Epidemiology of and Risk Factors in Postoperative Complications from Robotically Assisted Laparoscopic Radical Prostatectomy in Contemporary National Surgical Quality Improvement Program Data

Introduction: For localized clinically significant prostate cancer (csPCa), robotically assisted laparoscopic radical prostatectomy (RALP) is the gold standard surgical treatment. Despite low overall complication rate, continued quality assurance (QA) efforts to minimize complications of RALP are important, particularly given movement toward same-day discharge. In 2019, National Surgical Quality Improvement Program (NSQIP) began collecting RALP-specific data. In this study, we assessed pre- and perioperative factors associated with postoperative complications for RALP to further QA efforts. Materials and Methods: Surgical records of csPCa patients who underwent RALP were retrieved from the 2019 to 2021 NSQIP database, including new RALP-specific data. Multivariate logistic regression evaluated the association between risk factors and outcomes specific to RALP and pelvic lymph node dissection (PLND). Input variables included American Society of Anesthesiologists (ASA) class, age, operative time, and body mass index (BMI). Variables from the extended dataset with PLND information included number of nodes evaluated, perioperative antibiotics, postoperative venous thromboembolism (VTE) prophylaxis, history of prior pelvic surgery, and history of prior radiotherapy (RT). Outcomes of interest were any surgical complication, infection, pulmonary embolism, deep venous thrombosis, acute kidney injury, pneumonia, lymphocele, and urinary/anastomotic leak (UAL). Results: A total of 11,811 patients were included with 6.1% experiencing any complication. Prior RT, prior pelvic surgery, older age, higher BMI, lack of perioperative antibiotic therapy, longer operative time, PLND, and number of lymph nodes dissected were associated with higher risk of postoperative complications. Regarding procedure-specific complications, there were increased odds of UAL with prior RT, prior pelvic surgery, longer operative time, and higher BMI. Odds of developing lymphocele increased with prior pelvic surgery, performance of PLND, and increased number of nodes evaluated. Conclusion: In contemporary NSQIP data, RALP is associated with low complication rates; however, these rates have increased compared with historical studies. Attention to and counseling regarding risk factors for peri- and postoperative complications are important to set expectations and minimize risk of unplanned return to a health care setting after discharge.

Telemedicine in management of genitourinary malignancies: Patient and physician perspectives

PURPOSE

The rapid expansion of telemedicine has presented a challenge for the care of patients with genitourinary malignancies. We sought to assess patient and physician perspectives on the use of telemedicine for genitourinary cancer care.

METHODS

We conducted a prospective cross-sectional study of patients who had telemedicine visits with urology, medical oncology, or radiation oncology for management of genitourinary malignancies from July-August 2020. Patients and physicians each received a questionnaire regarding the telemedicine experience. Responses were scored on a 5-point Likert scale. The primary outcomes of the study were patient and physician satisfaction.

RESULTS

Of the 115 patients who enrolled, we received 96 patient responses and 46 physician responses. Overall, 77% of patients and 70% of physicians reported being "extremely satisfied" with the telemedicine encounter. Satisfaction was high among all components of the encounter including patient-physician communication, counseling, shared decision making, time spent, timeliness and efficiency, and convenience. Additionally, 78% of patients and 85% of physicians "strongly agreed" that they were able to discuss sensitive topics about cancer care as well as they could at an in-person visit. Nine telemedicine visits (9%) encountered technological barriers. Technological barriers were associated with lower overall satisfaction scores among both patients and physicians (p ≤ 0.01).

CONCLUSION

We observed high levels of patient and physician satisfaction for telemedicine visits for management of genitourinary malignancies. Technological barriers were encountered by 9% of patients and were associated with decreased satisfaction.

A population-based analysis of risk factors and outcomes of prostatic abscess

BACKGROUND

Prostate abscess is a severe complication of acute bacterial prostatitis. To date, a population-based analysis of risk factors and outcomes of prostatic abscess has not been performed.

METHODS

Using the National Inpatient Sample from 2010 to 2015, we identified rates of prostatic abscess among non-elective hospitalizations for acute prostatitis. Significant Elixhauser comorbidities and risk factors were analyzed using survey-weighted logistic regression. Additional survey-weighted regression models were constructed to analyze sepsis, in-hospital mortality, length of hospital stay (LOS), and total hospital charges.

RESULTS

A weighted total of 126,103 hospitalizations for acute prostatitis was identified, with 6,775 (5.4%) hospitalizations with prostatic abscess. Numerous risk factors for prostatic abscess were identified, with a history of prostate biopsy (adjusted OR: 5.7; p < 0.001), complicated diabetes mellitus (adjusted OR: 3.23, p < 0.001), and urethral stricture (adjusted OR: 3.15; p < 0.001) having the greatest magnitude of developing abscess. Moreover, those diagnosed with prostatic abscess had increased odds of sepsis (adjusted OR: 1.71, p < 0.001), in-hospital mortality (adjusted OR: 2.73, p < 0.001), LOS (adjusted Incidence Rate Ratio: 1.86, p < 0.001), and total hospital charges (adjusted Ratio: 2.06, p < 0.001).

CONCLUSIONS

Numerous risk factors were associated with the development of prostatic abscess, with those diagnosed experiencing greater odds of sepsis, in-hospital mortality, longer LOS, and greater hospital charges. Ultimately, better understanding of risk factors associated with this condition will enable clinicians to identify patients at high risk, thereby expediting and tailoring management.

