Initial Experience with Apixaban for Extended Venous Thromboembolism Prophylaxis After Radical Cystectomy.

Patients who undergo radical cystectomy (RC) are at elevated risk of venous thromboembolism and associated morbidity and mortality. Guidelines recommend extended thromboprophylaxis (ETP), typically with heparins, but adherence is low. Outside urology, low-dose apixaban has been used for postoperative ETP with success. We describe our first experiences with low-dose apixaban for ETP after RC for bladder cancer. In our sample of 72 patients who underwent RC for cancer and subsequently received apixaban 2.5 mg twice daily for ETP, there were no symptomatic thromboembolic events and no major bleeding events. Other complication rates were in line with historical reports. Our experience with apixaban 2.5 mg twice daily for ETP after RC demonstrates safety and potential efficacy. A transition from injectable to oral thromboprophylaxis has the potential to improve adherence and patient satisfaction, while allowing the possibility of further extending prophylaxis beyond 28 d, which may be beneficial in selected patients. Further evaluation of apixaban for thromboprophylaxis in urologic cancer surgery is warranted. PATIENT SUMMARY: Home injectable heparin is used for 4 weeks after bladder removal surgery to prevent blood clots. We evaluated our use of the oral medication apixaban for prevention of blood clots after bladder removal surgery and found that none of our patients had major bleeding events or symptomatic blood clots. We conclude that there should be further evaluation of the use of oral instead of injectable medication to prevent blood clots after urology surgery.

The Significant Role of Depression in Elderly Patients with Bladder Cancer.

BACKGROUND: Considering the relatively high 5-yr survival rate (76.9%) for bladder cancer (BC), its overall prevalence will probably continue to increase. Therefore, it is important to understand the effects of BC diagnosis and management, including psychological sequelae. OBJECTIVE: To determine the prevalence of depression among elderly patients with BC and identify patient characteristics associated with depression. DESIGN SETTING AND PARTICIPANTS: Survey responses from a population-based sample of 5787 patients older than 65 yr with a history of BC were retrieved from the Surveillance, Epidemiology and End Results-Medicare Health Outcomes Survey registry, spanning 1999-2014. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome measured is the prevalence of a positive depression screen. Cancer characteristics and demographic, socioeconomic, health-related, and activities of daily living (ADL)-related data were reviewed. Univariate analysis was conducted to identify correlation between a positive depression screen and patient characteristics. Multivariate analysis was performed to identify independent predictors of depression. RESULTS AND LIMITATIONS: The prevalence of a positive depression screen was 14.0%. Poor general health (p < 0.001), impairment of ADL (p < 0.001), greater number of comorbidities (p < 0.001), and income <$30 000 (p < 0.001) were identified as correlates of depression. Univariate analysis found no association between a positive depression screen and time since the initial cancer diagnosis (p = 0.858) or cancer stage (p = 0.90). Multivariate analysis showed higher levels of education (p = 0.0097), increasing age (p = 0.0027), and marriage (p < 0.0001) were protective against the development of depression. Limitations include the lack of consideration of treatment outcomes and whether patients have active disease or only a history of cancer. CONCLUSIONS: Depression affects a substantial percentage (14%) of elderly patients with BC. Poor general health and impaired ability to complete ADL were the greatest risk factors for depression. Acknowledgment of sociodemographic factors may improve awareness of depression in patients with BC and a potential need for psychosocial support. PATIENT SUMMARY: Depression affects a significant proportion of patients with bladder cancer. Social and demographic factors influence a patient's risk of depression. Acknowledgment of these factors may improve the detection of depression and a possible need for intervention.

First reported case of penile epithelial-myoepithelial carcinoma.

Epithelial-myoepithelial carcinoma (EMC) of the penis is a rare malignant tumor which has not previously been described in the literature. Genetic associations exist in EMC that could potentially help guide early diagnosis and treatment of this type of penile cancer. This serves as the first reported case of such cancer of the penis, and highlights the indolent course it takes to presentation, and the need for an appropriate histopathologic evaluation for the correct diagnosis.

Living with Bladder Cancer: Self-reported Changes in Patients' Functional and Overall Health Status Following Diagnosis.

