Independent predictors of mortality for patients with traumatic renal injury.

PURPOSE: To investigate the parameters of renal trauma, including emergent intervention type, that predict the mortality of patients with traumatic renal injury. METHODS: A retrospective database analysis was performed on patients who sustained a traumatic renal parenchymal injury identified by the 2017 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, ER and hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score, renal injury grade, and need for emergent intervention (angioembolization versus open surgery). Logistic regression was used to correlate intervention type and trauma parameters to mortality. RESULTS: A total of 4,876 of 1,004,440 trauma patients (0.49%) had a traumatic renal injury. Of those, 220 (4.5%) underwent an emergent intervention-29 (0.59%) angioembolization and 191 (3.9%) open renal surgery. 83 patients with a blunt renal trauma (2.0%) underwent renal intervention, whereas 136 (21.0%) with a penetrating injury required a procedure. Forty-five of the 220 patients (20.5%) who had a renal intervention died, while 377 of 4,656 (8.1%) who did not have an intervention died. Multiple logistic regression identified black race, age > 45 years, penetrating trauma, and ISS > 15 to be independent predictors of mortality. Neither angioembolization nor open renal surgery was associated with a significantly higher likelihood of mortality in the multivariable model. CONCLUSION: While procedural interventions are associated with higher mortality for patients with traumatic renal injury, other factors, such as race, age, trauma type, and injury severity may be more predictive of death under care.

Survival trends in patients with tracheal carcinoma from 1973 to 2011.

PURPOSE: The prognosis for primary tracheal cancer is dismal. We investigated whether there has been improvement in survival in tracheal cancer patients and how treatment modality affected overall and cancer-specific survival. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results database, 1144 patients with tracheal cancer were identified between 1973 and 2011. Patients were stratified by age group, gender, race, tumor histology, and treatment modality. Radical surgery and survival rates based upon these stratifications were determined. Longitudinal analyses of survival and the percentage of patients undergoing surgery and radiation were conducted. RESULTS: In the final cohort, 327 tracheal cancer patients (34%) underwent radical surgery. Patients of younger age, female gender, and who presented with non-squamous cell tumors were statistically more likely to undergo surgery. Over time, utilization of radiation has declined while use of radical surgery has increased. Concomitantly, 5-year survival has increased from approximately 25% in 1973 to 30% by 2006. Those who did not have surgery were 2.50 times more likely to die of tracheal cancer (95% Confidence Interval 2.00-3.11, p<0.001) than those who did have surgery. Additionally, patients who underwent radical surgery alone (without adjuvant radiation therapy) were 50% or 19% less likely to die of tracheal cancer than those who underwent no treatment or combination therapy, respectively (both p<0.001). CONCLUSIONS: Survival in patients with tracheal cancer is improving over time. The utilization of radical surgery is increasing and confers the highest survival advantage to patients who are candidates.

Readmissions After Colectomy: The Upstate New York Surgical Quality Initiative Experience.

BACKGROUND: Hospital readmissions remain a major medical and financial concern to the healthcare system and have become an area of interest in health outcomes performance metrics. There is a pressing need to identify process measures that may help reduce readmissions. OBJECTIVE: Our aim was to assess the patient characteristics and surgical factors associated with 30-day readmissions for colorectal surgery in Upstate New York. DESIGN: This was a retrospective cohort study. SETTINGS: The study included colectomy cases abstracted for the National Surgical Quality Improvement Program in the Upstate New York Surgical Quality Initiative from June 2013 to June 2014. PATIENTS: The study consists of 630 colectomies. Patients with a length of stay >30 days or who died during the index admission were excluded. MAIN OUTCOME MEASURES: Readmission within 30 days of surgery was the main outcome measure. RESULTS: Of 630 colectomy patients, 76 patients (12%) were readmitted within 30 days of surgery. Major and minor complications were associated with 30-day postoperative readmission (OR = 2.99 (95% CI, 1.70-5.28) and OR = 2.19 (95% CI, 1.09-4.43)) but excluded from final analysis because they included both predischarge and postdischarge complications. Risk factors independently associated with 30-day postoperative readmission included diabetes mellitus (OR = 1.94 (95% CI, 1.02-3.67)), smoker within the past year (OR = 2.01 (95% CI, 1.12-3.60)), no scheduled follow-up (OR = 2.20 (95% CI, 1.25-3.86)), and ileostomy formation (OR = 1.97 (95% CI, 1.03-3.77)). LIMITATIONS: Limitations include the retrospective design and only 30 days of postoperative follow-up. CONCLUSIONS: Consistent with national trends, 1 in 8 patients in the Upstate New York Surgical Quality Initiative program was readmitted within 30 days after colorectal surgery. This study identified several risk factors that may act as tangible targets for intervention, including preoperative smoking cessation programs, optimization of diabetic management, mandatory scheduled follow-up appointments on discharge, and ostomy care pathways.

Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma: population-based and single-institutional analysis.

PURPOSE: Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma is unclear. To assess whether PN provides adequate cancer control in high-risk disease (HRD), survival outcomes were compared in both a population-based cohort and an institutional cohort. METHODS: Surveillance, Epidemiology, and End Results database and a prospectively maintained institutional database were queried for patients with RCC who underwent PN or RN for a localized tumor ≤7 cm and were found to have high-grade and/or high-stage disease (HRD). Cancer-specific (CSS) or recurrence-free survival (RFS) and overall survival (OS) were primary outcomes measured and were compared between those who underwent PN and RN using multivariable Cox proportional hazards and propensity analysis. RESULTS: The population cohort consisted of 12,757 (24.9 %) patients with HRD, 85.2 and 14.8 % of which underwent RN and PN, respectively. RN was not associated with CSS (HR 1.23, p = 0.08) but was independently associated with poor OS (HR 1.16, p = 0.031). Propensity analysis showed that RN resulted in a 20 % increased risk of death from all causes (p = 0.008). In the institutional cohort, of 317 patients, 35.9 % had HRD, 56 and 52 of which underwent RN and PN, respectively. Adjusting for age-adjusted Charlson index, RN was a predictor of poor OS (OR 6.20, p = 0.041). Propensity analysis showed that RFS and OS were not related to nephrectomy type (RN HR 0.65, p = 0.627 and RN HR 1.70, p = 0.484). CONCLUSIONS: In patients with pathologic high-risk RCC, partial excision is associated with similar cancer control as compared to radical excision.

The Upstate New York Surgical Quality Improvement Opioid Reduction Project.

Over 5 million Americans currently abuse prescription opioids. Patients' first exposure to opioids is often after surgery. Few opioid guidelines account for the challenges to health care institutions that serve wide catchment areas. We standardized postoperative opioid prescribing recommendations amongst surgical providers at our institutions and analyzed postoperative prescribing habits. The Upstate New York Surgical Quality Improvement (UNYSQI) collaborative met with surgical champions from 16 hospitals to standardize opioid prescribing for 21 surgical procedures. The guidelines were distributed to all surgical care providers at participating institutions. 581,465 pills were dispensed for 12,672 surgeries (average of 45.9 pills per procedure) before implementation. Post-implementation, 1,097,849 pills were dispensed for 28,772 surgeries (average of 38.2 pills per surgery) with over 222,000 fewer pills being prescribed. Our project suggests opioid prescribing guidelines for institutions that serve diverse communities.

Histopathology of surgically treated renal cell carcinoma: survival differences by subtype and stage.

