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\begin{document}

\title{A retrospective analysis of the factors associated with increased risk
of readmission within 30 days following primary transurethral resection
of bladder tumour}



\author[1]{tarun jindal}%
\author[2]{Ankush Sarwal}%
\author[2]{Prateek Jain}%
\author[2]{Rajan Koju}%
\author[2]{Satyadip Mukherjee}%
\affil[1]{Affiliation not available}%
\affil[2]{Tata Medical Center}%


\vspace{-1em}



  
  \date{May 04, 2024}


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\selectlanguage{english}
\begin{abstract}
Background Transurethral resection of bladder tumour (TURBT) is
associated with a perioperative morbidity of 5-10\% which can lead to
unplanned readmissions. In this study, we aim to identify factors that
lead to an increased risk of unplanned readmissions within 30 days of
primary TURBT. Methods A retrospective study was conducted to identify
patients who had their primary TURBT at our institute from 2011-2019.
The clinico-demographic factors, history of smoking, intake of
anti-platelet drugs, co-morbidities, tumour size (\textless{} 3 cm or
\textgreater{} 3cm), multifocality and histopathological type were
abstracted. The patients who had a readmission were identified and
reasons for admission were recorded. Results A total of 435 patients
were identified. The median age was 66 years. There were 378 (86.9\%)
males, 110 (25.3\%) had history of smoking and 37 (8.5\%) had history of
intake of an anti-platelet agent. In the cohort 166 (38.2\%) were
diabetic, 239 (54.9\%) were hypertensive, 72 (16.6\%) had COPD, 78
(7.9\%) had hypothyroidism. A total of 206 (47.4\%) had a tumour of
\textgreater{}3cm, multifocality was seen in 140 (32.2\%) while muscle
invasive tumour was present in 161 (37\%) patients. A total of 22
(5.06\%) had re-admissions within 30 days with hematuria being the
commonest etiology. On the univariate and multivariate analysis, history
of smoking ( p=0.006 and 0.008, respectively) or intake of anti-platelet
agents (p\textless{}0.001 and \textless{}0.001, respectively) were
significantly associated with increased unplanned readmission.
Conclusion Our study revealed smoking and intake of anti-platelet agents
as the factors leading to increased risk of unplanned readmissions.%
\end{abstract}%



\sloppy


\textbf{A retrospective analysis of the factors associated with
increased risk of readmission within 30 days following
\emph{primary}transurethral resection of bladder tumour}

Tarun Jindal\textsuperscript{1} MCh, Ankush Sarwal\textsuperscript{1}MS,
Prateek Jain\textsuperscript{2} MS, Rajan Koju\textsuperscript{1}MS,
Satyadip Mukherjee\textsuperscript{1} MS

\textsuperscript{1}Department of Uro-oncology
and\textsuperscript{2}Department of Head and neck Surgery, Tata Medical
Centre, Kolkata, India

Type of article: Original article

Running title: Readmission after TURBT

\textbf{Acknowledgement:} None

None of the authors have any conflict of interests

\textbf{Corresponding Author:}

Dr Tarun Jindal MCh,

Consultant, Department of Uro-oncology,

Tata Medical Centre,

Kolkata, India

mail: \emph{drtarunjindal@gmail.com}

91-8126944676

\textbf{Abstract}

\textbf{Background} Transurethral resection of bladder tumour (TURBT) is
associated with a perioperative morbidity of 5-10\% which can lead to
unplanned readmissions. In this study, we aim to identify factors that
lead to an increased risk of unplanned readmissions within 30 days of
primary TURBT.

\textbf{Methods} A retrospective study was conducted to identify
patients who had their primary TURBT at our institute from 2011-2019.
The clinico-demographic factors, history of smoking, intake of
anti-platelet drugs, co-morbidities, tumour size (\textless{} 3 cm or
\textgreater{} 3cm), multifocality and histopathological type were
abstracted. The patients who had a readmission were identified and
reasons for admission were recorded.