Impact of numeracy on understanding of prostate cancer risk reduction in PSA screening

Prostate-specific antigen (PSA) screening for prostate cancer in men of average risk remains controversial. Patients' ability to incorporate risk reduction data into their decision-making may depend on their numeracy. We assessed the impact of patients' numeracy on their understanding of the risk reduction benefits of PSA screening. Men attending a general internal medicine clinic were invited to complete a survey. Four versions of the survey each included a three-item numeracy test and PSA risk reduction data, framed one of four ways: absolute (ARR) versus relative risk reduction (RRR), with or without baseline risk (BR). Respondents were asked to adjust their perceived risk of prostate-cancer mortality using the data presented. Accuracy of risk reduction was evaluated relative to how risk data were framed. Among a total of 200 respondents, a majority incorrectly answered one or more of the numeracy items. Overall accuracy of risk adjustment was only 20%. Accuracy varied with data framing: when presented with RRR, respondents were 13% accurate without BR and 31% accurate with BR; when presented with ARR, they were 0% accurate without BR and 35% accurate with BR. Including BR data significantly improved accuracy for both RRR (P = 0.03) and ARR groups (P < 0.01). Accuracy was significantly related to numeracy; numeracy scores of 0, 1, 2, and 3 were associated with accuracy rates of six, five, nine, and 36 percent, respectively (P < 0.01). Overall, numeracy was significantly associated with the accuracy of interpreting quantitative benefits of PSA screening. Alternative methods of communicating risk may facilitate shared decision-making in the use of PSA screening for early detection of prostate cancer.

Are there regional tendencies toward controversial screening practices? A study of prostate and breast cancer screening in a Medicare population

INTRODUCTION

Prostate and breast cancer screening in older patients continue to be controversial. Balancing the desire for early detection with avoidance of over-diagnosis has led to competing and contradictory guidelines for both practices. Despite similarities, it is not known how these screening practices are related at the regional level. In this study, we examined how screening PSA and mammography are related within healthcare regions, and, to better understand what may be driving these practices, whether they are associated with local intensity of care.

METHODS

We performed a retrospective cross-sectional study of fee-for-service Medicare beneficiaries in 2012. For each of 306 hospital referral regions (HRRs), we calculated rates of PSA screening for men aged ≥68 years, as well as rates of screening mammography for women aged ≥75 years, adjusted for age and race. Additionally, we determined regional rates of "healthcare intensity", including spending on tests and procedures, and intensity of end-of-life care. Pearson correlations of adjusted rates were calculated within HRRs.

RESULTS

The mean adjusted rate of PSA screening was 22%. The mean age of screened and unscreened patients was 75.0 and 77.4 years, respectively (p<0.0001). The mean adjusted rate of screening mammography was 23%; mean ages of screened and non-screened women were 79.95 and 83.67, respectively (p<0.0001). HRR-level PSA screening rates were independent of screening mammography rates (r=0.06, p=0.31). PSA screening rates were associated with spending on testing and procedures (r=0.42, p<0.0001) and various measures of intensity of EOL care (e.g. r=0.40, p<0.0001 for mechanical ventilator use). Screening mammography had low correlation with both health care spending and EOL care intensity measures (all r-values <0.3).

CONCLUSIONS

Regional rates of PSA screening rates were independent of screening mammography, thus these practices appear to be driven by different factors. Unlike mammography, PSA screening was associated with local enthusiasm for testing and treatment. Efforts to reduce over-testing should contemplate these practices differently, and future research should examine the factors motivating these screening practices.

Practice Makes Perfect: Correlations Between Prior Experience in High-level Athletics and Robotic Surgical Performance Do Not Persist After Task Repetition

OBJECTIVE

Robotic surgical skill development is central to training in urology as well as in other surgical disciplines. Here, we describe a pilot study assessing the relationships between robotic surgery simulator performance and 3 categories of activities, namely, videogames, musical instruments, and athletics.

DESIGN

A questionnaire was administered to preclinical medical students for general demographic information and prior experiences in surgery, videogames, musical instruments, and athletics. For follow-up performance studies, we used the Matchboard Level 1 and 2 modules on the da Vinci Skills Simulator, and recorded overall score, time to complete, economy of motion, workspace range, instrument collisions, instruments out of view, and drops. Task 1 was run once, whereas task 2 was run 3 times.

SETTING

All performance studies on the da Vinci Surgical Skills Simulator took place in the Simulation Center at Dartmouth-Hitchcock Medical Center.

PARTICIPANTS

All participants were medical students at the Geisel School of Medicine. After excluding students with prior hands-on experience in surgery, a total of 30 students completed the study.

RESULTS

We found a significant correlation between athletic skill level and performance for both task 1 (p = 0.0002) and task 2 (p = 0.0009). No significant correlations were found for videogame or musical instrument skill level. Students with experience in certain athletics (e.g., volleyball, tennis, and baseball) tended to perform better than students with experience in other athletics (e.g., track and field). For task 2, which was run 3 times, this association did not persist after the third repetition due to significant improvements in students with low-level athletic skill (levels 0-2).

CONCLUSIONS

Our study suggests that prior experience in high-level athletics, but not videogames or musical instruments, significantly influences surgical proficiency in robot-naive students. Furthermore, our study suggests that practice through task repetition can overcome initial differences that may be related to a background in athletics. These novel relationships may have broader implications for the future recruitment and training of robotic surgeons and may warrant further investigation.

Qualitative insights into how men with low-risk prostate cancer choosing active surveillance negotiate stress and uncertainty

Background

Active surveillance is a management strategy for men diagnosed with early-stage, low-risk prostate cancer in which their cancer is monitored and treatment is delayed. This study investigated the primary coping mechanisms for men following the active surveillance treatment plan, with a specific focus on how these men interact with their social network as they negotiate the stress and uncertainty of their diagnosis and treatment approach.

Methods

Thematic analysis of semi-structured interviews at two academic institutions located in the northeastern US. Participants include 15 men diagnosed with low-risk prostate cancer following active surveillance.

Results

The decision to follow active surveillance reflects the desire to avoid potentially life-altering side effects associated with active treatment options. Men on active surveillance cope with their prostate cancer diagnosis by both maintaining a sense of control over their daily lives, as well as relying on the support provided them by their social networks and the medical community. Social networks support men on active surveillance by encouraging lifestyle changes and serving as a resource to discuss and ease cancer-related stress.

Conclusions

Support systems for men with low-risk prostate cancer do not always interface directly with the medical community. Spousal and social support play important roles in helping men understand and accept their prostate cancer diagnosis and chosen care plan. It may be beneficial to highlight the role of social support in interventions targeting the psychosocial health of men on active surveillance.

