Background The majority of colorectal cancer is diagnosed in people aged >65 years, yet the elderly are less likely to undergo curative surgery. Chronological age is poorly correlated with post‐operative outcomes and is not an acceptable measure of risk. Conversely, frailty is a strong predictor of poor post‐operative outcomes and presents an opportunity for optimisation. This systematic review aims to assess the evidence between frailty and outcomes in patients of all ages undergoing colorectal cancer resections and to compare the predictive value of frailty status to that of age alone. Methods The review was registered on Prospero, CRD42019150542. PubMed was searched for articles reporting outcomes for frail patients undergoing elective or emergency colorectal cancer resection up until August 2019. All studies reporting outcomes in frail patients were deemed eligible for inclusion and assessed according to the PRISMA guidelines. Results Of the 143 identified studies, 17 were eligible for inclusion. Study type, frailty assessments and outcomes measured were highly variable. ‘Frailty’ was associated with significantly higher rates of post‐operative complications (7/7 studies), post‐operative mortality (5/7 studies), readmission (3/4 studies) and length of stay (3/3 studies). Seven of 11 studies reported no association between age and adverse outcomes. Conclusion Frailty is a predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. Standardisation of frailty assessment and outcome measure is needed. Accurate risk stratification of patients will allow us to make informed treatment decisions, identify patients who may benefit from preoperative intervention and tailor post‐operative care.

Objective: Pelvic fracture can be complicated by posterior urethral injury (PUI) in up to 25% of cases. PUI can produce considerable morbidity, including urethral stricture, erectile dysfunction (ED), and urinary incontinence. Optimal management of PUI is unclear, however, the current gold standard is placement of a suprapubic cystostomy with delayed urethroplasty (SCDU) performed several months later. Another option is early primary realignment (PR) with urethral catheter, performed either open or endoscopically. Through a systematic review and meta-analysis, we aimed to compare PR and SCDU regarding stricture, ED, and urinary incontinence rates. In light of advancing endoscopic techniques, we also aimed to compare early endoscopic realignment (EER) alone with SCDU. Methods: PubMed, Medline, and Embase were searched for eligible studies comparing PR, including EER, and suprapubic cystostomy plus delayed urethroplasty from database inception until July 17th, 2018. We also reviewed reference lists from relevant articles. Study quality assessment was conducted using a modified Newcastle-Ottawa (mNOS) scale (maximum score 9). Results: From 461 identified articles, 13 studies encompassing 414 PR and 308 SCDU patients met our eligibility criteria. Twelve studies were retrospective non-randomized case studies, with 1 prospective randomized case study. Included studies were of moderately low quality (mNOS mean score: 6.0 ± 0.6). Meta-analysis demonstrated that PR and SCDU had similar stricture rates [odds ratio (OR): 2.14; 95% confidence interval (CI): 0.67-6.85; p = 0.20], similar rates of ED (OR: 1.06; 95% CI: 0.62-1.81; p = 0.84), and similar rates of urinary incontinence (OR: 0.94; 95% CI: 0.49-1.79; p = 0.86). Six studies compared EER alone (229 patients) versus SCDU (195 patients). Meta-analysis demonstrated that these modalities also had similar stricture rates (OR: 4.14; 95% CI: 0.76-22.45; p = 0.10), similar rates of ED (OR: 0.79; 95% CI: 0.41-1.54; p = 0.49), and similar rates of urinary incontinence (OR: 1.10; 95% CI: 0.48-2.53; p = 0.82). Conclusion: For PUI patients, neither PR nor EER produces superior outcomes compared to SCDU regarding stricture, ED, and urinary incontinence rates. The quality of studies in the literature, however, is very poor, with the majority of studies being non-randomized retrospective case studies with potentially high bias. Additional high-quality research, particularly prospective studies and randomized controlled trials, are needed to strengthen the evidence base.

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