Is Uro-oncological Surgery Safe During the COVID-19 Pandemic? Comparative Morbidity and Mortality in Patients Undergoing Surgery 2019-2020.

INTRODUCTION: The SARS-CoV-2 infection has resulted in an unprecedented pandemic. Patients undergoing surgery are a group at risk of exposure. Also, patients with ongoing infection undergoing surgery may be more susceptible to developing complications. There is no significant data on surgical safety in the pandemic period. MATERIAL AND METHODS: Observational study based in a prospective database of urological oncological surgery. Data were obtained during the 2020 mandatory confinement period compared to the same period in 2019. The records were reviewed 45 days post-surgery. The objective was to compare surgical morbidity and mortality during the pandemic versus an average year in urological cancer surgery. RESULTS: During confinement period (2020), 85 patients underwent uro-oncology surgery, while in 2019, during the same period, 165. The Clavien-Dindo morbidity ≥3 in 2020 was 2.3% (n=2), and in 2019, it reached 6% (n=10). In 2020, 9 patients were readmitted (10.5%). One patient (1.1%) was re-interfered, with a perioperative mortality of 1.1%. In 2019, 21 patients (12.7%) were readmitted. Seventeen patients (10.3%) were re-interfered, with a perioperative mortality of 1.8%. The median number of days hospitalized was 2 (IQR=2) in 2020 and 3 (IQR=3) in 2019. No significant differences were found in population or morbimortality, except for reoperation in a normal year. CONCLUSION: Postoperative morbidity and mortality reported are lower than those shown in the literature concerning COVID-19 and similar to that historically reported by our centers. This study suggests that it is safe to operate patients with urological cancer following the appropriate protocols during a pandemic.

Comparative outcomes for older adults undergoing surgery for bladder and bowel dysfunction.

BACKGROUND/OBJECTIVES: To compare surgical outcomes between vulnerable nursing home (NH) residents and matched community-dwelling older adults undergoing surgery for bladder and bowel dysfunction. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 55,389 NH residents and propensity matched (based on procedure, age, sex, race, comorbidity, and year) community-dwelling older adults undergoing surgery for bladder and bowel dysfunction [female pelvic surgery, transurethral resection of the prostate, suprapubic tube placement, hemorrhoid surgery, rectal prolapse surgery]. Individuals were identified using Medicare claims and the Minimum Data Set (MDS) for NH residents between 2014 and 2016. MEASUREMENTS: Thirty-day complications, 1-year mortality, and weighted changes in healthcare resource utilization (hospital admissions, emergency room visits, office visits) in the year before and after surgery. RESULTS: NH residents demonstrated statistically significant increased risk of 30-day complications [60.1% v. 47.2%; RR 1.3 (95% CI 1.3-1.3)] and 1-year mortality [28.9% vs. 21.3%; RR 1.4 (95% CI 1.3-1.4)], compared to community-dwelling older adults. NH residents also demonstrated decreased healthcare resource utilization, compared to community-dwelling older adults, changing from 3.9 to 1.9 (vs.1.1 to 1.0) hospital admissions, 11 to 10.1 (vs. 9 to 9.7) office visits, and 3.4 to 2.2 (vs. 1.9 to 1.9) emergency room visits from the year before to after surgery. CONCLUSION: Despite matching on several important clinical characteristics, NH residents demonstrated increased rates of 30-day complications and 1-year mortality after surgery for bowel and bladder dysfunction, while demonstrating decreased healthcare resource utilization. These mixed findings suggest that outcomes may be more varied among vulnerable older adults and warrant further investigation.

Systemic dissemination of tumor cells during transurethral resection in patients with bladder tumor and its clinical relevance: A follow up study.

