Next Article in Journal
Head and Neck Cancers Are Not Alike When Tarred with the Same Brush: An Epigenetic Perspective from the Cancerization Field to Prognosis
Next Article in Special Issue
Urological Cancer Panorama in the Second Year of the COVID-19 Pandemic
Previous Article in Journal
Gastric Cancers Missed at Upper Endoscopy in Central Norway 2007 to 2016—A Population-Based Study
Previous Article in Special Issue
Prognostic and Predictive Factors in Advanced Urothelial Carcinoma Treated with Immune Checkpoint Inhibitors: A Review of the Current Evidence
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:

Prognostic Effect of Preoperative Psoas Muscle Hounsfield Unit at Radical Cystectomy for Bladder Cancer

Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Mie, Japan
Department of Urology, Ise Red Cross Hospital, 1-471-2 Funae, Ise 516-8512, Mie, Japan
Mie Prefectural General Medical Center, Department of Urology, 5450-132 Hinaga, Yokkaichi 510-8561, Mie, Japan
Author to whom correspondence should be addressed.
Cancers 2021, 13(22), 5629;
Submission received: 4 October 2021 / Revised: 4 November 2021 / Accepted: 4 November 2021 / Published: 10 November 2021
(This article belongs to the Special Issue Urological Cancer 2021)



Simple Summary

Radical cystectomy (RC) is the standard treatment for patients with advanced bladder cancer. Since RC is a highly invasive procedure, it is necessary to carefully predict the prognosis before surgery and to determine the surgical indication. According to the results of the retrospective analysis of our 177 RC cases, we found the Hounsfield units of the psoas muscle at the third lumbar vertebral level to be a prognostic factor. Univariate and multivariate analyses revealed that age, sex, clinical T stage, and psoas muscle Hounsfield units were significant preoperative factors for overall survival. Furthermore, risk classification using these four factors was useful for predicting the prognosis of patients with RC.


Radical cystectomy (RC) is the standard treatment for patients with advanced bladder cancer. Since RC is a highly invasive procedure, the surgical indications in an aging society must be carefully judged. In recent years, the concept of “frailty” has been attracting attention as a term used to describe fragility due to aging. We focused on the psoas muscle Hounsfield unit (PMHU) and analyzed its appropriateness as a prognostic factor together with other clinical factors in patients after RC. We retrospectively analyzed the preoperative prognostic factors in 177 patients with bladder cancer who underwent RC between 2008 and 2020. Preoperative non-contrast computed tomography axial image at the third lumbar vertebral level was used to measure the mean Hounsfield unit (HU) and cross-sectional area (mm2) of the psoas muscle. Univariate analysis showed significant differences in age, sex, clinical T stage, and PMHU. In multivariate analysis using the Cox proportional hazards model, age (hazard ratio (HR) = 1.734), sex (HR = 2.116), cT stage (HR = 1.665), and PMHU (HR = 1.758) were significant predictors for overall survival. Furthermore, using these four predictors, it was possible to stratify the prognosis of patients after RC. Finally, PMHU was useful as a simple and significant preoperative factor that correlated with prognosis after RC.

1. Introduction

Radical cystectomy (RC) is the gold standard treatment for patients with muscle invasive bladder cancer, patients with selected T1 high-grade non-muscle invasive bladder cancer, and patients with carcinoma in situ resistant to Bacillus Calmette–Guérin treatment [1]. RC remains one of the most invasive urological procedures, and its surgical indication needs to be carefully assessed in an aging society. According to the “Annual Report on the Aging Society 2020” from the Cabinet Office of Japan, the total population of Japan is 126.17 million as of 2019, of which 35.89 million are aged 65 years or older. Japan is facing an aging society ahead of the rest of the world. A systematic review has reported that perioperative mortality within 90 days after RC significantly increases in the elderly, and overall survival (OS) and cancer-specific survival (CSS) also decrease with age [2]. Aging is clearly a risk factor for RC. In recent years, the concept of “frailty” has been attracting attention as a term that expresses fragility due to aging [3]. If the prognosis can be predicted more accurately by assessing not only the clinical stage and age of the patient but also malnutrition and muscle weakness associated with decreased physical activity, it can help in deciding whether to perform surgery. Although few established definitions with regard to the elderly or frailty have been reported, there have been some attempts to define them with various assessments [3,4,5]. Several reports linking frailty and sarcopenia to predict prognosis in patients with bladder cancer have been reported [3,6,7,8,9,10]. As an indicator that may objectively represent frailty, we focused on the psoas muscle Hounsfield unit (PMHU), which is defined as the mean computed tomographic attenuation value of the psoas muscle. The main aim of this study is to assess the utility of PMHU as a preoperative prognostic marker in patients receiving RC for bladder cancer.

