Metabolic Syndrome as a Predictor for Postoperative Complications After Urologic Surgery

doi:10.1016/j.urology.2014.01.014

Urology

Volume 83, Issue 5, May 2014, Pages 1051-1059

https://doi.org/10.1016/j.urology.2014.01.014 Get rights and content

Objective

To elucidate whether metabolic syndrome (MS) has an effect on outcomes after nephrectomy, prostatectomy, or cystectomy.

Methods

Using the American College of Surgeons National Surgical Quality Improvement Program's database, patients undergoing cystectomy, nephrectomy, or prostatectomy between 2005 and 2011 were reviewed to assess for the presence of MS and a variety of perioperative complications.

Results

The overall complication rate for cystectomy, nephrectomy, and prostatectomy was 52.4%, 20.2%, and 8.7%, respectively. On multivariate analysis controlling for age, sex, body mass index, cardiac comorbidity, functional status, surgical approach (prostatectomy and nephrectomy), and surgery within 30 days, MS was not associated with perioperative complications in patients undergoing cystectomy (odds ratio [OR], 0.760; 95% confidence interval [CI], 0.476-1.213). On multivariate analysis, the presence of MS was a significant predictor of perioperative complications after radical nephrectomy (adjusted OR, 1.489; 95% CI, 1.146-1.934). With regards to prostatectomy, MS was not a significant predictor of complications (OR, 1.065; 95% CI, 0.739-1.535).

Conclusion

Patients in this cohort with MS undergoing cystectomy or prostatectomy did not experience a higher rate of complications compared with patients without MS, although patients with MS undergoing nephrectomy had a higher complication rate. It may be warranted to preoperatively counsel patients with MS undergoing nephrectomy that complication rates may be higher.

Section snippets

Methods

The data used for this study was obtained from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The NSQIP database collects data on 135 variables from >400 participating sites. These variables include preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes. Data are collected at participating sites from the hospital information system, and the NSQIP program performs audits at participating

Cystectomy

A total of 1095 patients in the NSQIP database underwent a cystectomy between 2005 and 2011. One thousand eighty-two patients had sufficient data to be labeled as with or without MS, and 76 patients (7%) met inclusion criteria for MS. Demographic information along with comorbidities is listed in Table 1. A majority of the cohort were men (76%). The median age for patients with and without MS was 67 years (interquartile range, 62-73 years) and 69 years (interquartile range 60-76 years),

Comment

In light of the striking increase in prevalence of MS and the significant associated risk of developing DM and CVD among these patients, MS has been described as an emerging global epidemic. Furthermore, although insulin resistance has been hypothesized to be the coupling factor between the glucose intolerance, HTN, elevated TG levels, low HDL levels, and obesity that highlights the syndrome, the pathogenesis remains unclear.¹² Importantly, patients with MS have double the risk of CVD over the

Conclusion

MS is an increasingly prevalent disorder associated with obesity, DM, and CVD. A chronic proinflammatory state is believed to underlie the condition. Although patients in this cohort with MS undergoing cystectomy or prostatectomy did not experience a higher rate of complications compared with patients without MS, patients with MS undergoing nephrectomy had a higher complication rate. It may be prudent to counsel patients with MS undergoing nephrectomy that they may have a higher complication

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Cited by (17)

