Safety of neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer and malignant ureteric obstruction.

OBJECTIVES: To determine whether patients with carcinoma invading bladder muscle (MIBC) and ureteric obstruction can safely receive cisplatin-based neoadjuvant chemotherapy (C-NAC), and to determine whether such patients require relief of obstruction with a ureteric stent or percutaneous nephrostomy prior to beginning C-NAC. PATIENTS AND METHODS: We performed a single-institution retrospective analysis of MIBC patients receiving C-NAC and falling into three groups: no ureteric obstruction (NO); relieved ureteric obstruction (RO); and unrelieved ureteric obstruction (URO). To address whether patients with obstruction can safely receive C-NAC, we compared patients with NO to those with RO, with the primary outcome of premature chemotherapy discontinuation. To investigate whether patients with obstruction should have the obstruction relieved prior to NAC, we compared RO to URO patients using a primary composite outcome of grade ≥ 3 adverse events, premature chemotherapy discontinuation, dose reduction, or dose interruption. The primary outcomes were compared using multivariable logistic regression. Sensitivity analyses were performed for the RO vs URO comparison, in which patients with only mild degrees of obstruction were excluded from the URO group. RESULTS: A total of 193 patients with NO, 49 with RO, and 35 with URO were analysed. There were no statistically significant differences between those with NO and those with RO in chemotherapy discontinuation (15% vs 22%; P = 0.3) or any secondary outcome. There was no statistically significant difference between those with RO and URO in the primary composite outcome (51% vs 53%; P = 1) or any secondary outcome. CONCLUSION: Patients with ureteric obstruction can safely receive C-NAC. Relief of obstruction was not associated with increased safety of C-NAC delivery.

Association of Surgical Delay and Overall Survival in Patients With T2 Renal Masses: Implications for Critical Clinical Decision-making During the COVID-19 Pandemic.

OBJECTIVE: To test for an association between surgical delay and overall survival (OS) for patients with T2 renal masses. Many health care systems are balancing resources to manage the current COVID-19 pandemic, which may result in surgical delay for patients with large renal masses. METHODS: Using Cox proportional hazard models, we analyzed data from the National Cancer Database for patients undergoing extirpative surgery for clinical T2N0M0 renal masses between 2004 and 2015. Study outcomes were to assess for an association between surgical delay with OS and pathologic stage. RESULTS: We identified 11,848 patients who underwent extirpative surgery for clinical T2 renal masses. Compared with patients undergoing surgery within 2 months of diagnosis, we found worse OS for patients with a surgical delay of 3-4 months (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.00-1.25) or 5-6 months (HR 1.51, 95% CI 1.19-1.91). Considering only healthy patients with Charlson Comorbidity Index = 0, worse OS was associated with surgical delay of 5-6 months (HR 1.68, 95% CI 1.21-2.34, P= .002) but not 3-4 months (HR 1.08, 95% CI 0.93-1.26, P = 309). Pathologic stage (pT or pN) was not associated with surgical delay. CONCLUSION: Prolonged surgical delay (5-6 months) for patients with T2 renal tumors appears to have a negative impact on OS while shorter surgical delay (3-4 months) was not associated with worse OS in healthy patients. The data presented in this study may help patients and providers to weigh the risk of surgical delay versus the risk of iatrogenic SARS-CoV-2 exposure during resurgent waves of the COVID-19 pandemic.

Prolonged Length of Stay After Robotic Prostatectomy: Causes and Risk Factors.

BACKGROUND: Robot-assisted radical prostatectomy (RARP) can generally be performed with 1-2 nights of postoperative monitoring before discharge from the hospital. Little is known about what causes individual patients to remain in hospital beyond the second postoperative day. METHODS: Data for RARPs performed between 2013 and 2015 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The fraction of cases with prolonged length of stay (PLOS) that can be reasonably attributed to complications was examined. Logistic regression was performed to identify risk factors for PLOS in the overall population and separately in the population of patients with PLOS without any perioperative complications. RESULTS: Of 11,440 patients, 10,342 (90.4%) were discharged on postoperative days 0-2; 80.6% (887/1101) of patients with PLOS did not experience any perioperative complications. The most common complication was bleeding requiring transfusion, but this was present in only 5.6% (62/1101) of patients with PLOS. Logistic regression identified predictors of PLOS as age, race, wound class, American Society of Anesthesiologists class, smoking, diabetes, dyspnea, dependent functional health status, congestive heart failure, operative time, and pelvic lymph node dissection. Results of this regression were insensitive to the exclusion of patients who experienced no perioperative complications. CONCLUSIONS: This study utilizes logistic regression on NSQIP data to identify risk factors for PLOS after RARP and, in particular, to evaluate the role of postoperative complications in PLOS. The analysis shows that postoperative complications account for a small minority of cases of PLOS after RARP.

Obesity and 30-Day Outcomes Following Minimally Invasive Nephrectomy.

