Reply to Vladimir Novotny, Manfred P. Wirth, Michael Froehner's Letter to the Editor re: Atiqullah Aziz, Matthias May, Maximilian Burger, et al. PROMETRICS 2011 research group. Prediction of 90-day Mortality After Radical Cystectomy for Bladder Cancer in a Prospective European Multicenter Cohort. Eur Urol 2014;66:156–163

Abstract

We thank Novotny et al. for their inspiring response to our manuscript on prediction of 90-d mortality after radical cystectomy for bladder cancer based on the Prospective Multicenter Radical Cystectomy Series 2011 (PROMETRICS 2011) [1]. After backward selection, our final multivariable model included age, the American Society of Anesthesiologists (ASA) score, hospital volume, and metastatic disease as the most informative, independent predictors of 90-d mortality, whereas the Charlson comorbidity index (CCI), among other parameters, was eliminated from our final model. As highlighted by the European Association of Urology (EAU) guidelines on muscle-invasive and metastatic bladder cancer [2], the ASA score—unlike the CCI— represents not a sum of point values corresponding with selected, single comorbidities of the individual patient but rather a stepwise assessment of the general physical state, even though this is based on the patient’s comorbidity profile [3,4]. However, the more broadly defined ASA score should not be disqualified per se as a surrogate for the patient’s comorbidity profile in clinical risk stratification before radical cystectomy. First, the majority of studies on outcome prediction in cystectomy patients could clearly identify a significant impact of the ASA score on postoperative survival in large series [5]. Second, the ASA score is already broadly accepted in clinical practice, whereas the utilization of other comorbidity indices mostly remains restricted to research projects. Thus, acceptance of tools for therapy decision making that rely on readily available parameters such as the ASA score might be enhanced. We entirely agree with Novotny et al. that a new debate about the implementation of the ASA score in EAU guidelines