Journal of Reconstructive Urology

.: ORIGINAL RESEARCH
Prognostik Nutrisyonel İndeksin Radikal Sistektomi ve İleal Kondüit Sonrası Komplikasyonları Öngörmedeki Değeri: Retrospektif Klinik Çalışma
Value of Prognostic Nutritional Index on Complications After Radical Cystectomy and Ileal Conduit: Retrospective Clinical Research
Şükrü KUMSARa
aDepartment of Urology, Başkent University İstanbul Health Application and Research Center, İstanbul, Türkiye
J Reconstr Urol. 2022;12(1):16-21
doi: 10.5336/urology.2021-87848
Article Language: EN
Full Text
ABSTRACT
 Objective: Prognostic nutritional index (PNI) is a method that can be easily calculated according to the serum albumin level and lymphocyte count and shows the nutritional and immune status of patients. PNI was originally developed as an indicator of the preoperative nutritional status of patients with gastrointestinal malignancies. The aim of this study is to evaluate the value of PNI in prediction of postoperative complications after radical cystectomy and ileal conduit. Material and Methods: We conducted a retrospective study of patients who underwent radical cystectomy and ileal conduit between 2011 and 2021. A total of 174 patients were included in this study. The patients were divided into 2 groups according to the cutoff value of the PNI: those with a PNI≥46 (normal group) and those with a PNI<46 (low PNI group). The clinicopathological features between the 2 groups were compared using the χ2 test. Results: A total of 174 radical cystectomy with ileal conduit patients were available for analysis. The cohort included 140 males and 34 females. Overall, 36 (20.6%) patients encountered a Grade ≥ III complication after surgery. In the normal group, 9 (17.5%) of patients had Grade ≥ III complication and 27 of patients (34.04%) in low PNI group had Grade ≥ III complication after surgery. When the groups were compared in terms of major complication rates, there were statistically significant more Grade ≥ III complications in the low PNI group (p<0.001). Conclusion: PNI can be used clinically to predict the possibility of serious postoperative complications in patients who are candidates for radical cystectomy.

Keywords: Urinary diversion; cystectomy; nutrition assessment; complications
ÖZET
 Amaç: Prognostik nutrisyonel indeks (PNİ), serum albumin düzeyi ve lenfosit sayısına göre kolaylıkla hesaplanabilen, hastaların beslenme ve bağışıklık durumunu gösteren bir yöntemdir. PNİ ilk olarak gastrointestinal kanserli hastaların ameliyat öncesi beslenme durumunun bir göstergesi olarak geliştirilmiştir. Bu çalışmanın amacı, kasa invaze mesane kanseri nedeniyle radikal sistektomi ve ileal kondüit uygulanan hastalarda PNİ'nin postoperatif komplikasyonları öngörmedeki değerini araştırmaktır. Gereç ve Yöntemler: 2011-2021 yılları arasında radikal sistektomi ve ileal kondüit uygulanan hastaları retrospektif olarak değerlendirdik. Bu çalışmaya toplam 174 hasta dâhil edildi. Hastalar PNİ eşik değerine göre PNİ≥46 olanlar (normal grup) ve PNİ<46 olanlar (düşük PNİ grubu) olmak üzere 2 gruba ayrıldı. İki grup arasındaki klinikopatolojik özellikler χ2 testi kullanılarak karşılaştırıldı. Bulgular: Toplam 174 radikal sistektomi ve ileal kondüit yapılan hasta analize uygundu. Kohort, 14 erkek ve 34 kadın hastadan oluşuyordu. Ameliyat sonrası 36 (%20,6) hastada Grade ≥ III komplikasyonla karşılaşıldı. Normal grupta 9 (%17,5) hastada cerrahi sonrası Grade ≥ III komplikasyon ile karşılaşılırken, düşük PNİ grupta 27 (%34,04) hastada Grade ≥ III komplikasyon görüldü. Gruplar majör komplikasyon oranları açısından karşılaştırıldığında, düşük PNİ grupta istatistiksel olarak anlamlı derecede daha fazla Grade ≥ III komplikasyon görüldü (p<0,001). Sonuç: PNİ, radikal sistektomi adayı hastalarda ciddi postoperatif komplikasyonları öngörmek için klinik olarak kullanılabilir.