OBJECTIVE: Tumor cells are shed during transurethral resection of bladder tumor (TURBT) and form the basis for use of single dose immediate chemotherapy instillation to reduce recurrences. Systemic dissemination of these cells along with the irrigation fluid is also possible but not consistently proven. In this study, we evaluated such dissemination of tumor cells into the circulation during TURBT and its clinical impact. METHODS: Patients with primary presentation of bladder tumor who underwent TURBT were included. Peripheral venous blood samples before and after TURBT were analyzed for circulating tumor cells (CTCs) using flow-cytometry. A CD45 negative cell with positive expression of cytokeratin 18, 19, and EpCam was defined as CTC. The CTC counts, pre and post TURBT, were compared and correlated with final histopathology. The patients were also followed up for any local and/or systemic recurrences. RESULTS: Nine (16.98%) out of 53 patients developed a measurable rise in CTCs after TURBT. All of these patients had high grade and muscle invasive disease. Overall, a measurable rise in CTCs was seen in 9 out of 17 (52.94%) patients with muscle invasive disease. There was no difference in the clinico-pathological stage or the status of cystectomy and/or chemotherapy between those who did or did not show a rise in CTCs. On follow up, 7 patients with muscle invasive disease developed local and/or systemic recurrences and the rise in CTCs was not found to be associated with adverse oncological outcomes. CONCLUSIONS: This study confirms the hypothesis of inadvertent dissemination of tumor cells into the circulation during TURBT, especially in patients with high grade and muscle invasive disease. The long-term oncological impact of such dissemination remains to be confirmed.

Implementation of frailty preoperative assessment to predict outcome in patients undergoing urological surgery: a systematic review and meta-analysis.

BACKGROUND: A common limit of the widely used risk scores for preoperative assessment is the lack of information about aspects linked to frailty that may affect outcome, especially in the setting of elderly patients undergoing urological surgery. Frailty has recently been introduced as an additional characteristic to be assessed for better identifying patients at risk of negative outcomes. OBJECTIVE: To examine the evidence for recent advances in preoperative assessment in patients undergoing urological surgery focussing on the detrimental effect of frailty on outcome, including major (mPCs) and total postoperative complications (tPCs), discharge to a facility, and mortality. The secondary aim was to establish which cut-off scores of the modified Frailty Index (mFI, 11 items) and/or simplified FI (sFI, five items) predicted PCs. METHODS: We searched PubMed, the Excerpta Medica database (EMBASE), Cochrane Library and clinicaltrial.gov from inception to 31 May 2020. Studies reporting relationships between the investigated outcomes and patients' frailty were included. We estimated odds ratios (ORs) through a random effect model by using Revman 5.4. RESULTS: Frailty, assessed by different tools, was associated with a significantly higher rate of 30-day (OR 1.73, 95% confidence interval [CI] 1.58-1.89) and 90-day (OR 2.09, 95% CI 1.14-3.82) mPCs and 30-day tPCs (OR 2.10, 95% CI 1.76-2.52). A mFI of ≥2 was associated with a higher rate of 30-day mPCs (OR 1.79, 95% CI 1.69-1.89) and greater 30-day mortality (OR 3.46, 95% CI 2.10-5.49). A pre-planned post hoc analysis also revealed that a sFI of ≥3 was predictive of mPCs (OR 3.30, 95% CI 2.12-5.12). CONCLUSIONS: Frailty assessment may help to predict PCs and mortality in patients undergoing major urological surgery. Either a mFi of ≥2 or sFI of ≥3 should be considered potential 'red flags' for preoperative risk assessment and decision-making. There is not enough evidence to confirm the necessity to perform frailty assessment in minor urological surgery.

Overlapping Urological Surgeries at a Tertiary Academic Center.

OBJECTIVE: To evaluate whether the practice of procedure-time overlapping surgery (OS) is associated with inferior outcomes compared to nonoverlapping surgery (NOS) in urology, to address the paucity of data surrounding urologic surgeries to support or refute this practice. MATERIALS AND METHODS: We performed a retrospective review of all urological surgeries at a single tertiary-level academic center, Emory University Hospital, from July 2016 to July 2018. Patients who received OS were matched 1:2 to patients who had NOS. The primary outcomes were perioperative and postoperative complications and mortality. RESULTS: We reviewed 8535 urological surgeries. In-room time overlap was seen in 50.5% of cases and procedure-time overlap in 7.4%. Eleven out of the 13 attending urologists performed OS. The average time in the operating room was greater for OS by an average of 14 minutes. The average operative time was greater for OS than NOS by 11 minutes, but this did not reach statistical significance. There was no significant difference between the cohorts for rate of blood transfusions, ICU stay, need for postoperative invasive procedures, length of postoperative hospital stay, discharge location, Emergency Room visits, hospital readmission rate, 30 and 90-day rates of postoperative complications, and mortality. CONCLUSION: Procedure-time overlapping surgeries constituted a minority of urological cases. OS were associated with greater in-room time. We found no increased risk of perioperative or postoperative adverse outcomes in OS compared to matched NOS.

