Ability of Surgical Residents to Impact Patient Tobacco Use in the Perioperative Setting

INTRODUCTION

Tobacco use significantly impacts patient morbidity and mortality, and is particularly important to the surgical community as it has a negative impact on surgical recovery. Despite its relevance, most surgeons do not engage in smoking cessation counseling.

METHODS

As part of the UCSF Medical Center quality improvement program, urology residents designed and led an initiative targeting urological patients undergoing surgery at UCSF between August 2013 and July 2014. Our primary objectives were to 1) elicit the smoking status of at least 80% of perioperative patients who stayed at least 1 night in the hospital and 2) obtain an inpatient smoking cessation consultation for patients who were active tobacco users.

RESULTS

A total of 934 patients were assessed, of whom 8.5% were current tobacco users, 37% were past users and 55% had never used tobacco. Current smokers were more likely to be younger and female, and less likely to have a cancer diagnosis compared to past or never smokers (all p ≤0.001). The rate of tobacco status assessment improved significantly throughout the quality improvement period, at 59.0% in quarter 1, 85.5% in quarter 2, 92.9% in quarter 3 and 94.4% by quarter 4. Patients who underwent smoking cessation consults were more likely to be prescribed nicotine replacement therapy during their hospital stay and upon discharge home.

CONCLUSIONS

Through our quality initiative program we demonstrated a fast, feasible and easily implemented approach to identify smokers, and obtain smoking cessation counseling and treatment. This practical approach represents a significant opportunity to effect change in smoking behavior at a teachable moment.

Age and baseline quality of life at radical prostatectomy--who has the most to lose?

PURPOSE

Although younger men have better health related quality of life scores after radical prostatectomy, many have higher baseline function with more to lose than older men. We examined the impact of age on sexual and urinary function and bother during the first 2 years after radical prostatectomy.

MATERIALS AND METHODS

Participants enrolled in CaPSURE™ reported sexual and urinary scores before and after radical prostatectomy using UCLA-PCI. Repeated measures mixed models were used to compare the change in health related quality of life with time between men who were younger (age 60 years or less) and older (age greater than 60 years). Logistic regression models were used to assess associations between age and clinically meaningful health related quality of life decreases (worsening). Models were adjusted for clinical characteristics.

RESULTS

Of 1,806 patients younger men reported higher sexual and urinary function scores at each time point and higher sexual function decrease rates at 1 year than older men (81% vs 75%, p<0.01). Younger men also had higher sexual bother decrease rates 1 year (74% vs 61%, p<0.01) and 2 years (62% vs 56%, p=0.02) after radical prostatectomy. On multivariate analysis age was associated with changes in sexual function and bother from baseline through 2 years (each p<0.01). Younger men had higher adjusted odds of sexual function decreases at 1 year (OR 1.15/5 years, 95% CI 1.01-1.30, p=0.03) but not at 2 years. Younger age was associated with lower odds of worsening sexual bother at 2 years (OR 0.79/5 years, 95% CI 0.67-0.94, p<0.01). Urinary function and bother decrease rates were similar by age. Secondary analyses of the age/health related quality of life interaction showed that men were at greater risk for health related quality of life decreases if baseline scores were above average regardless of age.

CONCLUSIONS

Younger men reported higher sexual and urinary function overall, and experienced greater decreases in sexual function immediately after radical prostatectomy than older men. While the 2 groups experienced similar relative sexual function decreases at 2 years, younger men had worse interim decreases at 1 year. Providers should consider these findings when discussing treatment timing, particularly with younger men diagnosed with early stage, low grade disease.

Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy

Background

We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP).

Patients and methods

Data were available from 716 consecutive patients before, during and after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded prostate weight into <50, 50–80 and >80 g, corresponding to small, moderate and large glands, respectively. Perioperative data and the histopathological and functional outcomes were compared across these groups by both univariable and multivariable-adjusted analyses.

