Frailty and Greater Health Care Resource Utilization Following Major Urologic Oncology Surgery

Comparison of retroperitoneal laparoscopic radical nephroureterectomy outcomes in elderly patients based on the Geriatric 8 (G8) screening tool

AIM

The Geriatric 8 (G8) screening tool consists of eight questions and is widely used to assess geriatric frailty. This study aimed to compare laparoscopic radical nephroureterectomy outcomes in patients aged >70 years with high and low G8 scores.

MATERIALS AND METHODS

Patients who underwent laparoscopic radical nephroureterectomy at a single center between 2017 and 2022 were included in this study. Patient background and perioperative outcomes were evaluated in two groups: low G8 (<14) and high G8 (≥14). The effects of age and body mass index (BMI) were assessed using logistic regression models adjusted for inverse-probability treatment weighting in the low G8 and high G8, respectively.

RESULTS

In total, 37 cases were categorized as low G8 and 30 cases as high G8. Significant differences in patient background were found in terms of age, BMI, American Society of Anesthesiologists physical status, presence of dementia, and estimated glomerular filtration rate (eGFR). Significant differences in perioperative outcomes were observed in the operative time and number of lymph node dissections. Postoperative delirium and eGFR were significantly higher in the low G8 group. The high G8 group showed significantly higher recurrence-free survival and overall survival rates than the low G8 group. After adjustment using the inverse-probability treatment weighting method, postoperative delirium and eGFR were significantly higher in the low G8 group but there were no significant differences in recurrence-free survival rates, cancer-specific survival, or overall survival.

CONCLUSION

After adjusting for age and BMI, preoperative G8 had a different frequency of postoperative delirium but had no effect on prognosis. Geriatr Gerontol Int 2025; 25: 694-700.

Frailty and malnutrition scores in predicting postoperative complications in minimally invasive prostatectomy for malignancy of the prostate

Prostate cancer (PCa), the second most common cancer in men, is typically diagnosed between ages 65 and 74. When planning radical prostatectomy, patient frailty and nutritional status must be carefully evaluated. This study investigates the association between frailty, malnutritional status, and postprostatectomy complications in PCa patients. We analyzed the ACS-NSQIP prostatectomy series (2019-2022), focusing on minimally invasive procedures, including only malignant neoplasm diagnoses. The modified 5-index frailty (mFI-5) was calculated, where values of 2 or higher indicated frailty. Nutritional risk was assessed using a Nutritional Risk Index (NRI) of ≤ 97.5 and preoperative hypoalbuminemia (≤ 3.5) as indicators of malnutrition. Incomplete records were excluded, and remaining data were analyzed using R 4.3.3. The study included 21,067 patients. Compared to non-frail patients, frail individuals were significantly older and showed higher rates of diabetes, smoking, elevated BMI, and ASA scores > 2 (all p < 0.001). Frail patients also experienced longer hospital stays and operative times (p < 0.001), along with higher rates of renal insufficiency (p = 0.018), urinary infections (p = 0.001), systemic shock (p = 0.003), and overall complications (p = 0.002) compared to non-frail patients. Of the 9,932 patients evaluated for nutritional status, 342 met malnutrition criteria. Those identified by NRI criteria, experienced longer hospital stays and higher rates of myocardial infarction, and those identified by low albumin levels, showed increased length of stay (p = 0.044), major complications (p = 0.013), and rates of return to the operating room (p = 0.005), when compared to the normal cohort. Frailty and malnutrition are independent risk factors for postoperative complication in minimally invasive prostatectomy, highlighting the need for preoperative optimization.

Frailty and Long-Term Health Care Utilization After Elective General and Vascular Surgery

Importance

Surgical quality improvement efforts have largely focused on 30-day outcomes, such as readmissions and complications. Surgery may have a sustained impact on the health and quality of life of patients considered frail, yet data are lacking on the long-term health care utilization of patients with frailty following surgery.

Objective

To examine the independent association of preoperative frailty on long-term health care utilization (up to 24 months) following surgery.

Design, Setting, and Participants

This retrospective, observational cohort study included patients undergoing elective general and vascular surgery performed in the Veterans Affairs (VA) Surgical Quality Improvement Program with study entry from October 1, 2013, to September 30, 2018. Patients were followed up for 24 months. Patients with nursing home visits prior to surgery, emergent cases, and in-hospital deaths were excluded. Data analysis was conducted from September 2022 to May 2024.

