Prognostic factors and outcomes in primary urethral cancer: results from the international collaboration on primary urethral carcinoma.

PURPOSE: To evaluate risk factors for survival in a large international cohort of patients with primary urethral cancer (PUC). METHODS: A series of 154 patients (109 men, 45 women) were diagnosed with PUC in ten referral centers between 1993 and 2012. Kaplan-Meier analysis with log-rank test was used to investigate various potential prognostic factors for recurrence-free (RFS) and overall survival (OS). Multivariate models were constructed to evaluate independent risk factors for recurrence and death. RESULTS: Median age at definitive treatment was 66 years (IQR 58-76). Histology was urothelial carcinoma in 72 (47 %), squamous cell carcinoma in 46 (30 %), adenocarcinoma in 17 (11 %), and mixed and other histology in 11 (7 %) and nine (6 %), respectively. A high degree of concordance between clinical and pathologic nodal staging (cN+/cN0 vs. pN+/pN0; p < 0.001) was noted. For clinical nodal staging, the corresponding sensitivity, specificity, and overall accuracy for predicting pathologic nodal stage were 92.8, 92.3, and 92.4 %, respectively. In multivariable Cox-regression analysis for patients staged cM0 at initial diagnosis, RFS was significantly associated with clinical nodal stage (p < 0.001), tumor location (p < 0.001), and age (p = 0.001), whereas clinical nodal stage was the only independent predictor for OS (p = 0.026). CONCLUSIONS: These data suggest that clinical nodal stage is a critical parameter for outcomes in PUC.

Abdominal adiposity, body composition and survival after liver transplantation.

BACKGROUND: Current measures of obesity do not accurately describe body composition. Using cross-sectional imaging, objective measures of musculature and adiposity are possible and may inform efforts to optimize liver transplantation outcomes. METHODS: Abdominal visceral fat area and psoas muscle cross-sectional area were measured on CT scans for 348 liver transplant recipients. After controlling for donor and recipient characteristics, survival analysis was performed using Cox regression. RESULTS: Visceral fat area was significantly associated with post-transplant mortality (p < 0.001; HR = 1.06 per 10 cm(2) , 95% CI: 1.04-1.09), as were positive hepatitis C status (p = 0.004; HR = 1.78, 95% CI: 1.21-2.61) and total psoas area (TPA) (p < 0.001; HR = 0.91 per cm(2) , 95% CI: 0.88-0.94). Among patients with smaller TPA, the patients with high visceral fat area had 71.8% one-yr survival compared to 81.8% for those with low visceral fat area (p = 0.15). At five yr, the smaller muscle patients with high visceral fat area had 36.9% survival compared to 58.2% for those with low visceral fat area (p = 0.023). CONCLUSIONS: Abdominal adiposity is associated with survival after liver transplantation, especially in patients with small trunk muscle size. When coupled with trunk musculature, abdominal adiposity offers direct characterization of body composition that can aid preoperative risk evaluation and inform transplant decision-making.

Oncological Outcomes of Patients with Concomitant Bladder and Urethral Carcinoma.

INTRODUCTION: The study aimed to investigate oncological outcomes of patients with concomitant bladder cancer (BC) and urethral carcinoma. METHODS: This is a multicenter series of 110 patients (74 men, 36 women) diagnosed with urethral carcinoma at 10 referral centers between 1993 and 2012. Kaplan-Meier analysis was used to investigate the impact of BC on survival, and Cox regression multivariable analysis was performed to identify predictors of recurrence. RESULTS: Synchronous BC was diagnosed in 13 (12%) patients, and the median follow-up was 21 months (interquartile range 4-48). Urethral cancers were of higher grade in patients with synchronous BC compared to patients with non-synchronous BC (p = 0.020). Patients with synchronous BC exhibited significantly inferior 3-year recurrence-free survival (RFS) compared to patients with non-synchronous BC (63.2 vs. 34.4%; p = 0.026). In multivariable analysis, inferior RFS was associated with clinically advanced nodal stage (p < 0.001), proximal tumor location (p < 0.001) and synchronous BC (p = 0.020). CONCLUSION: The synchronous presence of BC in patients diagnosed with urethral carcinoma has a significant adverse impact on RFS and should be an impetus for a multimodal approach.

An evaluation of the 'weekend effect' in patients admitted with metastatic prostate cancer.