Urinary tract stone deaths: data from the Australian and New Zealand Audits of Surgical Mortality.

OBJECTIVES: To analyse all mortalities related to surgery for urinary tract calculi in Australia from 1 January 2009 to 31 December 2018, and identify common causes, clinical management issues (CMIs), and areas for improvement. PATIENTS AND METHODS: All urological-related deaths reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) from 2009 to 2017 were analysed. The Bi-National Audit of Surgical Mortality (BAS) database was interrogated for any involvement with renal, ureteric or bladder stones and all relevant associated data analysed. Any CMIs documented by the peer reviewers were recorded and compared to those in urology and all of surgery ANZASM data. RESULTS: Of 1034 total urological deaths, 100 (9.7%) were related to stones. The mean (range) age of patients was 74.4 (21-97) years; 95% of the patients underwent at least one procedure, with 45 (47.4%) of these being elective. Urinary sepsis was responsible for 49.5% of the deaths, with 20% dying of cardiac events. In all, 39% (37/95) of deaths were associated with CMIs, the most common considerations being delays in diagnosis or treatment, perioperative management and inadequate preoperative evaluation. This is a considerably higher percentage than the 26% recorded for the general urology and all surgery national data. Ureterorenoscopy at 54% (12/22) had the highest rate of CMIs. CONCLUSION: Death related to stone surgery represents only a small proportion of all urological surgical deaths, but generates more CMIs amongst ANZASM peer assessors. Results could be improved with more rapid diagnosis and treatment. Careful case selection and access to all treatment options are recommended.

Correlation of Relative Value Units With Surgical Complexity and Physician Workload in Urology.

OBJECTIVE: To define the relationship between urology relative value units (RVUs) and measures of surgical complexity and physician workload. Secondary objectives include: (1) identifying procedures with outlying RVU values for their measures of surgical complexity and workload; and (2) calculating projected RVU values for these procedures. METHODS: We obtained surgical case data for 71 urology current procedural terminology (CPT) codes from the 2017 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Pearson correlation coefficients were calculated to measure the association between mean total work RVU and operative time, length of hospital stay, serious adverse events, readmissions, and mortality. We developed a multivariable regression model to predict mean total work RVU from these measures. Studentized residuals were used to identify outlying CPT codes for both bivariable and multivariable regression models, and empirically derived RVU values from complexity and work effort metrics were estimated. RESULTS: We analyzed 71 urology CPT codes encompassing 55,068 cases. RVUs correlated well with median length of hospital stay (R = 0.81), median operative time (R = 0.92), serious adverse events (R = 0.83), and readmissions (R = 0.74). RVUs were poorly correlated with mortality (R = 0.34). Outlying procedures identified using the multivariable model were retroperitoneal lymph node dissection (projected +21.09 RVUs), laparoscopic ureteroneocystotomy (projected -12.34 RVUs), and cystectomy with bilateral pelvic lymphadenectomy (projected +9.37 RVUs). CONCLUSION: Urology work RVUs correlate more with operative time than other measures of surgical complexity and physician workload. There exist several significant outlying procedures for various work measures. Incorporating objective work data may improve RVU assignments in the future.

The outcomes of isolated ureteral resection and reconstruction in non-urologic cancer patients who underwent cytoreductive surgery (CRC) and hyperthermic intraperitoneal chemotherapy (HIPEC).

