Value-based care for the treatment and evaluation of benign prostatic hyperplasia: an analysis of a metropolitan service area claims database.

PURPOSE: With an aging population, cost containment and improved outcomes will be crucial for a sustainable healthcare ecosystem. Current data demonstrate great variation in payments for procedures and diagnostic workup of benign prostatic hyperplasia (BPH). To help determine the best financial value in BPH care, we sought to analyze the major drivers of total payments in BPH. MATERIALS AND METHODS: Commercial and Medicare claims from the Truven Health Analytics Markestscan® database for the Austin, Texas Metropolitan Service Area from 2012 to 2014 were queried for encounters with diagnosis and procedural codes related to BPH. Linear regression was utilized to assess factors related to BPH-related payments. Payments were then compared between surgical patients and patients managed with medication alone. RESULTS: Major drivers of total payments in BPH care were operative, namely transurethral resection of prostate (TURP) [$2778, 95% CI ($2385-$3171), p < 0.001) and photoselective vaporization (PVP) ($3315, 95% CI ($2781-$3849) p < 0.001). Most office procedures were also associated with significantly higher payments, including cystoscopy [$708, 95% CI ($417-$999), p < 0.001], uroflometry [$446, 95% CI ($225-668), p < 0.001], urinalysis [$167, 95% CI ($32-$302), p = 0.02], postvoid residual (PVR) [$245, 95% CI ($83-$407), p < 0.001], and urodynamics [$1251, 95% CI ($405-2097), p < 0.001]. Patients who had surgery had lower payments for their medications compared to patients who had no surgery [$120 (IQR: $0, $550) vs. $532 (IQR: $231, $1852), respectively, p < 0.001]. CONCLUSION: Surgery and office-based procedures are associated with increased payments for BPH treatment. Although payments for surgery were more in total, surgical patients paid significantly less for BPH medications.

Occupational traumatic injuries rarely affect genitourinary organs: a retrospective, comparative study.

PURPOSE: To determine the mechanisms of injury associated with occupational injuries (OI) to genitourinary (GU) organs and compare GU OIs with GU non-OIs. METHODS: A single institution, retrospective study was conducted at a level 1 trauma center between 2010 and 2016 of all patients with GU injuries. OI was defined as any traumatic event that occurred in the workplace requiring hospital admission. Types of occupations were recorded in addition to the location of injury, mechanisms of injury, concomitant injuries, operative interventions, total cost, and mortality. GU OI patients were then compared to GU non-OI patients. RESULTS: 623 patients suffered a GU injury, of which 39 (6.3%) had a GU OI. Fall (43%) was the most common mechanism of injury; followed by motor vehicle collision/motorcycle crash (31%), crush injury (18%), and pedestrian struck (8%). The adrenal gland (38%) and kidney (38%) were the most commonly injured organs. There was no difference in mortality (13% GU OI vs. 15% GU non-OI, p = 0.70) or total direct cost ($21,192 ± 28,543 GU OI vs. $28,215 ± 32,332 GU non-OI, p = 0.45). Total costs were decreased with mortality from a GU injury (odds ratio (OR) 0.3, CI 0.26-0.59; p = < 0.001) and increased with higher injury severity scores (OR 1.1, CI 1.09-1.2; p = < 0.0001). Total costs were not affected by OI status. CONCLUSIONS: Occupational GU trauma presents with similar patterns of injury, hospital course, and direct cost as GU trauma that occurs in non-occupational settings.

Matched comparison of primary versus salvage laparoscopic pyeloplasty.

