Understanding the Prodromal Period of Necrotizing Soft Tissue Infections of the Genitalia (Fournier's Gangrene) and the Incidence, Duration, and Risk Factors Associated With Potential Missed Opportunities for an Earlier Diagnosis: A Population-based Longitudinal Study.

PURPOSE: The purpose of this paper was to investigate patterns of health care utilization leading up to diagnosis of necrotizing soft tissue infections of the genitalia and to identify risk factors associated with potential diagnostic delay. MATERIALS AND METHODS: IBM MarketScan Research Databases (2001-2020) were used to identify index cases of necrotizing soft tissue infections of the genitalia. We identified health care visits for symptomatically similar diagnoses (eg, penile swelling, cellulitis) that occurred prior to necrotizing soft tissue infections of the genitalia diagnosis. A change-point analysis identified the window before diagnosis where diagnostic opportunities first appeared. A simulation model estimated the likelihood symptomatically similar diagnosis visits represented a missed opportunity for earlier diagnosis. Patient and provider characteristics were evaluated for their associations with delay. RESULTS: We identified 8,098 patients with necrotizing soft tissue infections of the genitalia, in which 4,032 (50%) had a symptomatically similar diagnosis visit in the 21-day diagnostic window, most commonly for "non-infectious urologic abnormalities" (eg, genital swelling; 64%): 46% received antibiotics; 16% saw a urologist. Models estimated that 5,096 of the symptomatically similar diagnosis visits (63%) represented diagnostic delay (mean duration 6.2 days; mean missed opportunities 1.8). Risk factors for delay included urinary tract infection history (OR 2.1) and morbid obesity (OR 1.6). Visits to more than 1 health care provider/location in a 24-hour period significantly decreased delay risk. CONCLUSIONS: Nearly 50% of insured patients who undergo debridement for, or die from, necrotizing soft tissue infections of the genitalia will present to a medical provider with a symptomatically similar diagnosis suggestive of early disease development. Many of these visits likely represent diagnostic delay. Efforts to minimize logistic and cognitive biases in this rare condition may lead to improved outcomes if they lead to earlier interventions.

Immediate gemcitabine bladder instillation following bladder closure during robotic-assisted radical nephroureterectomy: a multi-institutional report of feasibility and initial outcomes.

Background: Bladder recurrence after radical nephroureterectomy (RNU) is common and randomized data supports utilization of prophylactic intravesical mitomycin to reduce recurrence. Recently, gemcitabine has been shown to be safe and effective at reducing recurrence following transurethral resection of bladder tumors. We sought to evaluate the safety and efficacy of a single, intraoperative gemcitabine instillation immediately following bladder cuff closure during RNU, and to compare outcomes with non-gemcitabine intravesical chemotherapy agents. Methods: We retrospectively reviewed all patients from two high volume centers who underwent robotic-assisted RNU between 2016-2020 and received either 2 g intravesical gemcitabine immediately following bladder cuff closure or non-gemcitabine intravesical chemotherapies [40 mg mitomycin C (MMC) or 50 mg doxorubicin] at the beginning of the procedure. Clinicopathologic factors were compared between cohorts. Bladder recurrence rates were evaluated using the Kaplan-Meier method and log-rank test. Results: During RNU, 24 patients received gemcitabine and 31 patients received non-gemcitabine chemotherapy. In total, 35% (19/55) of patients experienced a bladder cancer recurrence. There was no significant difference in estimated bladder recurrence-free survival (bRFS) between gemcitabine and non-gemcitabine patient cohorts (P=0.64). By 12 months post-surgery, 25% of patients had experienced bladder recurrence. The estimated 1-year bladder RFS survival was 73% for gemcitabine and 76% for non-gemcitabine chemotherapy. Overall survival and cancer-specific survival did not differ between cohorts. No adverse events potentially attributable to the use of gemcitabine were noted within 30 days postoperatively. Conclusions: Gemcitabine instilled immediately following bladder cuff closure during RNU has similar bRFS rates compared to established chemotherapy agents instilled at the start of surgery.

Favorable Outcomes With Early Component Separation, Primary Closure of Necrotizing Soft Tissue Infections of the Genitalia (Fournier's Gangrene) Debridement Wound Defects.

OBJECTIVE: To evaluate the efficacy of early necrotizing soft-tissue infections of the genitalia (NSTIG) component separation, primary wound closure (CSC). We hypothesized that early CSC would be safe, decrease the need for split-thickness skin grafting (STSG) and decrease wound convalescence time. MATERIALS/METHODS: Management of consecutive NSTIG patients from a single institution were evaluated. Three cohorts emerged: 1) those managed/closed by a reconstructive urologist (URO) using CSC principles (wide genital tissue mobilization with primary closure, when possible, +/- STSG), 2) those managed/closed by the general surgery/burn service, and 3) those managed conservatively with secondary closure. Total NSTIG anatomic extent (AE) was determined by assessing involvement of the penis, scrotum, perineum and suprapubic region, and ranged from 1 (<50% involvement of one area) to 8 (>50% involvement in all 4 areas). RESULTS: Of 84 FG patients meeting study criteria, 48 (57%) were closed primarily and 36 were left to heal by secondary intention. AE was greatest in patients managed by general surgery/burn service (4.5 ± 1.5), followed by URO (2.7 ± 1.8) and secondary intention cases (1.3 ± 0.5). Secondary procedure rates were similar between closure/non-closure cohorts (6.3% v 11%; P = 0.67). STSG use was predicted by wound size (though not time to closure)-specifically with suprapubic and/or penile wounds of >50% involvement. Wound convalescence time decreased by 64% when wounds were closed versus left open, controlling for AE. CONCLUSION: Early, same-admission primary closure of stable NSTIG wounds is safe and decreases wound convalescence time by over 60%.

30-day all-cause hospital readmission after cystectomy: no worse for rural Medicare residents.

OBJECTIVE: To evaluate rural/urban disparities in 30-day all-cause hospital admission after cystectomy. MATERIALS AND METHODS: We used the SEER-Medicare database to identify all Medicare beneficiaries who underwent radical cystectomy (ICD-9 codes 57.7, 57.71, 57.79, and 68.8) between the years 1991 and 2009, yielding a total sample size of 15,572. Our primary outcome was 30-day hospital readmission rate. Rural Urban Continuum Codes were used to designate county-level rural status based on patient residence. Location of surgery was not a variable considered in this analysis. A multivariable regression model was constructed with demographic and clinical variables as covariates. RESULTS: A total of 2,003 rural and 2,904 urban patients (31.1% vs. 31.8%, P = 0.33) were readmitted within 30 days of discharge. In the multivariable model, older age, unmarried status, lower socioeconomic status, higher Charlson comorbidity score, shorter index admission hospital stay, and discharge to a skilled nursing facility were associated with higher odds of readmission. The variables for gender, race, cancer stage, tumor grade, and type of urinary diversion were not significant. The odds ratio for readmission was not significant for patients from rural counties in the final model. CONCLUSIONS: Rural Medicare residents were not at higher risk for 30-day all-cause hospital readmission after cystectomy after accounting for various demographic and clinical variables.