The association of age with perioperative morbidity and mortality among men undergoing radical prostatectomy

Individualised Positive End-Expiratory Pressure Settings Reduce the Incidence of Postoperative Pulmonary Complications: A Systematic Review and Meta-Analysis

Background: Progressive atelectasis regularly occurs during general anaesthesia; hence, positive end-expiratory pressure (PEEP) is often applied. Individualised PEEP titration may reduce the incidence of postoperative pulmonary complications (PPCs) and improve oxygenation as compared to fixed PEEP settings; however, evidence is lacking. Methods: This systematic review and meta-analysis was registered on PROSPERO (CRD42021282228). A systematic search in four databases (MEDLINE Via PubMed, EMBASE, CENTRAL, and Web of Science) was performed on 14 October 2021 and updated on 26 April 2024. We searched for randomised controlled trials comparing the effects of individually titrated versus fixed PEEP strategies during abdominal surgeries. The primary endpoint was the incidence of PPCs. The secondary endpoints included the PaO2/FiO2 at the end of surgery, individually set PEEP value, vasopressor requirements, and respiratory mechanics. Results: We identified 30 trials (2602 patients). The incidence of PPCs was significantly lower among patients in the individualised group (RR = 0.70, CI: 0.58-0.84). A significantly higher PaO2/FiO2 ratio was found in the individualised group as compared to controls at the end of the surgery (MD = 55.99 mmHg, 95% CI: 31.78-80.21). Individual PEEP was significantly higher as compared to conventional settings (MD = 6.27 cm H2O, CI: 4.30-8.23). Fewer patients in the control group needed vasopressor support; however, this result was non-significant. Lung-function-related outcomes showed better respiratory mechanics in the individualised group (Cstat: MD = 11.92 cm H2O 95% CI: 6.40-17.45). Conclusions: Our results show that individually titrated PEEP results in fewer PPCs and better oxygenation in patients undergoing abdominal surgery.

The BETTY Score to Predict Perioperative Outcomes in Surgical Patients

The aim of this study is to evaluate a new user-friendly scoring system, namely the BETTY score, that aims to predict 30-day patient outcomes after surgery. In this first description, we rely on a population of prostate cancer patients undergoing robot-assisted radical prostatectomy. The BETTY score includes the patient's American Society of Anesthesiologists score, the body mass index, and intraoperative data, including operative time, estimated blood loss, any major intraoperative complications, hemodynamic, and/or respiratory instability. There is an inverse relationship between the score and severity. Three clusters assessing the risk of postoperative events were defined: low, intermediate, and high risk of postoperative events. A total of 297 patients was included. The median length of hospital stay was 1 day (IQR1-2). Unplanned visits, readmissions, any complications, and serious complications occurred in 17.2%, 11.8%, 28.3%, and 5% of cases, respectively. We found a statistically significant correlation between the BETTY score and all endpoints analyzed (all p ≤ 0.01). A total of 275, 20, and 2 patients were classified as low-, intermediate-, and high-risk according to the BETTY scoring system, respectively. Compared with low-risk patients, patients at intermediate-risk were associated with worse outcomes for all endpoints analyzed (all p ≤ 0.04). Future studies, in various surgical subspecialties, are ongoing to confirm the usefulness of this easy-to-use score in routine.

American Society of Anesthesiologists' (ASA) Physical Status System and Risk of Major Clavien-Dindo Complications After Robot-Assisted Radical Prostatectomy at Hospital Discharge: Analysis of 1143 Consecutive Prostate Cancer Patients

Objective

To test the hypothesis of associations of preoperative physical status system with major postoperative complications at hospital discharge in prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy (RARP).

Materials and Methods

In a period ranging from January 2013 to October 2020, 1143 patients were evaluated. The physical status was assessed by the American Society of Anesthesiologists' (ASA) system, which was computed trained anesthesiologists. The Clavien-Dindo system was used to classify postoperative complications, which were coded as major if greater than 1.

Results

ASA physical status system included class I in 102 patients (8.9%), class II in 934 subjects (81.7%), and class III in 107 cases (9.4%). Clavien-Dindo complications were distributed as follows: grade 1: 141 cases (12.3%), grade 2: 108 patients (9.4%), grade 3a: 5 subjects (0.4%), grade 3b: 9 patients (0.8%), and grade 4a: 3 cases (0.3%). Overall, major complications were detected in 125 cases (10.9%). On multivariate analysis, major Clavien-Dindo complications were predicted by ASA score grade II (adjusted odds ratio, OR = 2.538; 95%CI 1.007-6.397; p = 0.048) and grade III (adjusted OR 3.468; 95%CI 1.215-9.896; p = 0.020) independently by pelvic lymph node dissection (PLND) and/or blood lost.