PURPOSE: To compare our experience with salvage laparoscopic pyeloplasty, using a matched control set of primary laparoscopic pyeloplasty patients. METHODS: We retrospectively reviewed patients who underwent laparoscopic pyeloplasty from 1996 to 2014 by a single surgeon. At least 12 months of follow-up was required. Salvage patients were matched 1:3 with primary patients. Matching was based on age ±5 years, body mass index (BMI) ±5, and type of pyeloplasty (dismembered vs. non-dismembered). Primary outcome was failure as defined as re-intervention following laparoscopic pyeloplasty (does not include temporary stenting without definitive retreatment). RESULTS: Of 128 laparoscopic pyeloplasty procedures, ten were salvage. These patients were matched to 26 patients who underwent a primary laparoscopic pyeloplasty in a 1:3 manner. One salvage pyeloplasty failed to match due to BMI, and the closest matches were made. Four salvage patients had one overlapping match, reducing the primary group to 26 patients. There were no differences in pre-, intra-, and postoperative variables between groups, except for operative time (salvage 247 min, primary 175 min, p = 0.03). With similar duration of radiologic and symptomatic follow-up, there was no significant difference in the rate of freedom from intervention. CONCLUSION: When matching for factors that could affect success, salvage laparoscopic pyeloplasty performed as well as primary pyeloplasty except for a longer operative time. In experienced hands, salvage laparoscopic pyeloplasty for ureteropelvic junction obstruction recurrence after prior pyeloplasty is a safe and effective procedure, and should be considered an excellent alternative to the more commonly recommended endopyelotomy.

Medication Nonadherence and Effectiveness of Preventive Pharmacological Therapy for Kidney Stones.

PURPOSE: Among patients with kidney stones rates of adherence to thiazide diuretics, alkali citrate therapy and allopurinol, collectively referred to as preventive pharmacological therapy, are low. This lack of adherence may reduce the effectiveness of secondary prevention efforts, leading to poorer clinical health outcomes in patients with kidney stones. To examine the impact that medication nonadherence has on the secondary prevention of kidney stones, we compared clinical health outcomes between patients who adhered to their regimen and those who did not. MATERIALS AND METHODS: Using medical and pharmacy claims data we identified adult patients with a physician coded diagnosis for kidney stones. Among the subset with a prescription fill for a preventive pharmacological therapy agent, we then measured adherence to therapy within the first 6 months of initiating treatment using the proportion of days covered formula. We defined adherence as a proportion of days covered value of 80% or greater. Finally, we fitted multivariable logistic regression models to examine the association between medication adherence and the occurrence of a stone related clinical health outcome (an emergency department visit, hospitalization or surgery for stone disease). RESULTS: Of the 8,950 patients who met the study eligibility criteria slightly more than half (51.1%) were adherent to preventive pharmacological therapy. The frequency of emergency department visits, hospitalization and surgery for stone disease was significantly lower among adherent patients. After controlling for sociodemographic factors and the level of comorbid illness, patients who were adherent to therapy had 27% lower odds of an emergency department visit (OR 0.73, 95% CI 0.64-0.84), 41% lower odds of hospital admission (OR 0.59, 95% CI 0.49-0.71) and 23% lower odds of surgery for stone disease (OR 0.77, 95% CI 0.69-0.85) than nonadherent patients. CONCLUSIONS: Our data highlight the consequences of nonadherence to preventive pharmacological therapy among patients with kidney stones. To improve adherence further research is needed to understand patient and provider level factors that contribute to lower rates of adherence.

How Much Information is Lost When You Only Collect One 24-Hour Urine Sample during the Initial Metabolic Evaluation?