PURPOSE: Previous studies of the impact of renal cell carcinoma histopathology on survival are conflicting and generally limited to institutional analyses. Thus, we determined the role of renal cell carcinoma histopathology on the stage specific survival rate in a large population based cohort. MATERIALS AND METHODS: We used the 2000 to 2005 National Cancer Institute SEER (Surveillance, Epidemiology and End Results) database to identify 17,605 patients who underwent surgery for renal cell carcinoma and met study inclusion criteria. Patients were stratified by histological subtype (clear cell, papillary, chromophobe, collecting duct and sarcomatoid differentiation) and pathological stage. We performed Cox proportional hazard modeling and Kaplan-Meier survival analysis to determine overall and cancer specific survival. RESULTS: Patients with papillary and chromophobe pathology were less likely to present with T3 or greater disease (17.6% and 16.9%, respectively) while patients with collecting duct and sarcomatoid variants were more likely to present with T3 or greater disease (55.7% and 82.8%, respectively) compared to those with clear cell histology (p <0.001). On multivariate analysis histology was significantly associated with overall and cancer specific survival. Patients with chromophobe pathology had improved survival (HR 0.56, 95% CI 0.40-0.78) while those with collecting duct and sarcomatoid variants had worse survival (HR 2.07, 95% CI 1.44-2.97 and 2.26, 95% CI 1.93-2.64, respectively). CONCLUSIONS: Renal cell carcinoma histological subtype predicts overall and cancer specific survival. Patients with collecting duct and sarcomatoid variants of renal cell carcinoma have poor survival, even those who present with low stage disease. These data suggest inherent differences in renal cell carcinoma biology and may ultimately form the basis of future histologically targeted therapies.

Safety and outcomes of surgical treatment of renal cell carcinoma in the elderly.

INTRODUCTION: Treatment of the elderly patient with a small renal mass is becoming a common conundrum with scant data available to support treatment decisions. Goals were to assess risk of surgical treatment for renal cell carcinoma (RCC) in the elderly as compared to their younger counterparts. MATERIALS AND METHODS: A prospectively maintained database consisting of all renal tumors between August 2004 and November 2009 was utilized. Patients who underwent extirpative treatment for RCC were divided into groups based on age cutoff of < 75 and ≥ 75 years old. Primary outcome measures were likelihood of partial nephrectomy versus radical nephrectomy, complication rates, and overall and cancer-specific survival. A secondary outcome investigated was renal function. RESULTS: Of 347 patients identified, 273 were < 75, and 74 were ≥ 75 years old. The elderly group was less likely to undergo partial nephrectomy (26% versus 43%, p = 0.045). They also had a higher rate of pT3 disease (20% versus 11%, p = 0.018), worse baseline renal function (46 mL/min/m(2) versus 92 mL/min/m(2), p < 0.001) and a longer length of stay (3.5 days versus 2.2 days, p < 0.001). Complication rates and survival outcomes were similar between the groups. Only Eastern Cooperative Oncology Group (ECOG) ≥ 1 and Charlson index ≥ 2 predicted likelihood of experiencing a complication. CONCLUSIONS: Despite a longer length of stay, renal surgery is safe in selected elderly patients with minimal comorbidity and good functional status. The elderly have reduced baseline renal function indicating nephron sparing should be chosen whenever possible, when surgical intervention is elected.

The accumulation of ERAS (enhanced recovery after surgery) components reduces post-colectomy length of stay at small and low volume hospitals.

In small hospitals, where the majority of colectomy surgery is performed in the United States, adopting more individual ERAS components improves outcomes. The accumulation of individual ERAS components influences outcome more than an "ERAS designation" and this can be used by small hospitals to improve outcomes.

Renal cell carcinoma in octogenarians: nephron sparing surgery should remain the standard of care.

PURPOSE: Data regarding clinical outcomes in elderly patients with renal cell carcinoma are scarce. We determined management, and overall and cancer specific survival in elderly patients with renal cell carcinoma. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results database we identified 59,944 patients who underwent partial or radical nephrectomy for renal cell carcinoma between 1988 and 2005. Patients were separated into 2 groups of those younger than 80 years, and those 80 years old or older, and were stratified by clinical variables. Chi-square, multivariate logistic regression and Kaplan-Meier analyses were used to determine differences between the cohorts in terms of surgical approach, and overall and cancer specific survival. RESULTS: In total, 4,227 patients (7.5%) were older than 80 years old. Younger patients more likely underwent partial nephrectomy than their older counterparts (13% vs 8%, p <0.001). At a median followup of 37 months (range 0 to 215) for patients younger than 80 years, and 27 months (range 0 to 203) for octogenarians, older patients were 2.32 times more likely to die (95% CI 2.22-2.42, p <0.001) and 1.33 times more likely to die of renal cell carcinoma (95% CI 1.23-1.43, p <0.001) than their younger counterparts. Older patients who underwent radical nephrectomy were 2.54 times more likely to die of renal cell carcinoma (95% CI 1.68-3.84, p <0.001) than older patients who underwent partial nephrectomy. CONCLUSIONS: Older patients are less likely to undergo partial nephrectomy than their younger counterparts. Octogenarians treated with partial nephrectomy are less likely to die of renal cell carcinoma than those who undergo radical nephrectomy.

