Preoperative cardiopulmonary risk assessment as predictor of early noncancer and overall mortality after radical prostatectomy

doi:10.1016/S0090-4295(02)02250-1

Urology

Volume 61, Issue 3, March 2003, Pages 596-600

https://doi.org/10.1016/S0090-4295(02)02250-1 Get rights and content

Abstract

Objectives

To evaluate the capability of the preoperative cardiopulmonary risk assessment to predict early noncancer and overall mortality after radical prostatectomy for clinically localized prostate cancer.

Methods

In 444 consecutive radical prostatectomy patients, the American Society of Anesthesiologists Physical Status classification and the presence of cardiac insufficiency (New York Heart Association classification), angina pectoris (Canadian Cardiovascular Society classification), diabetes, hypertension, history of thromboembolism, and chronic obstructive or restrictive pulmonary disease were assessed. Kaplan-Meier time-event curves and Mantel-Haenszel hazard ratios were estimated for noncancer (other deaths were censored) and overall mortality. Cox proportional hazard models were used to analyze possible combined effects of risk factors.

Results

During an average follow-up of 4.7 years, 36 patients died: 15 of noncancer causes, 14 of prostate cancer, 6 of other cancers, and 1 in a car accident. The comorbidity scores for American Society of Anesthesiologists Physical Status classification, New York Heart Association classification, and Canadian Cardiovascular Society classification and combinations between the latter two scores were significantly associated with early noncancer mortality in a dose-response pattern. Furthermore, patients with chronic obstructive pulmonary disease were at increased risk. The association with overall mortality was less strong.

Conclusions

The preoperative cardiopulmonary risk assessment may be used as a predictor of early noncancer and overall mortality after radical prostatectomy and should be evaluated further as a source of prognostic information in surgical oncology.

Section snippets

Material and methods

All 444 patients (mean age 63.9 years, range 45 to 76) who underwent radical prostatectomy for clinically localized prostate cancer between December 1, 1992 and December 31, 1998, were included in this study. The patients were subdivided into three age groups (less than 60 years; 60 to 69 years; and 70 years or older at surgery). Comorbidity data with relevance for anesthesia (ASA classification [available at http://www.asahq.org/Profinfo/PhysicalStatus.html] and NYHA and CCS classifications

Results

The average follow-up was 4.7 years (surviving patients, range 2.1 to 8.6). In the univariate analysis, the risk of comorbid death was significantly greater among patients with severe systemic disease (ASA 3, Fig. 1), cardiac insufficiency (NYHA 1 or greater, Fig. 2), angina pectoris (CCS 1 or more, Fig. 3), or COPD (P <0.01) compared with those without these conditions. Of the 15 patients who died of comorbidity, 12 (80%) had at least one of the adverse factors (ASA 3, NYHA 1 or more, CCS 1

Comment

The results of this study confirm the prognostic value of the ASA classification in a radical prostatectomy cohort for the early postoperative period analogously to the experiences with head and neck cancer.5, 7 Moreover, the results demonstrate that the NYHA and CCS classifications of cardiac risk may also be used as predictors of comorbid and overall mortality during the first postoperative years. Although too few events occurred to generalize the prognostic model, nevertheless, the

Conclusions

The results of this study demonstrate the capability of preoperative cardiopulmonary risk assessment to predict comorbid and overall mortality with dose-response relationships during the first years after radical prostatectomy. The results of this study encourage additional investigation of preoperative cardiopulmonary risk assessment as source of prognostic information in surgical oncology.

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Cited by (18)

