Hospital volume and short-term outcomes after cytoreductive nephrectomy.

PURPOSE: To investigate the impact of hospital volume on short-term outcomes after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC). METHODS: We identified mRCC patients who underwent CN from 2006 to 2013 in the National Cancer Database. Annual hospital CN volume was categorized as high (top 20th percentile) and low. Multivariable logistic regressions were used to compare 30-day mortality, 90-day mortality, prolonged length of stay (PLOS, ≥7 days), and 30-day readmission rates. Sensitivity analyses were performed with hospital volume considered as a continuous variable. RESULTS: A total of 9789 patients were included with high-volume (n = 1916) defined as ≥8 cases and low-volume (n = 7873) as 1-7 cases annually. Multivariable logistic regression showed that high-volume was associated with lower odds of 30-day mortality (OR = 0.69, P = 0.013), 90-day mortality (OR = 0.65, P < 0.001), PLOS (OR = 0.82, P = 0.002), and 30-day readmission (OR = 0.78, P = 0.028). Sensitivity analyses showed that increasing hospital volume (per case) was associated with lower odds of 30-day mortality (OR = 0.965, P = 0.008), 90-day mortality (OR = 0.966, P < 0.001), PLOS (OR = 0.982, P = 0.001), and 30-day readmission (OR = 0.975, P = 0.012). CONCLUSION: Higher hospital volume was associated with better short-term outcomes after CN. Future studies are needed to validate our findings and explore the potential components leading to better outcomes in the higher volume hospitals.

Hospital volume and outcomes of robot-assisted partial nephrectomy.

OBJECTIVE: To evaluate the impact of hospital volume on outcomes of robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: Patients with renal cell carcinoma who underwent RAPN between 2010 and 2013 were identified in the National Cancer Database. Hospital yearly RAPN volume was categorized into groups by sorting patients as closely as possible into five groups of equal size (quintiles): very low; low; medium; high; and very high volume. Outcomes included 30-day mortality, 90-day mortality, open conversion, prolonged length of hospital stay (PLOS; defined as >3 days), 30-day readmission rate, and positive surgical margin (PSM) rate. Unadjusted analyses and multivariable logistic regressions were used to compare outcomes. Sensitivity analyses with hospital volume considered as a continuous variable were also performed. RESULTS: A total of 18 724 RAPN cases were included. Hospital volume quintiles were: very low volume, 1-7 cases (n = 3 693); low volume, 8-14 cases (n = 3 719); medium volume, 15-23 cases (n = 3 833); high volume, 24-43 cases (n = 3 649); and very high volume, ≥44 cases (n = 3 830). There was no significant difference in 30-day or 90-day mortality among the five groups. Multivariable logistic regression analysis (reference: very low volume) showed that higher hospital volume was associated with lower odds of conversion (low [odds ratio {OR}: 0.88; P = 0.377]; medium [OR: 0.60; P = 0.001]; high [OR: 0.57; P < 0.001]; very high [OR: 0.47; P < 0.001]), lower odds of PLOS (low [OR: 0.93; P = 0.197], medium [OR: 0.75; P < 0.001]; high [OR: 0.62; P < 0.001]; very high [OR: 0.45; P < 0.001]), and lower odds of PSMs (low [OR: 0.76; P < 0.001]; medium [OR: 0.76, P < 0.001]; high [OR: 0.59; P < 0.001]; very high [OR: 0.34; P < 0.001]). Sensitivity analyses confirmed increasing hospital volume (per 1-case increase) was associated with lower odds of conversion (OR: 0.986; P < 0.001), PLOS (OR: 0.989; P < 0.001) and PSMs (OR: 0.984; P < 0.001). A difference in 30-day readmission rate was found in unadjusted analysis but not in adjusted analyses. CONCLUSION: Undergoing RAPN at higher-volume hospitals may have better peri-operative outcomes (conversion to open and LOS) and lower PSM rates. Future studies are needed to explore the detailed components that lead to the superior outcomes in higher-volume hospitals.