Exposures

Preoperative frailty as assessed by the Risk Analysis Index (RAI-A) score: robust, less than 20; normal, 20 to 29; frail, 30 to 39; and very frail, 40 or more.

Main Outcomes and Measures

The primary outcome was health care utilization through 24 months, defined as inpatient admissions, outpatient visits, emergency department (ED) visits, and nursing home or rehabilitation services collected via Corporate Data Warehouse and Centers for Medicare & Medicaid Services data. χ2 Tests and analysis of variance were used to assess preoperative frailty status, and a Cox proportional hazards model was used to calculate the adjusted association of preoperative frailty on each postdischarge health care utilization outcome.

Results

This study identified 183 343 elective general (80.5%) and vascular (19.5%) procedures (mean [SD] age, 62 [12.7] years; 12 915 females [7.0%]; 28 671 Black patients [16.0]; 138 323 White patients [77.3%]; 94 451 Medicare enrollees [51.5%]) with mean (SD) RAI-A score of 22.2 (7.0). After adjustment for baseline characteristics and preoperative use of health care services, frailty was associated with higher inpatient admissions (frail: hazard ratio [HR], 1.75; 95% CI, 1.70-1.79; very frail: HR, 2.33; 95% CI, 2.25-2.42), ED visits (frail: HR, 1.39; 95% CI, 1.36-1.41; very frail: HR, 1.70; 95% CI, 1.65-1.75), and nursing home or rehabilitation encounters (frail: HR, 4.97; 95% CI, 4.36-5.67; very frail: HR, 7.44; 95% CI, 6.34-8.73). For patients considered frail and very frail, health care utilization was higher after surgery and remained significant through 24 months for all outcomes (using piecewise Cox proportional hazards modeling).

Conclusions and Relevance

In this study, frailty was a significant risk factor for high long-term health care utilization after surgery. This may have quality of life implications for patients and policy implications for health care systems and payers.

The modified 5-item frailty index as a predictor of perioperative risk in patients undergoing percutaneous nephrolithotomy

INTRODUCTION

The modified 5-item frailty index is a relatively new tool to assess the post-operative complication risks. In urology, there is limited literature on the impact of frailty on percutaneous nephrolithotomy (PCNL) outcomes. We aimed to compare the predictive value of the modified 5-item frailty index (mFI-5) to identify high risk patients prior to PCNL.

METHODS

A database of patients undergoing PCNL, between 2015 and 2022, was analyzed. Patient frailty was assessed using the mFI-5 index. The mFI-5 index was calculated based on the presence of the five co-morbidities: congestive heart failure within 30 days prior to surgery, diabetes mellitus, chronic obstructive pulmonary disease, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Patients were grouped as not frail (mFI-5 = 0), intermediate (mFI-5 = 1), and severely frail (mFI-5 ≥ 2). Primary outcomes were 30-day postoperative complications. Secondary outcomes were hospitalization: total hospital length of stay, reoperation, and unplanned readmission.

RESULTS

From a total of 320 PCNL patients included for analysis, 54.06% (n = 173) were not frail, 17.81% (n = 57) were intermediate, and 28.12% (n = 90) were severely frail. Frail patients were likely to be older (p = 0.002) and have a higher American Society of Anesthesiologists score (p = 0.001), chronic kidney disease (p < 0.001). Patients of intermediate or severe frailty were more likely to exhibit postoperative sepsis (p = 0.042), significant blood loss (p = 0.036) and require intensive care units admissions (p = 0.0015). Frail patients had a longer hospital length of stay (p < 0.001) and tended to require reoperation (p = 0.001), and unplanned readmission (p = 0.02).

CONCLUSION

Frailty assessment appears useful in stratifying those at risk of extended hospitalization, septic and hemorrhagic complications, readmission, or reoperation after PCNL. Preoperative assessment of frailty phenotype may give insight into treatment decisions and assist surgeons in counselling patients on expected course and hospital stay following PCNL.

Preoperative frailty and postoperative complications after non-cardiac surgery: a systematic review

OBJECTIVE

Many tools have been used to assess frailty in the perioperative setting. However, no single scale has been shown to be the most effective in predicting postoperative complications. We evaluated the relationship between several frailty scales and the occurrence of complications following different non-cardiac surgeries.

