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Keywords:

  • cystectomy;
  • serum albumin;
  • ASA score;
  • urothelial carcinoma

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

Objective

  • To evaluate the impact of the preoperative American Society of Anesthesiologists (ASA) score and serum albumin level on complications, recurrences and survival rates of patients who underwent radical cystectomy (RC) for urothelial bladder cancer (UBC).

Patients and Methods

  • In all, 1964 patients underwent RC for UBC at our institution between 1971 and 2008.
  • Preoperative serum albumin and ASA score were available in 1471 and 1140 patients, respectively.
  • A complication was defined as any surgery related/unrelated event leading to lengthening hospital stay or re-admission.
  • Endpoints were 90-day complication (90dC) rate, recurrence-free survival (RFS) and overall survival (OS).

Results

  • The median (range) follow-up was 12.4 (0.2–27.3) years. In all, 197 patients (13.4%) had a low albumin level (<3.5 g/dL) and 740 (64.8%) had a high ASA score (3 or 4).
  • Low serum albumin and a high ASA score were associated with higher 90dC rate (42% vs 34%, P = 0.03 and 40% vs 28%, P < 0.001, respectively).
  • On multiple logistic regression analysis, a high ASA score remained independently associated with increased 90dC rate (hazard ratio [HR] 1.52, P = 0.005) and decreased OS (HR 1.45, 95% confidence interval [CI] 1.13–1.86). A low serum albumin level was also independently associated with RFS (HR 1.68, 95% CI 1.16–2.43) and OS (HR 1.93, 95% CI 1.43–2.63).

Conclusion

  • A low serum albumin level was independently associated with cancer recurrence and decreased OS after RC.
  • A high ASA score was also independently associated with decreased OS.
  • These parameters potentially could be used as prognosticators after RC.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

In 2012, an estimated 73 510 new bladder cancer cases will be diagnosed and 14 880 patients will die from bladder cancer in the USA [1]. About 25% of bladder cancers are muscle-invasive for which radical cystectomy (RC) is the standard of care [2]. Most patients undergoing RC are elderly with multiple comorbidities that might place them at higher risk for perioperative complications and/or mortality [3].

The complication and mortality rate at ≤90 days after RC are reported as high as 60% and 7%, respectively [4]. Advanced age, operative blood loss and high American Society of Anesthesiologist (ASA) score are among risk factors identified for increased perioperative complications and mortality rate [4]. The ASA score has been commonly used to assess patients' comorbidities, although it has lacked the discriminative ability to provide insight into those at risk for a complication [5]. In addition, nutritional deficiency, which can be potentially assessed with serum albumin measurement, is a well-known risk factor for postoperative complications, e.g. wound healing and infectious complications [6, 7]. Accurate measurement of determinants of postoperative complications and mortality are crucial to provide a realistic framework for individual risk adjustment before RC. The association between serum albumin level, ASA score and oncological outcomes, in particular recurrence-free survival (RFS) is not clear. In the present study, we aimed to evaluate the impact of nutritional deficiency marked by hypoalbuminaemia and preoperative morbidity recognised by a high ASA score on the early complication and mortality rate (≤90 days after RC), RFS and OS in patients who underwent RC for urothelial bladder cancer (UBC).

Patients and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

We reviewed our Institutional Review Board-approved bladder cancer database of 1964 patients who underwent RC and bilateral lymph node dissection for UBC with intent to cure at our institution between 1971 and 2008. Only patients with available preoperative serum albumin level (since 1975; 1471 cases) and/or ASA score (since 1983; 1140 cases) were included. Primary endpoints of this study were early complication rate (90-day complication, 90dC), 90-day mortality rate (90dM), RFS and OS. An early complication was defined as any surgery related/unrelated adverse event leading to lengthening of hospital stay or re-admission ≤90 days after RC.