2. Materials and Methods

2.1. Study Design and Patients

We retrospectively reviewed the records of consecutive patients who underwent open radical cystectomy (ORC), laparoscopic radical cystectomy (LRC), or robot-assisted laparoscopic radical cystectomy (RARC) for bladder cancer at Mie University Hospital, Ise Red Cross Hospital, and Mie Prefectural General Medical Center. A total of 177 patients (113 patients at Mie University Hospital, 42 patients at Ise Red Cross Hospital, and 23 patients at Mie Prefectural General Medical Center) were enrolled.

2.2. Image Analyses

Abdominal non-contrast computed tomography (NCCT) images (1–5 mm-thick slices) taken within 3 months before RC were used to measure the imaging factors related to the psoas muscle. Four urologists (Y.S., S.K., T.O., and S.T.) freehand outlined each psoas muscle at the third lumbar vertebral level in the axial NCCT image (Figure 1).
The right and left total areas were used for the psoas muscle area (PMA) (mm2). The mean value of the mean computed tomographic attenuation value of the right and left psoas muscle was used for the PMHU (HU). The psoas mass index (PMI) (cm2/m2) was calculated by normalizing the cross-sectional area by height [11].

2.3. Statistical Analyses

All statistical analyses were performed using EZR version 1.33 [12]. Student’s t-test or Mann–Whitney U test was performed for comparisons between groups of continuous variables. Categorical variables were analyzed using the chi-squared test or Fisher’s exact test. The survival curve was estimated using the Kaplan–Meier method and analyzed using the log-rank test. Cox proportional hazards analysis was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) in univariate and multivariate analyses. In all tests, p < 0.05 was considered statistically significant.

3. Results

Of the 177 patients, 26 (14.7%) were women and 151 (85.3%) were men. The median age was 70 (quartile: 66–76) years, and the median follow-up period was 1002 (quartile: 358–1989) days. The 5-year OS, CSS, and recurrence-free survival (RFS) rates were 59.7%, 71.3%, and 48.7%, respectively. The median OS, CSS, and RFS were 8.86 years (95% CI, 5.00 years to not reached), not reached (95% CI, not reached to not reached), and 4.70 years (95% CI, 2.66 to 9.24 years), respectively. Platinum-based neoadjuvant and adjuvant chemotherapy were performed in 75 (42.4%) and 22 (12.4%) patients, respectively. The surgical procedures were ORC, LRC, and RARC in 119 (67.2%), 38 (21.5%), and 20 (11.3%) patients, respectively. There were 114 (64.4%) and 29 (16.4%) perioperative complications of Clavien–Dindo grade ≥2 and ≥3, respectively. The median length of hospital stay after RC was 26 (quartile: 22–41) days. The histopathological diagnosis after RC was urothelial carcinoma in 138 (77.8%) patients, and some histological variants were found in 39 (22.0%) patients. There were 71 (40.1%) patients with pT ≥3, 33 (18.6%) patients with pN positivity, and 89 (50.3%) patients with LVI positivity, all of which were significant prognostic factors for OS (p < 0.01, log-rank test). Body mass index, PMI, PMA, and PMHU were significantly different between men and women (Table 1).
For variables related to the psoas muscle, it was considered inappropriate to apply the same cutoff value for men and women; thus, the lower limit of the interquartile range for each sex (25 percentile) was used as the cutoff value.
The results of Cox proportional hazards analysis for OS were shown in Table 2.
Univariate analysis showed significant differences in age, sex, cT stage, and PMHU (p < 0.05). The median OS stratified by PMHU alone in the not-low and low PMHU groups were 9.24 years (95% CI, 6.40 years to not reached) and 2.78 years (2.06 years to not reached), respectively, and there was a significant difference among them (p = 0.014). Multivariate analysis using the four factors that were significantly different in the univariate analysis showed significant differences in all factors (p < 0.05).
We focused on these four factors to develop a risk classification for predicting OS in patients with bladder cancer after RC (Table 3). The Kaplan–Meier curve for OS according to the number of risks was shown in Figure 2.
Based on this result, we defined a group with one or fewer risk factors as a low-risk group, a group with two risk factors as an intermediate-risk group, and a group with three or more risk factors as a high-risk group (Table 3). The Kaplan–Meier curve and HR for each risk category were shown in Figure 3 and Table 4, respectively.
The median OS by our risk category in the low-risk, intermediate-risk, and high-risk groups (Table 3) were not reached (95% CI, 8.86 years to not reached), 6.40 years (95% CI, 2.67 years to not reached), and 2.06 years (95% CI, 0.94 to 2.78 years), respectively (p < 0.01). There were no significant differences among the risk groups in terms of postoperative hospital stay and the incidence of complications.

