Nikhil Vasdev 1, James Prentis 2, Rachael French 1,

Georgina Dines 1, Chris Snowden 2, Andrew C Thorpe 1

Department of Urology 1 and Anesthetics 2, Freeman Hospital, Newcastle upon Tyne, UK

IMPAIRED CARDIOPULMONARY RESERVE IN AN ELDERLY POPULATION IS RELATED TO

POSTOPERATIVE MORBIDITY AND HOSPITAL LENGTH OF STAY AFTER RADICAL CYSTECTOMY

INTRODUCTION• Radical Cystectomy with pelvic lymph node dissection remains the gold

standard surgical treatment for muscle invasive bladder cancer

• A Radical Cystectomy is associated with high rates of morbidity (19-64%) and mortality (6-11%), although there is a considerable variability between published series

• To define the relationship between pre-operative cardiopulmonary function and post operative parameters (Morbidity, Hospital Length of Stay) in a cohort of patients above the age of 70 who underwent an open radical cystectomy and ileal conduit formation

AIM

• Regional Ethics Approval

• Over a 3 year period all patients undergoing RC were pre-assessed using CPET

• Patients underwent a maximal progressive exercise test on an electronically braked ergometer (Lode,Gronigen,Netherlands)

• Parameters recorded

• Anaerobic Threshold

• Offline Ventilation (Ve), Oxygen consumption (VO2), Carbon Dioxide production (VCO2) and Cardiac function by 12 lead ECG

METHODS

STATISTICAL ANALYSIS• Kaplan-Meier Analysis - Relationship between postoperative complications

and hospital length of stay

• Logistic Regression Analysis – Relationship between preoperative gaseous exchange variables, derived from CPET, with the development of postoperative complications

• Receiver operator curves - Investigate independent variables as predictors of postoperative complications

RESULTS• Median age 70

• 82 patients attended the preassesment clinic and underwent preoperative CPET

• 5 patients were unable to attain the AT or perform the test

• 8 patients did not undergo cystectomy due to clinical determined fitness, advance malignancy or refusal of the planned operation

• Total of 69 patients were included in the study

RESULTSMorbidity and Hospital Length of Stay

• The median hospital length of stay (LOS) for the whole group was 17.5 days

• Patients who suffered from any postoperative complication had a significant increased length of hospital stay compared to those patients who had no complications (21 vs 15 days, p<0.0001, HR 3.66, CI 1.98 – 6.76)

• There was a significant difference in LOS between Clavien complication group (Chi squared 26.5, DF 2, p<0.0001)

• The median values for hospital LOS as per Clavien groups were

• No complication = 15 days (95% CI, 13.8 – 16.2)

• Clavien < 3 = 19 days (95% CI, 13.0 – 23.0)

• Clavien ≥ 3 = 30 days (95% CI, 28.9 – 31.1)

RESULTSMorbidity and Hospital Length of Stay

• Multivariate logistic regression analysis demonstrated that Anaerobic Threshold (AT) was the only significant independent predictor for post-operative major morbidity (Clavien ≥ 3) [Odds Ratio 0.74, 95% CI 0.57-0.97, p=0.03)

• ROC curves of AT to major complication development demonstrated good accuracy (95% CI 0.60-0.82, p=0.0018)

• When the optimal value of 12 ml/min/kg of the AT was used there was a significant relationship between cardiorespiratory fitness and length of hospital stay (Unfil 22 days vs fit 16 days) [HR 0.47, 95% CI 0.28-0.08,p=0.006)

• 2 patients died from Multiorgan failure (The AT for these patients were 8.4 and 9.8)

CONCLUSION

• Impaired preoperative cardiopulmonary reserve was related to major morbidity, prolonged hospital stay and increased use of critical care resource after radical cystectomy

• Our study has important health and economic implications for risk assessment, rationalization of postoperative resource and the potential for therapeutic preoperative intervention with exercise therapy

Paper in Press (BJUI-05/13)

FUNDING SOURCES / ACKNOWLEDGMENT

• The research leading to these results has received funding from

• The Medical Research Council Newcastle Centre for Brain Ageing and Vitality

• The UK National Institute for Health Research Biomedical Research Centre on Ageing & Age Related Diseases