Complications were prospectively collected and subsequently retrospectively stratified into type of organ involvement by one investigator (H.M.B.) ‘blinded’ to patient identification and outcomes. Types of complications included: (i) cardiorespiratory, (ii) gastrointestinal, (iii) renal and electrolyte, (iv) neurological, (v) haematological, (vi) wound healing, (vii) infectious, and (viii) other. Time to OS was calculated from the date of RC to the date of death (death from all causes). Time to recurrence was calculated from the date of RC to the date of first documented clinical recurrence (local, distant or both). If lost to follow-up before having a recurrence, the subjects were censored at the date of last follow-up. The ASA score was used to assess the physical status of patients before RC and stratified into high (3–4) and low (1–2) scores in this study. The serum albumin level was determined just preoperatively and stratified into low albumin group (<3.5 g/dL) and normal albumin group (≥3.5 g/dL). UBC staging was performed using the 2010 American Joint Committee on Cancer-TNM staging system [8]. All patients were followed postoperatively according to a standardised algorithm unless clinically indicated otherwise − at 4-month intervals for first year, 6-month intervals for second year and annually thereafter with blood tests and chest, abdomen and pelvis imaging. The median (range) follow-up was 12.4 (0.2–27.3) years. In lost to follow-up cases, patients were censored from the analysis at the date of last follow-up. Patients without evidence of disease at last follow up were noted to be ‘free of disease’.

Univariate and multivariable survival analysis were done using Kaplan–Meier and Cox proportional hazards models, respectively. Multiple logistic regression was used to analyse the association of multiple variables with 90dC adjusting for potential confounding variables. All P-values are two-sided; P ≤ 0.05 was considered to indicate statistical significance.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

In all, 1471 patients with available preoperative albumin levels were included of whom 197 patients (13.4%) had a low albumin level. The median (range) age was 67 (30–93) years in patients with a normal albumin level and 73 (49–91) years in those with a low albumin level. The ASA score was available for 1140 patients of whom 400 patients (35.1%) had an ASA score of ≤2 and 740 (64.9%) had an ASA score of ≥3. Baseline characteristics, stratified by ASA score and albumin level, are summarised in Tables 1 and 2, respectively.

Table 1. Clinical and pathological characteristics stratified by ASA score in 1140 patients
VariableASA 1–2ASA 3–4P
  1. NS, non-significant.

N400740 
N (%)
Age, years:
<60185 (46.3)136 (18.4)<0.001
60–69132 (33.0)244 (33.0)
70–7974 (18.5)267 (36.1)
≥809 (2.3)93 (12.5)
Gender:
Male320 (80.0)574 (77.6)NS
Female80 (20.0)166 (22.4)
Urinary diversion:
Orthotopic303 (75.7)571 (77.2)NS
Non-orthotopic97 (24.3)169 (22.8)
Pathological subgroup:
≤pT2, LN–256 (64.0)434 (58.6)NS
>pT2, LN–71 (17.8)144 (19.5)
pTany, LN+73 (18.2)162 (21.9)
Concomitant carcinoma in situ:
Absent151 (37.8)284 (38.4)NS
Present249 (62.2)456 (61.6)
Lymphovascular invasion:
Absent302 (75.5)514 (69.5)0.033
Present98 (24.5)226 (30.5)
Mean (range)
Operative time, hours6.1 (3–11.5)6 (3.2–11.2)NS
Hospital stay, days9.6 (4–45)10.4 (5–62)
N (%)
Transfusion rate:
Absent214 (53.5)219 (29.5)<0.001
Present186 (46.5)521 (70.4)
Neoadjuvant chemotherapy:
No375 (93.7)691 (93.3)NS
Yes25 (6.3)49 (6.7)
Adjuvant chemotherapy:
No297 (74.3)602 (81.4)0.006
Yes103 (25.7)138 (18.6)
Mortality ≤90 days:
No395 (98.8)714 (96.5)0.025
Yes5 (1.2)26 (3.5)
Complications ≤90 days:
No285 (71.3)441 (59.6)<0.001
Yes115 (27.7)299 (40.4)
Table 2. Clinical and pathological characteristics stratified by albumin level in 1471 patients
VariableNormal albumin (≥3.5 g/dL)Low albumin (<3.5 g/dL)P
  1. NS, non-significant.

