20
Mortalidad y complicaciones tras PTR: edad y comorbilidades
Table 3.
Multivariable models examining the risk of 30-day complication rates with age among men who underwent radical prostatectomy in Ontario, Canada, between 1990 and 1999
Variable
Any complication
Cardiac
Respiratory
Vascular
Wound/bleeding
Genitourinary
Miscellaneous medical
Miscellaneous surgical
Age
<60 y
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
60 to 69 y
1.08 (0.96 to 1.20)*
1.54 (1.05 to 2.26)
0.94 (0.67 to 1.33)
1.32 (0.87 to 2.01)
1.04 (0.88 to 1.23)
1.06 (0.88 to 1.27)
1.13 (0.90 to 1.41)
0.83 (0.66 to 1.04)
70 to 79 y
1.29 (1.09 to 1.52)
3.33 (2.14 to 5.18)
1.68 (1.09 to 2.61)
1.09 (0.58 to 2.04)
1.03 (0.80 to 1.33)
1.23 (0.95 to 1.59)
1.45 (1.07 to 1.98)
0.63 (0.43 to 0.92)
P
trend
.013
<.001
.01
.39
.89
.27
.058
.042
Diagnosis Count†
0
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
1.00 (referent)
1
3.84 (3.31 to 4.46)
3.09 (1.83 to 5.22)
5.99 (3.25 to 11.06)
2.53 (1.43 to 4.49)
5.28 (4.12 to 6.76)
2.90 (2.30 to 3.66)
3.07 (2.26 to 4.18)
29.92 (13.13 to 68.16)
2
5.20 (4.44 to 6.09)
4.90 (2.90 to 8.27)
8.71 (4.70 to 16.15)
4.98 (2.87 to 8.65)
5.62 (4.32 to 7.30)
3.42 (2.67 to 4.37)
3.98 (2.90 to 5.46)
41.96 (18.37 to 95.86)
3
5.72 (4.78 to 6.84)
6.36 (3.67 to 11.02)
10.05 (5.25 to 19.24)
3.09 (1.54 to 6.20)
5.30 (3.94 to 7.31)
4.18 (3.18 to 5.48)
4.37 (3.08 to 6.20)
52.52 (22.74 to 121.30)
4 or more
8.03 (6.81 to 9.50)
9.97 (6.02 to 16.40)
12.62 (6.81 to 23.38)
5.66 (3.18 to 10.08)
9.74 (7.51
12.63)
4.21 (3.26 to 5.45)
6.18 (4.52 to 8.46)
68.47 (30.00 to 156.28)
P
trend
<.001
<.001
<.001
<.001
<.001
<.001
<.001
<.001
c-statistic
0.70
0.74
0.73
0.71
0.72
0.67
0.68
0.76
*Numbers are odds ratios with 95% confidence intervals in parentheses. All models were adjusted for year of surgery.
†The Diagnosis Count
(25)
is a comorbidity index commonly used in health services research.
ARTICLE ARTICLES
30-Day Mortality and Major Complications after Radical
Prostatectomy: Influence of Age and Comorbidity
Shabbir M. H. Alibhai, Marc Leach, George Tomlinson, Murray D. Krahn,
Neil Fleshner, Eric Holowaty, Gary Naglie
Background:
Radical prostatectomy isassociated with excel-
lent long-term disease control for localized prostate cancer.
Prior studieshave suggested an increased risk of short-term
complicationsamongolder menwhounderwent radical pros-
tatectomy, but these studies did not adjust for comorbidity.
Methods:
We examined mortality and complications occur-
ring within 30 days following radical prostatectomy among
all 11010 men who underwent this surgery in Ontario,
Canada, between 1990 and 1999 usingmultivariable logistic
regression modeling. We adjusted for comorbidity using two
commoncomorbidity indices. Statistical testsweretwo-sided.
Results:
Overall, 53 men (0.5%) died, and 2246 (20.4%) had
one or more complicationswithin 30 daysof radical prosta-
tectomy. In models adjusted for comorbidity and year of
surgery, age wasassociated with an increased risk of 30-day
mortality (odds ratio = 2.04 per decade of age, 95% confi-
denceinterval [CI] = 1.23 to3.39). However, theabsolute30-
daymortality risk waslow, even inolder men, at 0.66% (95%
CI = 0.2 to 1.1%) for men aged 70–79 years. In adjusted
models, agewasassociated with an increased risk of cardiac
(
P
trend
<.001), respirat ry (
P
trend
= .01), and miscellaneous
m dical (
P
trend
= .058) compli ati ns. Sim larly, increasi g
comorbidity was associated with a higher risk of all catego-
riesof complications.
Conclusions:
Increasingcomorbidity is
a stronger predictor than ageof almost all categoriesof early
complications after radical prostatectomy. The risk of post-
operative mortality after radical prostatectomy is relatively
low for otherwise healthy older men up to age 79. [J Natl
Cancer Inst 2005;97:1525–32]
Prostate cancer is the most commonly diagnosed cancer in
men and the third most common cause of cancer death in men
(1)
.
