Risk stratification metrics for bladder cancer: Comprehensive Geriatric Assessments

Short-term Outcome of RPVBT Combined with Chemotherapy for Patients with Single, < 3 cm, T2 Stage Bladder cancer

BACKGROUND

To investigate the survival outcome of "radical" GreenLight photoselective vaporization of bladder tumor (RPVBT) in conjunction with postoperative chemotherapy for patients with single, < 3 cm in diameter, T2 stage muscle invasive bladder cancer (MIBC).

METHODS

Thirty-eight patients with single, < 3 cm, T2 stage bladder cancer were treated with RPVBT combined with chemotherapy and were included in the RPVBT group. To compare the differences in survival outcome, 80 patients with Ta/T1 bladder cancer and 30 patients with T2 bladder cancer were included as controls. The 80 patients with Ta/T1 bladder cancer underwent GreenLight photoselective vaporization of bladder tumors(PVBT), while 30 patients with T2 bladder cancer underwent radical cystectomy (RC) combined with pelvic lymph node dissection (PLND). Tumor recurrence and death were recorded, and recurrence-free survival (RFS) and overall survival (OS) curves were plotted to compare the survival difference between the RPVBT and control groups.

RESULTS

No significant differences were observed in comorbidities or living habits between the RPVBT and control groups. Blood loss [RPVBT: 20 (IQR10, 20) vs. RC: 100 (IQR90, 150) mL] and postoperative hospital stay [RPVBT: 5.5 (IQR5, 6), vs. RC: 10 (IQR8, 12) days] in the RPVBT group were significantly lower than that in the RC group. Urinary tract infection [RPVBT: 6 (15.8%) vs. PVBT: 14 (17.5%)] and bladder irritation sign [RPVBT: 11 (28.9%) vs. PVBT: 23 (28.8%) ] were the most common short-term complications in the RPVBT group, with no statistical difference between the RPVBT and PVBT group. The median follow-up time for survival endpoints was 22 (16, 27) months for the included patients after surgery. The outcomes of tumor recurrence at 12, 24, and 36 months were 2 (5.3%), 3 (7.9%), and 5 (13.2%) patients in the RPVBT groups, 13 (16.3%) and 3 (10%) patients experienced recurrence in the PVBT and RC groups at 36 months. No significant differences were noted among the three groups (P = 0.778). Additionally, Kaplan-Meier survival analysis revealed no statistically significant differences in RFS (P = 0.791) and OS (P = 0.689) among the three groups.

CONCLUSIONS

Our findings indicate that RPVBT combined with chemotherapy is a simple and feasible treatment option with fewer complications and satisfactory survival outcomes in patients with single, < 3 cm, T2 stage bladder cancer.

Elderly and bladder cancer: The role of radical cystectomy and orthotopic urinary diversion

The incidence of bladder cancer (BC) depends on advancing age and other risk factors, significantly impacting on surgical, functional and oncological outcomes. Radical cystectomy (RC) with urinary diversion is the gold standard therapy for muscle invasive bladder cancer; however, it remains a complex surgery and requires careful analysis of risk factors in order to potentially decrease post-surgical complication rates. Age in surgery is a limiting factor that can modify surgical and oncological outcomes, and is correlated with a high rate of post-dimssion hospital readmissions. The reconstruction of the bladder with the intestine represents a crucial point of radical cystectomy and the urinary derivation (UD) is at the center of many debates. A non-continent UD seems to be the best choice in elderly patients (>75 years old), while orthotopic neobladder (ON) is poorly practiced. We reviewed the literature to identify studies reporting outcomes, complications, patient- selection criteria, and quality-of-life data on elderly patients, who underwent ON following radical cystectomy. Reviewing the literature there is no clear evidence on the use of age as an exclusion criterion. Certainly, the elderly patient with multiple comorbidities is not eligible for ON, preferring other UD or rescue therapies. A careful preoperative selection of elderly patients could greatly improve clinical, surgical and oncological outcomes, giving the chance to selected patients to receive an ON.

Role of Multiparametric-MRI in Bladder Cancer

Purpose of Review

This narrative review article aims to show the actual role of imaging, in particular MRI, and the role of VI-RADS Score, in recognition and follow-up of the tumor.

Recent Findings

A team of professionals created VI-RADS with the goal of standardizing the acquisition and interpretation of multiparametric-MRI in bladder cancer.

Summary

Bladder cancer is the most common cancer involving the urinary system. It is the fourth most common urological cancer in men and the second most frequent cancer affecting the urinary tract. Main risks factors are advanced age, male sex, and cigarette smoking. Bladder cancer ranges from unaggressive and usually non-invasive tumors that recur and commit patients to long-term invasive surveillance, to aggressive and invasive tumors with high disease-specific mortality. At the time of diagnosis, 70% of patients are experiencing non-muscle-invasive bladder cancer. Vesical imaging-reporting and data system score (VI-RADS) is a scoring system useful to standardize the approach to multiparametric-MRI interpretation, and reporting for bladder cancer.