\textbf{Results} A total of 435 patients were identified. The median age
was 66 years. There were 378 (86.9\%) males, 110 (25.3\%) had history of
smoking and 37 (8.5\%) had history of intake of an anti-platelet agent.
In the cohort 166 (38.2\%) were diabetic, 239 (54.9\%) were
hypertensive, 72 (16.6\%) had COPD, 78 (7.9\%) had hypothyroidism. A
total of 206 (47.4\%) had a tumour of \textgreater{}3cm, multifocality
was seen in 140 (32.2\%) while muscle invasive tumour was present in 161
(37\%) patients. A total of 22 (5.06\%) had re-admissions within 30 days
with hematuria being the commonest etiology. On the univariate and
multivariate analysis, history of smoking ( p=0.006 and 0.008,
respectively) or intake of anti-platelet agents (p\textless{}0.001 and
\textless{}0.001, respectively) were significantly associated with
increased unplanned readmission.

\textbf{Conclusion} Our study revealed smoking and intake of
anti-platelet agents as the factors leading to increased risk of
unplanned readmissions.

\textbf{Key words:} Bladder cancer, Complication, Cystoscopy,
Readmission, Urinary bladder surgery

\textbf{'What is already known about this topic?'}

TURBT is associated with high risk of unplanned readmissions. There is
dearth of information that can lead to identification of variables
associated with readmissions.

\textbf{`What does this article add?'}

The article identifies the patients at risk of unplanned readmissions
after primary TURBT in a contemporary cohort. This can potentially lead
to early identification and modification of the factors.

\textbf{Introduction}

Bladder cancer is one of the commonest urological malignancies in
clinical practice. The management of disease relies heavily upon
transurethral resection of bladder tumour (TURBT) which can be
diagnostic as well as therapeutic. \textsuperscript{1} TURBT, although
considered to be a ``safe'' surgery, can be associated with
complications like hematuria, urinary retention, infections, etc. It has
been shown that the perioperative morbidity after TURBT ranges from
5-10\%.\textsuperscript{2-4}

The cost of treatment of patients of bladder cancer can be very high
considering the need of surveillance cystoscopies, TURBTs, intravesical
therapies, etc.\textsuperscript{5,6} As in the management of any other
diseases, it is prudent that efforts are made to decrease the overall
cost of management of bladder cancer. Unplanned readmissions have been
shown to have a significant economic impact on the health care
system.\textsuperscript{7} If the risk factors that lead to unplanned
readmissions after TURBT can be identified, we might be able to modify
them and decrease the readmissions. In this study, we analyze the
patient factors and tumour factors that may help in identifying the
patients who have a higher chance of unplanned readmission within 30
days after primary TURBT.

\textbf{Methods}

This was a retrospective study and an exempt was obtained from the
Institutional Review Board for this study. The contact details, clinical
details,image findings, diagnosis, treatment received, details of
histopathology, follow up, of all the patients coming for treatment at
our institute is recorded digitally. The data was collected from this
institutional digital database which records the information
prospectively. The patients who had a TURBT from 2011 to 2019 were
identified from the digital surgery log-book. We selected only those
patients who had their first TURBT. The patients who had a completion
TURBT or a re-staging TURBT or TURBT for recurrences or had no tumour
were excluded. As we anticipated that all patients who had a primary
TURBT might not come for follow up at our institution,we excluded those
did not have a follow up of three months post-surgery. The
clinico-demographic factors like their age at the time of surgery,
gender, body mass index (BMI), history of smoking (past/present), intake
of anti-platelet drugs (aspirin/aspirin+Clopidogrel/others), diabetes,
hypertension, chronic obstructive pulmonary disease (COPD),
hypothyroidism or other co-morbidities like Parkinsonism, stroke, renal
failure, hematological disorders, liver failure, tuberculosis, etc. were
abstracted from the patients' charts. The surgical details were
extrapolated from the digital surgery record. The operative findings
such as tumour size (\textless{} 3 cm or \textgreater{} 3cm), presence
or absence of multifocality and histopathology (low grade transitional
cell carcinoma (tcc)/high grade non muscle invasive tcc/muscle
invasive/other variants) were also collected. As an institutional
protocol, the post operative patients who came for follow up or with any
post-operative problems were always assessed by a member from the
operating team at the time of primary surgery. We identified the
patients who had an unplanned readmission within 30 days of their
surgery. The reason for readmissions were recorded from the digital
admission slips issued by the admitting team member. They were
classified under the categories of hematuria/retention, urinary tract
infection/fever and others which included dyselectrolytemia, pain or
other cardiac, neurological, respiratory, hematological and
gastrointestinal issues.

