Implementation of a Perioperative Venous Thromboembolism Prophylaxis Program for Patients Undergoing Radical Cystectomy on an Enhanced Recovery After Surgery Protocol.

BACKGROUND: Novel venous thromboembolism (VTE) prophylaxis programs, including postdischarge pharmacologic prophylaxis, have been associated with decreased VTE rates. Such practices have not been widely adopted in managing radical cystectomy (RC) patients. OBJECTIVE: To evaluate the effect of a perioperative VTE prophylaxis program on VTE rates after RC. DESIGN, SETTING, AND PARTICIPANTS: Single-institution, nonrandomized, pre- and post-intervention analysis of 319 patients undergoing RC at Brigham and Women's Hospital between July 2011 and April 2017. Patient and outcome data were prospectively collected as part of the American College of Surgeons National Surgical Quality Improvement Program. INTERVENTION: Before June 2015, patients only received postoperative pharmacologic and mechanical VTE prophylaxis in the inpatient setting. Starting June 2015, a perioperative VTE prophylaxis program was implemented as part of an enhanced recovery after surgery (ERAS) protocol, including a 28-d course of postdischarge enoxaparin. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was 30-d postoperative VTE rate. Secondary outcomes were perioperative bleeding rates, 30-d complication, readmission, and mortality rates, and length of stay. Univariate analysis was performed comparing outcomes between pre- and post-intervention cohorts. RESULTS AND LIMITATIONS: Of the 319 patients who underwent RC, 210 (66%) were in the pre- and 109 (34%) in the post-intervention cohort. VTE rate was significantly lower in the post-intervention cohort (n=1, 0.9% vs n=13, 6.2%; p=0.04). Rates of perioperative bleeding (35% vs 33%; p=0.80) and 30-d readmissions related to bleeding (1% vs 3.7%; p=0.19) did not differ significantly. Single-institution data limits generalizability, and patient compliance with postdischarge enoxaparin was unknown. CONCLUSIONS: Implementation of a perioperative VTE prophylaxis program as part of an ERAS protocol that includes extended postdischarge pharmacologic prophylaxis was associated with decreased rate of VTE events after RC. Perioperative bleeding and readmissions related to bleeding did not increase with this intervention. PATIENT SUMMARY: This study evaluated whether clotting complication rates after radical cystectomy (RC) for bladder cancer can be reduced by implementing a new postoperative care pathway. This pathway reduced rates of clotting complications without increasing bleeding rates and should be considered for all patients undergoing RC.

Multilevel Analysis of Readmissions After Radical Cystectomy for Bladder Cancer in the USA: Does the Hospital Make a Difference?

BACKGROUND: Hospitals are increasingly being held responsible for their readmissions rates. The contribution of hospital versus patient factors (eg, case mix) to hospital readmissions is unknown. OBJECTIVE: To estimate the relative contribution of hospital and patient factors to readmissions after radical cystectomy (RC) for bladder cancer. DESIGN, SETTING, AND PARTICIPANTS: We identified individuals who underwent RC in 2014 in the Nationwide Readmissions Database (NRD). The NRD is a nationally representative (USA), all-payer database that includes readmissions at index and nonindex hospitals. Survey weights were used to generate national estimates. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The main outcome was readmission within 30 d after RC. Using a multilevel mixed-effects model, we estimated the statistical association between patient and hospital characteristics and readmission. A hospital-level random-effects term was used to estimate hospital-level readmission rates while holding patient characteristics constant. RESULTS AND LIMITATIONS: We identified a weighted sample of 7095 individuals who underwent RC at 341 hospitals in the USA. The 30-d readmission rate was 29.5% (95% confidence interval [CI] 27.8-31.2%), ranging from 1.4% (95% CI 0.6-2.2%) in the bottom quartile to 73.6% (95% CI 68.4-78.7) in the top. In our multilevel model, female sex and comorbidity score were associated with a higher likelihood of readmission. The hospital random-effects term, encompassing both measured and unmeasured hospital characteristics, contributed minimally to the model for readmission when patient characteristics were held constant at population mean values (pseudo-R2<0.01% for hospital effects). Surgical volume, bed size, hospital ownership, and academic status were not significantly associated with readmission rates when these terms were added to the model. CONCLUSIONS: After adjusting for patient characteristics, hospital-level effects explained little of the large between-hospital variability in readmission rates. These findings underscore the limitations of using 30-d post-discharge readmissions as a hospital quality metric. PATIENT SUMMARY: The chance of being readmitted after radical cystectomy varies substantially between hospitals. Little of this variability can be explained by hospital-level characteristics, while far more can be explained by patient characteristics and random variability.