Conclusion

In RARP surgery, the risk of major postoperative Clavien-Dindo complications increased as the physical status system deteriorated independently by performing or not a PLND and/or large intraoperative blood lost. The ASA score system was an effective predictor of major Clavien-Dindo complications, which delayed LOHS in RARP surgery. Confirmatory studies are required.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01577-9.

Severe systemic disease of the American Society of Anesthesiologists' (ASA) physical status system classification associated with delayed length of hospital stay in 1329 consecutive patients treated with radical prostatectomy for clinical prostate cancer

BACKGROUND

The investigate the associations of the ASA physical status system with clinical, pathological, and perioperative features of prostate cancer (PCa) patients treated with radical prostatectomy (RP) that eventually associated with pelvic lymph node dissection (PLND).

METHODS

We performed a retrospective analysis of prospective collected data from January 2013 to October 2020, including1329 patients. The ASA system was preoperatively assessed for each patient. Evaluated clinical factors were grouped as preoperative, perioperative, and pathological and were statistically associated with the ASA system. Continuous variables were represented as medians with relative interquartile ranges (IQR) and categorical factors were assessed as frequencies (percentages). Associations and risk of each ASA Class with population features were assessed by the multinomial logistic regression model (univariate and multivariate analysis). All tests were two-sided with P<0.05 considered to indicate statistical significance.

RESULTS

Postoperative complications at discharge occurred in 27.2%. The distribution of the ASA physical status system was as follows: ASA I 108 patients (8.1%), ASA II 1081 subjects (81.3%) and ASA III 140 cases (10.5%). Median length of hospital state (LOHS) was the same for ASA groups I and II (4 days), but longer (5 days) for the ASA group III. On MVA, the risk of delayed hospital stay was associated only with ASA III patients and was independent from age and BMI. Clavien-Dindo complications greater than 2 did not show any independent association with the ASA system.

CONCLUSIONS

The ASA preoperative physical status system predicted the likelihood of longer LOHS.

Thirty-day morbidity and mortality of elective urological surgery in patients aged 80 years and over in a UK district general hospital

Purpose:

An ageing population has led to many people aged 80 and over requiring urological surgery. There are concerns that operating on octogenarians may be fraught with higher morbidity and mortality risk. Therefore, the purpose was to study postoperative outcomes in people aged 80 years and over undergoing elective urological surgery.

Materials and methods:

We retrospectively reviewed the 30-day readmissions and deaths in patients aged 80 years and over who had elective urological surgery over a seven and half year period from February 2011 to July 2018 in a district general hospital. Surgeries were stratified into minor, intermediate and major. Our data did not include supra-major surgeries like radical cystectomy as these are done in tertiary centres. We used logistic regression to examine factors associated with readmissions and death.

Results:

A total of 1239 patients had 2201 operations. The median age was 84.1 years. Procedures on the bladder were the most common, followed by prostate surgery. A 17.9% of operations resulted in an adverse outcome (death or readmission attributable to surgery) within 30 days. There were 21 deaths, equating to 1% of all surgeries undertaken. There was a significant difference in both readmissions and deaths by American Society of Anaesthesiologists (ASA) grade. The median time to readmission from surgery was 18 (IQR 13–23) days. The highest number of readmissions occurred in the third week after surgery. A 94% of the readmissions were for a minor complication (grade I Clavien Dindo), with haematuria and urinary retention being most common.

Conclusions:

This study informs hospitals, surgeons, patient advocacy groups and insurance, that the morbidity and mortality risks of non-supra major elective urological surgery in patients aged 80 and over are not disproportionately high.

Influence of Preoperative and Postoperative Factors on Prolonged Length of Stay and Readmission after Minimally Invasive Radical Prostatectomy

BACKGROUND

The mean length of stay (LOS) following minimally invasive radical prostatectomy (MI-RP) is less than 2 days. Our main objective was to utilize the National Surgical Quality Improvement Program Database (NSQIP) to evaluate preoperative factors that may contribute to prolonged hospital stay and readmission.

MATERIALS AND METHODS

Utilizing the NSQIP database, records for surgery with the Current Procedural Terminology (CPT) code 55866 (prostatectomy) between 2007 and 2017 were evaluated. Chi-square and t-tests were used to assess the effects of preoperative factors on prolonged LOS and rates of hospital readmission within 30 days. Odds ratios, p-values, and confidence intervals were determined using multivariable logistic regression.