Is patient outcome compromised during the initial experience with robot-assisted radical cystectomy? Results of 164 consecutive cases.

OBJECTIVE: • Robot-assisted radical cystectomy (RARC) remains controversial in terms of oncologic outcomes, especially during the initial experience. The purpose of this study was to evaluate the impact of initial experience of robotic cystectomy programs on oncologic outcomes and overall survival. PATIENTS AND METHODS: • Utilizing a prospectively maintained, single institution robotic cystectomy database, we identified 164 consecutive patients who underwent RARC since November 2005. • After stratification by age group, gender, pathologic T stage, lymph node status, surgical margin status, and sequential case number; we used chi-squared analyses to correlate sequential case number to operative time, surgical blood loss, lymph node yield, and surgical margin status. • We also addressed the relationship between complications and sequential case number. We then utilized Cox proportional hazard modeling and Kaplan-Meier survival analyses to correlate variables to overall mortality. RESULTS: • Sequential case number was not significantly associated with increased incidence of complications, surgical blood loss, or positive surgical margins (P= 0.780, P= 0.548, P= 0.545). Case number was, however, significantly associated with shorter operative time and mean number of lymph nodes retrieved (P < 0.001, P < 0.001). • Sequential case number was not significantly associated with survival; however, tumour stage, the presence of lymph node metastases, and positive surgical margins were significantly associated with death. • Although being the largest of its kind, this was a small study with short follow-up when compared to open cystectomy series. CONCLUSION: • Initial experience with RARC did not affect the incidence of positive surgical margins, operative/postoperative complications, or overall survival in a single-institution series.

Lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

OBJECTIVE: To evaluate the incidence of, and predictors for, lymphadenectomy in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer. PATIENTS AND METHODS: Utilizing the International Robotic Cystectomy Consortium (IRCC) database, 527 patients were identified who underwent RARC at 15 institutions from 2003 to 2009. After stratification by age group, sex, pathological T stage, nodal status, sequential case number, institutional volume and surgeon volume, logistic regression was used to correlate variables to the likelihood of undergoing lymphadenectomy (defined as ≥ 10 nodes removed). RESULTS: Of the 527 patients, 437 (82.9%) underwent lymphadenectomy. A mean of 17.8 (range 0-68) lymph nodes were examined. Tumour stage, sequential case number, institution volume and surgeon volume were significantly associated with the likelihood of undergoing lymphadenectomy. Surgeon volume was most significantly associated with lymphadenectomy on multivariate analysis. High-volume surgeons (> 20 cases) were almost three times more likely to perform lymphadenectomy than lower-volume surgeons, all other variables being constant [odds ratio (OR) = 2.37; 95% confidence interval (CI) = 1.39-4.05; P = 0.002]. CONCLUSION: The rates of lymphadenectomy at RARC for advanced bladder cancer are similar to those of open cystectomy series using a large, multi-institutional cohort. There does, however, appear to be a learning curve associated with the performance of lymphadenectomy at RARC.

Prospective clinical trial of preoperative sunitinib in patients with renal cell carcinoma.

