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.

Does treatment approach for small renal masses affect survival in patients 70 years old?

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Background: With the advent of modern imaging techniques small renal masses are being diagnosed more frequently. Many of these masses are benign, and those that are malignant are often low grade and rarely affect the survival. Surveillance is more commonly being advocated as an option for these masses. This study elucidates survival following different treatment approaches. Methods: SEER 18 data from 2004-13 identified 10,477 patients 70 years and older with renal cell carcinoma and tumors greater than or equal to 3 cm. Exclusion criteria included multiple primaries, distant metastasis and node positive disease. Data was collected on demographics, treatment patterns, overall survival and cancer specific survival. Kaplan-Meier analysis and Cox regression models were used to compare outcomes. Results: After exclusion 5084 patients remained. The mean age was 76.4 years. The mean tumor size was 2.3cm. Tumor laterality was right in 2610, left in 2467, bilateral in 2 and unspecified in 5. Racial analysis identified 84% of patients as white, 9% as black and 7% as other. Gender split was 51% male. Treatment methods included 791 ablations and 3324 surgical resections (radical or partial nephrectomy). The remaining 969 patients did not have treatment (surveillance). Survival was measured at 60 and 118 months. The overall survival was 75% and 54% respectively for ALL patients, 82% and 62% for ablation, 42% and 19% for surveillance and 82% and 62% for resection. Cancer specific survival was 97% and 96% for ablation, 83% and 74% for surveillance and 96% and 94% for resection. Surgical resection or ablation significantly improved survival at 5 and 10 years (p = < 0.0001). Multivariate analysis showed survival was affected by age and year of diagnosis, but not by tumor size. Conclusions: The significant difference in overall survival suggests appropriate selection of patients for surveillance based on medical comorbidities. Treatment with curative intent improves survival in patients with greater than or equal to 3 cm renal masses, even in patients 70 years and older, and must be offered to patients without significant comorbidities.

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.

A review of the stage, recurrence, treatment, and outcomes in penile cancer at a tertiary referral center

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Background: This was a retrospective review analyzing the epidemiological and pathological association of penile cancer as well as the clinical results in patients managed at the University of Missouri Hospital and Clinics (UMHC) and Harry S Truman VA. Methods: Records were obtained of patients with a pathological diagnosis of penile cancer from 2001−2014 at UMHC and at the Harry S Truman VA. These charts were retrospectively reviewed. Information regarding patient demographics, pathology, treatment, and outcomes were recorded. Results: Forty-four patients with a pathologic diagnosis of penile cancer were identified. Mean age at diagnosis was 64 with 41 being White, 2 unknown, 1 Black, and 1 Hispanic. Seventy-two percent had tobacco exposure, with 66% of all patients having smoked greater than 10 years. HPV was present in 20%. Circumcision status was reviewed showing overall 61% were circumcised, with 4.5% being circumcised before the age of 18. Premalignant lesions were identified in 36% of the patients, with condyloma acuminate being the most common followed by Lichen Sclerosus and severe dysplasia. The vast majority (98%) of penile cancers were squamous cell carcinoma (SCCa), with only one patient having a Buschke−Lowenstein tumor. Invasive SCCa without nodal involvement was the most common pathologic stage (41%) followed by nodal positive disease (36%) and CIS (23%). Of those with node positive disease, 56% were dead less than 5 years after nodal involvement. Ninety-nine procedures with curative intent were performed, with a mean of 2.25 procedure per patient. However, only 79 of the procedures led to a sustainable cure. Of those patients with metastatic disease 13.6% underwent chemotherapy and 9.1% received radiation. Conclusions: Our study reflects the trends in stage, recurrence, treatment, and outcomes at two large centers for penile cancer. In this patient group the majority had exposure to tobacco and almost exclusively had SCCa. A durable cure may require multiple operative interventions. Nodal involvement carries a poor prognosis and high risk of death in less than 5 years once diagnosed.