Early discharge and post-discharge outcomes in patients undergoing radical cystectomy for bladder cancer.

OBJECTIVE: To assess whether discharging patients early after radical cystectomy (RC) is associated with an increased risk of readmission and post-discharge complications. MATERIALS AND METHODS: The National Surgical Quality Improvement Program database was queried to identify patients who underwent an elective RC from 2012 to 2015. Patients were stratified into two groups: those with a length of hospital stay (LOS) of 4-5 days (early-discharge group) and those with an LOS of 6-9 days (routine-discharge group). We used multivariable logistic regression analyses to assess the impact of early discharge on 30-day readmission and post-discharge complication rates. Sensitivity analyses and subgroup analyses were performed to validate the robustness of our primary analyses. RESULTS: A total of 3 311 patients were included. Unadjusted outcomes comparison showed no difference in readmission rate (21.6% vs 23.0%) or post-discharge complication rate (17.7% vs 19.6%) between the early-discharge and the routine-discharge group. Multivariable logistic regression also showed that early discharge was not associated with increased odds of readmission (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.82-1.22; P = 1.000) or post-discharge complications (OR 0.95, 95% CI 0.77-1.17; P = 0.616). Two-step sensitivity analyses (excluding patients with LOS of 8-9 days, followed by patients with any pre-discharge adverse event) validated the robustness of our primary analyses. Subgroup analyses also yielded similar results in all subgroups except for the subgroup of patients aged ≥85 years. CONCLUSIONS: Early discharge after RC was not associated with increased readmissions or post-discharge complications. Future prospective studies, with defined peri-operative care pathways, are needed to identify potential components that may enable hospitals to discharge patients early without compromising post-discharge outcomes.

Impact of surgical waiting time on survival in patients with upper tract urothelial carcinoma: A national cancer database study.

PURPOSE: To evaluate the impact of surgical waiting time (SWT) on the survival outcome in patients with upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: We identified patients with nonmetastatic UTUC who underwent radical nephroureterectomy (RNU) between 2004 and 2013 in the National Cancer Database. The association between SWT and overall survival (OS) was evaluated using Cox proportional hazards regression. SWT was categorized into 6 groups: SWT ≤ 7 days, SWT 8 to 30 days, SWT 31 to 60 days, SWT 61 to 90 days, SWT 91 to 120 days, and SWT 121 to 180 days. Multivariable analyses were adjusted for patient, tumor, and facility-related factors. RESULTS: A total of 3,581 patients were included in the final overall cohort and 2,397 (66.9%) patients had the higher-risk disease (high-grade or ≥pT2). Multivariable Cox regressions showed that patients in the groups of SWT 31 to 60 days, SWT 61 to 90 days, and SWT 91 to 120 days had similar OS compared with patients who had SWT of 8 to 30 days in the overall cohort and higher-risk cohort. Patients with SWT 121 to 180 days had worse OS (HR = 1.61, 95% CI: 1.19-2.19, P = 0.002 in the overall cohort; HR = 1.56, 95% CI: 1.11-2.20, P = 0.010 in the higher-risk cohort). CONCLUSIONS: Increased SWT from diagnosis to RNU appears to be not associated with worse OS within 120 days after the diagnosis of UTUC but SWT>120 days may be associated with worsened survival. These findings might have important implications for trial design in the evaluation of neoadjuvant chemotherapy for UTUC and future clinical practice.

Predischarge Predictors of Readmissions and Postdischarge Complications in Robot-Assisted Radical Prostatectomy.