PURPOSE: Sunitinib is an approved treatment for metastatic renal cell carcinoma. We performed a prospective clinical trial to evaluate the safety and clinical response to sunitinib administered before nephrectomy in patients with localized or metastatic clear cell renal cell carcinoma. MATERIALS AND METHODS: Patients with biopsy proven clear cell renal cell carcinoma were enrolled in the study and treated with 37.5 mg sunitinib malate daily for 3 months before nephrectomy. The primary end point was safety. RESULTS: In an 18-month period 20 patients were enrolled. The most common toxicities were gastrointestinal symptoms and hematological effects. Grade 3 toxicity developed in 6 patients (30%). No surgical complications were attributable to sunitinib treatment. Of the 20 patients 17 (85%) experienced reduced tumor diameter (mean change -11.8%, range -27% to 11%) and cross-sectional area (mean change -27.9%, range -43% to 23%). Enhancement on contrast enhanced computerized tomography decreased in 15 patients (mean HU change -22%, range -74% to 29%). After tumor reduction 8 patients with cT1b disease underwent laparoscopic partial nephrectomy. Surgical parameters, such as blood loss, transfusion rate, operative time and complications, were similar to those in patients who underwent surgery during the study period and were not enrolled in the trial. CONCLUSIONS: Preoperative treatment with sunitinib is safe. Sunitinib decreased the size of primary renal cell carcinoma in 17 of 20 patients. Future trials can be considered to evaluate neoadjuvant sunitinib to maximize nephron sparing and decrease the recurrence of high risk, localized renal cell carcinoma.

Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

PURPOSE: Positive surgical margins at radical cystectomy confer a poor prognosis. We evaluated the incidence and predictors of positive surgical margins in patients who underwent robot assisted radical cystectomy for bladder cancer. MATERIALS AND METHODS: Using the International Robotic Cystectomy Consortium database we identified 513 patients who underwent robot assisted radical cystectomy, as done by a total of 22 surgeons at 15 institutions from 2003 to 2009. After stratification by age group, gender, pathological T stage, nodal status, sequential case number and institutional volume logistic regression was used to correlate variables with the likelihood of a positive surgical margin. RESULTS: Of the 513 patients 35 (6.8%) had a positive surgical margin. Increasing 10-year age group, lymph node positivity and higher pathological T stage were significantly associated with an increased likelihood of a positive margin (p = 0.010, <0.001 and p <0.001, respectively). Gender, sequential case number and institutional volume were not significantly associated with margin positivity. The rate of margin positive disease at cystectomy was 1.5% for pT2 or less, 8.8% for pT3 and 39% for pT4 disease. CONCLUSIONS: Positive surgical margin rates at robot assisted radical cystectomy for advanced bladder cancer were similar to those in open cystectomy series in a large, multi-institutional, prospective cohort. Sequential case number, a surrogate for the learning curve and institutional volume were not significantly associated with positive margins at robot assisted radical cystectomy.

The role of surveillance in the treatment of patients with muscle-invasive bladder cancer after chemotherapy.

OBJECTIVE: To determine the survival of patients at our institution who were clinically tumour-free (cT0) on re-staging transurethral resection (TUR) after treatment with chemotherapy for muscle-invasive bladder cancer. PATIENTS AND METHODS: In all, 55 patients with muscle-invasive, organ-confined transitional cell carcinoma of the bladder were treated with TUR followed by systemic chemotherapy, over a 10-year period. Patients were separated into two groups, those who were clinically T0 and those who showed persistent disease (>cT0) on re-biopsy after chemotherapy. Overall and disease-specific survival rates were calculated for the two groups. The cT0 group was further followed for tumour recurrence and clinical outcomes. RESULTS: Thirty-one patients (56%) were clinically T0 on TUR after chemotherapy; of these patients, 22 (71%) either died from other causes (with no disease recurrence) or are alive and with no evidence of disease at a mean follow-up of 53 months. Twenty of the 31 patients (65%) have retained their bladder with no evidence of cancer recurrence at a mean follow-up of 46 months. Disease-free status (cT0) at the time of TUR after chemotherapy was associated with significantly higher overall and cancer-specific survival (hazard ratio 3.40, P = 0.003; and 8.63, P = 0.001, respectively). CONCLUSION: Previous studies suggest that surveillance can be a reasonable option for patients with muscle-invasive transitional cell carcinoma of the bladder who show no evidence of disease on TUR after chemotherapy. Patients with persistent bladder cancer on re-biopsy after chemotherapy tend to fare poorly even with immediate cystectomy.

