Elsevier

Urology

Volume 63, Issue 5, May 2004, Pages 841-846
Urology

Adult urology
Use of American Society of Anesthesiologists physical status classification to assess perioperative risk in patients undergoing radical nephrectomy for renal cell carcinoma

https://doi.org/10.1016/j.urology.2003.12.048Get rights and content

Abstract

Objectives

To perform a retrospective analysis to determine the operative morbidity in patients with substantial comorbidities requiring renal surgery. Increasing numbers of patients requiring renal surgery are presenting with substantial comorbidities, such as diabetes mellitus, chronic obstructive pulmonary disease, and cardiovascular disease.

Methods

The American Society of Anesthesiologists (ASA) physical status classification was used to define perioperative risk. Of 1087 patients who underwent nephrectomy between 1989 and 2001, 237 patients were classified as ASA classification 1 or 2 (low risk), 297 were ASA classification 3 (intermediate risk), and 17 were ASA classification 4 (high risk).

Results

No statistically significant differences were found among the low-risk, intermediate-risk, or high-risk patients with regard to 1997 T stage distribution, mean tumor size, vascular and/or inferior vena cava involvement, percentage of partial nephrectomy, adjacent organ resection, or preoperative hemoglobin. Intermediate-risk patients did have a greater estimated blood loss (946 versus 739 mL, P = 0.05), leading to greater transfusion rates (42% versus 28%, P = 0.001). However, no increase occurred in intraoperative or postoperative morbidity. High-risk patients also had greater transfusion rates, as well as a greater rate of complications occurring more than 24 hours after surgery.

Conclusions

Partial or radical nephrectomy can be offered to patients with comorbid conditions. ASA classification 3 patients are more likely to require transfusion. This may have been a result of a lower threshold to transfuse patients with preoperative morbidities. However, the perioperative and postoperative complication rates were similar to those of low-risk patients. Not surprisingly, high-risk patients had greater rates of transfusions and complications.

Section snippets

Material and methods

A retrospective study was performed (under institutional review board approval; protocol No. KCP 99-233) with the outcome assessment determined on the basis of a chart review of 1087 patients who underwent surgery for renal cell carcinoma (RCC) between 1989 and 2001. All patients with metastatic disease and nodal disease were included, in addition to those with localized disease. Patients with RCC who did not undergo nephrectomy as part of their cancer treatment, patients with bilateral

Results

The patient and tumor characteristics are presented in Table I. The patients with ASA classification 3 (IR) were older (63 years versus 58 years) than those with ASA classification 1 or 2 (LR; P = 0.04). IR patients presented with metastatic disease (40%) more often than LR patients (31%) did (P = 0.03). However, no statistically significant differences were found in male versus female distribution, 1997 T stage, tumor size, nodal involvement, vascular or IVC involvement, rate of partial

Comment

Recently, investigators have demonstrated the importance of the Eastern Cooperative Oncology Group performance status (ECOG PS)7 in the prognostication of patients with RCC.8, 9, 10 However, although some surgeons may use the ECOG PS to help assess perioperative risk, scant mention is made in published reports of the use of ECOG PS to determine the risk of postoperative complications. Furthermore, unlike the ASA scale, the ECOG PS is determined on the basis of the effects that the malignancy

Conclusions

The incidence of perioperative and postoperative morbidity in IR (ASA classification 3) patients was no worse than in patients in the LR (ASA classification 1 or 2) group in patients undergoing partial or radical nephrectomy. The IR patients did have a slightly, but statistically significant, greater EBL on average, leading to greater transfusion rates. Renal surgery can be performed with acceptable morbidity in patients with comorbid disease as defined by an ASA physical status of 3.

Despite

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