OBJECTIVE: To evaluate the association between obesity and postoperative outcomes following minimally invasive partial nephrectomy (MIPN) and minimally invasive radical nephrectomy (MIRN). METHODS: Using the National Surgical Quality Improvement Project database, we identified adult patients who underwent either MIPN or MIRN from 2012 to 2016. Patients were stratified by body mass index (BMI) according the World Health Organization classification of obesity (nonobese [BMI 18.5-29.9 kg/m2], class I obesity [BMI 30-34.9 kg/m2], class II obesity [BMI 35-39.9 kg/m2], and class III obesity [BMI≥40 kg/m2]). Multivariable logistic regressions alternately including obesity class, comorbidity score, and both were used to evaluate the association among these variables with post-operative outcomes. RESULTS: A total of 21,334 patients (MIPN=10,444, MIRN=10,890) were included. When only obesity class or comorbidity score was included in our multivariable logistic regression model, both variables were associated with increased odds of overall 30-day complications. However, when both class or comorbidity were included in the model, comorbidity but not obesity was found to be associated with increased postoperative complications. Obesity was also not found to be associated with unplanned readmission. However, obesity was independently associated with prolonged operative time and discharge to continued care in the full model. CONCLUSION: This NSQIP study suggests that BMI does not independently predict the likelihood of overall complications or readmission within 30 days, and should not be considered a major barrier for MIPN or MIRN. Instead, obesity should be taken into consideration with other comorbidities when risk-stratifying patients prior to minimally invasive nephrectomy.

Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting.

AIM: To describe a technique for surgical correction of adult buried penis, including a technique for skin graft harvesting from the escutcheonectomy specimen itself, with an emphasis on remaining open questions in the literature. METHODS: We present our method for surgical correction of adult buried penis with a review of the literature. MAIN OUTCOME MEASURE: Components of successful buried penis repair include return of directed voiding, elimination of local skin inflammation and infection, improvement in hygiene, return of sexual functioning, cosmesis, and patient satisfaction. To date, there are no broadly accepted tools for comprehensive measurement of outcomes after buried penis repair. RESULTS: Adult buried penis repair is generally associated with excellent rates of satisfaction and improvement in functioning. Currently available data are extremely limited; however, they do suggest that, when in doubt, more aggressive debridement of diseased tissue combined with split-thickness skin grafting may provide superior outcomes. Split-thickness skin grafts are associated with excellent rates of successful graft take, even in cases of severe preoperative pathology and patient comorbidity. Although these grafts come at the cost of some increased surgical morbidity, they are associated with low rates of major complications. Morbidity can be further significantly decreased by harvesting the graft from the excised escutcheon itself, a technique that we present here. CONCLUSION: Surgical correction of adult buried penis is safe and effective; however, future work is required to further optimize outcomes and reduce surgical morbidity. Strother MC, Skokan AJ, Sterling ME, et al. Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting. J Sex Med 2018;15:1198-1204.

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.

Minimally Invasive Techniques for the Management of Adult UPJ Obstruction.

Ureteropelvic junction obstruction (UPJO) is a common congenital abnormality that often presents in adulthood. Open dismembered pyeloplasty was considered the gold standard for the management of this condition; however, recent advancements in laparoscopic and robotic surgery have dramatically shifted the landscape to more minimally invasive techniques. A literature search of ureteropelvic junction obstruction, pyeloplasty, endopyelotomy, laparoscopic pyeloplasty, robotic pyeloplasty, and microlaparoscopic pyeloplasty was performed. A focus was placed on literature published since 2013. Minimally invasive laparoscopic and robotic techniques have become the gold standard for the management of UPJO. With the rise of robotic pyeloplasty, open repairs are becoming less frequent, while endoscopic treatments have remained stable. Minimally invasive (robotic) techniques have become the gold standard for the management of UPJO. Newer, even less-invasive techniques are also showing promise, but technical challenges still exist.

Magnetic resonance imaging-targeted vs. conventional transrectal ultrasound-guided prostate biopsy: single-institution, matched cohort comparison.

OBJECTIVES: To compare magnetic resonance imaging-targeted biopsy (MRITB) and conventional transrectal ultrasound-guided biopsy (TRUSGB) in the detection of prostate cancer (PCa) at our institution. METHODS: Our prospective registry of patients undergoing prostate MRITB from December 2010 to July 2013 was analyzed. Patients were matched one-to-one to patients who underwent TRUSGB based on the following characteristics: age, prostate-specific antigen level, prostate volume, race, family history of PCa, initial digital rectal examination (DRE), prior use of 5-alpha reductase inhibitor, and prior diagnosis of PCa. MRITB was performed using a TargetScan system with the patient under general anesthesia. Magnetic resonance imaging suspicious regions (MSRs) were targeted with cognitive registration, and a full TargetScan template biopsy (TSTB) was also performed. RESULTS: In total, 34 MRITB patients were matched individually to 34 TRUSGB patients. As compared with TRUSGB, patients who underwent MRITB had a greater overall rate of PCa detection (76% vs. 56%, P = 0.12) and a significantly higher number with Gleason score≥7 (41% vs. 15%, P = 0.03), whereas the rates of Gleason score 6 PCa detection were similar between MRITB and TRUSGB (35% vs. 41%, P = 0.80). As compared with the TSTB, magnetic resonance imaging suspicious regions-directed biopsies during MRITB had a significantly higher overall PCa detection (54% vs. 24%, P<0.01) and Gleason score≥7 PCa detection (25% vs. 8%, P<0.01). When compared with TSTB, TRUSGB had similar detection rates for benign prostate tissue (76% vs. 79%, P = 0.64), Gleason score 6 PCa (16% vs. 14%, P = 0.49), and Gleason score ≥7 PCa detection (8% vs. 7%, P = 1.0). CONCLUSIONS: Cognitive registration MRITB significantly improves the detection of Gleason score≥7 PCa as compared with conventional TRUSGB.