Emphysematous Pyelonephritis with Renal Artery Pseudoaneurysm

Emphysematous pyelonephritis is an acute infection of the renal parenchyma and perinephric tissues caused by gas-forming microorganisms, resulting in the radiographic presence of gas in the kidney, collecting system, and surrounding spaces. Here we present a case of severe emphysematous pyelonephritis in the setting of Klebsiella urosepsis. Surgical exploration of the flank revealed infectious disintegration of the renal parenchyma into a large phlegmon. The post-operative course was complicated by renal artery pseudoaneurysm and cutaneous fistualization of a perinephric fluid collection. Despite the high rate of mortality associated with this condition, the patient survived and has remained clinically well.

Comparative study of separation between ex vivo prostatic malignant and benign tissue using electrical impedance spectroscopy and electrical impedance tomography

OBJECTIVE

Currently no efficient and reliable technique exists to routinely assess surgical margins during a radical prostatectomy. Electrical impedance spectroscopy (EIS) has been reported as a potential technique to provide surgeons with real-time intraoperative margin assessment. In addition to providing a quantified measure of margin status, a co-registered electrical impedance tomography (EIT) image presented on a surgeon's workstation could add value to the margin assessment process.

APPROACH

To investigate this, we conducted a comparative study between EIS and EIT to evaluate the potential these technologies might have for margin assessment. EIS and EIT data was acquired from ex vivo human prostates using a multi-electrode endoscopic impedance acquisition probe.

MAIN RESULTS

EIS and EIT show good predictive performance with a 0.76 and 0.80 area-under-curve (AUC), respectively, when considering discrete frequencies only. A machine learning (ML) algorithm is implemented to combine features, which improves the AUCs of EIS and EIT to 0.84 and 0.85, respectively. Single-step EIT takes significantly less time to reconstruct than multi-step EIT, yet provides similarly accurate classification results, making the single-step approach a potential candidate for real-time margin assessment. While the ML-based approach clearly exhibits benefits as compared to the single feature assessment, the decision to use EIS versus EIT is unclear since each approach performs better for different subsets of tissue classifications.

SIGNIFICANCE

The results presented in this paper corroborate our previous studies and present the strongest evidence yet that an intraoperative-capable impedance probe can be used to distinguish benign from malignant prostate tissues. An in vivo study with a large cohort will be necessary to definitively determine the preferred approach and to show the clinical effectiveness of using this technology for margin assessment.

Ensuring Evidence-Based Practice: A Study of Factors Associated with Nonuse of American Urological Association Guidelines

INTRODUCTION

Evidence-based guidelines are published by the AUA (American Urological Association) to improve the quality and consistency of urological care. The 2014 AUA Census reported a unique field regarding provider utilization of AUA Guidelines. We sought to identify factors associated with nonuse of AUA Guidelines to understand how education and dissemination of these guidelines might be improved.

METHODS

Using 2014 AUA Census data providers were stratified based on self-reported use or nonuse of AUA Guidelines. Bivariate analyses and multivariable logistic regression analysis were performed to identify factors associated with nonuse. Post-stratification weights were applied to calculate national estimates with SAS®, version 9.4.

RESULTS

The 2,202 survey respondents represented 11,680 practicing urologists. AUA guideline use was reported by 95.0% of the weighted population. There was no significant difference in utilization based on gender, race, country of origin, practice type or fellowship completion. After controlling for other variables urologists who reported practicing in a rural area were more likely to be nonusers (OR 1.06, 95% CI 1.03-1.09). Additionally, urologists who had been practicing longer were less likely to utilize guidelines compared with those earlier in the career (practicing 10 to 20 years OR 1.15, 95% CI 1.10-1.21 and more than 20 years OR 1.13, 95% CI 1.09-1.18, p <0.05).

CONCLUSIONS

Despite continued publication and dissemination of AUA Guidelines about 5% of urologists do not utilize guidelines. Later career status and rural geography were associated with nonuse. These data may inform efforts to improve dissemination and education regarding evidence-based practice.

Prostate Cancer Detection Using Composite Impedance Metric

Prostate cancer (PCa) recurrences are often predicted by assessing the status of surgical margins (SM)- positive surgical margins (PSM) increase the chances of biochemical recurrence by 2-4 times which may lead to PCa recurrence. To this end, an electrical impedance acquisition system with a microendoscopic probe was employed in an ex-vivo study of human prostates. This system measures the tissue bioimpedance over a range of frequencies (1 kHz to 1MHz), and computes a number of Composite Impedance Metrics (CIM). A classifier trained using CIM data can be used to classify tissue as benign or cancerous. The system was used to collect the impedance spectra from 14 excised prostates, which were obtained from men undergoing radical prostatectomy, for a total of 23 cancerous and 53 benign measurements. The data revealed statistically significant (p < 0.05) differences in the impedance properties of the benign and tumorous tissues, and among the measurements taken on the apical, base, and lateral surface of the prostate. Further, in the leave-one-patient-out cross validation, a maximum predictive accuracy of 90.79% was achieved by combining high frequency CIM phase data to train a support vector machine classifier with a radial basis function kernel. The observations are consistent with the physiology and morphology of benign and malignant prostate tissue. CIMs were found to be an effective tool in distinguishing benign from cancerous tissues.

What factors are associated with unplanned return following transurethral resection of bladder tumor? An analysis of a large single institution's experience

OBJECTIVE

This study sought to evaluate factors associated with unplanned hospital return (UR) following transurethral resection of bladder tumor (TURBT), the largest source of readmission among ambulatory urological procedures.

MATERIALS AND METHODS

A retrospective review of TURBTs at a single academic institution between April 2011 and August 2014 was performed. Demographics, comorbidities, length of stay, tumor size and multiple other factors were recorded. UR was recorded within 30 days of surgery. Bivariate and multivariable analyses were performed to determine factors associated with UR.

RESULTS

Among 708 patients undergoing TURBT, 23.9% were female with a mean age of 70 years. The rate of UR was 10.9%. The most common cause of UR was gross hematuria, accounting for 70%. On bivariate analysis, Foley catheter placement in the operating room, non-aspirin anticoagulation and index length of stay longer than 24 h were associated with hematuria-related UR (p < 0.05). Preoperative antibiotics, female gender and aspirin therapy were associated with lower rates of hematuria-related UR (p < 0.05), while tumor size, distance of residence to the hospital, and Foley on hospital discharge (rather than from the operating room) had no association (p > 0.05). On multivariable analysis, only Foley placement in the operating room remained associated with higher rates of hematuria-related UR, while preoperative antibiotics, female gender and aspirin therapy remained associated with a lower likelihood of this event.

