Reducing Infection Rates with Enhanced Preoperative Diabetes Mellitus Diagnosis and Optimization Processes.

OBJECTIVES: Hyperglycemia and increased preoperative hemoglobin A1c (HbA1c) are associated with perioperative morbidity and death. For nonurgent operations, adequate glycemic control before surgery is recommended. Our surgical practice needed a process for preoperative diabetes mellitus (DM) diagnosis and glycemic optimization. METHODS: Our review of the existing preoperative evaluation process found that patients without a DM diagnosis but with random plasma glucose ≥200 mg/dL received no additional screening. Patients with DM routinely receive neither preoperative HbA1c screening nor DM management when HbA1c is ≥8.0%. RESULTS: A new preoperative evaluation process was designed. HbA1c screening was automatically performed for patients with random plasma glucose ≥200 mg/dL. For patients with a DM diagnosis, an HbA1c test was performed. Specialty consultation was prompted for patients with known DM and HbA1c ≥8.0% and those with no DM diagnosis but HbA1c ≥6.5%. In the first year postimplementation, 9320 patients received a basic metabolic panel; 263 had random plasma glucose ≥200 mg/dL that triggered an HbA1c check. In total, 123 patients (99 with and 24 without a DM diagnosis) were referred to endocrinology; 13 received a new DM diagnosis. Twenty patients had surgery delayed for DM treatment. All of the patients received individualized medication instructions for the perioperative period. Among patients with random plasma glucose ≥200 mg/dL, incidence rates for surgical site infection pre- and postimplementation were 47.8/1000 and 3.8/1000 population. CONCLUSIONS: The implemented process benefited patients scheduled for nonurgent procedures by optimizing glucose control and lowering infection rates through earlier preoperative DM diagnosis, glycemic management, and standardized patient medication instruction.

Validation of new baseline renal function predictive model in robotic-assisted partial nephrectomy cohort.

OBJECTIVE: To validate a new baseline estimated glomerular filtration rate (NB-GFR) formula in a cohort of robotic-assisted partial nephrectomies (RAPN). METHODS: NB-GFR = 35 + preoperative GFR (× 0.65) - 18 (if radical nephrectomy) - age (× 0.25) + 3 (if tumor size >7 cm) - 2 (if diabetes). NB-GFR was calculated in 464 consecutive RAPN from a single surgeon cohort. 143 patients were excluded secondary to insufficient eGFR follow up. We analyzed NB-GFR accuracy utilizing the last observed eGFR 3-12 months post RAPN. Categorical variables were summarized with the frequency and percentage of patients. Numerical variables were summarized with the median, 25th percentile, and 75th percentile. RESULTS: The mean difference between observed and predicted NB-GFR was 4.6 ml/min/1.73m2 (95% CI -6.9 to 16.1 ml/min/1.73m2 ). There was a pattern of higher observed NB-GFRs being underestimated by the NB-GFR equation while lower observed NB-GFRs were overestimated by the NB-GFR equation. The NB-GFR formula had a high level of accuracy with 98.8% of predicted NB-GFRs falling within 30% of the observed NB-GFR (95% CI 86.8% to 99.5%). The median and interquartile range of the difference between observed and predicted NB-GFR was 3.9 ml/min/1.73m2 (IQR 0.7 to 8.2 ml/min/1.73m2 ). The sensitivity, specificity, positive predictive value, and negative predictive value for the ability of predicted NB-GFR to identify those with an observed NB-GFR <60 ml/min/1.73m2 after RAPN was 98%, 92%, 88%, and 99%, respectively. CONCLUSION: The NB-GFR equation developed with partial and radical nephrectomy cohorts is accurate in predicting post-operative eGFR 3-12 months following RAPN.

Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review.

BACKGROUND: Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes. METHODS: Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics. RESULTS: There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (ß = - 0.16, p < 0.001) and for each specialty (GS: ß = - 0.18, p < 0.001; CRS ß = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.

Posterior tibial nerve stimulation: is ultrasound guided needle placement more accurate?

