Haren Andrea, Lal Rajni, Walker David, Nair Rajesh, Partridge Judith, Dhesi Jugdeep
Perioperative Medicine Fellow, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK.
Perioperative Care of Older People undergoing Surgery (POPS) Fellow, Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.
Ther Adv Urol. 2020 May 10;12:1756287220916614. doi: 10.1177/1756287220916614. eCollection 2020 Jan-Dec.
Radical cystectomy (RC) and urinary diversion are the recommended treatment for patients with muscle invasive bladder cancer. This is complex surgery, associated with significant patient morbidity and mortality. Frailty has been shown to be an independent risk factor for adverse outcomes in several surgical populations. Preoperative assessment of frailty is advocated in current guidelines but is not yet standard clinical practice.
This systematic review and narrative synthesis aims to examine whether patients undergoing RC are assessed for frailty, what tools are used, and whether an association is found between frailty and adverse outcomes in this population.
Nine studies, published within the last 4 years, describe the use of tools reporting to measure frailty in the RC population. All demonstrate increased risk of adverse postoperative outcomes with higher frailty levels. Only one study used a validated frailty tool. The majority of studies measure frailty using variations on a tool derived from a large database (ACS-NSQIP) effectively counting co-morbidities, rather than assessing the multidomain nature of the frailty syndrome.
The recognition of frailty as an important consideration in the perioperative period is welcome. This systematic review and narrative synthesis demonstrates the need for collaboration in research and delivery of clinical care for older surgical patients. Such collaboration may provide clarity regarding terms such as frailty and multimorbidity, preventing the development of assessment tools inaccurately measuring these discreet syndromes interchangeably. More accurate assessment of patients in terms of frailty, multimorbidity and functional status may allow better modification and shared decision making leading to improved postoperative outcomes in older patients undergoing RC.
根治性膀胱切除术（RC）和尿流改道术是肌肉浸润性膀胱癌患者的推荐治疗方法。这是一项复杂的手术，会给患者带来较高的发病率和死亡率。在多个外科手术人群中，衰弱已被证明是不良结局的独立危险因素。当前指南提倡对衰弱进行术前评估，但这尚未成为标准的临床实践。
本系统评价和叙述性综合分析旨在研究接受RC手术的患者是否接受了衰弱评估、使用了哪些工具，以及在该人群中衰弱与不良结局之间是否存在关联。
在过去4年内发表的9项研究描述了用于测量RC人群衰弱情况的工具的使用。所有研究均表明，衰弱程度越高，术后不良结局的风险越高。只有一项研究使用了经过验证的衰弱工具。大多数研究使用从大型数据库（美国外科医师协会国家外科质量改进计划，ACS-NSQIP）衍生而来的工具的变体来测量衰弱，实际上是在计算合并症，而不是评估衰弱综合征的多领域性质。
将衰弱视为围手术期的一个重要考量因素是值得欢迎的。本系统评价和叙述性综合分析表明，在老年外科患者的研究和临床护理提供方面需要开展合作。这种合作可能会明确诸如衰弱和多重合并症等术语，防止开发出不准确地交替测量这些不同综合征的评估工具。根据衰弱、多重合并症和功能状态对患者进行更准确的评估，可能会实现更好的调整和共同决策，从而改善接受RC手术的老年患者的术后结局。
