Testing of a risk-stratified patient decision aid to facilitate shared decision-making for extended postoperative thromboprophylaxis after major abdominal surgery for cancer.

BACKGROUND: Use of extended pharmacologic thromboprophylaxis after major abdominopelvic cancer surgery should depend on best-available scientific evidence and patients' informed preferences. We developed a risk-stratified patient decision aid to facilitate shared decision-making and sought to evaluate its effect on decision-making quality regarding use of extended thromboprophylaxis. METHODS: We enrolled patients undergoing major abdominopelvic cancer surgery at an academic tertiary care centre in this pre-post study. We evaluated change in decisional conflict, readiness to decide, decision-making confidence, and change in patient knowledge. Participants were provided the appropriate risk-stratified decision aid (according to their Caprini score) in either the preoperative or postoperative setting. A sample size calculation determined that we required 17 patients to demonstrate whether the decision aid meaningfully reduced decisional conflict. We used the Wilcoxon matched-pairs signed ranks test for interval scaled measures. RESULTS: We included 17 participants. The decision aid significantly reduced decisional conflict (median decisional conflict score 2.37 [range 1.00-3.81] v. 1.3 [range 1.00-3.25], p < 0.01). With the decision aid, participants had high confidence (median 86.4 [range 15.91-100]) and felt highly prepared to make a decision (median 90 [range 55-100]). Median knowledge scores increased from 50% (range 0%-100%) to 75% (range 25%-100%). CONCLUSION: Our risk-stratified, evidence-based decision aid on extended thromboprophylaxis after major abdominopelvic surgery significantly improved decision-making quality. Further research is needed to evaluate the usability and feasibility of this decision aid in the perioperative setting.

Diagnosis, Management, and Follow-Up of the Incidentally Discovered Adrenal Mass: CUA Guideline Endorsed by the AUA.

PURPOSE: Incidental adrenal masses are common and require a multidisciplinary approach to evaluation and management that includes family physicians, urologists, endocrinologists, and radiologists. The purpose of this guideline is to provide an updated approach to the diagnosis, management, and follow-up of adrenal incidentalomas, with a special focus on the areas of discrepancy/controversy existing among the published guidelines from other associations. MATERIALS AND METHODS: This guideline was developed by the Canadian Urological Association (CUA) through a working group comprised of urologists, endocrinologists, and radiologists and subsequently endorsed by the American Urological Association (AUA). A systematic review utilizing the GRADE approach served as the basis for evidence-based recommendations with consensus statements provided in the absence of evidence. For each guideline statement, the strength of recommendation was reported as weak or strong, and the quality of evidence was evaluated as low, medium, or high. RESULTS: The CUA working group provided evidence- and consensus-based recommendations based on an updated systematic review and subject matter expertise. Important updates on evidence-based radiological evaluation and hormonal testing are included in the recommendations. This guideline clarifies which patients may benefit from surgery and highlights where short term surveillance is appropriate. CONCLUSION: Incidentally detected adrenal masses require a comprehensive assessment of hormonal function and oncologic risk. This guideline provides a contemporary approach to the appropriate clinical, radiographic, and endocrine assessments required for the evaluation, management, and follow-up of patients with such lesions.

Predicting the recurrence risk of renal cell carcinoma after nephrectomy: potential role of CT-radiomics for adjuvant treatment decisions.