PURPOSE: During the initial metabolic evaluation the need for 1 vs 2, 24-hour urine collections is debated. While data suggest that mean urine chemistry measures are similar on consecutive samples, it remains unclear how much, if any, information is lost when only 1 sample is collected. MATERIALS AND METHODS: Using analytical files from Litholink Corporation® (1995 to 2013) we identified adults with kidney stones who underwent initial metabolic testing. Next we determined the subset of patients who collected 2, 24-hour urine samples with urine creatinine varying by 10% or less during a 7-day time window. We then examined the degree of variability in urine chemistry profiles. Specifically we calculated the mean absolute value of the difference between samples as well as the percent difference for individual urine parameters. RESULTS: We identified 70,192 patients meeting our eligibility criteria. While the overall means for individual urine parameters did not vary between samples, the percent difference between the samples varied widely. For example, nearly 1 in 3 patients had a 30% or greater difference in urine calcium and volume between 2 consecutive samples. We noted that inconsistencies between samples often involved multiple parameters. For instance, 29% and 25% of patients had a 20% difference in 2 and 3 or more parameters, respectively. CONCLUSIONS: We observed substantial differences between consecutive 24-hour urine samples that could affect clinical decision making. In light of these findings clinicians must weigh the information lost from only 1 collection vs the burden to the patient of collecting 2.

Age, Gender and R.E.N.A.L. Nephrometry Score do not Improve the Accuracy of a Risk Stratification Algorithm Based on Biopsy and Mass Size for Assigning Surveillance versus Treatment of Renal Tumors.

PURPOSE: A previously published risk stratification algorithm based on renal mass biopsy and radiographic mass size was useful to designate surveillance vs the need for immediate treatment of small renal masses. Nonetheless, there were some incorrect assignments, most notably when renal mass biopsy indicated low risk malignancy but final pathology revealed high risk malignancy. We studied other factors that might improve the accuracy of this algorithm. MATERIALS AND METHODS: For 202 clinically localized small renal masses in a total of 200 patients with available R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, hilar tumor touching main renal artery or vein and location relative to polar lines) nephrometry score, preoperative renal mass biopsy and final pathology we assessed the accuracy of management assignment (surveillance vs treatment) based on the previously published risk stratification algorithm as confirmed by final pathology. Logistic regression was used to determine whether other factors (age, gender, R.E.N.A.L. score, R.E.N.A.L. score components and nomograms based on R.E.N.A.L. score) could improve assignment. RESULTS: Of the 202 small renal masses 53 (26%) were assigned to surveillance and 149 (74%) were assigned to treatment by the risk stratification algorithm. Of the 53 lesions assigned to surveillance 25 (47%) had benign/favorable renal mass biopsy histology while in 28 (53%) intermediate renal mass biopsy histology showed a mass size less than 2 cm. Nine of these 53 masses (17%) were incorrectly assigned to surveillance in that final pathology indicated the need for treatment (ie intermediate histology and a mass greater than 2 cm or unfavorable histology). Final pathology confirmed a correct assignment in all 149 masses assigned to treatment. None of the additional parameters assessed improved assignment with statistical significance. CONCLUSIONS: Age, gender, R.E.N.A.L. nephrometry score, R.E.N.A.L. score components and nomograms or combinations of these factors do not improve the predictive performance of a small renal mass management risk stratification algorithm based on renal mass biopsy and radiographic mass size.

Provider variation in the quality of metabolic stone management.

PURPOSE: Urinary stone disease is a chronic condition for which secondary prevention (dietary and medical therapy guided by 24-hour urine collection results) has an important role. Assessing the response to these interventions with followup testing is recommended and yet to our knowledge provider compliance with these guidelines is unknown. MATERIALS AND METHODS: Using Litholink® files from 1995 to 2013 we identified adults with urinary stone disease who underwent metabolic evaluation and the providers who ordered the evaluation. By focusing on patients with an abnormality on the initial collection we determined the proportion who underwent a followup test within 6 months of the initial test. Multilevel modeling was done to quantify variation in followup testing among providers after accounting for various patient and provider factors. RESULTS: A total of 208,125 patients had an abnormality on the initial collection, of whom only 33,413 (16.1%) performed a repeat collection within 6 months. While most variation in followup testing was attributable to the patient, the provider contribution was nontrivial (18.0%). The specialty of the ordering provider was important. Patients who saw a urologist had 24% lower odds of repeat testing compared to those who saw a primary care physician (OR 0.76, 95% CI 0.67-0.86, p <0.001). CONCLUSIONS: Followup testing is uncommon in patients with an abnormal initial 24-hour urine collection. Given the observed provider variation, efforts to educate providers on the value of followup testing are likely to have salutary effects on patients with metabolic stone disease.

