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

Longitudinal transitions in frailty and health-related quality of life investigated by a 5-year community study

The purpose of this study was to determine the association between frailty and quality of life (QOL) in a five-year longitudinal cohort of community-dwelling middle-aged and older adults and determine how to identify health-related QOL changes. This study included 124 volunteers (67 women; mean 65 years at baseline) who underwent health checkups in 2014 and 2019. The association between frailty status (robust, prefrail, frail), according to the Japanese Cardiovascular Health Study criteria, and health-related QOL, measured with the SF-36 questionnaire, were investigated. Five-year changes in frailty status were categorized into improved, maintained, and worsened groups. The baseline prevalence of prefrailty and frailty were 44.4% and 7.2%, respectively. Five years later, the frailty of 20 participants improved, 66 maintained frailty status, and frailty worsened in 38 participants. Significant trends toward higher scores on the physical component summary (PCS), role/social component summary (RCS), and subscales of physical functioning, role-physical, vitality, social functioning, and role-emotional were detected across groups with improvements in their frailty status from 2014 to 2019. The fully adjusted multivariable regression model revealed significantly higher PCS scores (β, 12.9; 95% confidence interval (CI), 6.0 to 19.9) and RCS scores (β, 13.6; 95% CI, 6.6 to 20.6) compared with the worsened group. In conclusion, this longitudinal cohort study demonstrates that frailty status is not static and improvements or maintenance of frailty are associated with better physical and social QOL outcomes. Addressing frailty early may reverse or mitigate its impact and improve the overall well-being of older adults.

Acute kidney disease after radical cystectomy for bladder cancer: a new onco-nephrological view

OBJECTIVE

To assess the incidence of acute kidney injury (AKI) and acute kidney disease (AKD) following radical cystectomy (RC) in patients with muscle-invasive bladder cancer (BCa).

MATERIALS AND METHODS

A consecutive cohort of 840 patients undergoing RC for muscle-invasive BCa at a tertiary institution (2010-2022) was analysed. Clinical variables, comorbidities, surgical techniques and oncological regimens were recorded pre- and post-surgery. Serum creatinine and estimated glomerular filtration rate (eGFR) were assessed at baseline, at 24, 48 and 72 h, and 6 days post-surgery for AKI, and at multiple intervals up to 60 days for AKD. Chronic kidney disease (CKD) stages G1 G2 and ≥G3 were classified according to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines. A multivariable logistic regression model was used to predict postoperative AKI or AKD risk.

RESULTS

Of the patients included in the study, 33% developed AKI and 54% developed AKD. Independent predictors included advanced age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.03-1.08), chronic hypertension (OR 1.43, 95% CI 1.03-2.00) and Charlson Comorbidity Index ≥2 (OR 1.59, 95% CI 1.09-2.33). Surgical factors, including use of a robot-assisted approach (OR 2.28, 95% CI 1.50-3.49) and ileal neobladder diversion (OR 1.84, 95% CI 1.05-3.24) were significant, possibly due to the associated prolonged operating times and metabolic challenges. Baseline renal function (CKD ≥G3, OR 2.17, 95% CI 1.28-3.68) and lower preoperative eGFR strongly correlated with AKD risk; a baseline eGFR below 20 mL/min was associated with an AKD risk ≥80%.

CONCLUSION

Our results showed that AKI and AKD are frequent complications of RC for muscle-invasive BCa. Personalised nephrological counselling pre- and post-surgery is essential to minimise morbidity and mortality.

The cumulative risk and severity of postoperative complications in patients with frailty undergoing major emergency abdominal surgery-A prospective cohort study

BACKGROUND

Major emergency abdominal surgery (MEAS) has high morbidity and mortality rates. With an aging and frail population, understanding the impact of frailty on postoperative complications is crucial.

METHODS

This prospective cohort study was conducted at a major university hospital in Denmark from October 1, 2020, to January 1, 2024. A total of 733 patients undergoing MEAS were assessed for frailty using the clinical frailty scale (CFS) at admission and grouped into low (CFS 1-3), moderate (CFS 4-6), and high (CFS 7-9) frailty categories. Postoperative complications were classified by the Clavien-Dindo score and comprehensive complication index (CCI) until discharge.

RESULTS

Patients with CFS one to three had 140 complications per 100 patients, CFS four to six had 267 complications per 100 patients, and CFS seven to nine had 297 complications per 100 patients (p < 0.001). Increased frailty was associated with higher severity of complications (Clavien-Dindo score). Median CCI scores were 8.7 (CFS 1-3), 29.6 (CFS 4-6), and 38.2 (CFS 7-9) (p < 0.001). The cumulative risk of complications was higher in patients with CFS four to six and seven to nine.

CONCLUSION

Higher frailty scores correlate with an increased number and severity of complications as well as a greater overall burden of postoperative complications. The clinical frailty scale is effective for preoperative identification of high-risk patients.