\textbf{Technical aspects of TURBT}

As an institutional protocol, the antiplatelet agents were stopped 5-7
days prior to the surgery and were started 5-7 days following surgery.
The energy source used in all of the procedures was unipolar diathermy.
The tumour base was uniformly coagulated by a roly-ball in all cases. A
5 mm margin around the base of the tumour was also scored. A 3-way
Foley's catheter was inserted at the end of the surgery and irrigation
was continued till the urine cleared up.

\textbf{Statistical analysis}

The statistical analysis was done using the Statistical Package for
Social Sciences (SPSS) version 25 (International Business Machine
Corporation, New York, USA). The median and ranges were calculated for
continuous variables, whereas proportions and frequency tables were used
to summarize categorical variables. We performed the Pearsons Chi-square
test or independent sample t-test (for nominal data) to assess the
impact of each clinico-demographic and tumour factor on the readmission.
Multivariate analysis was done using linear regression test. All the
variables were included for multivariate analysis. Backward elimination
(p \textless{}0.05 to remove) was performed to obtain final models. The
level of statistical significance for all tests was p \textless{}0.05
derived from two-tailed tests

\textbf{Results}

A total of 675 patients were identified of which 435 patients fulfilled
the inclusion and exclusion criteria. The median age at the time of the
TURBT was 66 years (IQR 58, 73). The median BMI was 25.38 (IQR 22.34,
27.81). Of the total cohort, 378 (86.9\%) were males, 110 (25.3\%) had a
history of smoking and 37 (8.5\%) had a history of intake of an
anti-platelet agent. In the antiplatelet group, 30 patients had history
of aspirin intake while 7 had history of both aspirin and clopidogrel.
It was observed that 92 (21.1\%) did not have any co-morbidity while 166
(38.2\%) were diabetic, 239 (54.9\%) were hypertensive, 72 (16.6\%) had
COPD, 78 (7.9\%) had hypothyroidism. It was also seen that 42.3\% of
patients had more than one co-morbidities. A total of 206 (47.4\%) had a
tumour of \textgreater{}3cm and the tumour was multifocal in 140
(32.2\%) of the patients. The muscle invasive tumour was seen in 161
(37\%) patients (Table 1). A total of 22 (5.06\%) re-admissions were
seen in this cohort. The median time to readmission was 9 days post
surgery. The commonest reason for readmission was hematuria/retention
which was present in 10 patients followed by urinary tract infections
(Table 2). A total of 6 patients needed blood transfusion and 7 required
surgical intervention in the form of bladder wash and hemostasis. There
was one mortality in the patients readmitted within 30 days due to
cardiac cause.

On the univariate analysis, among the clinical factors, only smoking and
history of intake of anti-platelet agents were significantly associated
with increased unplanned readmission (p=0.006; Odds ratio 3.16 and
\textless{}0.001 Odds ratio 7.55, respectively). The presence of
multiple co-morbidities too was not associated with an increased risk of
readmission with a p value of 0.75. The tumour related factors like
size, multifocality or histopathological findings did not have an
association with unplanned readmissions (Table 3).