CONCLUSIONS

UR following TURBT is common and typically results from gross hematuria. Patients with postoperative Foley catheterization in the operating room may require additional counseling or supervision before discharge, and should be considered for discharge with a Foley rather than having a prompt voiding trial.

Cognitive and Affective Representations of Active Surveillance as a Treatment Option for Low-Risk Prostate Cancer

Benefits of early diagnosis and treatment remain debatable for men with low-risk prostate cancer. Active surveillance (AS) is an alternative to treatment. The goal of AS is to identify patients whose cancer is progressing rapidly while avoiding treatment in the majority of patients. The purpose of this study was to explore cognitive and affective representations of AS within a clinical environment that promotes AS a viable option for men with low-risk prostate cancer. Participants included patients for whom AS and active treatment were equally viable options, as well as practitioners who were involved in consultations for prostate cancer. Data were generated from semistructured interviews and audits of consultation notes and were analyzed using thematic analysis. Nineteen patients and 16 practitioners completed a semistructured interview. Patients generally viewed AS as a temporary strategy that was largely equated with inaction. There was variation in the degree to which inaction was viewed as warranted or favorable. Patient perceptions of AS were generally malleable and able to be influenced by information from trusted sources. Encouraging slow deliberation and multiple consultations may facilitate greater understanding and acceptance of AS as a viable treatment option for low-risk prostate cancer.

Is age an independent risk factor for medical complications following minimally invasive radical prostatectomy? An evaluation of contemporary American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) data

While robotic-assisted laparoscopic radical prostatectomy (RALRP) is an effective treatment for localized prostate cancer, the risk of complications in older patients can be a deterrent to surgery. We evaluated the rate of medical complications following RALRP in a national dataset of safety events, and assessed whether age is an independent risk factor for these complications. Retrospective analysis of patients undergoing RALRP between 2009 and 2012 in the prospectively maintained American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was performed. Demographic and comorbid data were collated, medical complications occurring during the 30-day post-operative period were identified. We identified age-related comorbidities, and complications associated with these comorbidities. A binary logistic regression model with age and age-related comorbidities as predictors and specific complication as outcome, was used to evaluate whether age is an independent risk factor for these complications. 12,123 patients underwent RALRP between 2009 and 2012, with a mean age of 62 (22-92). Post-operative medical complications included urinary tract infection (UTI) (1.77 %), deep venous thrombosis (DVT) (0.67 %), pulmonary embolism (PE) (0.45 %), pneumonia (PNA) (0.27 %), myocardial infarction (MI) (0.12 %), and cerebrovascular accident (CVA) (0.01 %). Nine comorbidities were positively correlated with age (p < 0.05). Four medical complications were associated with these age-related comorbidities: MI, CVA, PNA, and UTI. On multivariate analysis, age was an independent risk factor for post-operative PNA (p < 0.05), but not for MI (p = 0.09), UTI (p = 0.3) or CVA (p = 0.2). Patient age was independently associated with post-operative pneumonia only. These data suggest that RALRP can be considered as a treatment option in selected older patients with minimal increased risk for post-operative complications.

Economic impact of urinary stones

Kidney stones have been rising in prevalence in the United States and worldwide, and represent a significant cost burden. Cost effectiveness research in this area may enable improvements in treatment efficiency that can benefit patients, providers and the healthcare system. There has been limited research in the cost effectiveness of surgical interventions for stone disease, despite the diverse treatment approaches that are available. Medical expulsive therapy (MET) has been shown to improve rates of stone passage for ureteral stones, and there is evidence that this practice should be liberalized from the standpoint of both clinical and cost effectiveness. While conservative treatment following a primary stone event appears to be cost effective, the economic impact of medical therapy for recurrent stone formers requires clarification despite its clinical efficacy. Future study regarding the cost effectiveness of prevention and interventions for stone disease are likely to improve both the quality and efficiency of care.

Image-Guided Embolization Coil Placement for Identification of an Endophytic, Isoechoic Renal Mass During Robotic Partial Nephrectomy

Background: Intraoperative ultrasonography has proven to be a useful tool for tumor identification during robot-assisted laparoscopic partial nephrectomy (RALPN). However, its utility is limited in renal tumors that are completely endophytic and isoechoic in nature. We present a novel approach to intraoperative tumor identification using preoperative percutaneous intratumoral embolization coil placement that may be utilized in the management of such cases.

Case Presentation: A 42-year-old Caucasian male was referred with an incidentally discovered right renal mass that was posterior and completely endophytic. He desired a RALPN; however, preoperative renal ultrasound demonstrated an isoechoic lesion. Thus, the patient underwent preoperative image-guided placement of an embolization coil within the tumor. This facilitated identification of the tumor intraoperatively using intracorporeal ultrasound centered on the coil and enabled resection with negative margins.

Conclusion: Utilizing a novel approach analogous to preoperative localization of other solid malignancies, such as breast cancer, we were able to effectively identify and resect an isoechoic renal mass during RALPN.

Unplanned Hospital Return for Infection following Ureteroscopy-Can We Identify Modifiable Risk Factors?

PURPOSE

Genitourinary infection after ureteroscopy with laser lithotripsy is a clinically significant event that may lead to expensive and morbid return to the hospital. We evaluate factors associated with infection after ureteroscopy with laser lithotripsy leading to unplanned hospital return.

MATERIALS AND METHODS

We performed a retrospective chart review evaluating all ureteroscopy with laser lithotripsy performed at a single academic institution from April 2011 to August 2014. Data were extracted including patient demographics, comorbidities, surgical encounter characteristics, preoperative urine culture status, antibiotic type/duration and compliance with the AUA Best Practice Statement for antibiotic prophylaxis. Bivariate and multivariate analyses were performed to determine factors associated with unplanned return to the hospital.