TRIAL REGISTRATION

The study was approved by the Capital Region of Denmark (P-2020-1166 and R-21038079) and the Danish Data Protection Agency (P-2021-431).

Association Between Low Testosterone and Perioperative Outcomes in Patients Undergoing Transurethral Prostate Surgery

Introduction Low testosterone (T) is linked with frailty, which predicts poor postoperative recovery across many surgical procedures. Therefore, low T may impact perioperative outcomes for surgical patients. We sought to characterize the association between low T, frailty, and perioperative outcomes in patients undergoing transurethral resection of the prostate (TURP) and laser photovaporization of the prostate (PVP). Materials and methods We retrospectively reviewed men across our integrated healthcare system who underwent TURP or PVP with a recorded T level within one year prior to their procedure date. Low T was defined as a serum T <300 ng/dL. We compared clinical characteristics, lab values, and frailty, determined by the Hospital Frailty Risk Score (HFRS), of patients with low vs. normal T. Univariable and multivariable analyses were used to assess the association between low T and hospital readmission at 30, 90, and 180 days postoperatively. Results Among 175 patients who underwent either TURP or PVP, 86 (49.1%) had low T, and 89 (50.9%) had normal T. Patients with low T were older (68.7 ± 9.3 vs. 64.8 ± 11.8 years old, p = 0.016) and had longer postoperative length of stay (4.2 ± 10.5 vs. 1.4 ± 0.9 days, p = 0.03). Patients with low T had a significantly higher rate of readmission within 180 days (28% vs. 13%, p = 0.02). Low T was not independently associated with frailty. On univariable logistic regression, preoperative T was associated with readmission at 90 and 180 days. On multivariable regression, low preoperative T was no longer associated with 90-day readmission. Conclusions Almost half of the men undergoing transurethral surgery in our cohort had low T. Low T was independently associated with a higher risk of 180-day readmission on multivariable analysis. These findings indicate a possible prognostic role for low T screening in men undergoing transurethral prostatic surgery. Further studies are needed to determine whether preoperative treatment of low T can impact perioperative outcomes.

Evidence gaps among systematic reviews examining the relationship of race, ethnicity, and social determinants of health with adult inpatient quality measures

Background

The field of healthcare epidemiology is increasingly focused on identifying, characterizing, and addressing social determinants of health (SDOH) to address inequities in healthcare quality. To identify evidence gaps, we examined recent systematic reviews examining the association of race, ethnicity, and SDOH with inpatient quality measures.

Methods

We searched Medline via OVID for English language systematic reviews from 2010 to 2022 addressing race, ethnicity, or SDOH domains and inpatient quality measures in adults using specific topic questions. We imported all citations to Covidence (www.covidence.org, Veritas Health Innovation) and removed duplicates. Two blinded reviewers assessed all articles for inclusion in 2 phases: title/abstract, then full-text review. Discrepancies were resolved by a third reviewer.

Results

Of 472 systematic reviews identified, 39 were included. Of these, 23 examined all-cause mortality; 6 examined 30-day readmission rates; 4 examined length of stay, 4 examined falls, 2 examined surgical site infections (SSIs) and one review examined risk of venous thromboembolism. The most evaluated SDOH measures were sex (n = 9), income and/or employment status (n = 9), age (n = 6), race and ethnicity (n = 6), and education (n = 5). No systematic reviews assessed medication use errors or healthcare-associated infections. We found very limited assessment of other SDOH measures such as economic stability, neighborhood, and health system access.

Conclusion

A limited number of systematic reviews have examined the association of race, ethnicity and SDOH measures with inpatient quality measures, and existing reviews highlight wide variability in reporting. Future systematic evaluations of SDOH measures are needed to better understand the relationships with inpatient quality measures.

Evaluating the Survival Benefits of Perioperative Chemotherapy in Frail and Morbid Muscle-Invasive Bladder Cancer Patients

INTRODUCTION

Current guidelines endorse the use of perioperative chemotherapy (POC) in muscle-invasive bladder cancer (MIBC) to enhance the long-term overall survival (OS) compared to radical cystectomy (RC) alone. This study aims to assess the impact of POC on the OS in frail and morbid (F-M) patients undergoing RC.

METHODS

A retrospective multicenter study of 291 patients who underwent RC between 2015 and 2019 was performed. Patients with both a Charlson comorbidity index ≥ 4 and Modified Frailty Index ≥ 2 were classified as the F-M cohort. We compared the clinical and pathological characteristics and outcomes of the F-M patients who received POC to those who underwent RC alone. Univariable and multivariable analyses were performed to identify the predictors of the OS.

