Healthcare system contact following ureteroscopy: does discharge instruction readability matter?

INTRODUCTION: We aimed to assess the impact of discharge instruction (DCI) readability on 30-day postoperative contact with the healthcare system. MATERIALS AND METHODS: Utilizing a multidisciplinary team, DCI were modified for patients undergoing cystoscopy, retrograde pyelogram, ureteroscopy, laser lithotripsy, and stent placement (CRULLS) from a 13th grade to a 7th grade reading level. We retrospectively reviewed 100 patients including 50 consecutive patients with original DCI (oDCI) and 50 consecutive patients with improved readability DCI (irDCI). Clinical and demographic data collected including healthcare system contact (communications [phone or electronic message], emergency department [ED], and unplanned clinic visits) within 30 days of surgery. Uni/multivariate logistic regression analyses used to identify factors, including DCI-type, associated with increased healthcare system contact. Findings reported as odds ratios with 95% confidence intervals and p values (< 0.05 significant). RESULTS: There were 105 contacts to the healthcare system within 30 days of surgery: 78 communications, 14 ED visits and 13 clinic visits. There were no significant differences between cohorts in the proportion of patients with communications (p = 0.16), ED visits (p =1.0) or clinic visits (p = 0.37). On multivariable analysis, older age and psychiatric diagnosis were associated with significantly increased odds of overall healthcare contact (p = 0.03 and p = 0.04) and communications (p = 0.02 and p = 0.03). Prior psychiatric diagnosis was also associated with significantly increased odds of unplanned clinic visits (p = 0.003). Overall, irDCI were not significantly associated with the endpoints of interest. CONCLUSIONS: Increasing age and prior psychiatric diagnosis, but not irDCI, were significantly associated with an increased rate of healthcare system contact following CRULLS.

A novel upper tract ureteroscopic biopsy technique: the "form tackle"

ABSTRACT Introduction and Objective: Upper tract urothelial carcinoma (UTUC) represents 5% of all urothelial malignancies (1-3). Accurate pathologic diagnosis is key and may direct treatment decisions. Current ureteroscopic biopsy techniques include cold-cup, backloaded cold-cup and stone basket (4-6). The study objective was to compare a standard cold-cup biopsy technique to a novel cold-cup biopsy technique and evaluate histopathologic results. Materials and Methods: We developed a novel UTUC biopsy technique termed the "form tackle" biopsy. Ureteroscope is passed into ureter/renal collecting system. Cold-cup forceps are opened and pressed into the lesion base (to engage the urothelial wall/submucosal tissue) then closed. Ureteroscope/forceps are advanced forward 3-10mm and then extracted from the patient. We compared standard versus novel upper tract biopsy techniques in a series of patients with lesions ≥1cm. In each procedure, two standard and two novel biopsies were obtained from the same lesion. The primary study aim was diagnosis of malignancy. IRB approved: 21-006907. Results: Fourteen procedures performed on 12 patients between June 2020 and March 2021. Twenty-eight specimens sent (14 standard, 14 novel) (Two biopsies per specimen). Ten procedures with concordant pathology. In 4 procedures the novel biopsy technique resulted in a diagnosis of UTUC (2 high-grade, 2 low-grade) in the setting of a benign standard biopsy. Significant difference in pathologic diagnoses was detected between standard and novel upper tract biopsy techniques (p=0.008). Conclusions: The "form tackle" upper tract ureteroscopic biopsy technique provides higher tissue yield which may increase diagnostic accuracy. Further study on additional patients required. Early results are encouraging.

A novel upper tract ureteroscopic biopsy technique: the "form tackle".