INTRODUCTION To compare the accuracy of the transcutaneous ultrasound (US) in detecting the tibial nerve (TN) as opposed to digital palpation in the performance of posterior tibial nerve stimulation (PTNS). MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, 25 adults were enrolled to quantify the difference in position of the distal TN by the use of US as opposed to cutaneous palpation. The position of the TN was determined first by the palpation method and then by using a L12-4MHz high frequency Linear Array Transducer. The difference in position between the two methods was determined in both proximal-distal (PD [Knee-Sole]) and anterior-posterior planes (AP). Statistical analysis was completed with numeric variables summarized with the sample median, range, and interquartile range (IQR). Categorical variables were summarized with the number and percentage of patients. Comparisons between AP and PD distances were performed using a nonparametric Wilcoxon signed rank test. Box and whisker plots were used to display individual observations graphically. All analyses and graphics were performed using SAS statistical software (version 9.4M5, SAS Institute Inc., Cary, NC, USA). RESULTS: Twenty-five patients were studied. The median AP distance between US and digital palpation was 2 mm (range, 0-5 mm; IQR, 2-3 mm). The median PD distance between US and digital palpation was 4 mm (range, 0-9 mm; IQR, 3-5 mm). The median difference between the AP and PD distances was 2 mm (range, -3-7 mm; IQR, 0-4 mm, p < 0.001). CONCLUSION: The use of US identifies the nerve with statistically significant greater accuracy than palpation technique along the PD plane.

Perioperative Resumption of Direct Oral Anticoagulants: Review of the Mayo Clinic Experience.

OBJECTIVE: We aimed to review recommendations for the postoperative resumption of direct oral anticoagulants (DOACs) and report complications 30 days postoperatively. METHODS: We retrospectively reviewed patients receiving DOAC therapy who underwent preoperative evaluations from January 1, 2015 through May 30, 2018. We noted days that DOAC therapy was withheld, postoperative time until resumption of the DOAC, and complications within 30 postoperative days. RESULTS: A total of 317 patients were included. Ten had complications. Complication rates among patients stratified by time to resumption were not significantly different, except for the deep vein thrombosis rate when DOACs were resumed after 72 hours (n = 2 [4.17%]; P = 0.02). The total time without DOACs did not affect the complication rates. CONCLUSIONS: We suggest withholding DOACs for 48 to 72 hours before surgery and resuming them 48 to 72 hours after surgery, if safe. The interruption of therapy was not associated with an increase in thrombotic events for patients who resumed DOACs within 72 hours postoperatively. Patients who resumed DOACs after 72 hours postoperatively had a low rate of thrombotic complications.

Independent external validation of a nomogram to define risk categories for a significant decline in estimated glomerular filtration rate after robotic-assisted partial nephrectomy.

OBJECTIVE: To validate the Martini nomogram predicting the decline in estimated glomerular filtration rate after robotic-assisted partial nephrectomy. METHODS: Estimated glomerular filtration rate of 406 patients from a single surgeon series was calculated before robotic-assisted partial nephrectomy and at postoperative intervals. To determine the risk group, we calculated the total score and corresponding risk of significant estimated glomerular filtration rate reduction at 15 months using the Martini nomogram. The primary outcome was a reduction in estimated glomerular filtration rate of ≥25% from preoperative levels between 1 and 12 months after surgery. RESULTS: The median length of follow up for this study was 12 months (interquartile range 6-12 months). Overall, 134 (33%) patients were in the low-, 143 (35%) in the intermediate-, 119 (29%) in the high- and 10 (2%) in the very high-risk groups. The Kaplan-Meier estimates for the probability of significant estimated glomerular filtration rate reduction by 12 months after robotic-assisted partial nephrectomy was 12.9% in the low-risk group, 24.0% in the intermediate-risk group, 49.7% in the high-risk group and 40.0% in the very high-risk group. Harrell's C-index for discriminating between those with and without a significant reduction in estimated glomerular filtration rate 1-12 months after robotic-assisted partial nephrectomy was 0.73 (95% confidence interval 0.68-0.78). CONCLUSIONS: The risk groups proposed by the Martini nomogram are accurate in predicting those at higher risk for a >25% decline in postoperative estimated glomerular filtration rate after robotic-assisted partial nephrectomy at 12 months.

Self-Reported Allergy to Thyroid Replacement Therapy: A Multicenter Retrospective Chart Review.

