Surgical High-risk Patients With ASA ≥ 3 Undergoing Radical Cystectomy: Morbidity, Mortality, and Predictors for Major Complications in a High-volume Tertiary Center

Indication for radical cystectomy (RC) is challenging in patients with severe preconditions (American Society of Anesthesiologists [ASA] >= 3). A total of 1206 patients undergoing RC between 2004 and 2017 were included. Both 90-day mortality and perioperative high-grade complications were about twice as high in patients with ASA >= 3 versus those with ASA <= 2. Major complications and mortality were significantly lower from 2010 to 2017 compared with 2004 to 2010. Our data might help estimating risks before RC in this vulnerable patient cohort. Background: The purpose of this study was to investigate major complications and risk factors for adverse clinical outcome in surgical high-risk (American Society of Anesthesiologists [ASA] 3-4) patients undergoing radical cystectomy (RC) in a high-volume setting. Patients and Methods: A total of 1206 patients underwent RC between 2004 and 2017 in our institution and were included. We assessed complications graded by the Clavien-DindoClassification system (CDC) in addition to the 90-day mortality rate and stratified results by the ASA classification. In a multivariate analysis, risk factors for high-grade complications (CDC > 3) were tested. Additionally, outcome parameters were compared between 2004 to 2010 and 2010 to 2017. Results: Patients with ASA >= 3 presented with more locally advanced tumors pT >= 3 (52.1% vs. 42.4%; P = .002) and positive lymphatic spread N1 (27.2% vs. 23.5%; P = .001) compared with patients with ASA <= 2. High-grade complications were significantly (P < .001) more prevalent in patients with ASA >= 3 compared with patients with ASA <= 2: CDC3 (14.6% vs. 9.4%), CDC4 (10.2% vs. 5.4%), and CDC5 (2.5% vs. 1.0%). The 90-day mortality rate (7.6% vs. 3.2%; P = .002) and perioperative reinterventions (23.5% vs. 13.1%; P < .001) were elevated in patients with ASA >= 3. ASA (odds ratio [OR], 2.701, 95% confidence interval [CI], 1.089-6.703; P = .032), previous abdominal operations (OR, 1.683; 95% CI, 1.188-2.384; P = .003), and body mass index > 30 (OR, 1.533; 95% CI, 1.021-2.304; P = .039) proved to function as independent predictors for major complications. CDC > 3 complications (31.7% vs. 24.3%; P = .029) and 90-day mortality (10.4% vs. 5.6%; P = .018) were significantly lower in the second half of the study period. Conclusions: Mortality and morbidity in surgical high-risk patients with ASA 3 to 4 undergoing RC is about twice as high compared with patients with ASA 1 to 2. ASA, previous abdominal operations, and elevated body mass index independently predict adverse clinical outcome in patients with ASA 3 to 4. Our results may help to weigh the surgical risk of RC in multimorbid patients. (C) 2018 Elsevier Inc. All rights reserved.