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The Association of Age with Perioperative Morbidity and Mortality Among Patients Undergoing Radical Cystectomy
Jorge Pereira, MD, Joseph Renzulli, MD, Gyan Pareek, MD, Dragan Golijanin, MD, Boris Gershman, MD.
Warren Alpert School of Medicine at Brown University, Division of Urology, Providence, RI, USA.

Background:
Bladder cancer affects a predominantly elderly population, for whom radical cystectomy (RC) remains the standard of care in the management of muscle-invasive disease. However, RC is underutilized in the elderly, despite limited data to suggest inferior perioperative outcomes compared to younger patients. We therefore examined the association of age with perioperative complications, hospital readmission, reoperation, and 30-day mortality among patients undergoing RC.
Methods:
We identified 7,625 adult patients aged 18-90 years who underwent RC from 2010-2015 in the National Surgical Quality Improvement Program (NSQIP) database. Thirty-day complications and perioperative outcomes were assessed using a standardized protocol as part of the NSQIP. The associations of age with 30-day complications and perioperative outcomes were evaluated using logistic regression, adjusted for patient features.
Results:
Age at surgery was distributed as follows: <60 years in 1,652 (21.7%) patients, 60-69 years in 2,282 (29.9%) patients, 70-79 years in 2,701 (35.4%) patients, and 80-89 years in 990 (13%) patients. Median operative time was 336 (IQR 259, 423) minutes. There were statistically significant differences in several baseline characteristics across age strata, with higher American Society of Anesthesiology (ASA) class and greater prevalence of diabetes, chronic obstructive pulmonary disease, and hypertension among older patients. Overall, 30-day complications occurred in 2,433 (31.9%) patients, and median time to first complication was 11 (IQR 6, 17) days. On multivariable analysis, patients aged 70-79 and 80-89 were found to have increased risk of blood transfusion (p<0.01), and 30-day mortality (p<0.01) (Table).
Conclusion:
Among patients undergoing RC, while increasing age is independently associated with an increased risk of 30-day mortality and perioperative blood transfusion, though not 30-day complications, hospital readmission, or reoperation. These results suggest that patients over age 70 should be carefully counseled on the risks and benefits of proceeding with RC.
Table: Multivariable analysis of the association of age with perioperative outcomes among patients undergoing radical cystectomy. Models adjusted for year of surgery, race, ASA class, smoking status, functional status, steroid use, operative time, and presence of the following comorbidities: chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, renal failure, and bleeding disorder.
EndpointAge (years)OR (95% CI)p
Any Complication<60----
60 -690.84(0.73, 0.97)0.02
70-791.01 (0.87, 1.16)0.93
80-890.95 (0.79, 1.14)0.58
Blood Transfusion<60----
60 -691.10 (0.95, 1.26)0.19
70-791.34 (1.16, 1.54)<0.01
80-891.60 (1.34, 1.91)<0.01
Readmission<60----
60 -690.94 (0.79, 1.12)0.48
70-790.88 (0.74, 1.06)0.17
80-890.98 (0.78, 1.23)0.83
Reoperation*<60----
60 -690.96 (0.72, 1.29)0.79
70-790.95 (0.70, 1.29)0.71
80-890.71 (0.47, 1.09)0.12
30-day mortality*<60----
60 -691.50 (0.85, 2.64)0.17
70-792.53 (1.47, 4.35)<0.01
80-894.28 (2.38, 7.71)<0.01

*ASA class 1 and 2 combined on multivariate analysis due to small number of events.


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