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.

"Shared decision-making" for prostate cancer screening: Is it a marker of quality preventative healthcare?

BACKGROUND

"Shared decision-making" (SDM) is a cornerstone of prostate cancer (PCa) screening guidelines due to tradeoffs between clinical benefits and concerns for over-diagnosis and over-treatment. SDM requires effort by primary-care-providers (PCP) in an often busy clinical setting to understand patient preferences with the backdrop of patient risk factors. We hypothesized that SDM for PCa screening, given its prominence in guidelines and practical challenges, may be associated with quality preventative healthcare in terms of other appropriate cancer screening and encouragement of other preventative health behaviors.

METHODS

From the 2020 Behavioral Risk Factor Surveillance Survey, 50-75 year old men who underwent PSA screening were assessed for their participation in SDM, PCa and colorectal cancer (CRC) screening, and other preventative health behaviors, like vaccination, exercise, and smoking status. Adjusted odds ratio of likelihood of PSA testing as a function of SDM was calculated. Likelihoods of SDM and PSA testing as a function of preventative health behaviors were also calculated.

RESULTS

Screening rates were 62 % for PCa and 88 % for CRC. Rates of SDM were 39.1 % in those with PSA screening, and 16.2 % in those without. Odds of PSA screening were higher when SDM was present (AOR = 2.68). History of colonoscopy was associated with higher odds of SDM (AOR = 1.16) and PSA testing (AOR = 1.94). Health behaviors, like regular exercise, were associated with increased odds of SDM (AOR = 1.14) and PSA testing (AOR = 1.28). History of flu vaccination (AOR = 1.29) and pneumonia vaccination (AOR = 1.19) were associated with higher odds of SDM. Those who received the flu vaccine were also more likely to have PSA testing (AOR = 1.36). Smoking was negatively associated with SDM (AOR = 0.86) and PSA testing (AOR = 0.93). Older age was associated with higher rates of PSA screening (AOR = 1.03, CI = 1.03-1.03). Black men were more likely than white men to have SDM (AOR = 1.6, CI = 1.59 - 1.6) and decreased odds of PSA testing (AOR = 0.94, CI = 0.94 - 0.95).

CONCLUSIONS

SDM was associated with higher odds of PSA screening, CRC screening, and other appropriate preventative health behaviors. Racial disparities exist in both SDM and PSA screening usage. SDM may be a trackable metric that can lead to wider preference-sensitive care and improved preventative care.

Modern internet search analytics and spine: what are patients asking and reading online?

Background

Google's People Also Ask feature uses various machine learning algorithms to distill the most frequently asked questions and link users to potential answers. The aim of this study is to investigate the most frequently asked questions related to commonly performed spine surgeries.

Methods

This is an observational study utilizing Google's People Also Ask feature. A variety of search terms were entered into Google for anterior cervical discectomy and fusion (ACDF), discectomy, and lumbar fusion. Frequently asked questions and linked websites were extracted. Questions were categorized by topic based on Rothwell's Classification system, and websites were categorized by type. Pearson's chi-squared and Student t tests were performed as appropriate.

Results

A total of 576 unique questions (181 ACDF, 148 discectomy, 309 lumbar fusion) were extracted with 372 unique websites and 177 domains. The most common website types were medical practice (41%), social media (22%), and academic (15%). The most popular question topics were specific activities & restrictions (22%), technical details (23%), and evaluation of surgery (17%). Questions related to technical details were more common in discectomy vs lumbar fusion (33% vs 24%, p=.03) and lumbar fusion vs ACDF (24% vs 14%, p=.01). Questions related to specific activities & restrictions were more common in ACDF vs discectomy (17% vs 8%, p=.02) and ACDF vs lumbar fusion (28% vs 19%, p=.016). Questions related to risks & complications were more common in ACDF vs lumbar fusion (10% vs 4%, p=.01).

Conclusions

The most frequently asked questions on Google regarding spine surgery are related to technical details and activity restrictions. Surgeons may emphasize these domains in consultations and direct patients to reputable sources of further information. Much of the linked information provided originates from nonacademic and nongovernment sources (72%), with 22% from social media websites.

County Rurality is Associated with Increased Tumor Size and Decreased Survival in Patients with Ewing Sarcoma

Background

Ewing Sarcoma (ES) is an aggressive tumor affecting adolescents and young adults. Prior studies investigated the association between rurality and outcomes, although there is a paucity of literature focusing on ES.

Objective

This study aims to determine whether ES patients in rural areas are subject to adverse outcomes.

Methods

This study utilized the Surveillance, Epidemiology, and End Results (SEER) database. A Poisson regression model was used with controls for race, sex, median county income, and age to determine the association between rurality and tumor size. A multivariate Cox Proportional Hazard Model was utilized, controlling for age, race, gender, income, and tumor size.

Results

There were 868 patients eligible for analysis, with a mean age of 14.14 years. Of these patients, 97 lived in rural counties (11.18%). Metropolitan areas had a 9.50% smaller tumor size (p<0.0001), compared to non-metropolitan counties. Patients of Black race had a 14.32% larger tumor size (p<0.0001), and male sex was associated with a 15.34% larger tumor size (p<0.0001). The Cox Proportional Hazard model estimated that metropolitan areas had a 36% lower risk of death over time, compared to non-metropolitan areas (HR: 0.64, p ≤ 0.04).

Conclusion

Patients in metropolitan areas had a smaller tumor size at time of diagnosis and had a more favorable survival rate for cancer-specific mortality compared to patients residing in rural areas. Further work is needed to examine interventions to reduce this discrepancy and investigate the effect of extremely rural and urban settings and why racial disparities occur.