Abstract
Background
Controlling Nutritional Status (CONUT) score was used for screening the preoperative nutritional status. The correlation between the CONUT score and the prognosis of patients with prostate cancer (PCa) has yet to be elucidated. Herein, we analyzed the prognostic value of CONUT scores in patients with PCa who underwent laparoscopic radical prostatectomy.
Materials and methods
Data of 244 patients were retrospectively evaluated. Perioperative variables and follow-up data were analyzed. The patients were categorized into 2 groups according to their preoperative CONUT scores. Postoperative complication and incontinence rates were also compared. The Kaplan-Meier method was used to estimate the median biochemical recurrence-free survival (BCRFS) between the 2 groups. Univariate and multivariate Cox regression analyses were performed to identify the potential prognostic factors for BCRFS.
Results
Patients were categorized into the low-CONUT group (CONUT score <3, n = 207) and high-CONUT group (CONUT score ≥3, n = 37). The high-CONUT group had a higher overall complication rate (40.5% vs.19.3%, p = 0.004), a higher major complication rate (10.8% vs. 3.9%, p = 0.013), and longer postoperative length of stay (8 days vs. 7 days, p = 0.017). More fever, urinary infection, abdominal infection, scrotal edema, rash, and hemorrhagic events (all p values < 0.05) were observed in the high-CONUT group. A higher rate of urinary incontinence was observed in the high-CONUT group at 1 (34.4% vs. 13.2%, p = 0.030) and 3 months (24.1% vs. 8.2%, p = 0.023) postoperatively. The high-CONUT group had shorter medium BCRFS (23.8 months vs. 54.6 months, p = 0.029), and a CONUT score ≥3 was an independent risk factor for a shorter BCRFS (hazards ratio, 1.842; p = 0.026).
Conclusions
The CONUT score is a useful predictive tool for higher postoperative complication rates and shorter BCRFS in patients with PCa who undergo laparoscopic radical prostatectomy.
Keywords: Controlling Nutritional Status score, Prostate cancer, Laparoscopic radical prostatectomy, Complication, Biochemical recurrence
1. Introduction
Prostate cancer (PCa) is one of the most common malignant tumors in men and the most common malignant tumor of the genitourinary system.[1,2] Radical prostatectomy is one of the main treatment options for localized PCa and plays an critical role in improving the long-term survival rate of patients. The popularization of minimally invasive technologies such as laparoscopy and robot-assisted surgery has further promoted innovation in the surgical treatment of PCa.
In recent years, the literature has indicated that impaired nutritional status may affect tolerance to surgery and the prognosis of patients with various types of cancer.[3–5] In this context, the Controlling Nutritional Status (CONUT) score was developed by Ignacio de Ulíbarri et al.[6] for screening the preoperative nutritional status. This index was calculated based on the preoperative serum albumin concentration, total peripheral blood lymphocyte count, and total cholesterol concentration (Supplementary Table S1, http://links.lww.com/CURRUROL/A46). The CONUT score is a useful predictor of survival in patients with colorectal, lung, and esophageal cancers.[7–9] However, the correlation between the CONUT score and the prognosis of patients with PCa has not been elucidated. In this retrospective study, we investigated the prognostic value of the CONUT score for postoperative complications and biochemical recurrence-free survival (BCRFS) in PCa patients who underwent laparoscopic radical prostatectomy (LRP).
2. Materials and methods
2.1. Patient selection
We retrospectively analyzed the data of patients with PCa who underwent LRP between September 2012 and August 2021 at Beijing Chaoyang Hospital, Capital Medical University. All patients were diagnosed with PCa using transrectal ultrasound-guided biopsy or transurethral resection of the prostate. The following exclusion criteria were used: (1) incomplete data; (2) presence of other malignant diseases not originating from the prostate; and (3) bone metastatic lesions indicated by magnetic resonance imaging, bone scan, or other imaging examinations. The decision to administer neoadjuvant androgen deprivation therapy was made at the discretion of the surgeons. The CONUT scores were calculated based on serum albumin concentration, total peripheral blood lymphocyte count, and total cholesterol concentration (Supplementary Table S1, http://links.lww.com/CURRUROL/A46), which were tested within 3 days before LRP. According to a previous report, a CONUT score of 3 was chosen as the cut-off to divide patients into the high-CONUT (CONUT score ≥3) and low-CONUT (CONUT score <3) groups.[10]
2.2. Surgical procedure
Laparoscopic radical prostatectomy was performed using the extraperitoneal approach by 2 urology surgeons with at least 5 years’ experience in laparoscopic surgery. A single dose of a second-generation cephalosporin was administered to all patients 1 hour before surgery. For those allergic to cephalosporins, levofloxacin was used as antibiotic prophylaxis. Early ambulation was encouraged, which included getting up slowly within 4 hours and getting out of bed within 6 hours postoperatively. All patients underwent routine physical thromboprophylaxis, including ankle pump exercises and use of antithrombotic elastic socks. For patients with a high risk of venous thromboembolism (Caprini score ≥5) or a history of venous thromboembolism, low-molecular-weight heparin was administered as prophylaxis.
