Optimizing cystectomy outcomes

Abstract

In this month’s issue of Cancer, Smith et al from the University of North Carolina at Chapel Hill present a unique patient-centered perspective and identify potential solutions for reducing complications and subsequent readmissions after radical cystectomy. Through semistructured interviews of readmitted patients, their caregivers, and health care providers, they have identified a critical lack of knowledge regarding normal and abnormal symptoms after discharge that is not mitigated by the standard preoperative education that many of us provide before a surgery of this magnitude. Radical cystectomy with pelvic lymphadenectomy and intestinal urinary diversion is the mainstay of treatment for invasive bladder cancer. It is a complex and morbid operation often performed in frail patients with significant comorbid conditions. Postoperatively, patients can experience long length of stays, high complication rates (35%-65%), and one of the highest readmission rates among surgical procedures (25%-30%). This is most often related to urinary tract infections, bowel complications such as ileus, a failure to thrive, dehydration, or wound complications. As with many other complex surgeries, a shift to perioperative management incorporating enhanced recovery after surgery (ERAS) pathways has improved some of these outcomes. According to a meta-analysis by Tyson and Chang, ERAS protocols have reduced lengths of stay, improved postoperative bowel function, and reduced some (low-grade) complications, but they have not reduced readmission rates; this confirms the findings of many published single-institution series around the world. On the heels of ERAS, an explosion of interventions to further reduce complications and prevent readmission have followed: identifying and reducing malnutrition, improving fitness through exercise, targeting mental health and anxiety, and comprehensive programs that target multiple domains (prehabilitation). Unfortunately, each of these interventions (including ERAS) entail additional information and education on top of an overload of preoperative education that Smith et al have identified as overwhelming for patients. One patient’s quotation sums it best: “It’s like drinking water from a fire hydrant.” Using a variety of statistical modeling methods on nationwide and institutional data sets, Hu et al and Krishnan et al at the University of Michigan have provided insight into the causes, timing, and associated symptoms of readmission. In summary, they found that the majority of patients (67%) were readmitted in the first 2 weeks after their discharge, with infection (51%) and a failure to thrive (36%) being the most common diagnoses. Standard clinicodemographic factors did not identify patients at risk of readmission. However, patients who experienced a complication during their initial postoperative stay and those who were discharged to a skilled nursing facility were at the highest risk for readmission. As expected, patients who reported symptoms of infection or a failure to thrive (eg, fever, poor oral intake for 2-3 days, weight loss, or vomiting) were more likely to be readmitted than those with noninfectious wound or other urinary concerns. Worrisome symptoms appeared 4 to 5 days after the discharge home. Patients who were readmitted communicated their concerns earlier during the postdischarge period (approximately 2 days after symptoms started) and used the emergency room as the primary method of first communication. A proposed follow-up schedule of an office visit on postdischarge day 4 followed by 4 phone calls on days 7, 9, 11, and 14 had the ability to detect 36% of readmissions. The type or order of patient encounters was less important than the timing of communication. This body of literature first identified the 5 W’s (who, what, why, where, and when) of readmission after radical cystectomy. The current study by Smith et al delves deeper and provides more meaningful context and an understanding of the communication characteristics (and breakdown) that result in readmission. Patients and caregivers reported a symptom list that significantly overlaps with the aforementioned conditions that lead to readmission (see Table 2 in Smith et al’s article). Despite this, they were unable to determine which required an emergent evaluation. At the core of their findings is a fundamental mismatch between the education provided (type, amount, and timing) and the ability of