Metastases to the kidney: a clinicopathological study of 43 cases with an emphasis on deceptive features.

AIMS: To review our experience with metastases to the kidney in surgical pathology material. METHODS AND RESULTS: The clinicopathological features of all metastases to the kidney in surgical pathology cases between May 1987 and May 2013 at our institution were reviewed. Autopsy cases were excluded. Forty-three cases (16 nephrectomies, 25 biopsies, and two fine needle aspirations) were included; the primary malignancy was diagnosed prior to/concurrently with the metastasis in nearly all cases. Common primary sites included the lung, breast, female genital tract, and head and neck; the majority were carcinomas. A primary renal tumour was suspected prior to the pathological diagnosis in 35% of cases. Unusual features included: common unilateral (77%) and unifocal (70%) involvement, lack of other distant organ metastases (37%), >10 years between primary and metastasis diagnoses (19%), lack of a discrete mass (5%), and renal vein extension (19% of resections). The most common dilemma was excluding urothelial or high-grade renal cell carcinoma; however, metastases from the thyroid commonly mimicked low-grade renal cell carcinomas. CONCLUSIONS: In surgical pathology material, metastases to the kidney most commonly present as solitary unilateral masses, and in a substantial subset of cases mimic a primary renal tumour.

Impact of warm versus cold ischemia on renal function following partial nephrectomy.

INTRODUCTION: We evaluated renal function following partial nephrectomy with cold ischemia (CI) versus warm ischemia (WI). METHODS: Data were collected from 1,396 patients at six institutions who underwent partial nephrectomy for a renal mass with normal contralateral kidney to evaluate percent change in glomerular filtration rate (GFR) at 3-18 months. A multivariate linear regression model tested the association of percent change GFR with clinical, operative, and pathologic factors. RESULTS: A total of 874 patients (63 %) underwent PN with CI and 522 (37 %) with WI. All patients undergoing laparoscopic and robotic-assisted partial nephrectomy (n = 443) had WI, whereas 92 % of open partial nephrectomy patients (n = 953) had CI. The CI group had a lower mean baseline GFR (72 vs. 80 ml/min/1.73 m(2)), longer median ischemia time (33 vs. 29 min), and larger mean tumor size (3.2 vs. 2.9 cm) with more advanced pathologic stage (T1b-T3: 25 vs. 16 %) (all p values <0.001). Patients with CI and WI demonstrated 12.3 and 10.1 % reductions in renal function from baseline, respectively (p = 0.067). Increasing age, female gender, and increasing tumor size were associated with reduction in renal function (all p values <0.001). Neither renal hypothermia nor operative technique independently predicted reduced renal function. Sensitivity analyses limited to ischemia time >30 min, baseline estimated glomerular filtration rate <60 ml/min/1.73 m(2), or tumors >4 cm did not significantly alter the findings. CONCLUSIONS: Increasing age, female gender, and larger tumor size independently predict a decrease in renal function following partial nephrectomy with a normal contralateral kidney. Within the limitations of a non-randomized comparison, including lack of parenchymal preservation percentage, neither surgical approach (open or laparoscopic) nor presence of hypothermia appears to be associated with long-term renal function.

Ureteroscopy for nephrolithiasis in transplanted kidneys.