2.3. Data collection
Baseline data, perioperative parameters, and pathological results were retrospectively collected from the electronic medical record system of a doctor who did not participate in the surgery. Postoperative complications were recorded and graded according to the Clavien-Dindo system, of which grades 1–2 were considered minor and grades 3–5 were considered major complications.[11] Fever was defined as an elevated ear temperature over 38.5°C. Hemorrhage was defined as progressive bleeding requiring blood transfusion or surgical hemostasis. In cases of increased drainage volume, the creatinine level in the drainage fluid was examined to exclude urine leakage from the urethral anastomotic fistula.
Whole blood hemoglobin was measured postoperatively. The baseline and lowest postoperative hemoglobin levels were utilized to calculate the degree of hemoglobin decline. The pelvic drainage tube was removed when the drainage volume was less than 10 mL on 2 consecutive days. The indwelling time of the pelvic drainage tube and the total drainage volume were recorded.
Data on biochemical recurrence (BCR) and postoperative urinary continence status were collected during the outpatient follow-up. Postoperative incontinence was defined as the use of more than 1 pad every 24 hours. The urinary continence status reported by the patients was documented at 1 month, 3 months, and 1 year after the urethral catheter was removed. Biochemical recurrence was defined as 2 consecutive prostate-specific antigen (PSA) values ≥0.2 ng/mL. If the postoperative PSA level failed to decrease below 0.2 ng/mL, the date of LRP was defined as the date of BCR. The BCRFS time was calculated from the date of surgery to the date of BCR or the last follow-up visit.
2.4. Statistical analyses
Normally distributed continuous variables were expressed as mean values with standard deviations and compared using the Student t test. Nonnormally distributed continuous variables were expressed as medians with interquartile ranges and compared using the Mann-Whitney U test. Categorical variables were compared using the chi-squared test or Fisher’s exact test, as appropriate. The Kaplan-Meier method was used to estimate the BCRFS median. The log-rank test was used to analyze survival differences between the high- and low-CONUT groups. Univariate and multivariate Cox regression analyses were used to identify the potential prognostic factors for BCRFS. Hazards ratios (HRs) and 95% confidence intervals were calculated for the CONUT score and other clinicopathological factors. Variables found to be significant in the univariate analysis (p < 0.05) were entered into multivariate analysis. IBM SPSS Statistics version 26.0 (IBM Corp, Armonk, NY, USA) and R (version 4.1.2; http://www.r-project.org/; The R Foundation for Statistical Computing, Vienna, Austria) were used for statistical analysis. All statistical tests were 2-tailed, and statistical significance was set at p value < 0.05.
3. Results
3.1. Baseline characteristics
A total of 291 consecutive patients were included in this study. Patients with missing clinical data (n = 47) were also excluded, resulting in a final cohort of 244 patients. A total of 207 (84.8%) patients were categorized into the low-CONUT group (CONUT score <3) and 37 (15.2%) were categorized into high-CONUT group (CONUT score ≥3). The baseline clinical characteristics of all patients are presented in Table 1. A total of 76 (31.1%) patients received neoadjuvant androgen deprivation therapy before surgery. Most patients (n = 69) received short-term neoadjuvant androgen deprivation therapy (<6 months) with a median duration of 8.9 weeks (range, 2.0–30.6 weeks). Patients with CONUT score ≥3 had lower body mass index (24.62 ± 3.14 kg/m2 vs. 25.68 ± 2.95 kg/m2, p = 0.046) and lower preoperative hemoglobin levels (137.5 ± 15.0 g/L vs. 142.2 ± 12.9 g/L, p = 0.048). Prostate volume, biopsy Gleason score, clinical T stage, and preoperative serum PSA level were not significantly different between the 2 groups (all p values > 0.05). A history of chronic diseases and abdominal surgery showed no significant differences between the 2 groups (all p values > 0.05).
Table 1.