INTRODUCTION AND OBJECTIVE: Upper tract urothelial carcinoma (UTUC) represents 5% of all urothelial malignancies (1-3). Accurate pathologic diagnosis is key and may direct treatment decisions. Current ureteroscopic biopsy techniques include cold-cup, backloaded cold-cup and stone basket (4-6). The study objective was to compare a standard cold-cup biopsy technique to a novel cold-cup biopsy technique and evaluate histopathologic results. MATERIALS AND METHODS: We developed a novel UTUC biopsy technique termed the "form tackle" biopsy. Ureteroscope is passed into ureter/renal collecting system. Cold-cup forceps are opened and pressed into the lesion base (to engage the urothelial wall/submucosal tissue) then closed. Ureteroscope/forceps are advanced forward 3-10mm and then extracted from the patient. We compared standard versus novel upper tract biopsy techniques in a series of patients with lesions ≥1cm. In each procedure, two standard and two novel biopsies were obtained from the same lesion. The primary study aim was diagnosis of malignancy. IRB approved: 21-006907. RESULTS: Fourteen procedures performed on 12 patients between June 2020 and March 2021. Twenty-eight specimens sent (14 standard, 14 novel) (Two biopsies per specimen). Ten procedures with concordant pathology. In 4 procedures the novel biopsy technique resulted in a diagnosis of UTUC (2 high-grade, 2 low-grade) in the setting of a benign standard biopsy. Significant difference in pathologic diagnoses was detected between standard and novel upper tract biopsy techniques (p=0.008). CONCLUSIONS: The "form tackle" upper tract ureteroscopic biopsy technique provides higher tissue yield which may increase diagnostic accuracy. Further study on additional patients required. Early results are encouraging.

Does MOSES pulse modulation reduce short-term catheter reinsertion following holmium laser enucleation of the prostate?

PURPOSE: Previously published studies have shown small prostate size, capsular perforation and intraoperative bladder distension are associated with failed trial without a catheter (TWOC) after HoLEP. The study objective was to determine the relationship between MOSES pulse modulation versus standard laser technology and short-term catheter reinsertion following failed TWOC. MATERIALS AND METHODS: The study included 487 patients who underwent HoLEP, using standard holmium laser settings (180 patients) or MOSES pulse modulation (255 patients), between August 2018 and February 2021. Catheter reinsertion defined as reinsertion following failed TWOC within 30 days of surgery. Association of pulse modulation with catheter reinsertion was examined using single and multivariable logistic regression models. Comparisons of pre and intraoperative characteristics between patients treated without and with pulse modulation were made using a Wilcoxon rank sum test for numeric characteristics or Fisher's exact test for categorical characteristics. RESULTS: Short-term catheter reinsertion occurred in 14% (26/180) of the standard laser setting group as compared with 10% (24/252) of the pulse modulation group. There was no statistically significant association with short-term catheter reinsertion in single (unadjusted OR [standard settings vs. pulse modulation], 1.60; 95% CI, 0.80-2.91; p=0.12) or multivariable analysis adjusting for specimen weight and operative time (adjusted OR [standard settings vs. pulse modulation], 1.44; 95% CI, 0.77-2.68; p=0.25). CONCLUSIONS: In this study, we found no association between post-HoLEP short-term catheter reinsertion following failed TWOC and MOSES pulse modulation. Although MOSES pulse modulation offers several well-documented advantages, catheter reinsertion events appear to be attributable to other factors.

Partial versus radical nephrectomy in clinical T2 renal masses.

OBJECTIVE: To report perioperative, renal functional and oncologic outcomes for patients undergoing partial or radical nephrectomy for cT2 renal masses. METHODS: Retrospective review of patients who underwent partial (n = 72) or radical nephrectomy (n = 379) for cT2 renal masses from 2000 to 2016. After propensity adjustment using inverse probability weighting, the following were compared by surgery (partial or radical nephrectomy): complications, renal function measured by estimated glomerular filtration rate as continuous and as <60 mL/min/1.73 m2 at 1 and 3 years postoperatively and overall, metastases-free survival and cancer-specific survival in patients with renal cell carcinoma. RESULTS: After propensity adjustment, clinical and radiographic features were well-balanced between groups. Overall and severe complications were more common for partial compared with radical nephrectomy, although not statistically significant (19 vs 13%, P = 0.14 and 4 vs 2%, P = 0.3, respectively). Estimated glomerular filtration rate change at 1 and 3 years was more pronounced in radical compared with partial nephrectomy (median -16 vs -5 and -14 vs -2, respectively, P < 0.001). A greater proportion of radical nephrectomy patients had an estimated glomerular filtration rate <60 at 1 and 3 years (55 vs 17% and 48 vs 17%, respectively, P < 0.01). In renal cell carcinoma patients, overall, metastases-free and cancer-specific survival were not significantly different between groups (median survivor follow up 7.1 years, interquartile range 3.6-11.4). CONCLUSIONS: Partial nephrectomy appears to be a relatively safe and a potentially effective treatment for cT2 renal masses, conferring better renal functional preservation compared with radical nephrectomy. These data support continued use of partial nephrectomy for renal masses >7 cm in appropriately selected patients.

