BACKGROUND The definition of frailty, as modeled by the Fried criteria, has been limited primarily to the physical domain. The purpose of this study was to assess the additive value of cognitive function with existing frailty criteria to predict poor postoperative outcomes in a large multidisciplinary cohort of patients undergoing major operations. STUDY DESIGN A 4-level composite frailty scoring system was created via the combination of the Fried frailty score and the Emory Clock Draw Test to assess preoperative frailty and cognitive impairment, respectively. Overall survival was defined as months from date of operation to date of death or last follow-up. RESULTS This study included 330 patients undergoing major operations; mean age was 58 years and a total of 53 patient deaths occurred during 4-year follow-up. Among the robust cohort, 20 of 168 patients died (11.9%), and among those who were both physically frail and cognitively impaired, 11 of 26 patients died (42.3%). Multivariable analysis demonstrated the physically frail and cognitively impaired cohort to have a 3.92 higher risk of death (95% CI 1.66 to 9.26) compared with the cohort of robust patients (p = 0.002). Kaplan-Meier survival curves reveal an overall difference in long-term survival (log-rank p < 0.0001), driven mainly by the high risk of mortality among patients with both physical frailty and cognitive impairment. CONCLUSIONS The use of a combined frailty and cognitive assessment score has a more powerful potential to predict adult patients at higher risk of overall survival than either measurement alone. The addition of cognitive assessment to physical frailty measure can lead to improved preoperative decision making and possibly early intervention, as well as more accurate patient counseling.

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Background Preoperative frailty has been associated with adverse postoperative outcomes. Additionally, low testosterone has been associated with physical frailty and cognitive decline. However, the impact of simultaneous frailty and low testosterone on surgical outcomes is understudied. Methods Preoperative frailty status and testosterone levels were obtained in patients undergoing a diverse range of surgical procedures. Preoperative frailty was evaluated independently and in combination with testosterone through the creation of composite risk groups. Relationships between preoperative frailty and composite risk groups with overall survival were determined using Kaplan–Meier and logistic regression analyses. Bivariate analysis was used to determine the associations between frailty and testosterone status on postoperative complications, length of hospital stay, and readmission rates. Results Median age of the cohort was 63 years, and the median follow-up time was 105 weeks. Thirty-one patients (23%) were frail, and 36 (27%) had low free testosterone. Bivariate analysis demonstrated a statistically significant relationship between preoperative frailty and overall survival (P = .044). In multivariate analysis, coexisting frailty and low free testosterone were significantly associated with decreased overall survival (hazard ratio 4.93, 95% confidence interval, 1.68–14.46, P = .004). Conclusion We observed preoperative frailty, both independently and in combination with low free testosterone levels, to be significantly associated with decreased overall survival across various surgical procedures. Personalizing the surgical risk assessment through the incorporation of preoperative frailty and testosterone status may serve to improve the prognostication of patients undergoing major surgery.

in diameter and of GII. UTUC developed in 59 (3.7%) of the patients; most of the patients were symptomatic and hematuria was the most common symptom in this cohort 64%, while UTUC was discovered on routine follow-up imaging in 30% of the patients. The median time for the development of UTUC was 20 (6-106 months). Most of the recurrences were on the ureter; either alone (39/59[66%) or ureteral with pelvicalyceal collecting system (10/59[17%), and (10/59[17%) were pelvicalyceal only. Among the isolated ureteral tumors (#39), distal ureteral tumors were more common (30/39[75%) than multicentric or proximal ureter (15% and 10% respectively). Bivariate analysis of the risk factors showed that gender, tumor size, site, tumor stage and grade were not predictors for the development of UTUC recurrence, but only bladder tumor number (single or multiple) and the number of previous recurrences were the predictors for UTUC recurrence (p[ 0.02 and 0.01 respectively). Three or more previous recurrences were the only predictors that sustained their significance in multivariate analysis (p[ 0.03 and 0.001 respectively). UTUC recurrence does not affect the overall survival.CONCLUSIONS: UTUC develops in 3.7% of patients with NMIBC. One-third (30%) of the patients were diagnosed with routine follow up imaging, so regular surveillance of the upper tract is still recommended to all patients. More strict surveillance is advised in the cases of those having had three or more bladder recurrences, yet the optimum protocol and frequency for upper tract imaging is to be determined by future prospective studies.

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