4. Discussion

In the present study, we investigated the significance of preoperative PMHU on the prognosis after RC in patients with bladder cancer. We showed that PMHU is a new prognostic marker along with sex, age, and cT stage, and that these predictors could be used to preoperatively stratify the prognosis of patients with bladder cancer after RC.
In recent years, medical technology innovations have led to minimally invasive surgery, but RC remains highly invasive because of the long operation time and high incidence of perioperative complication rates [2]. Elderly people had a higher 90-day mortality rate and more early complications after RC than younger people [2], and it is often discussed whether RC should be performed, especially for elderly patients.
In order to judge the indication for RC, it is required not only to evaluate the surgical tolerance such as cardiac function and respiratory function, but also to predict the postoperative prognosis to some extent. LVI and pN positivity and pT3 or higher grade have already been reported as postoperative factors related to prognosis [13], and similar results were obtained with our cases. However, pathological factors are the information that can only be known after RC. There are few reports on prognostic markers that are useful in deciding whether or not to perform RC itself.
In an aging society, the concept of frailty is drawing attention. Especially in the elderly, comprehensive assessment of patients’ frailty as well as their age may be useful for treating diseases and improving their quality of life [14,15]. Diagnosis of frailty requires the measurement of grip strength and walking speed [4,5], but there are few facilities that can be incorporated into the daily practice of treating patients with urological malignancies. In particular, it is not desirable to impose a heavy preoperative evaluation on patients with their malignancies.
Regarding the assessment of frailty, NCCT images are easy to acquire and non-invasive. PMA [16], psoas muscle volume (PMV) [9,17,18], PMI [9,11], mean PMHU [19], skeletal muscle index (SMI) [6,8,20], intramuscular adipose tissue content (IMAC) [21], and so on, have been reported as representative imaging factors for frailty. According to a systematic review by Cao et al., SMI, PMI, muscle attenuation, and IMAC were useful for assessing the risk of postoperative complications as NCCT-assessed sarcopenia indices [22]. Analysis of our data did not reveal significant results for PMA and PMI, but PMHU correlated with the prognosis of patients with bladder cancer after RC.
PMHU can be measured very simply and easily. No special training or software is required. NCCT images are always acquired in patients before RC, without the burden of adding new special tests to the patients. Low PMHU reflects skeletal muscle fat infiltration and may indirectly be used to assess frailty [23]. Increase in fat infiltration within skeletal muscle might precede loss of skeletal muscle volume during the progression of cancer cachexia [24].
PMHU is a factor that reflects muscle quality, while PMA and PMI are factors that reflect muscle mass [20,22]. In our data, this may be one of the reasons why only PMHU, not PMA and PMI, showed a significant correlation with OS. Assessing psoas muscle mass with an NCCT image at the L3 level is very simple but may not necessarily reflect systemic skeletal muscle mass [25]. PMV and SMI may reflect systemic muscle mass better than PMA and PMI, but at the expense of ease of measurement [18]. We consider PMHU to be a more practical predictor because of its ease of measurement and its accuracy for prognosis.
Frailty was also evaluated as a risk factor for perioperative complications in patients with bladder cancer [9,26]. Prediction of patients’ prognosis preoperatively may avoid surgical invasive procedures which would cause more harm than benefit in patients. According to our results, the median OS of high-risk patients who have three or more preoperative poor prognosis factors defined by age, sex, cT stage, and PMHU was only 2.06 years. Although our data would not give definitive prediction of perioperative complication, high-risk patients with poor prognosis in our risk classification might not recommend RC. Bladder sparing therapy combined with transurethral resection of the bladder tumor, chemotherapy, and radiation therapy are controversial, but they may be a good treatment option for patients with an apparently poor prognosis [9,27].
By preoperatively diagnosing frailty, it may be possible to improve the prognosis of cancer patients if interventions such as exercise therapy and nutritional guidance can be performed earlier [17,28]. Exercise therapy and essential amino acid supplement drinks have been shown to be useful in recovery from serious illnesses [29] and vitamin D supplementation was useful in improving sarcopenia in the elderly [30]. It goes without saying that treatment of the bladder cancer itself is important for improving the OS. However, in an aging society, we must understand the physical function and nutritional status of each patient before intervening with diverse treatments. To that end, the role of the rehabilitation team, which includes registered dietitians and physiotherapists, is also important, and more than ever it is necessary to deepen cooperation within the team.
There are several limitations of our study. The present study is a small retrospective study. Our results need to be prospectively validated in a larger cohort. In addition, the subjects of this study were limited to the Japanese population, and there is room for consideration of differences between races, especially regarding the cutoff value. Furthermore, the present study did not directly investigate the relationship between PMHU and frailty. In the future, the direct relationship between the already reported diagnostic factors of frailty and PMHU must be investigated [4,5]. In addition we believe that it should be examined in more detail whether perioperative nutrition therapy and physiotherapy for patients with low PMHU can improve the bladder cancer patients’ survival and quality of life.

