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Robotic Surgery in the Frail Elderly: Analysis of Perioperative Outcomes

  • Health Services Research and Global Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Purpose

The frail are considered at higher risk for unfavorable surgical outcomes (major complications/mortality). We assessed the safety of and outcomes associated with robotic surgery in the frail elderly undergoing gynecologic procedures.

Methods

We identified patients aged ≥ 65 years who underwent a robotic procedure between May 2007 and December 2016. Frailty was defined as the presence of at least three of five frailty factors—more than five comorbidities, low physical activity, weight loss, exhaustion, and fatigue. Perioperative outcomes were recorded. We compared variables among frail and non-frail patients and performed a multivariate logistic regression to detect variables associated with major complications (≥ grade 3) or 90-day mortality.

Results

We identified 982 patients: 71 frail and 911 non-frail patients. Median age was 71 years. Median BMI was 29.8 kg/m2. Thirty-four patients (3.5%) had a 30-day readmission. Seventy-seven (7.8%) had a postoperative complication, of which 23 (2.3%) were major. Ninety-day mortality was 0.5%. There were significant differences with regard to age (P < 0.001), body mass index (BMI) (P < 0.001) and performance status (P < 0.001); the frail were more likely to have had surgery for oncologic reasons (P = 0.047). There were differences in hospital stay (P < 0.001), postoperative (P = 0.042) and major complications (P = 0.007), and 90-day mortality (P = 0.05). At multivariable logistic regression, age ≥ 85 was associated with major complications. BMI, performance status, and major complications were associated with 90-day mortality.

Conclusions

The frail elderly have longer hospital stays and more complications after surgery than the general population, consistent with the reported literature. Careful selection of surgical candidates is required.

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References

  1. Yancik R. Cancer burden in the aged: an epidemiologic and demographic overview. Cancer. 1997;80:1273–83.

    Article  CAS  Google Scholar 

  2. Syddall H, Roberts HC, Evandrou M, Cooper C, Bergman H, Sayer AA. Prevalence and correlates of frailty among community-dwelling older men and women: findings from the Hertfordshire Cohort Study. Age Ageing. 2010;39:197–203.

    Article  Google Scholar 

  3. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14:392–7.

    Article  Google Scholar 

  4. Dodds C, Foo I, Jones K, Singh SK, Waldmann C. Peri-operative care of elderly patients—an urgent need for change: a consensus statement to provide guidance for specialist and non-specialist anaesthetists. Perioper Med Lond. 2013;2:6.

    Article  Google Scholar 

  5. Korc-Grodzicki B, Downey RJ, Shahrokni A, Kingham TP, Patel SG, Audision RA. Surgical considerations in older adults with cancer. J Clin Oncol. 2014;32:2647–53.

    Article  Google Scholar 

  6. Chereau E, Ballester M, Selle F, Rouzier R, Darai E. Ovarian cancer in the elderly: impact of surgery on morbidity and survival. Eur J Surg Oncol. 2011;37:537–42.

    Article  CAS  Google Scholar 

  7. Aloisi A, Tseng JH, Sandadi S, et al. Is robotic-assisted surgery safe in the elderly population? An analysis of gynecologic procedures in patients ≥ 65 years old. Ann Surg Oncol. 2019;26:244–51.

    Article  Google Scholar 

  8. Ballesta Lopez C, Cid JA, Poves I, Bettonica C, Villegas L, Memon MA. Laparoscopic surgery in the elderly patient. Surg Endosc. 2003;17:333–7.

    Article  CAS  Google Scholar 

  9. Bogani G, Cromi A, Uccella S, et al. Laparoscopic staging in women older than 75 years with early-stage endometrial cancer: comparison with open surgical operation. Menopause. 2014;21:945–51.

    Article  Google Scholar 

  10. Bijen CB, Briet JM, de Bock GH, Arts HJ, Bergsma-Kadijk JA, Mourits MJ. Total laparoscopic hysterectomy versus abdominal hysterectomy in the treatment of patients with early-stage endometrial cancer: a randomized multi center study. BMC Cancer. 2009;9:23.

    Article  Google Scholar 

  11. Walker JL, Piedmonte MR, Spirtos NM, et al. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 study. J Clin Oncol. 2012;30:695–700.