Results

Increased prostate size was associated with increased age, preoperative prostate-specific antigen levels, body mass index, operative duration, blood loss, lower biopsy and pathological Gleason scores, and lower pathological staging (P < 0.05). The incidence of extensive positive surgical margins was 14.8%, 9.7%, and 5.3% in small, moderate and large prostates, respectively (P < 0.001). However, after multivariable adjustment, only Gleason score and pathological stage were significantly associated with the incidence of positive margins (P < 0.05); prostate weight was not significantly associated. Overall, 78% and 92% of patients were potent and continent at 12 months, respectively, which was not affected by prostate size.

Conclusion

Patients with larger prostates had favourable pathological outcomes after RALP. When controlling for pathological stage, prostate size was not associated with margin positivity. Functionally, neither continence nor potency at 12 months was affected by prostate size.

Candidacy for active surveillance may be associated with improved functional outcomes after prostatectomy

OBJECTIVE

In an effort to curb overtreatment, active surveillance (AS) has grown in popularity as an option for men with low-risk prostate cancer. We evaluated the histopathologic and functional outcomes of patients who qualified for AS, but opted for robotic-assisted laparoscopic prostatectomy (RALP), and compared them to non-AS candidates.

METHODS

An institutional database of 1,477 RALP performed by a single surgeon was queried for AS candidates, defined as PSA <10 ng/mL, biopsy Gleason score ≤6 with a minimum of 10 biopsy cores, <3 positive cores with <50% tumor volume in a single core and clinical stage ≤T2a.

RESULTS

Of the 352 patients who would have qualified for AS, 159 (45%) were upgraded: 143 (41%) to Gl 3 + 4, 16 (4.5%) to 4 + 3, zero to Gleason 8 or higher. Seventeen (4.8%) patients were upstaged to pT3. AS candidates were younger and had more favorable tumor characteristics, but similar preoperative functional status. Bilateral nerve sparing was performed on 96% of AS candidates vs. 86% of non-AS candidates (P < 0.001). After 12 months of follow-up in patients who received bilateral nerve sparing, continence was higher in the AS cohort (98% vs. 92%, P < 0.001) but potency was equivalent (87% in each, P = 0.89). On multivariable analysis, candidacy for AS was independently associated with improved continence, but not potency.

CONCLUSIONS

In addition to having the expected favorable histopathologic features, AS candidates who desire definitive therapy have a high likelihood of achieving excellent functional outcomes, perhaps superior to non-AS candidates, following RALP.

Simple, age-based formula for predicting renal length in children

OBJECTIVE

To determine a simple, age based formula for predicting ideal renal length in children. Renal size is a valuable marker in the evaluation of children with urological disorders. Although many authors have described complex nomograms and multivariate formulas for determining renal size, we propose a simple and accurate formula.

MATERIAL AND METHODS

All renal ultrasound (US) studies performed over a 9-year period in patients <18 years of age were retrospectively evaluated, excluding patients with a history of urinary tract disease or with abnormal renal US findings.

RESULTS

Ultrasounds were performed in 778 children <18 years who met inclusion criteria. Sixty-one percent of the patient population was ≥1 year of age at the time of the US. Forty-four percent of the children were male. In children 1 year of age or older, the formula was length (cm) = age (years) × 0.3 + 6, R(2) = .81. In infants younger than 1 year, renal length was poorly estimated by a simple age-based formula.

CONCLUSION

Our proposed formula can be used to predict renal length in children older than 1 year.

Continuing robotically? The completion of a robot-assisted radical prostatectomy after laparotomy

The laparoscopic management of difficult adhesions can be quite challenging for even the most experienced of laparoscopic surgeons. We describe a case of managing a suspected enterotomy with a laparotomy during a robot-assisted radical prostatectomy and the surgical options after repair. The case was complicated by a Meckel's diverticulum fused and continuous with a urachal cyst, itself a rare occurrence. After the excision of the Meckel's diverticulum–urachal complex, the laparotomy incision was closed, and the prostatectomy was performed robotically. We discuss the controversies regarding continuation of a planned robotic procedure after a midline laparotomy.