5. Conclusions

PMHU was a preoperative predictor of prognosis in patients with bladder cancer who were about to undergo RC. The prognosis of patients could be stratified before RC using age, sex, cT stage, and PMHU. Not only can PMHU be measured without burdening patients and clinicians, but also this risk classification helps determine whether to perform RC in patients with bladder cancer before surgery.

Author Contributions

Conceptualization, Y.S. and T.I.; data curation, Y.S., T.O. (Takashi Okamoto), S.K. and S.T.; formal analysis, Y.S.; funding acquisition, T.I.; investigation, Y.S.; methodology, Y.S. and T.I.; project administration, Y.S. and T.I.; supervision, T.S. (Takuji Shibahara), M.K., S.M., K.N., T.S. (Takeshi Sasaki), T.O. (Takehisa Onishi), H.K., H.M. and T.I.; writing—original draft, Y.S. and T.I.; writing—review and editing, Y.S., T.S. (Takeshi Sasaki), K.N. and T.I. All authors have read and agreed to the published version of the manuscript.


This work was financially supported by Grants-in-Aid from the Ministry of Education for Science and Culture of Japan (21H03066).

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of Mie university (approval code H2020-110).

Informed Consent Statement

Informed consent was obtained in the form of opt-out on the web-site. Those who opted out were excluded.

Data Availability Statement

The data are available to other researchers on written request to the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.


