Omission of intraoperative drain placement during robotic partial nephrectomy and robotic radical prostatectomy is safe: an analysis of 18,000 patients.

PURPOSE: Placement of a drain during robotic assisted partial nephrectomy (RAPN) and robotic assisted radical prostatectomy (RARP) is standard practice for many urologists and can aid in assessment and management of complications such as urine leak, lymphocele, or bleeding. However, drain placement can cause discomfort and delay patient discharge, with questionable benefit. We aim to assess the correlation between drain placement with post operative complications. METHODS: The NSQIP targeted database was queried for patients who underwent RAPN or RARP from 2019 to 2021. Our primary outcomes included 30-day complication rates stratified by intraoperative drain placement. Secondary outcomes included procedure-specific complications, length of stay (LOS), and readmissions. Multivariable regression analyses, with Bonferroni correction, were performed for each post-operative complication. RESULTS: We identified 4738 and 13,948 patients who underwent RAPN and RARP, respectively. Drains were not placed in 2258 (47.7%) and 6700 (48%) patients, respectively. On adjusted multivariable analysis in the RAPN cohort, omission of drain placement was associated with decreased LOS (ß -0.45; 99.58% CI [-0.59, -0.32]) but no difference in overall complication rates. After adjusted analysis in the RARP cohort, omission of drain placement was associated with decreased risk of any complication (OR 0.73 [0.62-0.87]), infectious complication (OR 0.66 [0.49-0.89]), and LOS (ß -0.30 [-0.37, -0.24]). CONCLUSIONS: Using a large contemporary database, this study demonstrates that omission of drains during RAPN and RARP was safe without increased risk of postoperative complications. Despite inherent selection bias in this cohort, our data suggests that routine drain placement is not necessary for these procedures.

National Surgical Quality Improvement Program audit of contemporary perioperative care for radical cystectomy.

OBJECTIVE: To examine the impact of increased compliance to contemporary perioperative care measures, as outlined by enhanced recover after surgery (ERAS) guidelines, among patients undergoing radical cystectomy (RC). PATIENTS AND METHODS: From the National Surgical Quality Improvement Program database we captured patients undergoing RC between 2019 and 2021. We identified five perioperative care measures: regional anaesthesia block, thromboembolism prophylaxis, ≤24 h perioperative antibiotic administration, absence of bowel preparation, and early oral diet. We stratified patients by the number of measures utilised (one to five). Statistical endpoints included 30-day complications, hospital length of stay (LOS), readmissions, and optimal RC outcome. Optimal RC outcome was defined as absence of any postoperative complication, re-operation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable regressions with Bonferroni correction were performed to assess the association between use of contemporary perioperative care measures and outcomes. RESULTS: Of the 3702 patients who underwent RC, 73 (2%), 417 (11%), 1010 (27%), 1454 (39%), and 748 (20%) received one, two, three, four, and five interventions, respectively. On multivariable analysis, increased perioperative care measures were associated with lower odds of any complication (odds ratio [OR] 0.66, 99% confidence interval [CI] 0.6-0.73), and shorter LOS (ß -0.82, 99% CI -0.99 to -0.65). Furthermore, patients with increased compliance to contemporary care measures had increased odds of an optimal outcome (OR 1.38, 99% CI 1.26-1.51). CONCLUSIONS: Among the measures we assessed, greater adherence yielded improved postoperative outcomes among patients undergoing RC. Our work supports the efficacy of ERAS protocols in reducing the morbidity associated with RC.

Smoking is not associated with wound complications in augmented urethroplasty: a NSQIP analysis.

OBJECTIVE: To investigate if predictors of wound complications differed between patients undergoing excision and primary anastomosis urethroplasty (EPA) and augmented urethroplasty. METHODS: The National Surgical Quality Improvement Program database from 2006 to 2018 was queried for male patients undergoing urethroplasty. Thirty-day wound complications were identified and categorized (superficial/deep/organ-space surgical site infections and dehiscence). Multivariable logistic regression was performed to determine risk factors associated with wound complications. Smoking history was defined as current smoker within the past year. RESULTS: Urethroplasty was performed in 2251 males, with 25.46% (n = 573) using a flap or graft. There was no significant difference in wound complications for patients undergoing augmented urethroplasty (n = 17, 2.97%) or EPA (n = 45, 2.68%) (p = 0.9). The augmented group had a higher BMI, longer operative time, and longer length of stay. On multivariable logistic regression, risk factors associated with wound complications for patients undergoing EPA were diabetes (OR 2.56, p = 0.03) and smoking (OR 2.32, p = 0.02). However, these factors were not associated with wound complications in patients undergoing augmented urethroplasty. CONCLUSIONS: Smoking and diabetes were associated with increased wound complications for men undergoing EPA, but not in patients undergoing augmented urethroplasty. Patients with comorbidities associated with worse wound healing may be more likely to have a wound complication when undergoing EPA.