Holistic Assessment of Quality of Life Predicts Survival in Older Patients with Bladder Cancer

OBJECTIVE

To determine if clustering methods can use a holistic assessment of health-related quality-of-life after bladder cancer diagnosis to predict survival outcomes independent of clinical characteristics. In the United States, an estimated 81,180 cases of bladder cancer will be diagnosed in 2022. We aim to help address the knowledge gap concerning the impact of patient functional status on outcomes.

MATERIALS AND METHODS

This is a cross-sectional, retrospective cohort study of patients in the End Results-Medicare Health Outcomes Survey Registry. Age and 36-Item Short Form Survey (SF-36) responses were used as K-means inputs to identify homogenous clusters of older patients with bladder cancer. We analyzed the association between the identified clusters, patient and disease characteristics, and outcomes. We used Cox proportional hazard regression to compare overall survival.

RESULTS

We identified 5 homogenous clusters that exhibited differences in patient characteristics and survival. There was no significant difference in cancer stage or surgery type among the clusters. The Cox proportional hazard regression demonstrated significant associations of cluster with gender, age, education, marital status, smoking status, type of surgery, and cancer stage on overall survival. Cluster independently predicted overall survival.

CONCLUSION

Using unsupervised machine learning, we identified clusters of patients with bladder cancer who had similar mental and physical function scores. Cluster grouping suggests that patients' mental and physical function may not be based on disease or treatment. There are significant survival differences between all clusters, demonstrating that a holistic assessment of patient-reported health-related quality-of-life has the potential to predict survival and possible modifiable risk factors in older patients with bladder cancer.

Factors Influencing Quality of Life and Functional Outcomes in Patients With Bladder Cancer

Here, we review the quality of life and functional outcomes of patients with bladder cancer after treatment and assess potential contributing factors. For current scoring systems, we highlighted the most commonly used specificity scores. In addition, we discuss the impact and bias on the quality of life of patients undergoing urinary diversion modalities, robotic surgery, perioperative rehabilitation, and bladder-preserving radiochemotherapy. Through this review, clinicians will gain better insights regarding the importance of improving patients' quality of life with the goal of restoring their patients' normal function and participating in social activities.

Future Perspectives on Prehabilitation Interventions in Cancer Surgery

OBJECTIVE

This article provides a map of key knowledge gaps regarding the evidence supporting prehabilitation and its integration with enhanced recovery after surgery (ERAS) programs. Filling this lack of knowledge with future research will further establish the effectiveness of prehabilitation.

DATA SOURCES

These are electronic databases including PubMed and CINAHL.

CONCLUSION

Future efforts must embrace the elderly frail or cognitively impaired patient with specific needs to further promote restoration of postoperative function throughout the surgical pathway. Prehabilitation should be coupled and integrated within the existent concept of the ERAS framework, to facilitate the continuous evolution of screening, assessment, and optimization of high-risk surgical patients who are at risk of not being restored to physical and psychological function after surgery, including independence.

IMPLICATIONS FOR NURSING PRACTICE

In the future, the ERAS nurse will be an essential figure of the prehabilitation program, proactively coordinating the assessment, optimization, and adjustment of perioperative comorbidity and guiding the rehabilitation process to improve patients' outcomes. These skills and characteristics will be required to provide optimal nursing care in the context of an integrated prehabilitation ERAS pathway.

From Fast-track to Enhanced Recovery after Surgery (ERAS) in Radical Cystectomy Pathways –a Nursing Perspective

Objective

The purpose of this narrative review is to summarize existing knowledge and evidence about the establishment of enhanced recovery after surgery (ERAS) pathways with emphasize on radical cystectomy (RC), and the emerging and prominent role of nursing within the ERAS pathway. The current status of implementation and adherence to ERAS protocol in RC is discussed and the impact on primary outcomes according to ERAS is summarized.

Methods

The review was conducted based on a focused search in PubMed and CINAHL.

Results

The goal of a modern RC enhanced recovery protocols (ERPs) anno 2022 is to have a positive impact on patient care from diagnosis throughout recovery with focus on the quality, rather than speed, of recovery. This may be more in alignment with the patient's needs and preferences.

Conclusions

Nursing has been in the forefront since the establishment of ERAS, and the nurse-coordinator must be skilled in evidence-based medicine and have excellent communicative competencies to support the patient journey. Implementation of ERAS have reduced hospitalization by improved minimal surgery, optimized anesthetic regimes without increasing readmission rates. It is not known which items can reduce post-operative complications. In the future, nurses should seek a more prominent and leading role during the implementation process and take responsibility for continued education of the staff. Likewise, future nursing interventions will focus on early identification of modifiable risk factors, and a deeper exploration of the patients personally needs and preferences to upcoming surgery could optimize adherence throughout the pathway, which may add to positive outcomes.