METHODS

This systematic review was registered in PROSPERO (CRD42023473401). The search strategy included PubMed, Google Scholar, and Embase, covering manuscripts published from January 2000 to July 2023. We included prospective and retrospective studies that evaluated frailty using specific scales and tracked patients postoperatively. Studies on cardiac, neurosurgical, and thoracic surgery were excluded because of the impact of underlying diseases on patients' functional status. Narrative reviews, conference abstracts, and articles lacking a comprehensive definition of frailty were excluded.

RESULTS

Of the 2204 articles identified, 145 were included in the review: 7 on non-cardiac surgery, 36 on general and digestive surgery, 19 on urology, 22 on vascular surgery, 36 on spinal surgery, and 25 on orthopedic/trauma surgery. The reviewed manuscripts confirmed that various frailty scales had been used to predict postoperative complications, mortality, and hospital stay across these surgical disciplines.

CONCLUSION

Despite differences among surgical populations, preoperative frailty assessment consistently predicts postoperative outcomes in non-cardiac surgeries.

Impact of frailty on perioperative outcomes following percutaneous nephrolithotomy in older persons: evidence from the US Nationwide Inpatient Sample

To evaluate the impact of frailty on perioperative outcomes of older patients undergoing PCNL, utilizing the US Nationwide Inpatient Sample (NIS) database. Data of hospitalized patients ≥ 60 years who received PCNL were extracted from the 2010 to 2020 NIS database, and included demographics, clinical, and hospital-related information. Patients were assigned to low (< 5), medium (5-15), and high frailty risk (> 15) groups based on the hospital frailty risk score (HFRS). Associations between frailty risk and perioperative outcomes including total hospital cost were determined using population-weighted linear and logistic regression analyses. Data of 30,829 hospitalized patients were analyzed (mean age 72.5 years; 55% male; 78% white). Multivariable analyses revealed that compared to low frailty risk, increased frailty risk was significantly associated with elevated in-hospital mortality (adjusted odds ratio (aOR) = 10.70, 95% confidence interval (CI): 6.38-18.62), higher incidence of unfavorable discharge (aOR = 5.09, 95% CI: 4.43-5.86), prolonged hospital length of stay (LOS; aOR = 7.67, 95% CI: 6.38-9.22), increased transfusion risk (aOR = 8.05, 95% CI: 6.55-9.90), increased total hospital costs (adjusted Beta = 37.61, 95% CI: 36.39-38.83), and greater risk of complications (aOR = 8.52, 95% CI: 7.69-9.45). Frailty is a significant prognostic indicator of adverse perioperative outcomes in older patients undergoing PCNL, underscoring importance of recognizing and managing frailty in older patients.

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.

Operative duration as independent predictor of increased postoperative healthcare utilization

PURPOSE

Few studies have examined the risk factors for postoperative healthcare resource utilization (HRU) among minimally invasive partial nephrectomy (MIPN), minimally invasive prostatectomy (MIP), and cystectomy (Cx). The aim of this study is to assess if operative duration (OD) is a predictor of HRU in this population.

METHODS

The ACS-NSQIP database was filtered for MIPN, MIP, and Cx. Patient characteristics and intraoperative variables were examined. HRU was defined as prolonged length of stay (LOS), unplanned readmission within 30 days, and discharge to continued care facility. Multivariate regression analysis was used to identify independent predictors of HRU.

RESULTS

18,904 MIPN, 50,807 MIP, and 12,451 Cx were included. For MIPN, HRU was seen in 13.9% of cases < 1.75 h, increasing to 36.2% in OD > 4.5 h (p < 0.001). For MIP, HRU was seen in 10.6% of OD < 2 h, increasing to 32.2% for OD > 4.9 h (p < 0.001). For Cx, 57% of those with OD > 8.5 h required HRU compared to 42.1% for OD < 3.3 h (p < 0.001). On multivariate analyses, OD was an independent predictor for increased HRU for all procedures regardless of patient characteristics or comorbidities. For MIPN, OD > 4.5 h had 3.5-fold increased use of HRU (p < 0.001). For MIP, OD > 5 h had 3.7-fold increased use of HRU (p < 0.001). For Cx, OD > 8.5 h demonstrated a twofold increased use of HRU (p < 0.001).

CONCLUSIONS

OD during MIPN, MIP, and Cx is an independent predictor of increased HRU irrespective of patient comorbidities. Patients with OD > 4.5 h for MIPN, > 5 h for MIP, and > 8.5 h for Cx have 3.5-fold, 3.7-fold, and twofold increased risk of HRU, respectively.

