Impaired cardiopulmonary reserve in an elderly population is related to postoperative morbidity and length of hospital stay after radical cystectomy

Authors


Correspondence: James Prentis, Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK.

e-mail: james.prentis@nuth.nhs.uk

Abstract

Objective

  • To determine the relationship of preoperatively measured cardiorespiratory function, to the development of postoperative complications and length of hospital stay (LOS) in a cohort of patients undergoing radical cystectomy (RC), as RC and conduit formation is curative but is associated with significant postoperative morbidity and mortality.

Patients and Methods

  • Consecutive patients planned to have RC underwent cardiopulmonary exercise testing (CPET) to a standardised protocol.
  • The results of the CPET were ‘blinded’ from the clinicians involved in the care of the patients.
  • Patients were prospectively monitored for the primary outcome of postoperative complications, as defined by a validated classification (Clavien-Dindo).
  • Secondary outcome included LOS and mortality.

Results

  • In all, 82 patients underwent CPET before RC. Eight patients did not subsequently undergo RC and a further five did not exercise sufficiently to allow for appropriate determination of the cardiopulmonary variables of interest.
  • There was a significant difference in LOS between those patients who had a major perioperative complication (Clavien score > 3) and those that did not (16 vs 30 days; P < 0.001; hazard ratio [HR] 3.6, 95% confidence interval [CI] 2.1–6.3).
  • The anaerobic threshold (AT) remained as the only significant independent predictor variable for the presence or absence of major postoperative complications (odds ratio 0.74, 95% CI 0.57–0.97; P = 0.03).
  • When the optimal predictive value of AT of 12 mL/min/kg was used as a fitness marker, there was a significant relationship between fitness and LOS (median LOS: ‘unfit’ 22 days vs ‘fit’ 16 days; HR 0.47, 95% CI 0.28–0.80; P = 0.006)

Conclusion

  • Impaired preoperative cardiopulmonary reserve was related to major morbidity, prolonged LOS and increased use of critical care resource after RC.
  • This has important health and economic implications for risk assessment, rationalisation of postoperative resource and the potential for therapeutic preoperative intervention with exercise therapy.

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