Anahtar Kelimeler: Üriner diversiyon; sistektomi; beslenme değerlendirmesi; komplikasyonlar
REFERENCES:
  1. Lee RK, Abol-Enein H, Artibani W, Bochner B, Dalbagni G, Daneshmand S, et al. Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes. BJU Int. 2014;113(1):11-23. [Crossref]  [PubMed] 
  2. Bochner BH, Dalbagni G, Sjoberg DD, Silberstein J, Keren Paz GE, Donat SM, et al. Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol. 2015;67(6):1042-50. [Crossref]  [PubMed]  [PMC] 
  3. Comploj E, West J, Mian M, Kluth LA, Karl A, Dechet C, et al. Comparison of complications from radical cystectomy between old-old versus oldest-old patients. Urol Int. 2015;94(1):25-30. [Crossref]  [PubMed] 
  4. Oberle AD, West JM, Tobert CM, Conley GL, Nepple KG. Optimizing nutrition prior to radical cystectomy. Curr Urol Rep. 2018;19(12):99. [Crossref]  [PubMed]  [PMC] 
  5. Onodera T, Goseki N, Kosaki G. [Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients]. Nihon Geka Gakkai Zasshi. 1984;85(9):1001-5. Japanese. [PubMed] 
  6. Nozoe T, Kimura Y, Ishida M, Saeki H, Korenaga D, Sugimachi K. Correlation of pre-operative nutritional condition with post-operative complications in surgical treatment for oesophageal carcinoma. Eur J Surg Oncol. 2002;28(4):396-400. [Crossref]  [PubMed] 
  7. Mohri Y, Inoue Y, Tanaka K, Hiro J, Uchida K, Kusunoki M. Prognostic nutritional index predicts postoperative outcome in colorectal cancer. World J Surg. 2013;37(11):2688-92. [Crossref]  [PubMed] 
  8. Kang SH, Cho KH, Park JW, Yoon KW, Do JY. Onodera's prognostic nutritional index as a risk factor for mortality in peritoneal dialysis patients. J Korean Med Sci. 2012;27(11):1354-8. [Crossref]  [PubMed]  [PMC] 
  9. Kosuga T, Konishi T, Kubota T, Shoda K, Konishi H, Shiozaki A, et al. Value of prognostic nutritional index as a predictor of lymph node metastasis in gastric cancer. Anticancer Res. 2019;39(12):6843-9. [Crossref]  [PubMed] 
  10. Stenzl A, Cowan NC, De Santis M, Kuczyk MA, Merseburger AS, Ribal MJ, et al; European Association of Urology (EAU). Treatment of muscle-invasive and metastatic bladder cancer: update of the EAU guidelines. Eur Urol. 2011;59(6):1009-18. [Crossref]  [PubMed] 
  11. Mitropoulos D, Artibani W, Graefen M, Remzi M, Rouprêt M, Truss M; European Association of Urology Guidelines Panel. Reporting and grading of complications after urologic surgical procedures: an ad hoc EAU guidelines panel assessment and recommendations. Eur Urol. 2012;61(2):341-9. [Crossref]  [PubMed] 
  12. Gakis G, Efstathiou J, Lerner SP, Cookson MS, Keegan KA, Guru KA, et al; International Consultation on Urologic Disease-European Association of Urology Consultation on Bladder Cancer 2012. ICUD-EAU International Consultation on Bladder Cancer 2012: Radical cystectomy and bladder preservation for muscle-invasive urothelial carcinoma of the bladder. Eur Urol. 2013;63(1):45-57. [Crossref]  [PubMed] 
  13. Shabsigh A, Korets R, Vora KC, Brooks CM, Cronin AM, Savage C, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol. 2009;55(1):164-74. [Crossref]  [PubMed] 
  14. Novara G, De Marco V, Aragona M, Boscolo-Berto R, Cavalleri S, Artibani W, et al. Complications and mortality after radical cystectomy for bladder transitional cell cancer. J Urol. 2009;182(3):914-21. [Crossref]  [PubMed] 
  15. Roghmann F, Trinh QD, Braun K, von Bodman C, Brock M, Noldus J, et al. Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy. Int J Urol. 2014;21(2):143-9. [Crossref]  [PubMed] 
  16. Schiavina R, Borghesi M, Guidi M, Vagnoni V, Zukerman Z, Pultrone C, et al. Perioperative complications and mortality after radical cystectomy when using a standardized reporting methodology. Clin Genitourin Cancer. 2013;11(2):189-97. [Crossref]  [PubMed] 