BACKGROUND: Urinary system resections are performed during the cytoreductive surgery with hypertermic intraperitoneal chemotherapy (CRS-HIPEC). However, isolated ureter resection and reconstruction results are uncertain. The aim of this study was to evaluate the postoperative outcomes of isolated ureteral resection and reconstructions in patients who underwent CRC and HIPEC procedure. METHODS: A total of 257 patients that underwent CRC and HIPEC between 2015 and 2017 in the Department of Surgical Oncology, Faculty of Medicine, Ankara University, were retrospectively analyzed. Twenty patients that had undergone isolated ureteral resection and reconstruction were included in the study. Predisposing factors were investigated in patients who developed postoperative complications. RESULTS: The mean age of the patients was 55.1 years. The mean follow-up time of all the patients was 11.6 months. Postoperative mortality occurred in two patients. The mean PCI score was 13.9. Postoperative urologic complications were observed in eight patients after ureter reconstruction. There was no statistically significant difference between the groups in terms of reconstruction techniques and postoperative complications (P = 302). There was no correlation between age (P = 0.571) and gender (P = 0.161) with complications. CRS-HIPEC was performed mostly due to gynecologic malignancy. However, there was no correlation between the primary cancer diagnosis and the development of complications (P = 0.514). The hospital stay duration was higher in the group with complications (16.3 vs 8.8 days, P = 0.208). CONCLUSIONS: Ureteral resections and reconstructions can be performed for R0/1 resections in CRS-HIPEC operations. It leads to an increase in hospital stay. But there is no significant difference in the development of complications. In the management of complications, conservative approach was sufficient.

Perioperative Troponin is a Predictor of Both Short- and Intermediate-term Mortality Among Patients Undergoing Major Urologic Surgery.

OBJECTIVE: To determine whether a positive troponin is a predictor of intermediate- and long-term mortality in patients undergoing major urologic surgeries at our institution. METHODS: This is a retrospective analysis of patients undergoing major urologic surgery at the Cleveland Clinic from 2010-2015. Patients were stratified by the presence and maximum value of troponin blood-draw, if performed within 30 days of surgery. Survival analysis was performed using Kaplan-Meier function (univariate) and Cox regression analysis (continuous) to assess mortality risk. RESULTS: Within 30 days of surgery, 1305 (15.5%) patients a troponin drawn, and 304 (3.6%) of them had an abnormal troponin level (>0.01 ng/mL). Patients with positive troponin drawn for cause within 30 days of surgery had a significantly decreased overall survival at 5 years of 70.6% (95% CI 62.6, 77.2) when compared to patients with negative troponin (81.7% [95% CI 77.4, 85.3]) and no troponin drawn (90.4% [95% CI 89.0, 91.6]). CONCLUSION: For cause serum troponin blood draw and peak levels demonstrated a positive correlation with all-cause mortality in patients undergoing major urologic surgeries Prospective studies are needed to better understand the utility of postoperative troponin as predictive marker of mortality.

Impact of Concomitant Urologic Intervention on Clinical Outcomes After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

INTRODUCTION: The impact of concomitant urologic procedures (UPs) on perioperative and long-term outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is uncertain. METHODS: In total, 935 consecutive CRS/HIPEC procedures were performed between 1996 and 2016 in Sydney, Australia. Among these, 73 (7.8%) involved concomitant UP. The association of concomitant UP with 21 perioperative outcomes and overall survival was assessed using univariate and multivariate analyses. RESULTS: In-hospital mortality was 1.8%. Patients requiring UP were more likely to require transfusion of ≥5 units of red blood cells (P=0.031) and have a complete cytoreduction (79% vs. 60%, P<0.001). On multivariate analysis, UP was not associated with in-hospital mortality (2.7% vs. 1.7%, P=0.407) or grade III/IV morbidity (52% vs. 41%, P=0.376). The incidence of ureteric fistula (4% vs. 1%, P=0.004), return to theater (26% vs. 14%, P=0.005) and digestive fistula (22% vs. 11%, P=0.005) was higher in the UP group. The addition of a UP did not significantly impact overall survival for appendiceal cancer (P=0.162), colorectal cancer (P=0.315), or pseudomyxoma peritonei (P=0.120). CONCLUSIONS: Addition of a UP was not associated with an increased risk of grade III/IV morbidity or poorer long-term survival after CRS/HIPEC.

Perioperative Complications and Mortality in Patients with Urothelial Carcinoma and End-Stage Renal Disease Undergoing One-Stage Complete Urinary Tract Extirpation.

