Original Study
Preoperative Albumin Is Predictive of Early Postoperative Morbidity and Mortality in Common Urologic Oncologic Surgeries

https://doi.org/10.1016/j.clgc.2016.09.008Get rights and content

Abstract

Introduction

Multiple studies have linked preoperative nutrition status to postoperative outcomes. This relationship has been little studied in urology. We used a standardized, national, risk-adjusted surgical database to evaluate 30-day outcomes of patients undergoing common urologic oncologic procedures as they related to preoperative albumin.

Methods

The American College of Surgeons National Surgical Quality Improvement Program is a risk-adjusted dataset analyzing preoperative risk factors, demographics, and 30-day outcomes. From 2005 through 2012, we identified a total of 17,805 patients who underwent prostatectomy, nephrectomy, partial nephrectomy, cystectomy, or transurethral resection of bladder tumor (TURBT). Hypoalbuminemic patients were compared with those with normal preoperative albumin, and 30-day outcomes were evaluated. Logistic regression analyses were used to estimate odds ratios for mortality and complication rates.

Results

Evaluation of the cohort noted significantly increased overall morbidity, serious morbidity, and mortality in the hypoalbuminemic group (P < .01 for all procedures). Hypoalbuminemia was associated with a significantly higher 30-day mortality in major procedures such as cystectomy, and in smaller procedures such as TURBT (P < .01). Hypoalbuminemia was associated with a 6.4% 30-day mortality in the TURBT group compared with 0.6% in those with normal albumin (P < .0001). These findings remained significant after adjustment for other risk factors.

Conclusions

The large sample size, standardized data definitions, and quality control measures of the American College of Surgeons National Surgical Quality Improvement Program database allow for in-depth analysis of subtle but significant differences in outcomes between groups. Serum albumin is a strong predictor of short-term postoperative complications in the urologic oncology patient.

Introduction

The diagnosis and treatment of urologic malignancy is a benchmark of the practicing urologist. The American Cancer Society estimates that, in 2016, there were a total of 1,685,210 new cancer cases in the United States, and of these, 334,830 cases were diagnosed, treated, and managed by urologists.1 Urologic malignancy represents a broad spectrum of disease, with treatments ranging from watchful waiting to major extirpative surgery. In counseling patients through the process of diagnosis and treatment, the urologist must not only bear in mind the patient's oncologic burden and prognosis, but also their overall health and comorbidities.

A patient's nutritional status has been tied to the perioperative outcomes in a number of previous publications. Authors have explored the role of nutrition status in the perioperative setting in general surgical patients,2 cardiothoracic patients,3 gynecology patients,4 and urology patients.5, 6, 7 Albumin is a relatively well-accepted surrogate for a patient's nutrition status, and has been shown to be an independent predictor of poor outcome in the perioperative period for oncologic surgery.4, 8 These prior studies have evaluated how perioperative nutrition status and hypoalbuminemia have affected perioperative morbidity and mortality related to specific urologic malignancies, but none has undertaken as comprehensive of an analysis of urologic oncologic patients. Furthermore, many of these studies represent single institution data sets.8, 9 We used a standardized, national, risk-adjusted surgical database to evaluate the 30-day outcomes of patients undergoing common urologic oncologic procedures as they relate to preoperative nutritional status.

Section snippets

Materials and Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and improve quality of surgical care, analyzing preoperative risk factors, demographics, and 30-day postoperative outcomes. Since its inception in 1994 within the Veterans Health Administration System, the NSQIP was piloted in the private sector by the ACS in 2001 and, over the time of this study, included over

Results

A total of 17,805 patients undergoing cystectomy (n = 1374), PN (n = 2802), RN (n = 2782), prostatectomy (n = 6701), and TURBT (n = 4200) met inclusion criteria in the ACS-NSQIP database between 2005 and 2012. Of these, a total of 2564 patients (14%) were hypoalbuminemic at the time of their procedure. Hypoalbuminemic patients were more likely to be older, underweight, and of poor functional status. Hypoalbuminemia was seen more often in the inpatient as compared with outpatients, particularly

Discussion

Our study represents one of the largest analyses of postoperative outcomes for urologic patients as they relate to preoperative nutritional status. The strength of the ACS-NSQIP database allows for pooling of national data, acquired in a standardized fashion and externally validated, giving insight into “real-world” outcomes. Poor nutrition is a known risk factor for perioperative morbidity and mortality, and this has been explored in urologic patients with the focus on individual procedures.

Conclusions

Using the ACS-NSQIP database, we demonstrated that low serum albumin is associated with increased morbidity and mortality in urologic oncologic surgeries. This morbidity and mortality is increased in large extirpative surgeries as well as in “less invasive” endoscopic surgeries. Low serum albumin is also associated with an increased LOS. Given these findings, serum albumin may be useful in predicting patients at higher risk for complications, and may assist in surgical counseling and

Disclosure

The authors have stated that they have no conflicts of interest.

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