Effect of Uncontrolled Diabetes on Outcomes After Cystectomy in Patients With Bladder Cancer: A Population-Based Study

Interest of the POSPOM score in estimating postoperative complication risk after radical cystectomy

INTRODUCTION

Identifying patients at risk after cystectomy for cancer is essential. The POSPOM score is a non-specific urological surgery score for estimating postoperative hospital mortality. This study sought to validate the POSPOM score for predicting postoperative morbidity and mortality after cystectomy.

METHODS

The study retrospectively included all patients undergoing cystectomy for muscle-invasive or locally advanced bladder cancer between 2010 and 2019 in one center. The primary objective was validation of the POSPOM score for calculating severe postoperative morbidity [Clavien-Dindo (CDC)≥3] and 90-day mortality after cystectomy. Secondary objectives were comparison to other predictive scores [Charlson (CCI), ASA].

RESULTS

At 90days, out of 167 patients, 26% (n=44) had a CDC≥3 complication and 8.4% (n=14) had died. POSPOM correlated with the risk of death at 90days (P<0.001) and postoperative transfusion (P<0.01). Patients with CDC≥3 complications had higher CCI and POSPOM (median 6.5 vs. 5, P<0.01 and 6.49% vs. 5.58%, P=0.029, respectively). Patients who died postoperatively had higher CCI and POSPOM (median 8 vs. 6, P<0.001 and 23.9% vs. 5.58%, P<0.001, respectively). The prognostic value of the POSPOM score for predicting mortality appears better [AUC=0.886 (0.798-0.973)] compared with CCI [AUC=0.812 (0.710-0.915)] and ASA [AUC=0.739 (0.630-0.849)], but not for predicting morbidity.

CONCLUSION

This study confirms the robustness of the POSPOM score for estimating mortality and its limitations for predicting postoperative morbidity.

LEVEL OF EVIDENCE: 3

The Association between Diabetes Medication Use and Tumour Characteristics at Diagnosis in Patients with Urothelial Carcinoma: A Retrospective Registry-Based Study1

BACKGROUND: Observational studies indicate a potential association between diabetes medication use and aggressiveness of bladder cancer. OBJECTIVE: The objective is to exploratively study the association between diabetes medication use, as proxy for diabetes, and cancer characteristics of urothelial carcinoma at diagnosis. Furthermore, differences in associations between specific types of diabetes medication are studied. METHODS: The association between use of diabetes medication and urothelial carcinoma (UC) characteristics at diagnosis is studied. A retrospective registry-based study among UC patients in the Netherlands was performed for which two large linked registries from PHARMO and IKNL were used. Patients diagnosed with UC between 2000 and 2016 and no previous cancer were included in this study. UC patients using diabetes medication were matched on age and sex with subjects not using diabetes medication (ratio 1:2), resulting in 1,164 diabetes medication users and 2,318 non-users. Conditional logistic regression analysis was performed to determine odds ratios comparing cancer characteristics between different types of diabetes medication users to non-users. RESULTS: Noninsulin antidiabetic drugs (NIAD) use was associated with a muscle-invasive type of UC compared to non-users (OR = 1.31, 95% CI: 1.10–1.55 for T2+ versus Ta) as well as a poorly differentiated tumour (OR = 1.31, 95% CI: 1.07–1.59 for poorly versus well differentiated tumours). CONCLUSION: Users of diabetes medication are potentially more likely to be diagnosed with a more aggressive tumour than non-users; however, lifestyle factors could not be adjusted for.

Role of prehabilitation following major uro-oncologic surgery: a narrative review

PURPOSE

Functional status and physical independence play a key role in terms of quality of life, access to treatment, and continuity of care. Surgery, a central component of cancer treatments, leads to detrimental effects on functional capacity, which can be peculiarly relevant in vulnerable patients undergoing major procedures. Prehabilitation is a multidisciplinary intervention that uses the preoperative period to prevent or attenuate treatment-related functional decline and its subsequent consequences. This paper narratively reviews the rationale and the evidence of prehabilitation for uro-oncologic surgery.