Most patients have localized disease at the time of diagnosis
that is potentially curable with radical prostatectomy or radiation
therapy. In comparison with conservative management, where the
cancer is followed without local therapy (i.e., surgery or radiation),
radical prostatectomy is associated with lower disease-specific
mortality, lower rates of local progression and development of
metastases, and higher overall survival
(2)
.
Despite the impressive long-term outcomes with radical pros-
cians may believe that older men with prostate cancer are less
likely to live as long as younger men and, therefore, are less
likely to benefit from aggressive treatment
(6)
. Second, radical
prostatectomy is associated with substantial potential morbidity
and mortality, and many clinicians consider older men to be at
higher risk of surgery-associated short- and long-term complica-
tions
(7)
. Major long-term complications associated with radical
prostatectomy include urinary and sexual dysfunction
(8)
. Short-
term, perioperative morbidities include cardiovascular complica-
tions (e.g., myocardial infarction, congestive heart failure, and
arrhythmias), venous thromboembolism, rectal injury, and wound
infection
(9)
. Several studies have demonstrated higher radical
prostatectomy complication rates with increasing age
(9,10)
.
Begg et al. studi d complication rates amo g 11522 men who
underwent radical prostatectomy in the United States and re-
ported that at least one postoperative complication was experi-
enced by 28%, 31%, and 35% of men aged 65–69 years, 70–74
years, and 75 years or older, respectively
(10)
. Major postopera-
tive complications included cardiac (5.5% of patients), respira-
tory (11%), vascular (4.7%), wound-related or bleeding (2.6%),
genitourinary (2.8%), miscellaneous medical (7.6%), and mis-
cellaneous surgical (6.6%) complications
(10)
.
Published studies on complications following radical prosta-
tectomy are limited by a lack of information on the interaction
among age, comorbid conditions, and complication rates. How-
ever, increasing comorbidity has been shown to increase the risk
of a variety of adverse postoperative outcomes of a variety of
surgical procedures
(11,12)
. Indeed, in one of the few studies ex-
amining the impact of comorbidity on short-term complications,
Begg et al.
(10)
demonstrated increasing 30-day mortality and
postoperative complication rates with increasing comorbidity.
However, the interaction between age and comorbidity was not
examined.
As patients age, chronic comorbid illnesses become more
common
(13)
. However, association between age and comor-
bidity is imperfect, and many older adults have few or no
comorbid conditions. Knowing the independent contribution
of age and comorbidity to major short-term complications of
radical prostatectomy is important for at least two reasons.
Affiliations of authors:
Division of General Internal Medicine and Clinical
Epidemiology, University Health Network, Toronto, Canada (SMHA, ML, GT,
MDK, GN); Geriatric Program, Toronto Rehabilitation Institute, Canada (SMHA,
by guest on September 7, 2016
Downloaded from
Journal of the National Cancer Institute, Vol. 97, No. 20, October 19, 2005
Results:
Overall, 53 men (0.5%) died, and 2246 (20.4%) had
one or more complicationswithin 30 daysof radical prosta-
tectomy. In models adjusted for comorbidity and year of
surgery, agewasassociated with an increased risk of 30-day
mortality (odds ratio = 2.04 per decade of age, 95% confi-
denceinterval [CI] = 1.23 to3.39). However, theabsolute30-
daymortalityrisk waslow, even inolder men, at 0.66% (95%
CI = 0.2 to 1.1%) for men aged 70–79 years. In adjusted
models, agewasassociated with an increased risk of cardiac
(
P
trend
<.001), respiratory (
P
trend
= .01), and miscellaneous
medical (
P
trend
= .058) complications. Similarly, increasing
comorbidity wasassociated with a higher risk of all catego-
riesof complications.
Conclusions:
Increasingcomorbidity is
a stronger predictor thanageof almost all categoriesof early
complica ions fter radical prostatectomy. The risk of post-
operative mortality after radical prostatectomy is relatively
low for otherwise healthy older men up to age 79. [J Natl
Cancer Inst 2005;97:1525–32]
Prostate cancer is the most commonly diagnosed cancer in
men and the third most common caus of cancer death in me
(1)
.
Most patients have localized disease at the time of diagnosis
that is potentially curable with radical prostatectomy or radiation
therapy. In comparison with conservative management, where the
cancer is followed without local therapy (i.e., surgery or radiation),
radical prostatectomy is associated with lower disease-specific
mortality, lower rates of local progression and development of
metastases, and higher overall survival
(2)
.
Despite the impressive long-term outcomes with radical pros-
tatectomy, less than 5% of men over age 70 with prostate cancer
receive this treatment modality in Canada
(3)
. In one American
study of men with clinically localized disease, those under age 60
years were 25 times more likely to receive radical prostatectomy
than those aged 70 years or older
(4)
. In a recent survey, 69%
of Canadian urologists and 53% of American urologists agreed
with the statement that age 70 should be the upper age limit for
radical prostatectomy
(5)
.
Two possible explanations for these differences in the rate of
radical prostatectomy by age have been proposed. First, clini-
prost
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