The majority of urologists performing radical prostatectomy in developed populations are doing so with robotic platforms. Since adopting this approach, many of us have observed that our patients appear to have less pain and recover more rapidly. If we are brutally honest with ourselves, we have all probably lowered our bar for accepting patients for surgery on the basis of overall health because they seem to handle robotic-assisted surgery better than open surgery. In my own practice, for patients not willing to consider radiotherapy and were frail by my own subjective assessment, I would routinely send these patients for a review by one of my internal medicine colleagues who is by training a geriatrician and has developed a special interest in perioperative medicine. Almost always, these patients were then being cleared for surgery and gradually I have found that I am operating on more of these types of patients apart from just older patients.
The study by Rosiello and colleagues has not only confirmed my personal suspicions about the fact that we are operating more often on men with frailty but more disturbingly the fact that this may come at a cost of increased complications. Whilst I have opened the discussion with reference to robotic surgery, this study quite correctly does not attempt to evaluate any effect that the introduction of robotic surgery may have had on this data.
The National Inpatient Sample database was interrogated from 2008 to 2015, and there were 91,618 identified cases of radical prostatectomy. The Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator was used to identify frail patients. The results found that overall, 13.3% were defined as being frail and this corresponded to one in seven patients undergoing radical prostatectomy. Over time, the percentage of identified frail patients steadily increased from 10.3% in 2008 to 18.2% in 2015.
The percentage of men who were obese almost doubled during this time from 5.5% in 2008 to 10.4% in 2015. As to whether this reflects a change in our patient population or a lowering of our threshold to accept obese patients for surgery is unable to be determined. I would not be surprised if the latter played a role given that in my own experience, operating on an obese man is technically significantly easier using a robotic platform compared to an open surgical approach.
An important message from this paper is that frail patients were found to have higher rates of overall complications (16.6 vs. 8.6%; p < 0.001), major complications (4.9 vs. 2.6%; p < 0.001), and nonhome-based discharge (5.9 vs. 5.0%; p < 0.001). They were also higher total hospital charges and length of stay for frail versus non-frail patients.
It was also particularly interesting to note that there was only a very small overlap between frailty defined patients and patients who were either obese with a BMI³30 or with a Charlson comorbidty index (CCI) of ³2. It was therefore unsurprising that on multivariate analysis, that frailty proved to be an independent predictor of complications. Although this proved to be the case for frailty, it was noted that the CCI was the strongest predictor of postoperative complications.
It is important to recognize that this study makes no assertions about the impact of the introduction of robotic-assisted radical prostatectomy. However, the progressive increase in numbers of men with frailty being offered surgery corresponds well with the uptake of this technology. This study provides some food for thought in that if we lower our threshold for who we accept for surgery, that there may be an increased complication price to pay. The data is difficult to ignore and highlights a need for prospective data to specifically clarify the impact of operating on an increasingly frail population of men.
Written by: Henry Woo, MBBS, DMedSc, FRACS, Professor of Surgery, The University of Sydney, Surgery, Sydney Adventist Hospital Clinical School, Professor of Robotic Cancer Surgery, Chris O'Brien LifeHouse, Sydney, Australia
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