RESULTS

The F-M cohort included 102 patients. POC was administered to 44% of these patients: neoadjuvant (NAC) to 31%, adjuvant (AC) to 19%, and both to 6 (6%). The OS was significantly lower in the F-M cohort compared to in the healthier patients (median OS 42 months, p = 0.02). The F-M patients who received POC were younger, less morbid and had better renal function. Although POC was marginally associated with improved OS in the univariable analysis (p = 0.06), this was not significant in the multivariable analysis (p = 0.50). NAC was associated with improved OS in the univariable analysis (p = 0.004) but not after adjustment for competing factors (p = 1.00). AC was not associated with the OS.

CONCLUSIONS

POC does not improve the OS in F-M patients undergoing RC. Personalized treatment strategies and further prospective studies are needed to optimize care in this unique vulnerable population.

Association of Frailty With Clinical and Financial Outcomes Following Liver Transplantation

INTRODUCTION

Frailty, a measure of physiological aging and reserve, has been validated as a prognostic indicator of mortality in patients with cirrhosis. However, large-scale analyses of the independent association of frailty with clinical and financial outcomes following liver transplantation (LT) are lacking.

METHODS

Adults (≥18 years) undergoing LT were identified in the 2016-2020 National Readmissions Database. Frailty was defined using the binary Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable linear and logistic regression models were developed to evaluate the independent association of frailty with in-hospital mortality, perioperative complications, and costs.

RESULTS

Of an estimated 34 442 patients undergoing LT, 8265 (24%) were frail. After adjustment, frailty was associated with greater odds of mortality (adjusted odds ratio [AOR] 1.80; 95% Confidence Interval [CI]: 1.49-1.18), postoperative length of stay (β + 11 days; 95% CI: +10, +12), and hospitalization costs (+$86 880; 95% CI: +75 660, +98 100), as well as a two-fold increase in relative risk of nonhome discharge (AOR 2.17, 95% CI: 1.90-2.49).

CONCLUSIONS

Frailty is associated with an increased risk of in-hospital mortality, complications, and resource utilization among LT recipients. As the proportion of frail LT patients continues to rise, our findings underscore the need for novel risk-stratification and individualized care protocols for such vulnerable patients.

Bladder Cancer Survivors Who Do Not Smoke Have Better Longitudinal Health-Related Quality of Life Measures: An Assessment of the Comparative Effectiveness and Survivorship Health in Bladder Cancer (CEASE-BC) Study

PURPOSE

Cigarette smoking is the most common risk factor for the development of bladder cancer (BC), yet there is a paucity of data characterizing the relationship between smoking status and longitudinal health-related quality of life (HRQoL) outcomes in patients with BC. We examined the association between smoking status and HRQoL among patients with BC.

MATERIALS AND METHODS

Data were sourced from a prospective, longitudinal study open between 2014 and 2017, which examined HRQoL in patients aged ≥ 18 years old diagnosed with BC across North Carolina. The QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire core instrument) was administered at 3, 12, and 24 months after BC diagnosis. Our primary exposure of interest was current smoking status. Linear regression using generalized estimating equations was used to analyze the relationship between smoking status and various domains of the QLQ-C30.

RESULTS

A total of 154 patients enrolled in the study. Eighteen percent were classified as smoking at 3 months from diagnosis, and packs per day ranged from < 0.5 to 2. When controlling for time from diagnosis, demographic covariates, cancer stage, and treatment type, mean differences for physical function (7.4), emotional function (5.6), and fatigue measures (-8.2) were significantly better for patients with BC who did not smoke.

CONCLUSIONS

Patients with BC who do not smoke have significantly better HRQoL scores in the domains of physical function, emotional function, and fatigue. These results underscore the need to treat smoking as an essential component of BC care.

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.

Impact of clinical frailty on surgical and non-surgical complications after major emergency abdominal surgery

BACKGROUND

Major emergency abdominal surgery is associated with a high risk of morbidity and mortality. Given the ageing and increasingly frail population, understanding the impact of frailty on complication patterns after surgery is crucial. The aim of this study was to evaluate the association between clinical frailty and organ-specific postoperative complications after major emergency abdominal surgery.

METHODS

A prospective cohort study including all patients undergoing major emergency abdominal surgery at Copenhagen University Hospital Herlev, Denmark, from 1 October 2020 to 1 August 2022, was performed. Clinical frailty scale scores were determined for all patients upon admission and patients were then analysed according to clinical frailty scale groups (scores of 1-3, 4-6, or 7-9). Postoperative complications were registered until discharge.