Cost-effectiveness of Retrograde Intrarenal Surgery, Standard and Mini Percutaneous Nephrolithotomy, and Shock Wave Lithotripsy for the Management of 1-2cm Renal Stones.

OBJECTIVE: To perform a cost-effectiveness evaluation comparing the management options for mid-size (1-2cm) renal stones including percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and shockwave lithotripsy (SWL). METHODS: A Markov model was created to compare cost-effectiveness of PCNL, mini-PCNL, RIRS, and SWL for 1-2cm lower pole (index patient 1) and PCNL, RIRS, and SWL for 1-2 cm non-lower pole (index patient 2) renal stones. A literature review provided stone free, complication, retreatment, secondary procedure rates, and quality adjusted life years (QALYs). Medicare costs were used. The incremental cost-effectiveness ratio (ICER) was compared with a willingness-to-pay(WTP) threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed. RESULTS: At 3 years, costs for index patient 1 were $10,290(PCNL), $10,109(mini-PCNL), $5,930(RIRS), and $10,916(SWL). Mini-PCNL resulted in the highest QALYs(2.953) followed by PCNL(2.951), RIRS(2.946), and SWL(2.943). This translated to RIRS being most cost-effective followed by mini-PCNL(ICER $624,075/QALY) and PCNL(ICER $946,464/QALY). SWL was dominated with higher costs and lower effectiveness. For index patient 2, RIRS dominated both PCNL and SWL. For index patient 1: mini-PCNL and PCNL became cost effective if cost ≤$5,940 and ≤$5,390, respectively. SWL became cost-effective with SFR ≥75% or cost ≤$1,236. On probabilistic sensitivity analysis, the most cost-effective strategy was RIRS in 97%, mini-PCNL in 2%, PCNL in 1%, and SWL in 0% of simulations. CONCLUSION: For 1-2cm renal stones, RIRS is most cost-effective. However, mini and standard PCNL could become cost-effective at lower costs, particularly for lower pole stones.

Transurethral Resection of a Bladder Tumor in Pregnancy: Decidual Reaction Bladder Endometriosis.

Background: Decidual reaction bladder endometriosis (DRBE) is exceedingly rare with few reported cases in the literature. It presents as a bladder mass during pregnancy, and may be accompanied by lower urinary tract symptoms. Histologic diagnosis is necessary to rule out primary bladder malignancy. We present a case of a bladder tumor identified during pregnancy. The mass was managed endoscopically and found to be DRBE, a rare benign entity. Case Presentation: We present a 31 year old 15 weeks pregnant nonsmoker woman with a rapidly enlarging bladder mass concerning for primary bladder malignancy. Mass confirmed on formal renal/bladder ultrasound and in-office cystoscopy. After informed consent was obtained, the patient was taken to the operating room. A 5.5 cm bladder mass, with an atypical nodular appearance and minor calcifications, was identified. Transurethral resection of the mass was performed. Final pathology report showed florid endometriosis with stromal decidualization. Final diagnosis: pregnancy induced vesical decidualized endometriosis simulating a bladder tumor. Patient continued routine obstetrics follow-up, and has experienced no pregnancy-related complications. Three months after delivery the patient will follow up with outside urology provider for cystoscopy, and subsequent surgical management should it be necessary. Conclusion: DRBE is a rare benign bladder mass that presents in pregnancy. It can grow rapidly raising concern for an aggressive primary bladder malignancy. Any bladder mass identified in pregnancy should undergo early, appropriate work-up given the potential risk for bladder cancer. After diagnosis, DRBE is most often managed conservatively. After delivery, should the patient experience ongoing urinary symptoms, medical and surgical treatment options are available. Overall, DRBE is considered rare, but should be considered in the differential diagnosis for any bladder mass presenting during pregnancy.