OBJECTIVES: Previous trial results suggest that only a small number of patients with non-metastatic renal cell carcinoma (RCC) benefit from adjuvant therapy. We assessed whether the addition of CT-based radiomics to established clinico-pathological biomarkers improves recurrence risk prediction for adjuvant treatment decisions. METHODS: This retrospective study included 453 patients with non-metastatic RCC undergoing nephrectomy. Cox models were trained to predict disease-free survival (DFS) using post-operative biomarkers (age, stage, tumor size and grade) with and without radiomics selected on pre-operative CT. Models were assessed using C-statistic, calibration, and decision curve analyses (repeated tenfold cross-validation). RESULTS: At multivariable analysis, one of four selected radiomic features (wavelet-HHL_glcm_ClusterShade) was prognostic for DFS with an adjusted hazard ratio (HR) of 0.44 (p = 0.02), along with American Joint Committee on Cancer (AJCC) stage group (III versus I, HR 2.90; p = 0.002), grade 4 (versus grade 1, HR 8.90; p = 0.001), age (per 10 years HR 1.29; p = 0.03), and tumor size (per cm HR 1.13; p = 0.003). The discriminatory ability of the combined clinical-radiomic model (C = 0.80) was superior to that of the clinical model (C = 0.78; p < 0.001). Decision curve analysis revealed a net benefit of the combined model when used for adjuvant treatment decisions. At an exemplary threshold probability of ≥ 25% for disease recurrence within 5 years, using the combined versus the clinical model was equivalent to treating 9 additional patients (per 1000 assessed) who would recur without treatment (i.e., true-positive predictions) with no increase in false-positive predictions. CONCLUSION: Adding CT-based radiomic features to established prognostic biomarkers improved post-operative recurrence risk assessment in our internal validation study and may help guide decisions regarding adjuvant therapy. KEY POINTS: In patients with non-metastatic renal cell carcinoma undergoing nephrectomy, CT-based radiomics combined with established clinical and pathological biomarkers improved recurrence risk assessment. Compared to a clinical base model, the combined risk model enabled superior clinical utility if used to guide decisions on adjuvant treatment.

Hypothermia During Partial Nephrectomy for Patients with Renal Tumors: A Randomized Controlled Trial.

PURPOSE: Surgeons induce renal hypothermia during partial nephrectomy to preserve kidney function, without strong evidence of benefit. This trial examined the effectiveness and safety of renal hypothermia during partial nephrectomy. MATERIALS AND METHODS: We conducted a parallel randomized controlled trial of hypothermia versus no hypothermia (control group) during partial nephrectomy at 6 academic hospitals. Eligible patients had a planned open partial nephrectomy for the treatment of a renal tumor. During surgery, after clamping the renal hilum, patients were randomized to the intervention or control arm in a 1:1 ratio using permuted blocks of variable lengths (2 and 4), stratified by institution, using a computer-based program. Surgeons and study coordinators were masked to treatment allocation until the renal hilum was clamped. Overall glomerular filtration rates were determined before, and 1-year after, surgery. The primary outcome was measured glomerular filtration rate (mGFR) assessed by the plasma clearance of 99mTc-DTPA. The trial (NCT01529658) was designed with 90% power to detect a minimal clinically important difference in mGFR of 10 ml/minute/1.73 m2 at a 5% significance level. RESULTS: Of the 184 patients randomized, hypothermia and control patients had similar baseline mean mGFR (87.1 vs 81.0 ml/minute/1.73 m2). One hundred and sixty-one (79 hypothermia, 82 control) were alive with primary outcome data 1 year after surgery. The change in mGFR 1 year after surgery was -6.6 ml/minute/1.73 m2 in the hypothermia group and -7.8 ml/minute/1.73 m2 in the control group (mean difference 1.2 ml/minute/1.73 m2, 95% CI -3.3 to 5.6). Operated-kidney change in mGFR was similar between groups (-5.8 vs -6.3 ml/minute/1.73 m2; mean difference 0.5 ml/minute/1.73 m2, 95% CI -2.9 to 3.8). No clinically significant difference in the mGFR was observed when patients were stratified by pre-planned subgroups. Renal hypothermia did not impact the secondary outcomes of surgical complications and patient reported quality of life. CONCLUSIONS: Renal hypothermia during partial nephrectomy does not preserve kidney function in patients with normal or mildly impaired renal function.

Gas in the inferior vena cava from severe emphysematous pyelonephritis.

Emphysematous pyelonephritis is a life-threatening, urologic emergency. We present the case of a 54-yearold female who was found to have a large volume of air in her renal vein and inferior vena cava from severe emphysematous pyelonephritis. In this case report, the medical and operative management of this patient are reviewed, and the literature on the management of emphysematous pyelonephritis is summarized.

Thromboprophylaxis practice patterns and beliefs among physicians treating patients with abdominopelvic cancers at a Canadian centre.