Intravesical Extrusion of a Single-Incision Midurethral Sling Anchor With a Simple Transurethral Resection Technique: A Case Report.

Single-incision midurethral slings were introduced in 2006 with the goal of providing shorter operative time, less postoperative pain, and decreased rates of injury to surrounding structures (eg, bladder and/or obturator nerve). Although unrecognized bladder injury during SIMS placement is a rare complication, it can lead to irritative voiding symptoms and recurrent urinary tract infections. We present the case of minimally invasive approach to remove an extruded sling.

Causes of hospital readmissions after urologic cancer surgery.

OBJECTIVES: The Hospital Readmissions Reduction Program mandates reimbursement reductions to hospitals with higher than expected rates of readmissions. We examine causes and predictors of readmissions following major procedures in urologic oncology. MATERIALS AND METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, patients undergoing radical prostatectomy (RP), radical (RN) or partial nephrectomy (PN), and radical cystectomy (RC) during the year 2012 were abstracted. Rates of unplanned readmission within 30 days after surgery, as well as causes of readmission, were identified. Multivariable logistic regression models were fitted to examine the association between patient perioperative factors and odds of readmission. RESULTS: Overall, we observed a 5.5% unplanned 30-day readmission rate. Readmission rates for patients treated with RP, RN, PN, and RC were 4.1%, 5.2%, 4.5%, and 15.9%, respectively. For each procedure, approximately two-third of readmissions occurred within the first 10 days following hospital discharge. Commonest causes of readmission after RP included thromboembolic (13.6%), wound (12.2%), renal/genitourinary (12.2%), and gastrointestinal (11.8%); after RN, wound (12.9%) and gastrointestinal (12.9%); after PN, renal/genitourinary (19.6%), cardiovascular (9.8%), and bleeding/hematoma (9.8%); and after RC, renal/genitourinary (15.5%), wound (14.8%), and sepsis/infection (14.1%). RC was significantly associated with readmission. Patients undergoing open RP or PN were more likely to be readmitted relative to their minimally invasive counterparts (odds ratio = 1.53, 95% CI: 1.12-2.08, P = 0.007 and odds ratio = 2.51, 95% CI: 1.38-4.55, P = 0.003, respectively). CONCLUSIONS: Readmissions are relatively common following major urologic oncology procedures. Compared with RP, RN, or PN, RC patients experience the highest burden of readmission. Venous thromboembolism is a common modifiable cause of readmission following urologic cancer surgery. Minimally invasive approach is associated with decreased odds of readmission following RP and PN.

Tissue-Engineered Skin Substitutes.

BACKGROUND: Skin substitutes are frequently used by plastic surgeons today to treat a wide variety of cutaneous defects. They provide methods to heal wounds while minimizing donor sites. They are commonly used in burns, acute wounds, and chronic wounds. METHODS: The authors reviewed the literature on both the development of skin substitutes and their use today. The authors focused their work on what are currently the more commonly used types of skin substitutes in the United States. There is a wide interest in human-derived placental products, which will be the subject of a future publication. RESULTS: Commonly used skin substitutes include semisynthetic dermal scaffolds, allogenic cell constructs, and cellular and decellularized allogenic or xenogenic sources. For semisynthetic dermal scaffolds and allogenic cell constructs, there have been large clinical trials demonstrating their efficacy. CONCLUSIONS: Skin substitutes represent great progress for plastic surgery and provide several advances and options with which to heal wounds. More studies are needed to guide surgeons into the most appropriate use of these materials. Future developments, including advances in scaffolds, stem cells, and tissue processing, are likely to produce even more clinical options for our patients.