RESULTS

40,764 patients underwent MI-RP between 2007 and 2017. Of these, 11.7% reported a LOS of more than 2 days, while 3.9% of patients were readmitted to the hospital within 30 days. Preoperative congestive heart failure within 30 days of surgery was shown to be strongly associated with both prolonged LOS (OR = 6.16) and readmission (OR = 3.28). Bleeding requiring transfusion was demonstrated to be the most significant postoperative factor for prolonged LOS (OR= 23.9), while unplanned intubation was shown to be the most significant postoperative factor for readmission (OR=57.1). BMI over 30 was associated with both prolonged LOS and increase in readmission.

CONCLUSIONS

Upon NSQIP database analysis, cardiopulmonary factors and BMI were demonstrated to have negative impacts on postoperative quality indicators. Patients with comorbidities should be counselled preoperatively concerning their individual risk factors. Mitigation of these factors is important in ensuring optimal outcomes.

Severe intraoperative bleeding predicts the risk of perioperative blood transfusion after robot-assisted radical prostatectomy

To evaluate potential factors associated with the risk of perioperative blood transfusion (PBT) with implications on length of hospital stay (LOHS) and major post-operative complications in patients who underwent robot-assisted radical prostatectomy (RARP) as a primary treatment for prostate cancer (PCa). In a period ranging from January 2013 to August 2019, 980 consecutive patients who underwent RARP were retrospectively evaluated. Clinical factors such as intraoperative blood loss were evaluated. The association of factors with the risk of PBT was investigated by statistical methods. Overall, PBT was necessary in 39 patients (4%) in whom four were intraoperatively. Positive surgical margins, operating time and intraoperative blood loss were associated with perioperative blood transfusion on univariate analysis. On multivariate analysis, the risk of PBT was predicted by intraoperative blood loss (odds ratio, OR 1.002; 95% CI 1.001-1.002; p < 0.0001), which was associated with prolonged operating time and elevated body mass index (BMI). PBT was associated with delayed LOHS and Clavien-Dindo complications > 2. In patients undergoing RARP as a primary treatment for PCa, the risk of PBT represented a rare event that was predicted by severe intraoperative bleeding, which was associated with increased BMI as well as with prolonged operating time. In patients who received a PBT, prolonged LOHS as well as an elevated risk of major Clavien-Dindo complications were seen.

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.

Predictive Factors of the Risk of Long-Term Hospital Readmission after Primary Prostate Surgery at a Single Tertiary Referral Center: Preliminary Report

OBJECTIVE

To evaluate the predictors of the risk of long-term hospital readmission after radical prostatectomy (RP) in a single tertiary referral center where both open RP (ORP) and robot assisted RP (RARP) are performed.

MATERIALS AND METHODS

The risk of readmission was evaluated by clinical, pathological, and perioperative factors. Skilled and experienced surgeons performed the 2 surgical approaches. Patients were followed for complications and hospital readmission for a period of 6 months. The association of factors with the risk of readmission was assessed by Cox's multivariate proportional hazards.

RESULTS

From December 2013 to 2017, 885 patients underwent RP. RARP was performed in 733 cases and ORP in 152 subjects. Extended pelvic lymph node dissection (ePLND) was performed in 479 patients. Hospital readmission was detected in 46 cases (5.2%). Using a multivariate model, independent factors associated with the risk of hospital readmission were seminal vesicle invasion (hazard ratio [HR] 2.065; 95% CI 1.116-3.283; p = 0.021), ORP (HR 3.506; 95% CI 1.919-6.405; p < 0.0001), and ePLND (HR 5.172; 95% CI 1.778-15.053; p < 0.0001).

CONCLUSIONS

In a large single tertiary referral center, independent predictors of the risk of long-term hospital readmission after RP included ORP, ePLND, and seminal vesicle invasion. When surgery is chosen as a primary treatment of PCA, patients should be informed of the risk of long-term hospital readmission and its related risk factors.

Advanced Age Is a Risk Factor for Complications Following Abdominal Panniculectomy

BACKGROUND

Widespread adoption of bariatric surgery in the treatment of obesity has led to greater numbers of patients seeking panniculectomy, including aged patients, who represent a rapidly growing proportion of the U.S population. Although the quality of life and functional benefits of abdominal panniculectomy have been established, its safety in patients 65 years and older has not been evaluated.

METHODS

The American College of Surgeons National Surgical Quality Improvements (ACS-NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Age 65 years and older was the risk factor of interest, and primary outcomes included 30-day wound complications, overall complications, reoperation, readmission, and mortality. Multivariate regression was performed to control for confounders.

