- 69-year-old lady for TURBT.
- Incidental finding of large bladder tumour on surveillance imaging. No haematuria/obstructive symptoms
- Non-small cell lung cancer – Stage IV with Brain metastases, complete response to palliative radiotherapy
- Right parapharyngeal mass on previous surveillance PET.
- Asymptomatic. Biopsy showed atypia but ENT surgeons concerned about change in size and shape of mass.
- Listed for parotidectomy (cat 2)
- COPD, moderate disease FEV1/FVC = 0.6 (79%). 50 pack year smoking history
- Significant deconditioning; 3.9 METS on DASI. Walks 20-30m with stick or 4WW
- Clinical depression with suicidal ideation. Rarely leaves home
- Iron deficiency
- Reviewed at perioperative clinic 6/12 ago
- Referred for prehab, very motivated family but on hold currently due to COVID
- No change since last clinic review
Which Surgery Should Proceed First?
- Consensus that TURBT should occur
- Large bladder tumour with potential for obstructive symptoms
- Urologist is aware of patient limitations and prepared for a debulking procedure if surgery is technically difficult
- ENT procedure needs to be done but pharyngeal mass not malignant and remains asymptomatic
- Imperative to update ENT surgeons of delay of at least 6 weeks
- Clinical issues – deconditioning and Fe-deficiency both being addressed
- Depression is severely impacting functional capacity
- Prehabilitation – psychological as well as physical benefits; social aspect advantageous in isolated people
- GP manages depressive symptoms, on multiple pharmacotherapies with little effect
- Letter to GP in May regarding possibility of specialist input but nil yet.
- Psychiatry and psychology services currently very difficult to obtain
- Fe-infusion and proceed to TURBT
- GP letter regarding psychiatrist and/or psychologist for optimisation of mental health symptoms
- Prehab can occur pre-ENT surgery
- Discussion with family around Advanced Care Planning