Inpatient safety trends in laparoscopic and open nephrectomy for renal tumours.

UNLABELLED: Study Type--Cohort study Level of Evidence 2b. What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy for renal cancer provides equivalent long-term cancer control with shorter hospital stays, less postoperative pain, and faster resumption of normal activities, but it has diffused slowly into clinical practice, perhaps as a result of perceptions about safety. Patient safety outcomes for laparoscopic and open radical nephrectomy using validated measures remain incompletely characterized. This is the first study to investigate peri-operative outcomes of radical nephrectomy using validated patient safety measures. We found a 32% decreased probability of adverse patient safety events occurring in laparoscopic compared with open radical nephrectomy. The safety benefits of laparoscopy were attained only after 10% of cases were completed laparoscopically--a proportion some have proposed as the 'tipping point' for the adoption of surgical innovations. This observation could have implications for patient safety in the setting of diffusion of new surgical techniques. OBJECTIVE: • To compare peri-operative adverse patient safety events occurring in laparoscopic radical nephrectomy (LRN) with those occurring in open radical nephrectomy (ORN). METHODS: • We used the US Nationwide Inpatient Sample to identify patients undergoing kidney surgery for renal tumours from 1998 to 2008. • We used patient safety indicators (PSIs), which are validated measures of preventable adverse outcomes, and multivariate regression to analyse associations of surgery type with patient safety. RESULTS: • Open radical nephrectomy accounted for 235,098 (89%) cases while 28,609 (11%) cases were LRN. • Compared with ORN, LRN patients were more likely to be male (P= 0.048), have lower Charlson comorbidity scores (P < 0.001), and to undergo surgery at urban (P < 0.001) and teaching (P < 0.001) hospitals. • PSIs occurred in 18,714 (8%) of ORN and 1434 (5%) of LRN cases (P < 0.001). • On multivariate analysis, LRN was associated with a 32% decreased probability of any PSI (adjusted odds ratio 0.68, 95% confidence interval: 0.6 to 0.77, P < 0.001). Stratification by year showed that this difference was initially manifested in 2003, when the proportion of LRN cases first exceeded 10%. CONCLUSIONS: • We found that LRN was associated with substantially superior peri-operative patient safety outcomes compared with ORN, but only after the national prevalence of LRN exceeded 10%. • Further study is needed to explain these patterns and promote the safe diffusion of novel surgical therapies into broad practice.

Evidence-based treatment of jellyfish stings in North America and Hawaii.

We performed a systematic review of the evidence supporting various treatments for envenomation by jellyfish (cnidarian) and related organisms in North America and Hawaii. Our review produced 19 pertinent primary articles. Current research demonstrates variable response to treatment, often with conflicting results according to species studied, which contributes to considerable confusion about what treatment is warranted and efficacious. Our review suggests that vinegar causes pain exacerbation or nematocyst discharge in the majority of species. Hot water and topical lidocaine appear more widely beneficial in improving pain symptoms and are preferentially recommended. Unfortunately, they may be difficult to obtain at the site of envenomation, such as the beach or diving sites. In these instances, removing the nematocysts and washing the area with saltwater may be considered. If the envenomation is thought to be due to the bluebottle (Physalia), vinegar may be beneficial.

Is a return to baseline sexual function possible? An analysis of sexual function outcomes following laparoscopic radical prostatectomy.

