Age-stratified perioperative mortality after urological surgeries

Thirty-day morbidity and mortality of elective urological surgery in patients aged 80 years and over in a UK district general hospital

Purpose:

An ageing population has led to many people aged 80 and over requiring urological surgery. There are concerns that operating on octogenarians may be fraught with higher morbidity and mortality risk. Therefore, the purpose was to study postoperative outcomes in people aged 80 years and over undergoing elective urological surgery.

Materials and methods:

We retrospectively reviewed the 30-day readmissions and deaths in patients aged 80 years and over who had elective urological surgery over a seven and half year period from February 2011 to July 2018 in a district general hospital. Surgeries were stratified into minor, intermediate and major. Our data did not include supra-major surgeries like radical cystectomy as these are done in tertiary centres. We used logistic regression to examine factors associated with readmissions and death.

Results:

A total of 1239 patients had 2201 operations. The median age was 84.1 years. Procedures on the bladder were the most common, followed by prostate surgery. A 17.9% of operations resulted in an adverse outcome (death or readmission attributable to surgery) within 30 days. There were 21 deaths, equating to 1% of all surgeries undertaken. There was a significant difference in both readmissions and deaths by American Society of Anaesthesiologists (ASA) grade. The median time to readmission from surgery was 18 (IQR 13–23) days. The highest number of readmissions occurred in the third week after surgery. A 94% of the readmissions were for a minor complication (grade I Clavien Dindo), with haematuria and urinary retention being most common.

Conclusions:

This study informs hospitals, surgeons, patient advocacy groups and insurance, that the morbidity and mortality risks of non-supra major elective urological surgery in patients aged 80 and over are not disproportionately high.

Neoadjuvant Versus Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A Microsimulation Model

BACKGROUND

Upper tract urothelial carcinoma (UTUC) is clinically understudied, and there are no definitive recommendations regarding timing of perioperative chemotherapy. The objective of this study was to compare 3 treatment pathways in UTUC: nephroureterectomy (NU) alone, neoadjuvant chemotherapy (NAC), and adjuvant chemotherapy (AC) using a microsimulation model.

PATIENTS AND METHODS

An individual-level state transition model was constructed using TreeAgePro software to compare treatment strategies for patients with newly diagnosed UTUC. The base case was that of a 70-year-old patient with a radiographically localized upper tract tumor. Primary outcome was quality-adjusted life expectancy. Secondary outcomes included crude overall survival, rates of adverse events, and bladder cancer diagnoses.

RESULTS

A total of 100,000 patients were simulated. NAC was preferred, with an estimated quality-adjusted life expectancy of 7.50 years versus 6.79 years with NU alone and 7.23 years with AC. Median crude overall survival was 123 months with NAC, 96 months with NU only, and 111 months with AC. Overall, 40.0% of patients in the AC group with invasive pathology completed chemotherapy. In the NAC group, 83.3% of patients completed chemotherapy. In the NAC group, 37.5% of patients experienced an adverse chemotherapy event compared to 15.1% of patients in the AC group. Bladder cancer recurrence rates were 64.9%, 65.9%, and 67.4% over the patient's lifetime for the NU, NAC, and AC strategies, respectively.

CONCLUSION

This study supports the increased use of NAC in UTUC until robust randomized trials are completed. The ultimate choice should be based on patient and tumor factors.

Functional capacity as a predictor of postoperative delirium in transurethral resection of prostate patients in Northeast Brazil

INTRODUCTION

Postoperative delirium (POD) is a common disorder and its frequency varies from 15% to 25% after major elective surgery. There are few data on the incidence of POD in Brazil. Here, we sought to assess the incidence of POD following transurethral resection of the prostate (TURP) and to examine precipitating and predisposing factors associated.

METHOD

We performed a prospective observational study of elderly male patients undergoing TURP (N=55) in Northeast Brazil. Information on demographic, medical, cognitive and functional characteristics were collected. The participants were followed until hospital discharge. POD was diagnosed by the Confusion Assessment Method.

RESULTS

A total of three participants (5.45%) were identified with POD. Episodes of delirium lasted 3±1 days. The study sample consisted of a healthy population. Patients with POD had longer hospital stay and more precipitating factors. The POD group showed statistically significant lower Barthel index score (p<0.001) and higher Pfeffer's Functional Activities Questionnaire scores (p<0.01).

CONCLUSION

Loss of functional capacity was associated with POD in a healthy population of elderly patients undergoing TURP.