Comparison of Perioperative Risk Assessment Tools for Major Postoperative Complications After Radical Cystectomy

Background/Objectives: To compare the discriminatory performance of commonly used perioperative risk assessment tools, including the American Society of Anesthesiologists (ASA) Physical Status Classification, Estimation of Physiologic Ability and Surgical Stress (E-PASS), Surgical Outcome Risk Tool (SORT), and modified 5-item Frailty Index (mFI-5), for major postoperative complications after radical cystectomy. Methods: This retrospective observational study included 193 patients who underwent open radical cystectomy for bladder cancer between January 2017 and January 2025. Major postoperative complications were defined as Clavien–Dindo grade III or higher. The discriminatory performance of ASA, E-PASS Comprehensive Risk Score (CRS), SORT, and mFI-5 was assessed using receiver operating characteristic analysis. Pairwise comparisons of the areas under the receiver operating characteristic curves (AUCs) were performed using the DeLong test. Logistic regression models were used to evaluate associations with major complications, and exploratory analyses examined secondary postoperative outcomes. Results: Major postoperative complications occurred in 58 (30.1%) patients. The numerical AUC was highest for E-PASS CRS (0.618, 95% CI 0.536–0.701), followed by SORT (AUC 0.610, 95% CI 0.525–0.694), ASA (AUC 0.595, 95% CI 0.509–0.680) and mFI-5 (AUC 0.578, 95% CI 0.489–0.668). However, pairwise DeLong tests showed no statistically significant difference in discrimination between E-PASS CRS and SORT, or any of the other scores tested. In univariable analysis, high E-PASS CRS, high SORT score and mFI-5 ≥ 2 were significantly associated with major complications, while ASA classification was not. When all scores were entered into the multivariable model at the same time, none of the scores remained statistically significant. Conclusions: All of the risk assessment tools evaluated in this study demonstrated poor discriminatory ability for major postoperative complications following radical cystectomy. Although E-PASS CRS had the highest numeric AUC, its discrimination was not statistically better than the other scores analyzed. Existing risk tools may help with perioperative risk stratification but should not be used as stand-alone prediction models for major postoperative morbidity after radical cystectomy.