• 69-year-old lady for TURBT. 
• Incidental finding of large bladder tumour on surveillance imaging.  No haematuria/obstructive symptoms

Background:

• 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)

Issues

• 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 

Discussion

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

Optimisation options

• 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

Plan: 

• 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