The Impact of Metastasis Histopathology on Oncologic Outcomes for Patients With Surgically Resected Metastatic Renal Cell Carcinoma.

PURPOSE: Multiple prognostic models exist to assess survival among patients with metastatic clear cell renal cell carcinoma. However, the relative contribution of histopathological features of the metastasis has not been extensively studied. Herein, we compared models using clinical, primary tumor, and metastatic features to predict cancer-specific survival for patients with surgically resected metastatic clear cell renal cell carcinoma. MATERIALS AND METHODS: We studied 266 patients who had undergone nephrectomy between 1970 and 2019, and who had a single site of metastasis completely resected. Two versions of the metastatic clear cell renal cell carcinoma score published by Leibovich et al were calculated, using grade and necrosis from the primary tumor and using grade and necrosis from the metastasis. Predictive abilities of these 2 versions and a third model that included metastatic features only were compared using c-indexes from Cox proportional hazards models. RESULTS: A total of 197 patients died from renal cell carcinoma at a median of 2.3 years (IQR 1.1-4.5); median follow-up among survivors was 13.2 years (IQR 10.0-14.5). The Leibovich score using grade and necrosis from the metastasis (c=0.679) had similar predictive ability compared to the original Leibovich score using grade and necrosis from the primary tumor (c=0.675). A third model (c=0.707) demonstrated that metastasectomy within 2 years after nephrectomy, presence of bone metastasis, high grade, and sarcomatoid differentiation in the metastasis were significantly associated with cancer-specific survival. CONCLUSIONS: Scoring algorithms calculated using histopathological features of the metastasis can be used to predict cancer-specific survival for patients with surgically resected metastatic clear cell renal cell carcinoma. These findings are of particular importance for instances when primary tumor histopathology is not readily available.

Association of Frailty and Complications Following Prostate Biopsy: Results From a Population-Based, Privately Insured Cohort.

INTRODUCTION: Prostate needle biopsy (PNBx) is essential for prostate cancer diagnosis, yet it is not without risks. We sought to assess patients who underwent PNBx using a claims-based frailty index to study the association between frailty and postbiopsy complications from a large population-based cohort. We hypothesized that increased frailty would be associated with adverse outcomes. METHODS: Using Market Scan, we identified all men who underwent PNBx from 2010 to 2015. Individuals were stratified by claims-based frailty index into 2 prespecified categories: not frail, frail. Complications occurring within 30 days from prostate biopsy requiring emergency department, clinic, or hospital evaluations constituted the primary outcome. Unadjusted and adjusted analyses identified patient covariates associated with complications. RESULTS: We identified 193,490 patients who underwent PNBx. The mean age was 57.6 years (SD: 5.0). In all, 5% were prefrail, mildly frail, or moderately to severely frail. The rate of overall complications increased from 11.1% for not frail to 15.5% for frail men. After adjusting for covariates, individuals with any degree of frailty experienced a higher risk of overall complication (odds ratio [OR]: 1.29; P < .001), clinic (OR: 1.26; P < .001) and emergency department visits (OR: 1.32; P = .02), and hospital readmissions (OR: 1.41; P < .001). CONCLUSIONS: Frailty was associated with a higher risk of complications for patients undergoing PNBx. Frailty assessment should be integrated into shared decision-making to limit the provision of potentially harmful care associated with prostate cancer screening.

Cost of upper tract imaging obtained during hematuria evaluation: Analysis of a national claims database.