  1. Stein, J.P.; Lieskovsky, G.; Cote, R.; Groshen, S.; Feng, A.-C.; Boyd, S.; Skinner, E.; Bochner, B.; Thangathurai, D.; Mikhail, M.; et al. Radical Cystectomy in the Treatment of Invasive Bladder Cancer: Long-Term Results in 1,054 Patients. J. Clin. Oncol. 2001, 19, 666–675. [Google Scholar] [CrossRef] [PubMed]
  2. Fonteyne, V.; Ost, P.; Bellmunt, J.; Droz, J.P.; Mongiat-Artus, P.; Inman, B.; Paillaud, E.; Saad, F.; Ploussard, G. Curative Treatment for Muscle Invasive Bladder Cancer in Elderly Patients: A Systematic Review. Eur. Urol. 2018, 73, 40–50. [Google Scholar] [CrossRef] [PubMed]
  3. Chappidi, M.R.; Kates, M.; Patel, H.D.; Tosoian, J.J.; Kaye, D.R.; Sopko, N.A.; Lascano, D.; Liu, J.-J.; McKiernan, J.; Bivalacqua, T.J. Frailty as a marker of adverse outcomes in patients with bladder cancer undergoing radical cystectomy. Urol. Oncol. Semin. Orig. Investig. 2016, 34, 256.e1–256.e6. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  4. Cruz-Jentoft, A.J.; Baeyens, J.P.; Bauer, J.M.; Boirie, Y.; Cederholm, T.; Landi, F.; Martin, F.C.; Michel, J.-P.; Rolland, Y.; Schneider, S.M.; et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010, 39, 412–423. [Google Scholar] [CrossRef] [Green Version]
  5. Chen, L.-K.; Woo, J.; Assantachai, P.; Auyeung, T.-W.; Chou, M.-Y.; Iijima, K.; Jang, H.C.; Kang, L.; Kim, M.; Kim, S.; et al. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J. Am. Med. Dir. Assoc. 2020, 21, 300–307.e2. [Google Scholar] [CrossRef]
  6. Mayr, R.; Gierth, M.; Zeman, F.; Reiffen, M.; Seeger, P.; Wezel, F.; Pycha, A.; Comploj, E.; Bonatti, M.; Ritter, M.; et al. Sarcopenia as a comorbidity-independent predictor of survival following radical cystectomy for bladder cancer. J. Cachexia Sarcopenia Muscle 2018, 9, 505–513. [Google Scholar] [CrossRef]
  7. Fukushima, H.; Takemura, K.; Suzuki, H.; Koga, F. Impact of Sarcopenia as a Prognostic Biomarker of Bladder Cancer. Int. J. Mol. Sci. 2018, 19, 2999. [Google Scholar] [CrossRef] [Green Version]
  8. Fukushima, H.; Yokoyama, M.; Nakanishi, Y.; Tobisu, K.-I.; Koga, F. Sarcopenia as a Prognostic Biomarker of Advanced Urothelial Carcinoma. PLoS ONE 2015, 10, e0115895. [Google Scholar] [CrossRef]
  9. Saitoh-Maeda, Y.; Kawahara, T.; Miyoshi, Y.; Tsutsumi, S.; Takamoto, D.; Shimokihara, K.; Hayashi, Y.; Mochizuki, T.; Ohtaka, M.; Nakamura, M.; et al. A low psoas muscle volume correlates with a longer hospitalization after radical cystectomy. BMC Urol. 2017, 17, 87. [Google Scholar] [CrossRef]
  10. Hu, X.; Dou, W.-C.; Shao, Y.-X.; Liu, J.-B.; Xiong, S.-C.; Yang, W.-X.; Li, X. The prognostic value of sarcopenia in patients with surgically treated urothelial carcinoma: A systematic review and meta-analysis. Eur. J. Surg. Oncol. (EJSO) 2019, 45, 747–754. [Google Scholar] [CrossRef]
  11. Hamaguchi, Y.; Kaido, T.; Okumura, S.; Kobayashi, A.; Hammad, A.; Tamai, Y.; Inagaki, N.; Uemoto, S. Proposal for new diagnostic criteria for low skeletal muscle mass based on computed tomography imaging in Asian adults. Nutrition 2016, 32, 1200–1205. [Google Scholar] [CrossRef]
  12. Kanda, Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant. 2013, 48, 452–458. [Google Scholar] [CrossRef] [Green Version]
