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

Darweish, Alia; Tolchard, Stephen; Angell, Johanna; Pyke, Mark; Lewis, Simon; Dodds, Nicholas; Daweish, Alia; White, Paul; Gillatt, David

Abstract

© 2014 The Authors. BJU International © 2014 BJU International. 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 Methods In 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. Results The 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 (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). Conclusion Patients 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.

• Journal Article Type: Article
• Publication Date: Apr 1, 2015
• Journal: BJU International
• Print ISSN: 1464-4096
• Electronic ISSN: 1464-410X
• Publisher: Wiley
• Peer Reviewed: Peer Reviewed
• Volume: 115
• Issue: 4
• Pages: 554-561
• DOI: https://doi.org/10.1111/bju.12895
• Keywords: cardiopulmonary exercise testing, radical cystectomy, postoperative complications, anaerobic threshold
• Public URL: https://uwe-repository.worktribe.com/output/836761
• Publisher URL: http://dx.doi.org/10.1111/bju.12895