INTRODUCTION: To investigate the actual cost of hematuria evaluation using nationally representative claims data, given that the workup for hematuria burdens the healthcare system with significant associated costs. We hypothesized that evaluation with contrast-enhanced computed tomography (CT) confers more cost to hematuria evaluation than renal ultrasound (US). METHODS: Using a national, privately insured database (MarketScan), we identified all individuals with an incident diagnosis of hematuria. We included patients who underwent cystoscopy and upper tract imaging within 3 months of diagnosis. We tabulated the costs of the imaging study as well as the total healthcare cost per patient. A multivariable model was developed to evaluate patient factors associated with total healthcare costs. RESULTS: We identified 318,680 patients with hematuria who underwent evaluation. Median costs associated with upper tract imaging were $362 overall, $504 for CT with contrast, $163 for US, $680 for magnetic resonance imaging (MRI), $283 for CT without contrast, and $294 for retrograde pyelogram. Median cystoscopy cost was $283. Total healthcare costs per patient were highest when utilizing MRI and CT imaging. When adjusted for comorbidities, the use of any imaging other than ultrasound was associated with higher costs. CONCLUSIONS: In this nationally representative analysis, hematuria evaluation confers a significant cost burden, while the primary factor associated with higher costs of screening was imaging type. Based upon reduced cost of US-based strategies, further investigation should delineate its cost-effectiveness in the diagnosis of urological disease.

Association of Surgical Approach and Urinary Diversion in Radical Cystectomy for Bladder Cancer With Costs and Readmission: Results From a Large Private Health Insurance Cohort.

INTRODUCTION: We sought to assess the comparative hospital outcomes and costs among a population-based cohort of bladder cancer patients by surgical approach and diversion. METHODS: From a privately insured national database, we identified all bladder cancer patients who underwent open or robotic radical cystectomy and ileal conduit or neobladder from 2010 to 2015. The primary outcomes were length of stay, readmissions, and total health care costs at 90 days from surgery. We used multivariable logistic regression and generalized estimating equations to assess for 90-day readmission and health care costs, respectively. RESULTS: Most patients underwent open radical cystectomy with ileal conduit (56.7%; n = 1,680) followed by open radical cystectomy with neobladder (22.7%; n = 672), robotic radical cystectomy with ileal conduit (17.4%; n = 516), and robotic radical cystectomy with neobladder (3.1%; n = 93). On multivariable analysis, patients had higher odds of 90-day readmissions for open radical cystectomy and neobladder (OR: 1.36; P = .002) and robotic radical cystectomy with neobladder (OR 1.60; P = .03) relative to open radical cystectomy with ileal conduit. After adjusting for patient covariates, we also found lower adjusted total 90-day health care costs for open radical cystectomy with ileal conduit ($67,915) and open radical cystectomy with neobladder ($67,371) compared to robotic radical cystectomy with ileal conduit ($70,677) and neobladder ($70,818; P < .05). CONCLUSIONS: In our study, neobladder diversion was associated with higher odds of 90-day readmission, while robotic surgery increased total 90-day health care costs.

Geographic Variation of Infectious Complications Following Prostate Biopsy in The United States: Results From a Population-Based Cohort of Privately Insured Patients.

OBJECTIVE: To elucidate regional trends of infectious complications following transrectal ultrasound prostate biopsy (TRUS-PB) from a national, privately-insured database. MATEREIAL AND METHODS: Using Market Scan, we identified all men who underwent TRUS-PB from 2010 to 2015. Infectious complications (UTI, prostatitis, sepsis) occurring 30 days after the prostate biopsy from emergency room (ER) visits or hospital admissions constituted the primary outcomes. We analyzed unadjusted and adjusted rates of infectious complications from ER visits and hospital admissions per 100 prostate biopsies by state. Multivariable logistic regression analyses were used to identify patient covariates associated with infectious complications. RESULTS: During the study interval, we identified 193,490 patients who underwent TRUS-PB. The mean age was 57.6 years (SD: 5.0). Over time the unadjusted national rates of infectious complications remained similar from 0.4 ER visits per 100 prostate biopsies in 2010 -0.2 in 2015 (P = 0.83), and 1.2 hospital admissions per 100 prostate biopsies in 2010 to 1.1 in 2015 (P= 0.58). Connecticut had the lowest unadjusted infectious complication rate per 100 biopsies at 0.64, whereas West Virginia had the highest at 2.34. Multivariable analysis revealed higher Elixhauser status and patient age were associated with higher odds of infectious complications (P<0.05). CONCLUSIONS: While rates of infectious complications attributable to prostate biopsies remain relatively stable, significant variation exists at the state level regarding this adverse outcome.