Metabolic syndrome predicts worse perioperative outcomes in patients treated with radical prostatectomy for non-metastatic prostate cancer
2021, Surgical Oncology
Citation Excerpt :
MetS is associated with prostate cancer (PCa) aggressiveness and recurrence after local treatment [3–8]. However, there are no robust data to indicate whether or not MetS predicts early adverse outcomes after radical prostatectomy (RP) [9–12]. Nonetheless, several previous reports examined the effect of individual MetS components, namely either obesity [13–18] or hypertension [19] or diabetes [20–23], on perioperative outcomes after RP, without adjusting for possible combined effect of other MetS components.
Metabolic syndrome (MetS) and its components (high blood pressure, BMI $\geq$ 30, altered fasting glucose, low HDL cholesterol and high triglycerides) may undermine early perioperative outcomes after radical prostatectomy (RP). We tested this hypothesis.
Within the National Inpatient Sample database (2008–2015) we identified RP patients. The effect of MetS was tested in four separate univariable analyses, as well as in multivariable regression models predicting: 1) overall complications, 2) length of stay, 3) total hospital charges and 4) non-home based discharge. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics.
Of 91,618 patients: 1) 50.2% had high blood pressure, 2) 8.0% had BMI $\geq$ 30, 3) 13.0% had altered fasting glucose, 4) 22.8% had high triglycerides and 5) 0.03% had low HDL cholesterol. Respectively, one vs. two vs. three vs. four MetS components were recorded in 36.2% vs. 19.0% vs. 5.5% vs. 0.8% patients. Of all patients, 6.3% exhibited $\geq$ 3 components and qualified for MetS diagnosis. The rates of MetS increased over time (EAPC:+9.8%; p < 0.001). All four tested MetS components (high blood pressure, BMI $\geq$ 30, altered fasting glucose and high triglycerides) achieved independent predictor status in all four examined endpoints. Moreover, a highly statistically significant dose-response was also confirmed for all four tested endpoints.
MetS and its components consistently and strongly predict early adverse outcomes after RP. Moreover, the strength of the effect was directly proportional to the number of MetS components exhibited by each individual patient, even if formal MetS diagnosis of $\geq$ 3 components has not been met.
Association of metabolic syndrome with morbidity and mortality in emergency general surgery
2020, American Journal of Surgery
Citation Excerpt :
Patients were then marked as having MetS if NSQIP reported them as having a body mass index (BMI) ≥30 kg/m2, diabetes requiring medical intervention, and hypertension requiring medical intervention.16,17 As dyslipidemia is not recorded by NSQIP, this factor was left out of our MetS definition as commonly done in other MetS NSQIP studies.10,11 A diagnosis with diabetes requiring medication was used as a proxy for insulin resistance.
Metabolic syndrome (MetS) is defined by numerous comorbidities. We sought to assess MetS’s effect on the 7 main emergency general surgery (EGS) procedures that constitute 80% of EGS procedures, mortalities, complications, and costs.
Data were acquired from the ACS-NSQIP database from 2005 to 2017. Current procedural terminology (CPT) codes were utilized to identify cases. Patients with obesity, diabetes, and hypertension were defined as having MetS. MetS and non-MetS cohorts were propensity score matched, compared by outcomes, and assessed with multivariate logistic regression to attain odds ratios (OR).
Of 752,023 cases, 41,788 (5.6%) MetS cases were identified. Significant outcomes included superficial infection (OR: 1.51), pulmonary complications (OR: 1.17), renal complications (OR: 1.82), cumulative morbidity (OR: 1.22), and hospital readmission (OR: 1.41).
For patients undergoing these procedures, MetS increased risk for comorbidities and hospital readmission. MetS had a significant impact on mortality only for appendectomy.
Metabolic Syndrome Predicts Worse Perioperative Outcomes in Patients Treated With Partial Nephrectomy for Renal Cell Carcinoma
2020, Urology
Citation Excerpt :
Subgroup analyses according to PN surgical approach, namely open vs laparoscopic/robotic patients, are reported in Supplementary Table 5. The association between MetS and early adverse perioperative outcomes after PN has been poorly investigated.5-9 However, obesity,10,12-15,17 hypertension,20,21 and diabetes21,23-25 have been previously related to higher complication rates after PN.
To test the association between metabolic syndrome (MetS) and its components (high blood pressure, body mass index [BMI] ≥ 30, altered fasting glucose, low high-density lipoprotein cholesterol and high triglycerides) on perioperative outcomes after partial nephrectomy (PN).