Baseline data of all patients undergoing laparoscopic radical prostatectomy.
| Variables | Overall (n = 244) | High-CONUT group (n = 37) | Low-CONUT group (n = 207) | p |
|---|---|---|---|---|
| Age, yr, mean ± SD | 68.1 ± 6.7 | 69.2 ± 6.7 | 67.9 ± 6.7 | 0.284 |
| BMI, kg/m2, mean ± SD | 25.52 ± 3.00 | 24.62 ± 3.14 | 25.68 ± 2.95 | 0.046 |
| Biopsy Gleason score, n (%) | 0.685 | |||
| 6 | 64 (26.2) | 9 (24.3) | 55 (26.6) | |
| 3 + 4 | 45 (18.4) | 6 (16.2) | 39 (18.8) | |
| 4 + 3 | 51 (20.9) | 7 (18.9) | 44 (21.3) | |
| 8 | 39 (16.0) | 9 (24.3) | 30 (14.5) | |
| 9 or 10 | 45 (18.4) | 6 (16.2) | 39 (18.8) | |
| Clinical T stage, n (%) | 0.876 | |||
| cT1/2 | 215 (88.1) | 32 (86.5) | 177 (85.5) | |
| cT3 | 29 (11.9) | 5 (13.5) | 30 (14.5) | |
| Serum PSA level, ng/mL, median (IQR) | 15.38 (9.51–31.49) | 17.43 (9.84–39.26) | 15.31 (9.39–31.22) | 0.629 |
| D’Amico risk stratification, n (%) | 0.653 | |||
| Low risk | 24 (9.8) | 2 (5.4) | 22 (10.6) | |
| Intermediate risk | 89 (36.5) | 13 (35.1) | 76 (36.7) | |
| High risk | 131 (53.7) | 22 (59.5) | 109 (52.7) | |
| Neoadjuvant androgen deprivation therapy, n (%) | 76 (31.1) | 8 (18.9) | 68 (32.9) | 0.174 |
| Prostate volume, cm3, median (IRQ) | 37.15 (25.73–53.75) | 34.65 (25.85–50.04) | 38.50 (25.60–54.80) | 0.362 |
| Medical history, n (%) | ||||
| Hypertension | 109 (44.7) | 16 (43.2) | 93 (44.9) | 0.849 |
| Diabetes | 52 (21.3) | 11 (29.7) | 41 (19.8) | 0.175 |
| Coronary disease | 44 (18.0) | 8 (21.6) | 36 (17.4) | 0.538 |
| History of cerebral infarction | 19 (7.8) | 3 (8.1) | 16 (7.7) | 1.000 |
| Chronic obstructive pulmonary disease | 14 (5.7) | 3 (8.1) | 11 (5.3) | 0.452 |
| Other malignant diseases | 15 (6.1) | 3 (8.1) | 12 (5.8) | 0.708 |
| Abdominal surgical history | 52 (21.3) | 9 (24.3) | 43 (20.8) | 0.627 |
| Smoking history | 75 (30.7) | 7 (37.7) | 68 (32.9) | 0.091 |
| Hemoglobin, g/L, mean ± SD | 141.5 ± 13.3 | 137.5 ± 15.0 | 142.2 ± 12.9 | 0.048 |
| Albumin, g/L, median (IQR) | 41.3 (38.2–44.9) | 37.8 (34.2–43.2) | 41.6 (38.7–45.2) | <0.001 |
| Total lymphocyte count, /mm3, median (IQR) | 1886.18 (1482.89–2303.37) | 1392.50 (1099.49–1710.80) | 1940.20 (1621.62–2339.64) | <0.001 |
| Total cholesterol, mg/dL, median (IQR) | 169.18 (147.04–193.35) | 138.44 (133.02–154.29) | 172.08 (151.59–201.86) | <0.001 |
p < 0.05 is indicated by boldface.
BMI = body mass index; CONUT = Controlling Nutritional Status; IQR = interquartile range; PSA = prostate-specific antigen; SD = standard deviation.
3.2. Postoperative data
The postoperative data are presented in Table 2. There were no significant differences in the operating surgeon, operation time, pathological Gleason score, or pathological T stage between the 2 groups (all p values > 0.05). No patients underwent open surgery. Forty-three (17.6%) patients had minor complications (Clavien-Dindo grade 1–2), and 12 (4.9%) patients experienced major complications (Clavien-Dindo grade 3–5) during the perioperative period.
Table 2.