  13. Mari, A.; Kimura, S.; Foerster, B.; Abufaraj, M.; D’Andrea, D.; Gust, K.M.; Shariat, S.F. A systematic review and meta-analysis of lymphovascular invasion in patients treated with radical cystectomy for bladder cancer. Urol. Oncol. Semin. Orig. Investig. 2018, 36, 293–305. [Google Scholar] [CrossRef]
  14. Robinson, S.M.; Denison, H.J.; Cooper, C.; Sayer, A.A. Prevention and optimal management of sarcopenia: A review of combined exercise and nutrition interventions to improve muscle outcomes in older people. Clin. Interv. Aging 2015, 10, 859–869. [Google Scholar] [CrossRef] [Green Version]
  15. Billot, M.; Calvani, R.; Urtamo, A.; Sánchez-Sánchez, J.L.; Ciccolari-Micaldi, C.; Chang, M.; Roller-Wirnsberger, R.; Wirnsberger, G.; Sinclair, A.; Vaquero-Pinto, M.N.; et al. Preserving Mobility in Older Adults with Physical Frailty and Sarcopenia: Opportunities, Challenges, and Recommendations for Physical Activity Interventions. Clin. Interv. Aging 2020, 15, 1675–1690. [Google Scholar] [CrossRef]
  16. Smith, A.B.; Deal, A.M.; Yu, H.; Boyd, B.; Matthews, J.; Wallen, E.M.; Pruthi, R.S.; Woods, M.E.; Muss, H.; Nielsen, M.E. Sarcopenia as a Predictor of Complications and Survival Following Radical Cystectomy. J. Urol. 2014, 191, 1714–1720. [Google Scholar] [CrossRef]
  17. Miyake, M.; Morizawa, Y.; Hori, S.; Marugami, N.; Shimada, K.; Gotoh, D.; Tatsumi, Y.; Nakai, Y.; Inoue, T.; Anai, S.; et al. Clinical impact of postoperative loss in psoas major muscle and nutrition index after radical cystectomy for patients with urothelial carcinoma of the bladder. BMC Cancer 2017, 17, 237. [Google Scholar] [CrossRef] [Green Version]
  18. Matsubara, Y.; Nakamura, K.; Matsuoka, H.; Ogawa, C.; Masuyama, H. Pre-treatment psoas major volume is a predictor of poor prognosis for patients with epithelial ovarian cancer. Mol. Clin. Oncol. 2019, 11, 376–382. [Google Scholar] [CrossRef] [Green Version]
  19. Zhuang, C.-L.; Shen, X.; Huang, Y.-Y.; Zhang, F.-M.; Chen, X.-Y.; Ma, L.-L.; Chen, X.-L.; Yu, Z.; Wang, S.-L. Myosteatosis predicts prognosis after radical gastrectomy for gastric cancer: A propensity score–matched analysis from a large-scale cohort. Surgery 2019, 166, 297–304. [Google Scholar] [CrossRef]
  20. Van Rijssen, L.B.; van Huijgevoort, N.C.; Coelen, R.J.; Tol, J.A.; Haverkort, E.B.; Nio, C.Y.; Busch, O.R.; Besselink, M.G. Skeletal Muscle Quality is Associated with Worse Survival After Pancreatoduodenectomy for Periampullary, Nonpancreatic Cancer. Ann. Surg. Oncol. 2017, 24, 272–280. [Google Scholar] [CrossRef]
  21. Kitajima, Y.; Hyogo, H.; Sumida, Y.; Eguchi, Y.; Ono, N.; Kuwashiro, T.; Tanaka, K.; Takahashi, H.; Mizuta, T.; Ozaki, I.; et al. Severity of non-alcoholic steatohepatitis is associated with substitution of adipose tissue in skeletal muscle. J. Gastroenterol. Hepatol. 2013, 28, 1507–1514. [Google Scholar] [CrossRef]
  22. Cao, Q.; Xiong, Y.; Zhong, Z.; Ye, Q. Computed Tomography-Assessed Sarcopenia Indexes Predict Major Complications following Surgery for Hepatopancreatobiliary Malignancy: A Meta-Analysis. Ann. Nutr. Metab. 2019, 74, 24–34. [Google Scholar] [CrossRef]