METHODS

A narrative review was conducted in August 2020, aiming to: (1) identify and discuss the impact of modifiable determinants of postoperative outcomes in urology and (2) review randomized controlled trials (RCT) exploring the role of preoperative exercise, nutrition, and psychological interventions in uro-oncologic surgery.

RESULTS

Eight RCTs on preoperative conditioning interventions met the inclusion criteria, focusing on radical cystectomy for bladder cancer (RC) and radical prostatectomy for prostate cancer (RP). There is strong evidence that poor physical, nutritional and psychosocial status negatively impacts on surgical outcomes. Single modality interventions, such as preoperative exercise or nutrition alone, had no effect on 'traditional' surgical outcomes as length of stay or complication. However, multimodal approaches targeting postoperative functional status have shown to be effective and safe.

CONCLUSION

There is initial evidence on the effectiveness and safety of multimodal prehabilitation in preserving functional capacity following RC and RP. However, to date, outcomes such as complications and length of stay seem to be not affected by prehabilitation.

Predicting perioperative outcomes of robot-assisted radical cystectomy: Data from the Asian Robot-Assisted Radical Cystectomy Consortium

OBJECTIVES

To report the perioperative outcomes of robot-assisted radical cystectomy and elucidate their risk factors.

METHODS

A review of the Asian Robot-Assisted Radical Cystectomy Consortium database from 2007 to 2020 was performed. The perioperative outcomes studied included complication rates, time to solid food intake, estimated blood loss, length of hospital stay, and 30-day readmission rates.

RESULTS

Of 568 patients, the overall complication rate was 49.2%, comprising major complications in 15.6%. Preoperative hydronephrosis was associated with an increased risk of major complications (odds ratio 3.27, 95% confidence interval 1.48-7.26, P = 0.004) while neoadjuvant chemotherapy was protective (odds ratio 0.46, 95% confidence interval 0.25-0.84, P = 0.012). The median time to solid food intake was 4 days (interquartile range 3-7) and smoking was a risk factor (odds ratio 4.28, 95% confidence interval 2.36-7.79, P < 0.001) for prolonged time to solid food intake. Median length of hospital stay was 13 days (interquartile range 9-19), and diabetes mellitus (odds ratio 1.66, 95% confidence interval 1.08-2.56, P = 0.021), neoadjuvant chemotherapy (odds ratio 2.21, 95% confidence interval 1.46-3.33, P < 0.001), and orthotopic bladder substitute creation (odds ratio 2.82, 95% confidence interval 1.90-4.18, P < 0.001) were independent risk factors for prolonged length of hospital stay. The 30-day readmission rate was 23.4% and higher in those with bilateral hydronephrosis (odds ratio 4.58, 95% confidence interval 1.97-10.65, P < 0.001) and orthotopic bladder substitute creation (odds ratio 1.87, 95% confidence interval 1.16-3.02, P = 0.010).

CONCLUSIONS

There are preoperative conditions which are significant risk factors for adverse perioperative outcomes in robot-assisted radical cystectomy. Most are potentially modifiable and can direct strategies to reduce surgical morbidity related to this major oncological procedure.

Predicting factor analysis of postoperative complications after robot-assisted radical cystectomy: Multicenter KORARC database study

OBJECTIVES

To evaluate postoperative complications following robot-assisted radical cystectomy in patients diagnosed with bladder cancer and reveal if there are predictors for postoperative complications.

METHODS

Prospectively collected medical records of 730 robot-assisted radical cystectomy patients between 2007/04 and 2019/05 in 13 tertiary referral centers were reviewed. Perioperative outcomes were compared between two groups by postoperative complications (complication vs non-complication). We assessed recurrence-free survival, cancer-specific survival, and overall survival between groups. Regression analyses were implemented to identify factors associated with postoperative complications.