N1274197 
N (%):
Age, years:
<60346 (27.2)17 (8.6)<0.001
60–69426 (33.4)62 (31.5)
70–79405 (31.8)79 (40.1)
≥8097 (7.6)39 (19.8)
Gender:
Male1021 (80.1)133 (67.5)0.001
Female253 (19.9)64 (32.5)
Urinary diversion:
Orthotopic944 (74.1)120 (60.9)<0.001
Non-orthotopic330 (25.9)77 (39.1)
Pathological subgroup:
≤pT2, LN–754 (59.2)73 (37.1)<0.001
>pT2, LN–238 (18.7)58 (29.4)
pT any, LN+282 (22.1)66 (33.5)
Concomitant carcinoma in situ
Absent503 (39.5)94 (47.7)0.029
Present771 (60.5)103 (52.3)
Lymphovascular invasion:
Absent922 (72.4)114 (57.9)<0.001
Present352 (27.6)83 (42.1)
Mean (range):
Operative time, hours6 (1–11.5)5.9 (1–9)NS
Hospital stay, days10.5 (1–83)10.6 (5–59)
N (%):
Transfusion rate:  <0.001
Absent580 (45.5)44 (22.3) 
Present694 (54.4)153 (77.6)
Neoadjuvant chemotherapy:
No1182 (92.7)182 (92.3)NS
Yes92 (7.2)15 (7.6)
Adjuvant chemotherapy:
No986 (77.4)156 (79.2)NS
Yes288 (22.6)41 (20.8)
Mortality ≤90 days:
No1232 (96.7)182 (92.4)0.008
Yes42 (3.3)15 (7.6)
Complications ≤90 days:
No846 (66.4)115 (58.4)0.030
Yes428 (33.6)82 (41.6)

Compared to the low ASA score group, patients in the high ASA score group had a significantly higher 90dC rate on both univariate and multivariable analysis (Tables 1 and 3). The 90dC rate increased from 27.8% in patients with a low ASA score to 40.4% in patients with a high ASA score. Complications that occurred significantly more often in the high ASA score group were cardiorespiratory (P = 0.004), wound healing (P < 0.001), infectious (P = 0.024) and renal and electrolyte-related (P < 0.001) complications. An ASA score of ≥3 was furthermore statistically significantly associated with an increased 90dM rate on univariate analysis (P < 0.001; Table 1). Multivariable analysis was not performed due to the few events (N = 26). In all, 77% of these deaths were due to non-cancerous causes. The 5-year OS rate was 68.0% in the high ASA score group compared with 82.5% in the low ASA score group (P < 0.001; Fig. 1A). In addition, RFS was significantly lower in the high ASA score group compared with the low ASA score group (79.6% vs 73.3%, P = 0.015; Fig. 1B). On multivariable analysis, an ASA score of ≥3 was independently associated with decreased OS (hazard ratio [HR] 1.45, P = 0.003), but not decreased RFS (HR 1.00, P = 0.99) as shown in Table 4.

figure

Figure 1. Impact of ASA score on OS (A) and RFS (B).

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Table 3. Multivariable logistic regression analysis for 90dC rate after RC
VariableOR (95% CI)P
Patient age, years: 0.028
≤651.00 (Reference) 
>651.36 (1.03–1.79)
Gender:
Male1.00 (Reference)0.11
Female0.77 (0.55–1.06)
Tumour stage:
≤pT2b1.00 (Reference)0.047
≥pT3a1.25 (0.87–1.79)
Tumour grade: 0.08
Low1.00 (Reference) 
High1.37 (0.96–1.95)
Multifocal disease:
Absent1.00 (Reference)0.56
Present1.09 (0.82–1.43)
Lymph node status:
pN01.00 (Reference)0.05
pN1–30.78 (0.52–1.15)
Lymphovascular invasion:
Absent1.00 (Reference)0.91
Present0.98 (0.70–1.38)
ASA score:
1–21.00 (Reference)0.005
3–41.52 (1.14–2.03)
Albumin level:
Normal1.00 (Reference)0.06
Low1.41 (0.98–2.02)
Table 4. Multivariable analysis for OS and RFS (N = 1029)
VariableNumber of patientsOSRFS
HR (95% CI)PHR (95% CI)P
Patient age, years
≤654541.00 (Reference)<0.0011.00 (Reference)0.54
>655751.89 (1.49–2.40)0.92 (0.70–1.21)
Gender:
Male8071.00 (Reference)0.721.00 (Reference)0.34
Female2221.05 (0.81–1.36)1.16 (0.85–1.58)
Tumour stage:
≤pT2b6871.00 (Reference)<0.0011.00 (Reference)<0.001
≥pT3a3422.27 (1.71–3.02)3.15 (2.19–4.54)
Lymph node status:
pN08101.00 (Reference)<0.0011.00 (Reference)<0.001
pN1–32194.65 (3.34–6.47)7.66 (5.13–11.43)
Lymphovascular invasion:
Absent7371.00 (Reference)0.161.00 (Reference)0.002
Present2921.20 (0.93–1.55)1.62 (1.20–2.18)
Type of diversion:
Orthotopic8151.00 (Reference)0.851.00 (Reference)0.11
Non-orthotopic2141.03 (0.80–1.32)0.77 (0.55–1.06)
Adjuvant chemotherapy:
No8101.00 (Reference)<0.0011.00 (Reference)<0.001
Yes2190.41 (0.30–0.56)0.41 (0.29–0.59)
ASA score:
1–23501.00 (Reference)0.0031.00 (Reference)0.99
3–46791.45 (1.13–1.86)1.00 (0.75–1.34)
Albumin level:
Normal8711.00 (Reference)<0.0011.00 (Reference)0.006
Low1581.93 (1.43–2.63)1.68 (1.16–2.43)