Which comorbidity classification best fits elderly candidates for radical prostatectomy?
2013, Urologic Oncology: Seminars and Original Investigations
Citation Excerpt :
We used a heuristic approach based on relatively simple survival analyses to isolate an optimal classification for practical use. The criteria used to rank the classifications resulted from intensive work with comorbidity assessment in the radical prostatectomy setting [16,20,21]. Therefore, there are certainly subjective judgments involved driven by the properties of the investigated comorbidity classifications.
Comorbidity assessment may assist in the treatment choice for elderly men with prostate cancer. There is, however, no consensus on the best comorbidity classification for this purpose. In this study, we used a heuristic approach to identify an optimal comorbidity classification in elderly men selected for radical prostatectomy.
A total of 1,106 men aged 65 years or older who underwent radical prostatectomy for clinically localized prostate cancer were stratified by 11 3-sided comorbidity classifications. Overall survival was the study endpoint. The comorbidity classifications were evaluated considering 4 statistical (height of hazard ratios and P values, survival difference between high and low risk patients, dose-response relationship) and 4 clinical demands (survival rates in low and high risk group, balance of the proportion of the risk groups). The 3 best classifications in each category received 3, 2, or 1 point. After adding all points, the classification with the highest score was considered best.
With one exception, all comorbidity classifications were significant predictors of overall survival. Comparing the highest with the lowest risk group, the hazard ratios ranged between 1.67 and 3.93. Concerning the fulfillment of clinical and statistical demands, the American Society of Anesthesiologists (ASA) physical status classification and 1 derivative of it that included further more clearly defined diseases were the most promising candidates.
Stratifying candidates for radical prostatectomy according to their mortality risk using the ASA classification as a backbone supplemented by a list of more clearly defined concomitant diseases could be useful in clinical practice and outcome studies.
Delayed surgical treatment of benign prostatic hyperplasia: a subjective estimation of change in the operative risk profile
2006, Journal of Men's Health and Gender
Benign prostatic hyperplasia (BPH) patients are nowadays operated on at an older age, usually after they have received medical treatment for a long period of time. We correlated physical status classification indices (American Society of Anesthesiologists (ASA) and Goldman's) with the patients’ profiles and estimated, subjectively, the operative risk profile at the time of the first visit to a urologist for BPH-related lower urinary tract symptoms (LUTS).
Fifty-six patients aged 51–84 years, scheduled for transurethral or open adenomatectomy, were included in the study. Physical status indices were correlated with patient and disease characteristics, as well as with the time from the first visit seeking advice for BPH-related LUTS to the final decision for surgical treatment. Anesthesiologists estimated whether the operative risk would have been lower if surgery had been offered as a first line treatment option.
ASA and Goldman's indices did not correlate with patient and disease characteristics except for the correlations of the ASA index with comorbidity and with time from first visit, and Goldman's index with age. Subjects in whom the decision for surgery was delayed for more than 1 year from initial visit had significantly higher International Prostate Symptom Scores (IPSS) at surgery, and they also had a higher ASA index and acute urinary retention rate. In 12 cases (21.4%) anesthesiologists estimated that operative risk would have been less if surgery had been performed at the time of the first visit, with the probability of a hypothetical change in operative risk profile correlating only with the length of time of LUTS and concomitant cardiovascular or chronic obstructive pulmonary disease.
As the impact of medical treatment for LUTS/BPH will probably further increase over the coming years, patients at risk of developing complications needing surgery should be estimated for a possible future deterioration of their physical status and be advised accordingly.
Anaesthesia and prostate surgery
2005, Annales Francaises d'Anesthesie et de Reanimation
Objectifs. – Présenter les données actuelles sur l'anesthésie pour la chirurgie prostatique en insistant sur l'analyse et la prévention des risques spécifiques à cette chirurgie, le choix d'un schéma anesthésique adapté au geste chirurgical et au patient, la reconnaissance et le traitement des complications périopératoires spécifiques à la chirurgie prostatique.
Source des données. – Recherche informatisée à partir de Pubmed^® des articles sur le thème (1990–2004) et analyse des bibliographies.
Synthèse des données. – Il existe un consensus sur la nécessité d'urines vérifiées stériles en préopératoire de toute intervention chirurgicale portant sur la prostate. Le risque thromboembolique de la prostatectomie radicale pour cancer est comparable à celui de la chirurgie pelvienne carcinologique et ce risque est prolongé. En raison de leur âge, les patients présentent les tares cardiovasculaires, respiratoires, neurologiques et métaboliques du sujet âgé ou du vieillard. Les postures utilisées dans la chirurgie de la prostate ont des retentissements hémodynamiques et respiratoires et sont à l'origine de lésions neurologiques et musculaires. L'hémodilution normovolémique aiguë est une technique d'épargne transfusionnelle adaptée à la prostatectomie radicale rétropubienne. La prostatectomie radicale laparoscopique est en plein développement. Dans la chirurgie de l'adénome bénin, le volume à réséquer conditionne le choix de la technique chirurgicale : endoscopique jusqu'à 80 g, transvésicale au-dessus. L'anesthésie rachidienne est adaptée à la résection transuréthrale de la prostate, et doit procurer un niveau analgésique atteignant T9–T10. Elle présente l'avantage de permettre le dépistage précoce des complications liées à la résorption du liquide d'irrigation vésicale. Les bactériémies sont fréquentes lors des résections, malgré l'antibioprophylaxie recommandée.
Objectives. – To review the current data about anaesthetic management in prostate surgery with special regards on analysis and prevention of specific risks, appropriate anaesthetic procedure keeping with surgery and patient, recognition and treatment of adverse events.
Data sources and extraction. – The Pubmed^® database was searched for articles (1990–2004) combined with references analysis of major articles on the field.
Data synthesis. – It is strongly recommended to settle germfree urine in the preoperative period. The thromboembolic risk of radical retropubic prostatectomy for cancer parallels lower abdomen oncologic surgery and is prolonged. Preoperative evaluation of cardiovascular, respiratory, neurological and metabolic comorbidity is a source of prognostic information and an essential tool in the management of elderly patients with prostate disease. Extreme patient positioning applied in prostate surgery induces haemodynamic and respiratory changes and are associated with severe muscular and nervous injuries. The laparoscopic access for radical prostatectomy is a growing alternative to the open surgical procedure. Acute normovolaemic haemodilution is a consistent and cost-effective blood conservation strategy in reducing allogenic blood transfusion for radical retropubic prostatectomy. Whether open transvesical or transurethral prostatectomy for treatment of benign hypertrophy depends on the size of the gland: transurethral resection is safe up to 80 g. Intrathecal anaesthesia with a T9 cephalad spread of sensory block, produces adequate conditions for transurethral prostatectomy and allows a rapid diagnosis of irrigating fluid absorption syndrome. In spite of recommended preoperative antibiotic prophylaxis, bacteriemias are frequent during transurethral prostate resection.
Feasibility and limitations of comorbidity measurement in patients undergoing radical prostatectomy
2005, European Urology
To compare different comorbidity classifications as predictors of survival after radical prostatectomy (RPE).
444 consecutive RPE patients (mean follow-up 6.9 years) were stratified according to age, Charlson score, American Society of Anesthesiologists Physical Status classification (ASA), New York Heart Association classification of cardiac insufficiency, classification of angina pectoris of the Canadian Cardiovascular Society and a combination of both cardiac risk scores. Comorbid and overall mortality were the study endpoints. Mantel-Haenszel hazard ratios, p values and 8-year survival probabilities were used for comparison. A modified Charlson score was created by a restriction to the five individual conditions significantly associated with comorbid mortality.
When three strata (low, intermediate, high risk) were used, all stratifications displayed dose-response patterns and reached statistical significance as predictors of survival at least for the high-risk group. Only the ASA classification, however, discriminated three significantly different risk groups. Only the modified (restricted) Charlson score reached statistical significance as predictor of comorbid mortality in the age group of 70 or more years.
Although all investigated comorbidity classifications had some prognostic relevance in patients selected for RPE, their clinical applicability appears to be limited beyond the 70th year of life. The results of this study might, nevertheless, assist the treatment decision in patients with low-risk tumors eligible for modern watchful waiting strategies who mainly belong to the age group between 60–69 years where comorbidity seems to be of distinct prognostic value.
Comparison of the American Society of Anesthesiologists Physical Status classification with the Charlson score as predictors of survival after radical prostatectomy
2003, Urology
To compare the American Society of Anesthesiologists Physical Status (ASA) classification with the Charlson score in the radical prostatectomy setting. The ASA classification is a widely accepted way to evaluate perioperative risk. At present, the Charlson score is probably the most frequently used comorbidity measure to predict long-term survival after radical prostatectomy.
A total of 444 consecutive patients were enrolled in this study. The ASA classification was obtained from the anesthesia chart, and the Charlson score was assigned based on conditions noted during the preoperative cardiopulmonary risk assessment or mentioned on the discharge document. Kaplan-Meier time-event curves and Mantel-Haenszel hazard ratios were estimated for comorbid (noncancer) and overall survival.
After a mean follow-up of 5.9 years, both classifications were able to predict comorbid and overall survival in dose-response patterns. The ASA classification was superior in terms of a clearer discrimination of the survival curves (lower P values, higher hazard ratios). Both classifications identified a high-risk group (ASA 3 and Charlson score 2 or more), but only the ASA classification sufficiently defined a low-risk group (ASA 1).
In experienced hands, the ASA classification is a promising tool to improve the classification of prognostic comorbidity in the radical prostatectomy setting and may be used as an alternative to the Charlson score.
Diabetes and mortality in patients with prostate cancer: a meta-analysis
2016, SpringerPlus