RESULTS

Review of the database identified 7030 patients who underwent abdominal panniculectomy. When stratified by age, 6455 (91.8%) of patients were younger than 65, and 575 (8.2%) were 65 or older. Multivariate regression analysis demonstrated that age over 65 was a significant independent risk factor for wound complications (OR = 1.81; 95% CI 1.35-2.42; p < 0.001) and all complications (OR = 1.46; 95% CI 1.15-1.87; p = 0.002). BMI, smoking, diabetes, and partial or total dependence were also identified as significant independent risk factors for wound and all complications.

CONCLUSION

Our analysis demonstrates that advanced age is an independent risk factor for wound and overall complications following abdominal panniculectomy. These results highlight the importance of preoperative evaluation and optimization of modifiable preoperative risk factors as well as close postoperative follow-up for safe outcomes in patients 65 and older.

Open approach, extended pelvic lymph node dissection, and seminal vesicle invasion are independent predictors of hospital readmission after prostate cancer surgery: a large retrospective study

BACKGROUND

The aim of this study is to evaluate factors (clinical, pathological and perioperative) associated with the risk of hospital readmission after radical prostatectomy (RP) over the long term in a single tertiary referral center where both open RP (ORP) and robot assisted RP (RARP) are performed.

METHODS

From January 2013 to December 2018 patients older than 18 years, who provided signed consent and underwent open or robot assisted radical prostatectomy were enrolled and retrospectively evaluated. Patients who underwent any previous prostate cancer (PCA) treatments were excluded. Specifically, skilled and experienced surgeons performed the two surgical approaches. Patients were followed for complications and hospital readmission (RAD) for a period of six months. The association of factors with the risk of readmission was assessed by Cox's multivariate proportional hazards.

RESULTS

A total of 1062 patients underwent RP. RARP was performed in 891 cases and ORP in 171 subjects. Extended pelvic lymph node dissection (ePLND) was performed in 651 patients. Hospital readmission occurred in 53 cases (5%). Based on the final multivariate model, independent factors associated with the risk of hospital readmission were seminal vesicle invasion (HR=2.093; 95% CI: 1.177-3.722), ORP (HR=4.393; 95% CI: 2.516-7.672) and ePLND (HR=4.418; 95% CI: 1.544-12.639).

CONCLUSIONS

ORP, ePLND and seminal vesicle invasion are independent predictors of the risk of hospital readmission over the long term at a large single tertiary referral center. When surgery is chosen as a primary treatment of PCA, patients should be informed of the risk of hospital readmission and related risk factors. Assessing seminal vesicle invasion by preoperative clinical staging identifies locally advanced disease, which is associated with an increased risk of hospital readmission.

Impact of Age on Perioperative Outcomes at Radical Prostatectomy: A Population-Based Study

BACKGROUND

Radical prostatectomy (RP) represents one standard of care for patients with localized prostate cancer and is associated with several established postoperative complications.

OBJECTIVE

We tested the relationship between RP early postoperative outcomes and age within a population-based data repository.

DESIGN, SETTING, AND PARTICIPANTS

Within the National Inpatient Sample database (2008-2013), we identified patients who underwent robotically assisted or open RP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariable logistic regression (MLR), multivariable Poisson regression (MPR), and linear regression models were used. Cubic spline graphically depicted the relationship between age and complications.

RESULTS AND LIMITATIONS

Overall, 68780 patients underwent RP with a median age of 62 yr (interquartile range: 57-67 yr). In MLR models, patient age represented an independent predictor of overall [odds ratio (OR): 1.02, p<0.001], intraoperative (OR: 1.03, p<0.001), cardiac (OR: 1.03, p<0.001), miscellaneous medical (OR: 1.02, p<0.001), miscellaneous surgical (OR: 1.01, p=0.01), pulmonary (OR: 1.02, p<0.001), and vascular complications (OR: 1.05, p<0.001); blood transfusions (OR: 1.02, p<0.001); and bowel obstruction (OR: 1.02, p<0.001). In MPR models, patient age was associated with longer stay (OR: 1.001, p=0.02). Similar results were recorded after adjustment for clustering in stratified analyses (<70 vs ≥70 yr) and in the subgroup of patients that underwent robotically assisted RP. For nine out of twelve examined outcomes, a virtually direct relationship existed with increasing age, in cubic spline analyses.

CONCLUSIONS

Virtually all early postoperative RP complications are directly related to age. In consequence, these observations should be considered from an individual patient perspective as well as from a health management perspective.

PATIENT SUMMARY

RP is provided through a wide patient age spectrum. Virtually all early postoperative RP complications are directly related to age. Individual patient's age needs to be considered in treatment decision-making.