    Article  Google Scholar 

  12. Lin F, Zhang QJ, Zheng FY, et al. Laparoscopically assisted versus open surgery for endometrial cancer—a meta-analysis of randomized controlled trials. Int J Gynecol Cancer. 2008;18:1315–25.

    Article  CAS  Google Scholar 

  13. Palomba S, Falbo A, Mocciaro R, Russo T, Zullo F. Laparoscopic treatment for endometrial cancer: a meta-analysis of randomized controlled trials (RCTs). Gynecol Oncol. 2009;112:415–21.

    Article  Google Scholar 

  14. Kornblith AB, Huang HQ, Walker JL, Spirtos NM, Rotmensch J, Cella D. Quality of life of patients with endometrial cancer undergoing laparoscopic international federation of gynecology and obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study. J Clin Oncol. 2009;27:5337–42.

    Article  Google Scholar 

  15. Sarlos D, Kots LA. Robotic versus laparoscopic hysterectomy: a review of recent comparative studies. Curr Opin Obstet Gynecol. 2011;23:283–8.

    Article  Google Scholar 

  16. Sarlos D, Kots L, Stevanovic N, von Felten S, Schar G. Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol. 2012;120:604–11.

    Article  Google Scholar 

  17. Paraiso MF, Ridgeway B, Park AJ, et al. A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy. Am J Obstet Gynecol. 2013;208:368 e1–7.

    Google Scholar 

  18. Chen SH, Li ZA, Huang R, Xue HQ. Robot-assisted versus conventional laparoscopic surgery for endometrial cancer staging: a meta-analysis. Taiwan J Obstet Gynecol. 2016;55:488–94.

    Article  Google Scholar 

  19. Guy MS, Sheeder J, Behbakht K, Wright JD, Guntupalli SR. Comparative outcomes in older and younger women undergoing laparotomy or robotic surgical staging for endometrial cancer. Am J Obstet Gynecol. 2016;214:350.e1–350.e10.

    Article  Google Scholar 

  20. Lewis JH, Kilgore ML, Goldman DP, et al. Participation of patients 65 years of age or older in cancer clinical trials. J Clin Oncol. 2003;21(7):1383–9.

    Article  Google Scholar 

  21. Moore KN, Grainger LS, Smith C, et al. Pathologic findings and outcomes for octogenarians presenting with uterine malignancy. Gynecol Oncol. 2007;106:572–8.

    Article  Google Scholar 

  22. Lavoue V, Zeng X, Lau S et al. Impact of robotics on the outcome of elderly patients with endometrial cancer. Gynecol Oncol. 2014;133:556–62.

    Article  Google Scholar 

  23. Vaknin Z, Perri T, Lau S, et al. Outcome and quality of life in a prospective cohort of the first 100 robotic surgeries for endometrial cancer, with focus on elderly patients. Int J Gynecol Cancer. 2010;20:1367–73.

    PubMed  Google Scholar 

  24. Fried LP, Tangen CM, Walston J, Cardiovascular Health Study Collaborative Research Group, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–56.

    Article  CAS  Google Scholar 

  25. Cigolle CT, Ofstedal MB, Tian Z, Blaum CS. Comparing models of frailty: the health and retirement study. J Am Geriatr Soc. 2009;57:830–9.

    Article  Google Scholar 

  26. Kiely DK, Cupples LA, Lipsitz LA. Validation and comparison of two frailty indexes: the MOBILIZE Boston study. J Am Geriatr Soc. 2009;57:1532–9.

    Article  Google Scholar 

  27. Rockwood K, Andrew M, Mitnitski A. A comparison of two approaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci. 2007;62:738–43.

    Article  Google Scholar 

  28. Aubrun F, Marmion F. The elderly patient and postoperative pain treatment. Best Pract Res Clin Anaesthesiol. 2007;21:109–27.

    Article  Google Scholar 

  29. Fleming ND, Havrilesky LJ, Valea FA, et al. Analgesic and antiemetic needs following minimally invasive vs open staging for endometrial cancer. Am J Obstet Gynecol. 2011;204:65.e1–65.e6.

    Article  Google Scholar 

  30. Dunker S, Hsu HY, Sebag J, et al. Perioperative risk factors for posterior ischemic optic neuropathy. J Am Coll Surg. 2002;194:705–10.

