EAU 2017: Can pre-operative functional status (FS) or gait velocity (GV) replace cardiopulmonary exercise testing (CPET) as an independent predictor of survival and complications following radical cystectomy (RC)?

London, England (UroToday.com) Radical cystectomy, amongst cases done by urologists, remains a significant stress for patients and families. As patients can often be under anesthesia for 4+ hours and then expect a hospital stay between 4-10 days, and as many patients are older and often with multiple comorbidities, the surgery carries significant morbidity. Optimizing patients prior to surgery is critically important. In most institutions, cardiopulmonary exercise testing (CPET) is increasingly employed to risk-stratify patients prior to RC, but it is a costly, labor intensive process and may be poorly tolerated test in some.

The authors herein assess whether pre-operative functional status (FS) and pre-operative gait velocity (GV), both simple assessments in the outpatient clinic, can act as an alternative to CPET and establish criteria predictive of survival and complications following RC.

This was a prospective single-institution assessment of 100 patients undergoing RC in a 4 month window. Basic demographic breakdown was as follows: 80 male patients, mean age 67 years, age range 56-83. The mean Charlson co-morbidity index scores for patients undergoing RC was 4.8. Of the patients, 81 and 19 patients underwent robotic and open procedures, respectively.

Pre-operative FS was calculated using the Nottingham Extended Activities of Daily Living (NEADL) and Time-Up and Go (TUAG) scores, which assess a patient’s ability to do activities of daily living. These assessments were then correlated with outcome parameters of CPET-anaerobic threshold (AT), 90-day mortality and Clavien-Dindo complications (CDC).

The median pre-operative NEADL score was 63 (24-66) and the median TUAG score was 10.0 (6.64-20.5). With increasing age, corresponding deterioration in TUAG scores were noted. There was no statistical correlation between pre-operative NEADL, TUAG and CPET-AT. With regards to GV, median pre-operative GV was 1.07m/s (0.28-2.77) versus 0.52 m/s (0.01-1.27) on discharge. There is a direct relationship between pre-operative GV and AT (p<0.001) - pre-operative GV of <1m/s, 1-2m/s and >2m/s, corresponded to a median AT of 9.7, 12.1 and 13.9 ml/min/kg, respectively.

After confirming that AT correlated to median length of stay, they then showed that a GV <1m/s was associated with a higher morbidity compared to GV >1m/s (CDC 2-5, 62% versus 51%) and increased 90-day mortality (3% versus 1%).

Limitations / Discussion Points:
Unfortunately, the poster was not presented in its scheduled session. However, some limitations noted from the abstract itself are:
1. It is unclear if the authors went on to assess NEADL and TUAG association with clinical outcomes, or if they stopped once there was no association with AT.
2. While AT was associated with LOS, no mention of its association with clinical outcomes. Its possible that AT may not be the gold standard.

While the intention is good (clinic-based assessment and predictors of cinical outcomes from major surgery), further evaluation is required.

Presented by: R. Nair

Co-authors: Downs C., Parsons B., Fynmore T., Omar K., Thurairaja R., Khan M.S.

Institution(s): Guy's and St Thomas' NHS Foundation Trust, Dept. of Urology, London, United Kingdom

Written by: Thenappan Chandrasekar , Clinical Fellow, University of Toronto
Twitter: @tchandra_uromd

at the #EAU17 -March 24-28, 2017- London, England