The multivariate analysis revealed that out of all the factors studied,
only smoking and anti-platelet intake were associated with an increased
risk of readmission with p values of 0.008 and \textless{}0.001,
respectively (Table 3).

\textbf{Discussion}

The unplanned hospital admissions lead to a major financial burden on
the health care system. It has been reported that even if 10\% of such
admissions can be avoided, millions of dollars can be saved, especially
in the Medicare and insurance setting. \textsuperscript{8} This has led
to a lot of interest by the researches in identifying the factors that
can predict the chances of unplanned readmission. In United States, a
Hospital Readmissions Reduction Program has been initiated to this
effect which penalizes the hospitals which have higher than expected
readmission rates.\textsuperscript{7,8} In our country too, a lot of
health insurance policies mandate that readmission within 30 days of
discharge be considered as a part of the same hospitalization leading to
loss of hospital revenues.

TURBT is a commonly performed surgery for bladder cancer. There is a
large variation in the reported rates of complications depending upon
the study methodology and categorization.\textsuperscript{2-4} There are
only a few studies that have specifically evaluated the incidence and
identified the risk factors of unplanned readmissions after TURBT. To
the best of our knowledge, ours is the first such study in a cohort of
patients from a developing nation. Ghali et al retrospectively reviewed
708 patients who had a TURBT and found the rate of unplanned readmission
to be 4.9\%. The major reason was hematuria and on multivariate
analysis, the history of Foley's catheterisation in the operating room
was the only factor found to be associated with a higher rate of
unplanned readmissions.\textsuperscript{9} Austin et al included a total
of 172 patients of which 138 patients had a TURBT as a daycare
procedure. They reported the rates of readmission within 28 days to be
7.2\% in daycare cases and 5.9\% in the inpatient
cohorts.\textsuperscript{10} Pereira et al analyzed 24,100 patients from
the National Surgical Quality Improvement Program database which is
probably the largest cohort to date. They found the rate of unplanned
hospital admissions to be 3.8\%. They reported that on multivariate the
presence of a higher American Society of Anaesthesiology (ASA) category,
tumour size \textgreater{}5cm, and steroid use were associated with a
significantly high risk of unplanned readmission within 30 days of
surgery. They did not observe a higher risk of readmission for patients
with a history of diabetes, smoking, COPD, bleeding disorder, renal
failure or heart failure.\textsuperscript{4} Rambachan et al too used
the National Surgical Quality Improvement Program database to identify
7,795 patients who had a urologic surgery. They found that though the
overall rate of unplanned readmission within 30 days was 3.7\%, TURBT
had a risk of 4.97\% which was the highest among all the surgeries
evaluated. They found that higher ASA, bleeding disorders, male gender
and age were significant risk factors for
readmission.\textsuperscript{11} Our study had a readmission rate of
5.06\% which is similar to the rate seen in previous studies.

We found that the history of smoking or the intake of anti-platelet
agents were the only factors that were significantly associated with the
risk of unplanned readmission. It has been well documented that smoking
is associated with increased risk of major bleeding which can manifest
as gastrointestinal, pulmonary or even urological
bleeding.\textsuperscript{12} The antiplatelet agents too are known to
increase perioperative bleeding hence most of the clinicians tend to
stop these antiplatelet agents in the perioperative period. The
variables associated with increased risk of readmission in our study are
different from the previous studies. This difference may be due to the
different selection criteria used in our study that analyzed only those
patients who had their first TURBT. Similar to the findings of Pereira
et al, we too did not find an association of age, gender or
co-morbidities like diabetes, hypertension, COPD, and hypothyroidism
with the risk of readmission.\textsuperscript{4} As a significant
percentage of patients in our cohort had multiple co-morbidities, we
also assessed its effect on readmission and found no significant
association.