The Association Between Duration of Antibiotics and Infectious Complications Following Radical Cystectomy: Analysis of the 2019-2021 NSQIP Database.

OBJECTIVES: To identify the impact of the duration of peri-operative antibiotics on infectious complications following radical cystectomy. METHODS: The National Surgical Quality Improvement Project (NSQIP) targeted database was queried for patients undergoing radical cystectomy from 2019 to 2021. Baseline patient characteristics were collected. Antibiotic duration was classified as <24 hours (short), 24-72 hours (intermediate) or >72 hours (long). Infectious complication data were collected including surgical site infection (SSI), urinary tract infection (UTI), organ space infection, pneumonia, sepsis, and clostridium difficile infection up to 30 days after surgery. Univariate and multivariable analyses were performed to compare duration of antibiotic therapy to infectious outcomes. RESULTS: Of the 4363 patients who underwent radical cystectomy, 3250 (74%), 827 (19%) and 286 (6.6%) received short, intermediate, and long duration of peri-operative antibiotics, respectively. Infectious complication occurred in 954 (22%) patients, including 227 (5.2%) SSI, 280 (6.4%) UTI, 268(6.1%) organ space infection, 87 (2%) pneumonia, and 378 (8.7%) sepsis. Clostridium difficile infection occurred in 89 (2%) patients. On multivariable analysis, there was no significant difference in overall infectious complication rates with long-duration antibiotics. However, intermediate duration of antibiotics in open surgery was associated with a decreased risk of SSI (OR 0.58; 95%CI 0.37-0.91) compared to those treated with short-term antibiotics. CONCLUSION: Despite guideline recommendations, 26% of patients in this database received >24 hours of peri-operative antibiotics without decreased risk of overall infectious complication. An intermediate course of antibiotics decreased risk of SSI in open surgery compared to the guideline recommend <24-hour course. Greater education regarding antibiotic stewardship and further studies investigating infectious complications are warranted.

Effect of United States Medical Licensing Examination Score Cutoffs on Recruitment of Underrepresented Applicants in the Urology Match.

OBJECTIVE: To determine how the use of United States Medical Licensing Examination (USMLE) score cutoffs during the screening process of the Urology Residency Match Program may affect recruitment of applicants who are underrepresented in medicine (URM). MATERIALS AND METHODS: Deidentified data from the Association of American Medical Colleges' (AAMC) Electronic Residency Application Service (ERAS) system was reviewed, representing all applicants to our institution's urology residency program from 2018 to 2022. We analyzed self-reported demographic variables including race/ethnicity, age, sex/gender, as well as USMLE Step 1 and Step 2 scores. Chi-square tests and ANOVA were used to determine the association between race/ethnicity and other sociodemographic factors and academic metrics. Applicants were stratified according to USMLE Step 1 cutoff scores and the distribution of applicants by race/ethnicity was assessed using a Gaussian nonlinear regression fit. RESULTS: A total of 1258 applicants submitted applications to our program during the 5-year period, including 872 males (69.3%) and 386 females (30.7%). Most applicants were White (43.5%), followed by Asian (28.3%), Hispanic/Latino (11.7%), and Black (7.0%). There was an association between race/ethnicity and USMLE scores. Median USMLE Step 1 scores for White, Asian, Hispanic/Latino, and Black applicants were 242, 242, 237, and 232, respectively (P < .001). As cutoff score increases, percentage of URM applicants decreases. CONCLUSION: The use of cutoffs based on USMLE scores disproportionately affects URM applicants. Transitioning from numeric scores to pass/fail may enhance holistic review processes and increase the representation of URM applicants offered interviews at urology residency programs.

Comparing the rate of immunotherapy treatment change due to toxicity by sex.

BACKGROUND: Immuno-oncology therapy (IO) is associated with a variety of treatment-related toxicities. However, the impact of toxicity on the treatment discontinuation rate between males and females is unknown. We hypothesized that immune-related adverse events would lead to more frequent treatment changes in females since autoimmune diseases occur more frequently in females. AIMS: Our aim was to determine if there was a difference in the rate of immunotherapy treatment change due to toxicity between males and females. METHODS AND RESULTS: The Oncology Research Information Exchange Network Avatar Database collected clinical data from 10 United States cancer centers. Of 1035 patients receiving IO, 447 were analyzed, excluding those who did not have documentation noting if a patient changed treatment (n = 573). Fifteen patients with unknown or gender-specific cancer were excluded. All cancer types and stages were included. The primary endpoint was documented treatment change due to toxicity. Four hundred and forty-seven patients (281 males and 166 females) received IO treatment. The most common cancers treated were kidney, skin, and lung for 99, 84, and 54 patients, respectively. Females had a shorter IO course than males (median 3.7 vs. 5.1 months, respectively, p = .02). Fifty-four patients changed treatment due to toxicity. There was no significant difference between females and males on chi-square test (11.4% vs. 12.5%, respectively, p = 0.75) and multivariable logistic regression (OR 0.924, 95% CI 0.453-1.885, p = .827). Significantly more patients with chronic obstructive pulmonary disease (COPD) changed therapy due to toxicity (OR 2.491, 95% CI 1.025-6.054, p = .044). CONCLUSION: Females received a shorter course of IO than males. However, there was no significant difference in the treatment discontinuation rate due to toxicity between males and females receiving IO. Toxicity-related treatment change was associated with COPD.

Ergonomics in Urology: Current Landscape and Future Directions.

Optimal ergonomics are essential to improving clinical performance and longevity among urologists, as poor ergonomics can contribute to work-related injury and physician burnout. While a majority of urologists experience muscular injury throughout their career, women and trainees are disproportionately affected. These disparities are exacerbated by the lack of formal ergonomics education within urologic training programs. This review provides an overview of practical approaches to optimize ergonomics across working environments for urologists and trainees. We highlight intraoperative techniques and novel devices which have been shown to reduce work-related injury, and we identify knowledge gaps to guide future areas of ergonomic research.

The Role of Salvage Radical Prostatectomy in Patients with Radiation-Resistant Prostate Cancer.

There are multiple treatment strategies for patients with localized prostate adenocarcinoma. In intermediate- and high-risk patients, external beam radiation therapy demonstrates effective long-term cancer control rates comparable to radical prostatectomy. In patients who opt for initial radiotherapy but have a local recurrence of their cancer, there is no unanimity on the optimal salvage approach. The lack of randomized trials comparing surgery to other local salvage therapy or observation makes it difficult to ascertain the ideal management. A narrative review of existing prospective and retrospective data related to salvage radical prostatectomy after radiation therapy was undertaken. Based on retrospective and prospective data, post-radiation salvage radical prostatectomy confers oncologic benefits, with overall survival ranging from 84 to 95% at 5 years and from 52 to 77% at 10 years. Functional morbidity after salvage prostatectomy remains high, with rates of post-surgical incontinence and erectile dysfunction ranging from 21 to 93% and 28 to 100%, respectively. Factors associated with poor outcomes after post-radiation salvage prostatectomy include preoperative PSA, the Gleason score, post-prostatectomy staging, and nodal involvement. Salvage radical prostatectomy represents an effective treatment option for patients with biochemical recurrence after radiotherapy, although careful patient selection is important to optimize oncologic and functional outcomes.

Pelvic radiation-induced urinary strictures: etiology and management of a challenging disease.

Radiation is a common treatment modality for pelvic malignancies. While it can be effective at cancer control, downstream effects can manifest months to years after treatment, leaving patients with significant morbidity. Within urology, a particularly difficult post-radiation consequence is urinary tract stricture, either of the urethra, bladder neck, or ureter. In this review, we will discuss the mechanism of radiation damage and treatment options for these potentially devastating urinary sequelae.

Top Ten Tips Palliative Care Clinicians Should Know About Urological Care.

Patients receiving palliative care (PC) can present with or develop a host of urological needs or complications. These needs can include attention to sexual health, urinary incontinence, genitourinary bleeding, and urinary tract obstruction by benign, malignant, or urinary stone diseases. These varied conditions require that PC clinicians understand invasive and noninvasive medical, surgical, and radiation options for treatment. This article, written by a team of urologists, geriatricians, and PC specialists, offers information and guidance to PC teams in an accessible "Top Ten Tips" format to increase comfort with and skills around assessment, evaluation, and specialist referral for urological conditions common in the PC setting.

Single-Port Robotic Radical Prostatectomy: Short-Term Outcomes and Learning Curve.

Introduction and Objective: In 2018, the U.S. Food and Drug Administration approved the da Vinci single-port (SP) system, in which four instruments are still utilized, but enter through a single-site access trocar. Herein, we report the largest case series for SP robot-assisted radical prostatectomy (RARP) to date. Our primary aim is to analyze the perioperative and short-term outcomes of this procedure. Our secondary aim is an assessment of the learning curve with this new platform. Methods: A total of 157 patients underwent SP RARP by two surgeons who have completed >3000 multiport robotic surgeries collectively. Institutional Review Board-approved prospectively collected data were used. Basic demographic preoperative variables and perioperative outcomes were analyzed. Results: Median patient age and prostate-specific antigen was 63 years and 6.3 ng/mL before treatment (interquartile range [IQR] 4.7-8.2 ng/mL). Average prostate weight was 47 g. The median operating time was 195 minutes (IQR 165-221.25 minutes) with a median estimated blood loss of 100 mL (IQR 100-200 mL). Surgeon 1's operating time stabilized around case #56, and Surgeon 2 around case #26. Surgeon 2 used the transperitoneal approach for the first 7 cases. There were no intraoperative complications. There were six total postoperative complications (3.8%) and four (2.5%) were Clavien-Dindo scale ≥IIIa. One hundred ten patients went home same day, 45 stayed 1 night at the hospital, with only 2 patients requiring stay in the hospital for more than 1 night (70%, 29%, and 1% respectively). With the median follow-up period of 9 months, rates of biochemical recurrence, pad-free, and potency preservation were 8.3%, 82.5%, and 64.4%, respectively. Conclusions: This case series confirms the safety and efficacy of SP RARP with acceptable short-term outcomes. There is a significant learning curve for this new modality. Shorter hospital stay appears to be an early benefit of the SP platform.

Clearing up Clear Cell: Clarifying the Immuno-Oncology Treatment Landscape for Metastatic Clear Cell RCC.

Patients with advanced or malignant renal cell carcinoma at the time of diagnosis have historically had a poor prognosis. Immunonologic agents have significantly altered the therapeutic landscape and clinical outcomes of these patients. In this review, we highlight recent and upcoming clinical trials investigating the role of immunotherapies in clear cell RCC. In particular, we emphasize immunotherapy-based combinations, including immune checkpoint inhibitor (ICI) combinations, neoadjuvant, and adjuvant ICI, and ICI agents combined with anti-VEGF therapy.

Dissecting the role of lymphadenectomy in the management of renal cell carcinoma: past, present, and future.

Lymph node involvement in renal cell carcinoma (RCC) portends a poor prognosis. However, the role of lymph node dissection (LND) at the time of tumor resection is not fully understood. Conflicting data have been published regarding the survival implications of LND during RCC surgery, and the optimal patient population for which LND might be beneficial has yet to be identified. Based on recent data characterizing the outcomes of node-positive RCC, some have advocated for revising the current staging guidelines to better reflect these findings. Given the paucity of high-quality evidence supporting or refuting the routine use of LND in RCC, further research is needed to shed light on this important topic. There are a number of ongoing clinical trials evaluating the role of perioperative (neoadjuvant and adjuvant) systemic therapy, which include patients with node-positive RCC, and will serve to guide changes in treatment practices for this patient population moving forward.

Clinicopathological and survival analysis of clinically advanced papillary and chromophobe renal cell carcinoma.

INTRODUCTION: Clinically, the papillary (pRCC) and chromophobe (chRCC) histologic subtypes of renal cell carcinoma (RCC) are viewed as more indolent compared to the more-common clear cell histology (ccRCC). However, there remain advanced cases of these purportedly less-aggressive histologies that lead to significant mortality. We therefore sought to evaluate outcomes of advanced pRCC and chRCC compared to ccRCC utilizing the National Cancer Database's registry of RCC patients. MATERIALS AND METHODS: A total of 115,365 ccRCC patients, 28,344 pRCC patients, and 11,942 chRCC patients met eligibility criteria. Overall survival (OS) was estimated using the Kaplan-Meier method (median follow-up 3.6 years). OS was compared between stage III and IV ccRCC, pRCC, and chRCC using multivariable Cox proportional hazards model adjusted for clinical and treatment characteristics. RESULTS: A total of 25.7% of ccRCC patients, 14.1% of pRCC patients, and 14.8% of chRCC patients had stage III to IV disease. The 5-year OS for stage III ccRCC, pRCC, and chRCC was 66.9%, 63.6%, and 80.5%, respectively. The 5-year OS for stage IV ccRCC, pRCC and chRCC was 19.7%, 13.3%, and 22.0%, respectively. The hazard of death was significantly higher for stage IV pRCC vs. ccRCC (hazard ratio = 1.29; 95% confidence interval = 1.19, 1.39; P < 0.01) and similar for stage IV chRCC vs. ccRCC (hazard ratio = 1.01; 95% confidence interval = 0.85, 1.21; P = 0.885). CONCLUSIONS: pRCC and chRCC are rare but similarly fatal compared to ccRCC when advanced or metastatic. With most clinical trials devoted toward ccRCC, greater efforts to identify aggressive variants and treatment strategies for metastatic pRCC and chRCC are necessary.

An evaluation of race, ethnicity, age, and sex-based representation in phase I to II renal cell carcinoma clinical trials in the United States.

INTRODUCTION: Enrollment of a representative study population permits generalizable and reliable results for clinical trials. We sought to evaluate whether patients enrolled in trials for advanced renal cell carcinoma (RCC) are representative of the overall population of advanced RCC patients in the United States. MATERIALS AND METHODS: The clinicaltrials.gov results database was queried for interventional clinical trials directed at clinically advanced (stage III/IV) RCC that enrolled patients from the US only. We identified 375 patients from 18 phase I to II trials that met eligibility criteria. The American College of Surgeons' National Cancer Database (NCDB) which includes data on approximately 70% of all US cancer diagnoses was queried and we identified 75,308 patients with advanced (stage III/IV) RCC. Demographic characteristics were summarized and compared between the 2 populations. RESULTS: Compared to the US population of advanced RCC (NCDB), significant under-representation in clinical trials was observed for patients aged 65+ (26.3% vs. 50.4%; P<0.001) and among those with Hispanic ethnicity (2.7% vs. 7.2%; P = 0.005). A trend toward under-representation was observed for black patients (7.0% vs. 9.8%, P = 0.076) but not for white patients (89.9% vs. 87.0%, P = 0.107) or other racial groups (P>0.05 for all). Female patients made up 30.3% of trial enrollees and 33.3% of the US advanced RCC population (P = 0.221). CONCLUSION: Significant under-representation was observed for elderly and Hispanic patients with a trend toward under-representation for black and female patients in phase I to II RCC clinical trials. Greater efforts to include underrepresented populations are necessary to improve the effectiveness and generalizability of clinical trials in kidney cancer.

The effects of A1 pulley release after flexor tendon repair in a cadaveric model.

BACKGROUND: Decreasing rupture rates after flexor tendon repair is accomplished by increasing the strength of the repair and by decreasing the forces across tendons during rehabilitation. The authors sought to determine whether A1 pulley release affects work of flexion after a zone 2 flexor tendon repair. METHODS: Four fresh-frozen cadaveric hands were thawed to room temperature. The flexor digitorum profundus and flexor pollicis longus tendons were tested in a tensile testing machine. In hands 1 and 2, work of flexion of uninjured tendons was evaluated through the sequential division of the A1 pulley, starting with either the proximal 50 percent or the distal 50 percent of the pulley. In hands 3 and 4, zone 2 flexor digitorum profundus lacerations were created and repaired using a modified Kessler technique; then, sequential division of the A1 pulley was performed. Force-excursion curves were generated and used to calculate work of flexion. Analysis of variance was performed for multigroup comparisons, and t tests were performed for pairwise comparisons. Values of p < 0.05 were considered statistically significant. RESULTS: In uninjured tendons, work of flexion decreased with sequential division of the A1 pulley. After tendon repair, work of flexion increased significantly from baseline in all digits. A1 pulley release after flexor tendon repair produced significant decreases in work of flexion in all digits. CONCLUSIONS: A1 pulley release effectively decreases work of flexion after flexor tendon repair. Release performed at the time of tendon repair may decrease the forces across tendons in the postoperative period.