RESULTS

Any total and high-grade complication (Clavien-Dindo grade ≥3) rates were 57.8% and 21.1%, respectively. Patients in complication group had significantly higher proportion of diabetes mellitus (P = 0.048), chronic kidney disease (P = 0.011), dyslipidemia (P < 0.001), longer operation time (P = 0.001), more estimated blood loss (P = 0.001), and larger intraoperative fluid volume (P < 0.001). There was a significant difference in cancer-specific survival (log-rank P = 0.038, median cancer-specific survival: both groups not reached). Dyslipidemia (odds ratio 2.59, P = 0.002) and intraoperative fluid volume (odds ratio 1.0002, P = 0.040) were significantly associated with high-grade postoperative complications. Diabetes mellitus (odds ratio 1.97, P = 0.028), chronic kidney disease (odds ratio 1.89, P = 0.046), dyslipidemia (odds ratio 5.94, P = 0.007), and intraoperative fluid volume (odds ratio 1.0002, P = 0.009) were significantly associated with any postoperative complications.

CONCLUSIONS

Patients with diabetes mellitus, chronic kidney disease, dyslipidemia, or a relatively large intraoperatively infused fluid volume are more likely to develop postoperative complications. Patients with postoperative complications might have a possibility of lower cancer-specific survival rate.

Diabetes Mellitus and Obesity as Risk Factors for Bladder Cancer Prognosis: A Systematic Review and Meta-Analysis

BACKGROUND

Urinary bladder carcinoma is common in developed settings, and prognosis may be impacted by lifestyle factors such as excess body weight and diabetes mellitus. The present meta-analysis aimed to systematically collate and analyze evidence on the impact of diabetes and excess BMI on bladder cancer outcomes.

METHODS

PubMed, Scopus, and Google Scholar databases were screened for relevant studies that examined the association between bladder cancer outcomes and diabetes and/or excess body weight. The primary outcomes for this study were mortality (both all-cause and cancer-specific), risk of cancer progression, and recurrence. Strength of association was presented in the form of pooled adjusted hazard ratios (HR). Statistical analysis was performed using STATA version 16.0.

RESULTS

Twenty-five articles met inclusion criteria. Nine of these examined diabetes mellitus while 16 studied body mass index. All studies were retrospective. Diabetic patients had significantly higher risk for all-cause mortality (HR 1.24, 95% CI: 1.07, 1.44, n=3), cancer specific mortality (HR 1.67, 95% CI: 1.29, 2.16, n=7), disease progression (HR 1.54, 95% CI: 1.15, 2.06, n=8), and recurrence (HR 1.40, 95% CI: 1.32, 1.48, n=8) compared to non-diabetics. No statistically significant risk change for all-cause mortality, cancer specific mortality, disease progression, and recurrence was found for overweight patients. However, obese individuals were at higher risk for disease progression (HR 1.88, 95% CI: 1.41, 2.50, n=3) and recurrence (HR 1.60, 95% CI: 1.06, 2.40, n=7) compared to normal BMI patients.

CONCLUSIONS

These findings suggest that diabetes and excess body weight negatively influences bladder cancer prognosis and outcome. The increased risk of mortality due to diabetes was similar to that in the general population. Since retrospective studies are potentially susceptible to bias, future prospective studies on this subject are required.

Determining the Impact of a Cancer Diagnosis on Diabetes Management: A Systematic Literature Review

OBJECTIVES

Cancer patients with comorbid diabetes have a 50% increased risk of all-cause mortality compared with cancer patients without diabetes. Less attention to diabetes management (glucose control, medication adherence, and diabetes self-management behaviors) during active cancer treatment is hypothesized as an explanation for worse outcomes among diabetic cancer patients. The objective of this systematic review is to determine and quantify how a cancer diagnosis impacts diabetes management.

METHODS

Quantitative and qualitative studies evaluating diabetes management among patients were identified by searching 4 databases: MEDLINE, EMBASE, The Cochrane Library, and Web of Science. Two independent reviewers extracted data and summarized results from eligible studies. Study quality was formally assessed.

RESULTS

Thirty-six studies met all inclusion criteria. We observed heterogeneity across studies in terms of study design, sample size, cancer site, type of diabetes management evaluated, and quality. Numerous articles discussed that overall, glucose control, medication adherence, and diabetes self-management behaviors declined following a cancer diagnosis. However, findings were inconsistent across studies.