Endoscopic Management of Iatrogenic Ureteral Injury: A Case Report and Review of the Literature.

Background: Iatrogenic ureteral injury represents an uncommon, but significant, complication of gynecologic surgery. Endoscopy has typically played little to no role in the treatment of these injuries, which are traditionally managed with re-exploration or delayed repair. Delayed repair with temporary urinary diversion exposes the patient to significant morbidity. We present a case in which iatrogenic ureteral injury is managed definitively with endoscopy alone. Case Presentation: We present a 32-year-old female who developed a delayed postpartum hemorrhage following cesarean section, necessitating emergent hysterectomy. Postoperatively, there was concern for right ureteral injury. A computed tomography (CT) urogram was obtained showing right-sided hydronephrosis, but no obvious ureteral injury. After developing right flank pain, the patient was taken to the operating room for further evaluation. On semirigid ureteroscopy, a suture was identified within the lumen of the ureter and incised with the holmium laser, effectively treating the obstruction. At a 10-week follow-up, a renal ultrasound showed no hydronephrosis. At 8 months, the patient reports she is doing well with no flank pain. Conclusion: We present, to the best of our knowledge, the first published report in the United States of an iatrogenic ureteral ligation managed effectively in an acute postoperative setting with endoscopic holmium laser release, without balloon dilation, sparing the patient from delayed surgical intervention and the potentially associated morbidity. It is our belief that an initial retrograde pyelogram followed by a ureteroscopic evaluation should be performed as this allows for proper characterization of the injury, and may allow one to attempt definitive endoscopic management.

Robot-assisted partial cystectomy with intraoperative frozen section examination: Evolution and evaluation of a novel technique.

PURPOSE: To describe a novel modification to robot-assisted partial cystectomy (RAPC) that allows for intraoperative surgical margin assessment by bimanual-examination and frozen-section analysis. MATERIALS AND METHODS: A total of 7 patients underwent RAPC at a single tertiary-care institution between 2008 and 2013. The technique evolved over the study-period and permitted real-time intraoperative surgical margin evaluation in the last 5 patients via bimanual-examination and frozen-section analysis, utilizing the GelPOINT platform (a hand-assist device). The GelPOINT platform was placed through a 4- to 5-cm vertical supraumbilical incision and allowed for rapid retrieval of the bladder specimen without compromising the pneumoperitoneum or prolonging the operative time. Perioperative, oncological and functional outcomes were evaluated; all patients had a minimum 12-month follow-up. At the time of last follow-up, a cross-sectional survey of patients was performed to evaluate regret/satisfaction utilizing validated questionnaires. RESULTS: The mean age was 72.5 years; 71.4% of the patients were men (n=5). All patients underwent RAPC for a malignant indication. The mean operative and console times were 291 and 217 minutes, respectively. No patient had a positive surgical margin. Mean length-of-stay was 1.7 days. At a median follow-up of 38.9 months, 1 patient experienced a local recurrence 6 months postsurgery. The only mortality was secondary to Lewy-body disease, in the same patient, 1 year postoperatively. Patient assessment of regret and satisfaction indicated 0% regret and 0% dissatisfaction. CONCLUSIONS: The 'modified' technique of RAPC is technically feasible, safe, and reproducible; further, RAPC leads to favorable oncological, functional and quality-of-life outcomes in patients eligible for partial cystectomy.

Predicting lymph node invasion in patients treated with robot-assisted radical prostatectomy.