    Article  Google Scholar 

  31. Frey MK, Ihnow SB, Worley MJ Jr, et al. Minimally invasive staging of endometrial cancer is feasible and safe in elderly women. J Minim Invasive Gynecol. 2011;18:200–4.

    Article  Google Scholar 

  32. Zeng XZ, Lavoue V, Lau S, et al. Outcome of robotic surgery for endometrial cancer as a function of patient age. Int J Gynecol Cancer. 2015;25:637–44.

    Article  Google Scholar 

  33. Zakhari A, Czuzoj-Shulman N, Spence AR, Gotlieb WH, Abenhaim HA. Hysterectomy for uterine cancer in the elderly: a comparison between laparoscopic and robot-assisted techniques. Int J Gynecol Cancer. 2016;26:1222–7.

    Article  Google Scholar 

  34. Bourgin C, Lambaudie E, Houvenaeghel G, Foucher F, Levêque J, Lavoué V. Impact of age on surgical staging and approaches (laparotomy, laparoscopy and robotic surgery) in endometrial cancer management. Eur J Surg Oncol. 2017;43:703–9.

    Article  CAS  Google Scholar 

  35. Backes FJ, ElNaggar AC, Farrell MR, et al. Perioperative outcomes for laparotomy compared to robotic surgical staging of endometrial cancer in the elderly: a retrospective cohort. Int J Gynecol Cancer. 2016;26:1717–21.

    Article  Google Scholar 

  36. Magrina JF, Zanagnolo V, Giles D, et al. Robotic surgical management of endometrial cancer in octogenarians and nonagenarians: analysis of perioperative outcomes and review of the literature. J Robot Surg. 2010;4:109–15.

    Article  Google Scholar 

  37. Bishop EA, Java J, Moore KN, et al. Operative outcomes among a geriatric population of endometrial cancer patients: an ancillary data analysis of Gynecologic Oncology Group study LAP2 [abstract]. Gynecol Oncol. 2014;133:7.

    Article  Google Scholar 

Download references

Funding

The study was funded in part by the National Institutes of Health/National Cancer Institute Memorial Sloan Kettering Cancer Center Support Grant (P30 CA008748).

Author information

Author notes

  1. Alessia Aloisi MD

    Present address: European Institute of Oncology, Milan, Italy

  2. Jill Tseng MD

    Present address: University of California, Irvine, Irvine, CA, USA

  3. Theresa Kuhn MD

    Present address: Emory University School of Medicine, Atlanta, GA, USA

Authors and Affiliations

  1. Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Alessia Aloisi MD, Jill Tseng MD, Theresa Kuhn MD, Jacqueline Feinberg MD, Dennis S. Chi MD, Carol L. Brown MD, Jennifer J. Mueller MD, Ginger J. Gardner MD, Oliver Zivanovic MD, Elizabeth L. Jewell MD, Kara Long Roche MD, Vance Broach MD, Nadeem R. Abu-Rustum MD & Mario M. Leitao Jr. MD

  2. Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA

    Dennis S. Chi MD, Carol L. Brown MD, Jennifer J. Mueller MD, Ginger J. Gardner MD, Oliver Zivanovic MD, Elizabeth L. Jewell MD, Kara Long Roche MD, Vance Broach MD, Nadeem R. Abu-Rustum MD & Mario M. Leitao Jr. MD

Authors
  1. Alessia Aloisi MD
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  2. Jill Tseng MD
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  4. Jacqueline Feinberg MD
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Corresponding author

Correspondence to Mario M. Leitao Jr. MD.

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Disclosures

Dr. Leitao is an ad-hoc speaker for Intuitive Surgical. Outside the submitted work. Dr. Chi serves on the medical advisory boards of Apyx Medical Co. and Verthermia Inc; he also had stock investments in Intuitive Surgical and Transenterix (sold in 2018). Outside the submitted work, Dr. Jewell reports other relationships with Summit Biomedical. Outside the submitted work, Dr. Abu-Rustum reports institutional research funding from Stryker and GRAIL.

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Aloisi, A., Tseng, J., Kuhn, T. et al. Robotic Surgery in the Frail Elderly: Analysis of Perioperative Outcomes. Ann Surg Oncol 27, 3772–3780 (2020). https://doi.org/10.1245/s10434-020-08475-w

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  • DOI: https://doi.org/10.1245/s10434-020-08475-w

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