RESULTS

A total of 520 patients were identified. Patients with a low clinical frailty scale score (1-3) experienced fewer total complications (120 complications per 100 patients) compared with patients with clinical frailty scale scores of 4-6 (250 complications per 100 patients) and 7-9 (277 complications per 100 patients) (P < 0.001). A high clinical frailty scale score was associated with a high risk of pneumonia (P = 0.009), delirium (P < 0.001), atrial fibrillation (P = 0.020), and infectious complications in general (P < 0.001). Patients with severe frailty (clinical frailty scale score of 7-9) suffered from more surgical complications (P = 0.001) compared with the rest of the cohort. Severe frailty was associated with a high risk of 30-day mortality (33% for patients with a clinical frailty scale score of 7-9 versus 3.6% for patients with a clinical frailty scale score of 1-3, P < 0.001). In a multivariate analysis, an increasing degree of clinical frailty was found to be significantly associated with developing at least one complication.

CONCLUSION

Patients with frailty have a significantly increased risk of postoperative complications after major emergency abdominal surgery, especially atrial fibrillation, delirium, and pneumonia. Likewise, patients with frailty have an increased risk of mortality within 90 days. Thus, frailty is a significant predictor for adverse events after major emergency abdominal surgery and should be considered in all patients undergoing major emergency abdominal surgery.

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.

Robot-Assisted Urological Oncology Procedures, Outcomes, and Safety in Frail Patients: A Narrative Review of Available Studies

In this study, we assess the impact of frailty on the success rate and risk of complications of robot-assisted urological procedures and introduce effective preoperative screening tools to evaluate frail patients' fitness to tolerate robot-assisted urological surgery. We performed a search of electronic databases for available studies, published up to August 2023, investigating the outcomes of robot-assisted urological oncology procedures and their safety in frail patients. Sixteen studies were ultimately selected, investigating the implications of frailty in robot-assisted radical cystectomy, robotassisted partial nephrectomy, and robot-assisted radical prostatectomy. All the studies used the Clavien-Dindo classification of complications with serious complications considered as Clavien-Dindo 3. Frail patients significantly benefit from robot-assisted urological procedures in comparison to open surgery, with lower rates of blood transfusion and a shorter length of stay. However, they also have a higher risk of postoperative complications than non-frail patients, as well as increased rates of conversion to open, total hospital costs, and in-hospital mortality after robot-assisted procedures. Robot-assisted urological procedures can improve the postoperative recovery of frail patients in comparison to open surgery. Reliable frailty indexes such as the Johns Hopkins indicator and simplified frailty index, as well as the Geriatric 8 screening tool, should be routinely used in the preoperative assessment of frail patients to optimize surgical decision-making.

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.

Impairment in Activities of Daily Living Assessed by the Barthel Index Predicts Adverse Oncological Outcomes After Radical Cystectomy for Bladder Cancer

INTRODUCTION

We tested the association between functional impairment in activities of daily living (ADL) assessed through the Barthel Index (BI), and oncological outcomes following radical cystectomy (RC) for bladder cancer (BCa).

PATIENTS AND METHODS

We retrospectively analyzed data of 262 clinically nonmetastatic BCa patients, who underwent RC between 2015 and 2022, with available follow-up. According to preoperative BI, patients were divided in 2 groups: BI ≤90 (moderate/severe/total dependency in ADL) versus BI 95 to 100 (slight dependency/independency in ADL). Kaplan-Meier plots compared disease recurrence (DR)-, cancer-specific mortality (CSM)-, and overall mortality (OM)-free survival according to established categories. Multivariable Cox regression models tested the BI as an independent predictor of oncological outcomes.

RESULTS

According to the BI, the patient cohort was distributed as follows: 19% (n = 50) BI ≤90 versus 81% (n = 212) BI 95-100. Compared to patients with BI 95 to 100, patients with BI ≤90 were less likely to receive intravesical immuno- or chemotherapy (18% vs. 34%, p = .028), and more frequently underwent less complex urinary diversion as ureterocutaneostomy (36% vs. 9%, p < .001), or harbored muscle-invasive BCa at final pathology (72% vs. 56%, p = .043). In multivariable Cox regression models adjusted for age, ASA physical status score, pathological T and N stage, and surgical margins status, BI ≤90 independently predicted higher DR (HR [hazard ratio]:2.00, 95%CI [confidence interval]:1.21-3.30, p = .007), CSM (HR:2.70, 95%CI:1.48-4.90, p = .001), and OM (HR:2.09, 95%CI:1.28-3.43, p = .003).

CONCLUSION

Preoperative impairment in ADL was associated with adverse oncological outcomes following RC for BCa. The integration of the BI into clinical practice may improve the risk assessment of BCa patients candidates to RC.

11-item modified frailty index and outcomes after radical cystectomy

INTRODUCTION

To investigate the association between modified frailty index (mFI) scores and radical cystectomy outcomes.

MATERIALS AND METHODS

We conducted a multicenter retrospective analysis of 292 patients who underwent radical cystectomy between 2015 and 2019. The patients were stratified according to mFI scores (mFI 0-1 vs. mFI ≥2). Baseline characteristics were compared between groups. The primary endpoints were cancer-specific survival (CSS) and overall survival (OS), and the secondary endpoint was the 30-day postoperative complication rate.

