Cardiopulmonary reserve as determined by cardiopulmonary exercise testing correlates with length of stay and predicts complications after radical cystectomy

Abstract

ObjectiveTo investigate whether poor preoperative cardiopulmonary reserve and comorbid state dictate high-risk status and can predict complications in patients undergoing radical cystectomy (RC). Patients and MethodsIn all, 105 consecutive patients with transitional cell carcinoma (TCC; stage T1-T3) undergoing robot-assisted (38 patients) or open (67) RC in a single UK centre underwent preoperative cardiopulmonary exercise testing (CPET). Prospective primary outcome variables were all-cause complications and postoperative length of stay (LOS). Binary logistic regression analysis identified potential predictive factor(s) and the predictive accuracy of CPET for all-cause complications was examined using receiver operator characteristic (ROC) curve analysis. Correlations analysis employed Spearman's rank correlation and group comparison, the Mann-Whitney U-test and Fisher's exact test. Any relationships were confirmed using the Mantel-Haenszel common odds ratio estimate, Kaplan-Meier analysis and the chi-squared test. ResultsThe anaerobic threshold (AT) was negatively (r = −206, P = 0.035), and the ventilatory equivalent for carbon dioxide (VE/VCO2) positively (r = 0.324, P = 0.001) correlated with complications and LOS. Logistic regression analysis identified low AT (<11 mL/kg/min), high VE/VC02 (≥33) and hypertension as significant factors, such that, in their presence patients were 5.55-times more likely to have complications at 90 days postoperatively [P = 0.001, 95% confidence interval (CI) 2.2-13.9]. ROC analysis showed a high significance (area under the curve 0.78, 95% CI 0.69-0.87; P < 0.001). In addition, based on CPET criteria >50% of patients presenting for RC had significant heart failure, whereas preoperatively only very few (2%) had this diagnosis. Analysis using the Mann-Whitney test showed that a VE/VCO2 ≥33 was the most significant determinant of LOS (P = 0.004). Kaplan-Meier analysis showed that patients in this group had an additional median LOS of 4 days (P = 0.008). Finally, patients with an American Society of Anesthesiologists grade of 3 (ASA 3) and those on long-term β-blocker therapy were found to be at particular risk of myocardial infarction (MI) and death after RC with odds ratios of 4.0 (95% CI 1.05-15.2; P = 0.042) and 6.3 (95% CI 1.60-24.8; P = 0.008). ConclusionPatients with poor cardiopulmonary reserve and hypertension are at higher risk of postoperative complications and have increased LOS after RC. Heart failure is known to be a significant determinant of perioperative death and is significantly under diagnosed in this patient group.

2016 Focused Update: Clinical Recommendations for Cardiopulmonary Exercise Testing Data Assessment in Specific Patient Populations

“…18-21 Surgical procedures in which CPX has demonstrated prognostic value include abdominal aortic aneurysm repair, [22][23][24][25] radical cystectomy, 26 liver transplantation, 27 hepatic resection, 28 lung resection, [29][30][31][32][33] bariatric surgery, 34,35 and colorectal surgery. 36,37 In fact, the American College of Chest Physicians clinical practice guidelines for evaluation procedures of patients with lung cancer being considered for surgical resection recommend the use of CPX to assess risk.…”

Comparaison des méthodes de détermination des seuils ventilatoires: implications pour la stratification du risque chirurgical

“…Accordingly, we developed a computer program that chooses a deflection point in ventilation based on the least mean square error of the fit between the log of oxygen uptake and the log of ventilation. 22 Given the caveats related to determining the VT, guidelines on CPET suggest confirming the VT visually using one of several methods. 6,8,9 Because the VT has been increasingly applied to assess surgical outcomes, 5,[12][13][14][15][16][17]23 a reliable determination of this point is critically important in evaluating perioperative prognosis.…”

“…In the current study, we sought to quantify agreement between methods of determining the VT. We compared visual readings by experienced reviewers, automated determination by a metabolic system, and the application of a computer-derived program (developed by the authors) which employs the point with the least mean square error of the fit between the log of oxygen uptake and the log of ventilation. The latter has been suggested as the optimal mathematical technique to define a breakpoint between two regression lines and has been applied to interpret the VT. 22,24,25 Our overall objective was to provide insight into the reliability of common methods for determining the VT and to highlight the implications for assessing surgical outcomes.…”

Cardiopulmonary exercise testing: fortune‐teller or guardian angel?

“…The rise of multi-parametric MRI (mpMRI) for the assessment of patients with suspicion of prostate cancer has led to an enormous shift in the practice of every urologist dealing with frontline diagnostics [1].…”

“…The Bristol group [1] has therefore prospectively studied the role of CPET in 105 patients undergoing either robot-assisted or open radical cystectomy for TCC, using allcause complications and length of stay as the primary outcome variables.…”