Within the National Inpatient Sample database (2000-2015) we identified all PN patients. First, temporal trends of MetS were reported. Second, the effect of MetS components was tested in multivariable logistic regression models predicting overall and specific perioperative complications. Third, we tested for dose-response from the concomitant effect of multiple MetS components. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics.
Of 25,875 patients: (1) 59.3% had high blood pressure, (2) 14.7% had BMI ≥ 30, (3) 21.7% had altered fasting glucose, (4) 20.2% had high triglycerides, and (5) <0.01% had low high-density lipoprotein cholesterol. One vs 2 vs 3 vs 4 MetS components were recorded in 34.9% vs 22.9% vs 8.9% vs 2.2% patients. Of all, 11.1% exhibited ≥ 3 components and qualified for MetS. The rates of MetS increased over time (estimated annual percentage changes: +12.0%;P <.001). The 4 tested MetS components (high blood pressure, BMI ≥ 30, altered fasting glucose, and high triglycerides) achieved independent predictor status in multivariable models predicting overall, cardiac, miscellaneous medical, vascular, and respiratory complications, as well as transfusions. Moreover, a statistically significant dose-response was confirmed for the same endpoints.
MetS and its components consistently and strongly predict perioperative complications after PN. Moreover, the strength of the effect was directly proportional to the number of MetS components exhibited by each individual patient, even if formal MetS diagnosis of ≥ 3 components has not been met.
Metabolic Syndrome: Major Risk Factor for Morbidity and Mortality in Severely Injured Trauma Patients
2020, Journal of the American College of Surgeons
Citation Excerpt :
Other sources of infection that could have led to severe sepsis, such as non-catheter-associated bloodstream infections, Clostridium difficile, and fungemia, were not captured in this study. Nevertheless, the increase in complications is consistently seen in recent literature exploring the effect of MetS on outcomes in vascular surgery, orthopaedics, and urology.4,13,14 We found a 2.2% incidence of MetS in our cohort, which is lower than the 10.3% cited by Edelstein and colleagues'15 review of 107,117 patients undergoing total hip and/or knee arthroplasty and the 7.9% reported by Cichos and colleagues16 in their study on 3,348,207 hip fracture patients.
Metabolic syndrome (MetS) increases cardiovascular risk and is associated with poor patient outcomes. We hypothesized that MetS confers an increased risk of morbidity and mortality in severely injured trauma patients.
We performed a retrospective review of trauma patients from 2014 through 2018, excluding patients younger than 16 years, with Injury Severity Score <16, and with incomplete height and/or weight documentation. Metabolic syndrome was defined as the presence of diabetes, hypertension, and BMI ≥30 kg/m². Outcomes included length of stay (LOS), complications, discharge location, and mortality.
There were 4,489 patients meeting criteria, of which 100 (2.2%) had MetS. Patients with MetS were older (64.0 vs 38.6 years; p < 0.0001), but with similar Injury Severity Scores (22 vs 22; p = 0.7). Hospital LOS was significantly longer with MetS (16.5 vs 11 days; p < 0.0001), as was ICU LOS (9 vs 5 days; p = 0.0002). MetS correlated with higher rates of acute kidney injury (19% vs 3.6%; p < 0.0001), ARDS (11.0% vs 4.6%; p = 0.01), cardiac arrest (10.0% vs 4.0%; p = 0.01), MI (2.0% vs 0.3%; p = 0.05), severe sepsis (8.0% vs 3.3%; p = 0.03), unplanned intubation (11.0% vs 5.0%; p = 0.02), unplanned ICU admission (13.0% vs 6.1%; p = 0.02), and non-home discharge (51.0% vs 30.2%; p = 0.0007). After controlling for age, Glasgow Coma Scale, Injury Severity Score, sex, and mechanism, MetS remained an independent predictor of mortality (odds ratio 2.5; 95% CI 1.33 to 4.7; p = 0.004).
MetS occurs infrequently in our severely injured trauma population, but is strongly associated with increasing LOS, as well as cardiac, pulmonary, infectious, and renal complications. MetS also significantly and independently predicts death and should be identified early to facilitate prompt multidisciplinary treatment.
Metabolic Syndrome Associated with Increased Rates of Medical Complications After Intracranial Tumor Resection
2019, World Neurosurgery
Citation Excerpt :
This disorder has important implications for health care providers.3,4 In particular, MetS has been shown to increase the risk of postoperative morbidity and mortality in multiple surgical settings.5-10 Inevitably, neurosurgeons in the United States will be faced with increasing numbers of these multimorbid patients requiring operative procedures.
When diagnosed simultaneously, obesity, diabetes, and hypertension form a medical constellation called metabolic syndrome (MetS). The prevalence of MetS in Western cultures has been on a steady increase and MetS has been associated with increased postoperative complications in multiple surgical settings.
In this study, we evaluate the relationship between MetS and the outcomes of craniotomy for supratentorial brain tumor.