RESULTS

One group included 164 patients with mFI 0-1 and the other included 128 patients with mFI ≥2. The cohort's median age was 69 years, and median follow-up for survivors was 33 months. Thirty-day major postoperative complication rate was 19%. Ninety patients (31%) died during the study period, 70 of them (24%) from bladder cancer. Older age, male sex, lower kidney function, and diversion to an ileal conduit were significantly more common in the mFI ≥2 group. The postoperative complication rates were comparable between groups, but the CSS and OS were significantly lower in the frailer group (p = 0.007 and p = 0.03, respectively). An mFI score ≥ 2 emerged as an independent risk factor for cancer-specific death (hazard ratio [HR] = 1.7, p = 0.03) and overall-mortality (HR = 1.8, p = 0.008).

DISCUSSION

High mFI scores are associated with shorter CSS and OS after radical cystectomy. Healthcare providers should be encouraged to calculate frailty preoperatively for judicious patient selection in light of the predicted outcomes.

Association between frailty status and complications in patients undergoing surgical excision of malignant esophageal neoplasms

Background

Research within the last decade highlights the patients' frailty status as an important predictor of esophageal cancer outcomes, but the literature evaluating frailty's role in these patients remains limited. We evaluated the role of frailty in patients undergoing resection of malignant esophageal neoplasms.

Methods

We used the Nationwide Readmissions Database from 2016 and 2017 to identify patients who underwent excision of a malignant esophageal neoplasm. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Propensity score matching identified 289 frail patients and 281 non-frail patients. Mann-Whitney U testing was performed and receiver operating characteristic (ROC) curves were created, following the creation of logistic regression models for predicting discharge disposition. The area under the curve (AUC) served as a proxy for model performance.

Results

Frail patients had significantly more nonroutine discharges, longer inpatient lengths of stay, higher costs, more acute infections, posthemorrhagic anemia and deep vein thrombosis, and greater mortality (P<0.05). No significant differences were found between the 2 cohorts with respect to readmission rates, pulmonary embolism or dysphagia. Predictive models for patient discharge disposition demonstrated that frailty status in combination with age resulted in better ROC curves (AUC: 0.652) compared to models using age alone (AUC: 0.601).

Conclusions

Frailty was found to be significantly correlated with higher rates of inpatient medical complications following esophagectomy. The inclusion of patient frailty status in predictive models for discharge disposition resulted in a better predictive capacity compared to those using age alone.

Robot-assisted radical cystectomy with intracorporeal reconstruction of urinary diversion by mechanical stapler: prospective evaluation of early and late complications

Introduction

Radical cystectomy with pelvic lymph node dissection is the gold standard treatment for non-metastatic muscle-invasive bladder cancer and high-risk non-muscle-invasive bladder cancer. For years, the traditional open surgery approach was the only viable option. The widespread of robotic surgery led to its employment also in radical cystectomy to reduce complication rates and improve functional outcomes. Regardless of the type of approach, radical cystectomy is a procedure with high morbidity and not negligible mortality. Data available in the literature show how the use of staplers can offer valid functional outcomes, with an acceptable rate of complications shortening the operative time. The aim of our study was to describe the perioperative outcomes and complications associated with robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) using a mechanical stapler.

Material and methods

From January 2015 to May 2021, we enrolled patients who underwent RARC with pelvic node dissection and stapled ICUD (ileal conduit or ileal Y-shaped neobladder according to the Perugia ileal neobladder) in our high-volume center. Demographic features, perioperative outcomes and early (≤30 days) and late (>90 days) post-operative complications according to the Clavien-Dindo classification, were recorded for each patient. We also analyzed the potential linear correlation between demographic, pre-operative as well as operative features and the risk of post-operative complications.

Results

Overall, 112 patients who underwent RARC with ICUD were included with a minimum follow-up of 12 months. Intracorporeal Perugia ileal neobladder was performed in 74.1% of cases while ileal conduit was performed in 25.9%. The mean operative time, estimated intraoperative blood loss, and LOS were 289.1 ± 59.7 min, 390.6 ± 186.2 ml, and 17.5 ± 9.8 days, respectively. Early minor and major complications accounted for 26.7% and 10.8%, respectively. Overall late complications were 40.2%. The late most common complications were hydronephrosis (11.6%) and urinary tract infections (20.5%). Stone reservoir formation occurred in 2.7% of patients. Major complications occurred in 5.4%. In the sub-analysis, the mean operative time and the estimated blood loss improved significantly from the first 56 procedures to the last ones.

Conclusion

RARC with ICUD performed by mechanical stapler is a safe and effective technique. Stapled Y-shaped neobladder did not increase the complication rate.