Postoperative period data of all patients.
| Variables | Overall (n = 244) | High-CONUT group (n = 37) | Low-CONUT group (n = 207) | p |
|---|---|---|---|---|
| Intraoperative details | ||||
| Operating surgeon, n (%) | 0.174 | |||
| Surgeon 1 | 168 (68.9) | 29 (78.4) | 139 (67.1) | |
| Surgeon 2 | 76 (31.1) | 8 (21.6) | 68 (32.9) | |
| Operation time, min, median (IQR) | 140 (120–180) | 150 (120–202.5) | 135 (120–180) | 0.123 |
| PLND, n (%) | 231 (94.7) | 36 (97.3) | 195 (94.2) | 0.698 |
| Nerve-sparing procedure, n (%) | 31 (12.7) | 7 (18.9) | 24 (11.8) | 0.280 |
| Estimated intraoperative bleeding, mL, median (IQR) | 80 (50–100) | 100 (50–200) | 50 (50–100) | 0.002 |
| Pathological data | ||||
| Pathological Gleason score, n (%) | 0.632 | |||
| 6 | 36 (14.8) | 5 (13.5) | 31 (15.0) | |
| 3 + 4 | 69 (28.3) | 10 (27.0) | 59 (28.5) | |
| 4 + 3 | 65 (26.6) | 13 (35.1) | 52 (25.1) | |
| 8 | 20 (8.2) | 1 (2.7) | 19 (9.2) | |
| 9 or 10 | 54 (22.1) | 8 (21.6) | 46 (22.2) | |
| Pathological T stage, n (%) | 0.427 | |||
| pT2 | 156 (63.9) | 21 (56.8) | 135 (65.2) | |
| pT3 | 88 (36.1) | 16 (43.2) | 72 (34.8) | |
| Positive surgical margin, n (%) | 116 (47.5) | 17 (45.9) | 99 (47.8) | 0.833 |
| Positive lymph nodes metastasis, n (%) | 32 (13.1) | 7 (18.9) | 25 (12.1) | 0.289 |
| In-hospital data | ||||
| Hemoglobin decline, g/L, median (IQR) | 21 (15–29) | 24 (17–32) | 20 (13–29) | 0.047 |
| Pelvic drainage duration, d, median (IQR) | 5 (4–7) | 6 (4–8) | 5 (3–6) | 0.017 |
| ICU stay after surgery, n (%) | 11 (4.5) | 2 (5.4) | 9 (4.3) | 0.400 |
| Total drainage volume, mL, median (IQR) | 200 (120–317) | 224 (134–360) | 195 (115–310) | 0.206 |
| Postoperative hospital stay, d, median (IQR) | 7 (5–8) | 8 (6–12) | 7 (5–8) | 0.002 |
| Blood transfusion during perioperative period, n (%) | 5 (2.0) | 3 (8.1) | 2 (0.9) | 0.028 |
| Postoperative complication | ||||
| Overall complications, n (%) | 55 (22.5) | 15 (40.5) | 40 (19.3) | 0.004 |
| Highest grade complication, n (%) | 0.013 | |||
| None | 189 (77.5) | 22 (59.5) | 167 (80.7) | |
| Minor (Clavien-Dindo grade 1–2) | 43 (17.6) | 11 (29.7) | 32 (15.5) | |
| Major (Clavien-Dindo grade 3–5) | 12 (4.9) | 4 (10.8) | 8 (3.9) | |
| Minor complications, n (%) | ||||
| Fever | 8 (3.3) | 5 (13.5) | 3 (1.4) | 0.007 |
| Urinary infection | 4 (1.6) | 3 (8.1) | 1 (0.5) | 0.012 |
| Abdominal infection | 4 (1.6) | 3 (8.1) | 1 (0.5) | 0.012 |
| Anastomotic leak necessitating prolonged catheterization | 10 (4.1) | 1 (2.7) | 9 (4.3) | 1.000 |
| Scrotal edema | 5 (2.0) | 3 (8.1) | 2 (1.0) | 0.026 |
| Rash | 9 (3.7) | 4 (10.8) | 5 (2.4) | 0.032 |
| Chest tightness and palpitation | 9 (3.7) | 2 (6.0) | 6 (2.9) | 0.348 |
| Major complications, n (%) | ||||
| Hemorrhage | 7 (2.9) | 4 (10.8) | 3 (1.4) | 0.011 |
| VTE | 2 (0.8) | 1 (2.7) | 1 (0.5) | 0.281 |
| Pelvic effusion necessitating puncture | 2 (0.8) | 1 (2.7) | 1 (0.5) | 0.281 |
| Anastomotic stenosis necessitating surgery | 3 (1.2) | 1 (2.7) | 2 (1.0) | 0.391 |
| Death | 1 (0.4) | 0 (0) | 1 (0.5) | - |
| Rehospitalization within 3 months after discharge, n (%) | 9 (3.7) | 1 (2.7) | 8 (3.9) | 1.000 |
p < 0.05 is indicated by boldface.
