CPET before major urological surgery

67-year-old man for consultation. Referred by CPET team due to, sub-optimal test.


  • NIDDM – normal HbA1c. single agent. No complications
  • Hypertension and hypercholesterolaemia


  • Muscle-invasive bladder cancer – for NAC then surgery
  • CPET – impaired cardio-respiratory function (pre-NAC)
    • Max Test – HRmax – 92%, RER 1.22
    • Peak vo2 15.2ml/kg/min AT 9.7ml/kg/min, nadir VE/VCO2 44.1
    • HRR – 3bpm
    • O2 pulse and HR rose appropriately until workload of 45 watts then plateaued; indicating a limitation in stroke volume
    • Limited by leg pain/fatigue.
    • No chest pain, desaturation, or ischaemic ECG changes.
  • DASI 6.7 METs
  • Deconditioned, rarely exercises. Previously been walking regularly with NDIS worker but ceased due to covid.
  • Schizo-affective disorder
    • stable on current therapy for 20 years
    • Patient concerned that being in hospital could precipitate a relapse.
    • Expressing concerns regarding ileal conduit


  • CPET results place patient in high-risk category for major surgery.
  • Raised nadir VE/Vco2 indicates impairment in ventilatory efficiency – normal spirometry therefore possible cardiac cause?
  • HRR less than 12 is also an indicator of higher risk for perioperative m&m
  • RCRI = 1
  • NSQIP – above average risk for cardiac, respiratory, and renal complications.
  • Patient discussion – understands risks. Motivated to exercise. Remains uncertain if wants to proceed with surgery, will revisit issues with surgeon and urology CNC.
  • Echocardiogram considered – no clinical indication. Should we perform based on CPET?
  • CPET results are significant in this patient but form one aspect of the perioperative assessment. Not in keeping with clinical picture, therefore further consideration required.


  • For further discussion at CPET MDT
  • Prehabilitation – funding is possible via NDIS pathway
  • Likely re-test post NAC and prehab