SAN DIEGO, CA USA (UroToday.com) - As the elderly population in the U.S. continues to dramatically increase, urologists are faced with unique management dilemmas for those patients requiring surgery.
Drs. Badrinath Konety (University of Minnesota), Gary Steinberg (University of Chicago), and Mark Schoenberg (Johns Hopkins) participated a panel discussion moderated by Dr. Jeffrey M. Holzbeierlein (University of Kansas Hospital).
The median age at diagnosis of bladder cancer is 73 years, and it is estimated that > 20 million people in the United States will be >85yrs old by 2020. “There is an age- related bias against cancer surgery in the elderly,” said Dr. Konety, “but cystectomy can be safely performed in octogenarians.” It’s important to consider both the chronologic and biologic age of patients undergoing surgery. Although several series report comparable rates of morbidity and mortality in the elderly, complications in the elderly can increase 30-day mortality by 26%. Surgeons should be especially aware of frailty among elder patients, which is defined as excess vulnerability to stressors and limited ability to maintain or regain homeostasis after a destabilizing event. The Frailty Index is easily calculable, and includes 5 components: shrinking (>10 lbs. in the past year), weakness (grip strength), exhaustion (effort and motivation), low physical activity, and slow walking speed. Patients are then classified as non-frail, intermediately frail, or frail
The risk of complications after major surgery increases with increasing fraility, with 19%, 34%, and 43% of non-frail, intermediately frail, and frail patients, respectively, experiencing complications. Increasing frailty is also associated with increased hospital length of stay (17% more frail patients will require discharge to other facilities), and 6-month mortality. In operative candidates, a comprehensive geriatric assessment should be performed, including functional status, activities of daily living, instrumental activities of daily living, depression, mood, gait, co-morbidity burden, and cognitive scale. Impaired cognition and depression can adversely impact post-operative recovery. The “get up and go” test is a simple test clinicians can perform in the office. From a seated position in a straight back chair, patients are instructed to stand up, walk 10 feet, turn around and walk back. Successful test “passage” requires completion within 20 seconds. Test failure is associated with a 4-fold increase risk in post-operative mortality. Finally, a mini-cognitive evaluation (3-item recall and clock draw) should be performed, as failure is associated with a 17% increased risk of post-operative nursing home admission. The PACE study of moderate/major cancer surgery in the elderly revealed an overall low mortality rate of 2.4%, which reflects feasibility of surgery in the elderly. With adequate functional assessment used to predict morbidity and mortality, cystectomy can safely be performed in the elderly.
Dr. Steinberg then focused on modifiable risk factors for elderly patients undergoing cystectomy. Alarmingly, only 21% of patients > 65-years-old with pT2 urothelial carcinoma undergo cystectomy (SEER data). “A number of series have shown that cystectomy in patients older than 75-years-of-age is safe and increases survival,” and “complications in the elderly following cystectomy are no different than in younger patients.” In a large series of elderly patients undergoing cystectomy (mean age 79.2 years), age has been shown to predict 90-day morbidity (43%) but not 90-day mortality (3.7%), with a 5-year mortality/metastasis-free rate of 62%. A study of transesophageal echocardiogram (TEE) to guide perioperative fluid management in octogenarians is ongoing at The University of Chicago, and Dr. Steinberg recommended utilizing hospitalists and geriatricians, post-operatively, to aid in patient management.
Dr. Schoenberg closed by emphasizing surgeons and urologists “can’t control comorbidity,” but should “control the variables you can (control): body temperature, resuscitation, and operative time.” General anesthesia impairs thermoregulatory afferent, efferent, and central processing, and hypothermia can lead to increased oxygen consumption, increased blood pressure, ventricular dysrhythmias, myocardial infarction, decreased platelet function, and increased wound infections. Perioperative hypothermia is associated with a two-fold increase in morbid post-operative cardiac events and can be easily prevented. While no data support a correlation between decreased operative time and improved surgical outcomes, extended operative times have been associated with increased rates of post-operative infections and prolonged hospital stay. The risk of infection increases linearly with every 30-minute increase in operative time, and surgeons should strive to “get elder patients off the table” as safely and expediently as possible.
Presented by Jeffrey M. Holzbeierlein, MD, Badrinath R. Konety, MD, Gary David Steinberg, MD and Mark Phillip Schoenberg, MD at the American Urological Association (AUA) Annual Meeting - May 4 - 8, 2013 - San Diego Convention Center - San Diego, California USA
Reported for UroToday.com by Jeffrey J. Tomaszewski, MD