Background: There is inadequate high-quality evidence on thromboprophylaxis for patients undergoing surgery for abdominopelvic cancer. We surveyed physicians who treat patients with abdominopelvic cancer to determine current thromboprophylaxis practice patterns and to determine where research is needed. Methods: We created an online survey with questions on thromboprophylaxis topics, including type of thromboprophylaxis used, timing of initial thromboprophylaxis dose, use of thromboprophylaxis during chemotherapy, use of extended-duration thromboprophylaxis and areas for future research. The survey questions were reviewed by external content experts to ensure they were appropriate and relevant. Surgeons, thrombosis experts and medical oncologists who manage patients with abdominopelvic cancers at 1 large Canadian academic centre were invited to complete the survey between January and April 2019. Results: Of the 57 physicians invited, 42 (74%) completed the survey, including 27 surgeons (response rate 79%), 9 thrombosis experts (response rate 75%) and 6 medical oncologists (response rate 55%). Most surgeons (22 [82%]) reported using mechanical thromboprophylaxis, whereas only 1 thrombosis expert (11%) recommended mechanical thromboprophylaxis. There was substantial variability in the timing of the initial dose of thromboprophylaxis, with 9/10 urologists (90%) and all 7 general surgeons giving the first dose intraoperatively, and three-quarters of thoracic surgeons (3/4 [75%]), gynecologists (3/4 [75%]) and thrombosis experts (7/9 [78%]) starting thromboprophylaxis after surgery. All medical oncologists believed chemotherapy increases the risk of venous thromboembolism, but 4 (67%) reported that they do not routinely prescribe thromboprophylaxis owing to bleeding concerns. Most respondents (35/38 [92%]) felt there was a need for more research on thromboprophylaxis and indicated willingness to participate in future clinical trials. Conclusion: Variability exists in contemporary thromboprophylaxis practice patterns among physicians treating patients with abdominopelvic cancer. Future research is needed to standardize care and improve outcomes for patients.

Contexte: On manque de données de qualité élevée sur la thromboprophylaxie chez les patients traités en chirurgie pour un cancer abdomino-pelvien. Nous avons sondé des médecins traitant ces patients afin de déterminer les tendances actuelles relatives à cette pratique et pour cerner les besoins en recherche. Méthodes: Nous avons créé un sondage en ligne sur la thromboprophylaxie, comprenant des questions sur le type utilisé, le moment d'administration de la dose initiale, le recours durant la chimiothérapie, l'utilisation prolongée et les domaines de recherche à explorer. Les questions ont été validées par des experts de contenu externes, qui ont veillé à ce qu'elles soient appropriées et pertinentes. Des chirurgiens, des experts en thrombose et des oncologues qui s'occupent de patients atteints de cancers abdomino-pelviens dans un grand centre hospitalier universitaire canadien ont été invités à remplir le sondage entrer janvier et avril 2019. Résultats: Des 57 médecins sollicités, 42 (74%) ont répondu au sondage, dont 27 chirurgiens (taux de réponse de 79%), 9 experts en thrombose (taux de réponse de 75 %) et 6 oncologues (taux de réponse de 55 %). La majorité des chirurgiens (22 [82 %]) recouraient à la thromboprophylaxie mécanique, alors qu'un seul expert en thrombose (11 %) recommandait cette pratique. Le moment d'administration de la dose initiale variait considérablement: 9 urologues sur 10 (90%) et chacun des 7 chirurgiens généralistes administraient la première dose durant l'opération, alors que les trois quarts des chirurgiens thoraciques (3/4 [75%]), des gynécologues (3/4 [75%]) et des experts en thrombose (7/9 [78%]) commençaient la thromboprophylaxie après l'intervention. Tous les oncologues étaient d'avis que la chimiothérapie augmentait le risque de thromboembolie veineuse, mais 4 (67%) ont indiqué qu'ils ne prescrivaient pas d'emblée de thromboprophylaxie en raison des risques de saignements. La plupart des répondants (35/38 [92%]) considéraient qu'il faudrait étudier davantage la thromboprophylaxie et ont indiqué leur volonté de participer à d'éventuels essais cliniques. Conclusion: À l'heure actuelle, les pratiques liées à la thromboprophylaxie varient chez les médecins traitant des patients atteints de cancers abdomino-pelviens. Il faudra mener d'autres études pour normaliser la prestation des soins et améliorer les résultats pour les patients.