RESULTS

Among 550 patients undergoing ureteroscopy with laser lithotripsy 45% (248) were female with an average age of 56.8 (± 14.8) years. Overall 3.4% (19 patients) had an unplanned return for genitourinary infection, with most (78.9%, 15 of 19) requiring inpatient readmission. Overall compliance with AUA Best Practice Statement for antibiotic prophylaxis was 48.7% (268 of 550). Rates of infection related returns were higher in patients undergoing preoperative stenting (84.2% vs 58.6%, p=0.025), those with an operative time greater than 120 minutes (89.5% vs 32.6% p <0.001) and those for whom there was AUA Best Practice Statement compliance for antibiotic prophylaxis (78.9% vs 47.6%, p=0.007). These factors remained significant on multivariate analysis (p <0.05).

CONCLUSIONS

Preoperative stenting and longer operative time were associated with a greater likelihood of serious genitourinary infection after ureteroscopy with laser lithotripsy. These patients may warrant additional antibiotic prophylaxis but further research is needed to answer this question more definitively. Interestingly the AUA Best Practice Statement compliance for antibiotic prophylaxis was also associated with a higher risk of infection, underscoring the need for locally appropriate prophylaxis strategies and further study of optimal prophylaxis regimens.

Stone specialist, cancer surgeon, or both? Optimizing the endourology fellowship training model

BACKGROUND

The traditional endourology fellowship model includes advanced training in minimally invasive surgery (MIS) for both benign disease/kidney stones and oncology. We have anecdotally observed, however, that many former endourology fellows subspecialize within their practices. Recently the fellowship paradigm, accredited by the Endourological Society (EUS), has been modified to allow for emphasis on benign disease/kidney stones or laparoscopy/robotic surgery, which is heavily weighted toward oncology. In this study, we sought to assess the practice patterns of former endourology fellows to evaluate various fellowship models.

METHODS

Email addresses for 320 of the 327 endourology fellowship graduates between 2001 and 2010 identified by the EUS were obtained. These were cross-referenced with the American Urological Association (AUA) member database to maximize the yield of valid addresses. A 20-question electronic survey (SurveyMonkey Inc., Palo Alto, CA) was sent to this group. Eleven addresses were invalid and 24 recipients opted out of the survey.

RESULTS

Responses were received from 121 of 285 former fellows with active email addresses who did not opt out of the survey (42.5%). Of these respondents, 86% completed fellowships in North America and 71% completed 1-year fellowships. Among respondents in academic practice (46%), 44% reported a "mixed" benign and oncology-based practice, compared to 68% of nonacademic practitioners (P=0.009). Among academic practitioners, 33% practice predominantly MIS for benign disease, and 24% practice predominantly MIS for oncology, versus 23.1% (P=0.3) and 9% (P=0.04), respectively, of nonacademic practitioners. Most fellows had stability of clinical interests (benign v malignant disease) before and after their fellowship.

CONCLUSION

Fellowship-trained endourologists who work in an academic setting are more likely to have a subspecialized practice. A subset of private practice endourologists also have focused practices in benign disease. While the traditional fellowship model will be useful for some graduates, subspecialized tracks may improve the efficiency of the training model.

3D Microendoscopic Electrical Impedance Tomography for Margin Assessment During Robot-Assisted Laparoscopic Prostatectomy

Radially configured microendoscopic electrical impedance probes intended for intraoperative surgical margin assessment during robot-assisted laparoscopic prostatectomy (RALP) were examined through simulation, bench-top experimentation, and ex vivo tissue studies. Three probe designs with 8, 9, and 17 electrodes, respectively, were analyzed through finite element method based simulations. One mm diameter spherical inclusions ( σinclusion = 1 S/m) are positioned at various locations within a hemispherical background ( σbackground = 0.1 S/m) of radius 5 mm. An 8-electrode configuration is not able to localize the inclusion at these positions while 9 and 17-electrode configurations are able to accurately reconstruct the inclusion at maximum depth of 1 mm and 3 mm, respectively. All three probe designs were constructed and evaluated using saline phantoms and ex vivo porcine and human prostate tissues. The 17-electrode probe performed best in saline phantom studies, accurately reconstructing high contrast, 1-mm-diameter metal cylindrical inclusions in a saline bath ( σsaline = 0.1 S/m) with a position and area error of 0.46 mm and 0.84 mm2, respectively. Additionally, the 17-electrode probe was able to adequately distinguish cancerous from benign tissues in three ex vivo human prostates. Simulations, bench-top saline experiments, and ex vivo tissue sampling suggest that for intraoperative surgical margin assessment during RALP, the 17-electrode probe (as compared to an 8 and 9 electrode probe) will be necessary to provide sufficient accuracy and sensitivity.

A prospective, multi-institutional study of flexible ureteroscopy for proximal ureteral stones smaller than 2 cm

PURPOSE

Flexible ureteroscopy is rapidly becoming a first line therapy for many patients with renal and ureteral stones. However, current understanding of treatment outcomes in patients with isolated proximal ureteral stones is limited. Therefore, we performed a prospective, multi-institutional study of ureteroscopic management of proximal ureteral stones smaller than 2 cm to better define clinical outcomes associated with this approach.

MATERIALS AND METHODS

Adult patients with proximal ureteral calculi smaller than 2 cm were prospectively identified. Patients with concomitant ipsilateral renal calculi or prior ureteral stenting were excluded from study. Flexible ureteroscopy, holmium laser lithotripsy and ureteral stent placement was performed. Ureteral access sheath use, laser settings and other details of perioperative and postoperative management were based on individual surgeon preference. Stone clearance was determined by the results of renal ultrasound and plain x-ray of the kidneys, ureters and bladder 4 to 6 weeks postoperatively.

RESULTS

Of 71 patients 44 (62%) were male and 27 (38%) were female. Mean age was 48.2 years. ASA(®) score was 1 in 12 cases (16%), 2 in 41 (58%), 3 in 16 (23%) and 4 in 2 (3%). Mean body mass index was 31.8 kg/m(2), mean stone size was 7.4 mm (range 5 to 15) and mean operative time was 60.3 minutes (range 15 to 148). Intraoperative complications occurred in 2 patients (2.8%), including mild ureteral trauma. Postoperative complications developed in 6 patients (8.7%), including urinary tract infection in 3, urinary retention in 2 and flash pulmonary edema in 1. The stone-free rate was 95% and for stones smaller than 1 cm it was 100%.