  23. Aubrey, J.; Esfandiari, N.; Baracos, V.E.; Buteau, F.A.; Frenette, J.; Putman, C.T.; Mazurak, V.C. Measurement of skeletal muscle radiation attenuation and basis of its biological variation. Acta Physiol. 2014, 210, 489–497. [Google Scholar] [CrossRef] [Green Version]
  24. Kliewer, K.L.; Ke, J.-Y.; Tian, M.; Cole, R.M.; Andridge, R.R.; Belury, M.A. Adipose tissue lipolysis and energy metabolism in early cancer cachexia in mice. Cancer Biol. Ther. 2014, 16, 886–897. [Google Scholar] [CrossRef] [Green Version]
  25. Rutten, I.J.; Ubachs, J.; Kruitwagen, R.F.; Beets-Tan, R.G.; Damink, S.O.; Van Gorp, T. Psoas muscle area is not representative of total skeletal muscle area in the assessment of sarcopenia in ovarian cancer. J. Cachexia Sarcopenia Muscle 2017, 8, 630–638. [Google Scholar] [CrossRef] [Green Version]
  26. Palumbo, C.; Knipper, S.; Pecoraro, A.; Rosiello, G.; Luzzago, S.; Deuker, M.; Tian, Z.; Shariat, S.F.; Simeone, C.; Briganti, A.; et al. Patient frailty predicts worse perioperative outcomes and higher cost after radical cystectomy. Surg. Oncol. 2020, 32, 8–13. [Google Scholar] [CrossRef]
  27. Ploussard, G.; Daneshmand, S.; Efstathiou, J.A.; Herr, H.W.; James, N.D.; Rödel, C.M.; Shariat, S.F.; Shipley, W.U.; Sternberg, C.N.; Thalmann, G.N.; et al. Critical Analysis of Bladder Sparing with Trimodal Therapy in Muscle-invasive Bladder Cancer: A Systematic Review. Eur. Urol. 2014, 66, 120–137. [Google Scholar] [CrossRef]
  28. PERIOP OG Working Group; Tully, R.; Loughney, L.; Bolger, J.; Sorensen, J.; McAnena, O.; Collins, C.G.; Carroll, P.A.; Arumugasamy, M.; Murphy, T.J.; et al. The effect of a pre- and post-operative exercise programme versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (The PERIOP-OG Trial): Study protocol for a randomised controlled trial. Trials 2020, 21, 638. [Google Scholar] [CrossRef]
  29. Jones, C.; Eddleston, J.; McCairn, A.; Dowling, S.; McWilliams, D.; Coughlan, E.; Griffiths, R. Improving rehabilitation after critical illness through outpatient physiotherapy classes and essential amino acid supplement: A randomized controlled trial. J. Crit. Care 2015, 30, 901–907. [Google Scholar] [CrossRef]
  30. Muir, S.W.; Montero-Odasso, M. Effect of Vitamin D Supplementation on Muscle Strength, Gait and Balance in Older Adults: A Systematic Review and Meta-Analysis. J. Am. Geriatr. Soc. 2011, 59, 2291–2300. [Google Scholar] [CrossRef]
Figure 1. Measurement of the psoas muscle area (PMA) and the mean psoas muscle Hounsfield unit (PMHU) on the preoperative axial non-contrast computed tomography image at the third lumbar vertebral level.
Figure 1. Measurement of the psoas muscle area (PMA) and the mean psoas muscle Hounsfield unit (PMHU) on the preoperative axial non-contrast computed tomography image at the third lumbar vertebral level.
Cancers 13 05629 g001
Figure 2. Kaplan–Meier curves for overall survival according to the number of risks.
Figure 2. Kaplan–Meier curves for overall survival according to the number of risks.
Cancers 13 05629 g002
Figure 3. Kaplan–Meier curves for overall survival according to risk category.
Figure 3. Kaplan–Meier curves for overall survival according to risk category.
Cancers 13 05629 g003
Table 1. Patient characteristics.
Table 1. Patient characteristics.
Variables Total Cases (n = 177)Men
(n = 151)
(n = 26)
