Enhanced Recovery after Partial and Radical Nephrectomy Reduces Length of Stay, Opioid Use and Cost.

INTRODUCTION: Enhanced recovery after surgery pathways are multidisciplinary, multimodal approaches to perioperative care that aim to improve patient outcomes. In this study we evaluate the outcomes of the implementation of enhanced recovery after surgery pathways in patients undergoing nephrectomy. METHODS: A retrospective analysis was performed comparing patients who underwent renal surgery before vs after implementation of enhanced recovery after surgery pathways. Data analyzed included length of stay, opioid use, cost and complications before and after the enhanced recovery after surgery protocol was implemented. RESULTS: There were 76 patients in the pre-enhanced recovery after surgery group and 42 in the enhanced recovery after surgery group. Median length of stay in the pre-enhanced vs enhanced recovery after surgery group was 3 days vs 2 days (p <0.005). For open procedures median length of stay was 5 days vs 2 days (p <0.001). For robotic procedures median length of stay decreased from 3 days to 2 days (p <0.001). Median length of stay was lower in the enhanced recovery after surgery group independent of age, sex, body mass index, American Society of Anesthesiologists® score and anesthesia time. Median total morphine equivalents decreased from 4 mg to 0 mg (p <0.005) while median total oxycodone went from 52.5 mg to 8.75 mg (p <0.005). Direct cost per patient decreased from $13,036 pre-enhanced recovery after surgery to $9,779 (p <0.001) in the enhanced recovery after surgery group, representing a 25% decrease. The 30-day readmission rates did not change after implementation of enhanced recovery after surgery protocol, and a National Surgical Quality Improvement Program sampling showed similar rates in complications, although this was not amenable to statistical analysis. CONCLUSIONS: Enhanced recovery after surgery improves the care of patients undergoing renal surgery. It significantly decreased length of stay, opioid use and hospital cost without having a significant effect on complications.

What can we learn from pediatric urology certification logs?

OBJECTIVES: To use the billing logs submitted to obtain insight into the operative practice of pediatric urology. The American Board of Urology recently offered a certificate of special qualification in pediatric urology. As a part of the application process, the candidates for this certificate submitted billing logs. METHODS: We reviewed the practice logs of practitioners applying for a certificate of added competence in pediatric urology in 2007 and 2008. The de-identified logs were grouped by case severity and type. In addition, the numbers of cases by a given practitioner were grouped by percentiles. We also analyzed the data for differences in experience, geography, and practice type. RESULTS: A total of 230 logs from the first 2 years of applications were analyzed. The median number of cases was 505 annually, with the most common procedure being circumcision (55 annually), followed by orchiopexy (40 annually) and hernia repair (40 annually). Major procedures were rarer (eg, proximal hypospadias, 2 annually; pyeloplasty, 8 annually; nephrectomy/partial nephrectomy, 4 annually; and genital reconstruction, 1 annually). CONCLUSIONS: In 2006 and 2007, the typical applicant for a subspeciality certificate in pediatric urology had a surgical practice that was primarily of penile and groin cases, with few major cases.

Cost-benefit analysis of scrotal ultrasound in treatment of adolescents with varicocele.

PURPOSE: Varicoceles are a major cause of male factor infertility, although management of adolescent varicoceles is controversial. Most clinicians advocate repair if there is a persistent testicular size discrepancy of greater than 20%. Using previously published data, we performed a cost-benefit analysis of testicular ultrasound vs orchidometry to evaluate for this size difference. MATERIALS AND METHODS: We performed a PubMed search using the terms "adolescent varicocele," "ultrasound and varicocele," and "testis size and varicocele." Using the data from the relevant studies and Medicare reimbursement data from our region, we determined the cost of missing a persistent testicular size difference of greater than 20%. RESULTS: Approximately 25% of adolescents with varicocele have a persistent size discrepancy of greater than 20%. Approximately 40% of this group would be identified as having a size discrepancy with conventional orchidometry. The annual cost of ultrasound for every adolescent male with a varicocele would be $364 million if the imaging were done in an office based setting. If the testing were done at a hospital, the annual cost would be $795 million. The cost per case of missed persistent size discrepancy spanning 3 years is approximately $5,597 for office ultrasound and $12,226 for hospital ultrasound. CONCLUSIONS: There is limited evidence that adolescent varicocele repair improves paternity in adulthood. In an era of increasing health care costs the expense of ultrasound to evaluate for size discrepancy is significant and should be thoughtfully evaluated.

Variations in practice patterns regarding constipation in children with urinary tract infections.

Studies suggest a correlation between constipation and urinary tract infections (UTIs) in children. Diagnoses and treatment of constipation are not clear. This clinical practice was documented in urology offices. Variation noted suggests more research is needed for evidence-based practice in this population.