INTRODUCTION: To develop a nomogram to predict lymph node invasion (LNI) in the contemporary North American patient treated with robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: We included 2,007 patients treated with RARP and pelvic lymph node dissection (PLND) at a single institution between 2008 and 2012. D'Amico low risk patients underwent an obturator and hypogastric PLND, while extended PLND was reserved for intermediate/high risk patients. Logistic regression analysis tested the relationship between LNI and all available predictors. Independent predictors of LNI were used to develop a novel nomogram. Discrimination, calibration and decision-curve analysis were used to analyze the performance of our novel nomogram, and compare it to open radical prostatectomy (ORP)-based models, namely the Godoy nomogram. RESULTS: Overall, 5.3% of our patients harbored LNI. Median number of lymph nodes removed was 6.0 (interquartile range: 4-11). The most parsimonious multivariable model to predict LNI consisted of the following independent predictors: PSA value, clinical stage, and primary and secondary Gleason scores (all p ≤ 0.02). The discrimination of our novel model was 86.2%, and its calibration was virtually optimal. Using a 2% nomogram cut off, 58% of patients would be spared PLND, while missing only 9.4% of individuals with LNI. The novel nomogram compared favorably to the Godoy nomogram, when discrimination, calibration and net-benefit were used as benchmarks. CONCLUSIONS: Approximately 5% of contemporary North American patients harbor LNI at RARP. Our novel nomogram can accurately identify these patients, and this may help to improve patient selection, and avoid unnecessary PLND in the majority of patients.

Racial/Ethnic Disparities in Perioperative Outcomes of Major Procedures: Results From the National Surgical Quality Improvement Program.

OBJECTIVE: To determine the association between race/ethnicity and perioperative outcomes in individuals undergoing major oncologic and nononcologic surgical procedures in the United States. BACKGROUND: Prior work has shown that there are significant racial/ethnic disparities in perioperative outcomes after several types of major cardiac, general, vascular, orthopedic, and cancer surgical procedures. However, recent evidence suggests attenuation of these racial/ethnic differences, particularly at academic institutions. METHODS: We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify 142,344 patients undergoing one of the 16 major cancer and noncancer surgical procedures between 2005 and 2011. RESULTS: Eighty-five percent of the cohort was white, with black and Hispanic individuals comprising 8% and 4%, respectively. In multivariable analyses, black patients had greater odds of experiencing prolonged length of stay after 10 of the 16 procedures studied (all P < 0.05), though there was no disparity in odds of 30-day mortality after any surgery. Hispanics were more likely to experience prolonged length of stay after 5 surgical procedures (all P < 0.04), and were at greater odds of dying within 30 days after colectomy, heart valve repair/replacement, or abdominal aortic aneurysm repair (all P < 0.03). Fewer disparities were observed for Hispanics, than for black patients, and also for cancer, than for noncancer surgical procedures. CONCLUSIONS: Important racial/ethnic disparities in perioperative outcomes were observed among patients undergoing major cancer and noncancer surgical procedures at American College of Surgeons National Surgical Quality Improvement Program institutions. There were fewer disparities among individuals undergoing cancer surgery, though black patients, in particular, were more likely to experience prolonged length of stay.

Impact of smoking on perioperative outcomes after major surgery.

BACKGROUND: To investigate the impact of smoking on perioperative outcomes in patients undergoing one of the 16 major cardiovascular, orthopedic, or oncologic surgical procedures. METHODS: We relied on the American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2011). Procedure-specific multivariable logistic regression models assessed the association between smoking status (non, former, or current smokers) and risk of 30-day morbidity and mortality. RESULTS: Overall, 141,802 patients were identified. A total of 12.5%, 14.6%, and 14.9% of non, former, and current smokers, respectively, experienced at least one complication (P < .001). In multivariable models, current smokers had higher odds of overall, pulmonary, wound, and septic/shock complications following most cardiovascular and oncologic surgeries compared with nonsmokers. The odds of experiencing such adverse outcomes were significantly lower in former smokers compared with current smokers, but still higher compared with nonsmokers. CONCLUSIONS: The effect of smoking on perioperative outcomes is procedure dependent. Current and, even though mitigated, former smoking negatively influence outcomes following cardiovascular or oncologic procedures. Patients undergoing major procedures should be encouraged to discontinue tobacco smoking to achieve optimal procedural outcomes.