CONUT = Controlling Nutritional Status; ICU = intensive care unit; IQR = interquartile range; PLND = pelvic lymph node dissection; SD = standard deviation; VTE = venous thromboembolism.
Patients in the high-CONUT group had a significantly higher rate of overall complications (40.5% vs. 19.3%, p = 0.004) and major complications (10.8% vs. 3.9%, p = 0.013). They more frequently experienced fever (13.5% vs. 1.4%, p = 0.007), urinary infection (8.1% vs. 0.5%, p = 0.012), abdominal infection (8.1% vs. 0.5%, p = 0.012), scrotal edema (8.1% vs. 1.0%, p = 0.026), and rash (10.8% vs. 2.4%, p = 0.032). More patients in the high-CONUT group experienced hemorrhagic events (10.8% vs. 1.4%, p = 0.011) and required blood transfusion (8.1% vs. 0.9%, p = 0.028). In addition, patients with CONUT score ≥3 showed significantly higher estimated intraoperative bleeding (100 mL vs. 50 mL, p = 0.002) and hemoglobin decline (24 g/L vs. 20 g/L, p = 0.047). They also had a longer duration of pelvic drainage (6 days vs. 5 days, p = 0.017) and a longer postoperative length of stay (8 days vs. 7 days, p = 0.017). Nine patients were readmitted within 3 months after discharge, and 4 of the whom underwent a second surgery because of urethral stricture at the bladder neck-urethral anastomosis. One patient in the low-CONUT group died of pulmonary embolism after discharge.
3.3. Prognostic outcomes
The follow-up data of 188 patients were retrieved, including 159 in the low-CONUT group and 29 in the high-CONUT group. A total of 38 (20.2%) reported urinary incontinence within 3 months of surgery. Patients with CONUT score ≥3 had a significantly higher rate of incontinence at 1 month (34.4% vs. 13.2%, p = 0.030) and 3 months (24.1% vs. 8.2%, p = 0.023) after LRP (Table 3). No significant difference was observed 1 year postoperatively (6.9% vs. 5.7%, p = 0.688). Kaplan-Meier curve analysis showed that CONUT score ≥3 was significantly associated with shorter medium BCRFS (23.8 months vs. 54.6 months; p = 0.029) (Fig. 1). Univariate and multivariate Cox regression analyses revealed that a CONUT score ≥3 (HR, 1.842; p = 0.026) and preoperative serum PSA level (HR, 1.002, p = 0.005) were independent risk factors for BCR (Table 4). Subset analysis according to risk stratification showed that a CONUT score ≥3 was an independent risk factor for BCR in the low- and high-risk groups (Supplementary Table S2, http://links.lww.com/CURRUROL/A46).
Table 3.
Follow-up data of postoperative incontinence.
| Follow-up interval | Overall (n = 188) | High-CONUT group (n = 29) | Low-CONUT group (n = 159) | p |
|---|---|---|---|---|
| 1 month, n (%) | 38 (20.2) | 10 (34.4) | 28 (13.2) | 0.030 |
| 3 months, n (%) | 20 (10.6) | 7 (24.1) | 13 (8.2) | 0.023 |
| 1 year, n (%) | 11 (4.7) | 2 (6.9) | 9 (5.7) | 0.688 |
p < 0.05 is indicated by boldface.
CONUT = Controlling Nutritional Status.
Figure 1.
Kaplan-Meier curve analysis of biochemical recurrence-free survival in patients who underwent laparoscopic radical prostatectomy. CONUT = Controlling Nutritional Status.
Table 4.
Univariate and multivariate cox analyses of biochemical recurrence-free survival.
| Variables | Univariate analysis | Multivariate analysis | ||
|---|---|---|---|---|
| HR (95% CI) | p | HR (95% CI) | p | |
| Age | 1.019 (0.980–1.060) | 0.342 | ||
| BMI | 1.063 (0.982–1.152) | 0.131 | ||
| Preoperative serum PSA level | 1.002 (1.000–1.003) | 0.007 | 1.002 (1.001–1.003) | 0.005 |
| Neoadjuvant androgen deprivation therapy | 1.432 (0.926–2.216) | 0.107 | ||
| CONUT score ≥3 | 1.799 (1.053–3.075) | 0.032 | 1.842 (1.075–3.156) | 0.026 |
| Pathological Gleason score >7 | 1.116 (0.702–1.776) | 0.643 | ||
| Pathological T3 stage | 1.543 (0.979–2.432) | 0.062 | 1.464 (0.925–2.319) | 0.104 |
| Positive surgical margin | 1.309 (0.829–2.065) | 0.247 | ||
p < 0.1 in the univariate analysis and p < 0.05 in the multivariate analysis are indicated by boldface.
