Frailty Indexes Help Predict Morbidity in Urologic Procedures

Alicia Ault

June 03, 2015

NEW ORLEANS — Surgeons should turn to frailty indexes to determine how well patients will do after renal procedures, radical prostatectomy, and radical cystectomy, according to several clinicians presenting here at the American Urological Association 2015 Annual Meeting.

It is exciting to see urology-specific indexes, said Tomas Griebling, MD, from the University of Kansas School of Medicine in Kansas City, who moderated the news conference held in advance of the presentations. "There's been much less work in urologic healthcare related to geriatric issues than in general surgery or orthopedics," he told reporters.

This is despite the fact that "urology ranks third in terms of the volume of geriatric care that we provide," he explained. In fact, "in many ways, urology is very much a geriatric specialty."

In the field of renal surgery, Jamie Pak, MD, from the Columbia University Medical Center in New York City, and his colleagues developed a frailty index to predict adverse events and death in patients undergoing partial nephrectomy, radical nephrectomy, or nephroureterectomy.

Their modified index was inspired by the Canadian Study on Health and Aging Frailty Index, which has been shown to be highly predictive of morbidity and mortality (BMC Geriatr. 2008;8:24).

Dr Pak's team used the 11 variables from the Canadian index that were available in the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database, and added four that were relevant to their patient population: weight loss of at least 10% in the previous 6 months; chemotherapy or radiation prior to surgery; history of metastasis; and severe renal failure or current dialysis.

In the retrospective study of almost 15,000 patients, those with a modified frailty score of at least 0.27 were more likely to die within 30 days than those with a lower score, Dr Pak reported. And higher scores were strongly associated with an increased risk for septic shock, ventilator dependence, unplanned intubation, longer operating times, and longer hospital stays.

Dr Pak was also a member of the teams that used the 15 variables to assess patients undergoing radical prostatectomy and radical cystectomy. Results from both studies were presented by Danny Lascano, MD, from the Columbia University Medical Center.

Radical Prostatectomy

To assess the modified index in radical prostatectomy, the team looked at scores in 23,350 patients diagnosed with prostate cancer. Of the 219 patients with a score of at least 0.2, three (1.5%) died within 30 days, compared with 0.1% of those with a lower score.

Of the 219 men with an elevated score, 13 had a Clavien-Dindo IV complication, compared with 81 of 11,312 of men with a lower score (6.0% vs 0.7%).

There were several limitations to this study, Dr Lascano told reporters. There was no information on disease severity, and because there were so few patients with a high frailty score, it could be that surgeons are already choosing not to operate on frail patients.

Use of the modified index was not as straightforward for radical cystectomy, in part because it is not generally an elective procedure, Dr Lascano explained. In addition, it has high morbidity — with 20% to 40% of patients requiring postsurgical readmission — and a high 30-day mortality rate, in the range of 1.5% to 3.0%.

High Morbidity in Cystectomy

From 2005 to 2012, 3388 patients underwent radical cystectomy. Twelve of the 176 patients with a higher score died, as did 21 of the 1108 with a lower score (7.0% vs 2.0%).

The complication rate was also higher in the 30 patients with a higher score than in the 73 patients with a lower score (17.0% vs 6.6%).

In addition, patients with a higher score were more likely to be ventilator-dependent, develop acute renal failure, and require dialysis and blood transfusions.

Again, there was no information on disease severity, which limits some of the usefulness of the mortality data, said Dr Lascano. The correlation between the modified index and 30-day mortality was not significant, he pointed out, and some of the complications could have be related to surgeon- or hospital-specific variables.

But, he told reporters, "we definitely need something better to measure frailty in this population."

Frailty measures have been around since at least 2001, when Linda Fried and her colleagues at Johns Hopkins University published their research on frailty in older adults (J Gerontol A Biol Sci Med Sci. 2001;56:M146-M156). Despite this, surgeons still tend to rely on age as a predictor of morbidity and mortality, said Dr Griebling.

There are a variety of instruments available that measure different conceptual domains. "Making sure we capture what's important is really critical," he said. "I think there's going to be more and more emphasis on this and incorporation of these into guidelines and recommendations for older adults."

Dr Pak and Dr Lascano have disclosed no relevant financial relationships. Dr Griebling is involved in trials with the Donald W. Reynolds Foundation, Medtronic, the National Institute on Aging, and Pfizer.

American Urological Association (AUA) 2015 Annual Meeting: Abstract MP63-01, presented May 18, 2015; abstract MP14-03, presented May 16, 2015; abstract MP64-07, presented May 18, 2015.

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