Development and Acceptability Testing of a Patient Decision Aid for Urinary Diversion with Radical Cystectomy.

PURPOSE: The choice of urinary diversion at cystectomy is a life altering decision. Patient decision aids are clinical tools that promote shared decision making by providing information about management options and helping patients communicate their values. We sought to develop and evaluate a patient decision aid for individuals undergoing cystectomy with urinary diversion. MATERIALS AND METHODS: We used the IPDAS (International Patient Decision Aids Standards) to guide a systematic development process. A literature review was performed to determine urinary diversion options and the incidence of outcomes. We created a prototype using the Ottawa Decision Support Framework. A 10-question survey was used to assess patient decision aid acceptability among patients, allied health professionals and urologists. The primary outcome was acceptability of the patient decision aid. RESULTS: Ileal conduit and orthotopic neobladder were included as primary urinary diversion options because they had the most evidence and are most commonly performed. Continent cutaneous diversion was identified as an alternative option. Outcomes specific to ileal conduit were stomal stenosis and parastomal hernia. Outcomes specific to neobladder were daytime and nighttime urinary incontinence and urinary retention. Acceptability testing was completed by 8 urologists, 9 patients and 1 advanced practice nurse. Of the respondents 94% reported that the language was appropriate, 94% reported that the length was adequate and 83% reported that option presentation was balanced. The patient decision aid met all 6 IPDAS defining criteria, all 6 certification criteria and 21 of 23 quality criteria. CONCLUSIONS: We created a novel patient decision aid to improve the quality of decisions made by patients when deciding among urinary diversion options. Effectiveness testing will be performed prospectively.

Variations in blood glucose levels following gastrostomy tube insertion in a paediatric population.

BACKGROUND: Radiologic insertion of a gastrostomy or gastrojejunostomy tube is a common procedure in children. Glucagon is used to create gastric hypotonia, permitting gastric distension and facilitating percutaneous puncture. Glucagon can cause hyperglycaemia and potentially rebound hypoglycaemia. The safety of glucagon and incidence of hypoglycaemia has not been studied following gastrostomy or gastrojejunostomy tube insertion. OBJECTIVE: To determine variations in blood glucose in children post gastrostomy or gastrojejunostomy tube insertion. Secondarily, to determine the frequency of hypoglycaemia and hyperglycaemia in children who did or did not receive glucagon. MATERIALS AND METHODS: This is a retrospective observational study of 210 children undergoing percutaneous gastrostomy or gastrojejunostomy tube insertion over a 2-year period. We studied the children's clinical and laboratory parameters. Abnormal blood glucose levels were defined according to age-established norms. We used descriptive statistics and ANOVA. RESULTS: We analysed 210 children with recorded blood glucose levels. More than 50% of the children were less than the third percentile for weight. In the glucagon group (n = 187) hyperglycaemia occurred in 82.3% and hypoglycaemia in 2.7% (n = 5). In the no glucagon group (n = 23), hyperglycaemia occurred in 43.5% and there were no cases of hypoglycaemia. The peak blood glucose occurred within 2 h, with normalization by 6 h post-procedure. Five children became hypoglycaemic, all received glucagon; 4/5 had weights <3rd percentile. Logistic regression analysis revealed no factors significantly associated with hypoglycaemia. CONCLUSION: Greatest blood glucose variability occurs between 1 h and 3 h post-procedure. Hyperglycaemia is common and more severe with glucagon, and hypoglycaemia rarely occurs. These findings have assisted in developing clinical guidelines for post-percutaneous gastrostomy/gastrojejunostomy tube insertion.

Fixed-effect Versus Random-effects Models for Meta-analyses: Random-effects Models.

Random-effects models can account for variability both within and between studies. This makes them suitable for meta-analyses in surgery, where there is often significant heterogeneity between studies or heterogeneity owing to intrinsic differences attributable to patient or population factors.

A Matched Analysis of Active Surveillance Versus Nephrectomy for T1a Small Renal Masses.