CONCLUSIONS

Flexible ureteroscopy is associated with excellent clinical outcomes and acceptable morbidity when applied to patients with proximal ureteral stones smaller than 2 cm.

Comorbidities and causes of death in the management of localized T1a kidney cancer

OBJECTIVE

The objectives of the present study were analyze specific comorbidities associated with survival and actual causes of death for patients with small renal masses, and to suggest a simplified measure associated with decreased overall survival specific to this population.

METHODS

The Surveillance, Epidemiology and End Results-Medicare database (1995-2007) was queried to identify patients with localized T1a kidney cancer undergoing partial nephrectomy, radical nephrectomy or deferring therapy. We explored independent associations of specific comorbidities with causes of death, and developed a simplified cardiovascular index. Cox proportional hazards, and Fine and Gray competing risks regression were used.

RESULTS

Of 7177 Medicare beneficiaries in the study population, 754 (10.5%) deferred therapy, 1849 (25.8%) underwent partial nephrectomy and 4574 (63.7%) underwent radical nephrectomy with none of the selected comorbidities identified in 3682 (51.3%) patients. Congestive heart failure, chronic kidney disease, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and cerebrovascular disease were associated with decreased overall survival. The cardiovascular index provided good survival risk stratification, and reclassified 1427 (41%) patients with a score ≥1 on the Charlson Comorbidity Index to a 0 on the cardiovascular index with minimal concession of 5-year survival.

CONCLUSIONS

Congestive heart failure, chronic kidney disease, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes and cerebrovascular disease were associated with decreased overall survival among Medicare beneficiaries with small renal masses. The cardiovascular index could serve as a clinically useful prognostic aid when advising older patients that are borderline candidates for surgery or active surveillance.

Percutaneous nephrolithotomy for removal of encrusted ureteral stents: a multicenter study

PURPOSE

Encrusted ureteral stents are a challenging endourologic problem. We performed a multi-institutional review of percutaneous nephrolithotomy (PCNL) as primary treatment for encrusted stents.

MATERIALS AND METHODS

We identified 36 patients who underwent PCNL for treatment of an encrusted stent. A retrospective review was performed to compile details of procedures and outcomes for these patients.

RESULTS

In 36 patients, 38 renal units underwent PCNL for encrusted ureteral stents. The mean patient age was 47.1 years (±16.7), and the female:male ratio was 15:21. Mean stent indwelling time before removal was 28.2 months (±27.8). The reason for long indwelling time was reported in 25 cases; these reasons included "patient unaware stent needed to be removed" (17 cases), pregnancy (2 cases), other comorbidities (3 cases), and patient incarceration (3 cases). In 3 cases, the stent had become encrusted within 3 months of placement. Mean operative time was 162 minutes (±71). There were no major intraoperative complications, and no patients required blood transfusion. Litholapaxy was required for bladder coil encrustations in 22 cases (58%), and ureteroscopy with lithotripsy was required for encrustation of the ureteral portion of the stent in 13 cases (34.2%). Second look percutaneous procedures were required in 13 cases (34.2%). The stent was removed at the time of PCNL without need for concomitant or delayed ureteroscopy and/or cystolitholapaxy in 8 cases (21%). Ultimately, all stents were removed successfully. Patients were rendered stone free according to radiographs in 24 cases (63%).

CONCLUSIONS

In this multicenter review, PCNL is confirmed to be a safe and effective means of addressing the retained and encrusted ureteral stent. PCNL without ureteroscopy or litholapaxy was sufficient in a minority of cases (21%). Adjunctive endourologic modalities are often required, and the surgeon should anticipate the need for concomitant antegrade ureteroscopic laser lithotripsy and/or cystolitholapaxy. Although complete stent removal can be anticipated, residual fragments are not uncommon.

Survival after diagnosis of localized T1a kidney cancer: current population-based practice of surgery and nonsurgical management

OBJECTIVE

To compare overall and cancer-specific survival (CSS) of patients who undergo nonsurgical management (NSM), partial nephrectomy (PN), and radical nephrectomy (RN). NSM is being increasingly used for older patients with early-stage kidney cancer and competing risks of death. However, survival is poorly characterized for this approach compared with surgery with PN or RN.

METHODS

The Surveillance, Epidemiology and End Results-Medicare database from 1995 to 2007 was used to identify patients aged 65 years or older diagnosed with localized T1a kidney cancer treated with PN, RN, or NSM. We used Cox proportional hazards regression, Fine and Gray competing risks regression, and propensity score matching to adjust for patient and tumor characteristics.

RESULTS

Of 7177 Medicare beneficiaries meeting the inclusion criteria, 754 (10.5%) underwent NSM, 1849 (25.8%) PN, and 4574 (63.7%) RN, with 436 (57.8%), 389 (21.0%), and 1598 (34.9%) patients dying from any cause, respectively, at a median follow-up of 56 months. Overall survival favored PN and RN compared with NSM (hazard ratio [95% CI]: 0.40 [0.34-0.46] and 0.50 [0.45-0.56], respectively) as did CSS (hazard ratio [95% CI]: 0.42 [0.27-0.64] and 0.62 [0.46-0.85], respectively). However, there was no difference in CSS between any 2 treatment groups for younger patients (<75 years), whereas there was an excess of kidney cancer deaths for NSM patients aged 75-79 years and an attenuated difference for patients aged 80 years or older.

CONCLUSION

NSM was associated with an increased risk of kidney cancer death among Medicare beneficiaries aged 75-79 years. Evolving active surveillance protocols will need to develop robust selection criteria to maximize cancer survival for older patients with kidney cancer.

Failing to follow up: predicting patients that will "no-show" for medically advised imaging following endourologic stone surgery

INTRODUCTION

The purpose of this study is to evaluate predictors of poor compliance after treatment of urinary stone disease.

MATERIALS AND METHODS

This study was a retrospective analysis of patients who underwent stent removal following percutaneous nephrolithotomy (PCNL) or ureteroscopy (URS) between 2008-2012. All patients were scheduled for follow up evaluation and renal ultrasound at 4-6 weeks following stent removal. Patients were stratified based on appointment compliance and demographic variables including gender, age, insurance type (Government Assisted Insurance [GAI] or Private Insurance [PI]), initial procedure, season, distance between home and clinic, average monthly gas price at follow up, and median education attainment. Logistic regression was performed to determine independent predictors of missed follow up.