Comparative effectiveness of robotic and open radical prostatectomy.

Radical prostatectomy (RP) has undergone a remarkable transformation from open to minimally-invasive surgery over the last two decades. However, it is important to recognize there is still conflicting evidence regarding key outcomes. We aimed to summarize current literature on comparative effectiveness of robotic and open RP for key outcomes including oncologic results, health-related quality of life (HRQOL) measures, safety and postoperative complications, and healthcare costs. The bulk of the paper will discuss and interpret limitations of current data. Finally, we will also highlight future directions of both surgical approaches and its potential impact on health care delivery.

The Impact of Performing a 3D Mapping Biopsy Prior to Primary Cryotherapy for the Treatment of Prostate Cancer.

OBJECTIVE: To study the implications of adding a 3D mapping biopsy (3DMB) prior to prostate cryotherapy (PCT) for the treatment of prostate cancer on the following outcomes: recurrence and biochemical failure (BCF), quality of life outcomes, and complication rates. METHODS: A retrospective analysis of patients treated with either targeted focal therapy, or subtotal CT for localized prostate cancer was performed. The cohort was stratified by patients who had only had a transrectal ultrasound-guided biopsy (TRUS) and those who had undergone 1 additional 3DMB before definitive treatment. Pre- and postprocedural Prostate Symptom Score (IPSS) and Sexual Health Inventory for Men (SHIM) surveys were collected. BCF was defined using the Phoenix criteria. Patients with BCF were re-biopsied. Differences in pre/post changes in IPSS and SHIM scores were examined with Mann-Whitney U tests, binary measures with chi-square tests, and pre/post changes in PSA with t tests. A Kaplan-Meier time to BCF and recurrence analysis is presented. RESULTS: A total of 534 patients underwent PCT following TRUS only (n = 331) and TRUS with subsequent 3DMB (n = 203) between March 2007 and June 2016. No differences were observed in IPSS (P = .60) or SHIM scores drop (P = .06) between groups. PSA drop seemed more pronounced in the TRUS only biopsy group compared to the 3DMB, but again without statistical significance (P = .06). Recurrence rate and BCF were lower in the 3DMB group (P <.01). There was a higher rate of short-term complications detected in the TRUS only group (P = .02). CONCLUSION: BCF and local recurrence rates were lower among patients who underwent a confirmatory 3DMB before PCT, most likely due to better risk stratification in these patients. The addition of a 3DMB did not seem to adversely impact either rate of complications or functional outcomes.

The patient-physician interactions as seen by undergraduate medical students

CONTEXT: The interaction between a physician and his or her patient is complex and occurs by means of technical performance and through a personal relationship. OBJECTIVE: To assess the interaction between the medical professional and his or her patient with the participation of medical students assuming a role as observers and participants in a medical appointment in an outpatient office. DESIGN: Questionnaire interview study. SETTING: General Medicine outpatient offices, Hospital das Clínicas, Faculty of Medicine, University of Säo Paulo. PARTICIPANTS: Medical students performed an ethnographical technique of observation, following 199 outpatient medical appointments with Clinical Medicine Residents. MAIN MEASUREMENTS: A questionnaire filled out by observer students measured the physician's attitudes towards patients, as well as patients' expectations regarding the appointment and his or her understanding after its completion. RESULTS: Patients showed higher enthusiasm after the appointment (4.47 + or - 0.06 versus 2.62 + or - 0.10) (mean + or - SEM), as well as some negative remarks such as in relation to the waiting time. The time spent in the consultation was 24.66 + or - 4.45 minutes (mean + or - SEM) and the waiting time was 123.09 + or - 4.91 minutes. The physician's written orientation was fairly well recalled by the patient when the doctor's letter could be previously understood. CONCLUSION: Patients benefit from physicians who keep the focus on them. In addition, this program stimulated the students for their accomplishment of the medical course