INTRODUCTION: While percutaneous nephrolithotomy (PCNL) is often the procedure of choice for renal and ureteral calculi in transplant kidneys, retrograde ureteroscopy (URS) is a less frequently applied but excellent option if stone burden is small. We retrospectively examined nine surgical cases performed in seven patients in what appears to be the largest single institutional series reported to date. MATERIALS AND METHODS: Seven patients underwent nine retrograde URS between June of 2009 and September of 2013, by two endourologists. These cases were reviewed retrospectively. RESULTS: Among the nine procedures, we were able to address the stone(s) endoscopically in seven. Among these procedures, laser lithotripsy was used in six cases, and basket stone extraction was applied in four procedures. Ureteral stents were placed following six procedures with ureteral access and treatment. Postoperative imaging revealed the patient to be stone free after five of the seven procedures with ureteral access and treatment. There were two postoperative urinary tract infections, and no major complications. Of the nine total procedures, six were outpatient, two were followed by observation stay < 24 hours, and one patient was admitted > 24 hours. Among the two failures, one underwent PCNL and the other had percutaneous nephrostomy (PNT) placed but expired from unrelated causes prior to the intended PCNL. CONCLUSIONS: Retrograde URS with laser lithotripsy and/or basket extraction is a reasonable option for treating small renal transplant stones, with most patients in our series being discharged as outpatients, having complete stone clearance and avoiding PCNL.

Wire-reinforced ureteral stents to rescue from nephrostomy tube in extrinsic ureteral obstruction.

INTRODUCTION: Ureteral obstruction due to extrinsic compression is associated with significant morbidity and mortality. Management options for this condition include renal drainage with percutaneous nephrostomy (PCN) or internal ureteral stent placement. A significant portion of patients will have disease progression leading to internal stent obstruction which is almost uniformly managed with PCN. We evaluated a novel, wire-reinforced internal ureteral stent as an alternative to PCN in those patients who fail initial internal ureteral stent placement. MATERIALS AND METHODS: A retrospective chart review was performed to identify patients with extrinsic ureteral obstruction that failed conventional plastic internal ureteral stent placement and ultimately underwent placement of wire-reinforced internal ureteral stents (Scaffold) at the University of Michigan Health System between 2006-2011. Outcomes assessed included time to Scaffold stent failure and failure free time with Scaffold stent in place. RESULTS: A total of 8 patients were identified with extrinsic ureteral obstruction that failed initial conventional ureteral stenting and had a Scaffold stent placed. Scaffold stents ultimately failed in 3 out of 8 patients. Mean time to Scaffold stent failure was 197 days (range 20-536). In the remaining 5 patients, mean failure-free time with Scaffold stents in place was 277 days (range 18-774). CONCLUSION: Scaffold stent placement is a viable alternative to PCN in those patients with extrinsic ureteral obstruction who fail conventional internal ureteral stent placement.

Prevalence of 24-hour urine collection in high risk stone formers.

PURPOSE: Secondary prevention has an important role in urinary stone disease. The core of secondary prevention is the identification of modifiable risk factors by a 24-hour urine collection, which then directs selective medical therapy. While this decreases the recurrence rate, little is known about the frequency with which 24-hour urine collections are obtained. MATERIALS AND METHODS: Using medical claims from 2002 to 2006 we identified adults with incident urinary stone episodes. With appropriate diagnosis codes we determined those at high risk for recurrence. Of these patients we determined the proportion in whom a 24-hour urine collection was done within 6 months of diagnosis. Finally, we fitted regression models to measure associations between patient and provider level factors, and obtaining a 24-hour urine collection. RESULTS: We identified 28,836 patients at high risk for recurrence. The prevalence of 24-hour urine testing increased from 7.0% in 2003 to 7.9% in 2006 (p = 0.011), although the overall prevalence was exceedingly low at 7.4%. Multivariable regression revealed that region of residence and level of comorbid illness were independently associated with 24-hour urine collection, as was the type of physician who performed the followup. For instance, the odds of metabolic evaluation were 2.9 times higher when a patient was seen by a nephrologist (OR 2.92, 95% CI 2.32-3.67), and more than threefold higher when seen by a urologist (OR 3.87, 95% CI 3.48-4.30). CONCLUSIONS: Obtaining 24-hour urine collections in stone formers at high risk is uncommon, raising a quality of care concern.

