Variations in Opioid Use Following Robotic Radical Prostatectomy in South Florida

Introduction: Opioid dependency has been a persistent issue in the United States over the past two decades. Increased efforts have been made to reduce opioid prescribing. Our objective was to quantify at-home opioid requirements following radical prostatectomy. Methods: Written questionnaires were administered to patients 1 week following robot-assisted laparoscopic radical prostatectomy (RALP). Patients provided data on opioid use, pain levels, and demographic characteristics. Results: Sixty-five patients were included. Median age (interquartile range [IQR]) was 69 (62-72) years. The majority were white (85%) and hispanic (67%). Prescriptions ranged from 6 to 15 pills of 5-mg oxycodone equivalents. Twenty-two percent (145/663) of the prescribed pills in the study were consumed. Fifty-four percent (35/65) of patients did not take opioids. Of the 30 patients who took opioids, median use (IQR) was 4.5 (3-6) pills. Forty-six percent (30/65) reported catheter-related pain. Patients who took opioids reported higher levels of pain. On generalized linear regression, younger age, lower levels of education, and living with a family member were factors associated with increased risk for opioid use (all p < 0.05). Conclusions: Despite the Florida Department of Health's restriction on narcotic prescriptions to 3-day supplies, opioids are still overprescribed in our region. The majority of patients do not require opioids after RALP, and patients who do require an opioid analgesic can be adequately managed with less than 6 pills of 5-mg oxycodone equivalents.

Overcoming Drug Resistance in Advanced Prostate Cancer by Drug Repurposing

Prostate cancer (PCa) is the second most common cancer in men. Common treatments include active surveillance, surgery, or radiation. Androgen deprivation therapy and chemotherapy are usually reserved for advanced disease or biochemical recurrence, such as castration-resistant prostate cancer (CRPC), but they are not considered curative because PCa cells eventually develop drug resistance. The latter is achieved through various cellular mechanisms that ultimately circumvent the pharmaceutical’s mode of action. The need for novel therapeutic approaches is necessary under these circumstances. An alternative way to treat PCa is by repurposing of existing drugs that were initially intended for other conditions. By extrapolating the effects of previously approved drugs to the intracellular processes of PCa, treatment options will expand. In addition, drug repurposing is cost-effective and efficient because it utilizes drugs that have already demonstrated safety and efficacy. This review catalogues the drugs that can be repurposed for PCa in preclinical studies as well as clinical trials.

THE ROLE OF HEALTH LITERACY IN PROSTATE CANCER SCREENING

OBJECTIVE

To determine if there is an association between self-reported health literacy and rates of prostate cancer screening through PSA testing.

METHODS

This secondary data analysis utilized information from the 2016 Behavioral Risk Factor Surveillance System (BRFSS). The primary exposure was self-reported health literacy, and the primary outcome was whether patients underwent prior PSA testing. Males 55-69 years old from 13 states were included in the study and were excluded if they had any missing data. Participants were categorized into low, moderate, or high level of health literacy. Confounders were adjusted for using binary logistic regression. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

A total of 12,149 participants were included. Five percent of participants reported low health literacy, 54% moderate health literacy, and 41% high health literacy. Compared with study participants who self-reported high levels of health literacy, the odds of undergoing PSA testing were 59% lower in those with low health literacy (OR 0.41; 95% CI 0.28-0.64) and 30% lower in those with moderate health literacy (OR 0.70; 95% CI 0.60-0.83).

CONCLUSIONS

Our research demonstrates a positive association between self-reported health literacy and the likelihood of PSA screening. While PSA screening can be controversial, health literacy may serve as a window into which patients are more likely to be proactive in their urologic care. Future studies examining how health literacy effects other urologic conditions is necessary.

Trends in Positioning for Robotic Prostatectomy: Results From a Survey of the Endourological Society

Purpose: most robot-assisted laparoscopic prostatectomies (RALP) are performed with the patient in lithotomy, carrying risks of positioning-related complications. Newer robot models have allowed for supine positioning, potentially avoiding these pitfalls. We gauged the current sentiment on patient positioning among surgeons who perform robot-assisted surgery.