BMI = body mass index; CI = confidence interval; CONUT = Controlling Nutritional Status; HR=hazard ratio; PSA = prostate-specific antigen.
4. Discussion
The present study explored the prognostic value of the CONUT score, a screening tool for nutritional status, in patients with PCa undergoing LRP. Demographic and baseline disease characteristics were generally well balanced between the high-CONUT and low-CONUT groups, which were divided using a CONUT score ≥3 as the threshold. We found that patients with high preoperative CONUT scores experienced greater intraoperative blood loss, longer drainage duration, and longer hospital stay. They experienced more postoperative complications, including fever, infection, scrotal edema, rash, and hemorrhagic events, and required more blood transfusions. Our study also showed that a high-CONUT score correlated with a higher rate of short-term incontinence and BCR postoperatively. These results indicate that the CONUT score is a prognostic factor for patients with PCa undergoing LRP.
The CONUT score is an efficient tool for assessing the nutritional status and detecting malnutrition in hospitalized patients. The CONUT score is calculated based on serum albumin concentration, lymphocyte count, and total cholesterol level, which can be easily collected preoperatively from routine blood analysis. Serum albumin concentration, lymphocyte count, and total cholesterol levels are associated with multiple physiological functions, including the immune response, infection, inflammation, tissue repair, and regeneration.[10] Albumin concentration represents not only the nutritional status but is also a reliable indicator of systemic immunity and inflammation, such as inflammation caused by cancer cells.[12,13] It has been previously reported to be associated with poor prognosis in patients with cancer.[14] The antitumor effects of lymphocytes include the induction of apoptosis, inhibition of tumor growth and migration, and mediation of cytotoxicity.[15] The decrease in lymphocyte count may promote a microenvironment favorable for cancer proliferation and metastasis, leading to poor prognosis in patients with advanced cancer.[16] Cholesterol metabolism also enhances the immune response of CD8(+) T cells, and thus participates in antitumor mechanisms.[17] Low serum cholesterol levels have been reported to be associated with poor prognosis in cancer patients.[18–20] In summary, a higher CONUT score reflects not only poor nutritional status, but also systemic inflammation and an impaired immune response, suggesting that the ability to tolerate therapy may be compromised in these patients.
Recently, several studies have examined the correlation between high-CONUT scores and poor postoperative prognosis in patients with urological carcinoma. Elghiaty et al.[21] found that patients with renal cancer with high preoperative CONUT scores had shorter recurrence-free, cancer-specific, and overall survival. Ishihara et al.[22] reported that the preoperative CONUT score is a predictive biomarker of survival in patients treated with radical nephroureterectomy. Huang et al.[23] and Nemoto et al.[24] reported that the CONUT score was an independent predictor of poor prognosis in patients with bladder cancer who underwent transurethral resection of bladder tumors and radical cystectomy, respectively. At present, however, there is still a lack of evidence regarding the prognostic value of the CONUT score in patients with PCa. The study by Zhang et al.[10] reported CONUT score as a prognostic indicator of PSA progression-free survival in 94 patients with oligometastatic PCa who underwent radical prostatectomy. However, the correlation between CONUT score and prognosis in patients with PCa undergoing LRP remains unclear.
In this study, we analyzed the prognostic value of preoperative CONUT score in patients with PCa undergoing LRP. We found that patients with high-CONUT scores (CONUT score ≥3) experienced more perioperative complications. It was worth noting that these patients had higher incidence of fever (≥38.5°C), urinary infection, abdominal infection, and rash, suggesting a tendency to experience immune dysfunction. Although there was no significant difference in the total drainage volume between the 2 groups, patients in the high-CONUT group had a significantly longer drainage-dwelling time, higher estimated intraoperative bleeding, higher hemoglobin decline, and more hemorrhagic events, which indicated a higher bleeding risk. Patients with high-CONUT scores had significantly higher rates of incontinence at 1 and 3 months, suggesting poor short-term urinary control after LRP. In addition, consistent with a previous report, we also found that CONUT score ≥3 was significantly correlated with shorter BCRFS.[10] In summary, patients with PCa and high-CONUT scores had a poor prognosis after undergoing LRP. Appropriate nutritional and immunological interventions may enhance tolerance to surgery, reduce complications, and improve the long-term prognosis of these patients.[25,26]
Our study had some limitations. First, it was a retrospective study with the potential for selection bias. Our study was conducted at a single center. As a result, the cohort was relatively small, and the number of patients with a high-CONUT score was limited. Second, we used a preoperative CONUT score ≥3 as the cut-off, which may be inconsistent with some previous studies that focused on the prognostic value of the CONUT score in malignant diseases. Third, more than half (n = 131, 53.7%) of the patients were stratified as high-risk, and 88 patients (36.1%) had pT3 stage disease. However, multivariate Cox analysis did not support a correlation between pT3 stage and BCR after LRP (HR, 1.464; p = 0.104). Therefore, further studies with larger sample sizes are warranted. Fourth, we used more than 1 pad per day to define incontinence after LRP. Data on pad weight and urinary control status before the LRP were not retrieved.