The modified 5-item frailty index is a predictor of post-operative complications in vulvar cancer: a National Surgical Quality Improvement Program (NSQIP) analysis

OBJECTIVE

To determine whether frailty is associated with post-operative complications following surgery for vulvar cancer.

METHODS

This retrospective study used a multi-institutional dataset from the National Surgical Quality Improvement Program (NSQIP) database (2014-2020) to analyze the relationship between frailty, procedure type, and post-operative complications. Frailty was determined using the modified frailty index-5 (mFI-5). Univariate and multivariable-adjusted logistic regression analyses were performed.

RESULTS

Of 886 women, 49.9% underwent radical vulvectomy alone, and 19.5% and 30.6% underwent concurrent unilateral or bilateral inguinofemoral lymphadenectomy, respectively; 24.5% had mFI ≥2 and were considered frail. Compared with non-frail women, those with an mFI ≥2 were more likely to have an unplanned readmission (12.9% vs 7.8%, p=0.02), wound disruption (8.3% vs 4.2%, p=0.02), and deep surgical site infection (3.7% vs 1.4%, p=0.04). On multivariable-adjusted models, frailty was a significant predictor for minor (OR 1.58, 95% CI 1.09 to 2.30) and any complications (OR 1.46, 95% CI 1.02 to 2.08). Specifically, for radical vulvectomy with bilateral inguinofemoral lymphadenectomy, frailty was significantly associated with major (OR 2.13, 95% CI 1.03 to 4.40) and any complications (OR 2.10, 95% CI 1.14 to 3.87).

CONCLUSION

In this analysis of the NSQIP database, nearly 25% of women undergoing radical vulvectomy were considered frail. Frailty was associated with increased post-operative complications, especially in women concurrently undergoing bilateral inguinofemoral lymphadenectomy. Frailty screening prior to radical vulvectomy may assist in patient counseling and improve post-operative outcomes.

Impact of functional impairment and cognitive status on perioperative outcomes and costs after radical cystectomy: The role of Barthel Index

OBJECTIVES

To investigate the association between Barthel Index (BI), which measures level of patients independence during daily living activities (ADL), and perioperative outcomes in a large cohort of consecutive bladder cancer (BCa) patients, who underwent radical cystectomy (RC) at a tertiary referral center.

METHODS

We retrospectively evaluated data from clinically nonmetastatic BCa patients treated with RC between 2015 and 2022. For each patient, BI was assessed preoperatively. According to BI score, patients were divided into three groups: ≤60 (total/severe dependency) vs. 65-90 (moderate dependency) vs. 95-100 (slight dependency/independency). Regression analyses tested the association between BI score and major postoperative complications (Clavien-Dindo >2), length of in-hospital stay (LOHS), 90-days readmission, and total costs.

RESULTS

Overall, 288 patients were included. According to BI score, the patient cohort was distributed as follows: 4% (n = 11) BI ≤60 vs. 15% (n = 42) BI 65-90 vs. 81% (n = 235) BI 95-100. Patients with BI ≤60 had more frequent ureterocutaneostomy performed, shorter operative time, higher rates of postoperative complications, longer LOHS, higher rates of readmission, and were associated with higher total costs, compared to patients with BI 65-90 and 95-100. In multivariable regression models, BI ≤60 remained an independent predictor of increased risk of major postoperative complications (odds ratio: 6.62, p = 0.006), longer LOHS (rate ratio: 1.25, p < 0.001), and higher costs (β: 2.617, p = 0.038).

CONCLUSIONS

Total/severe dependency in ADL assessed by BI was associated with higher rates of major postoperative complications, longer hospitalization, and higher costs in BCa patients treated with RC. BI assessment should be considered during patients selection process and counseling before surgery.

A novel computerized approach to scoping reviews using Synthesis software: the first 15 years of The American College of Surgeons National Surgical Quality Improvement Program

Scoping reviews of innovations in health care characterized by large numbers and types of publications present a unique challenge. A novel software application, Synthesis, can efficiently scan the literature to map the evidence and inform practice. We applied Synthesis to the National Surgical Quality Improvement Program (NSQIP), a high-quality database designed to measure risk-adjusted 30-day surgical outcomes for national and international benchmarking. The scoping review describes the breadth of studies in the NSQIP literature. We performed a comprehensive electronic literature search using PubMed, MEDLINE, Web of Knowledge and Scopus to capture all NSQIP articles published between Jan. 1, 2000, and Dec. 31, 2020. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. We imported references into Synthesis to semiautomate data management. Extracted data included surgical specialty, study type and year of publication. Of the 4661 NSQIP articles included, 3631 (77.9%) were published within the last 5 years. Among NSQIP-related articles, the most common study types were based on outcomes (46.7%) and association (41.7%), and the most common surgical specialties were general surgery and orthopedic surgery, representing 35.7% and 24.0% of the articles, respectively. Synthesis enabled a rapid review of thousands of NSQIP publications. The scoping review provided an overview of the articles in the NSQIP literature and suggested that the NSQIP is increasingly being described in publications of quality and safety in surgery.