OBJECTIVES: Outcome measures following radical prostatectomy are not standardized. Though excellent potency rates are widely reported, few studies address a return to baseline function. We analyze validated sexual health-related quality-of-life outcomes by a strict definition, a return to baseline function, and compare them to less stringent, yet more frequently referenced, categorical definitions of potency. METHODS: Patients undergoing laparoscopic radical prostatectomy from April 2001 to September 2007 completed the Expanded Prostate Cancer Index Composite (EPIC) questionnaire at baseline and 3, 6, 12, and 24 months postoperatively. We defined a return to baseline as a recovery to greater than one-half standard deviation of the studied population below the patient's own baseline (clinically detectable threshold). We compared these outcomes to a categorical definition of potency involving intercourse frequency. To limit confounders, we performed subset analyses of preoperatively potent men who received bilateral nerve preservation. Factors predictive of return to baseline function were assessed in multivariable analysis. RESULTS: A total of 568 patients met inclusion criteria. Mean age and follow-up were 57.2 years and 16.9 months, respectively. Using the categorical definition, 85% of preoperatively potent men with bilateral nerve preservation were "potent" at 24 months; however, only 27% returned to their baseline sexual function. In multivariable analyses baseline function, number of nerves spared, and age were independent predictors of a return to baseline function. CONCLUSION: While most preoperatively potent men who receive bilateral nerve preservation engage in intercourse postoperatively, few return to their baseline sexual function. We believe that these data provide context for the expectations of patients who elect extirpative therapy.

Association of surgeon subjective characterization of nerve sparing quality with potency following laparoscopic radical prostatectomy.

PURPOSE: We assessed whether a surgeon self-graded assessment of neurovascular bundle preservation quality predicted potency following laparoscopic radical prostatectomy. MATERIALS AND METHODS: From April 2001 to January 2007 a total of 767 laparoscopic radical prostatectomies were performed by 2 surgeons who graded left and right neurovascular bundle sparing qualities on a scale of 0 to 5. The total number of nerves spared was also recorded. We defined a composite variable, the bilateral sum neurovascular bundle sparing score, to encode 1 independent variable (scale of 0 to 10) for analysis. Multivariate linear regression models were evaluated to assess the significance of the bilateral sum neurovascular bundle sparing score for predicting validated potency outcomes, controlling for significant clinical variables in preoperatively potent men (Sexual Health Inventory for Men 21 or greater). The bilateral sum neurovascular bundle sparing score based model was compared to a model based on the separate number of nerves spared. RESULTS: A total of 313 patients were preoperatively potent, of whom 226 (72%), 77 (25%) and 10 (3%) underwent bilateral, unilateral and no neurovascular bundle sparing, respectively. Of the men who underwent bilateral neurovascular bundle sparing 64.3% were engaging in intercourse by 1 year. Regression models indicated that the bilateral sum neurovascular bundle sparing score and the number of nerves spared were highly significant independent positive predictors of postoperative sexual function (p <0.001). The bilateral sum neurovascular bundle sparing score model provided differential prognostic information in the majority group that underwent bilateral nerve preservation. Other independently predictive variables were patient age at surgery, months since surgery and preoperative Sexual Health Inventory for Men 21 to 25 (each p <0.001). CONCLUSIONS: Cavernous nerve preservation during laparoscopic radical prostatectomy is not an all or none phenomenon. A surgeon subjective sense of neurovascular bundle sparing quality may aid in accurately characterizing the return of sexual function following laparoscopic radical prostatectomy. Partial nerve preservation may lead to an incremental improvement in the return of sexual function.

The impact of prostate size on urinary quality of life indexes following laparoscopic radical prostatectomy.