BACKGROUND AND OBJECTIVE: Robot-assisted radical prostatectomy (RARP) has become the preferred surgical treatment for localized prostate cancer in the United States. Little is reported about the association between predischarge outcomes and postdischarge outcomes following RARP. The objective of this study was to explore the predischarge predictors of readmissions and postdischarge complications in RARP. MATERIALS AND METHODS: The National Surgery Quality Improvement Program (NSQIP) database was used to identify prostate cancer patients who underwent elective RARP from 2012 to 2014. Multivariable logistic regression was performed to assess potential predischarge predictors of readmissions and NSQIP-defined postdischarge complications within 30 days of RARP. To test the robustness of primary analysis, a secondary multivariable logistic regression was performed in the cohort of patients without any NSQIP-defined predischarge complications. RESULTS: A total of 9975 patients were included. The readmission rate in the cohort was 3.3% (n = 332), and 4.4% (n = 441) had at least one complication. Multivariable logistic regression showed that American Society of Anesthesiologists (ASA) score of 3-4 (odds ratio [OR] = 1.27, 95% confidence interval [CI] = 1.00-1.62, p = 0.050), increasing operative time (OT, per minute) (OR = 1.002, 95% CI = 1.000-1.003, p = 0.012), increasing length of hospital stay (LOS, per day) (OR = 1.36, 95% CI = 1.23-1.49, p < 0.001), and predischarge complication (OR = 2.15, 95% CI = 1.27-3.65, p = 0.004) were associated with readmission. Increasing OT (OR = 1.002, 95% CI = 1.001-1.004, p = 0.002) and increasing LOS (OR = 1.16, 95% CI = 1.02-1.30, p = 0.020) were associated with postdischarge complications. Logistic regression in patients without predischarge complications (n = 9804) confirmed that ASA score of 3-4 (OR = 1.37, 95% CI = 1.07-1.75, p = 0.013), increasing OT (OR = 1.002, 95% CI = 1.000-1.003, p = 0.022), and increasing LOS (OR = 1.34, 95% CI = 1.21-1.49, p < 0.001) were associated with readmissions. Secondary analyses also confirmed that increasing OT (OR = 1.002, 95% CI = 1.001-1.004, p = 0.002) and increasing LOS (OR = 1.18, 95% CI = 1.04-1.34, p = 0.011) were associated with postdischarge complications. CONCLUSIONS: Predischarge complications, OT, and LOS are associated with readmissions and postdischarge complications after RARP. It may be possible to identify patients at a higher risk of postdischarge adverse events to direct prevention interventions. Further prospective studies are needed to validate our findings.

Correlation of fundus autofluorescence with fluorescein and indocyanine green angiography in choroidal melanocytic lesions.

PURPOSE: To correlate fundus autofluorescence (FAF) patterns with fluorescein/indocyanine green angiographic (FA/ICGA) features in choroidal melanocytic lesions. METHODS: Retrospective chart review of 30 consecutive patients with choroidal nevi and melanoma who underwent FAF photography and FA/ICGA. The FAF pattern was classified as patchy or diffuse. The FA images were evaluated at the arterial, early venous, late venous, midphase, and late phases. The ICGA images were evaluated at the early and midlate phase. The fluorescence within the tumor was classified as hyperfluorescent, pinpoint hyperfluorescent, isofluorescent, or hypofluorescent with respect to the surrounding retina or choroid. Statistical analysis was performed using two sample t test for continuous data. For categorical or ordinal data, Pearson chi-square or Fisher's exact test was used depending on the sample size being studied. RESULTS: Nineteen of 30 tumors (63.3%) were choroidal melanoma and 11 (36.7%) were choroidal nevus. Thirteen choroidal melanomas had a diffuse FAF pattern. Six choroidal melanomas and 11 choroidal nevi had a patchy FAF pattern. The diffuse FAF pattern was significantly associated with the clinical diagnosis of choroidal melanoma versus choroidal nevus (P = 0.00001), increased tumor thickness (P = 0.00001), and increased tumor base diameter (P = 0.001), partially pigmented or amelanotic versus pigmented lesion color (P = 0.006), early venous hyperfluorescence on FA (P = 0.015), and late hyperfluorescence on FA (P = 0.018). CONCLUSION: Diffuse FAF is more often associated with larger choroidal melanomas as well as early venous and late hyperfluorescence on FA angiography.