Evaluating Factors That Influence Healthcare Resource Utilization in Transurethral Resection of Prostate

INTRODUCTION

Transurethral resection of prostate (TURP) remains the gold standard for treatment of benign prostatic hyperplasia (BPH) but is associated with complications. The association of healthcare resource utilization (HRU) and TURP has been poorly studied. We seek to evaluate HRU in patients undergoing TURP and identify factors contributing to outcomes.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was reviewed from 2012-2018 for TURP by CPT code. HRU was defined as discharge to continued care, unplanned readmission within 30 days, or prolonged length of stay (>75th percentile). We included preoperative variables, including age, BMI, diabetes, and ASA class. OD was broken into deciles by minutes. Preoperative characteristics and outcomes were compared against OD. Predictors of HRU were found using a stepwise multivariate logistic regression.

RESULTS

38,749 patients were included. Variables significantly associated with OD (values are 3 shortest and 3 longest deciles, respectively): any HRU (35.9%, 32.4%, 31.4% and 32.4%, 33.7%, 37.6%), and prolonged length of stay (31.3%, 27.6%, 26.5% and 28.0%, 30.4%, 34.1%). Findings in the first decile seemed to be an outlier, shown in Figure 1. Complications associated with OD are shown in Figure 2. On multivariable analysis, patients with OD > 58 minutes were more likely to have increased HRU, OR 1.22, 1.33, 1.54, 1.78 for deciles 58-66, 67-78, 78-99 and >100, respectively, p<0.005. Preoperative variables associated with HRU on multivariable analysis include age 71-80 and >80, COPD, dyspnea, hypertension, diabetes, not functionally independent, ASA class III and IV-V, and dirty/infected wound class, p<0.005.

CONCLUSIONS

OD is an independent predictor of HRU in patients undergoing TURP and is more modifiable than other preoperative variables associated with increased HRU. Patients in the longest decile were more likely to have complications and increased HRU. Further study is needed to evaluate causation.

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.

Impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for renal cancer: a systematic review

BACKGROUND

Frailty has been recognized as a major risk factor for adverse perioperative and oncological outcomes in patients with genitourinary malignancies. Yet, the evidence supporting such an association in patients with renal cell carcinoma (RCC) is still sparse. Herein we provide an updated comprehensive overview of the impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for RCC.

EVIDENCE ACQUISITION

A systematic review of the English-language literature was conducted using the MEDLINE (Via PubMed), Web of Science and the Cochrane Library databases according to the principles highlighted by the EAU Guidelines Office and the PRISMA statement recommendations. The review protocol was registered on PROSPERO (CRD42021242516). The overall quality of evidence was assessed according to GRADE recommendations.

EVIDENCE SYNTHESIS

Overall, 18 studies were included in the qualitative analysis. Most of these were retrospective single-centre series including patients undergoing surgery for non-metastatic RCC. The overall quality of evidence was low. A variety of measures were used for frailty assessment, including the Canadian Study of Health and Aging Frailty Index, the five-item frailty index, the Modified Rockwood's Clinical Frailty Scale Score, the Hopkins Frailty score, the Groningen Frailty Index, and the Geriatric nutritional risk index. Sarcopenia was defined based on the Lumbar skeletal muscle mass at cross-sectional imaging, the skeletal muscle index, the total psoas area, or the psoas muscle index. Overall, available studies point to frailty and sarcopenia as potential independent risk factors for worse perioperative and oncological outcomes after surgery or ablation for different RCC stages. Increased patient's frailty was indeed associated with higher risk of perioperative complications, healthcare resources utilization, readmission rates and longer hospitalization periods, as well as potentially lower cancer specific or overall survival.

CONCLUSIONS

Frailty has been consistently associated with worse outcomes after surgery for RCC, reinforcing the value of preoperative frailty assessment in carefully selected patients. Given the low quality of the available evidence (especially in the setting of tumour ablation), prospective studies are needed to standardize frailty assessments and to identify patients who are expected to benefit most from preoperative geriatric evaluation, aiming to optimize decision-making and postoperative outcomes in patients with RCC.

Frailty predicts outcome of partial nephrectomy and guides treatment decision towards active surveillance and tumor ablation

PURPOSE

To examine frailty and comorbidity as predictors of outcome of nephron sparing surgery (NSS) and as decision tools for identifying candidates for active surveillance (AS) or tumor ablation (TA).