Methods: we surveyed members of the Endourological Society regarding their practice settings and their opinions on positioning for robot-assisted laparoscopic prostatectomy. Summary statistics were reviewed and data were analyzed using chi-square tests and t-tests.

Results: our survey had 92 eligible respondents. The majority were fellowship-trained, with 51% trained in robotics and 57% practicing in the U.S. with a mean of 13 years of practice. Most were working in an academic setting (69%) and performing at least 25 robotic prostatectomies yearly. 28 respondents used the Intuitive Surgical Inc. da Vinci® Xi™ exclusively (30%), and nearly two-thirds used it sometimes. Although 54% of respondents considered using supine positioning, less than half of these surgeons used it regularly, while 75% overall preferred lithotomy. A majority attributed this choice to surgical team familiarity with lithotomy positioning. Surgeons in the U.S. and those using the da Vinci® Xi™ were more likely to consider supine positioning.

Conclusions: lithotomy position is the standard for RALP procedures; nonetheless, it poses significant risks that might be avoided with supine positioning. Our survey suggests that, although supine positioning has been considered, it has not gained momentum in practice. Addressing factors of inertia in training practices and one’s surgical team might allow for novel and safer approaches.

The Association Between Race and 5-year Survival in Patients With Clear Cell Renal Cell Carcinoma: A Cohort Study

OBJECTIVE

To determine if race was associated with 5-year cause-specific survival in patients with clear cell renal cell carcinoma.

MATERIALS AND METHODS

Outcomes were investigated using the Surveillance Epidemiology and End Results database with data from 13 states between the years 2007-2015. Covariates included age, sex, insurance, marital status, and tumor stage at diagnosis. Patients <18 years old or with missing data for race, survival time or insurance status were excluded. Cox regression models were used to determine associations through hazard ratios (HR) with 95% confidence intervals (CI) and to adjust for covariates.

RESULTS

A total of 8421 subjects were included in the analysis. After adjustment, there was no association between race and 5-year cause-specific survival in patients with ccRCC (Black- HR: 0.96, 95%CI: 0.83,1.12; American Indian/Alaskan- HR: 1.01, 95%CI: 0.75,1.36; Asian Pacific Islander- HR: 0.99, 95%CI: 0.82,1.12). Older individuals and those with regional or distant tumors showed an increased hazard of death, while females and insured patients showed decreased hazard.

CONCLUSION

Our study found that race was not associated with 5-year cause-specific survival from clear cell renal cell carcinoma. However inferior overall survival in Blacks with RCC has been well demonstrated in the literature. Our findings suggest that differences in survival may not be driven by cause-specific factors such as renal cell carcinoma, but rather social determinants of health which disproportionality affect Black patients. Further studies with more power that incorporate information on income, comorbidities, education status, and access to care are therefore necessary.

A Comparison Between AMS 700 and Coloplast Titan: A Systematic Literature Review

There are only two three-piece inflatable penile prostheses (IPP) available to patients in the American market: the AMS (American Medical Systems) 700^TM series (Boston Scientific, Massachusetts) and the Coloplast Titan® series (Coloplast, Minnesota), and data comparing the two are scant. The aim of our study was to summarize the current scientific evidence comparing the two.

A systematic literature review was conducted on PubMed. A 10-year filter was placed to include only studies published after Coloplast launched the Titan Touch® release pump. Eligibility criteria included articles discussing specifically the AMS 700^TM and Coloplast Titan® models. Further searches for studies on patient/partner satisfaction were conducted. Abstracts were reviewed to include studies focusing specifically on the models we are studying and studies on patient satisfaction using the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire.

