SIU-WJU Article of the Month – August 2019
Refining patient selection for radical cystectomy: which is the best comorbidity classification?
SIU Academy®. Dr. Marco Moschini and Dr. Rafael Sanchez-Salas . 08/15/19; 279757 Topic: Surgery
Dr. Marco Moschini and Dr. Rafael Sanchez-Salas
  Dr. Marco Moschini and Dr. Rafael Sanchez-Salas
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Abstract
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Purpose

There is no consensus on the best comorbidity measure in candidates for radical cystectomy. The aim of this study was to identify tool best suited to identify patients at risk for 90-day or premature long-term non-bladder cancer mortality.

Methods

We studied 1268 patients who underwent radical cystectomy to identify patients at risk for 90-day and later-than-90-day mortality, respectively. Six classifications were investigated as possible predictors of both types of mortality. Multivariable models including age as continuous variable and each classification separately were calculated. A heuristic ranking was based on the evaluation of the hazard ratios, p values, Akaike’s information criteria, and concerning the logit models also the areas under the curve.

Results

The median follow-up was 5.7 years. Within 90 days after surgery, the mortality rate was 4.2%. The greatest inde-pendent contribution concerning the prediction of 90-day mortality was seen with the American Society of Anesthesiolo-gists (ASA) physical status classification (classes 3–4 versus 1–2: hazard ratio 7.98, 95% confidence interval 3.54–18.01, p < 0.0001). In the longer term, countable diseases (Canadian Cardiovascular Society classification of angina pectoris, conditions contributing the Charlson score) were of greater importance. The results of heuristic ranking were confirmed by multivariate analyses including age and all classifications together.

Conclusions

Besides to chronological age, clinicians should pay particular attention to the ASA classification to identify patients at risk for 90-day mortality after radical cystectomy, whereas long-term mortality is more determined by countable comorbid diseases.

Keywords
Bladder · Comorbidity · Competing mortality · Competing risk analysis · Cystectomy · 90-day mortality · Logit model · Proportional hazards model
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