Surgical and medical co-management optimizes surgical outcomes in older patients with chronic diseases undergoing robot-assisted laparoscopic radical prostatectomy

Figures & data

Table 1. Interventions for optimization.

Preoperative

Surgical evaluation by surgery

Risk assessment with identification of high-risk patients by the internist

Promotion of healthy lifestyle changes, alcohol and smoking cessation

Control and optimization of pre-existing comorbidities

Rehabilitation: exercise components to optimize the cardiovascular,  and respiratory condition

Nutritional counseling and assessment

Some kind of oral medication stopped and/or replacement

Fully explain every protocol with the patient and/or proxies

Preoperative in 24 h

Preoperative visits of ICU medical care and anesthesiologists,  psychological counseling

10 h of fasting from solids and 2 h without liquids

The nasogastric tube was intubated before entering  the operation room

Oral administration of 1000 mL carbohydrate-containing liquid  during the day

Half insulin, stop low molecular weight heparin

Intraoperative

Lung-protective ventilation

Normothermia: increasing the ambient room temperature,  systemic warming devices, et al.

Hemodynamic management, maintaining optimal fluid balance

Antibiotics were used 0.5–1 h before surgery

Stretch socks were used to prevent venous thrombosis

Postoperative in 24 h

Take in ICU

Analyses of vital signs and inflammatory parameters

Uniform venous fluid infusion, avoidance of high positive fluid balance

High attention to the risk of sepsis, antibiotics,  practices in hospital (hand) hygiene

Multimodal analgesia and nausea control

Early ambulation

Oxygen atomization inhalation, airway clearance,  noninvasive ventilation in hypoxemic patients

Extended VTE prophylaxis

Early removal of nasogastric suction, early oral feeding of clear fluids

Postoperative over 24 h

Timely advance to standard diet as tolerated

Analgesia, regularly scheduled doses of NSAIDs and acetaminophen

Removal of intra-abdominal drains in time

Removal of urinary catheter in 2–4 weeks

Avoidance of bleeding related to anticoagulant administration

Early respiratory muscle training (after pre-operative training)

Careful reintroduction of patient’s chronic medication

Medicine for prostate cancer

Table 2. Patient characteristics at baseline.

Parameters	SMC (n = 92)	Traditional (n = 92)	p-Value
Age (years), mean ± SD	75.35 ± 4.49	73.88 ± 4.88	0.035*
Tumor stage, cases (%)			0.372
T2N0M0	69 (75.0)	75 (81.5)
T3N0M0	23 (25.0)	17 (18.5)
Current smoker	41 (44.6)	36 (39.1)	0.275
Alcohol intake	29 (31.5)	27 (29.3)	0.436
BMI, mean ± SD	24.69 ± 2.82	24.59 ± 2.86	0.826
Mobility, MET^a, mean ± SD	5.75 ± 1.49	6.18 ± 1.32	0.038*
Polypharmacy	39 (42.4)	30 (32.6)	0.171
Chronic disease, cases (%)
Hypertension	64 (69.6)	61 (66.3)	0.376
Ischemic heart disease	52 (56.5)	49 (53.3)	0.384
Rhythm	37 (40.2)	35 (38.0)	0.440
COPD	15 (16.3)	12 (13.0)	0.339
Asthma	14 (15.2)	12 (13.0)	0.416
Lacunar cerebral infarction	53 (57.6)	49 (53.3)	0.328
Diabetes	47 (51.1)	42 (45.7)	0.278
Hyperlipidemia	39 (42.4)	36 (39.1)	0.382
Fatty liver disease	22 (23.9)	20 (21.7)	0.430
Chronic viral hepatitis	9 (9.8)	7 (7.6)	0.397
Gastric ulcer or chronic gastritis	16 (17.4)	13 (14.1)	0.343
Constipate	18 (19.6)	16 (17.4)	0.425
Other tumors	7 (7.6)	5 (5.4)	0.383
Chronic renal insufficiency	10 (10.9)	8 (8.7)	0.402
Anxiety or depression	8 (8.7)	6 (6.5)	0.391
History of abdominal surgery	12 (13.0)	9 (9.8)	0.322
Laboratory values, mean ± SD
White blood cell, 10^9/L	6.09 ± 2.42	5.75 ± 1.37	0.606
Hemoglobin, g/dL	138.77 ± 8.59	137.75 ± 6.37	0.361
Platelet, 10^9/L	194.92 ± 53.05	198.97 ± 46.21	0.582
Albumin, g/L	41.04 ± 3.09	41.41 ± 3.12	0.421
Glutamic-pyruvic transaminase (GPT), U/L	33.96 ± 17.25	30.22 ± 15.27	0.121
Serum total bilirubin (TB), µmol/L	13.94 ± 4.07	14.30 ± 4.51	0.576
Serum creatinine (Cr), µmol/L	72.95 ± 43.21	74.79 ± 34.61	0.749
Blood urea nitrogen (BUN), mmol/L	5.17 ± 2.09	5.25 ± 2.06	0.790
Total cholesterol (TC), mmol/L	4.62 ± 1.11	4.70 ± 0.98	0.599
Triglyceride (TG), mmol/L	1.51 ± 0.24	1.47 ± 0.22	0.217
Fasting blood glucose (Glu), mmol/L	5.49 ± 0.58	5.62 ± 0.65	0.142
Glycosylated hemoglobin (HbA1c), %	5.58 ± 0.78	5.62 ± 0.70	0.735
PO2 in artery, mmHg	90.01 ± 7.03	91.76 ± 5.92	0.258
ASA scores^b, cases (%)			0.043*
ASA II	25 (27.2%)	38 (41.3%)
ASA III	67 (72.8%)	54 (58.7%)

* Significant p-value < 0.05.