In patients with a low albumin level, the 90dC rate was significantly higher than in patients with a normal albumin level (41.6% vs 33.6%, P = 0.030). Wound healing (P = 0.008) and gastrointestinal (P = 0.004) complications occurred significantly more often in the low albumin group than in the normal albumin group. On multivariable analysis, the association between albumin level and 90dC rate was lost (odds ratio [OR] 1.41, P = 0.06; Table 3). The 90dM rate was significantly higher in patients with a low albumin level (P = 0.008) on univariate analysis. However, multivariable analysis was not performed due to the few events (N = 15). In all, 87% of these deaths were due to non-cancerous causes. The 5-year OS was 37.9% in the low albumin group compared with 63.2% in the high albumin group (P < 0.001; Fig. 2A). In addition, the 5-year RFS rate was significantly lower in patients with a low albumin level than in those with a high albumin level (53.1% vs 68.6%, P < 0.001; Fig. 2B). Adjusting for multiple potential confounding factors, low albumin level remained independently associated with both decreased OS (HR 1.93, P < 0.001) and RFS (HR 1.68, P = 0.006), as shown in Table 4. Considering albumin as a continuous variable did not change these associations significantly.

figure

Figure 2. Impact of albumin level on OS (A) and RFS(B).

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

In the present study we assessed the impact of the preoperative albumin level and ASA score on the 90dM rate, 90dC rate, and long-term survival outcomes after RC. The results of the present study confirm that a high ASA score is independently associated with the increased risk of complications after RC, consistent with previous studies [9-12]. The 90dC rate was 1.5-fold higher in the high ASA score group (ASA score of ≥3) compared with the low ASA score group, while others reported an even larger increase in complication rate [9]. In addition to a higher 90dC rate, the 90dM rate was significantly higher in the group of patients with an ASA score of ≥3. Although multivariable analysis could not be performed due to a low 90dM rate, this finding is consistent with other studies [9, 13, 14]. In fact, Mayr et al. [14] recently evaluated four comorbidity indices (Adult Comorbidity Evaluation-27 [ACE-27], Charlson Comorbidity Index [CCI], Eastern Cooperative Oncology Group [ECOG] performance status and ASA classification) and found the ASA score and ACE-27 to have the best predictive accuracy for 90dM after RC. In the present database, 618 patients had available CCI and categorical ASA score was correlated with CCI (data not shown). Thus, the ASA score appears to be an effective tool to assess the risk of complications and mortality after RC and is furthermore routinely obtained preoperatively. Nonetheless, prospective studies are needed to validate these findings and to investigate whether further comorbidity information may improve outcome prediction after RC [15].