Efficacy of Pre and Rehabilitation in Radical Cystectomy on Health Related Quality of Life and Physical Function, A Systematic Review

Objective

Methods

Results

Conclusions

•

There is no significant association between pre and/ or rehabilitation interventions and global HRQoL.

•

Physical prehabilitation interventions can improve physical function before radical cystectomy.

•

Enteral nutrition reduces risk such as sarcopenia, frailty and increase benefits to the patient.

•

Pre- and postoperative stoma education is effective and impacts significantly on self-efficacy.

•

Cognitive interventions focusing on depression and anxiety should be addressed in future research.

Comparative Study of Perioperative and Oncological Outcomes Between Elderly Patients and Younger Patients Who Received Radical Cystectomy and Pelvic Lymph Node Dissection: A Single-Center Retrospective Study

PURPOSE

To compare the perioperative and survival outcomes of patients over 75 years and younger patients who received radical cystectomy.

PATIENTS AND METHODS

A total of 119 patients aged ≥75 years and 488 patients aged <75 years were enrolled. All patients underwent radical cystectomy with pelvic lymph node dissection. Clinical characteristics and perioperative outcomes were compared between the two groups. Overall survival and progression-free survival were analyzed by using the Kaplan-Meier method. Cox regression analysis and logistic regression analysis were used to identify the risk factors affecting the outcomes observed.

RESULTS

There was no significant difference in perioperative complications between the elderly patient group and the younger patient group (p = 0.349). The 5-year overall survival of elderly patients was lower than that of young patients (p < 0.001). Age ≥75 years was a risk factor for overall survival (HR = 1.69 [95% CI: 1.22-2.35]; p = 0.002) and progression-free survival (HR = 1.69 [95% CI: 1.14-2.50]; p = 0.008) for patients who received radical cystectomy but was not a poor risk factor for major complications (HR = 1.25 [95% CI: 0.47-3.31]; p = 0.658) after radical cystectomy. In addition, preoperative renal insufficiency was associated with a higher risk of major complications.

CONCLUSION

In our cohort, compared with younger patients, elderly patients aged ≥75 years had worse survival outcomes, but age ≥75 years was not a risk factor for major complications after radical cystectomy with pelvic lymph node dissection. Radical surgery should be encouraged for elderly patients who can tolerate aggressive treatments.

Muscle-invasive Bladder Cancer in the Elderly Patient With a Focus on Hypofractionated Radiotherapy

Muscle-invasive bladder cancer is most frequently diagnosed in older patients and the presence of multimorbidity and frailty is common. This means that many patients are unsuitable for definitive treatment with radical cystectomy/(chemo)radiotherapy and are at risk of poor survival outcomes and considerable disease-related morbidity. Screening tools for functional status may be useful to determine the most appropriate treatment for an older person and to identify patients most likely to benefit from comprehensive geriatric assessment and its targeted prehabilitation interventions. For patients unsuitable for definitive treatment, ultrahypofractionated radiotherapy schedules may provide good local control with acceptable toxicity. Short fractionated palliative radiotherapy schedules can provide effective symptom control for patients unsuitable for longer courses of treatment.

The Potential of Prehabilitation in Radical Cystectomy Pathways: Where Are We Now?

OBJECTIVE

The growing recognition of prehabilitation has caused an emerging paradigm shift in surgical cancer care and an integrated component of the cancer care continuum. This narrative review aims to update and inform the urological community of the potential of prehabilitation before radical cystectomy.

DATA SOURCES

A nonsystematic narrative review was performed through a database search in PubMed, and CINAHL using the following search terms: enhanced recovery after surgery (ERAS); Frailty; Prehabilitation and/or Rehabilitation; Physical Activity and/or exercises; Nutrition; Nutritional Care; Smoking cessation; Alcohol cessation; Prevention; Supportive Care; and combined with Radical Cystectomy.

CONCLUSION

A multimodal and multi-professional approach during the preoperative period may offer an opportunity to preserve or enhance physiological integrity and optimize surgical recovery. Studies indicate a positive effect of prehabilitation on postoperative functional capacity and earlier return to daily activities and health related quality of life. Meaningful outcomes that reflect recovery from a patient's perspective and clinical outcome measures, as well as validating metrics, are necessary to establish whether prehabilitation diminish the risk of developing long-term disability in high-risk patients.