An evaluation of the timing of surgical complications following nephrectomy: data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

PURPOSE: The rates of complications following radical/partial nephrectomy (RN/PN) are well known; however, the data regarding timing are opaque. Accordingly, we sought to assess the median time-to-event for 19 principal postoperative complications within 30 days following surgery. METHODS: Patients undergoing RN/PN were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011). Primary endpoint was time-to-complication. Secondary endpoints included length-of-stay (LOS), re-intervention, re-admission and 30-day mortality. Multivariable regression models assessed the predictors for pre-/post-discharge complications and the effect of time-to-complication on secondary outcomes. RESULTS: Overall, 3820 patients underwent nephrectomy (RN = 63.6 %). The overall complication rate was 16.8 %, and the median LOS was 4 days. The majority of major complications (88.1 %), including bleeding/transfusion, renal, septic, deep venous thrombosis or pulmonary embolism, pulmonary, cardiac and neurologic, occurred prior to discharge. Conversely, the relatively minor complications, including wound and urinary tract infections, occurred predominantly post-discharge (70.7 %). The median time to major complications was 3 versus 13 days for minor complications. In multivariable analyses, age [odds ratio (OR) 1.02, p < 0.001], American Society of Anesthesiologists score ≥ 2 (p < 0.01) and PN (p < 0.001) were predictors of pre-discharge complications, while female gender (OR 1.67, p < 0.001), hypertension (OR 1.28, p = 0.007) and diabetes (OR 1.48, p < 0.001) were predictors of post-discharge complications. Creatinine ≥ 1.2 mg/dl and hematocrit < 30 increased (p < 0.01), whereas a minimally invasive approach decreased the odds (p < 0.05) for both pre-/post-discharge complications. For a given complication, time-to-complication did not affect the odds for mortality (p = 0.343) or re-intervention (p = 0.872). CONCLUSIONS: Approximately one in six patients suffers a complication following RN/PN; major complications tend to occur early with the majority occurring pre-discharge. Knowledge regarding the timing and risk factors for complications may facilitate improved patient-physician communication, both at admission and at discharge.

Adjuvant Radiotherapy in Prostate Cancer Patients Treated with Surgery: The Impact of Age and Tumor Characteristics.

BACKGROUND: The overall mortality (OM) and cancer-specific mortality (CSM) benefits of adjuvant radiotherapy (aRT) in treating prostate cancer (PCa) patients with adverse pathologic characteristics at radical prostatectomy (RP) are unclear. OBJECTIVE: To test the impact of aRT on survival in PCa patients treated with RP according to adverse pathologic characteristics (Gleason score [GS] 8-10; pT3b/4, lymph node invasion [LNI]) and age categories (<70 vs ≥70 yr). DESIGN, SETTING, AND PARTICIPANTS: A total of 7616 patients with pT3/4 pN0/1 PCa treated with RP between 1995 and 2009 within the Surveillance Epidemiology and End Results-Medicare linked database were included. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cox regression analysis was used to test the relationship between aRT and CSM, as well as OM in the entire cohort. Stratification was performed according to tumor characteristics and age categories. RESULTS AND LIMITATIONS: In patients with fewer than two adverse pathologic characteristics, aRT did not improve CSM or OM. Conversely, in patients with two or more adverse pathologic characteristics, the 10-yr CSM-free rate was 92% in patients treated with aRT versus 82% in patients treated without aRT (p<0.001). This survival improvement was confirmed in patients aged <70 yr (p=0.01) but not in those ≥70 yr (p=0.1). In multivariable analyses, aRT was an independent predictor of lower CSM risk (hazard ratio: 0.45; p=0.02) only among patients aged <70 yr with two or more adverse pathologic characteristics. Similar trends were observed when OM was examined as an end point. CONCLUSIONS: Age and tumor characteristics should be considered in the selection of optimal aRT candidates after surgery. Only patients aged <70 yr with two or more adverse pathologic characteristics (GS 8-10, pT3b/4, LNI) appear to benefit from aRT. PATIENT SUMMARY: The usefulness of adjuvant radiotherapy after surgery for prostate cancer greatly depends on tumor characteristics and patient age. Only patients with advanced local tumor characteristics aged <70 yr seem to benefit from this treatment modality.

Predicting pathological outcomes in patients undergoing robot-assisted radical prostatectomy for high-risk prostate cancer: a preoperative nomogram.