Nutritional deficiency is an established risk factor for adverse perioperative outcomes [11, 16]. However, the optimal indices for nutritional status are a topic of debate. Recently, it has been suggested that the albumin level alone may be a sufficient marker of nutritional status [16]. In fact, the albumin level alone has been associated with poor perioperative outcomes [16-19]. Gibbs et al. [11], analysing >54 000 non-cardiac surgery cases, reported an increase in the 30-day mortality rate from 1% in patients with an albumin level of ≥4.6 g/dL to 28% in patients with albumin levels of ≤2.1 g/dL. Extending the follow-up window to 90-days after RC, we found the 90dM rate increased from 3.3% in patients with a normal albumin level (≥3.5 g/dL) to 7.6% in patients with a low albumin level (<3.5 g/dL; Table 2). In addition to increased 90dM, the 90dC rate was significantly higher in patients with a low albumin on univariate analysis (P = 0.030), but not on multivariable analysis (OR 1.41; P = 0.06). Possibly the number of patients with a low albumin level were too low to detect a potential significant association. Thus, the albumin level may be a potential marker for poor perioperative outcomes, but warrants prospective validation. In addition, the possibilities and effectiveness of nutritional interventions requires further investigation.

Cardiorespiratory, wound healing, infectious and renal and electrolyte complications were more common in patients with a high ASA score than in those with a low ASA score. This finding was not unexpected considering the underlying (severe) systemic disease with predisposition to poor recovery after surgery. Wolters et al. [13] reported similar findings in a general surgery cohort of 6301 patients. In their series, broncho-pulmonary and cardiac complications as well as wound infections and UTIs were increasingly more common in higher ASA classes. For the albumin level, wound healing and gastrointestinal complications were more common in patients with a low albumin level. Possibly, the low albumin level reflects a poor nutritional status that alters the body immune system and delaying wound repair.

To date, neither the ASA score nor preoperative albumin levels are incorporated in post-RC survival nomograms [20]. In fact, limited data is available on the impact of ASA score or albumin level on long-term survival outcomes after RC. One study found an ASA score of ≥3 to be associated with decreased OS, but not cancer-specific survival [14]. In the present study, comprising a larger cohort with longer follow-up, an ASA score of ≥3 was independently associated with decreased OS adjusting for a number of potential confounding variables (Table 4). A high ASA score was also univariately associated with RFS (P = 0.015), but this association was not independent on multivariable analysis (Table 4). For the albumin level, one study has reported an adverse association between albumin level and long-term OS [16]. Also, Lambert et al. [21] reported a significantly higher OS at 3 years after RC in patients with normal albumin compared with low albumin. To the best of our knowledge, the impact of albumin on RFS has not been previously investigated. In the present study, survival outcomes of patients with low albumin levels were relatively poor, with 5-year RFS and OS rates of 53.1% and 37.9%, respectively. Although baseline differences between the low and normal albumin groups were present, a low albumin level was independently associated with both decreased RFS and OS adjusting for potential confounding variables (Table 4). The exact explanation for the impact of albumin on RFS and OS is not known; it may be due to altered immune modulation, more aggressive behaviour of UBC or higher burden of micro-metastatic disease at the time of RC in patients with compromised nutritional status. Although the explanation remains unknown, these findings suggest that both the ASA score and albumin level, upon external validation, might improve the predictive accuracy of current nomograms.

The present study is subject to several limitations. First, we conducted a retrospective study with its inherent limitations. In particular, ASA scores and/or albumin levels were not available for all patients. In addition, ASA scores were determined by multiple anesthesiologists and inter-observer variability may have occurred. Also, some of the clinical and pathological characteristics were not equally distributed between different albumin level and ASA score cohorts. Complications were not registered using an externally validated complication classification, e.g. the Clavien classification [22]. Instead, complications were registered in a standardised, prospective manner and subsequently grouped by one ‘blinded’ person. Nonetheless, we acknowledge this classification is non-validated. Notwithstanding these limitations, data from the present large study may aid in the preoperative individual risk assessment for perioperative and long-term outcomes in patients undergoing RC.