Appendiceal Carcinoid Tumors: Is There a Survival Advantage to Colectomy over Appendectomy?

BACKGROUND: Guidelines recommend colectomy for appendiceal carcinoid tumors larger than 2 cm, but physicians debate whether colectomy would be beneficial in treating smaller tumors. We sought to determine when colectomy confers a survival advantage over appendectomy. METHODS: Appendiceal carcinoid patients in the US Surveillance, Epidemiology, and End Results (SEER) database (1988-2011) were stratified by age group, gender, TNM stage, tumor grade, and race. Kaplan-Meier and logistic regression analyses relating grade, stage, and receipt of colectomy to overall and cancer-specific survival were performed. RESULTS: Of 817 patients who underwent surgical extirpation of an appendiceal carcinoid, 338 (41%) had appendectomy alone and 479 (59%) had additional colectomy. Surprisingly, patients who underwent colectomy had worse cancer-specific survival (HR 1.98, 95% CI 1.32-2.98, p = 0.001) than those who underwent appendectomy, and colectomy did not confer a survival advantage over appendectomy in any subset analysis including low-grade or high-grade tumors, smaller or larger than 2 cm, or node-positive, non-metastatic tumors. Even when accounting for stage and grade, colectomy was not associated with significantly better survival rates. Furthermore, as colectomy frequency has increased over the last decade, the 5-year survival rate has trended down. The main predictors of cancer-specific mortality in carcinoid patients were high-grade (grades 3-4) and high-stage (node positive or metastatic) tumors. CONCLUSIONS: Survival in patients with carcinoid tumor of the appendix is primarily determined by tumor grade and stage. Our study found no survival advantage to colectomy over appendectomy in a large cohort of patients with the disease. Further investigation is necessary prior to recommending change of practice for patients with appendiceal carcinoid tumors.

The Impact of Anticoagulation on Trauma Outcomes : An National Trauma Data Bank Study.

BACKGROUND: Increased prevalence of patients on anticoagulants and the advent of new therapies raise concern over how these patients fare if they sustain a traumatic injury. We investigated the role of prehospitalization anticoagulation therapy in trauma-related mortality and postacute disposition. METHODS: A retrospective analysis was performed on patients who sustained traumatic injury identified in the 2017 National Trauma Data Bank (NTDB). Patients with and without anticoagulation therapy were analyzed to identify differences in demographics, injury type, Injury Severity Score (ISS), and trauma outcomes including hospital length of stay, ER, final hospital disposition, and mortality. Logistic regression was used to correlate anticoagulation to mortality and facility discharge. RESULTS: Of the 1 000 596 patients included, 73 602 (7%) patients were on anticoagulants at the time of their trauma. Increased age was the strongest predictor for anticoagulation therapy (odds ratio 5.54, 95% CI 5.44-5.63), but being female and white were also independent predictors of anticoagulation (P < .001). Patients on anticoagulants had a significantly longer length of stay (5.11 days; 95% CI 5.06-5.15) than those who were not (4.37 days, 95% CI 4.36-4.39), were 2.20 times more likely to die (95% CI 2.12-2.28, P < .001), and were 2.77 times more likely to be discharged to a facility (95% CI 2.73-2.81, P < .001). Anticoagulation remained a significant predictor of worse trauma outcomes even when accounting for age and ISS in multivariate analysis. DISCUSSION: Anticoagulation preceding trauma-related admission is associated with higher mortality and an increased likelihood of the need for a posthospital care facility.

Sociodemographic factors associated with nephrectomy in patients with metastatic renal cell carcinoma.