While patients with a small renal mass (SRM) on active surveillance (AS) experience excellent metastasis-free survival (MFS) and cancer-specific survival (CSS), differences in overall survival (OS) observed may be explained by selection of older/comorbid patients for AS. Few studies have evaluated AS versus primary intervention in clinically balanced groups. We identified patients aged 55-75 yr with an SRM (≤4 cm, T1a) in our institutional database (2000-2020). Patients from AS and nephrectomy subgroups were matched exactly for age, sex, Eastern Cooperative Oncology Group (ECOG) performance status, biopsy status, and histology. The primary outcomes were OS and an event-free survival (EFS) composite that included OS, CSS, MFS, progression, or systemic therapy, which we tested in Cox proportional-hazards models. We identified 377 patients (205 AS, 172 nephrectomy). The cohort was balanced after matching (n = 110; mean age 64 yr, 77% male, and 75% ECOG score 0). In each arm, 47% were biopsied (predominantly clear-cell histology). The predicted 5-yr OS was 96% for the nephrectomy group and 95% for the AS group (hazard ratio for nephrectomy vs AS [HR] 0.83, 95% confidence interval [CI] 0.13-5.32; p = 0.8), with corresponding 5-yr EFS rates of 93% and 96% (HR 1.88, 95% CI 0.35-10.15; p = 0.5). Among SRM cases well matched for age and overall health status, we observed higher 5-yr OS and EFS rates for AS than previously reported; the rates were not significantly different from those after nephrectomy. The matched characteristics of our population are similar to those for treatment arms in contemporary cohorts and the results support the safety of AS in younger, healthier patients. PATIENT SUMMARY: While it has been shown that active surveillance for small kidney tumors is safe in older and more frail patients, its safety in younger, healthier patients has not been confirmed. We compared outcomes for patients aged 55-75 yr who were managed with surgery or active surveillance, and were similar in age and overall health. The probability of death after 5 years was low overall and not significantly different between the groups, suggesting that active surveillance is safe in routine clinical practice.

The Importance of Repeat Imaging Prior to Treatment Decision-making in Testicular Cancer: Commentary From the Inaugural Global Society of Rare Genitourinary Tumors Summit.

Testicular cancer is a rare cancer that often affects young and otherwise healthy patients. Imaging plays a critical role in the staging and surveillance of patients with testicular cancer. Indeterminate findings on staging or surveillance imaging, can lead to challenging management decisions for clinicians and patients. In this article, we review the importance of short-interval, repeat imaging for several scenarios faced by patients with testicular cancer and their clinicians. The challenging scenarios and recommendations provided in this article summarize the discussion from the inaugural Global Society of Rare Genitourinary Tumors (GSRGT) Summit held on December 11-12, 2020.

Surgeon-level versus hospital-level quality variance in kidney cancer surgery.

PURPOSE: To determine whether variance in kidney cancer surgery quality indicators (QIs) is most impacted by surgeon-level or hospital-level factors in order to inform quality improvement initiatives. MATERIALS AND METHODS: The ICES and Veterans Affairs (VA) databases were queried for patients undergoing surgery for localized kidney cancer. Kidney cancer surgery QIs were defined within each cohort. Quality of care was benchmarked at a surgeon- vs. hospital-level to identify statistical outliers, using available clinicopathological data to adjust for differences in case-mix. Variance between surgeons and hospitals was calculated for each QI using a random-effects model. RESULTS: The QI with the greatest amount of variance explained by hospital and surgeon-level factors was proportion of cases performed with minimally invasive surgery (MIS). The majority of this variance was due to surgeon-level factors for both the VA and ICES cohorts. The proportion of cases performed using an MIS approach was also the QI with the greatest number of outlier hospitals and surgeons compared to the average performance. The proportion of partial nephrectomies performed for patients at risk of chronic kidney disease was the QI with the greatest amount of variance due to hospital-level factors for the ICES cohort. CONCLUSIONS: The proportion of localized kidney cancer cases performed using an MIS approach is the QI requiring the greatest attention. Quality improvement initiatives should focus on surgeon-level factors to increase the number of MIS cases being performed for patients with localized renal masses.

Optimizing the management of patients with small renal masses in a Canadian context: A Markov decision-analysis model.

