Relief of Urinary Symptom Burden after Primary Prostate Cancer Treatment.

PURPOSE: Harms of prostate cancer treatment on urinary health related quality of life have been thoroughly studied. In this study we evaluated not only the harms but also the potential benefits of prostate cancer treatment in relieving the pretreatment urinary symptom burden. MATERIALS AND METHODS: In American (1,021) and Spanish (539) multicenter prospective cohorts of men with localized prostate cancer we evaluated the effects of radical prostatectomy, external radiotherapy or brachytherapy in relieving pretreatment urinary symptoms and in inducing urinary symptoms de novo, measured by changes in urinary medication use and patient reported urinary bother. RESULTS: Urinary symptom burden improved in 23% and worsened in 28% of subjects after prostate cancer treatment in the American cohort. Urinary medication use rates before treatment and 2 years after treatment were 15% and 6% with radical prostatectomy, 22% and 26% with external radiotherapy, and 19% and 46% with brachytherapy, respectively. Pretreatment urinary medication use (OR 1.4, 95% CI 1.0-2.0, p = 0.04) and pretreatment moderate lower urinary tract symptoms (OR 2.8, 95% CI 2.2-3.6) predicted prostate cancer treatment associated relief of baseline urinary symptom burden. Subjects with pretreatment lower urinary tract symptoms who underwent radical prostatectomy experienced the greatest relief of pretreatment symptoms (OR 4.3, 95% CI 3.0-6.1), despite the development of deleterious de novo urinary incontinence in some men. The magnitude of pretreatment urinary symptom burden and beneficial effect of cancer treatment on those symptoms were verified in the Spanish cohort. CONCLUSIONS: Men with pretreatment lower urinary tract symptoms may experience benefit rather than harm in overall urinary outcome from primary prostate cancer treatment. Practitioners should consider the full spectrum of urinary symptom burden evident before prostate cancer treatment in treatment decisions.

Adverse health outcomes associated with surgical management of the small renal mass.

PURPOSE: Partial and radical nephrectomy are treatments for the small renal mass. Partial nephrectomy is considered the gold standard as it may protect against renal dysfunction compared to radical nephrectomy. However, both treatments may cause adverse health outcomes. MATERIALS AND METHODS: A matched cohort study was performed using the SEER (Surveillance, Epidemiology and End Results)-Medicare data set. Individuals treated with partial or radical nephrectomy for 4 cm or smaller nonmetastatic renal cell carcinoma were compared to 2 control groups (nonmuscle invasive bladder cancer and noncancer). A greedy algorithm matched surgical groups to controls. Medicare claims were examined for renal, cardiovascular and secondary cancer events. RESULTS: Patients who underwent partial nephrectomy (1,471) and radical nephrectomy (4,299) were matched to controls. The time to event model demonstrated an increased risk of renal events for both treatments. Compared to the bladder cancer control and noncancer control groups, radical nephrectomy hazard ratios for renal events were 2.415 (p <0.0001) and 6.211 (p <0.0001), respectively, while partial nephrectomy hazard ratios were 1.513 (p <0.0001) and 4.926 (p <0.0001), respectively. Secondary cancers were increased for partial nephrectomy and radical nephrectomy compared to both control groups (p <0.0001). Cardiovascular events were increased for both treatments compared to noncancer controls (p <0.0001), but not compared to bladder cancer controls. CONCLUSIONS: Partial nephrectomy and radical nephrectomy may lead to adverse health outcomes. Compared to controls, partial nephrectomy and radical nephrectomy are associated with worsened renal outcomes. The increase in secondary cancers and cardiovascular events with both treatments is notable, and requires further investigation. Further research should investigate if active surveillance of the appropriately selected small renal mass limits adverse health outcomes.

Medicare payments for outpatient urological surgery by location of care.

PURPOSE: The cost implications associated with offloading outpatient surgery from hospitals to ambulatory surgery centers and the physician office remain poorly defined. Therefore, we determined whether payments for outpatient surgery vary by location of care. MATERIALS AND METHODS: Using national Medicare claims from 1998 to 2006, we identified elderly patients who underwent 1 of 22 common outpatient urological procedures. For each procedure we measured all relevant payments (in United States dollars) made during the 30-day claims window that encompassed the procedure date. We then categorized payment types (hospital, physician and outpatient facility). Finally, we used multivariable regression to compare price standardized payments across hospitals, ambulatory surgery centers and the physician office. RESULTS: Average total payments for outpatient surgery episodes varied widely from $200 for urethral dilation in the physician office to $5,688 for hospital based shock wave lithotripsy. For all but 2 procedure groups, ambulatory surgery centers and physician offices were associated with lower overall episode payments than hospitals. For instance, average total payments for urodynamic procedures performed at ambulatory surgery centers were less than a third of those done at hospitals (p <0.001). Compared to hospitals, office based prostate biopsies were nearly 75% less costly (p <0.001). Outpatient facility payments were the biggest driver of these differences. CONCLUSIONS: These data support policies that encourage the provision of outpatient surgery in less resource intensive settings.