The impacts of preoperative frailty on readmission after cardiac implantable electrical device implantation

Cardiac implantable electrical devices (CIED) such as pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapies are generally recommended for older patients and those with severe heart failure (HF). However, there is currently a lack of evidence on the relationship between frailty and readmission rates among patients with CIED. This study investigated whether preoperative frailty influenced readmission rates among patients with CIED over a one-year period following implantation. The study retrospectively analyzed 101 patients who underwent CIED implantations. To compare frailty-based differences in their characteristics and readmission rates, these participants were categorized into frailty and non-frailty groups via the modified frailty index (mFI). The frailty group had a significantly higher readmission rate than the non-frailty group (non-frailty group vs. frailty group = 1 vs. 8 patients: P < 0.05). Further, a multivariate analysis showed that frailty was a significant readmission factor. Based on individual analyses with/without histories of HF, the readmission rate also tended to be higher among individuals considered frail via the mFI (readmission rate in HF patients: non-frailty group vs. frailty group = 1 vs. 5 patients: P = 0.65; non-HF patients: non-frailty group vs. frailty group = 0 vs. 3 patients: P = 0.01). Participants with preoperative frailty showed higher readmission rates within a one-year period following implantation compared to those without preoperative frailty. This tendency was consistent regardless of HF history. The mFI may thus help predict readmission among patients with CIED.

Frailty and Sarcopenia: Impact on Outcomes Following Elective Degenerative Lumbar Spine Surgery

STUDY DESIGN

This is a retrospective review of prospectively collected data.

OBJECTIVE

The aim was to evaluate the impact of frailty and sarcopenia on outcomes after lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Elderly patients are commonly diagnosed with degenerative spine disease requiring surgical intervention. Frailty and sarcopenia result from age-related decline in physiological reserve and can be associated with complications after elective spine surgery. Little is known about the impact of these factors on patient-reported outcomes (PROs).

METHODS

Patients older than 70 years of age undergoing elective lumbar spine surgery were included. The modified 5-item frailty index (mFI-5) was calculated. Sarcopenia was defined using total psoas index, which is obtained by dividing the mid L3 total psoas area by VB area (L3-TPA/VB). PROs included Oswestry disability index (ODI), EuroQual-5D (EQ-5D), numeric rating scale (NRS)-back pain, NRS leg pain (LP), and North American Spine Society (NASS) at postoperative 12 months. Clinical outcomes included length of stay (LOS), 90-day readmission and complications. Univariate and multivariable regression analyses were performed.

RESULTS

Total 448 patients were included. The mean mFI-5 index was 1.6±1.0 and mean total psoas index was 1.7±0.5. There was a significant improvement in all PROs from baseline to 12 months ( P <0.0001). After adjusting for age, body mass index, smoking status, levels fused, and baseline PROs, higher mFI-5 index was associated with higher 12-month ODI ( P <0.001), lower 12-month EQ-5D ( P =0.001), higher NRS-L P ( P =0.039), and longer LOS ( P =0.007). Sarcopenia was not associated with 12-month PROs or LOS. Neither sarcopenia or mFI-5 were associated with 90-day complication and readmission.

CONCLUSIONS

Elderly patients demonstrate significant improvement in PROs after elective lumbar spine surgery. Frailty was associated with worse 12 months postoperative ODI, EQ-5D, NRS-LP scores, and longer hospital stay. While patients with sarcopenia can expect similar outcomes compared with those without, the mFI-5 should be considered preoperatively in counseling patients regarding expectations for disability, health-related quality of life, and leg pain outcomes after elective lumbar spine surgery.

LEVEL OF EVIDENCE

3.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Frailty Assessment for Outcome Prediction of Patients With Prostate Cancer Receiving Radical Prostatectomy: A Meta-Analysis of Cohort Studies

A meta-analysis was conducted to investigate the association between frailty and postoperative complications in patients with prostate cancer following radical prostatectomy. A systematic search of PubMed, Embase, and Web of Science was conducted for relevant cohort studies. A random-effect model was chosen to combine the results. Five cohort studies including 171,929 patients were included. Results showed that patients with frailty had higher risk of severe postoperative complications (Clavien-Dindo IV complications, risk ratio [RR]: 1.87, 95% confidence interval [CI]: 1.67 to 2.10, p < .001; I² = 18%) and all-cause mortality (RR: 2.89, 95% CI: 1.86 to 4.50, p < 0.001; I² = 18%). Subgroup analyses showed consistent results in patients receiving open and robot-assisted radical prostatectomy, and also in studies with univariate and multivariate analyses. In conclusion, preoperative frailty may be a predictor of severe postoperative complications and all-cause mortality of patients with prostate cancer following radical prostatectomy.