Population level assessment of hospital based outcomes following laparoscopic versus open partial nephrectomy during the adoption of minimally invasive surgery.

PURPOSE: The comparative outcomes of laparoscopic and open partial nephrectomy remain incompletely defined. Therefore, we used population based data to examine resource use and short-term outcomes among patients with kidney cancer treated with laparoscopic vs open partial nephrectomy. MATERIALS AND METHODS: Using linked SEER (Surveillance, Epidemiology, and End Results)-Medicare data we identified patients with kidney cancer treated with laparoscopic or open partial nephrectomy from 2000 through 2007. We then used Medicare claims to identify several postoperative outcomes including intensive care unit care, length of stay, rehospitalizations, operative mortality and postoperative complications. We fit multivariate logistic regression models to estimate the association between each outcome and surgical approach (ie laparoscopic partial nephrectomy vs open partial nephrectomy), adjusting for patient and tumor characteristics. RESULTS: We identified 651 (28%) and 1,670 (72%) patients treated with laparoscopic partial nephrectomy and open partial nephrectomy, respectively. Compared to those who underwent open partial nephrectomy, patients treated with laparoscopic partial nephrectomy had a 34% lower probability of requiring intensive care unit time (20.0% vs 30.2%, p <0.001) and shorter median length of stay (3 vs 5 days, p <0.001), with no differences observed in the likelihood of rehospitalization or operative mortality. While the frequency of postoperative complications was similar (35.5% vs 36.1%, p = 0.829), patients treated with laparoscopic partial nephrectomy had a nearly twofold greater probability of genitourinary complications and postoperative hemorrhage (p <0.001). CONCLUSIONS: At a population level the patients with kidney cancer treated with laparoscopic partial nephrectomy experienced a shorter and less intense hospitalization, supporting the benefits of laparoscopy. However, the greater likelihood of procedure related complications highlights the need for continued efforts aimed at ensuring the safe adoption and application of this advanced surgical technique.

An observational analysis of provider adherence to AUA guidelines on the management of benign prostatic hyperplasia.

PURPOSE: We retrospectively evaluated urologist adherence to the AUA guidelines on the management of new patients with benign prostatic hyperplasia related lower urinary tract symptoms in a large university urology group. MATERIALS AND METHODS: All first time benign prostatic hyperplasia/lower urinary tract symptom visits to the urology clinic at the Northwestern Medical Faculty Foundation between January 1, 2008 and December 31, 2012 were evaluated using an institutionally managed electronic medical record data repository. Clinical documentation and orders from each encounter were assessed to determine the rate of performance of guideline measures. Approximately 1% of all results were manually reviewed in a validation process designed to determine the reliability of the electronic medical record based system. RESULTS: A total of 3,494 eligible encounters were evaluated in the final analysis. Provider adherence rates with the 9 measures recommended in the guidelines varied by measure from 53.0% to 92.8%. The rate of performance of 5 not routinely recommended measures was 10.2% or less. Post-void residual and urinary flow measurement were optional measures, and were performed on 68.1% and 4.6% of new encounters respectively. Manual validation revealed the electronic medical record data extraction was concordant with manual review in 96.7% of cases (95% CI 94.8-98.5). CONCLUSIONS: Using electronic medical record based data extraction techniques, we reliably document a baseline adherence rate with AUA guidelines on the management of benign prostatic hyperplasia. Establishing this benchmark will be important for future investigation into patient outcomes related to guideline adherence and into methods for improving provider adherence.

Expulsive therapy versus early endoscopic stone removal in patients with acute renal colic: a comparison of indirect costs.