BACKGROUND: Complete urinary tract extirpation (CUTE) is a complex procedure with substantial risk for perioperative complications. The association between clinical characteristics and the risk of major postoperative complications has not been systematically investigated. OBJECTIVE: The aim of this study was to analyze the incidence and risks for major perioperative complications after CUTE. METHODS: Respective chart review of 81 patients with urothelial carcinoma (UC) who were treated with one-stage CUTE between January 2004 and December 2015. Fisher's exact test with Chi square and two-tailed t test were used in categorical and continuous variables, respectively. Univariable and multivariable logistic regression models were used to evaluate the probability of major complications. RESULTS: In this population, 53 (65.4%) patients had Clavien grade 0-2 complications ('no major complications') and 28 (34.6%) patients had Clavien grade 3-5 complications ('major complications'). Compared with the major complications group, patients in the no major complications group were younger, had lower Charlson Comorbidity Index (CCI), higher preoperative serum albumin, and shorter duration of hospitalization (p < 0.05 for all). Major complications were more common in low-volume surgeons (p = 0.002). On multivariate logistic regression analyses, CCI ≥ 5 (odds ratio [OR] 6.25, 95% confidence interval [CI] 1.42-27.47; p = 0.015) and surgery by a provider who performed three or fewer cases during the study interval (OR 13.4, 95% CI 2.20-80.89; p = 0.005) were independent predictors for major complications. CONCLUSIONS: High CCI should alert providers to increased probability of major complications, and warrant vigilant management after CUTE. Surgeon volume was inversely related to major postoperative complications.

Surgical Complications and Their Repercussions.

PURPOSE: Surgical complications have a significant impact on intended quality of care. The aim of our study was to identify factors that contribute to the propagation of additional postoperative complications. MATERIALS AND METHODS: Over a 1-year period, we prospectively identified and retrospectively reviewed data on all patients who experienced a surgical complication within 30 days of their procedure. A complication was defined as any deviation from the expected postoperative course and was described using the Clavien-Dindo classification. Data reviewed included length of stay (LOS), Clavien grade, readmission status, and management of the complication. Surgeries were stratified into retroperitoneal, pelvic, and endoscopic procedures. The association between complications and Clavien grade was measured using Spearman rank-order correlation. The probability of subsequent complications and readmission was measured using exact logistic regression. RESULTS: Of the 4414 patients who underwent a urologic procedure, 191 (4.3%) had at least one complication. One hundred thirty-four (70%) of these patients had more than one complication, 84 (44%) had more than three complications, and 12 (6.3%) had up to a seventh complication. LOS was affected by the severity of the initial complication. Patients with initial Clavien grades 1, 2, 3a, 3b, and 4 had an LOS of 3.75, 4.17, 4.21, 4.94, and 8.58 days, respectively. Variables associated with the risk of developing a second complication included diabetes mellitus, longer operative times (OR 1.83), and greater estimated blood loss (OR 1.32). CONCLUSIONS: Surgical patients with an initial complication are at higher risk for multiple subsequent postoperative complications. Complications are associated with an extended LOS and higher readmission rates. Diabetes, longer operative time, and greater blood loss were identified as risk factors for multiple complications.

Surgical mortality in patients more than 80 years of age.

INTRODUCTION: Patients aged >80 years account for a considerable proportion of the population admitted to hospital under general surgeons. We aimed to establish the prevalence of mortality in patients aged >80 years who underwent emergency general, vascular and urological surgery within a 13-month period at a large teaching hospital in the UK. MATERIALS AND METHODS: A retrospective analysis was carried out of all patients aged ≥80 years admitted on acute on-call emergency under general, vascular or urological surgeons. Patient demographics (including comorbidities and sex) were recorded. American Society of Anesthesiologists scores were reviewed from anaesthetic records. The outcome measure was 30-day mortality for those who had undergone emergency general, vascular or urological surgery. RESULTS: A total of 4,069 patients were admitted under general, vascular and urological surgeons during the study period. Of these patients, 521 were aged >80 years. Sixty-three patients underwent emergency surgery and 12 died <30 days after surgery (mortality = 19%). The most common procedure was laparotomy (20 cases). The most common co-morbidity was cardiac disease, which included hypertension, ischaemic heart disease, and hypercholesterolemia. A considerable proportion of patients also had malignant disease and arthritis. CONCLUSIONS: The present study suggests that emergency surgery should not be denied to subjects aged >80 years based on age alone. Mortality varies according to the type of emergency procedure. Mortality was highest after laparotomy and vascular surgery whereas, for more routine procedures such as hernia repair and abscess drainage, survival was almost 100% after 30 days.