METHODS

Frailty and comorbidity were assessed using the modified frailty index of the Canadian Study of Health and Aging (11-CSHA) and the age-adjusted Charlson-Comorbidity Index (aaCCI) as well as albumin and the radiological skeletal-muscle-index (SMI) in a cohort of n = 447 patients with localized renal masses. Renal tumor anatomy was classified according to the RENAL nephrometry system. Regression analyses were performed to assess predictors of surgical outcome of patients undergoing NSS as well as to identify possible influencing factors of patients undergoing alternative therapies (AS/TA).

RESULTS

Overall 409 patient underwent NSS while 38 received AS or TA. Patients undergoing TA/AS were more likely to be frail or comorbid compared to patients undergoing NSS (aaCCI: p < 0.001, 11-CSHA: p < 0.001). Gender and tumor complexity did not vary between patients of different treatment approach. 11-CSHA and aaCCI were identified as independent predictors of major postoperative complications (11-CSHA ≥ 0.27: OR = 3.6, p = 0.001) and hospital re-admission (aaCCI ≥ 6: OR = 4.93, p = 0.003) in the NSS cohort. No impact was found for albumin levels and SMI. An aaCCI > 6 and/or 11-CSHA ≥ 0.27 (OR = 9.19, p < 0.001), a solitary kidney (OR = 5.43, p = 0.005) and hypoalbuminemia (OR = 4.6, p = 0.009), but not tumor complexity, were decisive factors to undergo AS or TA rather than NSS.

CONCLUSION

In patients with localized renal masses, frailty and comorbidity indices can be useful to predict surgical outcome and support decision-making towards AS or TA.

Risk factors for progression of chronic kidney disease after robotic partial nephrectomy in elderly patients: results from a multi-institutional collaborative series

BACKGROUND

Robotic partial nephrectomy (RPN) in patients ≥75 years is certainly underused with concerns regarding surgical quality and a negligible impact on renal function. The aim of this study was to identify predictors of progression of chronic kidney disease for purely off-clamp (ocRPN) and on-clamp RPN (onRPN) in elderly patients on a multi-institutional series.

METHODS

A collaborative minimally-invasive renal surgery dataset was queried for "RPN" performed between July 2007 and March 2021 and "age≥75 years". A total of 205 patients matched the inclusion criteria. Descriptive analyses were used. Frequencies and proportions were reported for categorical variables while medians and interquartile ranges (IQR) were reported for continuous variables. Baseline, perioperative and functional data were compared between groups. New-onset of stages 3b,4,5 CKD in onRPN and ocRPN cohorts was computed by Kaplan-Meier analysis. Univariable and multivariable Cox regression analyses were performed to identify predictors of progression to severe CKD (sCKD [stages ≥3b]). For all statistical analyses, a two-sided p < 0.05 was considered significant.

RESULTS

Mean age of the cohort considered was 78 years (IQR 76-80). At a median follow-up of 29 months (IQR 14.5-44.5), new onset CKD-3b and CKD-4,5 stages was observed in 16.6% and 2.4% of patients, respectively. At Kaplan-Meier analysis, onRPN was associated with a significantly higher risk of developing sCKD (p=0.002). On multivariable analysis, hypertension (HR 2.64; 95% CI 1.14-6.11; p=0.023), on-clamp approach (HR 3.41; 95% CI 1.50-7.74; p=0.003) non-achievement of trifecta (HR 0.36; 95% CI 0.17-0.78; p=0.01) were independent predictors of sCKD.

CONCLUSIONS

RPN in patients≥75 years is a safe surgical option. On-clamp approach, hypertension and non-achievement of trifecta were independent predictors of sCKD in the elderly after RPN.

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.

The effect of frailty on postoperative readmissions, morbidity, and mortality in endometrial cancer surgery

OBJECTIVES

To determine the impact of frailty on postoperative readmission, morbidity, and mortality among patients undergoing surgery for endometrial cancer.

METHODS

Patients with endometrial cancer undergoing hysterectomy between 2010 and 2014 were identified using the Nationwide Readmissions Database. Frailty was classified using criteria outlined by the Johns Hopkins Adjusted Clinical Groups Frailty Diagnoses Indicators. Primary outcomes were divided by index surgical admission (intensive level of care, mortality, non-routine discharge), 30-days (readmission and mortality), and 90-days (readmission and mortality) after discharge. Multivariable log linear regression models were fit to analyze the effect of frailty on these outcomes, adjusting for patient, hospital, and clinical factors.