5. Conclusions
In the present study, we found that patients with PCa and high-CONUT scores had more complications, a higher bleeding risk, and a longer length of stay during the perioperative period of LRP. A CONUT score ≥3 was correlated with poor short-term urinary control and also an independent risk factor for shorter BCRFS after LRP. The CONUT score is a potential clinical tool for evaluating the surgical tolerance and prognosis of patients with PCa.
Acknowledgments
None.
Statement of ethics
Our study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) and approved by the Institutional Review Board of Beijing Chaoyang Hospital, Capital Medical University (No. 2022-Ke-55), which waived the requirement for informed consent for this retrospective analysis.
Funding source
This study was supported by the National Natural Science Foundation of China (grant number 82170783).
Author contributions
TX: Made a substantial contribution to the design of the study and was the major contributor in writing the manuscript; XY, GZ: Collected data; FC, YC, LS, MW, WW, NX: Contributed to the study design; YN: Designed the study and revised the manuscript; All the authors have read and approved the final version of the manuscript.
Data availability
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
Footnotes
Supplemental Digital Content is available for this article.
How to cite this article: Xiong T, Ye X, Zhu G, Cao F, Cui Y, Song L, Wang M, Wasilijiang W, Xing N, Niu Y. Prognostic value of Controlling Nutritional Status score for postoperative complications and biochemical recurrence in prostate cancer patients undergoing laparoscopic radical prostatectomy. Curr Urol 2024;18(1):43–48. doi: 10.1097/CU9.0000000000000231
Contributor Information
Tianyu Xiong, Email: xiongty_ccmu@163.com.
Xiaobo Ye, Email: 2486480093@qq.com.
Guangyi Zhu, Email: zhugy2017@126.com.
Fang Cao, Email: caofang9416@163.com.
Yun Cui, Email: cuiyunbjmu@163.com.
Liming Song, Email: wfslm@163.com.
Mingshuai Wang, Email: urowms@163.com.
Wahafu Wasilijiang, Email: wallonce@126.com.
Nianzeng Xing, Email: xingnz@cicams.ac.cn.
Conflict of interest statement
YN is an editorial board member of Current Urology. This article was accepted after a normal external review. No conflict of interest has been declared by the other authors.
Reference
- 1.Ferlay J Soerjomataram I Dikshit R, et al. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136(5):E359–E386. [DOI] [PubMed] [Google Scholar]
- 2.Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin 2022;72(1):7–33. [DOI] [PubMed] [Google Scholar]
- 3.Shastri AA Lombardo J Okere SC, et al. Personalized nutrition as a key contributor to improving radiation response in breast cancer. Int J Mol Sci 2021;23(1):175. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Gliwska E, Guzek D, Przekop Z, Sobocki J, Głąbska D. Quality of life of cancer patients receiving enteral nutrition: A systematic review of randomized controlled trials. Nutrients 2021;13(12):4551. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Carr RA Harrington C Stella C, et al. Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer. Cancer Med 2022;11(3):592–601. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ignacio de Ulíbarri J González-Madroño A de Villar NG, et al. CONUT: A tool for Controlling Nutritional Status. First validation in a hospital population. Nutr Hosp 2005;20(1):38–45. [PubMed] [Google Scholar]
- 7.Iseki Y Shibutani M Maeda K, et al. Impact of the preoperative Controlling Nutritional Status (CONUT) score on the survival after curative surgery for colorectal cancer. PloS One 2015;10(7):e0132488. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Akamine T Toyokawa G Matsubara T, et al. Significance of the preoperative CONUT score in predicting postoperative disease-free and overall survival in patients with lung adenocarcinoma with obstructive lung disease. Anticancer Res 2017;37(5):2735–2742. [DOI] [PubMed] [Google Scholar]