PURPOSE: We assessed the effects of prostate size on long-term health related quality of life and functional outcomes after laparoscopic radical prostatectomy. MATERIALS AND METHODS: A total of 729 consecutive patients who underwent laparoscopic radical prostatectomy for localized prostate cancer were stratified by pathological prostate gland weight, including group 1--less than 35 gm, group 2--35 to 70 gm and group 3--greater than 70 gm. Urinary health related quality of life was assessed preoperatively and at regular intervals following laparoscopic radical prostatectomy using the validated Expanded Prostate Cancer Index Composite questionnaire. RESULTS: A total of 613 evaluable patients were studied with a mean age of 57.7 years, a preoperative prostate specific antigen of 6.0 ng/ml, a median preoperative and postoperative Gleason score of 6, and a mean pathological gland weight of 51.3 gm (range 13.4 to 145.7). Patients with the largest glands had significantly worse baseline urinary function, as demonstrated by Expanded Prostate Cancer Index Composite urinary domain summary (p <0.001) and subscale scores, including scores for urinary bother (p <0.001), urinary irritative/obstructive (p = 0.001) and urinary incontinence (p = 0.03). Patients in group 3 also had significantly older age, a higher body mass index, longer operative time and more blood loss (each p <0.05). Despite preoperative differences and possible confounders all groups approached similar urinary health related quality of life outcomes at all time points postoperatively. At 12 months patients with the largest glands had improved Expanded Prostate Cancer Index Composite urinary irritative/obstructive and urinary bother subscale scores compared to their baseline scores (p <0.05). CONCLUSIONS: In laparoscopic radical prostatectomy despite preoperative differences increasing prostatic size is not associated with delayed or worse postoperative urinary health related quality of life. Furthermore, in patients with large glands an improvement in urinary irritative/obstructive and bother symptoms from baseline may be seen 12 months postoperatively.

Laparoscopic appendectomy is safer than open appendectomy in an elderly population.

BACKGROUND AND OBJECTIVES: This study describes perioperative patient safety outcomes comparing laparoscopic appendectomy with open appendectomy in the elderly population (defined as age≥65 years) during the diffusion of laparoscopic appendectomy into widespread clinical practice. METHODS: We performed a cross-sectional analysis of patients undergoing open or laparoscopic appendectomy in the US Nationwide Inpatient Sample, a 20% sample of inpatient discharges from 1056 hospitals, from 1998 to 2009, and used weighted sampling to estimate national trends. Multivariate logistic regression modeling was used to examine the association of laparoscopy with perioperative outcomes. RESULTS: Patients who met the inclusion criteria totaled 257,484. Of these, 87,209 (34%) underwent laparoscopic appendectomy. These patients were younger (P<.001); had lower Charlson comorbidity scores (P<.001); were more likely to be white (P<.001), to be privately insured (P=.005), and to undergo surgery in urban hospitals (P<.001); and were less likely to have appendiceal rupture (P<.001). Laparoscopic appendectomy was associated with a decreased length of stay (4.44 days vs 7.86 days, P<.001), fewer total patient safety indicator events (1.8% vs 3.5%, P<.001), and a decreased mortality rate (0.9% vs 2.8%, P<.001). On multivariate analyses, we observed a 32% (odds ratio, 0.68) decreased probability of patient safety events occurring in laparoscopic appendectomy cases versus open appendectomy cases as measured by patient safety indicators. CONCLUSION: The data suggest that laparoscopic appendectomy is associated with improved clinical outcomes in the elderly and that diffusion of laparoscopic appendectomy is not associated with adverse patient safety events in this population.

Prostate size is not associated with recovery of sexual function after minimally invasive radical prostatectomy.

OBJECTIVES: To investigate the association of prostate weight with recovery of sexual function after minimally invasive radical prostatectomy. METHODS: Between April 2001 and September 2007, two surgeons performed 856 consecutive laparoscopic radical prostatectomies for clinically localized prostate cancer. Patients were stratified into three groups by prostate weight: <35 g, 35-70 g, and >70 g. Sexual and urinary outcomes were assessed prospectively using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Patients who underwent nerve sparing (unilateral or bilateral) with complete preoperative EPIC data, a minimum preoperative Sexual Health Inventory for Men score ≥21, and a minimum of 3 months of complete postoperative EPIC data were included in the analysis. RESULTS: Of the cohort of 856 men, 324 (38%) had complete, evaluable data and met the inclusion criteria for this study. Preoperatively, there were no significant differences by prostate weight in the EPIC sexual function or bother subscale scores or the proportion of patients participating in sexual intercourse. Postoperatively, we observed statistically similar returns to baseline EPIC sexual function and bother subscale scores and participation in sexual intercourse across all gland weight groups at all time points. EPIC sexual domain scores and the proportions of patients participating in sexual intercourse continued to increase up to 24 months postoperatively, but no group returned to preoperative function at any sampling point. CONCLUSIONS: Prostate size is not associated with postoperative recovery of sexual function in men undergoing minimally invasive radical prostatectomy.