The Coloplast device demonstrated slightly greater resistance to the stimulated forces of penetration and gravity. Coloplast implants coated with vancomycin/gentamicin had the highest infection rate followed by the AMS penile prosthesis and the rifampin/gentamicin coating had the lowest infection rate. Prosthesis durability and survival were similar between both brands. Overall satisfaction was high but comparisons are inconsistent.

The literature is inconclusive about which device is superior. We suggest randomized, multicenter, prospective studies to help further elucidate the highlights of each product.

Insurance status as a modifier of the association between race and stage of prostate cancer diagnosis in Florida during 1995 and 2013

BACKGROUND

Cancer stage at diagnosis is a critical prognostic factor regarding a patient's health outcomes. It has yet to be shown whether insurance status across different race has any implications on the stage of disease at the time of diagnosis. This study aimed to investigate whether insurance status was a modifier of the association between race and stage of previously undetected prostate cancer at the time of diagnosis in Florida between 1995 and 2013.

METHODS

Secondary data analysis of a cross-sectional survey using information from the Florida Cancer Data System (n = 224,819). Study participants included black and white males diagnosed with prostate cancer in Florida between 1995 and 2013. The main outcome variable was stage of prostate cancer at diagnosis. The main independent variable was race (black vs white). Adjusted logistic regression models were used to explore the association between race, insurance status and stage at diagnosis. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

Black males were more likely to be diagnosed with late stage prostate cancer (OR 1.31; 95% CI 1.27-1.35). Being uninsured (OR 2.28; 95% CI 2.13-2.45) or having Medicaid (OR 1.84; 95% CI 1.70-1.98) was associated with a diagnosis of late stage cancer. Stratified analysis for health insurance revealed that blacks had an increased risk for late stage cancer if uninsured (OR 1.29; 95% CI 1.07-1.55) and if having Medicare (OR 1.39; 95% CI 1.31-1.48).

CONCLUSION

Insurance status may modify the effect of race on late stage prostate cancer in black patients.

Giant Fungating Basal Cell Carcinoma of the Scrotum

We present an unusual case of basal cell carcinoma (BCC) arising from a non-sun-exposed area. The patient was 69-year-old male with an enlarging giant fungating mass protruding from his scrotum for which he did not seek medical treatment until recently. The mass did not involve the scrotum or epididymis and was confirmed on ultrasound. The patient underwent wide surgical excision and was diagnosed with BCC of the scrotum. Scrotal BCC appears to be more aggressive and more likely to metastasize compared with lesions arising from other areas of the body.

Urology Patients and the Internet: Socioeconomic Status and Language Skills Significantly Impact Use

INTRODUCTION

Patient Internet use and resources are likely multifactorial. We assess how socioeconomic factors and language skills affect Internet use by patients.

METHODS

We prospectively surveyed 116 patients with a bilingual questionnaire before they underwent urological surgery from July to September 2013. We obtained institutional review board approval for this study. Patients were surveyed for demographic data, English abilities, Internet use, anxiety level and understanding of the surgery.

RESULTS

Patients with low English abilities were significantly more likely to have lower incomes and education (p <0.05). In addition, patients with low English abilities were significantly more likely neither to have Internet access nor to have used it to research their surgery. On multivariate analysis those with low confidence in English were 2.8 times more likely not to have used the Internet to research their surgery when controlling for age. Increased age remained statistically associated with a lower likelihood of using the Internet even when controlling for all demographic data. Lastly, patients with low confidence in English were significantly less likely to report increased anxiety before surgery (OR 0.147) when controlling for all demographic data including ethnicity.

CONCLUSIONS

In our community those patients with low confidence in their English abilities are less likely to have access to, and use, the Internet before undergoing surgery. Older patients also use the Internet less often. Urologists should be aware of this potential language and age gap. Those with low English skills should likely be provided with additional counseling.

Lessons Learned from Routine Intraoperative Ureteral Margin Frozen Sections during Radical Cystectomy

INTRODUCTION

We examined the practice patterns of intraoperative ureteral frozen section during radical cystectomy and the impact of ureteral margin positivity on operative characteristics and oncologic outcomes.

