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Impact of the Controlling Nutritional Status (CONUT) Score on Perioperative Morbidity and Oncological Outcomes in Patients with Bladder Cancer Treated with Radical Cystectomy - Beyond the Abstract

Radical cystectomy (RC) and pelvic lymph-node dissection (PLND) with or without neoadjuvant chemotherapy (NAC) represents the current standard-of-care treatment for both muscle-invasive bladder cancer (MIBC) and high-risk as well Bacillus Calmette-Guerin (BCG) unresponsive non- muscle-invasive bladder cancer (NMIBC).1 RC and urinary diversion (UD) is a complex surgical procedure with a recognized high perioperative morbidity due to patient, disease, and surgical determinants.2 Despite several improvements in surgical techniques like mini-invasive surgery and perioperative management, both morbidity profile and survival following RC have remained largely optimizable, adopting individualized treatment strategies especially for frail and elderly patients.2

The Controlling Nutritional Status (CONUT) score is a validated nutritional assessment system that comprehensively evaluates the host’s anabolism and immunocompetence and is widely used to select patients for nutritional support. High CONUT-score has been identified as a prognostic biomarker of poor survival among cancer patients undergoing radical surgery.3-7 It was calculated from albumin, lymphocytes, and total cholesterol collected from blood test before surgery. The optimal CONUT cut-off value was defined by creating a time-dependent receiver operating characteristic (ROC), defining a cut-off score3 in our cohort.

We retrospectively analyzed a multi-institutional cohort of 347 patients treated with RC for clinical-localized BC between 2005 and 2019. 235 (67.7%) patients were classified into the low CONUT group (CONUT-score 0, 1, 2), whereas the remaining 112 (32.3%) patients were classified into the high CONUT group (CONUT-score ≥3).

In total, 269 (77.5%) patients experienced complications after RC. On multivariable analysis, high CONUT was associated with significantly increased odds of both any-grade (OR 3.58, 95% CI 1.71−8.18, P=0.001) and major complications (OR 2.56, 95% CI 1.37-4.79, P = 0.003), respectively. The addition of the CONUT-score to the reference models improved the discriminating ability for prediction of any-grade (+4.0%, P=0.03) and major complications (+4.0%, P = 0.04), respectively.

A total of 68 (19.6%) patients were readmitted after discharge. Multivariable analysis identified high CCI (≥2) (OR 1.25, 95% CI 1.10−2.62, P = 0.02), open approach (OR 17.0, 95% CI 3.33−31.6, P = 0.01), and high preoperative CONUT-score (OR 2.39, 95% CI 1.19−4.89, P = 0.01) as independent predictors for unplanned readmission within 30 days. The addition of the CONUT-score to the reference model improved the discriminating ability for prediction of 30 days readmission (+5.0%, P = 0.02). Even on survival outcomes, CONUT-score showed how at 2 years follow-up high CONUT was significantly associated with worse RFS (27.8% vs. 73.4%, HR 4.08, P < 0.001), OS (42.1% vs. 75.1%, HR 3.39, P < 0.001) and CSS (47.9% vs. 84.3%, HR 5.16, P < 0.001).

An important point to emphasize is the fact that the BMI cannot rule out the presence of malnutrition since its lack of specificity in characterizing the true body composition.

We found that high CONUT-score was strongly associated with a poorer post-operative course and worse oncological outcomes. The CONUT-score could serve as a screening tool to identify RC candidates who may potentially benefit from an intensified regimen of supportive and nutritional cares to reduce post-operative complications. These findings highlight the clinical relevance of nutritional-risk assessment described by the CONUT-score as a comprehensive, personalized risk-stratification tool for patients’ counseling prior to RC.8

Written by: Fabio Traunero MD, Francesco Claps MD, & Nicola Pavan MD, Urological Clinic, Department of Medicine, University of Trieste, Trieste, Italy

References:

  1. Witjes JA, Bruins HM, Thomas R, et al. European association of urology guidelines on muscle-invasive and metastatic bladder cancer: Summary of the 2020 guidelines. Eur Urol 2021;79:82–104.
  2. Satkunasivam R, Tallman CT, Taylor JM, Miles BJ, Klaassen Z, Wallis CJD. Robot-assisted radical cystectomy versus open radical cystectomy: a meta-analysis of oncologic, perioperative, and complication-related outcomes. Eur Urol Oncol 2019;2:443–7. 
  3. Ignacio De Ulıbarri J, Gonzalez-Madrono A, De Villar NGP, et al. CONUT: A tool for Controlling Nutritional Status. First validation in a hospital population. Nutr. Hosp. 2005;20:38–45.
  4. Kheirouri S, Alizadeh M. Prognostic potential of the Preoperative Controlling Nutritional Status (CONUT) score in predicting survival of patients with cancer: A systematic review. Adv Nutr 2021;12:234– 50.
  5. Miyake M, Morizawa Y, Hori S, et al. Integrative assessment of pre- treatment inflammation-, nutrition-, and muscle-based prognostic markers in patients with muscle-invasive bladder cancer undergoing radical cystectomy. Oncol 2017;93:259–69.
  6. Claps F, Rai S, Mir MC, et al. Prognostic value of preoperative albumin-to-fibrinogen ratio (AFR) in patients with bladder cancer treated with radical cystectomy. Urol Oncol 2021;39:835.e9–17.
  7. Nemoto Y, Kondo T, Ishihara H, et al. The controlling nutritional status CONUT score in patients with advanced bladder cancer after radical cystectomy. In Vivo 2021;35:999–1006.
  8. Claps F, Mir MC, van Rhijn BWG et al. Impact of the controlling nutritional status (CONUT) score on perioperative morbidity and oncological outcomes in patients with bladder cancer treated with radical cystectomy. Urol Oncol. 2023 Jan;41(1):49.e13-49.e22.
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