Functional Status in Patients Requiring Nursing Home Stay After Radical Cystectomy.

OBJECTIVE: To evaluate the ability to perform activities of daily living (ADLs) in patients who required nursing home (NH) care after radical cystectomy (RC), as this surgery can impair patients' ability to perform ADLs in the postoperative period. METHODS: Patients undergoing RC were identified in a novel database of patients with at least two NH assessments linked with Medicare inpatient claims. The NH assessment included the Minimum Data Set (MDS)-ADL Long Form (0-28; a higher score equals greater impairment), which quantifies ADLs. Paired t-tests and chi-squared analysis were used for comparisons. RESULTS: We identified 471 patients that underwent RC and had at least one MDS-ADL assessment. In total, 245 patients lived elsewhere prior to RC and went to an NH after RC, while 122 patients lived in an NH before and after RC. Mean age of the population was 80.7 years (standard deviation 5.7). Of the 245 patients who did not live in a facility before RC, 68% of patients were discharged directly to an NH and 31% were discharged to another location before NH. There was no difference in MDS-ADL score between these groups (16.4 vs 15.0, P = .09). Among the patients who lived in an NH before and after RC, the mean pre- and post-operative MDS-ADL scores were significantly different (12.1 vs 16.6, P<.0001). CONCLUSION: ADLs, as measured by the MDS-ADL Long Form score, worsen after RC. This should be an important part of the risks and benefits conversation with patients, their families, and caregivers.

Comparative Perioperative Outcomes in Septuagenarians and Octogenarians Undergoing Radical Cystectomy for Bladder Cancer-Do Outcomes Differ?

BACKGROUND: Treatment choice for muscle invasive bladder cancer continues to be radical cystectomy. However, radical cystectomy carries a relatively high risk of morbidity and mortality compared with other urological procedures. OBJECTIVE: To compare surgical complications following radical cystectomy in septuagenarians and octogenarians. DESIGN, SETTING, AND PARTICIPANTS: The National Surgical Quality Improvement Program database (2009-2013) was used to identify patients who were 70 yr and older and underwent radical cystectomy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The data were analyzed for demographics and comorbidities, and compared for complications, including pulmonary, thromboembolic, wound, and cardiac complications. Patients who were 70-79 yr of age were compared with those 80 yr and older. Univariate and multivariate analyses were completed. RESULTS AND LIMITATIONS: A total of 1710 patients aged ≥70 yr met our inclusion criteria. Of them, 28.8% (n=493) were 80 yr and older, while 71.2% (n=1217) were between 70 and 79 yr old. Operative time (338.4 vs 307.2min, p=0.0001) and the length of stay (11.9 vs 10.4 d, p=0.0016) were higher in the octogenarian group. The intra- and postoperative transfusion rates, reoperative rates, wound dehiscence rates, and pneumonia, sepsis, and myocardial infarction rates were similar between the two groups. The wound infection rate (7.3% vs 4.1%, p=0.01) was higher in the septuagenarians and mortality rate (4.3% vs 2.3%, p=0.04) was higher in the octogenarian group. CONCLUSIONS: Radical cystectomy can safely be performed in octogenarians without increased cardiac, pulmonary, and thromboembolic complications when compared with septuagenarians. These patients need to be counseled that the mortality rate is slightly higher compared with that in septuagenarians. Chronological age alone should not be used to decide on offering radical cystectomy. PATIENT SUMMARY: We looked at complications following radical cystectomy in patients aged 80 yr and older. We found that there was no significant difference for wound, cardiac, or pulmonary complications, but there was an increased risk of mortality in this age group.

Forty-Three-Year-Old Female with Dopamine Secreting Pheochromocytoma of the Adrenal Gland.

We report on a 43-year-old, asymptomatic female who presented with incidental finding of left adrenal mass. MRI gave concerns for possible pheochromocytoma but markers for pheochromocytoma were not elevated as expected. 24-hour urine dopamine levels (6988 µg/day) were significantly elevated. The patient successfully underwent robotic assisted radical left adrenalectomy and was diagnosed with a dopamine secreting pheochromocytoma. Pathology revealed increased malignant potential associated with the tumor. The patient underwent full metastatic workup, which was negative. At two years of follow-up there was no recurrence and normalization of lab values.

Feasibility and safety study for the use of wound protectors during robotic radical cystectomy and ileal conduit.

Robot-assisted laparoscopic radical cystectomy (RALRC) is increasingly being performed for the treatment of muscle-invasive bladder cancer. There is increased tension while performing the ureteroileal anastomosis through a small incision. Patients are at risk to suffer wound and skin complications perioperatively due to possible contamination with bowel contents. The Alexis® retractor helps with retraction of small incisions potentially reducing tension and also reduces wound infection rates as reported in the colorectal literature. This pilot study evaluates the use of the Alexis® wound protector (WP) in RALRC with ileal conduit (IC). The WP was used in 15 consecutive patients at a single institution who all underwent RALRC with IC. All patients had preoperative bowel preparations, antibiotics, and had surgical preparation with chlorhexidine with alcohol in the standard fashion. The Alexis® device was placed following RALRC to protect the skin and fascia during ileal conduit formation. The ileal conduit was then created extracorporeally through the WP in the standard fashion. RALRC with IC was successfully completed in all 15 patients. Patients had no wound complications defined as documentation of cellulitis or hernia on progress or follow-up notes. Using our technique with the WP we had no cases of surgical site infection. Wound barrier protection has been recommended for use in colorectal surgery and we believe that these recommendations translate to RALRC with IC due to the use of bowel to form the urinary diversion. Further studies with the use of WP in this procedure are necessary to validate our findings.

Comparative survival following different treatment modalities for stage T2 bladder cancer in octogenarians.

PURPOSE: A higher rate of comorbidities and an anticipated higher operative risk in octogenarians may influence urologists in opting for less aggressive and less effective treatment modalities for muscle-invasive bladder cancer. This study was performed to compare survival after different treatment modalities in octogenarians with stage T2 bladder cancer. METHODS: Patients that were 80 years or older with a diagnosis of transitional cell carcinoma of the bladder were identified using the Surveillance, Epidemiology, and End Results-17 registry database between 1988 and 2007. Patients were analyzed for treatment method and outcomes, including overall survival (OS) and cancer-specific survival (CSS). RESULTS: A total of 3,232 patients met inclusion criteria. Of these, 69 % (N = 2,216) underwent only transurethral resection (TURBT), 23 % (N = 733) underwent pelvic radiation therapy (RT), and 9 % (N = 283) underwent definitive surgical therapy. The 3-, 5-, and 10-year OS rates were 22.2, 15.0, and 4.4 %, respectively, for TURBT; 27.8, 18.3, and 3.5 % for RT; and 52.7, 39.1, and 17.2 % for definitive surgery. The 3-, 5-, and 10-year CSS rates were 38.3, 33.4, and 27.4 %, respectively, for TURBT; 41.6, 35.0, and 27.2 % for RT; and 66.6, 55.5, and 49.9 % for definitive surgery. Both partial and radical cystectomy had significantly longer CSS rates at 3 and 5 years when compared to RT (p ≤ 0.001). CONCLUSIONS: Compared to other treatment modalities, surgery, either radical cystectomy or partial cystectomy, offers the best OS and CSS for men aged 80 years or older with T2 bladder cancer.