Median age at RC (IQR) 70 (66–76)70 (66–76)72.5 (65–76)0.687
Median BMI (IQR) 22.92 (20.94–24.95)23.11 (21.20–25.07)21.22 (19.03–22.68)<0.01
ASA-PS121 (12%)17 (11%)4 (15%)0.755
2120 (68%)103 (68%)17 (65%)
336 (20%)31 (21%)5 (19%)
Clinical T stage, n (%)NMIBC51 (29%)45 (30%)6 (23%)0.163
270 (40%)61 (40%)9 (35%)
327 (15%)19 (13%)8 (31%)
429 (16%)26 (17%)3 (12%)
Clinical N stage, n (%)0154 (87%)132 (87%)22 (85%)0.752
≥123 (13%)19 (13%)4 (15%)
Neoadjuvant chemotherapy, n (%)No102 (58%)90 (60%)12 (46%)0.207
Yes75 (42%)61 (40%)14 (54%)
Median PMA (mm2) (IQR) 1129 (894–1455)1242 (983–1510)679 (521–887)<0.01
Median PMI (cm2/m2) (IQR) 4.31 (3.41–5.41)4.66 (3.66–5.60)2.88 (2.34–3.89)<0.01
Median PMHU (HU) (IQR) 43.14 (39.26–47.54)43.40 (39.56–47.75)40.93 (34.56–45.16)0.043
IQR = interquartile range, BMI = body mass index, ASA-PS; American Society of Anesthesiologists physical status, NMIBC = non-muscle invasive bladder cancer, PMA = psoas muscle area, PMI = psoas mass index, PMHU = psoas muscle Hounsfield unit.
Table 2. Cox proportional hazards analysis of overall survival in patients undergoing radical cystectomy.
Table 2. Cox proportional hazards analysis of overall survival in patients undergoing radical cystectomy.
VariablesCategoryHR95% CIp ValueHR95% CIp Value
Age<70Reference Reference
SexMenReference Reference
Clinical T stage<3Reference Reference
Clinical N stage0Reference
Neoadjuvant chemotherapyNoReference
BMINot lowReference
PMANot lowReference
PMINot lowReference
PMHUNot lowReference Reference
HR = hazard ratio, CI = confidence interval, ASA-PS = American Society of Anesthesiologists physical status, BMI = body mass index, PMA = psoas muscle area, PMI = psoas mass index, PMHU = psoas muscle Hounsfield unit.
Table 3. Risk factors and risk category.
Table 3. Risk factors and risk category.
Risk Factors01
1. Age<70≥70
2. SexMenWomen
3. Clinical T stage<3≥3
4. PMHUMen: ≥39.56 HU
Women: ≥34.56 HU
Men: <39.56 HU
Women: <34.56 HU
Risk Category
Low-riskIf <2 risk factors present
Intermediate-riskIf 2 risk factors present
High-riskIf ≥3 risk factors present
PMHU = psoas muscle Hounsfield unit.
Table 4. Hazard ratio for each risk category.
Table 4. Hazard ratio for each risk category.
Risk CategorynHR95% CIp Value
HR = hazard ratio, CI = confidence interval.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Sugino, Y.; Sasaki, T.; Kato, M.; Masui, S.; Nishikawa, K.; Okamoto, T.; Kajiwara, S.; Shibahara, T.; Onishi, T.; Tanaka, S.; et al. Prognostic Effect of Preoperative Psoas Muscle Hounsfield Unit at Radical Cystectomy for Bladder Cancer. Cancers 2021, 13, 5629.

AMA Style

Sugino Y, Sasaki T, Kato M, Masui S, Nishikawa K, Okamoto T, Kajiwara S, Shibahara T, Onishi T, Tanaka S, et al. Prognostic Effect of Preoperative Psoas Muscle Hounsfield Unit at Radical Cystectomy for Bladder Cancer. Cancers. 2021; 13(22):5629.

Chicago/Turabian Style

Sugino, Yusuke, Takeshi Sasaki, Manabu Kato, Satoru Masui, Kouhei Nishikawa, Takashi Okamoto, Shinya Kajiwara, Takuji Shibahara, Takehisa Onishi, Shiori Tanaka, and et al. 2021. "Prognostic Effect of Preoperative Psoas Muscle Hounsfield Unit at Radical Cystectomy for Bladder Cancer" Cancers 13, no. 22: 5629.

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop