Interaction of patient age and high-grade prostate cancer on targeted biopsies of MRI suspicious lesions.

OBJECTIVES: To evaluate the interaction of patient age and Prostate Imaging-Reporting and Data System (PI-RADS) score in determining the grade of prostate cancer (PCa) identified on magnetic resonance imaging (MRI)-targeted biopsy in older men. PATIENTS AND METHODS: From a prospectively accrued Institutional Review Board-approved comparative study of MRI-targeted and systematic biopsy between June 2012 and December 2022, men with at least one PI-RADS ≥3 lesion on pre-biopsy MRI and no prior history of PCa were selected. Ordinal and binomial logistic regression analyses were performed. RESULTS: A total of 2677 men met study criteria. The highest PI-RADS score was 3 in 1220 men (46%), 4 in 950 men (36%), and 5 in 507 men (19%). The median (interquartile range [IQR]) patient age was 66.7 (60.8-71.8) years, median (IQR) prostate-specific antigen (PSA) level was 6.1 (4.6-9.0) ng/mL, median (IQR) prostate volume was 48 (34-68) mL, and median (IQR) PSA density was 0.13 (0.08-0.20) ng/mL/mL. Clinically significant (cs)PCa and high-risk PCa were identified on targeted biopsy in 1264 (47%) and 321 (12%) men, respectively. Prevalence of csPCa and high-risk PCa were significantly higher in the older age groups. On multivariable analyses, patient age was significantly associated with csPCa but not high-risk PCa; PI-RADS score and the interaction of age and PI-RADS score were significantly associated with high-risk PCa but not csPCa. CONCLUSION: In our cohort, the substantial rate of high-risk PCa on MRI-ultrasound fusion targeted biopsies in older men, and its significant association with MRI findings, supports the value of pre-biopsy MRI to localise disease that could cause cancer mortality even in older men.

A Novel Risk Prediction Model to Triage Difficult Urethral Catheterizations.

OBJECTIVE: To construct a risk prediction model to identify cases of difficult urethral catheterizations (DUC) in order to prevent complications from improper placement. MATERIALS AND METHODS: Using a single-institution database of urologic consults for Foley catheterizations from June 2016 to January 2020, a model to predict DUC in male patients was constructed. DUC was defined as requiring the use of a guidewire, cystoscopy, urethral dilation, and/or suprapubic tube (SPT) placement, while a simple Foley was defined as an uncomplicated placement of a regular or coudé catheter. A final model to predict DUC was constructed using multivariable logistic regression and internally validated using bootstrap statistics. RESULTS: A total of 841 consults were identified, with 181 (21.5%) classified as a DUC. On multivariable regression, patient-specific factors as overweight BMI (OR: 1.71; P = .014), urethral stricture disease (OR: 7.38; P < .001), BPH surgery (OR: 2.47; P < .001), radical prostatectomy (OR: 4.32; P = .001), and genitourinary (GU) prosthetic implants (OR: 3.44; P = .046) were associated with DUC. Situational factors such as blood at the meatus (OR: 2.40; P < .001), and consulting team (eg, surgery OR: 4.82; P < .001) were also significant. Bootstrap analysis of the final model demonstrated good overall accuracy (predictive accuracy: 75%). CONCLUSION: This model is a promising tool to help providers identify patients who likely require catheterization by a urologist and potentially reduce catheterization-related complications. The high rate of uncomplicated catheterizations also highlights the need for continuing education amongst healthcare professionals. External validation and application to the initial Foley encounter will shed light on its overall utility.

Survival and oncologic outcomes of complete transurethral resection of bladder tumor prior to neoadjuvant chemotherapy for muscle-invasive bladder cancer.

OBJECTIVES: Prior studies have shown that pathologic complete response at radical cystectomy, a significant prognostic factor, can be attributed to both neoadjuvant chemotherapy (NAC) and high-quality transurethral resections (TURBT) prior to NAC. It remains unclear whether the visual completeness of TURBT prior to NAC plays an important role in subsequent outcomes. We sought to assess the association of completeness of TURBT prior to NAC with response and survival outcomes. METHODS AND MATERIALS: We retrospectively reviewed all patients with clinically localized muscle-invasive bladder cancer at our institution who received NAC from 2000 to 2017. Complete TURBT was defined as resection of all visible tumor in entirety, resection to normal-appearing muscle, and/or repeat pre-NAC TURBT revealing cT0. Patients who were restaged as cT0 after NAC and refused cystectomy were placed on an active surveillance/delayed intervention (ASDI) protocol. The primary endpoints were overall and cancer-specific survival. The secondary endpoints were recurrence-free and muscle-invasive recurrence-free survival. RESULTS: Of 93 patients, 62 (67%) underwent complete TURBT prior to chemotherapy. Compared to patients with incomplete TURBT, those with complete TURBT had lower rates of variant histology (13% vs. 32%) and hydronephrosis (15% vs. 39%). Also, 36% of patients with incomplete TURBT had ≥cT3 disease prior to NAC, compared to none in the complete TURBT cohort. Patients with complete TURBT were more likely to defer RC and pursue ASDI (61% vs. 32%). Those with complete TURBT had lower rates of pT2 or higher disease at cystectomy (48% vs. 75%), with a lower rate of N+ disease trending towards significance (17% vs. 37%). Patients with complete TURBT had higher 5-year overall (77% vs. 46%, P = 0.003) and cancer-specific (85% vs. 50%, P = 0.001) survival. On Cox regression analysis, complete TURBT was significantly associated with superior cancer-specific, recurrence-free, and muscle-invasive recurrence-free survival. CONCLUSIONS: A complete TURBT prior to NAC is associated with improved survival and oncologic outcomes in this cohort with muscle-invasive bladder cancer. The extent to which complete TURBT simply represents a proxy for less aggressive disease or is actually a beneficial therapeutic intervention which improves response to chemotherapy is difficult to define retrospectively.

Diagnostic yield of repeat evaluation for asymptomatic microscopic hematuria after negative initial workup.

PURPOSE: The American Urological Association guideline for asymptomatic microhematuria recommends in patients with a negative initial workup, repeat workup should be considered for those with persistent/recurrent microhematuria. However, there is little data on the yield of repeat evaluation. Our hypothesis was that repeat workup yields a low detection rate of urologic malignancy. MATERIALS AND METHODS: We retrospectively reviewed all patients at our institution who underwent microhematuria workup with cystoscopy and upper tract imaging from May 2010 to June 2016. Microhematuria was defined as ≥3 RBCs/HPF on a properly collected specimen in the absence of a benign cause. Demographics, age, smoking history, history of radiation, and findings on repeat cystoscopy and imaging were collected. Our primary endpoint was a new diagnosis of urologic malignancy. RESULTS: Our initial cohort included 1,332 patients, of whom 21 were diagnosed with urothelial carcinoma and 7 with suspicious renal masses on initial workup. A total of 637 patients with negative initial workup had persistent/recurrent microhematuria. Repeat cystoscopy was performed in 161 (25%) patients at a median of 39 months, and repeat upper tract imaging was performed in 317 (50%) patients at a median of 39 months. Overall, repeat cystoscopy revealed new bladder cancer in 2 (1.2%) patients and repeat imaging revealed new suspicious renal mass in 4 (1.3%) patients. CONCLUSIONS: We observed a low number of newly diagnosed malignancies among patients with persistent/recurrent asymptomatic microhematuria who had a prior negative workup. Additional research is required to determine the utility of a repeat AMH workup.

The intravesical injection of highly purified botulinum toxin for the treatment of neurogenic detrusor overactivity.

INTRODUCTION: We aimed to assess safety and efficacy of incobotulinumtoxinA for the treatment of neurogenic detrusor overactivity (NDO). METHODS: We identified patients with NDO confirmed on urodynamics (UDS) and reported urgency incontinence (UI) in those who received intravesical incobotulinumtoxin A injection for neurogenic bladder between November 2013 and May 2017. Parameters studied were daytime frequency, daily incontinence episodes, daily pad use, clean intermittent catheterization (CIC) volumes, symptom scores (UDI6, IIQ7, PGII), and complications. RESULTS: We examined 17 male patients who met inclusion criteria and underwent incobotulinumtoxinA injection. Mean age was 61.2±15.4 years. Fourteen patients (82%) were taking oral antimuscarinics prior to the incobotulinumtoxin A injection. There were improvements in the following parameters: average daily pads (4.5 to 3.3, p=0.465), daily urinary frequency (9.4 to 4.6, p=0.048), daily incontinent episodes (2.5 to 0.4, p=0.033), CIC volumes (400 to 550 mL, p=0.356), hours in between CIC (3.6 to 5.2, p=0.127), and the validated questionnaires UDI6 (30.6 to 7.4, p=0.543) and IIQ7 (52.4 to 6.8, p=0.029). There were no documented symptomatic urinary tract infections (UTIs) within 30 days of injection or reports of de novo urinary retention. Nine of 17 patients (53%) reported being dry at their first postoperative visit. CONCLUSIONS: In this preliminary pilot study of a small cohort of males with NDO and UI, significant improvements were seen following incobotulinumtoxinA injection in daily frequency, incontinence episodes, hours in between CIC, and quality of life. Larger-scale and long-term studies are required to confirm these results, but initial findings are promising for wider use of this formulation.

Bladder Preservation for Patients With Bladder Paragangliomas: Case Series and Review of the Literature.

Bladder paragangliomas are rare tumors, with no prospective studies or guidelines on the management of this disease. We present a case series of 6 patients managed with bladder preservation over a median follow-up period of 124 months. We also present a review of the recent literature on bladder paragangliomas. We aim to provide a timely synthesis of the recent evidence on bladder paragangliomas as changing paradigms necessitate individualized treatment.

A Phase I Trial of Intravesical Cabazitaxel, Gemcitabine and Cisplatin for the Treatment of Nonmuscle Invasive bacillus Calmette-Guérin Unresponsive or Recurrent/Relapsing Urothelial Carcinoma of the Bladder.

PURPOSE: For patients with bacillus Calmette-Guérin unresponsive or recurrent/relapsing nonmuscle invasive bladder cancer, multi-agent intravesical trials have been limited. In this study we investigate the safety of intravesical cabazitaxel, gemcitabine and cisplatin in the salvage setting. MATERIALS AND METHODS: This was a dose escalation, drug escalation trial for patients with bacillus Calmette-Guérin unresponsive or recurrent/relapsing nonmuscle invasive bladder cancer who declined or were ineligible for radical cystectomy. All patients underwent a 6-week induction regimen of sequentially administered cabazitaxel, gemcitabine and cisplatin. Complete response was defined as no cancer on post-induction transurethral bladder tumor resection and negative urine cytology, while partial response allowed for positive cytology. Responders continued with maintenance cabazitaxel and gemcitabine monthly for the first year and bimonthly for the second year. RESULTS: A total of 18 patients were enrolled. Mean age was 71 years, median followup was 27.8 months (range 16.3 to 46.9) and mean number of previous rounds of intravesical therapies before trial enrollment was 3.7. Nine patients (50%) had received intravesical chemotherapy after bacillus Calmette-Guérin and 7 (39%) were previously treated in a phase I clinical trial setting. At enrollment 6 (33%) subjects had T1 disease and 13 (72%) had carcinoma in situ. There were no dose limiting toxicities. Initial partial and complete response rates were 94% and 89%, respectively. At 1 year recurrence-free survival was 0.83 (range 0.57 to 0.94) and at 2 years estimated recurrence-free survival was 0.64 (0.32 to 0.84). CONCLUSIONS: In this high risk and highly pretreated cohort of bacillus Calmette-Guérin unresponsive or recurrent/relapsing nonmuscle invasive bladder cancer cases combination intravesical cabazitaxel, gemcitabine and cisplatin was a well tolerated and potentially effective regimen.

Gender Differences in the Urology Residency Match-Does It Make a Difference?

OBJECTIVE: To assess the differences between the male and female urology resident applicant pool. Urology is a competitive field with a selective match process. Women have historically been a minority in medicine. Although this has equalized, women continue to be underrepresented in urology. MATERIALS AND METHODS: All application submitted through the Electronic Residency Application Service to the Columbia University Department of Urology for the 2015 and 2016 match were reviewed. The differences between the cohorts of matched female and male urology applicants were assessed. RESULTS: Two hundred fifty-six students in 2015 and 259 students in 2016 submitted applications to Columbia and completed rank lists (60% of the national cohort in 2015 and 62% in 2016). We did find that the overall male applicant pool had a slightly lower number of honors (3 vs 2, P = .02) and higher United States Medical Licensing Examination (USMLE) step 1 score (238 vs 234, P <.001). The only other statistically significant difference between the matched male and female cohorts was the average number of urology subinternships (1.4 [0.9] for men vs 1.18 [0.8] for women, P = .04). CONCLUSION: Overall matched male and female applicants appeared to have very similar qualifications. Men had a higher USMLE step 1 score and women had a higher average number of honors. These data support the finding that contemporary male and female residency candidates who matched in urology had comparable achievements, and the criteria for residency selection in both cohorts are similar.

Oncologic Outcomes of Definitive Treatments for Low- and Intermediate-Risk Prostate Cancer After a Period of Active Surveillance.

BACKGROUND: To compare oncologic outcomes of different definitive treatment (DT) modalities in a cohort of patients with prostate cancer (PCa) after active surveillance (AS). METHODS: We identified 237 patients with National Comprehensive Cancer Network (NCCN) low- and intermediate-risk prostate cancer diagnosed from 1990 to 2012 who did not undergo immediate DT within 12 months of diagnosis (ie, AS patients as well as watchful waiting and those refusing DT). Charts were examined for clinical/pathologic data and type of DT: surgery (RP), radiation including brachytherapy (XRT), cryotherapy, and androgen deprivation therapy monotherapy (ADT). The impact of DT on oncologic outcomes of biochemical recurrence (BCR), metastasis, disease-specific (DSS), and overall survival (OS) was examined with the Cox proportional hazards model, along with the Kaplan-Meier method and log-rank test. RESULTS: After median time on AS of 63.4 months, 40% of patients underwent DT: 47% XRT, 28% RP, 14% ADT, and 11% cryotherapy. On multivariable analysis, the use of XRT predicted higher BCR (hazard ratio [HR] 6.1, P = .001) and worse overall mortality (HR 2.1, P = .03) compared with other treatments, controlling for age, Charlson Comorbidity Index (CCI), stage, Gleason score, and NCCN risk category. Median follow-up was 71.7 months. On Kaplan-Meier analysis, 10-year OS was superior for RP versus XRT among patients with prostatic specific antigen (PSA) velocity >2.0 ng/mL/y. CONCLUSIONS: Low- and intermediate-risk patients with PCa who progress to DT after AS may be inadequately treated with radiation therapy compared with other DT modalities, especially when pretreatment PSA velocity is > 2 ng/mL/y.

Utilization Trends and Short-term Outcomes of Robotic Versus Open Radical Cystectomy for Bladder Cancer.

OBJECTIVE: To compare utilization trends and short-term outcomes of robotic versus open radical cystectomy for bladder cancer since the introduction of the robotic modifier (ICD-9 17.4x). MATERIALS AND METHODS: Using the Statewide Planning and Research Cooperative System database, an all-payer administrative system on all hospital discharges in New York State, we identified patients undergoing radical cystectomy (57.71) with a diagnosis of bladder cancer (188.0-188.9, 233.7, 236.7) from October 2008 to December 2012. Primary outcomes were inpatient complications and mortality at index stay. RESULTS: Of the 2525 patients, 24.2% (610 of 2525) underwent robotic and 75.8% (1915 of 2525) underwent open radical cystectomy. The proportion of robotic cases increased from 19.9% (119 of 597) in 2009 to 28.9% (173 of 598) in 2012 (P < .05). From 2009 to 2012, the number of open surgeons decreased from 117 to 109, and that of robotic increased from 56 to 66. Robotic patients had lower approach-specific surgeon and hospital volume, and more likely underwent lymph node dissection, ileal conduit diversion, blood transfusion, and prolonged length of stay. On multivariate analysis, robotic approach conferred a reduced risk of blood transfusion (odds ratio: 0.600, 95% confidence interval: 0.492-0.732, P < .0005) but had no association with prolonged length of stay. There were no significant differences in inpatient complications or mortality at index stay, parenteral nutrition, length of stay, hospital charges, readmission rates up to 90 days, or mortality up to 90 days between the surgical approaches. CONCLUSION: Despite the rapid dissemination and more recent experience of robotic radical cystectomy, we report lower rates of blood transfusion and otherwise similar short-term outcomes with open radical cystectomy.

Prevalence of Research Publication Misrepresentation Among Urology Residency Applicants and Its Effect on Match Success.

OBJECTIVE: To report the prevalence of research misrepresentation among urology residency applicants and assess its effect on match success. MATERIALS AND METHODS: All applications to the Columbia University urology residency program for the 2014-2015 match cycle were reviewed. "In-press," "accepted," and "submitted" manuscripts were verified using PubMed, Google Scholar, and journal websites. Misrepresentation for "in-press" and "accepted" manuscripts was defined as: (1) nonexistent manuscript, (2) nonauthorship of existent manuscript, (3) self-promotion to a higher author rank, and/or (4) existent manuscript in a nonpeer-reviewed publication. Logistic regression was performed to identify associated factors of misrepresentation and of match success. RESULTS: Of 257 applicants, 204 (79.4%) reported 1098 total manuscripts and 142 (55.3%) reported 371 unpublished manuscripts. About 5% (13 of 257) of applicants misrepresented 1 or more publications: 10 listed nonexistent manuscripts, 1 listed a publication for which he/she was listed a lower author rank than reported, 1 listed an accepted manuscript in a nonpeer-reviewed publication and for which he/she was not listed as an author, and 1 listed 4 in-press manuscripts in a nonpeer-reviewed publication. Only 55.8% (139 of 249) of "submitted" manuscripts were published within 12 months, with 41% (51 of 139) published in a journal of a lower impact factor than the reported journal of submission. Higher number of unpublished manuscripts was associated with misrepresentation. Higher Step 1 score, number of away sub-internships, and publication ratio were associated with match success. CONCLUSION: Research misrepresentation is a persistent issue in urology residency applications. However, misrepresentation in this cohort did not confer a significant advantage in match success.

Utilization trends and outcomes up to 3 months of open, laparoscopic, and robotic partial nephrectomy.

The aim of the study was to compare the utilization trends and short-term outcomes of open, laparoscopic, and robotic partial nephrectomy in New York State since the introduction of the robotic modifier in October 2008. The Statewide Planning and Research Cooperative System database is an all-payer, administrative database covering all hospital discharges within New York State. All patients who underwent partial nephrectomy (ICD-9 55.4) for kidney cancer (189.0) from October 2008 to December 2012 were identified. Patients with a minimally invasive modifier (54.21, 54.51) without the robotic modifier (17.4x) were categorized in the laparoscopic cohort. Logistic regression was performed to assess outcomes by surgical approach. Of the 5107 patients, 57.9% (2959/5107) underwent open, 12.1% (617/5107) laparoscopic, and 30.0% (1531/5107) robotic partial nephrectomy. From 2009 to 2012, the percentage of robotic cases increased from 17.7 to 39.8%. In comparison to open patients, those undergoing laparoscopic and robotic approaches, respectively, were less likely to receive blood transfusion (OR 0.54, p < 0.0005 and OR 0.45, p < 0.0005) and to experience a prolonged length of stay (OR 0.52, p < 0.0005 and OR 0.30, p < 0.0005). Patients undergoing robotic approach were also less likely to have an inpatient complication (OR 0.74, p = 0.004) and be readmitted within one (OR 0.73, p = 0.005) and 3 months (OR 0.69, p < 0.0005), but were at higher risk of excess hospital charges (OR 1.216, p = 0.01). Robotic partial nephrectomy is the predominant minimally invasive approach in New York State. Minimally invasive partial nephrectomy has multiple short-term advantages over open, with the costlier robotic approach having additional advantages with less inpatient complication and readmission risk.

Analysis of Transurethral Resection of the Prostate Costs across New York State Hospitals Using Severity of Illness Score.

INTRODUCTION: Using data on surgical treatment for benign prostatic hyperplasia we evaluated the effect of beneficiary health status on hospital reported costs. METHODS: We examined the records of 9,895 patients in the New York State Hospital Inpatient Cost Transparency database who underwent surgical treatment for benign prostatic hyperplasia, including laser prostatectomy and traditional transurethral resection of the prostate, in New York State from 2009 to 2011. RESULTS: Using the 3M™ APR-DRG (All Patient Refined Diagnosis Related Group) severity of illness index as a measure of patient preoperative health we found a significant increase in the cost of transurethral resection of the prostate for patients with higher severity of illness scores. We confirmed an increase in the cost and the cost variability of transurethral resection of the prostate for patients with higher severity of illness scores. CONCLUSIONS: Our findings illustrate the inherent unpredictability of cost forecasting and budgeting for these patients.

Male Urethral, Penile, and Incontinence Surgery: Is Resident Exposure Adequate?

OBJECTIVE: To evaluate trends in male urethral and penis/incontinence case volumes among urology residents and assess these for adequate surgical training/competency. METHODS: Accreditation Council for Graduate Medical Education (ACGME) case logs of urology residents graduating from U.S. programs from 2009 to 2013 were reviewed to determine the surgical volume of select index categories. Male urethral cases encompass urethrectomy and urethroplasty, whereas male penis/incontinence cases include urethral slings and sphincters. Case volumes as "surgeon," "assistant," and "teaching assistant" were reviewed and compared to ACGME minimum requirements. RESULTS: A total of 1032 graduating residents reported case logs. For male urethral surgery, residents reported weighted averages (standard deviation [SD]) of 12.7 (9.0) cases as "surgeon," 1.5 (3.5) cases as "assistant," and 0.2 (1.0) as "teaching assistant." The minimum requirement for these cases is 5. The annual 10th percentiles as "surgeon" ranged from 4 to 5 cases throughout the study period. For male penis/incontinence cases, residents reported weighted averages (SD) of 45.5 (22.7) cases as "surgeon," 3.6 (5.5) cases as "assistant," and 1.5 (3.0) cases as "teaching assistant." The minimum requirement is 10 cases. The 10th percentiles as "surgeon" ranged from 19 to 23 cases. CONCLUSION: Although the majority of residents met the minimum standard for these cases, about 10% of residents did not meet the requirement for male urethral surgery. In addition, a review of learning curves for these procedures suggests that the ACGME minimum requirements may be insufficient to confer actual competency in skill. Increasing this number in training or specialized postgraduate training programs is needed to provide actual competency.

Validation of a frailty index in patients undergoing curative surgery for urologic malignancy and comparison with other risk stratification tools.

OBJECTIVE: To retrospectively validate and compare a modified frailty index predicting adverse outcomes and other risk stratification tools among patients undergoing urologic oncological surgeries. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2005 to 2013 to identify patients undergoing cystectomy, prostatectomy, nephrectomy, and nephroureterectomy. Using the Canadian Study of Health and Aging Frailty Index, 11 variables were matched to the database; 4 were also added because of their relevance in oncology patients. The incidence of mortality, Clavien-Dindo IV complications, and adverse events were assessed with patients grouped according to their modified frailty index score. RESULTS: We identified 41,681 patients who were undergoing surgery for presumed urologic malignancy. Patients with a high frailty index score of >0.20 had a 3.70 odds of a Clavien-Dindo IV event (CI: 2.865-4.788, P<0.0005) and a 5.95 odds of 30-day mortality (CI: 3.72-9.51, P<0.0005) in comparison with nonfrail patients after adjusting for race, sex, age, smoking history, and procedure. Using C-statistics to compare the sensitivity and specificity of the predictive ability of different models per risk stratification tool and the Akaike information criteria to assess for the fit of the models with the data, the modified frailty index was comparable or superior to the Charlson comorbidity index but inferior to the American Society of Anesthesiologists Risk Class in predicting 30-day mortality or Clavien-Dindo IV events. When the modified frailty index was augmented with the American Society of Anesthesiologists Risk Class, the new index was superior in all aspects in comparison to other risk stratification tools. CONCLUSION: Existing risk stratification tools may be improved by incorporating variables in our 15-point modified frailty index as well as other factors such as walking speed, exhaustion, and sarcopenia to fully assess frailty. This is relevant in diseases such as kidney and prostate cancer, where surveillance and other nonsurgical interventions exist as alternatives to a potentially complicated surgery. In these scenarios, our modified frailty index augmented by the American Society of Anesthesiologists Risk Class may help inform which patients have increased surgical complications that may outweigh the benefit of surgery although this index needs prospective validation.

Patterns of care for readmission after radical cystectomy in New York State and the effect of care fragmentation.

OBJECTIVE: To determine if readmission after radical cystectomy (RC) to the original hospital of the procedure (OrH) vs. readmission to a different hospital (DiffH) has an effect on outcomes. METHODS: The New York Statewide Planning and Research Cooperative System database was queried for discharges between January 1, 2009 and November 31, 2012 after RC in New York State. Primary outcome was mortality within 30 and 90 days. Secondary outcomes included length of stay for readmission, rate of transfers/subsequent readmissions, hospital charges per readmission, and, if applicable, length of intensive care unit stays. Multivariate linear regression analyses were performed to adjust for confounding factors in predicting mortality. RESULTS: During the study period, 2,338 patients were discharged from 100 New York State hospitals after RC. Overall rate of readmission was 28.5% and 39.7% within 30 and 90 days, respectively. Of all readmitted patients, 80.4% and 77.1% were first readmitted to OrH within 30 and 90 days, respectively. Patients readmitted to OrH were younger (P<0.0005) and had a lower All Patient Refined Severity of Illness (P = 0.004). Patients readmitted to DiffH had shorter length of stay (P<0.0005) and lower hospital charges per readmission (P<0.0005), but higher rates of transfers/subsequent readmissions (P = 0.007) and intensive care unit stays (P = 0.002) at 90 days. Patients initially readmitted to DiffH also had a higher rate of mortality (30d, 7.8% vs. 2.3%, P = 0.002; 90d, 5.2% vs. 2.5%, P = 0.05), but initial readmission status was not significant for mortality when controlling for other variables of interest. CONCLUSION: Initial readmission to DiffH vs. OrH after RC was associated with higher rates of mortality, likely owing to underlying differences in the populations.

Delay from biopsy to radical prostatectomy influences the rate of adverse pathologic outcomes.

BACKGROUND: We sought to determine maximum wait times between biopsy diagnosis and surgery for localized prostate cancer, beyond which the rate of adverse pathologic outcomes is increased. METHODS: We retrospectively reviewed 4,610 patients undergoing radical prostatectomy between 1990 and 2011. Patients were stratified by biopsy Gleason score and PSA value. For each stratification, χ2 analysis was used to determine the smallest 15-day multiple of surgical delay (e.g., 15, 30, 45…180 days) for which adverse pathologic outcomes were significantly more likely after the time interval than before. Adverse outcomes were defined as positive surgical margins, upgrading from biopsy, upstaging, seminal vesicle invasion, or positive lymph nodes. RESULTS: Two thousand two hundred twelve patients met inclusion criteria. Median delay was 64 days (mean 76, SD 47). One thousand six hundred seventy-five (75.7%), 537 (24.3%), and 60 (2.7%) patients had delays of <=90, >90, and >180 days, respectively. Twenty-six percent were upgraded on final pathology and 23% were upstaged. The positive surgical margin rate was 24.2% and the positive lymph node rate was 1.1%. Significant increases in the proportion of adverse pathological outcomes were found beyond 75 days in the overall cohort (P = 0.03), 150 days for patients with Gleason <=6, and PSA 0-10 (P = 0.038), 60 days for patients with Gleason 7 and PSA >20 (P = 0.032), and 30 days for patients with Gleason 8-10 and PSA 11-20 (0.041). CONCLUSION: In low-risk disease, there is a considerable but not unlimited surgical delay which will not adversely impact the rate of adverse pathologic features found. In higher risk disease, this time period is considerably shorter.