Unnecessary imaging for the staging of low-risk prostate cancer is common

OBJECTIVE

To quantify the rate of overuse of preoperative imaging procedures in a referral cohort of low-risk patients. International evidence-based best practice guidelines discourage routine imaging for staging purposes in low-risk patients with newly diagnosed prostate cancer.

MATERIAL AND METHODS

An institutional database comprised of all patients undergoing robotic-assisted laparoscopic prostatectomy was queried for "low-risk" patients between May 2005 and January 2010. "Low-risk" was defined by the most inclusive criteria for imaging recommendations: prostate-specific antigen ≤10 ng/mL and Gleason score ≤6. We defined staging imaging as a bone scan, computed tomography (CT) of the pelvis or endorectal magnetic resonance imaging performed after the diagnosis of prostate cancer and before prostatectomy for the indication of "prostate cancer." Six-hundred seventy-seven patients were identified as having low-risk disease and comprised our study population.

RESULTS

Of the 677 patients identified as low risk, 328 (48%) underwent at least one preoperative imaging procedure despite the guideline recommendations. Two-hundred two of 677 (30%) patients were administered at least 2 of the 3 modalities, and 18/677 (3%) patients received all 3 imaging examinations before prostatectomy. Suspicious results from the CT (7/265%, 2.7%) or bone scan (21/241%, 8.7%) resulted in 27 patients undergoing additional radiographic imaging, none of which resulted in suspicious lesions requiring intervention or biopsy.

CONCLUSIONS

Despite international evidence-based guidelines for the staging of newly diagnosed prostate cancer patients, many urologists continue to refer low-risk patients for unnecessary imaging studies. This may place the patient at increased risk from radiation or contrast exposure and places an unnecessary financial burden on the patient and health care system.

Endorectal magnetic resonance imaging has limited clinical ability to preoperatively predict pT3 prostate cancer

OBJECTIVE

• To assess the clinical value of preoperative knowledge of the presence of extracapsular extension (ECE) or seminal vesicle invasion (SVI) in the planning for prostatectomy.

MATERIALS AND METHODS

• An institutional database of 1161 robotic-assisted laparoscopic prostatectomies (RALP) performed by a single surgeon (D.B.S.) was queried for those who underwent endorectal coil magnetic resonance imaging (erMRI) before robotic-assisted laparoscopic prostatectomy. • erMRI reports were dichotomized into positive or negative and compared with the final histopathology. The erMRIs performed at academic centres were compared with those performed in non-academic settings. • A sub-group of high-risk patients was also analyzed for erMRI accuracy.

RESULTS

• The 179 patients who underwent erMRI had significantly worse disease compared to the 982 patients without imaging. Of the 110 patients with histopathologically organ-confined disease, 81 (74%) were correctly diagnosed as such on erMRI, whereas 29 (26%) were felt to have cT3 disease and constituted false-positives. Among the 69 patients with pT3 disease, erMRI correctly predicted 30 (43%), whereas 39 (57%) were incorrectly considered organ-confined. • The overall sensitivity and specificity for diagnosing pT3 disease was 43% and 73%. • When stratified by pT3a and pT3b, the sensitivity and specificity of erMRI to accurately diagnose ECE is 33% and 81%, respectively. In evaluating SVI, erMRI has a sensitivity and specificity of 33% and 89%, respectively. The positive predictive value of erMRI to assess for ECE and SVI is 50% in both, with a negative predictive value of 61% and 63%, respectively. • erMRIs performed at academic centres compared to non-academic locations demonstrated similar rates of sensitivity at 67% vs 77% and specificity at 39% vs 54%, respectively (P = 0.33).

CONCLUSIONS

• In the setting of the present study, which was designed to be more reflective of current practice patterns in the USA, erMRI has limited clinical value in preoperatively detecting ECE and SVI. • The accuracy of detecting T3 disease did not improve in academic centres or in high-risk patients.