^aMET: metabolic equivalent; ^bASA classification: I = normal healthy patient; II = mild systemic disease; III = severe systemic disease.

Table 3. Operative parameters.

Parameters	SMC (n = 92)	Traditional (n = 92)	p-Value
Anesthesia time (min), mean ± SD	152.83 ± 24.78	150.00 ± 24.04	0.923
Skin-to-skin operation time (min), mean ± SD	105.11 ± 20.01	100.33 ± 18.37	0.138
Pneumoperitoneum time (min), mean ± SD	64.67 ± 16.93	61.63 ± 16.31	0.738
The blood loss(mL), mean ± SD	64.78 ± 35.00	68.91 ± 44.14	0.086
Total intraoperative fluid (mL), mean ± SD	826.09 ± 192.79	867.93 ± 266.81	0.005*
Hypotension, cases (%)	13(14.1%)	31(33.7%)	0.003*

* Significant p-value < 0.05.

^a Hypotension was defined as an average arterial pressure lower than 65 mmHg and lasted for more than 10 min.

Table 4. Postoperative parameters.

Parameters, mean ± SD	SMC (n = 92)	Traditional (n = 92)	p-Value
Postoperative in 24 h
The pain score	1.83 ± 0.92	1.91 ± 1.17	0.027*
Ambulate, h	12.59 ± 6.05	15.46 ± 8.85	0.045*
Nasogastric tube, h	13.35 ± 6.40	16.68 ± 9.03	0.035*
Oral feeding, h	14.13 ± 6.53	17.27 ± 9.09	0.039*
Postoperative in 21 days
Intra-abdominal drains catheter, days	3.90 ± 1.46	4.50 ± 1.79	0.024*
Time of removing the urinary catheter, days	14.47 ± 2.91	14.90 ± 4.54	0.440#
Laboratory values, difference
White blood cell, 10^9/L	8.29 ± 3.10	8.58 ± 2.87	0.882
Hemoglobin difference, g/L	18.29 ± 7.23	24.60 ± 8.77	0.037*
Albumin difference, g/L	7.27 ± 2.32	9.63 ± 2.96	0.004*

* Significant p-value < 0.05.

Table 5. Comparison of postoperative complications by Clavien Classification System.

Clavien grades	Complication by organ and type	SMC (n = 92), cases (%)	Traditional (n = 92), cases (%)	p-Value
Grade I		15 (16.3)	27 (29.3)	0.035*
Pulmonary	Atelectasis /pleural effusion/hypercapnia	12 (13.0)	23 (25.0)	0.039*
Cardiovascular	Blood pressure lability/arrhythmia	10 (10.9)	21 (22.8)	0.030*
Neurological	Transient confusion	6 (6.5)	16 (17.4)	0.023*
Gastrointestinal	Noninfectious diarrhea/nausea/vomiting	11 (12.0)	22 (23.9)	0.035*
Urinary	Transient elevation of serum creatinine/lower UTI	2 (2.2)	10 (10.9)	0.033*
Surgical site	Wound infection	2 (2.2)	2 (2.2)	1.000
Grade II		13 (14.1)	26 (28.3)	0.019*
Pulmonary	Pneumonia/bronchiectasis/hypoxemia	8 (8.7)	23 (25.0)	0.003*
Cardiovascular	Myocardial injury/tachyarrhythmia/hypertension	7 (7.6)	17 (18.5)	0.029*
Neurological	Transient ischemic attack/delirium	3 (3.3)	13 (14.1)	0.016*
Gastrointestinal	Infectious diarrhea/liver abnormalities/pancreatitis/ileus	10 (10.9)	22 (23.9)	0.020*
Vascular	Venous thrombosis	3 (3.3)	12 (13.0)	0.028*
Urinary	Urinary tract infection/acute renal injury	5 (5.4)	15 (16.3)	0.018*
Surgical site	Phlegmonous infection/hematoma/postop bleeding	6 (6.5)	7 (7.6)	0.774
Grade III		1 (1.1)	7 (7.6)	0.030*
Cardiovascular	Acute coronary syndrome/bradyarrhythmia/atrial fibrillation	1 (1.1)	5 (5.4)	0.097
Surgical site	Wound dehiscent/poka hernia/urine leakage	1 (1.1)	2 (2.2)	0.560
Grade IV		1 (1.1)	8 (8.7)	0.035*
Pulmonary	Respiratory failure/non-invasive ventilator/asthma	1 (1.1)	6 (6.5)	0.054
Cardiovascular	Acute heart failure/myocardial infarction/shock	1 (1.1)	4 (4.3)	0.174
Vascular	Pulmonary embolism	0 (0.0)	1 (1.1)	1.000
Urinary	Acute renal failure	0 (0.0)	1 (1.1)	1.000

* Significant p value < 0.05.