RESULTS

A total of 301 patients were included, 153 women (51% female) with a mean age of 54 ± 14.2 years. Of the cohort, 22.6% (n = 68) did not return for follow up. GAI was the only variable associated with a greater risk of non-compliance on univariate analysis (OR 2.13 [95% CI 1.12-3.86] p = 0.011) and multivariate analysis (OR 3.14.10 [95% CI 1.48-6.7], p < 0.01). Gender, age, procedure, season, distance, gas prices, and education were not significant predictors.

CONCLUSION

In our study, evaluating characteristics associated with missed follow up after stent removal for PCNL and URS, possession of GAI was the only factor associated with non-compliance. Urologists should be aware that persons with GAI may be at increased risk of missed follow up and should use this information to target interventions to improve compliance.

Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy (RP): a 20-year institutional experience

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Standard clinical care pathways to discharge have been established for a number of operations including radical prostatectomy (RP). The pathway after RP has changed dramatically over the past two decades due to improvements in surgical technique, anaesthesia and most recently, the introduction of minimally invasive RP (MIRP). This study adds evidence that the emergence of MIRP is associated with a decrease in LOS for all patients undergoing RP. In addition, it catalogues the development of the clinical care pathway over 20 years at a large, tertiary care hospital with extensive experience in RP. Finally, it defines the common reasons patients fall 'off-pathway' (ileus, urine leak, anaemia and re-exploration for bleeding) and defines the immediate perioperative morbidity profile of RP. Specifically, it addresses approach-specific morbidities and indicates that MIRP is associated with higher rates of 'off-pathway' discharge, most often due to ileus.

OBJECTIVE

To investigate the development of the clinical care pathway to discharge after radical prostatectomy (RP) at a large, academic medical centre over the past 20 years, focusing on the rates and reasons for deviation.

PATIENTS AND METHODS

In all, 18 049 men were identified from the Johns Hopkins RP database who had undergone surgery since 1991. Patients in whom the length of stay (LOS) was ≤95th percentile, defined the clinical care pathway to discharge and those in whom LOS was ≥98th percentile were termed 'off-pathway'.

RESULTS

The mean LOS decreased from 7.7 days in 1991 to 1.6 days in 2010. Of 7126 patients undergoing RP since 2005, 1803(25.3%), 4881(68.5%) and 312 (4.4%) were discharged on postoperative day (POD) 1, 2 and 3, respectively; 126 (1.8%) patients, discharged on POD4-21 were 'off-pathway'. The most common reasons for delay of discharge were ileus (44, 0.615%), urine leak (12, 0.17%), anaemia requiring blood transfusion (nine, 0.126%) and bleeding requiring re-exploration (six, 0.08%). The proportion of patients 'off-pathway' was 1.20%, 1.06% and 4.01% for retropubic RP (RRP), laparoscopic RP (LRP) and robot-assisted laparoscopic RP (RALRP), respectively (P < 0.001). Ileus delayed discharge in 0.28%, 0.37% and 1.9% of patients undergoing RRP, LRP and RALRP, respectively (P < 0.001).

CONCLUSIONS

The clinical care pathway to discharge after RP has changed dramatically at our institution over the past 20 years. RALRP appears to result in a higher proportion of 'off-pathway' patients, primarily due to ileus, compared with RRP and LRP. However, very few patients were discharged 'off-pathway'.

Multiphasic enhancement patterns of small renal masses (≤4 cm) on preoperative computed tomography: utility for distinguishing subtypes of renal cell carcinoma, angiomyolipoma, and oncocytoma

OBJECTIVE

To analyze the enhancement patterns of small renal masses (SRMs) during 4-phase computed tomography (CT) imaging to predict histology.

METHODS

One-hundred consecutive patients with SRMs and 4-phase preoperative CT imaging, who underwent extirpative surgery with a pathologic diagnosis of renal cell carcinoma (RCC), angiomyolipoma (AML), or oncocytoma, were identified from a single institution. An expert radiologist, blinded to histologic results, retrospectively recorded tumor size, RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor, and the location relative to polar lines) nephrometry score, tumor attenuation, and the renal cortex on all 4 acquisitions (precontrast, corticomedullary, nephrogenic, and delayed density).

RESULTS

Pathologic diagnoses included 48 clear-cell RCCs (ccRCCs), 22 papillary RCCs, 10 chromophobe RCCs, 13 oncocytomas, and 7 AMLs. There was no significant difference in median tumor size (P = .8), nephrometry score (P = .98), or anatomic location (P >.2) among histologies. Significant differences were noted in peak enhancement (P <.001) and phase-specific enhancement (P <.007) by histology. Papillary RCCs demonstrated a distinct enhancement pattern, with a peak Hounsfield unit (HU) of 56, and greatest enhancement during the NG and delayed phases. The highest peak HU were demonstrated by ccRCC (117 HU) and oncocytoma (125 HU); ccRCC more often peaked in the corticomedullary phase, whereas oncocytoma peaked in the nephrogenic phase.

CONCLUSION

In a series of patients with SRMs undergoing 4-phase CT, tumor histologies demonstrated distinct enhancement patterns. Thus, preoperative 4-phase CT imaging may provide useful information regarding pathologic diagnosis in patients undergoing extirpative surgery.

Contemporaneous comparison of open vs minimally-invasive radical prostatectomy for high-risk prostate cancer

OBJECTIVES

To analyze pathological and short-term oncological outcomes in men undergoing open and minimally-invasive radical prostatectomy (MIRP) for high-risk prostate cancer (HRPC; prostate-specific antigen level [PSA] >20 ng/mL, ≥ cT2c, Gleason score 8-10) in a contemporaneous series.

PATIENTS AND METHODS

In total, 913 patients with HRPC were identified in the Johns Hopkins Radical Prostatectomy Database subsequent to the inception of MIRP at this institution (2002-2011) Of these, 743 (81.4%) underwent open radical retropubic prostatectomy (ORRP), 105 (11.5%) underwent robot-assisted laparoscopic radical prostatectomy (RALRP) and 65 (7.1%) underwent laparoscopic radical prostatectomy (LRP) for HRPC. Appropriate comparative tests were used to evaluate patient and prostate cancer characteristics. Proportional hazards regression models were used to predict biochemical recurrence.