PURPOSE: While medical expulsive therapy is associated with lower health care expenditures compared to early endoscopic stone removal in patients with renal colic, little is known about the effect of medical expulsive therapy on indirect costs. MATERIALS AND METHODS: Using a previously validated claims based algorithm we identified a cohort of patients with acute renal colic. After determining the up-front treatment type (ie an initial course of medical expulsive therapy vs early endoscopic stone removal) we compared differences in rates of short-term disability filing. We used propensity score matching to account for differences between treatment groups such that patients treated with medical expulsive therapy vs early endoscopic stone removal were similar with regard to measured characteristics. RESULTS: In total, 257 (35.8%) and 461 (64.2%) patients were treated with medical expulsive therapy or early endoscopic stone removal, respectively. There were no differences between treatment groups after propensity score matching. In the matched cohort the patients treated with medical expulsive therapy had a 6% predicted probability of filing a claim for short-term disability compared to 16.5% in the early endoscopic stone removal cohort (p <0.0001). Among the patients who filed for short-term disability those prescribed medical expulsive therapy had on average 1 fewer day of disability than those treated surgically (0.9 vs 1.8 days, p <0.001). CONCLUSIONS: An initial trial of medical expulsive therapy is associated with significantly lower indirect costs to the patient compared to early endoscopic stone removal. These findings have implications for providers when counseling patients with acute renal colic.

Variability in computed tomography diameter measurements of solid renal masses.

PURPOSE: To determine whether the frequency of intra-observer measurement discrepancies ≥5 mm for solid renal masses varies by renal mass characteristics and CT contrast phase. MATERIALS AND METHODS: This HIPAA-compliant retrospective study was approved by our IRB. We selected single CT images performed during the nephrographic phase (NP) of renal enhancement in 97 patients, each with a single solid renal mass. Mass location, margin, heterogeneity, and growth pattern were assessed. Six readers measured each mass on two occasions >3 weeks apart. Readers also measured the masses on images in 50 patients who had corticomedullary phase (CMP) images obtained during the same study. Results were assessed using Chi-square/Fisher's exact and Wilcoxon Signed Rank tests, and logistic regression analyses. RESULTS: For NP to NP comparisons, intra-reader measurement differences ≥5 mm were seen for 3.7% (17/463) of masses <4 cm, but increased to 16.8% (20/119) for masses >4 cm (p < 0.0001). Masses with poorly defined margins (15.9% [22/138] vs. 3.4% [15/444] for well-defined margins, p < 0.0001) and heterogeneity (15.3% [22/144], vs. 5.0% [14/282] for minimally heterogeneous, vs. 0.6% [1/156] for homogeneous, p < 0.0001), were more frequently associated with measurement differences ≥5 mm. Differences ≥5 mm were more frequent when only CMP images were utilized (14% [42/299]), or when CMP images were compared with NP images (26% [77/299]). CONCLUSIONS: A ≥5 mm intra-reader variation in measured size of solid renal masses <4 cm is uncommon for NP to NP comparisons. Variation increases when masses are ≥4 cm, poorly defined, or heterogeneous; or when CMP images are utilized.

Hand-assisted and standard laparoscopic radical nephrectomy after prior renal surgery.

INTRODUCTION: With the increasing use of partial nephrectomy, cases of ipsilateral tumor recurrence will inevitably occur. We aimed to evaluate the efficacy and feasibility of laparoscopic radical nephrectomy (LRN) for a previously operated kidney, through a case-matched comparison with LRN in patients without prior renal surgery. MATERIALS AND METHODS: Among 550 patients who underwent hand-assisted or standard LRN at our institution between August 1996 and January 2013, we identified patients who had prior laparoscopic or open surgical renal surgery. Each study patient was matched 1:2 with patients who had not had prior renal surgery. Matching was exact by surgical approach, gender, side of surgery, and American Society of Anesthesiologists score, and closest possible by age and body mass index. RESULTS: LRN was performed in 9 patients (6 hand-assisted and 3 standard) with prior open surgical or laparoscopic renal surgery. There were no conversions to open surgery. Primary surgeon tended to be to attending urologist more often than the trainee in the study compared to the control patients, an indication of increased technical difficulty. Additionally, there were four intraoperative injuries recorded in the study group (44%) and just one such event in the control group (5.6%) (p = 0.0297). CONCLUSIONS: Although LRN after prior renal surgery is challenging, requiring the expertise of experienced surgeons and being associated with appreciable rate of intraoperative injuries, these cases can be completed laparoscopically (especially with the selective use of hand-assistance) and are associated with duration of hospitalization and postoperative complication rates similar to those in patients undergoing LRN without prior renal surgery.