Impact of preoperative laboratory frailty index on mortality and clinical outcomes in older surgical patients with cancer

Frailty in older patients is associated with poor postoperative outcomes. The use of uncomplicated frailty measurement tools is preferred in busy clinical settings. Therefore, we validated the frailty index using routine laboratory data and the surgical outcomes of older patients with cancer who underwent cancer resection. We retrospectively analyzed 9015 patients aged 65 years and older who underwent cancer resection at a single tertiary hospital. Based on electronic-medical-record data regarding preoperative blood test results and vital signs, Laboratory Frailty Index (FI-Lab) scores were generated to measure preoperative frailty. The associations of FI-Lab with postoperative length of stay (LOS), readmission within 30 days, intensive care unit (ICU) admission within 30 days, and mortality were evaluated. The mean FI-Lab score of the 9015 patients was 0.20 ± 0.10. Increased FI-Lab scores (0.25–0.4; > 0.4) were associated with longer LOS, increased readmission within 30 days of surgery, ICU admission, and increased mortality, compared with FI-Lab scores < 0.25. The FI-Lab score, as a frailty indicator, was able to predict the risk of poor postoperative outcomes. Therefore, the FI-Lab is a potentially useful tool for assessing preoperative frailty in older patients with cancer in acute clinical setting.

Novel Antimicrobial Strategies to Prevent Biofilm Infections in Catheters after Radical Cystectomy: A Pilot Study

Catheter-associated infections in bladder cancer patients, following radical cystectomy or ureterocutaneostomy, are very frequent, and the development of antibiotic resistance poses great challenges for treating biofilm-based infections. Here, we characterized bacterial communities from catheters of patients who had undergone radical cystectomy for muscle-invasive bladder cancer. We evaluated the efficacy of conventional antibiotics, alone or combined with the human ApoB-derived antimicrobial peptide r(P)ApoB_L^Ala, to treat ureteral catheter-colonizing bacterial communities on clinically isolated bacteria. Microbial communities adhering to indwelling catheters were collected during the patients’ regular catheter change schedules (28 days) and extracted within 48 h. Living bacteria were characterized using selective media and biochemical assays. Biofilm growth and novel antimicrobial strategies were analyzed using confocal laser scanning microscopy. Statistical analyses confirmed the relevance of the biofilm reduction induced by conventional antibiotics (fosfomycin, ceftriaxone, ciprofloxacin, gentamicin, and tetracycline) and a well-characterized human antimicrobial peptide r(P)ApoB_L^Ala (1:20 ratio, respectively). Catheters showed polymicrobial communities, with Enterobactericiae and Proteus isolates predominating. In all samples, we recorded a meaningful reduction in biofilms, in both biomass and thickness, upon treatment with the antimicrobial peptide r(P)ApoB_L^Ala in combination with low concentrations of conventional antibiotics. The results suggest that combinations of conventional antibiotics and human antimicrobial peptides might synergistically counteract biofilm growth on ureteral catheters, suggesting novel avenues for preventing catheter-associated infections in patients who have undergone radical cystectomy and ureterocutaneostomy.

Analysis of readmissions data among frail and non-frail patients presenting for acoustic neuroma

The incidence of acoustic neuromas in the United States is 1.09 per 100,000 with 23,739 newly diagnosed cases in the years 2004 to 2010. Because the recent literature has supported that frailty can serve as a more accurate predictor of patient outcomes when evaluated with age, and is an important variable to consider in the course of patient treatment. The objective of this study was to compare the outcomes of frail patients who had undergone surgery for acoustic neuroma with their non-frail counterparts.The authors conducted a retrospective cohort study of geriatric patients receiving cranial neurosurgery for acoustic neuroma between 2016 and 2017 by using the Nationwide Readmission Database. A total of 396 frail patients and 402 non-frail patients were identified through the database of undergoing surgery for acoustic neuroma. Frail patients had statistically higher rates of readmission (p < 0.01), post-operative infection (p < 0.01), facial paralysis (p < 0.01), urinary tract infection (p < 0.01), hydrocephalus (p < 0.01), and dysphagia (p < 0.01). These post-op morbidities likely led to the increased length of stay (p < 0.01), non-routine discharge (p < 0.01), and all payer cost seen in frail patients (p < 0.01). However, no significant difference was found between frail and non-frail patients with regards to CSF leak, post hemorrhagic anemia, myocardial infarction, and mortality. Patient frailty status is a significant predictor of poor outcomes in the postoperative sequelae of acoustic neuroma surgery. Further, models including patient frailty plus age outperformed those using age alone for prediction of several postoperative complications.

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.