OBJECTIVE: To identify which high-risk patients with prostate cancer may harbour favourable pathological outcomes at radical prostatectomy (RP). PATIENTS AND METHODS: We evaluated 810 patients with high-risk prostate cancer, defined as having one or more of the following: PSA level of >20 ng/mL, Gleason score ≥8, clinical stage ≥T2c. Patients underwent robot-assisted RP (RARP) with pelvic lymph node dissection, between 2003 and 2012, in one centre. Only 1.6% (13/810) of patients received any adjuvant treatment. Favourable pathological outcome was defined as specimen-confined disease (SCD; pT2-T3a, node negative, and negative surgical margins) at RARP-specimen. Logistic regression models were used to test the relationship among all available predicators and harbouring SCD. A logistic regression coefficient-based nomogram was constructed and internally validated using 200 bootstrap resamples. Kaplan-Meier method estimated biochemical recurrence (BCR)-free and cancer-specific mortality (CSM)-free survival rates, after stratification according to pathological disease status. RESULTS: Overall, 55.2% patients harboured SCD at RARP. At multivariable analysis, PSA level, clinical stage, primary/secondary Gleason scores, and maximum percentage tumour quartiles were all independent predictors of SCD (all P < 0.04). A nomogram based on these variables showed 76% discrimination accuracy in predicting SCD, and very favourable calibration characteristics. Patients with SCD had significantly higher 8-year BCR- (72.7% vs 31.7%, P < 0.001) and CSM-free survival rates (100% vs 86.9%, P < 0.001) than patients with non-SCD. CONCLUSIONS: We developed a novel nomogram predicting SCD at RARP. Patients with SCD achieved favourable long-term BCR- and CSM-free survival rates after RARP. The nomogram may be used to support clinical decision-making, and aid in selection of patients with high-risk prostate cancer most likely to benefit from RARP.

Sepsis after major cancer surgery.

BACKGROUND: Cancer patients undergoing procedures are at increased risk of sepsis. We sought to evaluate the incidence of postoperative sepsis following major cancer surgeries (MCS), and to describe patient and/or hospital characteristics associated with heightened risk. METHODS: Patients undergoing 1 of 8 MCS (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, and prostatectomy) within the Nationwide Inpatient Sample from 1999-2009 were identified (N = 2,502,710). Logistic regression models fitted with generalized estimating equations were used to estimate primary predictors (procedure, age, gender, race, insurance, Charlson Comorbidity Index, hospital volume, and hospital bed size) effect on sepsis and sepsis-associated mortality. Trends were evaluated with linear regression. RESULTS: The incidence of MCS-related sepsis increased 2.0% per year (P < 0.001), whereas mortality remained stable. Odds of sepsis were highest among esophagectomy patients (odds ratio [OR]: 3.13, 2.76-3.55) and those with non-private insurance (OR: 1.33, 1.19-1.48 to OR: 1.89, 1.71-2.09). Odds of sepsis-related mortality were highest among lung resection patients (OR: 2.30, 2.00-2.64) and those experiencing perioperative liver failure (OR: 5.68, 4.30-7.52). Increasing hospital volume was associated with lower odds of sepsis and sepsis-related mortality (OR: 0.89, 0.84-0.95 to OR: 0.58, 0.53-0.62 and OR: 0.88, 0.77-0.99 to OR: 0.78, 0.67-0.93). CONCLUSIONS: Between 1999 and 2009, the incidence of MCS-related sepsis increased; however, sepsis-related mortality remained stable. Significant disparities exist in patient and hospital characteristics associated with MCS-related sepsis. Hospital volume is an important modifiable risk factor associated with improved sepsis-related outcomes following MCS.

Readmissions after major urologic cancer surgery.