OBJECTIVES: To investigate whether mortality is increased for patients with metastatic prostate cancer (mCaP) admitted over the weekend. PATIENTS AND METHODS: Using the Nationwide Inpatient Sample (NIS) between 1998 and 2009, admitted patients with a diagnosis of prostate cancer and concomitant metastases were identified. Rates of in-hospital mortality, complications, use of imaging and procedures were assessed. Adjusted logistic regression models examined associations of mortality and complications. RESULTS: A weighted sample of 534,011 patients with mCaP was identified, including 81.7% weekday and 18.3% weekend admissions. Of these, 8.6% died after a weekday vs 10.9% after a weekend admission (P < 0.001). Patients admitted over the weekend were more likely to be treated at rural (17.8% vs 15.7%), non-teaching (57.6% vs 53.7%) and low-volume hospitals (53.4% vs 49.4%) (all P < 0.001) compared with weekday admissions. They presented higher rates of organ failure (25.2% vs 21.3%), and were less likely to undergo an interventional procedure (10.6% vs 11.4%) (all P < 0.001). More patients admitted over the weekend had pneumonia (12.2% vs 8.8%), pyelonephritis (18.3% vs 14.1%) and sepsis (4.5% vs. 3.5%) (all P < 0.001). In multivariate analysis, weekend admission was associated with an increased likelihood of complications (odds ratio [OR] 1.15, 95% confidence Interval [CI] 1.11-1.19) and mortality (OR 1.20, 95% CI 1.14-1.27). CONCLUSION: In patients with mCaP weekend admissions are associated with a significant increase in mortality and morbidity. Our findings suggest that weekend patients may present with more acute medical issues; alternatively, the quality of care over the weekend may be inferior.

Sepsis after major cancer surgery.

BACKGROUND: Cancer patients undergoing procedures are at increased risk of sepsis. We sought to evaluate the incidence of postoperative sepsis following major cancer surgeries (MCS), and to describe patient and/or hospital characteristics associated with heightened risk. METHODS: Patients undergoing 1 of 8 MCS (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, and prostatectomy) within the Nationwide Inpatient Sample from 1999-2009 were identified (N = 2,502,710). Logistic regression models fitted with generalized estimating equations were used to estimate primary predictors (procedure, age, gender, race, insurance, Charlson Comorbidity Index, hospital volume, and hospital bed size) effect on sepsis and sepsis-associated mortality. Trends were evaluated with linear regression. RESULTS: The incidence of MCS-related sepsis increased 2.0% per year (P < 0.001), whereas mortality remained stable. Odds of sepsis were highest among esophagectomy patients (odds ratio [OR]: 3.13, 2.76-3.55) and those with non-private insurance (OR: 1.33, 1.19-1.48 to OR: 1.89, 1.71-2.09). Odds of sepsis-related mortality were highest among lung resection patients (OR: 2.30, 2.00-2.64) and those experiencing perioperative liver failure (OR: 5.68, 4.30-7.52). Increasing hospital volume was associated with lower odds of sepsis and sepsis-related mortality (OR: 0.89, 0.84-0.95 to OR: 0.58, 0.53-0.62 and OR: 0.88, 0.77-0.99 to OR: 0.78, 0.67-0.93). CONCLUSIONS: Between 1999 and 2009, the incidence of MCS-related sepsis increased; however, sepsis-related mortality remained stable. Significant disparities exist in patient and hospital characteristics associated with MCS-related sepsis. Hospital volume is an important modifiable risk factor associated with improved sepsis-related outcomes following MCS.

The importance of improving the quality of emergency surgery for a regional quality collaborative.

