factors for high-grade complications (CDC ≥ 3) were tested. Additionally, outcome parameters were compared between 2004 to 2010 and 2010 to 2017.

RESULTS

Patients with ASA ≥ 3 presented with more locally advanced tumors pT ≥ 3 (52.1% vs. 42.4%; P = .002) and positive lymphatic spread N1 (27.2% vs. 23.5%; P = .001) compared with patients with ASA ≤ 2. High-grade complications were significantly (P < .001) more prevalent in patients with ASA ≥ 3 compared with patients with ASA ≤ 2: CDC3 (14.6% vs. 9.4%), CDC4 (10.2% vs. 5.4%), and CDC5 (2.5% vs. 1.0%). The 90-day mortality rate (7.6% vs. 3.2%; P = .002) and perioperative reinterventions (23.5% vs. 13.1%; P < .001) were elevated in patients with ASA ≥ 3. ASA (odds ratio [OR], 2.701, 95% confidence interval [CI], 1.089-6.703; P = .032), previous abdominal operations (OR, 1.683; 95% CI, 1.188-2.384; P = .003), and body mass index ≥ 30 (OR, 1.533; 95% CI, 1.021-2.304; P = .039) proved to function as independent predictors for major complications. CDC ≥ 3 complications (31.7% vs. 24.3%; P = .029) and 90-day mortality (10.4% vs. 5.6%; P = .018) were significantly lower in the second half of the study period.

CONCLUSIONS

Mortality and morbidity in surgical high-risk patients with ASA 3 to 4 undergoing RC is about twice as high compared with patients with ASA 1 to 2. ASA, previous abdominal operations, and elevated body mass index independently predict adverse clinical outcome in patients with ASA 3 to 4. Our results may help to weigh the surgical risk of RC in multimorbid patients.