PURPOSE: Studies suggest that radical nephrectomy imparts a survival benefit in select patients with metastatic renal cell carcinoma. We determined the roles of patient age, gender, race and in particular marital status in the decision to pursue nephrectomy and the ensuing effect on overall survival. MATERIALS AND METHODS: Using the Surveillance, Epidemiology and End Results database we identified 11,182 patients between 1988 and 2004 who were diagnosed with metastatic renal cell carcinoma. Patients were separated into 2 groups, including those who underwent nephrectomy and those who did not, and they were stratified by the mentioned variables. Logistic regression and Kaplan-Meier analyses were used to determine the likelihood of undergoing nephrectomy and of overall survival in the cohorts. RESULTS: In the final cohort 3,443 patients (31%) underwent radical nephrectomy. These patients experienced longer median survival than those who did not undergo surgery (11 vs 4 months, p <0.001). The survival benefit was statistically similar regardless of age group, race, gender and marital status. However, nephrectomy was more commonly performed in younger age groups, and in white and married patients. While age group and race were statistically significant predictors of undergoing nephrectomy (OR 0.64, 95% CI 0.61-0.66 and OR 0.79, 95% CI 0.70-0.89, respectively), marital status was the most important predictor (OR 1.52, 95% CI 1.39-1.66). CONCLUSIONS: Patients with metastatic renal cell carcinoma who undergo radical nephrectomy experience a survival advantage over those who do not undergo surgery. Married patients are more likely to undergo nephrectomy than their unmarried counterparts. Physicians must be aware of this bias when selecting patients for nephrectomy.

Manuscript publication by urology residents and predictive factors.

PURPOSE: Many academic institutions have set expectations for peer reviewed publications, yet there is no objective guideline to gauge the performance of a urology resident or program. We quantified and determined predictive factors for resident manuscript production. MATERIALS AND METHODS: Electronic surveys were sent to 255 chief residents and recent graduates of 83 accredited urological training programs in the United States and Canada. Survey questions pertained to manuscript submission and acceptance before and during residency, months of research incorporated into residency, PhD degree status and the pursuit of fellowship training. RESULTS: Surveys were completed by 127 residents from 83 programs. The median number of manuscripts submitted and accepted during residency was 3 (range 0 to 32) and 2 (range 0 to 25), respectively. Months of protected research time and the number of publications before residency were significantly predictive of the number of manuscripts submitted during residency (p <0.001 and p <0.001, respectively). The number of manuscripts submitted during residency was significantly associated with entering fellowship training (p <0.05). CONCLUSIONS: Manuscript preparation and publication are important aspects of the training process at a number of urological surgery residency programs. While the majority of residents are not involved in publication before residency, most submit and publish at least 1 manuscript as first author in a peer reviewed journal during residency. The number of prior publications and months of allotted research time are significantly predictive of resident manuscript productivity. In turn, manuscript submission is indicative of the decision to pursue fellowship training.

Trends in pelvic lymphadenectomy at the time of radical cystectomy: 1988 to 2004.

PURPOSE: Studies suggest that patients who undergo thorough lymphadenectomy for bladder cancer benefit from improved survival. We evaluated the incidence of and trends in lymphadenectomy in conjunction with radical cystectomy for bladder cancer. MATERIALS AND METHODS: Using the Surveillance, Epidemiology and End Results registry we identified 8,072 eligible patients with bladder cancer who underwent radical cystectomy with or without lymphadenectomy from 1988 to 2004. After stratification by age group, race, stage, grade and year of diagnosis we performed logistic and linear regression to correlate variables to the mean number of lymph nodes sampled and the likelihood of undergoing lymphadenectomy (classified as 1 or more, 5 or more and 10 or more nodes removed). RESULTS: In the final cohort 1,660 patients (21%) did not have any lymph nodes sampled at radical cystectomy. This number decreased from 37% in 1988 to 16% in 2004. During this period the mean number of lymph nodes removed increased by 2.6 nodes over all definitions of lymphadenectomy and the percentage of patients undergoing any form of lymph node dissection increased by an average of 19%. Year of diagnosis was most strongly predictive of the likelihood of undergoing lymphadenectomy and most correlative with the mean number of nodes sampled. CONCLUSIONS: Over time there has been improvement in terms of the performance of lymphadenectomy and node counts obtained during radical cystectomy. If these trends continue the incidence and quality of lymphadenectomy should continue to increase, ultimately to the benefit of the patients being treated.