OBJECTIVE: To determine patterns of adverse drug reactions (ADRs), including immediate drug hypersensitivity reactions (DHRs) and predictable ADRs, to thyroid replacement therapy (TRT). TRT is the treatment of choice for hypothyroidism. Levothyroxine (LT4) is among the most commonly prescribed medications in the United States, with over 70 million prescriptions annually. Documented immediate DHRs to TRT are rare, with only a few case reports. METHODS: An 11-year (2008-2018) retrospective medical chart review of identified patients with self-reported allergy to TRT. ADRs to TRT were divided into immediate DHRs and predictable ADRs. RESULTS: A total of 466 patients were included in our study. We found an overall incidence of ADRs to TRT of 0.3%. Median age was 61.2 years; 85.8% were women, and 94.4% were Caucasian. The principal indication for TRT was autoimmune hypothyroidism (73.6%), followed by postsurgical hypothyroidism (17.4%) and subclinical hypothyroidism (6.7%). Predictable ADR manifestations to TRT were reported more commonly than DHR manifestations (57.5% vs. 42.5%, respectively). The most frequently reported of the former were palpitations (16.4%), nausea/vomiting (9.3%), and tremor (6.3%), while rash (23.8%), hives (9.5%), and pruritus (7.1%) were the most common regarding the latter. Fifty-six percent of the patients with an ADR to TRT tolerated an alternative TRT presentation. CONCLUSION: In our cohort, the majority of self-reported allergies to TRT were due to predictable ADRs rather than an immediate DHR. ABBREVIATIONS: ADR = adverse drug reaction; DHR = drug hypersensitivity reaction; FDA = Food and Drug Administration; LT3 = liothyronine; LT4 = levothyroxine; SCAR = severe cutaneous adverse drug reaction; TRT = thyroid replacement therapy.

Disposable Cystoscopes Do Not Decrease Post Renal Transplant Stent Removal Symptomatic Infection Rates.

OBJECTIVE: To evaluate the effect of disposable cystoscopes on the rate of symptomatic urinary tract infections (UTI) following post-renal transplant cystoscopic stent removal. METHODS: We performed a retrospective study of post-renal transplant cystoscopic stent removals in our outpatient clinic from March 2019 to March 2022. Our clinic converted to disposable cystoscopes in October 2021. All outpatient, phone, and portal encounters were reviewed for 30 days following the procedure. The primary outcome was the number of post-procedural symptomatic UTI within 30 days of the procedure. Symptomatic UTI was defined as fever, dysuria, or hematuria accompanied by a positive urine culture. RESULTS: A total of 323 patients had post-transplant stent removals including 123 with reusable scopes and 200 with disposable scopes. Around 1.6% (2/123) of patients with a reusable cystoscope experienced symptomatic UTI's. They had positive urine cultures for Escherichia coli and Klebsiella. 2.0% (4/200) of patients with a disposable cystoscopy had a symptomatic UTI. The 3 types of positive urine cultures they experienced were E Coli, Klebsiella, and Enterococcus. CONCLUSION: The conversion from reusable to disposable cystoscopes did not decrease symptomatic UTI following renal transplant stent removal.

Association of day of surgery and distance traveled with length of stay in patients undergoing robotic-assisted partial nephrectomy (RAPN) at a tertiary medical center.

The objective of this study is to analyze the association between surgical day of the week and distance traveled with prolonged length of stay (LOS) following robotic-assisted partial nephrectomy (RAPN). 563 consecutive RAPN performed by a single surgeon were evaluated. Early week RAPN was considered Monday through Wednesday, while late-week RAPN was defined as surgery performed Thursday through Friday. Distance traveled for RAPN was evaluated as greater than or less than 60 miles. The respective groups were compared to see if the surgical day of the week or distance traveled influenced the hospital stay or prolonged hospital stay (defined as hospital length of stay equal or greater than 3 days). Overall, 213 patients (38.0%) undergoing RAPN experienced a prolonged LOS. A total of 380 patients underwent early week RAPN compared to 183 late-week RAPN. Patients undergoing late-week RAPN were more likely to have a prolonged LOS compared to early week RAPN (n = 81, 44% vs. n = 133, 35%, respectively; p = 0.004). 229 patients traveled less than 60 miles, while 332 patients traveled more than 60 miles to receive RAPN. 135 patients (40.7%) traveling more than 60 miles experienced a prolonged stay compared to 78 patients (34.1%) traveling less than 60 miles, although this difference was not statistically significant (p = 0.128). Patients who underwent RAPN at the end of the week were more likely to have a prolonged LOS, while distance traveled for RAPN did not appear to affect likelihood of prolonged LOS.