Open surgical partial nephrectomy for upper tract urothelial carcinoma.

We aimed to determine the ability of partial nephrectomy to prevent end-stage renal disease and tumor recurrence or progression in patients with upper tract urothelial carcinoma. Retrospectively, eight patients undergoing partial nephrectomy for upper tract urothelial carcinoma were identified and their medical records reviewed. All patients had imperative indications for nephron sparing, and diagnosis of upper tract urothelial carcinoma not adequately amenable to endoscopic management. Although three patients suffered acute tubular necrosis, only one required postoperative hemodialysis. During the follow-up period 25% (2/8) developed end-stage renal disease, including the one patient who had received postoperative hemodialysis. Recurrences occurred in five of seven patients with adequate oncological surveillance. Recurrences were successfully treated endoscopically in 80% (4/5) patients, and one patient had metastases. Of the eight patients, four have died. Death occurred 4 months, 1 year, 1.2 years and 3.5 years after partial nephrectomy. Of these patients, one succumbed to metastatic disease; the exact cause of death is unknown in the other three, but there was no documentation of metastatic cancer. The mean duration of follow up in the remaining four patients, all without evidence of metastatic urothelial cancer, is 71 months (range 22-108 months). In summary, partial nephrectomy for upper tract urothelial carcinoma in patients with imperative indications averts end-stage renal disease in most patients, and appears to be associated with acceptable disease-specific survival. Partial nephrectomy is a sparingly used option in patients with upper tract urothelial carcinoma refractory to endoscopic management who have imperative indications for nephron sparing.

Decreased Opioid Use and Equivalent Pain Score Outcomes After Robotic Urologic Surgery Using a Simplified Opioid Minimization Protocol: A Safety-Net Hospital Experience.

INTRODUCTION: We aimed to implement a simplified opioid minimization (OM) protocol after robotic urologic surgery in a safety-net hospital to decrease opioid consumption without compromising patient-reported pain or satisfaction. METHODS: Robotic urologic surgery was performed in 103 consecutive patients at a safety-net hospital. An opioid control (OC) cohort was established from January to May 2021, and the OM protocol was implemented from June to October 2021. On postoperative day (POD) 2 and POD7, a validated survey was used to assess pain and satisfaction. Opioid dispensation records were queried from the Prescription Monitoring Program. Outcomes were compared by univariate methods. RESULTS: There were no demographic differences between the OM (n = 45) and OC (n = 35) cohorts. Total opioids received within 30 days of surgery decreased by 68% in the OM vs OC cohort (median [IQR] 32.5 [7.5-65] vs 100 [30-173] morphine milligram equivalents, P < .001). The median amount of opioids prescribed at discharge for the OM cohort was 0 (IQR:0-0) vs 75 morphine milligram equivalents (IQR:0-112.5) for the OC cohort (P < .001). Pain severity did not differ between cohorts on POD2 (median [IQR]: OM=3/10 [2-5], OC=3.5/10 [2-6]; P = .5) or POD7 (median [IQR]: OM=2/10 [0-3], OC=1/10 [0-3]; P = .8), and POD7 satisfaction with pain management remained high for both cohorts (P = .8). CONCLUSIONS: Our simplified OM protocol decreased total opioid use after robotic urologic surgery by 68% without compromising pain or satisfaction.