METHODS

The records of patients who underwent radical cystectomy at our institution from 2004 to 2011 were identified. Intraoperative ureteral frozen section characteristics were examined, including number, laterality, positivity, conversion to negative and final permanent section status. Logistic regression analysis was performed for predictors of operative time, change in urinary diversion, and biopsy confirmed upper tract recurrence and metastasis.

RESULTS

A total of 590 intraoperative ureteral frozen sections were sent for analysis from 241 patients (mean age 69 years). The sections were positive in 12.9% of cases and conversion to negative was accomplished in 82%. Multiple sections were associated with longer operating time (561 vs 511 minutes, p=0.011). Sensitivity for the sections was 100% and specificity was 93.6%. Taking multiple ureteral resections did not alter the planned urinary diversion in any patient or increase perioperative complication rates. At a mean followup of 22±19.8 months, 7 patients (3%) experienced upper tract recurrence. Intraoperative ureteral frozen section conversion to negative was associated with improved overall survival but not with upper tract recurrence.

CONCLUSIONS

Our practice of taking intraoperative ureteral frozen sections provided excellent sensitivity and specificity, and the prolonged operative time did not translate into increased perioperative complications. Conversion of positive to negative was associated with improved overall survival, independent of patient comorbidities and post-operative complications. No association was seen with upper tract recurrence but this was likely due to our high conversion rate to negative margins (82%), negative permanent section ureteral margin status in 97% of cases and the long followup time needed to demonstrate an association.

Reducing robotic prostatectomy costs by minimizing instrumentation

INTRODUCTION AND OBJECTIVE

Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny. While robotic surgery professes to offer multiple advantages, including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study provides a simple framework for the careful consideration of costs during the selection of equipment and materials.

MATERIALS AND METHODS

Two experienced robotic surgeons at our institution as well as several at other institutions were queried about their preferred instrument usage for robot-assisted prostatectomy. Costs of instruments and materials were obtained and clustered by type and price. A minimal set of instruments was identified and compared against alternative instrumentation. A retrospective review of 125 patients who underwent robotically assisted laparoscopic prostatectomy for prostate cancer at our institution was performed to compare estimated blood loss (EBL), operative times, and intraoperative complications for both surgeons. Our surgeons now conceptualize instrument costs as proportional changes to the cost of the baseline minimal combination.

RESULTS

Robotic costs at our institution were reduced by eliminating an energy source like the Ligasure or vessel sealer, exploiting instrument versatility, and utilizing inexpensive tools such as Hem-o-lok clips. Such modifications reduced surgeon 1's cost of instrumentation to ∼40% less compared with surgeon 2 and up to 32% less than instrumentation used by surgeons at other institutions. Surgeon 1's combination may not be optimal for all robotic surgeons; however, it establishes a minimally viable toolbox for our institution through a rudimentary cost analysis. A similar analysis may aid others in better conceptualizing long-term costs not as nominal, often unwieldy prices, but as percent changes in spending. With regard to intraoperative outcomes, the use of a minimally viable toolbox did not result in increased EBL, operative time, or intraoperative complications.

CONCLUSION

Simple changes to surgeon preference and creative utilization of instruments can eliminate 40% of costs incurred on robotic instruments alone. Moreover, EBL, operative times, and intraoperative complications are not compromised as a result of cost reduction. Our process of identifying such improvements is straightforward and may be replicated by other robotic surgeons. Further prospective multicenter trials should be initiated to assess other methods of cost reduction.

An Adult Case of Paratesticular Spindle Cell Rhabdomyosarcoma

Paratesticular rhabdomyosarcoma (RMS) occurs more frequently in children and is rare in adults. Embryonal RMS is the most common subtype of paratesticular RMS. Spindle cell is a rare variant of embryonal RMS and is associated with a favorable prognosis in children. Data in adults is lacking. We present a case of paratesticular RMS in a 24-year-old man.