Comparison of validated instruments measuring sexual function in men.

OBJECTIVES: There is no universally accepted instrument to measure sexual function (SF) in men. We compare validated SF measures in a single cohort. METHODS: We compare the Sexual Health Inventory for Men (SHIM), Expanded Prostate Cancer Index Composite SF domain (EPIC-SF), and a reconstructed University of California Los Angeles Prostate Cancer Index SF domain (PCI-SF) in 856 men scheduled for radical prostatectomy. We define potency thresholds for the PCI-SF and EPIC-SF. RESULTS: Mean age, body mass index, Gleason sum, and PSA were 57 years, 26.7 kg/m(2), 6.3, and 5.9 ng/mL, respectively. Mean instrument scores were as follows: SHIM 20.1; EPIC-SF 65; PCI-SF 71. All instruments were significantly intercorrelated (r = 0.99 for EPIC-SF vs PCI-SF, r = 0.75 for SHIM vs EPIC-SF, r = 0.77 for SHIM vs PCI-SF, all P < .001). The SHIM had the greatest negative skew and ceiling effect (P < .001). Although high scores on either the EPIC-SF or PCI-SF translated reliably to high SHIM scores, the reverse was not true. Subjects who reported no erectile dysfunction (ED) on the SHIM (>or=22) had diverse overall SF, whereas those who scored highly on the EPIC-SF or PCI-SF had both excellent erectile function (potency) and overall SF (including orgasmic function, erectile function, and sexual desire). EPIC-SF scores >or=65 and PCI-SF scores >or=75 define men that are both potent and have good SF. CONCLUSIONS: The SHIM is intended as an instrument to assess ED. It is, however, inadequate as a measure of overall SF. The EPIC-SF and PCI-SF capture gradations of both sexual and erectile function and may also be used to define potency more comprehensively.

The impact of prostate size on perioperative outcomes in a large laparoscopic radical prostatectomy series.

PURPOSE: To clarify the effects of pathologic prostate specimen weight on perioperative outcomes in laparoscopic radical prostatectomy (LRP), a subject that has recently been analyzed in numerous smaller series. PATIENTS AND METHODS: Data from our Institution Review Board-approved database was queried with attention to operative, perioperative, and pathologic outcomes. For analysis, LRP patients were divided into three groups by pathologic specimen weight: <35 g, 35 to 70 g, and >70 g, and outcomes assessed. Outcomes were also analyzed using prostate weight as a continuous variable by multivariate regression. RESULTS: Between April 2001 and April 2007, 802 consecutive patients underwent LRP for localized prostate cancer, and complete perioperative data were available for 720 (90%) of these men. Mean age, body mass index (BMI), preoperative prostate-specific antigen (PSA) and postoperative Gleason score were 57.6 years, 26.7 kg/m(2), 5.9 ng/mL, and 6.3, respectively. Mean specimen weight was 51.3 g. When compared with lighter counterparts, patients with the heaviest glands were older (P < 0.01), had a higher PSA level (P < 0.01), and had a higher percentage of pathologically organ-confined disease (P < 0.01). By multivariate regression analysis, increasing prostate weight was associated with longer operative times, more blood loss, longer lengths of stay, and more perioperative complications (all P < 0.05). Of note, smaller glands trended toward a higher rate of positive surgical margins overall (P = 0.07) and in pT(2) disease (P = 0.05), but there was no association between surgical margins and gland size in pT(3) disease (P = 0.27). Increasing BMI was also independently predictive of positive margins regardless of prostate size (P < 0.01). CONCLUSIONS: Although perioperative outcomes are generally excellent after LRP irrespective of gland size, a larger prostate size is associated with longer operative time, more blood loss, longer length of stay, and increased complications. Patients with smaller glands and organ-confined disease appear to have a higher rate of positive surgical margins.