Frailty as a predictor of complications after radical cystectomy: A prospective study of various preoperative assessments

Burg, Madeleine L.; Clifford, Thomas G.; Bazargani, Soroush; Lin‐Brande, Michael; Miranda, Gus; Cai, Jie; Schuckman, Anne; Djaladat, Hooman; Daneshmand, Siamak

doi:10.1016/j.urolonc.2018.10.002

Cited by 52 publications

(61 citation statements)

References 27 publications

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“…Although RC provides the best long-term oncological prognosis in MIBC and recurrent high-risk NMIBC, surgical morbidity and mortality are high. Especially in frail patients, RC has been associated with poor postoperative outcomes [7][8][9][17][18][19].…”

Section: Discussionmentioning

confidence: 99%

Preoperative frailty and outcome in patients undergoing radical cystectomy

et al. 2020

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Objective To determine the value of preoperative frailty screening in predicting postoperative severe complications and 1‐year mortality in patients undergoing radical cystectomy (RC). Patients and Methods Prospective cohort single‐centre study in patients undergoing RC from September 2016 to December 2017. Preoperative frailty screening was implemented as standard care and was used to guide shared decision‐making during multidisciplinary team meetings. Frailty screening consisted of validated tools to assess physical, mental and social frailty. Patients were considered frail when having two or more frailty characteristics. The primary endpoint was the composite of a severe complication (Clavien–Dindo Grade III–V) within 30 days and 1‐year all‐cause mortality. The secondary endpoints included any complication (Clavien–Dindo II–V), length of stay, readmission within 30 days, and all‐cause mortality. Logistic regression analysis and the concordance statistic (c‐statistic) were used to describe the association and predictive value of preoperative frailty screening. Results A total of 63 patients were included; 39 (61.9%) were considered frail. Preoperative frailty was associated with a seven‐fold increased risk of a severe complication or death 1 year after RC [adjusted odds ratio (OR) 7.36, 95% confidence interval (CI) 1.7–31.8; 22 patients]. Compared to the American Society of Anesthesiologists (ASA) score and Charlson Comorbidity Index, frailty showed the best model performance (Nagelkerke R2 0.20) and discriminative ability(c‐statistic 0.72, P < 0.01) for the primary endpoint. After adding frailty to the conventional ASA risk score, the c‐statistic improved by 11% (P < 0.01). Overall survival was significantly worse in frail patients (23.2 months, 95% CI 18.7–30.1) vs non‐frail patients (32.9 months, 95% CI 30.0–35.9; P = 0.01). Conclusions Frail patients undergoing RC are at high risk of postoperative adverse outcomes including death. Preoperative frailty screening improves preoperative risk stratification and may be used to guide patient selection for RC.

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Section: Discussionmentioning

confidence: 99%

Preoperative frailty and outcome in patients undergoing radical cystectomy

et al. 2020

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“…In addition to chronological age, clinical features reflecting biological age have been used to identify patients unfit for RC. Frailty, defined as a syndrome of physiological decline with increased vulnerability to adverse health outcomes, is a predictor of worse postoperative outcomes after RC . Sarcopenia, defined as the degenerative loss of skeletal muscle mass, is another predictor of postoperative complication after RC .…”

Section: Introductionmentioning

confidence: 99%

“…Frailty, defined as a syndrome of physiological decline with increased vulnerability to adverse health outcomes, 5 is a predictor of worse postoperative outcomes after RC. 6,7 Sarcopenia, defined as the degenerative loss of skeletal muscle mass, 8 is another predictor of postoperative complication after RC. 9,10 A curative, but less invasive, treatment option for MIBC patients with such clinical adverse characteristics is urgently required.…”

Section: Introductionmentioning

confidence: 99%

Feasibility and outcomes of selective tetramodal bladder‐preservation therapy in elderly patients with muscle‐invasive bladder cancer

et al. 2020

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Objective To assess the feasibility and functional/oncological outcomes of selective tetramodal bladder‐preservation therapy in elderly patients with muscle‐invasive bladder cancer. Methods This study analyzed 154 patients with non‐metastatic muscle‐invasive bladder cancer who were enrolled into the protocol. After maximal transurethral resection and induction chemoradiotherapy, patients with clinical complete response were offered consolidative partial cystectomy to achieve bladder preservation; otherwise, radical cystectomy was recommended. Postoperative complications, preserved bladder function, and oncological outcomes were compared between elderly (aged ≥75 years) and younger patients (aged <75 years). Frailty and sarcopenia were further assessed as potential factors that could affect the feasibility and outcomes of the protocol. Results A total of 44 patients (29%) were elderly, and 31 (20%) were frail (modified frailty index 2–3). Sarcopenia was observed in 68 (54%) of 126 eligible patients. Clinical complete response to induction chemoradiotherapy was achieved in 125 (81%) patients, and the bladder‐preservation protocol was completed in 107 (69%) patients with consolidative partial cystectomy. Over a median follow‐up period of 48 months, 5‐year cancer‐specific and muscle‐invasive bladder cancer recurrence‐free survival rates after protocol completion were 98% and 95%, respectively. There were no significant differences in complication rates related to partial cystectomy, preserved bladder function, and oncological outcomes between the elderly and younger groups. Neither frailty nor sarcopenia negatively affected these outcomes. Conclusions Tetramodal bladder‐sparing therapy incorporating consolidative partial cystectomy is feasible and yielded favorable functional/oncological outcomes in patients with muscle‐invasive bladder cancer, regardless of advanced age, frailty or sarcopenia. This protocol could be a viable treatment option for such high‐risk patient populations.

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“…Overall, our systematic review included 60 907 patients. The characteristics of the 11 studies selected, frailty indicators, and early postoperative outcomes are reported in Supplementary Table S1 [21][22][23][24][25][26][27][28][29][30][31]. Eligible articles were published between 2015 and 2019 involving patients that underwent RC from 2000 to 2018.…”

Section: Study Population and Designmentioning

confidence: 99%

“…In all, 10 of the 11 studies had a retrospective design. Eight retrospective studies used a frailty index based on the available data points in a national database like the National Inpatient Sample database [22], Nationwide Readmissions Database [23] or ACS-NSQIP database [21,[24][25][26][27][28]; one study used available data from a single-centre cohort [29] and another study from a multicentre cohort [30]; the only prospective study used a frailty assessment based on data from a singlecentre cohort [31].…”

Section: Study Population and Designmentioning

confidence: 99%

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

Ornaghi

Afferi

Antonelli

et al. 2020

Arab Journal of Urology

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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 inhospital 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.

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Frailty as a predictor of complications after radical cystectomy: A prospective study of various preoperative assessments

Cited by 52 publications

References 27 publications

Preoperative frailty and outcome in patients undergoing radical cystectomy

Preoperative frailty and outcome in patients undergoing radical cystectomy

Feasibility and outcomes of selective tetramodal bladder‐preservation therapy in elderly patients with muscle‐invasive bladder cancer

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

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