Perioperative Aspirin Use Is Associated with Bleeding Complications during Robotic Partial Nephrectomy.

PURPOSE: Daily aspirin use following cardiovascular intervention is commonplace and creates concern regarding bleeding risk in patients undergoing surgery. Despite its cardio-protective role, aspirin is often discontinued 5-7 days prior to major surgery due to bleeding concerns. Single institution studies have investigated perioperative outcomes of aspirin use in robotic partial nephrectomy (RPN). We sought to evaluate the outcomes of perioperative aspirin (pASA) use during RPN in a multicenter setting. MATERIALS AND METHODS: We performed a retrospective evaluation of patients undergoing RPN at 5 high volume RPN institutions. We compared perioperative outcomes of patients taking pASA (81 mg) to those not on aspirin. We analyzed the association between pASA use and perioperative transfusion. RESULTS: Of 1,565 patients undergoing RPN, 228 (14.5%) patients continued pASA and were older (62.8 vs 56.8 years, p <0.001) with higher Charlson scores (mean 3 vs 2, p <0.001). pASA was associated with increased perioperative blood transfusions (11% vs 4%, p <0.001) and major complications (10% vs 3%, p <0.001). On multivariable analysis, pASA was associated with increased transfusion risk (OR 1.94, 1.10-3.45, 95% CI). CONCLUSIONS: In experienced hands, perioperative aspirin 81 mg use during RPN is reasonable and safe; however, there is a higher risk of blood transfusions and major complications. Future studies are needed to clarify the role of antiplatelet therapy in RPN patients requiring pASA for primary or secondary prevention of cardiovascular events.

Societal costs of localized renal cancer surgery.

INTRODUCTION: Hospital-related costs of renal cancer surgery have been described, but the societal costs of surgery-related lost productivity are poorly understood. We estimated the societal cost of renal cancer surgery by assessing surgery-related time off work (TOW) taken by patients and their caretakers. MATERIALS AND METHODS: A total of 413 subjects who underwent partial or radical nephrectomy enrolled in an IRB-approved prospective study received an occupational survey assessing employment status, work physicality, income, surgery-related TOW, and caretaker assistance. We excluded subjects with incomplete occupational information or metastatic disease. We estimated potential wages lost using individual income and TOW, and used logistic regression to evaluate for factors predictive of TOW > 30 days. RESULTS: Of the 219 subjects who responded, 138 were employed at time of surgery. Ninety-seven subjects returned to work, met the inclusion criteria, and were analyzed. Mean age was 54 and 56% of subjects had sedentary jobs. TOW ranged from 7 to 92 days; mean and median TOW was 35 and 33 days, respectively and 58% of subjects took > 30 days off. Mean potential wages lost for TOW was $10,152. Eighty-three percent of subjects had at least one caretaker take TOW (mean/median caretaker TOW: 11/7 days, respectively) to assist in recovery. Subjects with sedentary jobs were less likely to take > 30 days off (OR 0.30; 95% CI 0.09-0.99). CONCLUSIONS: Most renal cancer surgery patients take over 1 month off work. Recognizing the associated societal costs may allow better adjustment of patient expectations, and more comprehensive cost-effectiveness analyses in renal cancer care.

How digital transformation can accelerate data use in health systems.

Introduction: We are in an era of rapid technological advance and digitalization. Countries around the world want to leverage technology to improve health outcomes by accelerating data use and increasing evidence-based decision-making to inform action in the health sector. Yet, there is no "one size fits all" approach to achieving this. To understand more, PATH and Cooper/Smith conducted a study documenting and analyzing the experiences of five African countries (Burkina Faso, Ethiopia, Malawi, South Africa, and Tanzania) that are on this digitalization journey. The goal was to examine their different approaches and develop a holistic model of digital transformation for data use that identifies what the essential components for digitalization success are and how they interact with each other. Methods: Our research had two phases: first, we analyzed documentation from the five countries to identify core components and enabling factors for successful digital transformation, as well as barriers encountered; and second, we held interviews with key informants and focus groups within the countries to fill gaps and validate findings. Findings: Our findings show that the core components of digital transformation success are highly interrelated. We found that the more successful digitalization efforts address issues that cut across components-such as stakeholder engagement, health workforce capacity, and governance structures-and consider more than just systems and tools. Specifically, we found two critical components of digital transformation that have not been addressed in previous models like the eHealth strategy building blocks developed by the World Health Organization and the International Telecommunication Union: (a) cultivating a culture of data use throughout the health sector and (b) managing the process of system-wide behavior change required to move from manual or paper-based to digital systems. Conclusion: The resulting model is based on the study's findings and is intended to inform low- and middle-income (LMIC) country governments, global policymakers (such as WHO), implementers, and funders. It provides specific, concrete, evidence-based strategies these key stakeholders can implement to improve digital transformation for data use in health systems, planning, and service delivery.

Reducing Pseudoaneurysm and Urine Leak After Robotic Partial Nephrectomy: Results Using the Early Unclamping Technique.

OBJECTIVE: To present our experience using the early unclamping technique for robotic partial nephrectomy with particular attention to delayed complications, namely pseudoaneurysm and urine leak. We hypothesized that early hilar unclamping allows for improved control of end arteries and renorrhaphy after tumor resection, reducing overall delayed complications after partial nephrectomy with no increased risk of blood transfusion. METHODS: This single institution retrospective review of a prospectively maintained database includes patients undergoing robotic partial nephrectomy with early unclamping technique for presumed renal malignancy between 2009 and 2018. Patient demographics and perioperative parameters are described, particularly rates of pseudoaneurysm and urine leak. Results are compared to previously published partial nephrectomy studies using various clamping and renorrhaphy techniques. RESULTS: Four hundred and sixty three patients were included in the study. Mean operative time and warm ischemia time were 186 and 14.7 minutes, respectively. Mean estimated blood loss was 242 cc. Thirty-day postoperative complication rate was 14.7%, with 88% of these Clavien I-II. Urine leak occurred in 1 patient (0.2%) undergoing a simultaneous partial nephrectomy and pyelothitotomy for partial staghorn stone. Postoperative transfusion rate was 1.33% and our pseudoaneurysm rate was 0%. CONCLUSION: The early unclamping technique for robotic partial nephrectomy is reliable and safe, with low pseudoaneurysm and urine leak rates which compare favorably to other published techniques.