INTRODUCTION: Within a large, statewide collaborative, significant improvement in surgical quality has been appreciated (9.0% reduction in morbidity for elective general and vascular surgery). Our group has not noted such quality improvement in the care of patients who had emergency operations. With this work, we aim to describe the scope of emergency surgical care within the Michigan Surgical Quality Collaborative, variations in outcomes among hospitals, and variations in adherence to evidence-based process measures. Overall, these data will form a basis for a broad-based quality improvement initiative within Michigan. METHODS: We report morbidity, mortality, and costs of emergency and elective general and vascular surgery cases (N = 190,826) within 34 hospitals participating in the Michigan Surgical Quality Collaborative from 2005 to 2010. Adjusted hospital-specific outcomes were calculated using a stepwise multivariable logistic regression model. Adjustment covariates included patient specific comorbidities and case complexity. Hospitals were also compared on the basis of their adherence to evidence-based process measures [measures at the patient level for each case-Surgical Care Improvement Project (SCIP)-1 and SCIP-2 compliance]. RESULTS: Emergency procedures account for approximately 11% of total cases, yet they represented 47% of mortalities and 28% of surgical complications. The complication-specific cost to payers was $126 million for emergency cases and $329 million for elective cases. Adjusted patient outcomes varied widely within Michigan Surgical Quality Collaborative hospitals; morbidity and mortality rates ranged from 16.3% to 33.9% and 4.0% to 12.4%, respectively. The variation among hospitals was not correlated with volume of emergency cases and case complexity. Hospital performance in emergency surgery was found to not depend on its share of emergent cases but rather was found to directly correlate with its performance in elective surgery. For emergency colectomies, there was a wide variation in compliance with SCIP-1 and SCIP-2 measures and overall compliance (42.0%) was markedly lower than that for elective colon surgery (81.7%). CONCLUSIONS: Emergency surgical procedures are an important target for future quality improvement efforts within Michigan. Future work will identify best practices within high-performing hospitals and disseminate these practices within the collaborative.

Patient-Reported Quality of Life and Convalescence After Minimally Invasive Kidney Cancer Surgery.

OBJECTIVE: To better characterize recovery after minimally invasive kidney surgery, we present a study describing patient-reported health-related quality of life (HRQOL) following minimally invasive radical nephrectomy (RN) and partial nephrectomy (PN). METHODS: Patients who underwent minimally invasive PN or RN for renal cancer were invited to enroll in a prospective, patient-reported HRQOL study using the Convalescence and Recovery Evaluation (CARE) instrument and Short Form-12. Patients completed questionnaires at baseline, 2, 4, 8, and 12 weeks after surgery. Mixed repeated measures model were used to assess time effect on HRQOL scores and predictors of scores within each surgery groups. RESULTS: One hundred seventy-seven patients were included in the study: 50 had RN and 127 had PN. At 2 weeks, both groups had significant decreases in Overall CARE, as well as the Pain, Gastrointestinal, and Activity domain scores which remained slightly below baseline at 4 weeks. At 4 weeks only 50% of patients in both the RN and PN cohorts returned to baseline overall CARE score. By 12 weeks 82% returned to baseline overall CARE score in the RN group while 76% of patients did so in the PN group. CONCLUSION: Convalescence after minimally invasive renal surgery can often extend beyond 4 weeks post-treatment in PN and RN subjects. This information may be used to provide more accurate preoperative counseling in an attempt to improve overall patient satisfaction.

The prognostic effect of salvage surgery and radiotherapy in patients with recurrent primary urethral carcinoma.

BACKGROUND: To evaluate the impact of salvage therapy (ST) on overall survival (OS) in recurrent primary urethral cancer (PUC). PATIENTS: A series of 139 patients (96 men, 43 women; median age = 66, interquartile range: 57-77) were diagnosed with PUC at 10 referral centers between 1993 and 2012. The modality of ST of recurrence (salvage surgery vs. radiotherapy) was recorded. Kaplan-Meier analysis with log-rank was used to estimate the impact of ST on OS (median follow-up = 21, interquartile range: 5-48). RESULTS: The 3-year OS for patients free of any recurrence (I), with solitary or concomitant urethral recurrence (II), and nonurethral recurrence (III) was 86.5%, 74.5%, and 48.2%, respectively (P = 0.002 for I vs. III and II vs. III; P = 0.55 for I vs. II). In the 80 patients with recurrences, the modality of primary treatment of recurrence was salvage surgery in 30 (37.5%), salvage radiotherapy (RT) in 8 (10.0%), and salvage surgery plus RT in 5 (6.3%) whereas 37 patients did not receive ST for recurrence (46.3%). In patients with recurrences, those who underwent salvage surgery or RT-based ST had similar 3-year OS (84.9%, 71.6%) compared to patients without recurrence (86.7%, P = 0.65), and exhibited superior 3-year OS compared to patients who did not undergo ST (38.0%, P<0.001 compared to surgery, P = 0.045 to RT-based ST, P = 0.29 for surgery vs. RT-based ST). CONCLUSIONS: In this study, patients who underwent ST for recurrent PUC demonstrated improved OS compared to those who did not receive ST and exhibited similar survival to those who never developed recurrence after primary treatment.

Penile Preservation With Subcutaneous Transposition During Fournier's Gangrene.