BACKGROUND: Bladder cancer affects life quality, overall health, and mortality negatively. The effect of bladder cancer on activities of daily living (ADLs) is not well established. OBJECTIVE: To examine the effect of bladder cancer diagnosis on ADLs, in addition to physical, mental, and overall health measures. DESIGN SETTING AND PARTICIPANTS: Using data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) registry, responses regarding ADLs and overall health were evaluated in bladder cancer patients over time. The Short Form 12 health survey responses were analyzed to determine the change in physical and mental health scores following bladder cancer diagnosis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Changes in self-reported ability to perform ADLs and health outcomes following bladder cancer diagnosis were evaluated. Chi-square statistics were used to determine whether the baseline and follow-up surveys were statistically independent for each ADL. Composites scores for physical health (PCS12) and mental health (MCS12) were compared with two-sample t test. RESULTS AND LIMITATIONS: A total of 498 patients with surveys before and after bladder cancer diagnosis were identified. An increased percentage of patients reported difficulty in all ADL tasks following bladder cancer diagnosis; this increase was statistically significant for bathing (p = 0.02) and using the toilet (p = 0.03). These patients also reported a significant decline in overall health status (p = 0.0002). A significant reduction in the mean PCS12 and mean MCS12 composite scores was observed (p < 0.0001 and p = 0.0003, respectively). CONCLUSIONS: Patients with bladder cancer report a significant decline in functional status and overall health, including both physical and mental well-being after diagnosis. Further study is needed for factors that may be most predictive of the decline in functional independence for this population. PATIENT SUMMARY: There is a decreased ability to perform daily activities following bladder cancer diagnosis, and patients report a decrease in their physical and mental health. This information can help patients and their caregivers anticipate patient needs following bladder cancer diagnosis, in addition to helping manage their expectations when making decisions regarding treatment options.

Burnout in the Urology Workforce: Voluntary Survey Results in the United States.

INTRODUCTION: Burnout among urologists is significant with studies estimating approximately 40% meet the criteria for burnout. This study sought to survey practicing urologists to identify factors associated with burnout and its implications. METHODS: A 16-question survey was created on SurveyMonkey.com and distributed to urologists by email via their American Urological Association section. Descriptive statistics and chi-square testing were used for analysis, and logistic regression was used for multivariate analysis to assess factors associated with burnout. RESULTS: There were 466 respondents of whom 460 were actively practicing. In all, 78% of respondents reported burnout with 45% reporting it as either moderate or severe. Respondents were 90% male and 41% fellowship trained. Females tended to report worse burnout with 4 times greater likelihood to report severe burnout on multivariate analysis (p=0.01). There was also a difference in reasons cited for burnout among genders. Females most often cited lack of personal time (51%) while males most often complained about insurance and regulations (62%). Initial analysis did not show a difference based on fellowship. Multivariate analysis revealed a possible protective role of fellowship training with nonfellowship trained urologists twice as likely to report moderate burnout (p=0.017). CONCLUSIONS: A large number of urologists are experiencing burnout. This affects patient interaction and planned time to retirement. Most urologists do not have interventions in place to assess or prevent/change their levels of burnout. Further investigation and intervention aimed at physician wellness need to occur to prevent the worsening of this trend.

Propranolol as an effective therapy for infantile haemangioma of the urinary bladder.

Infantile haemangiomas are one of the most common tumours in infancy, but typically present as cutaneous lesions; haemangiomas of the urinary bladder are incredibly rare. Although benign, these can sometimes ulcerate and bleed, causing haematuria in the case of bladder lesions. Propranolol is a well-documented medical therapy for cutaneous lesions, but surgical treatment dominates the literature on bladder haemangiomas. We present the case of a child with infantile haemangiomas of the urinary bladder, as well as internal and cutaneous lesions, treated with propranolol. At 6-week follow-up cystoscopy and MRI, there was a significant improvement in both bladder and internal lesions, respectively. Follow-up with dermatology 9 months after initiation of propranolol demonstrated excellent regression of the cutaneous lesions with a marked decrease in both size and prominence. This case demonstrates the potential role of propranolol in the treatment of bladder haemangiomas in lieu of more invasive surgical techniques.

Factors Affecting Missed Appointments in a Pediatric Urology Outpatient Clinic.

INTRODUCTION: Missed appointments can have an adverse effect on patient care and clinic efficiency. We hypothesized that increased fuel costs and travel distance, nonchronic health conditions, different seasons, government subsidized insurance and older age would result in higher no-show rates in our pediatric urology outpatient clinic. METHODS: We retrospectively reviewed 1,315 consecutive scheduled visits from 514 patients during 2008 to 2009. Patient arrival status was recorded, as well as demographic data, chief complaint, type of visit, the month and day of the week of the scheduled appointment, and distance traveled. The average gas price at the time of the appointment was also recorded. A logistic regression model analysis fitted by the method of generalized estimating equations was used to determine correlations of the outcome with a single independent variable. Factors that had an association with p <0.10 were then included in a multifactor logistic model fitted by the generalized estimating equation method. RESULTS: The overall rate of no-shows was 39%. On multifactor analysis the variables associated with higher rates of missed appointments included increasing patient age (p <0.01), having federal insurance (p=0.04), being uninsured (p <0.01), nonchronic conditions (p=0.03), return visits (p <0.01), Friday appointments (p=0.04) and summer appointments (p=0.05). CONCLUSIONS: No-show rates varied by multiple factors such as age, insurance status, chief complaint and new or return status. Contrary to conventional wisdom, distance traveled and gas prices were not associated with missed appointments. This pilot information may present an opportunity to improve clinic efficiency and improve patient access.