IMPLICATIONS FOR NURSING PRACTICE

Uro-oncology nurses are at the forefront in every ERAS program and vital in screening patients ahead of surgery for common risk factors, current impairments, and limitations that can compromise baseline functional capacity. The growing movement to standardize clinical implementation of prehabilitation, indicate there is a clear need for further investigation, optimization of a multimodal approach and an open discussion between health care providers from different areas of expertise who might best support and promote these initiatives.

Organization Factors in the ERAS Bladder Cancer Pathway: The Multifarious Role of the ERAS Nurse, Why and What Is Important?

OBJECTIVE

This paper provides an overview of the multifarious role of nursing in enhanced recovery after surgery (ERAS) in advanced bladder cancer surgery with procedure-specific recommendations in radical cystectomy pathways.

DATA SOURCES

Electronic databases including PubMed and CINAHL.

CONCLUSION

The growing evidence of preoperative, perioperative, and postoperative interventions and the concept of reacting proactively in ERAS, has led to the paradigm shift in the surgical pathway with establishment of nurse-led multi-professional prehabilitation academies. Moreover, although most patients will recover in real-life at home, there is a need for a change in postoperative and discharge management. Thus, a highly skilled discharge nurse is required to secure a comprehensive, safe discharge plan adjusted to the patient's needs in close cooperation with the primary care setting, family, and survivorship clinic if needed. Limited efforts have been made to evaluate rational principles and goals for rehabilitation after radical cystectomy; an important issue with major patient and perhaps socioeconomic consequences, wherein the ERAS nurse may take the future lead.

IMPLICATION FOR NURSING PRACTICE

It has become a governmental demand in many countries to involve the patient and family in treatment decisions and care by using shared decision tools, and to educate and inform each family in concordance with the patient's needs and preferences, and the health care systems must react accordingly. However, to provide person-centeredness care within advanced surgical pathways, there remains a need for thought-leaders, strategic planners, managers, and decision-makers to anchor the process of change and stop "we do it anyway" arguments to defend organizational cultures that are not conducing the evidence-recommend practice.

[OUTCOMES OF BLADDER CANCER IN NONAGENARIANS]

(Objectives) We evaluated the chronological change in the number and proportion of elderly patients with bladder cancer. We also retrospectively investigated the clinical outcomes of bladder cancer in patients of ≥90 years of age. (Patients and methods) We evaluated the chronological change in the number and proportion of patients of ≥90 years of age who were clinically diagnosed with bladder cancer and who underwent transurethral resection of a bladder tumor (TUR-BT) at our hospital between 2008 and 2018. We also assessed the clinicopathological factors, perioperative outcomes, and clinical outcomes in bladder cancer patients of ≥90 years of age. (Results) The number and proportion of bladder cancer patients of ≥90 years of age increased with time. A total of 39 patients of ≥90 years of age underwent TUR-BT at our hospital, among whom 22 were diagnosed with primary bladder cancer. The median age was 91 years. No grade ≥III complications were observed after TUR-BT. Two out of 6 with pT1 disease underwent second TUR-BT. Two out of 7 with pT1 disease or carcinoma in situ received intravesical BCG therapy. Six deaths were observed during the study period, 2 of which were due to bladder cancer. At 1 and 3 years after TUR-BT, the overall survival rates of the 22 patients were 80.4% and 68.9%, respectively. (Conclusions) The number and proportion of elderly patients with bladder cancer increased with time. The current standard of care including second TUR-BT and intravesical BCG therapy for high-risk non-muscle invasive bladder cancer was underutilized in nonagenarians.

Frailty, geriatric assessment and prehabilitation in elderly patients undergoing urological surgery - is there a need for change of the daily clinical practice? Synthesis of the available literature

Introduction

The population of older people is heterogeneous and constantly growing. Over 50% of urological operations are performed in elderly patients. Some elderly patients present with frailty syndrome - a state of increased vulnerability to external stressors resulting in increased risk of hospitalizations, adverse treatment outcomes and death. Currently, there is no widely accepted system of qualification and preparation for surgical treatment developed specifically for elderly patients.

Material and methods

We searched Medline/Pubmed, Embase and Cochrane Libraries databases from 2000-2020 (week 5). The following medical subject headings (MeSH) terms were used to ensure the sensitivity of the searches: geriatric assessment, frailty, urology, and prehabilitation. Relevant articles were also identified through a manual search of the reference lists of potentially relevant articles.

Results

A total of 23 papers met the criteria and were included in the current study. Screening for frailty seems to be promising in predicting adverse outcomes, but frail patients should undergo detailed geriatric assessment (GA) which may indicate a need for preoperative intervention which can be unavailable during the hospitalization. The concept of prehabilitation is becoming increasingly discussed in thoracic and abdominal surgery, but only a few studies are available in the field of urology.

Conclusions

Geriatric assessment seems to be a valuable tool for urologists in daily clinical practice. A proper form of prehabilitation may provide enhanced recovery after surgery.