Impact of Inner Layer Renorrhaphy Suture on Renal Artery Pseudoaneurysm Formation Following Robotic-assisted Partial Nephrectomy.

OBJECTIVE: To report the impact of resection base inner layer renorrhaphy suture type on renal artery pseudoaneurysm (RAP) rate following robotic-assisted partial nephrectomy (RAPN). METHODS: Five hundred and sixty-three consecutive RAPNs performed by a single surgeon were retrospectively reviewed. Patients were classified into 3 categories: (1) No base suture, (2) monofilament barbed suture (2-0 V-Loc 180 absorbable suture, Medtronic, Minneapolis, MN), (3) polyglactin 910 (2-0 Vicryl coated suture, Ethicon Inc, Cincinnati, OH). In a secondary analysis, we evaluated suturing (Vicryl and V-Loc) vs no base suture. All patients had outer cortical renorrhaphy performed with 0-Vicryl suture utilizing the standard sliding clip technique. RESULTS: One hundred ten patients (19.5%) had V-Loc suturing, 255 patients (45.3%) had Vicryl suturing, and 198 patients (35.2%) had no base suture. Patients had a median age of 62.8years (interquartile range: 53.5-69.7) and median RENAL score was 8 (6-9). Median mass size from preoperative imaging was 3.0 cm (2.5-4.0) for V-Loc, 3.3 cm (2.5-4.2) for Vicryl, and 2.0 cm (1.8-3.0) for no base suture (P < .001). Overall, 21 patients (3.7%) developed a symptomatic postoperative RAP. The rate of RAP was 3.6% (4/110) for V-Loc, 3.9% (10/255) for 2-0 Vicryl, and 3.5% (7/198) for no base suture (P = 1.00). Similarly, the rate of RAP was 3.5% (7/198) for no base suture and 3.8% (14/365) for base suture (P = 1.00). CONCLUSION: Utilization of base suture and type of base suture used during RAPN was not predictive of postoperative RAP development.

Analysis of fixed and variable operating room (or) time point efficiency in partial nephrectomies: open versus robotic-assisted.

To analyze operating room (OR) efficiency by evaluating fixed and variable OR times for open (OPN) and robotic-assisted partial nephrectomies (RAPN). We analyzed consecutive OPN and RAPN performed by one surgeon over a 24-month period. All patients were placed in the lateral decubitus position and secured with a beanbag regardless of approach. Fixed (non-procedural) OR times were prospectively collected and defined as: in-room to anesthesia-release time (IRAT), anesthesia release to cut time (ARCT), and close to wheels-out time (CTWO). Variable OR time was procedural cut to close time (CTCT). Comparisons of fixed and variable OR time points between OPN and RAPN were performed using the Wilcoxon rank-sum test. 146 RAPN and 31 OPN were evaluated from 2019-2020. Median IRAT was similar for RAPN versus OPN [20 min (IQR: 16-25) vs. 20 min (IQR: 16-26), P = 0.57]. Median ARCT was longer for RAPN than it was for OPN [40 min (IQR: 36-46) vs. 34 min (IQR: 30-39), P < 0.001]. Median CTWO was similar for OPN (12 min, IQR: 9-14) and RAPN (11 min, IQR: 7-15) (P = 0.89). Median CTCT was longer for RAPN (202 min, IQR: 170-236) compared to OPN (164 min, IQR: 154-184) (P < 0.001). In a single surgeon, partial nephrectomy series with the same patient positioning, utilization of robotic technology was associated with longer surgeon operating time as well as less efficient fixed OR times, specifically ARCT.

Conversion to Disposable Cystoscopes Decreased Post-procedure Encounters and Infections Compared to Reusable Cystoscopes.