RESULTS

Age, race, body mass index, preoperative PSA level, clinical stage, number of positive cores and Gleason score at final pathology were similar between ORRP and MIRP. On average, men undergoing MIRP had smaller prostates and more organ-confined (pT2) disease (P = 0.02). The number of surgeons and surgeon experience were greatest for the ORRP cohort. Overall surgical margin rate was 29.4%, 34.3% and 27.7% (P = 0.52) and 1.9%, 2.9% and 6.2% (P = 0.39) for pT2 disease in men undergoing ORRP, RALRP and LRP, respectively. Biochemical recurrence-free survival among ORRP, RALRP and LRP was 56.3%, 67.8% and 41.1%, respectively, at 3 years (P = 0.6) and the approach employed did not predict biochemical recurrence in regression models.

CONCLUSIONS

At an experienced centre, MIRP is comparable to open radical prostatectomy for HRPC with respect to surgical margin status and biochemical recurrence.

Impact of robotic technique and surgical volume on the cost of radical prostatectomy

BACKGROUND AND PURPOSE

Our present understanding of the effect of robotic surgery and surgical volume on the cost of radical prostatectomy (RP) is limited. Given the increasing pressures placed on healthcare resource utilization, such determinations of healthcare value are becoming increasingly important. Therefore, we performed a study to define the effect of robotic technology and surgical volume on the cost of RP.

METHODS

The state of Maryland mandates that all acute-care hospitals report encounter-level and hospital discharge data to the Health Service Cost Review Commission (HSCRC). The HSCRC was queried for men undergoing RP between 2008 and 2011 (the period during which robot-assisted laparoscopic radical prostatectomy [RALRP] was coded separately). High-volume hospitals were defined as >60 cases per year, and high-volume surgeons were defined as >40 cases per year. Multivariate regression analysis was performed to evaluate whether robotic technique and high surgical volume impacted the cost of RP.

RESULTS

There were 1499 patients who underwent RALRP and 2565 who underwent radical retropubic prostatectomy (RRP) during the study period. The total cost for RALRP was higher than for RRP ($14,000 vs 10,100; P<0.001) based primarily on operating room charges and supply charges. Multivariate regression demonstrated that RALRP was associated with a significantly higher cost (β coeff 4.1; P<0.001), even within high-volume hospitals (β coeff 3.3; P<0.001). High-volume surgeons and high-volume hospitals, however, were associated with a significantly lower cost for RP overall. High surgeon volume was associated with lower cost for RALRP and RRP, while high institutional volume was associated with lower cost for RALRP only.

CONCLUSIONS

High surgical volume was associated with lower cost of RP. Even at high surgical volume, however, the cost of RALRP still exceeded that of RRP. As robotic surgery has come to dominate the healthcare marketplace, strategies to increase the role of high-volume providers may be needed to improve the cost-effectiveness of prostate cancer surgical therapy.

Practice patterns in the emergency care of kidney stone patients: an analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS)

INTRODUCTION

The emergency department (ED) is a common setting for evaluation of patients with urolithiasis based on acute symptoms and a propensity for recurrent disease. We sought to characterize practice patterns in the emergency treatment of stone disease, and to identify potential disparities in care based on non-medical factors.

MATERIALS AND METHODS

We performed a cross-sectional analysis of ED visits using the National Hospital Ambulatory Medical Care Survey from 2005-2009. Visits with a diagnosis of urolithiasis were identified. The associations between patient, provider and institutional characteristics were analyzed with regard to timing of clinical assessment, use of diagnostic imaging, and use of medical expulsive therapy (MET).

RESULTS

The likelihood of a delay in clinical assessment ranged from 30.8%-37.9%. Neither patient nor provider characteristics were associated with a delay in assessment, although urban location (p = 0.004) was more likely, and proprietary ownership was less likely (p = 0.002) to be associated with delay. Factors associated with use of CT included ambulance arrival (p = 0.043), initial ED visit (p = 0.000), and Northeast region (p = 0.030). Patients seen by a resident/intern were more likely to receive MET (p = 0.028). Overall, 10.8% of patients were presenting for follow up treatment, and 7.1% had been seen in the same ED within the last 72 hours.

CONCLUSIONS

Kidney stones are associated with a high rate of repeated presentations to the ED. Certain non-medical factors did impact details of management. Future efforts should focus on optimizing clinical pathways to improve the efficiency of acute care for kidney stone patients.

Comparative analysis of minimally invasive partial nephrectomy techniques in the treatment of localized renal tumors

OBJECTIVE

To report our initial experience with robot-assisted laparoscopic partial nephrectomy compared with traditional laparoscopic partial nephrectomy.

METHODS

A retrospective review of the Johns Hopkins minimally invasive urologic surgery database identified 207 consecutive patients who had undergone laparoscopic or robotic-assisted laparoscopic partial nephrectomy from 2007 to 2011 by a single surgeon. The patient demographics and pathologic, operative, and perioperative outcomes were compared between the surgical techniques. The early oncologic outcomes are reported for the entire cohort.

RESULTS

A total of 102 and 105 patients underwent laparoscopic partial nephrectomy and robotic-assisted laparoscopic partial nephrectomy, respectively. The demographic data were comparable between the 2 groups. The clinical and pathologic tumor characteristics were similar between the 2 groups, and a significant proportion (≥48%) of patients in each group had moderate to high complexity tumors. Patients undergoing robotic-assisted laparoscopic partial nephrectomy had decreased warm ischemia times, estimated blood loss, and operative times on univariate and multivariate analysis. No difference was seen in the total perioperative or significant urologic complications between the 2 groups. A review of the early oncologic outcomes revealed no local recurrences and 1 case of metastatic renal cell carcinoma.

CONCLUSION

Minimally invasive partial nephrectomy is associated with favorable perioperative outcomes and low morbidity. Robotic-assisted laparoscopic partial nephrectomy appears to be associated with favorable warm ischemia times compared with laparoscopic partial nephrectomy.