INTRODUCTION: We examine the incidence and predictors of readmission after major urologic cancer surgery using a national, prospective-maintained database specifically developed to assess quality of surgical care. MATERIALS AND METHODS: Patients undergoing major urologic cancer surgery (radical prostatectomy [RP], radical nephrectomy [RNx], partial nephrectomy [PNx]), radical cystectomy [RC]) in 2011 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) using Current Procedural Terminology (CPT) codes. Those readmitted within 30 days after surgery were identified. Multivariable logistic regression models examined the association between patient characteristics and the odds of readmission. RESULTS: Overall, we identified 5356 RP, 1301 RNx, 918 PNx and 623 RC patients, of which 206 (3.8%), 533 (6.8%), 348 (6.3%) and 129 (20.7%) were readmitted within 30 days respectively. Independent predictors of readmission for RP included age (Odds Ratio [OR]: 1.02, p = 0.02), American Society of Anesthesiology (ASA) score 3-5 (versus 1-2, OR: 1.35, p = 0.04), smoking status (OR: 1.53, p = 0.04), and the occurrence of wound complications (OR: 9.31, p < 0.001), thromboembolic (OR: 14.7, p < 0.001), and renal failure (OR: 1.62, p = 0.01) complications during the index hospitalization. For RC patients, the only predictor of readmission was age (OR: 0.98, p = 0.04). Predictors of readmission for RNx included higher ASA score (OR: 1.77, p = 0.03), and the presence of any complications during the index hospitalization (OR: 2.21, p = 0.03). CONCLUSIONS: Several patient characteristics have a significant impact on the risk of 30 day readmission after major urologic cancer surgery. Our data suggests that improving prevention and management of complications during the index hospitalization may lead to a substantial decrease in readmission rates.

Role of robot-assisted radical prostatectomy in the management of high-risk prostate cancer.

We aimed to evaluate the role of robot-assisted radical prostatectomy (RARP) in the management of high-risk prostate cancer (PCa), with a focus on oncological, functional and perioperative outcomes. Further, we also aimed to briefly describe our novel modification to conventional RARP that allows immediate organ retrieval and examination for intra-operative surgical margin assessment. A literature search of PubMed was performed for articles on the management of high-risk PCa. Papers written in English and concerning clinical outcomes following RARP for locally advanced and high-risk PCa were selected. Outcomes data from our own center were also included. A total of 10 contemporary series were evaluated. Biopsy Gleason score ≥ 8 was the most common cause for classification of patients into the high-risk PCa group. Biochemical failure rate, in the few series that looked at long-term follow-up, varied from 9% to 26% at 1 year. The positive surgical margin rate varied from 12% to 53.3%. Urinary continence rates varied from 78% to 92% at 1 year. The overall complication rates varied from 2.4% to 30%, with anastomotic leak and lymphocele being the most common complications. Long-term data on oncological control following RARP in high-risk patients is lacking. Short-term oncological outcomes and functional outcomes are equivalent to open radical prostatectomy (RP). Safety outcomes are better in patients undergoing RARP when compared with open RP. Improved tools for predicting the presence of organ-confined disease (OCD) are available. High-risk patients with OCD would be ideal candidates for RARP and would benefit most from surgery alone.

Patient-reported sexual outcomes after holmium laser enucleation of the prostate: a 3-year follow-up study.

OBJECTIVE: To evaluate the long-term patient reported sexual function outcomes of holmium laser enucleation of the prostate (HoLEP) for the treatment of lower urinary tract symptoms secondary to prostate enlargement. METHODS: Three hundred ninety-three patients underwent a HoLEP between August 2007 and July 2013 and were reviewed in this retrospective analysis. Sexual function outcomes were assessed before HoLEP, and again at 3, 6, 12, 24, and 36 months after surgery using the International Index of Erectile Function 5 survey. International Prostate Symptom Scores (IPSS) were included for comparison and contextual functional outcome analysis. RESULTS: At the time of surgery, the mean age was 70.9 years (52.0-89.0 years), mean body mass index was 27.7 kg/m(2) (18.0-48.0 kg/m(2)), and mean prostate volume was 96.7 g (20.1-375.0 g). Mean International Index of Erectile Function 5 scores at 3 (13.3 ± 8.37), 6 (12.1 ± 8.76), 12 (12.1 ± 8.83), 24 (12.6 ± 8.80), and 36 months (12.5 ± 8.45) showed no significant change from baseline. There was, however, a significant improvement from baseline seen in IPSS over the same time period (P = .0001). CONCLUSION: These data confirm HoLEP has a significant impact on IPSS and no adverse impact on long-term patient reported sexual function. We believe this series represents the largest cohort with the longest follow-up to date. It represents an important tool for preoperative patient counseling for those patients considering surgical therapy for benign prostatic hyperplasia.