Cases of craniotomy for supratentorial brain tumors were extracted from the American College of Surgeons National Surgical Quality Improvement Program for 2012–2016. The 15,136 patients identified were divided into 2 cohorts based on the presence (4.1%) or absence (95.9%) of MetS. We compared the 2 cohorts for preoperative comorbidities, intraoperative details, and postoperative morbidity and mortality.
Patients in the MetS+ cohort were significantly older (63.4 vs. 56.1 years) and were more likely to show comorbidities of various organ systems (all P ≤ 0.05). However, operative times were similar (P = 0.573). The number of medical complications was almost double in patients with MetS (15.8% vs. 8.5%; P ≤ 0.001). Unplanned readmissions (14.6% vs. 10.4%; P = 0.004), reoperations (6.9% vs. 4.6%; P = 0.007), and mortality (5.6% vs. 2.9%; P ≤ 0.001) were also more frequent in our MetS+ group. Nevertheless, surgical complications localized to the operative site were not statistically increased (7.4% vs. 5.8%; P = 0.098).
A diagnosis of MetS does not seem to be associated with increased rates of surgical site events. However, neurosurgeons should be aware that these patients have a significantly higher likelihood of general medical complications, readmissions, reoperations, and death.
Role of Metabolic Syndrome on Perioperative and Oncological Outcomes at Radical Prostatectomy in a Low-risk Prostate Cancer Cohort Potentially Eligible for Active Surveillance
2019, European Urology Focus
Metabolic syndrome (MetS) is considered a potential risk factor for adverse outcomes after radical prostatectomy (RP). Furthermore, studies about the effect of MetS on low-risk prostate cancer (PCa) and its implications in active surveillance (AS) are limited.
To investigate the role of MetS (using International Diabetes Federation–American Heart Association/National Heart, Lung, and Blood Institute criteria) on perioperative and oncological outcomes after RP in low-risk PCa and in a subgroup potentially eligible for AS.
A total of 3662 patients treated with RP for low-risk PCa and further stratified as very low risk (VLR) PCa—prostate-specific antigen density of ≤0.15 ng/ml/cm³, ≤2 cores involved, and no core with >50% cancer involvement—at a tertiary referral hospital were identified.
Outcomes analyzed were pathological outcomes, perioperative complications, biochemical failure (BCF), and overall survival. Pathological outcomes and complications were analyzed with logistic regression models. Kaplan–Meier curves and Cox proportional hazards models were used to analyze survival outcomes.
In univariate/multivariate analyses, MetS was associated with upgrading and positive surgical margins in the entire cohort, upgrading only in the VLR group. In Kaplan–Meier analysis, MetS patients had a higher rate of overall death (p < 0.0001) and BCF (p = 0.03) for MetS patients. In the VLR group, no differences were found for BCF (p = 0.064). Further, in Cox proportional hazards models, MetS was not associated with BCF (hazard ratio = 1.23; 95% confidence interval [CI] = 0.95–1.60, p = 0.12). MetS patients had a higher rate of complications compared with non-MetS patients (23.7% vs 19.7%; p = 0.01). In multivariate analysis, MetS was associated with a higher rate of complications (odds ratio = 1.24, 95% CI = 1.04–1.49, p = 0.018) but did not impact the rate of major ones. This study is limited by its retrospective design.
In low-risk PCa treated with RP but potentially eligible for AS, MetS impacted perioperative and pathological outcomes, suggesting further study of MetS in patients undergoing AS.
Metabolic syndrome negatively impacts perioperative and pathological outcomes in low-risk prostate cancer patients treated with radical prostatectomy but potentially eligible for active surveillance, in a large American single-center cohort. These findings suggest the need for a more cautious approach to low-risk prostate cancer in patients with metabolic syndrome.

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: Financial Disclosures: The authors declare that they have no relevant financial interests.

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Health Services ResearchMetabolic Syndrome as a Predictor for Postoperative Complications After Urologic Surgery

Objective

Methods

Results

Conclusion

Section snippets

Methods

Cystectomy

Comment

Conclusion

Lancet

Surgery

Am J Transpl

Lancet

Urol Oncol

J Urol

J Am Coll Surg

J Urol

Urol Oncol

Prevalence of obesity in the United States, 2009-2010

NCHS Data Brief

Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation

Diabet Med

Clinical review: prevalence and incidence of endocrine and metabolic disorders in the United States: a comprehensive review

J Clin Endocrinol Metab

Metabolic syndrome and the risk for chronic kidney disease among nondiabetic adults

J Am Soc Nephrol

Urological aspects of the metabolic syndrome

Nat Rev Urol

Health Services Research
Metabolic Syndrome as a Predictor for Postoperative Complications After Urologic Surgery