Reluctance of general practitioners to refer gross hematuria patients to urology

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Presentation and outcome following radical cystectomy in Hispanics with bladder cancer

OBJECTIVE

Significant racial and ethnic differences in the epidemiology of bladder cancer (BC) exist. Studies have shown African Americans to have lower incidence of bladder cancer than Caucasians, but higher incidence of invasive BC. Hispanics are the largest minority group in the United States. However, no reported studies on bladder cancer among Hispanics are available to date. As our center is in a unique position to study BC in Hispanic patients we were prompted to assess presentation and outcome of patients undergoing radical cystectomy (RC) for BC.

MATERIALS AND METHODS

Between January 1992 and May 2006, 448 RC were performed. All relevant data were collected and entered into a database. Patients were categorized by ethnicity as Hispanic and non-Hispanic White. African-American and other minority groups were excluded because of the small number. Comparative analysis of Hispanic and non-Hispanic White patients was performed.

RESULTS

67 (17%) patients were Hispanic. Mean follow-up period was 41 (SD +/- 40) months. Clinical and pathological data between these two groups were compared. Pre-cystectomy T stage was not significantly different between both groups. However, after RC incidence of < or = T1 disease in Hispanics was lower (22%) than Caucasians (37%). This difference, statistically significant (P = 0.024) indicates that Hispanics who undergo RC present with higher stage disease. Kaplan-Meier log rank test indicated a difference in disease free survival and disease specific survival between the two groups but however it did not reach statistical significance (Log Rank P = 0.082, P = 0.063). No significant difference in overall survival was observed (P = 0.465).

CONCLUSIONS

Hispanic patients managed with RC for bladder carcinoma present with higher stage disease.

Neobladder reconstruction following radical cystoprostatectomy for invasive bladder cancer

A survey on neobladder reconstruction after radical cystectomy due to invasive bladder cancer is presented. Stress is laid on the selection patients, factors affecting the choice of urinary diversion, contraindications for neobladder, oncological factors influencing selection of neobladder, continence, complications and other factors which may affect a favourable outcome.

Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey

INTRODUCTION

Hematuria is a common finding that may be a sign of serious underlying urologic disease. Thus, the AUA guidelines (written in conjunction with the American Academy of Family Practice) recommend urologic evaluation for patients with both microscopic and gross hematuria. We sought to evaluate practice patterns of the evaluation of hematuria by primary care physicians (PCPs) in two locations in the United States.

METHODS

Anonymous questionnaires regarding use of urinalysis (UA) and evaluation of hematuria were mailed to 586 PCPs in Miami, Florida and 1,915 in Dallas, Texas. Surveys were mailed to physicians who identified themselves as practitioners of internal medicine, family practice, primary care, or obstetrics and gynecology.

RESULTS

Surveys were completed by 788 PCPs including 270 (46%) and 518 (26%) PCPs in Miami and Dallas, respectively. Screening UAs were obtained on all patients by 77% and 64%, of physicians in Miami and Dallas, respectively. In both Miami and Dallas, only 36% of PCPs reported referring patients with microscopic hematuria to an urologist. In patients with gross hematuria, referral rates were 77% and 69% in Miami and Dallas, respectively.

CONCLUSIONS

While many PCPs use UA in many of their patients routinely, few PCPs automatically refer their patients with microscopic hematuria to urology and not all patients with gross hematuria are referred. Further investigations regarding why and when patients are referred to urology is warranted. Increasing awareness of the complete and timely evaluation of hematuria may be beneficial in preventing a delay in bladder cancer.

Factors affecting erectile function after radical retropubic prostatectomy: results from 1620 consecutive patients

OBJECTIVE

To report the return of erectile function in 1620 consecutive men after radical retropubic prostatectomy (RRP), chosen by half of men diagnosed with clinically localized prostate cancer, and the goal of which is to completely excise the tumour while preserving continence and erectile function.