Venous thromboembolism (VTE) prophylaxis and urological pelvic cancer surgery: a UK national audit.

OBJECTIVES: To evaluate the use of post-discharge venous thromboembolism (VTE) prophylaxis in UK pelvic cancer centres consistent with national guidelines. METHODS: Data was collected from healthcare professionals from 64 UK pelvic cancer centres. RESULTS: After radical cystectomy (RC), all cancer centres routinely use low-molecular-weight heparin (LMWH) in the perioperative period. After RC 67% of cancer centres use post-discharge LMWH routinely. After radical prostatectomy (RP), 98% of units use perioperative LMWH VTE prophylaxis routinely. After RP, 61% of hospitals always use post-discharge LMWH. In all, 27% of all UK cancer centres reported deaths or serious VTE complications from urological pelvic cancer surgery in the last 2 years. CONCLUSIONS: The National Institute for Health and Care Excellence (NICE) issued explicit guidance of VTE prophylaxis after pelvic and abdominal cancer surgery. Conversion of national guidance into local policy is ≈60% for UK pelvic cancer centres. A lack of good quality evidence is cited as a reason for not adhering to NICE guidance.

Preventable mortality after common urological surgery: failing to rescue?

OBJECTIVE: To assess in-hospital mortality in patients undergoing many commonly performed urological surgeries in light of decreasing nationwide perioperative mortality over the past decade. This phenomenon has been attributed in part to a decline in 'failure to rescue' (FTR) rates, e.g. death after a complication that was potentially recognisable/preventable. PATIENTS AND METHODS: Discharges of all patients undergoing urological surgery between 1998 and 2010 were extracted from the Nationwide Inpatient Sample and assessed for overall and FTR mortality. Admission trends were assessed with linear regression. Logistic regression models fitted with generalised estimating equations were used to estimate the impact of primary predictors on over-all and FTR mortality and changes in mortality rates. RESULTS: Between 1998 and 2010, an estimated 7,725,736 urological surgeries requiring hospitalisation were performed in the USA; admissions for urological surgery decreased 0.63% per year (P = 0.008). Odds of overall mortality decreased slightly (odds ratio [OR] 0.990, 95% confidence interval [CI] 0.988-0.993), yet the odds of mortality attributable to FTR increased 5% every year (OR 1.050, 95% CI 1.038-1.062). Patient age, race, Charlson Comorbidity Index, public insurance status, as well as urban hospital location were independent predictors of FTR mortality (P < 0.001). CONCLUSION: A shift from inpatient to outpatient surgery for commonly performed urological procedures has coincided with increasing rates of FTR mortality. Older, sicker, minority group patients and those with public insurance were more likely to die after a potentially recognisable/preventable complication. These strata of high-risk individuals represent ideal targets for process improvement initiatives.

[Urological diseases most frequently involved in medical professional liability claims]. / Patologías urológicas más frecuentemente implicadas en las reclamaciones por responsabilidad profesional médica.

Clinical safety and medical professional liability are international major concerns, especially in surgical specialties such as urology. This article analyzes the claims filed at the Council of Medical Colleges of Catalonia between 1990 and 2012, exploring urology procedures. The review of the 173 cases identified in the database highlighted the importance of surgical procedures (74%). Higher frequencies related to scrotal-testicular pathology (34%), especially testicular torsion (7.5%) and vasectomy (19.6%), and prostate pathology (26 %), more specifically the surgical treatment of benign prostatic hyperplasia (17.9%). Although urology is not among the specialties with the higher frequency of claims, there are special areas of litigation in which it is advisable to implement improvements in clinical safety.

The Postoperative Morbidity Index: a quantitative weighing of postoperative complications applied to urological procedures.