- 9.Toyokawa T Kubo N Tamura T, et al. The pretreatment Controlling Nutritional Status (CONUT) score is an independent prognostic factor in patients with resectable thoracic esophageal squamous cell carcinoma: Results from a retrospective study. BMC Cancer 2016;16(1):722. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Zhang W Wu Y Zhang Z, et al. Controlling Nutritional Status score: A new prognostic indicator for patients with oligometastatic prostate cancer. Curr Probl Cancer 2019;43(5):461–470. [DOI] [PubMed] [Google Scholar]
- 11.Clavien PA Barkun J de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: Five-year experience. Ann Surg 2009;250(2):187–196. [DOI] [PubMed] [Google Scholar]
- 12.Leitch EF Chakrabarti M Crozier JE, et al. Comparison of the prognostic value of selected markers of the systemic inflammatory response in patients with colorectal cancer. Br J Cancer 2007;97(9):1266–1270. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.McMillan DC, Elahi MM, Sattar N, Angerson WJ, Johnstone J, McArdle CS. Measurement of the systemic inflammatory response predicts cancer-specific and non-cancer survival in patients with cancer. Nutr Cancer 2001;41(1–2):64–69. [DOI] [PubMed] [Google Scholar]
- 14.Ayhan A, Günakan E, Alyazıcı İ, Haberal N, Altundağ Ö, Dursun P. The preoperative albumin level is an independent prognostic factor for optimally debulked epithelial ovarian cancer. Arch Gynecol Obstet 2017;296(5):989–995. [DOI] [PubMed] [Google Scholar]
- 15.Li CC Chang TH Wu WJ, et al. Significant predictive factors for prognosis of primary upper urinary tract cancer after radical nephroureterectomy in Taiwanese patients. Eur Urol 2008;54(5):1127–1134. [DOI] [PubMed] [Google Scholar]
- 16.Mantovani A, Allavena P, Sica A, Balkwill F. Cancer-related inflammation. Nature 2008;454(7203):436–444. [DOI] [PubMed] [Google Scholar]
- 17.Ray-Coquard I Cropet C Van Glabbeke M, et al. Lymphopenia as a prognostic factor for overall survival in advanced carcinomas, sarcomas, and lymphomas. Cancer Res 2009;69(13):5383–5391. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Cengiz O, Kocer B, Sürmeli S, Santicky MJ, Soran A. Are pretreatment serum albumin and cholesterol levels prognostic tools in patients with colorectal carcinoma? Med Sci Monit 2006;12(6):CR240–CR247. [PubMed] [Google Scholar]
- 19.de Martino M Leitner CV Seemann C, et al. Preoperative serum cholesterol is an independent prognostic factor for patients with renal cell carcinoma (RCC). BJU Int 2015;115(3):397–404. [DOI] [PubMed] [Google Scholar]
- 20.Yang W Bai Y Xiong Y, et al. Potentiating the antitumour response of CD8(+) T cells by modulating cholesterol metabolism. Nature 2016;531(7596):651–655. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Elghiaty A Kim J Jang WS, et al. Preoperative Controlling Nutritional Status (CONUT) score as a novel immune-nutritional predictor of survival in non-metastatic clear cell renal cell carcinoma of ≤ 7 cm on preoperative imaging. J Cancer Res Clin Oncol 2019;145(4):957–965. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Ishihara H Kondo T Yoshida K, et al. Preoperative Controlling Nutritional Status (CONUT) score as a novel predictive biomarker of survival in patients with localized urothelial carcinoma of the upper urinary tract treated with radical nephroureterectomy. Urol Oncol 2017;35(9):539.e9–539.e16. [DOI] [PubMed] [Google Scholar]
- 23.Huang J Zhao L Wang K, et al. Controlling Nutritional Status score evaluates prognosis in patients with non-muscle invasive bladder cancer. Cancer Control 2021;28:10732748211021078. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Nemoto Y Kondo T Ishihara H, et al. The Controlling Nutritional Status CONUT score in patients with advanced bladder cancer after radical cystectomy. In Vivo 2021;35(2):999–1006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Paccagnella A, Morassutti I, Rosti G. Nutritional intervention for improving treatment tolerance in cancer patients. Curr Opin Oncol 2011;23(4):322–330. [DOI] [PubMed] [Google Scholar]
- 26.Di Minno A Aveta A Gelzo M, et al. 8-Hydroxy-2-deoxyguanosine and 8-iso-prostaglandin F2α: Putative biomarkers to assess oxidative stress damage following robot-assisted radical prostatectomy (RARP). J Clin Med 2022;11(20):6102. [DOI] [PMC free article] [PubMed] [Google Scholar]