INTRODUCTION: We evaluated for differences in post-procedure 30-day encounters or infections following office cystoscopy using disposable vs reusable cystoscopes. METHODS: Cystoscopies performed from June to September 2020 and from February to May 2021 in our outpatient practice were retrospectively reviewed. The 2020 cystoscopies were performed with reusable cystoscopes, and the 2021 cystoscopies were performed with disposable cystoscopes. The primary outcome was the number of post-procedural 30-day encounters defined as phone calls, patient portal messages, emergency department visits, hospitalizations, or clinic appointments related to post-procedural complications such as dysuria, hematuria, or fever. Culture-proven urinary tract infection within 30 days of cystoscopy was evaluated as a secondary outcome. RESULTS: We identified 1,000 cystoscopies, including 494 with disposable cystoscopes and 506 with reusable cystoscopes. Demographics were similar between groups. The most common indication for cystoscopy in both groups was suspicion of bladder cancer (disposable: 153 [30.2%] and reusable: 143 [28.9%]). Reusable cystoscopes were associated with a higher number of 30-day encounters (35 [7.1%] vs 11 [2.2%], P < .001), urine cultures (73 [14.8%] vs 3 [0.6%], P = .005), and hospitalizations attributable to cystoscopy (1 [0.2%] vs 0 [0%], P < .001) than the disposable scope group. Positive urine cultures were also significantly more likely after cystoscopy with a reusable cystoscope (17 [3.4%] vs 1 [0.2%], P < .001). CONCLUSIONS: Disposable cystoscopes were associated with a lower number of post-procedure encounters and positive urine cultures compared to reusable cystoscopes.

Analysis of Transurethral Resection of Bladder Tumor Efficiency Utilizing Nonprocedural Operating Room Times.

OBJECTIVE: To analyze the contribution of nonprocedural operating room (OR) times to transurethral resection of bladder tumor (TURBT) operative efficiency. METHODS: Over a 24-month period, all nonprocedural OR times from TURBT surgeries performed at a single institution were prospectively collected. Nonprocedural times included: in-room to anesthesia release time, anesthesia release to cut time, and close to wheels out time. Procedural OR time was cut to close time. We also analyzed the impact of time of day on TURBT efficiency (morning vs afternoon). Comparisons between groups were made using the Wilcoxon rank sum test for continuous variables. RESULTS: We identified 777 consecutive TURBT procedures from 2019 to 2020. The median total OR time was 63 minutes (interquartile range: 50-81 minutes). The nonprocedural time occupied a median of 49.4% of the total operating time (interquartile range: 38.9%-60.4%). Median anesthesia release to cut time was slower when 1 TURBT was performed a day compared to 2 or more (13 minutes vs 12 minutes, P = .04). Median close to wheels out time was faster when there was 1 TURBT in a day (7 minutes vs 8 minutes, P = .02). Median in-room to anesthesia release time was faster in the morning than it was in the afternoon (10 minutes vs 11 minutes, P = .02). CONCLUSION: Nonprocedural times made up roughly half of the total TURBT operating time and should be considered in OR efficiency analyses. TURBT OR efficiency may be related to the number of TURBTs performed in a day as well as the time of day of TURBT start.

Evaluation of Routine Postoperative Labs Following Robotic Assisted Partial Nephrectomy in Patients With Normal Preoperative Renal Function.

OBJECTIVE: To evaluate predictors of abnormal routine postoperative day 1 (POD1) labs in patients with normal pre-operative renal function following robotic assisted partial nephrectomy (RAPN) and the associated clinical outcomes of these lab results. METHODS: We analyzed 500 consecutive RAPN from a single surgeon series. Patients with chronic kidney disease (CKD) III or greater were excluded from the study. Three hundred ninty-three RAPN were included in the analysis. Routine POD1 lab tests including hemoglobin (Hgb), creatinine, potassium, and sodium were evaluated to determine rates of abnormal values and rates of clinical intervention. Abnormal Hgb at POD1 was defined as <8 g/dL or ≥3 g/dL decrease from the preoperative (baseline) value. Abnormal sodium (Na) preoperatively and postoperatively was defined as <135 mEq/L or >145 mEq/L. Abnormal potassium (K) was defined preoperatively and POD1 as <3.5 mEq/L or >5 mEq/L. RESULTS: Of 37.4% (147/393) had one or more abnormal labs at POD1. Of the 101 patients with abnormal Hgb, 15 patients required blood transfusion. Twenty-six patients had abnormal sodium for which two were treated with IV fluids. Twenty-seven patients had potassium abnormalities (12/25 were hypokalemia). Acute kidney injury stage I was seen in 27 patients (6.9%) and stage II in 3 (0.8%). Patients with abnormal labs were more likely to have larger renal mass, higher R.E.N.A.L. scores, intraoperative complications, longer operative times, and higher EBL on multivariate analysis. CONCLUSION: POD1 serum laboratory tests appear to be necessary following RAPN in patients with normal pre-operative renal function.

Statin Use and Association with Postoperative Estimated Glomerular Filtration Rates in Patients Undergoing Robot-Assisted Partial Nephrectomy.