In conclusion, a low serum albumin level was independently associated with decreased RFS and OS after RC for UBC. In addition, a high ASA score was independently associated with increased 90dC rate and decreased OS. Upon external validation, incorporation of the preoperative albumin level and ASA score may improve outcome prediction of post-RC nomograms.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References

We would like to thank Sameer Chopra for his help with the manuscript.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. Conflict of Interest
  9. References
  • 1
    National Cancer Institute. Bladder cancer. Available at: http://www.cancer.gov/cancertopics/types/bladder. Accessed May 2013
  • 2
    Bischoff CJ, Clark PE. Bladder cancer. Curr Opin Oncol 2009; 21: 272277
  • 3
    Maffezzini M, Gerbi G, Campodonico F, Parodi D. A multimodal perioperative plan for radical cystectomy and urinary intestinal diversion: effects, limits and complications of early artificial nutrition. J Urol 2006; 176: 945949
  • 4
    Shabsigh A, Korets R, Vora KC et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009; 55: 164174
  • 5
    Chang SS, Cookson MS, Baumgartner RG, Wells N, Smith JA Jr. Analysis of early complications after radical cystectomy: results of a collaborative care pathway. J Urol 2002; 167: 20122016
  • 6
    Mainous MR, Deitch EA. Nutrition and infection. Surg Clin North Am 1994; 74: 659676
  • 7
    Karl A, Staehler M, Bauer R et al. Malnutrition and clinical outcome in urological patients. Eur J Med Res 2011; 16: 469472
  • 8
    Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. Urinary bladder. AJCC Cancer Staging Manual, 7 edn. New York: Springer, 2010: 497
  • 9
    Boström PJ, Kössi J, Laato M, Nurmi M. Risk factors for mortality and morbidity related to radical cystectomy. BJU Int 2008; 103: 191196
  • 10
    Hautmann RE, de Petriconi RC, Volkmer BG. Lessons learned from 1,000 neobladders: the 90-day complication rate. J Urol 2010; 184: 990994
  • 11
    Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri S. Peri-operative serum albumin level as a predictor of operative mortality and morbidity: results from the national VA surgical risk study. Arch Surg 1999; 134: 3642
  • 12
    Zebic N, Weinknecht S, Kroepfl D. Radical cystectomy in patients aged ≥ 75 years: an updated review of patients treated with curative and palliative intent. BJU Int 2005; 95: 12111214
  • 13
    Wolters U, Wolf T, Stützer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcomes. Br J Anaesth 1996; 77: 217222
  • 14
    Mayr R, May M, Martini T et al. Comorbidity and performance indices as predictors of cancer-independent mortality but not of cancer-specific mortality after radical cystectomy for urothelial carcinoma of the bladder. Eur Urol 2012; 62: 662670
  • 15
    Froehner M, Koch R, Wirth MP. Re: Roman Mayr, Mattias May, Thomas Martini, et al. Comorbidity and performance indices as predictors of cancer-independent mortality but not of cancer-specific mortality after radical cystectomy for urothelial carcinoma of the bladder. Eur Urol 2013; 63: e9
  • 16
    Gregg JR, Cookson MS, Phillips S et al. Effect of pre-operative nutritional deficiency on mortality after radical cystectomy for bladder cancer. J Urol 2011; 185: 9096
  • 17
    Beghetto MG, Luft VC, Mello ED, Polanczyk CA. Accuracy of nutritional assessment tools for predicting adverse hospital outcomes. Nutr Hosp 2009; 24: 5662
  • 18
    Hollenbeck BK, Miller DC, Taub DA et al. The effects of adjusting for case mix on mortality and length of stay following radical cystectomy. J Urol 2006; 176: 13631368
  • 19
    Morgan TM, Keegan KA, Barocas DA et al. Predicting the probability of 90-day survival of elderly patients with bladder cancer treated with radical cystectomy. J Urol 2011; 186: 829834
  • 20
    Shariat SF, Karakiewicz PI, Palapattu GS et al. Nomograms provide improved accuracy for predicting survival after radical cystectomy. Clin Cancer Res 2006; 12: 66636676
  • 21
    Lambert JW, Ingham M, Gibbs BB, Given RW, Lance RS, Riggs SB. Using preoperative albumin levels as a surrogate marker for outcomes after radical cystectomy for bladder cancer. Urology 2013; 81: 587592
  • 22
    Clavien P, Sanabria J, Strasberg S. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 1992; 111: 518526
Abbreviations
90dC

90-day complication (rate)

90dM

90-day mortality (rate)

ACE-27

Adult Comorbidity Evaluation-27

ASA

American Society of Anesthesiologists

CCI

Charlson Comorbidity Index

HR

hazard ratio

OR

odds ratio

OS

overall survival

RC

radical cystectomy

RFS

recurrence-free survival

UBC

urothelial bladder cancer