Our study has several strengths. As the data was extrapolated from the
digital database, the problems associated with record retrieval,
especially in a long term study, are not there. This makes our data more
reliable. The surgical details of TURBT such as the type of energy used
(unipolar/bipolar), routine use of roly-ball are often missing in the
previous studies, especially the ones using multi-institutional
databases.\textsuperscript{4,11} This are potential confounding
variables and can have an effect on the results observed in the previous
studies. The reasons for readmissions were also the ones that were
mentioned by the primary team at the time of admission rather than being
analyzed by a third-party from the case history. This avoids the problem
of miscategorization of the patients.

There are a few limitations of our study. Firstly, our study is
retrospective and hence there can be inadvertent bias. Secondly, it is
possible that some patients might not have presented back to our center
and were managed outside. To minimize this error, we excluded the
patients who did not have a follow up of at least three months after
surgery. Thirdly, we did not record the length of hospital stay,
duration of catheterisation after surgery, ASA category, operative
times, details of the smoking history (pack years), which have may have
an impact on the risk of unplanned readmissions.\textsuperscript{4,9}

To conclude, our study provides a detailed analysis of a homogeneous,
contemporary cohort of patients who had a primary TURBT and the
identifies the risk factors leading to increased risk of unplanned
readmissions within 30 days of primary surgery. The history of smoking
or intake of anti-platelet agents can help the clinician in identifying
and counselling the patients who are at risk of readmissions.

\textbf{References}

1 Prakash G, Pal M, Odaiyappan K, et al. Bladder cancer demographics and
outcome data from 2013 at a tertiary cancer hospital in India. Indian J
Cancer 2019 ; 56 : 54-8

2 Patel HD, Ball MW, Cohen JE, Kates M, Pierorazio PM, Allaf ME.
Morbidity of urologic surgical procedures: an analysis of rates, risk
factors, and outcomes. Urology. 2015 ; 85 : 552-9.

3 Gregg JR, McCormick B, Wang L, et al. Short term complications from
transurethral resection of bladder tumor. Can J Urol. 2016 ; 23 :
8198-203.

4 Pereira JF, Pareek G, Mueller-Leonhard C, et al. The Perioperative
Morbidity of Transurethral Resection of Bladder Tumor: Implications for
Quality Improvement. Urology. 2019 ; 125 : 131-7.

5 Avritscher EB, Cooksley CD, Grossman HB, et al. Clinical model of
lifetime cost of treating bladder cancer and associated complications.
Urology. 2006 ; 68 : 549-53.

6 Racioppi M, Volpe A, Falabella R, et al. The cost of treatment and
follow-up of bladder cancer in Italy. Arch Ital Urol Androl. 2007 ; 79 :
111-7.

7 Wadhera RK, Joynt Maddox KE, Kazi DS, Shen C, Yeh RW. Hospital
revisits within 30 days after discharge for medical conditions targeted
by the Hospital Readmissions Reduction Program in the United States:
national retrospective analysis. BMJ. 2019 ; 366 : l4563.

8 McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction
program. Circulation. 2015 May 19 ; 131 : 1796-803.

9 Ghali F, Moses RA, Raffin E, Hyams ES. What factors are associated
with unplanned return following transurethral resection of bladder
tumor? An analysis of a large single institution's experience. Scand J
Urol. 2016 ; 50 : 370-3

10 Austin T, Robinson R, Wilby D, Hall S, Hodgson D. Day case primary
trans-urethral resection of bladder tumour (TURBT) as standard in a
single UK centre. Should this be the new norm? J Clin Urol. 2020,1-6.
doi.org/10.1177/2051415819890479

11 Rambachan A, Matulewicz RS, Pilecki M, Kim JY, Kundu SD. Predictors
of readmission following outpatient urological surgery. J Urol. 2014 ;
192 : 183-8.

12 Langsted A, Nordestgaard BG. Smoking is Associated with Increased
Risk of Major Bleeding: A Prospective Cohort Study. Thromb Haemost. 2019
Jan;119:39-47.

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