A 50-year-old male with past medical history of diabetes mellitus presented with extensive Fournier's Gangrene. He had a wide-spread area of involvement and the wound vacuum placement involved the entirety of the phallus. We describe a surgical technique where the penis can be diverted from the site of the wound to allow for more secure wound vacuum placement and future reconstructive options.

Potential Implications of Shortening Length of Stay Following Radical Cystectomy in a Pre-ERAS Population.

OBJECTIVE: To investigate whether shortened inpatient length of stay (LOS) after radical cystectomy (RC) is associated with increased complication rates after hospital discharge. MATERIALS AND METHODS: The analytic cohort comprised 484 consecutive patients with 90-day follow-up who underwent RC at our institution from 2005 to 2012 and with LOS ≤9 days. Patients were categorized according to LOS as short (s-LOS; ≤5 days) or routine (r-LOS; 6-9 days). The primary outcome was major complications (Clavien-Dindo grades 3-5) occurring within 90 days after discharge. A Cox proportional hazards model was used to determine the association between LOS and post-discharge major complications. Hospital readmission was a secondary outcome. RESULTS: Patients in the s-LOS cohort had fewer comorbidities (P < .01), less frequently received neoadjuvant chemotherapy (P = .02), and more often underwent robotic RC (P < .01). Major outpatient complications occurred in 18.1% of s-LOS patients vs 11.2% of r-LOS patients, and s-LOS was associated with a significant independent increase in the risk of major outpatient complications (hazard ratio 1.91, 95% confidence interval 1.03-3.56, P = .04). There was also a statistically significant association between s-LOS and readmission (hazard ratio 1.60, 95% confidence interval 1.01-2.44, P = .048). CONCLUSION: Early discharge post RC appears to be associated with an increased risk of major outpatient complications, suggesting that attempts to reduce LOS may need to be supplemented by additional outpatient services to diminish this effect. Further attention should be given to understanding how to better support patients discharged after a short LOS.

Safety considerations for synthetic sling surgery.

Implantation of a synthetic midurethral sling (SMUS) is the most commonly performed anti-incontinence operation in women worldwide. The effectiveness of the SMUS is comparable to that of the historical gold standards--autologous fascial slings and the Burch colposuspension. Much controversy, however, has evolved regarding the safety of this type of sling. Overall, the quality of the studies with respect to assessing risks of SMUS-associated complications is currently poor. The most common risks in patients with SMUS include urethral obstruction requiring surgery (2.3% of patients with SMUS), vaginal, bladder and/or urethral erosion requiring surgery (1.8%) and refractory chronic pain (4.1%); these data likely represent the minimum risks. In addition, the failure rate of SMUS implantation surgery is probably at least 5% in patients with stress urinary incontinence (SUI). Furthermore, at least one-third of patients undergoing sling excision surgery develop recurrent SUI. Considering the additional risks of refractory overactive bladder, fistulas and bowel perforations, among others, the overall risk of a negative outcome after SMUS implantation surgery is ≥15%.

The impact of resident involvement in minimally-invasive urologic oncology procedures.

INTRODUCTION: Robotic and laparoscopic surgical training is an integral part of resident education in urology, yet the effect of resident involvement on outcomes of minimally-invasive urologic procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a large multi-institutional prospective database. METHODS: Relying on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (2005-2011), we abstracted the 3 most frequently performed minimally-invasive urologic oncology procedures. These included radical prostatectomy, radical nephrectomy and partial nephrectomy. Multivariable logistic regression models were constructed to assess the impact of trainee involvement (PGY 1-2: junior, PGY 3-4: senior, PGY ≥5: chief) versus attending-only on operative time, length-of-stay, 30-day complication, reoperation and readmission rates. RESULTS: A total of 5459 minimally-invasive radical prostatectomies, 1740 minimally-invasive radical nephrectomies and 786 minimally-invasive partial nephrectomies were performed during the study period, for which data on resident surgeon involvement was available. In multivariable analyses, resident involvement was not associated with increased odds of overall complications, reoperation, or readmission rates for minimally-invasive prostatectomy, radical and partial nephrectomy. However, operative time was prolonged when residents were involved irrespective of the type of procedure. Length-of-stay was decreased with senior resident involvement in minimally-invasive partial nephrectomies (odds ratio [OR] 0.49, p = 0.04) and prostatectomies (OR 0.68, p = 0.01). The major limitations of this study include its retrospective observational design, inability to adjust for the case complexity and surgeon/hospital characteristics, and the lack of information regarding the minimally-invasive approach utilized (whether robotic or laparoscopic). CONCLUSIONS: Resident involvement is associated with increased operative time in minimally-invasive urologic oncology procedures. However, it does not adversely affect the complication, reoperation or readmission rates, as well as length-of-stay.

Predictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma.

INTRODUCTION: Patients with renal cell carcinoma who were treated with radical nephrectomy (RN) or partial nephrectomy (PN) are at risk of postoperative acute kidney injury (AKI), and in consequence, short- and long-term adverse outcomes. We sought to identify independent predictors of 30-day AKI in patients undergoing RN or PN. MATERIALS AND METHODS: Between 2005 and 2011, patients who underwent RN or PN for renal cell carcinoma within the National Surgical Quality Improvement Program data set were identified. Patients with preexisting severe renal failure, defined as a preoperative estimated glomerular filtration rate<30 ml/min/1.73 m(2), were excluded from the analyses. AKI was defined as an elevation of serum creatinine>2mg/dl above baseline or the need for dialysis within 30 days of surgery. Univariable and multivariable logistic regression analyses were used to examine the association between preoperative factors and the risk of postoperative AKI. RESULTS: Overall, 1,944 (58.6%) and 1,376 (41.4%) patients underwent RN and PN, respectively. Overall, 1.8% of the patients included in the study experienced AKI within an average of 5.4 days after RN or PN. Independent predictors for AKI included obesity (odds ratio [OR] = 2.24, P = 0.04), history of neurovascular disease (OR = 5.29, P<0.001), and a preoperative chronic kidney disease stage II (OR = 10.00, P = 0.03) or stage III (OR = 26.49, P = 0.02). Furthermore, RN (OR = 2.87, P = 0.02) or the open approach (OR = 2.18, P = 0.04) was significantly associated with postoperative AKI. AKI was significantly associated with adverse postoperative outcomes, such as prolonged length of stay, occurrence of any complication, and mortality (all P <0.001). CONCLUSIONS: The assessment of preoperative kidney function and comorbidity status is essential to identify patients at risk of postoperative AKI. In addition to preoperative chronic kidney disease stages II and III, neurovascular disease, obesity, and surgical approach (RN or open) represent predictors of 30-day AKI. Careful patient selection as well as preoperative planning may help reduce this unfavorable postoperative outcome.

Morbidity and mortality after benign prostatic hyperplasia surgery: data from the American College of Surgeons national surgical quality improvement program.

BACKGROUND AND PURPOSE: With the aging population, it is becoming increasingly important to identify patients at risk for postsurgical complications who might be more suited for conservative treatment. We sought to identify predictors of morbidity after surgical treatment of benign prostatic hyperplasia (BPH) using a large national contemporary population-based cohort. METHODS: Relying on the American College of Surgeons National Surgical-Quality Improvement Program (ACS-NSQIP; 2006-2011) database, we evaluated outcomes after transurethral resection of the prostate (TURP), laser vaporization of the prostate (LVP), and laser enucleation of the prostate (LEP). Outcomes included blood-transfusion rates, length of stay, complications, reintervention rates, and perioperative mortality. Multivariable logistic-regression analysis evaluated the predictors of perioperative morbidity and mortality. RESULTS: Overall, 4794 (65.2%), 2439 (33.1%), and 126 (1.7%) patients underwent TURP, LVP, and LEP, respectively. No significant difference in overall complications (P=0.3) or perioperative mortality (P=0.5) between the three surgical groups was found. LVP was found to be associated with decreased blood transfusions (odds ratio [OR]=0.21; P=0.001), length of stay (OR=0.12; P<0.001) and reintervention rates (OR=0.63; P=0.02). LEP was found to be associated with decreased prolonged length of stay (OR=0.35; P=0.01). Men with advanced age at surgery and non-Caucasians were at increased risk of morbidity and mortality. In contrast, normal preoperative albumin and higher preoperative hematocrit (>30%) levels were the only predictors of lower overall complications and perioperative mortality. CONCLUSIONS: All three surgical modalities for BPH management were found to be safe. Advanced age and non-Caucasian race were independent predictors of adverse outcomes after BPH surgery. In patients with these attributes, conservative treatment might be a reasonable alternative. Also, preoperative hematocrit and albumin levels represent reliable predictors of adverse outcomes, suggesting that these markers should be evaluated before BPH surgery.