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Adult urology: CME articlePreoperative cardiopulmonary risk assessment as predictor of early noncancer and overall mortality after radical prostatectomy

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

Conclusions

Comorbidity considerations in geriatric oncology research

CA Cancer J Clin

Perspectives on comorbidity and cancer in older patientsapproaches to expand the knowledge base

J Clin Oncol

Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patientsan Italian Group for Geriatric Oncology study

J Clin Oncol

Importance of comorbidity in head and neck cancer

Laryngoscope

The American Society of Anesthesiologists’ class as a comorbidity index in a cohort of head and neck cancer surgical patients

Head Neck

Comorbidity and survival of elderly head and neck cancer carcinoma patients

Cancer

Prognostic determinants in supraglottic carcinomaunivariate and Cox regression analysis

Head Neck

The impact of comorbidity on the survival of patients with squamous cell carcinoma of the head and neck

Head Neck

Contemporary update of prostate cancer staging nomograms (Partin tables) for the new millennium

Urology

Validation study of the accuracy of a postoperative nomogram for recurrence after radical prostatectomy for localized prostate cancer

J Clin Oncol

The impact of co-morbidity on life expectancy among men with localized prostate cancer

J Urol

Adult urology: CME article
Preoperative cardiopulmonary risk assessment as predictor of early noncancer and overall mortality after radical prostatectomy