Objective: To evaluate the association between preoperative statin use with changes in estimated glomerular filtration rate (eGFR) after robot-assisted partial nephrectomy (RAPN). Methods: Three hundred eighty-nine consecutive patients undergoing RAPN were evaluated. Associations of preoperative statin use with change in eGFR from pre-RAPN to postoperative day 1 (POD1), 1, 6, and 12 months after RAPN were evaluated using longitudinal mixed-effects regression models with random patient-specific intercepts and slopes while accounting for imbalance of preoperative patient and tumor characteristics between groups with stabilized inverse propensity score weighting. Postoperative eGFR change from baseline was measured as total change, maintaining eGFR within 10% of baseline, and as going from eGFR >60 mL/min/1.73 m2 to <60 mL/min/1.73 m2. Results: One hundred sixty-seven (43.0%) of 389 patients were on statin therapy preoperatively. Statin patients were older (66 vs 58 years) and had higher rates of comorbidities, including diabetes mellitus (31.7% vs 14.9%) and hypertension (82.6% vs 45%). Statin patients tended to have lower preoperative eGFR (mean ± standard deviation, 71.1 ± 17.6 vs 77.4 ± 19.4 mL/min/1.73 m2). There was no evidence of an association of preoperative statin use with changes in eGFR at any time point after RAPN (p = 0.66). Conclusion: Patients on preoperative statins undergoing RAPN had lower eGFR preoperatively compared with those not taking those medications. There was no evidence of an association between preoperative statin use and change in post-RAPN eGFR in the immediate postoperative period or at 1 year after surgery.

Impact of Severe Acute Respiratory Syndrome Coronavirus 2-Induced COVID-19 on Fixed Operating Room Times in Urologic Operations.

Objective: To evaluate the impact of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, on operating room (OR) efficiency for urologic procedures using the concept of fixed OR times. Patients and Methods: Over a 24-month period, urology OR data were prospectively collected. Operations were divided into fixed and variable time points. The fixed OR times were in-roomw to anesthesia-release time, anesthesia-release to cut time, in-room to cut time, and close to wheels-out time. Data from January 1, 2019, to December 31, 2019, were pre-COVID-19 data, and data from April 1, 2020, to December 31, 2020, were post-COVID-19 data. Operations were grouped into endoscopic, implant, major open, and robotic-assisted cases. In the post-COVID-19 era, all patients had a negative polymerase chain reaction test result within 48 hours of operation. The Wilcoxon rank sum test was used to compare the fixed OR times between the pre- and post-COVID-19 eras. Results: A total of 3189 procedures were evaluated: 2058 endoscopic operations (1124 in the pre-COVID-19 era and 934 in the post-COVID-19 era), 343 implant procedures (192 in the pre-COVID-19 era and 151 in the post-COVID-19 era), 222 major open procedures (119 in the pre-COVID-19 era and 103 in the post-COVID-19 era), and 566 robotic-assisted procedures (338 in the pre-COVID-19 era and 228 in the post-COVID-19 era). There were no fixed OR times in any of the examined groups that were negatively impacted by COVID-19. The percentage of the total OR time occupied by fixed OR variables in the pre-COVID-19 era was 40.6% for endoscopic operations, 41.1% for implant procedures, 29.8% for major open procedures, and 21.8% for robotic-assisted procedures. Conclusion: A substantial portion of the total OR time includes fixed time points. Furthermore, COVID-19 did not have a negative impact on fixed OR times in a negative testing environment. Urologic OR efficiency should be maintained in the post-COVID-19 era.

Analysis of Holmium Laser Enucleation of Prostate Fixed Operating Room Times.

OBJECTIVE: To evaluate factors influencing fixed operating room time during holmium laser enucleation of the prostate. MATERIALS AND METHODS: A prospective observational study was performed for all holmium laser enucleation of the prostate (HoLEP) cases performed by a single surgeon over a 24-month period. Operating room (OR) time was divided into fixed and variable time. The variable time was defined as cut-to-close time. Fixed time included in room time to anesthesia release time (IRAT), anesthesia release time to cut time (ARCT), and close time to wheels out (CTWO). The effects of time of day and anesthesia personnel (AP) changes on fixed operating room time were evaluated. RESULTS: A total of 406 HoLEPs were analyzed. There was no statistically significant difference in nonprocedural OR times between morning and afternoon surgeries (IRAT, P = .38, ARCT P = .10, CTWO P = .77). Median nonprocedural OR times accounted for 27% (IQR: 22%-31%) of the total procedure time in the AM group and 29% (IQR: 24%-33%) in the PM group (P = .005). Of the HoLEPs,78.1% (178/228) experienced one or more AP changes during the procedure. The median fixed OR time was not significantly different between procedures with 1 AP and procedures with ≥2 APs (IRAT, P = .53; ARCT, P = .71; CTWO, P = .98). CONCLUSION: Fixed operating room time makes up a significant portion of HoLEP procedures and should be considered when evaluating OR efficiency. The time of day and number of anesthesia personnel involved did not affect the fixed OR times.

