Introduction of a Combined Anaesthetic-Geriatrician Pre-Op Assessment for Older Patients undergoing Elective Urological Surgery

Introduction

Older adults (≥75y) represent a significant and growing proportion of patients undergoing major urological cancer resections (cystectomy, prostatectomy, nephrectomy), with frailty prevalence 20–50% driving high postoperative risks including delirium, prolonged length of stay (LOS), and mortality. Preoperative Comprehensive Geriatric Assessment (CGA) with cardiopulmonary exercise testing (CPEX) reduces delirium by 29–37%, LOS by 1–3 days, and readmissions, per national guidelines (NICE NG180, 2020; CPOC/BGS, 2021). However, joint anaesthetic-geriatrician clinics are underutilized in urology.

Method

We retrospectively reviewed clinic letters and CPEX reports for all 114 patients (mean age 77.4 years, range 67–91; 68% male; mean Clinical Frailty Scale [CFS] 3.2) referred to our expanded joint clinic at a UK district general hospital from 4 April 2024 to 29 October 2025. Outcomes included 30/90-day mortality (overall and cystectomy subgroup), readmissions, and correlations with CPEX (e.g., VO2 at anaerobic threshold [AT], work/predicted ratio).

Results

98/114 (86%) proceeded to surgery; 48 (42%) underwent cystectomy (18 robotic, 30 open). Mean VO2 AT: 13.6 mL/kg/min (25% <11, high-risk). Mean LOS: 7.9 days (cystectomy 11.1; non-cystectomy 4.4, p<0.001). Discharge home: 78%. Overall mortality: 12.3% (in-hospital 7.9%); 30-day ~8% (cystectomy 8.3%); 90-day 10.2% (cystectomy 12.5%). Readmissions: 22/98 (22%). Mortality correlated with low CPEX (AT <11: 20% vs ≥11: 8%; work/predicted <0.8: 17% vs ≥0.8: 6%), higher CFS (≥4: 15% vs ≤3: 9%), and age ≥80 (16% vs <80: 10%). Carlisle scores >10 predicted higher mortality (33–43%). Patients unable to complete CPEX had poor outcomes: 30% died overall, and among those who declined surgery, mortality reached 25%.

Discussion

This retrospective analysis demonstrates the feasibility of CGA and CPEX in a joint clinic for older adults with frailty undergoing elective urological surgery. Correlations between mortality and poor CPEX metrics (e.g., ability to complete, low AT, work/predicted ratio), higher levels of frailty, and high Carlisle scores highlight these tools' value for risk stratification and optimisation, potentially reducing complications including death, prolonged length of stay and readmissions. Limitations include retrospective design, no control group, and small sample. Findings support broader adoption of multidisciplinary pathways in urology; prospective studies are needed.