BACKGROUND: The reporting of post-operative complications in the urological field is lacking of a uniform quantitative measure to assess severity, which is essential in the analysis of surgical outcomes. The purpose of this study was to evaluate the feasibility of estimating quantitative severity weighing of post-operative complications after common urologic procedures. METHODS: Using a large healthcare system's quality database, complications were identified in eleven common urologic procedures (e.g., insertion or replacement of inflatable penile prosthesis, nephroureterectomy, partial nephrectomy, percutaneous nephrostomy tube placement, radical cystectomy, radical prostatectomy, renal/ureteral/bladder extracorporeal shockwave lithotripsy (ESWL), transurethral destruction of bladder lesion, transurethral prostatectomy, transurethral removal of ureteral obstruction, and ureteral catheterization) from January 1, 2011 to December 31, 2011. Complications were classified by the Expanded Accordion Severity Grading System, which was then quantified by validated severity weighting scores. The Postoperative Morbidity Index (PMI) for each procedure was calculated where an index of 0 would indicate no complication in any patient and an index of 1 would indicate that all patients died. RESULTS: This study included 654 procedures of which 148 (22%) had one or more complications. As would be expected, a more complex procedure like radical cystectomy possessed a higher PMI (0.267), while a simpler procedure like percutaneous nephrostomy tube placement possessed a lower PMI (0.011). The PMI of the additional nine procedures fell within the range of these PMIs. These PMIs could be used to compare surgeons, hospitals or procedures. CONCLUSIONS: Quantitative severity weighing of post-operative complications for urologic procedures is feasible and may provide exceptionally informative data related to outcomes.

Tandem ureteral stents for the decompression of malignant and benign obstructive uropathy.

PURPOSE: To evaluate the utility of two ipsilateral ureteral stents placed for benign and malignant ureteral obstruction. METHODS: We performed a retrospective analysis of all cases of tandem ureteral stent (TUS) insertion at our institution from July 2007 through January 2013. Student t, Fisher exact, and log-rank test were used. RESULTS: TUS insertion or exchange was performed in 187 cases. There were 66 patients (75 renal units) who underwent successful TUS insertion. Malignant ureteral obstruction (MUO) was the cause for obstruction in 39 renal units (34 patients) vs benign ureteral obstruction (BUO) in 36 renal units (32 patients). Four patients with BUO and 15 patients with MUO underwent stent exchanges at a mean 145 and 128 days, respectively. Serum creatinine levels were stable poststent placement (P=0.4). Degree of hydronephrosis improved (paired t test P<0.03) after stent placement for both benign and malignant cohorts. TUS placement was noted to fail (flank pain with worsening hydronephrosis or increasing creatinine level) in five renal units with MUO (12.8%) and none with BUO. Stent failure (either conventional or TUS) suggested worsening survival in those with MUO. Median survival for those with MUO and a history of stent failure (10 of 14 died, 71%) was 66 days compared with 432 days for those without a history of stent failure (8 of 20 died, 40%) (log-rank test P=0.007). CONCLUSION: Our experience with the TUS, the largest to date, demonstrated that they are highly successful in both benign and malignant causes of obstruction, comparing favorably with metallic ureteral stents. Stent failure may be predictive for shorter survival.

Factors associated with adverse outcome following urologic surgery in patients aged 80 years and older.

BACKGROUND AND AIMS: This study was designed to find predictors for adverse post-operative outcomes in elderly patients aged 80 years and older, who underwent urologic surgery. METHODS: In this prospective observational study, we analysed data, including age, gender, American Society of Anesthesiologists (ASA) class, co-morbidities, number of regular medications, type and extent of surgery, type of anesthesia, duration of surgery and hospitalization, post-operative morbidity and mortality. We studied the correlations between each pre- and intra-operative parameter to the consequence, to find predictors for adverse outcome. RESULTS: During a 12-month period, 217 patients underwent 294 urologic procedures in our institution. Ninety-eight procedures (33%) were followed by complications and 11 patients (5%) died. Patients who had uneventful surgery and hospitalization were significantly younger than those who experienced morbidity or mortality. There was a significantly higher complication rate among patients with a higher ASA class or with ischemic heart disease, following higher graded or longer operations, and after emergency surgery. CONCLUSIONS: Older age is a significant risk factor. Patients with higher ASA class or ischemic heart disease are at higher risk for post-operative complications and thus, require careful follow-up. In this age population, extensive or prolonged surgery should be carefully considered.