Novel plasma glycoprotein biomarkers predict progression-free survival in surgically resected clear cell renal cell carcinoma.

INTRODUCTION: Limited data exists on utilization of protein post-translational modifications as biomarkers for clear cell renal cell carcinoma (ccRCC). We employed high-throughput glycoproteomics to evaluate differential expression of glycoprotein-isoforms as novel markers for ccRCC progression-free survival (PFS). METHODS: Plasma samples were obtained from 77 patients treated surgically for ccRCC. Glycoproteomic analyses were carried out after liquid chromatography tandem mass spectrometry. Age-adjusted Cox proportional hazard models were constructed to evaluate PFS. Optimized Harrell's C-index was employed to dichotomize the collective for the construction of Kaplan-Meier curves. RESULTS: The average length of follow-up was 3.4 (range: 0.04-9.83) years. Glycoproteomic analysis identified 39 glycopeptides and 14 non-glycosylated peptides that showed statistically significant (false discovery rate P ≤ 0.05) differential expression associated with PFS. Five of the glycosylated peptides conferred continuous hazard ratio (HR) of > 6 (range 6.3-11.6). These included prothrombin A2G2S glycan motif (HR = 6.47, P = 9.53E-05), immunoglobulin J chain FA2G2S2 motif (HR = 10.69, P = 0.001), clusterin A2G2 motif (HR = 7.38, P = 0.002), complement component C8A A2G2S2 motif (HR = 11.59, P = 0.002), and apolipoprotein M glycopeptide with non-fucosylated and non-sialylated hybrid-type glycan (HR = 6.30, P = 0.003). Kaplan-Meier curves based on dichotomous expression of these five glycopeptides resulted in hazard ratios of 3.9 to 10.7, all with P-value < 0.03. Kaplan-Meyer plot using the multivariable model comprising 3 of the markers yielded HR of 11.96 (P < 0.0001). CONCLUSION: Differential glyco-isoform abundance of plasma proteins may be a useful source of biomarkers for the clinical course and prognosis of ccRCC.

Analysis of Operating Room Efficiency During Robot-Assisted Urologic Surgeries Utilizing Fixed (Nonprocedural) Operative Times.

Objective: To analyze operating room (OR) efficiency by evaluating fixed OR times for three common urologic robot-assisted procedures. Methods: Over a 24-month period, we prospectively collected intraoperative data for 635 consecutive robot-assisted surgeries. Fixed (nonprocedural) OR times were evaluated for robot-assisted partial nephrectomy (RAPN) (n = 146), robot-assisted radical cystectomy (RARC) (n = 77), and robot-assisted radical prostatectomy (RARP) (n = 412). Fixed OR times were defined as nonprocedural time in the OR, including in-room time to anesthesia release time (IRAT), anesthesia release to cut time (ARCT), in-room time to cut time (IRCT; IRAT+ARCT), and close time to wheels out time (CTWO). The effects of operation time of day and the number of anesthesia personnel (AP) present in procedure on fixed OR times were also analyzed. Results: Fixed OR times occupied 15.1% (IQR: 12.9%-17.1%) (RARC), 26.6% (22.9%-30.8%) (RAPN), and 20.1% (17.4%-23.1%) (RARP) of total OR time. Time of day did not have a negative effect on fixed OR times for robotic urologic surgeries. Median AP count was highest for RARC (median: 3 and range: 1-7). We did not find any association between AP count and fixed OR times for any of the procedures (p ≥ 0.19). Conclusions: Fixed OR times made up a significant percentage of total OR time for robot-assisted procedures and should be incorporated into OR efficiency analyses. The number of AP per case and time of day of procedure did not negatively impact fixed OR times in urologic robotic surgeries.