Surgical quality among Medicare beneficiaries undergoing outpatient urological surgery.

PURPOSE: The cost efficiency gains achieved from moving procedures to ambulatory surgery centers and offices may be mitigated if the quality of surgical care at these facilities is not comparable to that at the hospital. Motivated by this, we assessed short-term morbidity and mortality for patients by location of care. MATERIALS AND METHODS: Using a national sample of Medicare claims (1998 to 2006), we identified elderly beneficiaries who underwent one of 22 common outpatient urological procedures. After determining the facility type where each procedure was performed, we measured 30-day mortality, unexpected admissions and postoperative complications. Finally, we fit multivariable logistic regression models to evaluate the association between occurrence of an adverse event and the ambulatory setting where surgical care was delivered. RESULTS: During the study period, there was a substantial increase in the frequency of nonhospital based outpatient surgery. Compared to ambulatory surgery centers and offices, hospitals treated more women (p <0.001). Those patients also tended to be less healthy (p <0.001). While patients experienced fewer postoperative complications following surgery at an ambulatory surgery center, procedures performed outside the hospital were associated with a higher likelihood of a same day admission (ambulatory surgery centers OR 6.96, 95% CI 4.44-10.90 and offices OR 3.64, 95% CI 2.48-5.36). However, notably with case mix adjustment the probability of any adverse event was exceedingly low across all ambulatory settings. CONCLUSIONS: These data indicate that small but measurable variation in surgical quality exists by location of care delivery.

Readmission and Prolapse Recurrence After Abdominal and Vaginal Apical Suspensions in Older Women.

OBJECTIVE: Our objective was to evaluate 30-day readmission, 12-month prolapse recurrence, and complications after apical surgeries in older women. METHODS: A retrospective cohort study was conducted using 2002-2011 Medicare data in women 65 years or older who underwent abdominal sacrocolpopexy with synthetic mesh, vaginal uterosacral, or sacrospinous colpopexy with 12 months follow-up. Vaginal mesh procedures were excluded. The primary outcome was 30-day inpatient readmission. Secondary outcomes were complications and prolapse recurrence, defined as either reoperation or pessary insertion. We used Pearson χ, Fisher exact tests, and analyses of variance to examine difference between surgical treatment groups. Odds ratios (ORs) utilizing Charlson Comorbidity Index, age, race, and procedure type were calculated to assess the differences in the outcomes probability. RESULTS: Of 3,015 women, 863 underwent abdominal sacrocolpopexy, 510-uterosacral and 1,642-sacrospinous ligament suspensions. The 30-day readmission was 7.4% (95% confidence interval [CI] 5.7-9.2%; OR 2.4, 95% CI 1.7-3.5, P<.01) after abdominal sacrocolpopexy and 4.5% (95% CI 2.7-6.3%; OR 1.3, 95% CI 0.8-2.1, P=.3) after uterosacral compared with 3.5% (95% CI 2.6-4.4% P<.01) after sacrospinous ligament suspensions. Prolapse recurrence did not differ between the groups (8.2%, 95% CI 6.4-10.1%; 10.6%, 95% CI 7.9-13.3%; and 9.9%, 95% CI 8.4-11.3%, P=.3, respectively). Women had 30-day gastrointestinal complications (6.1%, 95% CI 4.5-7.7%; 1.2%, 95% CI 0.2-2.1%; and 1.1%, 95% CI 0.6-1.6%, P<.01), surgical site infections (5.9%, 95% CI 4.3-7.5%; 3.1%, 95% CI 1.6-4.7%; and 3.7%, 95% CI 2.8-4.6%, P=.01), genitourinary complications (10.9%, 95% CI 8.8-13%; 17.7%, 95% CI 14.3-21%; and 13.6%, 95% CI 12-15.3%, P<.01), and medical complications (7.4%, 95% CI 5.7-9.2%; 7.8%, 95% CI 5.5-10.2%; and 4.4%, 95% CI 3.4-5.4%, P<.01; all after abdominal sacrocolpopexy, uterosacral, and sacrospinous ligament suspensions, respectively). CONCLUSION: Vaginal apical suspensions compared with abdominal sacrocolpopexy with synthetic mesh are associated with lower rates of postoperative 30-day readmission without an increase in prolapse recurrence among older women.