  17. De Nunzio C, Cindolo L, Leonardo C, Antonelli A, Ceruti C, Franco G, et al. Analysis of radical cystectomy and urinary diversion complications with the Clavien classification system in an Italian real life cohort. Eur J Surg Oncol. 2013;39(7):792-8. [Crossref]  [PubMed] 
  18. Siegrist T, Savage C, Shabsigh A, Cronin A, Donat SM. Analysis of gender differences in early perioperative complications following radical cystectomy at a tertiary cancer center using a standardized reporting methodology. Urol Oncol. 2010;28(1):112-7. [Crossref]  [PubMed] 
  19. Svatek RS, Fisher MB, Matin SF, Kamat AM, Grossman HB, Nogueras-González GM, et al. Risk factor analysis in a contemporary cystectomy cohort using standardized reporting methodology and adverse event criteria. J Urol. 2010;183(3):929-34. [Crossref]  [PubMed] 
  20. Stein JP, Skinner DG. Radical cystectomy for invasive bladder cancer: long-term results of a standard procedure. World J Urol. 2006;24(3):296-304. [Crossref]  [PubMed] 
  21. Hautmann RE, de Petriconi RC, Volkmer BG. Lessons learned from 1,000 neobladders: the 90-day complication rate. J Urol. 2010;184(3):990-4; quiz 1235. [Crossref]  [PubMed] 
  22. Hautmann RE, de Petriconi RC, Pfeiffer C, Volkmer BG. Radical cystectomy for urothelial carcinoma of the bladder without neoadjuvant or adjuvant therapy: long-term results in 1100 patients. Eur Urol. 2012;61(5):1039-47. [Crossref]  [PubMed] 
  23. Nielsen ME, Mallin K, Weaver MA, Palis B, Stewart A, Winchester DP, et al. Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the National Cancer Data Base. BJU Int. 2014;114(1):46-55. [Crossref]  [PubMed]  [PMC] 
  24. Porter MP, Gore JL, Wright JL. Hospital volume and 90-day mortality risk after radical cystectomy: a population-based cohort study. World J Urol. 2011;29(1):73-7. [Crossref]  [PubMed] 
  25. Okada S, Shimada J, Teramukai S, Kato D, Tsunezuka H, Miyata N, et al. Risk stratification according to the prognostic nutritional index for predicting postoperative complications after lung cancer surgery. Ann Surg Oncol. 2018;25(5):1254-61. [Crossref]  [PubMed] 
  26. Kanda M, Fujii T, Kodera Y, Nagai S, Takeda S, Nakao A. Nutritional predictors of postoperative outcome in pancreatic cancer. Br J Surg. 2011;98(2):268-74. [Crossref]  [PubMed] 
  27. Nozoe T, Kohno M, Iguchi T, Mori E, Maeda T, Matsukuma A, et al. The prognostic nutritional index can be a prognostic indicator in colorectal carcinoma. Surg Today. 2012;42(6):532-5. [Crossref]  [PubMed] 
  28. Jiang N, Deng JY, Ding XW, Ke B, Liu N, Zhang RP, et al. Prognostic nutritional index predicts postoperative complications and long-term outcomes of gastric cancer. World J Gastroenterol. 2014;20(30):10537-44. [Crossref]  [PubMed]  [PMC] 
  29. Gregg JR, Cookson MS, Phillips S, Salem S, Chang SS, Clark PE, et al. Effect of preoperative nutritional deficiency on mortality after radical cystectomy for bladder cancer. J Urol. 2011;185(1):90-6. [Crossref]  [PubMed]  [PMC] 
  30. Ornaghi PI, Afferi L, Antonelli A, Cerruto MA, Odorizzi K, Gozzo A, et al. The impact of preoperative nutritional status on post-surgical complication and mortality rates in patients undergoing radical cystectomy for bladder cancer: a systematic review of the literature. World J Urol. 2021;39(4):1045-81. [Crossref]  [PubMed] 
  31. Buzby GP, Mullen JL, Matthews DC, Hobbs CL, Rosato EF. Prognostic nutritional index in gastrointestinal surgery. Am J Surg. 1980;139(1):160-7. [Crossref]  [PubMed] 

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