INTRODUCTION: The management of patients with a small renal mass (SRM) varies significantly. The objective of this study was to determine which initial management strategy resulted in the greatest quality-adjusted life months (QALM) for an index patient with a SRM. METHODS: A Markov decision analysis was used to determine the effect of 1) treating patients with a partial nephrectomy (PN); 2) active surveillance (AS); and 3) renal mass biopsy on QALM over a 10-year horizon. All relevant health states were modelled. Biopsy sensitivity and specificity were modelled assuming an 80% prevalence of cancer using procedural pathology as the gold standard. Health state utilities were obtained from the Tufts Medical Centre Cost-Effective Analysis Registry. Deterministic sensitivity analyses were used to test key assumptions. RESULTS: Over a 10-year time horizon for a 70-year-old male with a 2 cm SRM, the biopsy strategy resulted in 38.07 QALM, whereas treating all patients with PN resulted in 37.69 QALM and AS in 36.25 QALM. The model was most sensitive to the probability that a patient would remain alive at baseline. Biopsy was the preferred strategy when sensitivity was greater than 77%. As the underlying probability of cancer increased, the threshold of renal mass biopsy sensitivity to still favor biopsy increased. CONCLUSIONS: Renal mass biopsy is the preferred initial management strategy for an index patient with a SRM to optimize QALM. When the probability of cancer is high, centers should aim for a sensitivity of at least 77% in order to consider a biopsy as the first strategy.

Extended-duration thromboprophylaxis for abdominopelvic surgery: Development and evaluation of a risk-stratified patient decision aid to facilitate shared decision making.

Background: Extended-duration thromboprophylaxis is used to decrease risk of venous thromboembolism (VTE) after surgery but may increase the risk of bleeding. The decision to complete a course of extended-duration thromboprophylaxis can be challenging. Objective: The objective of this study was to develop an acceptable patient decision aid (PtDA) to facilitate shared decision making for the use of extended-duration thromboprophylaxis following major abdominal surgery. Methods: An evidence-based, risk-stratified PtDA was created. The evidence on benefits and harms of a 28-day postoperative course of low-molecular-weight heparin (LMWH) versus in-hospital prophylaxis only were synthesized. Outcomes included minor bleeding, major bleeding, clinically significant VTE, and fatal VTE. Risks were calculated and reported by Caprini score. Alpha testing of the PtDA draft with various stakeholders was performed using a 10-question survey to assess acceptability of the PtDA with patients, thrombosis experts, and surgeons. The primary outcome was the acceptability of the PtDA. Results: Acceptability testing was performed with 11 patients, 11 thrombosis experts, and 11 surgeons. Most responders felt the language on the PtDA was easy to follow (28/33, 85%), and that the information was well balanced between management options (9/11 [82%] patients; 17/21 [80%] clinicians). Most patients (9/11, 82%) and clinicians (18/22, 82%) believed it would be a useful clinical tool, and were satisfied with the overall quality of the PtDA (27/33, 82%). Conclusions: A risk-stratified, evidence-based PtDA was created to facilitate shared decision making for the use of extended-duration LMWH following major abdominal surgery. This clinical tool was acceptable with patients and physicians and is available at https://decisionaid.ohri.ca/decaids.html.

Development, implementation, and uptake of a novel Canadian Resident Matching Service (CaRMS) residency recruitment committee strategy in the era of COVID-19.

INTRODUCTION: Given restrictions on electives outside of medical students' home institutions during the COVID-19 pandemic, the objective of this study was to create a novel recruitment strategy for the University of Ottawa's (uOttawa) urology residency program. METHODS: A steering committee was formed and created a three-part recruitment strategy that included a new uOttawa urology website, a residency program social media campaign (Twitter and Instagram), and a virtual open house (VOH). Descriptive data from the website and Instagram and Twitter accounts were collected. Attendees of the VOH completed a mixed-methods survey, which collected quantitative and qualitive responses assessing aspects of the VOH and virtual resource use. RESULTS: From August 1 to December 31, 2020, the uOttawa urology website had 1707 visits. The Twitter account had a total of 29 000 views with 1000-5000 views per tweet. Thirty-one candidates attended the VOH. Survey responders reported that the most frequently used resources to gain knowledge of the program were the website (81%) and Twitter account (71%). The most helpful and informative resources were the uOttawa urology website, the VOH, and direct conversations with residents arranged through the website. Despite not having completed an elective, 26 students (84%) felt they had an understanding of what it might feel like to train in the program. Suggestions by students for future initiatives included one-on-one virtual meetings, another VOH, and more information on selection processes. CONCLUSIONS: A multifaceted, virtual recruitment strategy can be implemented to improve candidate understanding and engagement with residency programs while visiting elective opportunities remain limited.