CONCLUSIONS

Although the effects of a cancer diagnosis on diabetes management are mixed, when results across studies were synthesized together, diabetes management appeared to generally decline after a cancer diagnosis. Declines in diabetes management seem to be primarily due to shifts in the priority of care from diabetes management to cancer. A next critical step in this line of work is to identify patient and provider level predictors of better or worse diabetes management to design and test interventions aimed at improving effective diabetes management for cancer patients.

The association between metabolic syndrome and bladder cancer susceptibility and prognosis: an updated comprehensive evidence synthesis of 95 observational studies involving 97,795,299 subjects

Background

The association between metabolic syndrome (MS) and bladder cancer (BC) was not fully investigated, and most primary studies and pooled analyses were only focused on certain specific components.

Objective

To further investigate this issue and obtain more precise findings, we conducted this updated evidence synthesis of published studies, which involved not only MS components but also the MS in its entirety.

Materials and methods

We searched the PubMed, EMBASE, and Web of Science databases for observational studies on the association between BC susceptibility and/or mortality, and MS and its components. We extracted data from included studies, evaluated heterogeneity, and performed meta-analytic quantitative syntheses.

Results

A total of 95 studies with 97,795,299 subjects were included in the present study. According to the results, MS significantly increased the risk of BC (risk ratio [RR]=1.11, 95% CI=1.00–1.23); diabetes significantly increased the risk of BC (RR=1.29, 95% CI=1.19–1.39) and associated with poor survival (RR=1.24, 95% CI=1.08–1.43). Excessive body weight was associated with increased susceptibility (RR=1.07, 95% CI=1.02–1.12), recurrence (RR=1.46, 95% CI=1.18–1.81), and mortality (RR=1.17, 95% CI=1.00–1.37). As indicated by cumulative meta-analysis, sample size was inadequate for the association between BC susceptibility and MS, the association between BC recurrence and excessive body weight, and the association between BC survival and diabetes. The sample size of the meta-analysis was enough to reach a stable pooled effect for other associations.

Conclusion

Diabetes and excessive body weight as components of MS are associated with increased susceptibility and poor prognosis of BC. Uncertainty remains concerning the impact of overall MS, hypertension, and dyslipidemia on BC susceptibility and prognosis, for which further investigations are needed.

Reported rates of clostridium difficile following radical cystectomy in national datasets compared to individual institutions

BACKGROUND

Clostridium difficile infection (CDI) is an important cause of hospital acquired morbidity with implications for quality of care. Radical cystectomy is a surgical procedure associated with high rates of morbidity one of which is a high rate of CDI. The rate of CDI among patients undergoing radical cystectomy may be estimated based on the reports from single institutions or by querying national databases. This study aims to compare rates of CDI reported in single institution series with rates obtained from national datasets.

METHODS

A search was conducted on PubMed and Google Scholar using the terms "cystectomy+difficile" and "cystectomy+complication." Three hundred fifty articles were screened and 46 met criteria for inclusion based on the presence of specific rates of C. difficile following radical cystectomy. In the case of articles reporting on the same database, only the article with a larger sample size was included in the pooled analysis. One study reviewing a single institution was excluded from pooled analysis because it did not relate the rate of CDI specifically with cystectomy. Multi-institutional studies were not included in pooled analysis.

RESULTS

After exclusion of repeated data and multi-institutional studies, the pooled analysis consisted of 39 studies. Thirty five articles reported rates of CDI in single institutions and 4 articles reported rates found in national databases. Studies focusing on a single institution reported an average 5.02% (standard deviation = 4.88) incidence of CDI, compared to an average of 1.92% (standard deviation = 0.22) in databases. The rate of CDI found by totaling patients and incidence of infection found that databases show a rate of 1.95%, while institutions show a rate of 4.11% (P < 0.0000001).

CONCLUSION

The rate of CDI following radical cystectomy may be underestimated in national databases. This has implications for the development of health policy and quality measures based on the rate of CDI.