PATIENTS AND METHODS

From January 1992 to October 2006, one surgeon performed RRP with a nerve-sparing technique where feasible. Men with erectile dysfunction before surgery, salvage RRPs, those not having a nerve-sparing procedure, neoadjuvant or adjuvant therapy within 6 months of RRP and a follow-up of <6 months were excluded from the analyses. Erectile function was evaluated by the surgeon when possible or by an annual questionnaire. Potency was defined as erectile function sufficient for intercourse with or without a phosphodiesterase-5 inhibitor.

RESULTS

Of 619 men who had a bilateral and of 178 who had a unilateral nerve-sparing RRP, 72% and 53%, respectively, were potent. When stratifying by age groups (<or=49, 50-59, 60-69 and >or=70 years) potency rates were 86%, 76%, 58% and 37%, respectively. Potency was more common after bilateral than unilateral nerve-sparing RRP in all age groups (P < 0.001). Age, bilateral nerve-sparing (odds ratio 2.9) and surgeon experience were associated with potency in a multivariate analysis.

CONCLUSION

Careful patient selection and meticulous surgical technique are essential to achieve the right balance between cancer control and morbidity. The patient's age, nerve-sparing RRP and the surgeon's experience were the significant predictors of return of potency after RRP.

Intraoperative cell salvage during radical cystectomy does not affect long-term survival

OBJECTIVES

To evaluate the risk of long-term recurrence for patients who received cell-salvaged blood during radical cystectomy (RC).

METHODS

We retrospectively analyzed an RC database and compared those who did and did not receive cell-salvaged blood according to baseline parameters, pathologic outcomes, and recurrence.

RESULTS

A total of 378 patients underwent RC between 1992 and 2005 by one surgeon. Of these, 65 (17.2%) received cell-salvaged blood and 313 (82.8%) did not. The two groups had similar baseline characteristics. There were no differences between the two groups when compared by pathologic stage. The median follow-up for patients who did and did not receive cell-salvaged blood was 19.1 and 20.7 months, respectively (P = 0.464). The 3-year disease-specific survival rate for the two groups was 72.2% and 73.0%, respectively (P = 0.90).

CONCLUSIONS

Intraoperative cell salvage is a safe blood management strategy for patients undergoing RC. There is no increased risk of metastatic disease or death for those who receive cell-salvaged blood. Concerns about spreading tumors cells by IOCS during RC would seem unwarranted. However, only a prospective, multicenter, randomized trial would provide the most valid assessment of the safety of IOCS.

Modified Pfannenstiel approach for radical retropubic prostatectomy: a 3-year experience

A modified Pfannenstiel approach for radical retropubic prostatectomy (RRP) has been described previously. We present our experience with this approach for performing a RRP over the past 3 years. Between January 2003 and July 2006, 544 consecutive RRPs by modified Pfannenstiel approach between January 2003 and July 2006 were performed. We analyzed blood loss, transfusions, use of drain, pain score, analgesia and hospital stay. Patients were followed up at 6 weeks, three monthly for a year and six monthly thereafter. All clinical and operative variables were entered into a database and analyzed. A total of 544 men underwent RRP with median follow-up of 11 (s.d.+/-10.5) months. The mean age was 60 (s.d.+/-7) years. About 83, 91 and 95% of patients had nerve sparing, bladder neck preservation and a lymph node dissection, respectively. Fifty-three patients had a concurrent inguinal hernia repair through the same incision. Mean estimated blood loss was 431 (s.d.+/-267) ml. The pathological staging distribution was T2, 82%; T3a, 9%; and T3b, 9%. The mean pain score at days 1 and 7 were 3.7 (s.d.+/-2.5) and 3.3 (s.d.+/-3), respectively. The median hospital stay was 36 h (s.d.+/-24). About 5.5% have had biochemical recurrence. At 12 months 97% were continent and 46% potent. RRP using a modified Pfannenstiel approach offers safety and efficacy. It facilitates repair of associated inguinal hernia through the same incision.