Venous thromboembolism risk in patients receiving neoadjuvant chemotherapy for bladder cancer.

INTRODUCTION: There is limited evidence to inform thromboprophylaxis use for patients receiving neoadjuvant chemotherapy prior to surgery in bladder cancer. We sought to determine the incidence of venous thromboembolism (VTE) in patients receiving neoadjuvant chemotherapy and cystectomy. We also assessed if the Khorana score was associated with VTE risk. METHODS: A retrospective cohort study was performed on consecutive patients who received a radical cystectomy for bladder cancer at The Ottawa Hospital between January 2016 and August 2020. Demographic information, chemotherapy data, operative characteristics, VTE and bleeding outcomes were collected from the start of treatment to 90 days postoperative. A Khorana score was calculated for each patient who received neoadjuvant chemotherapy. The primary outcome for this study was the incidence of VTE from the time the patient started treatment with neoadjuvant chemotherapy until 90 days post-cystectomy. Secondary outcomes included risk factors for VTE during neoadjuvant chemotherapy. RESULTS: Among 181 radical cystectomy cases during the study period, 123 had muscle-invasive disease and 72 (39.8%) received neoadjuvant chemotherapy. Eighteen (25.0%) patients who received neoadjuvant chemotherapy and radical cystectomy developed a VTE from the start of chemotherapy to 90 days postoperative. Thirteen of the 18 VTEs (72%) occurred while the patient was receiving chemotherapy. In multivariable analysis, the only factor associated with a significantly increased risk of VTE was treatment with neoadjuvant chemotherapy (Relative risk (RR) 3.05, 95% confidence interval [CI] 1.16-8.02; P = 0.02). A higher Khorana score was not associated with an increased risk of VTE in patients who received neoadjuvant chemotherapy (RR = 0.33, 95% CI 0.08-1.28, P = 0.11). One (1.4%) patient had a major bleeding event during neoadjuvant chemotherapy. CONCLUSIONS: Patients receiving neoadjuvant chemotherapy and radical cystectomy are at very high-risk of VTE. Prospective studies that assess the benefits and harms of pharmacologic thromboprophylaxis in this population are needed.

A survey of physician perception and practices regarding pharmacological thromboprophylaxis during chemotherapy for bladder cancer.

INTRODUCTION: Patients with advanced bladder cancer receiving chemotherapy have a high risk of venous thromboembolism (VTE); however, we hypothesized these patients were not routinely offered thromboprophylaxis. The objective of this study was to characterize practice patterns and perceptions of Canadian urologic and medical oncologists, and to identify research needs regarding thromboprophylaxis for patients with bladder cancer. METHODS: An online survey was distributed to Canadian urologic and medical oncologists who manage advanced bladder cancer. The survey explored physician opinions regarding VTE rates, risk stratification scores, thromboprophylaxis use in different treatment settings, and interest in clinical trials. RESULTS: Seventy physicians were invited and 36 (51%) completed the survey, including 20 (56%) urologic oncologists and 16 (44%) medical oncologists. Most respondents (35; 97%) believed that exposure to platinum chemotherapy increases VTE risk. For patients receiving neoadjuvant chemotherapy, 34 (94%) respondents estimated the risk of VTE to be 10% or higher, yet 25 (69%) indicated they do not routinely recommend thromboprophylaxis. Physicians frequently (10; 40%) defer the decision to another physician, while eight (32%) believe there is not enough evidence to guide best management. Similar responses were obtained for metastatic patients. Almost all (94%) respondents were interested in participating in a thromboprophylaxis trial for patients with bladder cancer. CONCLUSIONS: Patients with bladder cancer receiving chemotherapy in Canada are not routinely offered thromboprophylaxis. We found strong interest among Canadian oncologists to participate in clinical trials examining this topic.