RESULTS

From 2010 to 2014, there were 144,809 surgical endometrial cancer cases with a 1.8% frailty rate. Frailty was associated with an increased risk of intensive level of care (aRR = 3.61, 95% CI: 2.95, 4.42), non-routine discharge (aRR = 1.59, 95% CI: 1.51, 1.68), and inpatient mortality (aRR = 2.05, 95% CI: 1.68, 2.51) during index admission. Frail patients were more likely to be readmitted within 30 days (RR 1.33, 95% CI 1.22-1.47) and 90-days (RR 1.21, 95% CI 1.12, 1.32), and were at increased risk of mortality during their 30-day readmission (aRR = 1.75, 95% CI: 1.28-2.39). Frailty was not associated with 90-day mortality. Hospitalization costs for frail patients were significantly higher than for non-frail patients during index admission and readmissions within 30 and 90 days (p < 0.05 for all).

CONCLUSIONS

Frailty affects postoperative outcomes in endometrial cancer patients and is associated with an increased rate of readmission and 30-day mortality among those who are readmitted. Gynecologic cancer providers should screen for frailty and consider outcomes in frail patients when counseling them for surgery.

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

Association between the baseline frailty and quality of life in patients with prostate cancer (FRAQ-PC study)

BACKGROUND

The association between baseline frailty and health-related quality of life (HRQOL) in patients with prostate cancer (PC) remains unknown.

METHODS

We retrospectively evaluated the association of pretreatment frailty with HRQOL in 409 patients with PC from February 2017 to April 2020. Frailty and HRQOL were evaluated using the geriatric 8 (G8) screening tool and QLQ-C30 questionnaire, respectively. The primary objective was comparison of G8 and QOL scores between the localized diseases (M0 group) and metastatic castration-sensitive PC (mCSPC group). Secondary objectives were to study the association of G8 and QOL scores in each group and effect of frailty (G8 ≤ 14) on worse QOL.

RESULTS

The median age of patients was 70 years. There were 369 (surgery: 196, radiotherapy: 156, androgen deprivation therapy alone: 17) patients in the M0 and 40 patients in the mCSPC groups. There was a significant difference between the M0 and mCSPC groups in the G8 score (14.5 vs. 12.5), functioning QOL (94 vs. 87), global QOL (75 vs. 58), and 100-symptom QOL (94 vs. 85) scores. G8 scores were significantly associated with functioning, global, and 100-symptom QOL scores in both M0 and mCSPC groups. The multivariable logistic regression analyses showed that frailty (G8 ≤ 14) was significantly associated with worse global QOL, functioning QOL, and 100-symptom QOL scores.

CONCLUSION

The baseline frailty and HRQOL were significantly different between the localized and metastatic disease. The baseline frailty was significantly associated with worse HRQOL in patients with PC.

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.

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.

Differences in short-term outcomes between open versus robot-assisted radical cystectomy in frail malnourished patients

INTRODUCTION

We tested whether frail patients may benefit from robot-assisted (RARC) relative to open radical cystectomy (ORC).

MATERIALS AND METHODS

Frail patients treated with RC were identified within the National Inpatient Sample database (2008-2015). The effect of RARC vs. ORC was tested in five separate multivariable models predicting: complications, failure to rescue (FTR), in-hospital mortality, length of stay (LOS) and total hospital charges (THCs). As internal validity measure, analyses were repeated among non-frail patients. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics.

RESULTS

Of 11,578 RC patients, 3477 (30.0%) were frail. RARC was performed in 488 (14.0%) frail patients and 1386 (17.1%) non-frail patients. Among frail, RARC was only independently associated with shorter LOS (median 8 vs. 9 days, relative ratio [RR] 0.79, p < 0.001). Conversely, among non-frail, RARC was independently associated with lower complications (57.3 vs. 59.1%, odds ratio [OR] 0.82, p = 0.004) and shorter LOS (median 6 vs. 7 days, RR 0.88, p < 0.001), but also predicted higher THCs (+2850.3 US dollars, p = 0.001).

CONCLUSIONS

In frail patients, the use of RARC did not result in better short-term outcomes except for one-day advantage in LOS. Conversely, in non-frail patients, the use of RARC resulted in lower complication rates and shorter LOS at the cost of higher THCs. In consequence, the benefit of RARC appears relatively marginal in frail patients and our data do not suggest a clear and clinically-meaningful benefit of RARC over ORC in frail radical cystectomy population.

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.