Short-term complications associated with the use of transvaginal mesh in pelvic floor reconstructive surgery: Results from a multi-institutional prospectively maintained dataset.

AIMS: Vaginal reconstructive surgery can be performed with or without mesh. We sought to determine comparative rates of perioperative complications of native tissue versus vaginal mesh repairs for pelvic organ prolapse. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database, we concatenated surgical data from vaginal procedures for prolapse repair, including anterior and posterior colporrhaphy, paravaginal defect repair, enterocele repair, and vaginal colpopexy using Current Procedural Terminology (CPT) coding. We stratified this data by the modifier associated with mesh usage at the time of the procedure. We then compared 30-day perioperative outcomes, postoperative complications (bleeding, infection, etc), and readmission rates between women with and without mesh-based repairs. RESULTS: We identified 10 657 vaginal reconstructive procedures without mesh and 959 mesh-based repairs from 2009 through 2013. Patients undergoing mesh repair were more likely to experience at least one complication than native tissue repair (9.28% vs 6.15%, P < 0.001), with the overall complication rate also being higher in the mesh group (11.37% vs 9.39%, P = 0.03). Procedures with mesh had a higher rate of perioperative bleeding requiring transfusion than native tissue repair (2.3% vs 0.49%, P < 0.001), and organ surgical site infection (SSI) (0.52% vs 0.17%, P = 0.02). There were no significant differences in rates of readmission, superficial, or deep SSIs, pneumonia, urinary tract infection, sepsis, or renal failure. CONCLUSIONS: The use of vaginal mesh for pelvic organ prolapse repair appears to result in a higher rate of perioperative complications than native tissue repair. Patients undergoing these procedures should be counselled preoperatively concerning these risks.

Cost-Effective and Readily Replicable Surgical Simulation Model Improves Trainee Performance in Benchtop Robotic Urethrovesical Anastomosis.

INTRODUCTION: Our objective was to develop a simple, cost-effective and reusable model for urethrovesical anastomosis for robotic-assisted radical prostatectomy and evaluate its impact on fundamental surgical skills and confidence of urology trainees. METHODS: A model for the bladder, urethra and bony pelvis was created from materials easily purchased online. Each participant performed several trials of urethrovesical anastomosis using the da Vinci Si® surgical system. Pre-task confidence was assessed prior to each attempt. Two blinded researchers measured the following outcomes: time-to-anastomosis, number of suture throws, perpendicular needle entry and atraumatic needle driving. Integrity of the anastomosis was estimated by gravity filling and measuring pressure at which leakage occurred. These outcomes were translated into an independently validated Prostatectomy Assessment Competency Evaluation score. RESULTS: The model took 2 hours to create and total cost was 64 U.S. dollars. Twenty-one residents enrolled and demonstrated significant improvement in time-to-anastomosis, perpendicular needle driving, anastomotic pressure and total Prostatectomy Assessment Competency Evaluation score between the first and third trial. Pre-task confidence was measured on a Likert scale (1-5) and improved significantly over the 3 trials (Likert scale of 1.8, 2.8 and 3.3). CONCLUSIONS: We developed a cost-effective model of urethrovesical anastomosis that does not require the use of a 3D printer. This study demonstrates significant improvement of fundamental surgical skills and validated surgical assessment score for urology trainees over several trials. Our model shows potential for increasing accessibility of robotic training models for urological education. Additional investigation will be required to further assess the utility and validity of this model.

Survival outcomes following radical cystectomy in patients with prior pelvic radiation for prostate cancer: A matched cohort analysis.

OBJECTIVES: To determine the impact of prior pelvic radiation therapy (XRT) on outcomes following radical cystectomy (RC) for bladder cancer. MATERIALS AND METHODS: We performed a retrospective review comparing patients with bladder cancer requiring RC and prior history of XRT for prostate cancer to those undergoing RC without XRT history at our institution from 2011-2018. Propensity score matching was performed with the following variables: age, chronic kidney disease, nutritional deficiency, neoadjuvant chemotherapy use, Charlson comorbidity index, surgical approach, urinary diversion type, and pathologic T-stage. Perioperative, pathologic and oncologic outcomes were analyzed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Categorical variables were assessed utilizing the Pearson Chi Square Test, and continuous variables with the Wilcoxon rank-sum test. The Kaplan-Meier method with stratified-log rank was used to compare survival outcomes. Multivariable Cox proportional hazards models were utilized to identify predictors of overall and recurrence free survival. RESULTS: 227 patients were included, of which 47 had radiotherapy for prostate cancer. 47% of patients in the radiation cohort received external beam radiation therapy, 47% received brachytherapy and 7% received both. There were no differences in recurrence-free survival (P = 0.82) or overall survival (P = 0.25). Statistically significant differences in perioperative or postoperative outcomes such as 90-day complication, readmission, mortality rates, or ureteroenteric anastomotic stricture rates were not found. Rates of node-positive disease, median lymph node yield, positive surgical margin rates, lymphovascular invasion, or variant histology were not significantly different between cohorts. CONCLUSIONS: After matching for T-stage and other clinical variables, history of pelvic XRT for prostate cancer in patients who later required RC for bladder cancer, was not associated with an increased rate of perioperative complications or an independent predictor of RFS or OS.

Comparison of Oncologic Outcomes Following Open and Robotic-assisted Radical Cystectomy with both Extracorporeal and Intracorporeal Urinary Diversion.

OBJECTIVES: To compare oncologic endpoints between open radical cystectomy (ORC) and robotic-assisted radical cystectomy with extracorporeal urinary diversion (eRARC) or intracorporeal urinary diversion (iRARC). MATERIALS AND METHODS: Retrospective review of all patients undergoing curative-intent radical cystectomy with urinary diversion for urothelial bladder cancer at a single-institution from 2010-2018. Primary outcomes included recurrence location and rates, recurrence-free (RFS) and overall survival (OS). Survival estimates were obtained using the Kaplan-Meier method and compared using log-rank analysis. Cox proportional-hazards model was used to identify predictors of survival. RESULTS: 265, 366 and 285 patients underwent ORC, eRARC, and iRARC, respectively (n = 916). Median follow-up was 52, 40 and 37 months for ORC, eRARC and iRARC, respectively (P < 0.001). Ileal conduit was more commonly performed in iRARC (85%, P < 0.001). Neobladder rates did not vary. Neoadjuvant (p=0.4) or adjuvant therapy use (P = 0.36), pT-stage (P = 0.28) or pN-stage (P = 0.1) did not differ. Positive soft tissue margin rates were higher in ORC (7.2%-ORC, 3.6%-eRARC, 3.2%-iRARC, P = 0.041). Differences in recurrence rates or location were not observed. Surgical approach was not associated with any survival endpoint on proportional-hazards or Kaplan-Meier analysis. Hazard ratios and 95% CI for RFS were 1 (0.72-14) and 0.93 (0.66-1.3) for eRARC and iRARC, respectively, when compared to ORC as the referent. CONCLUSION: These findings from a large, single-institution in conjunction with randomized-controlled trial data suggest that RARC does not compromise perioperative or long-term oncologic outcomes when compared to ORC.

Performance of Adult Pyeloplasty Relative to Endourological Management in the Era of Robotic Surgery: Data from the Nationwide Inpatient Sample.

INTRODUCTION: Reports of robot-assisted pyeloplasty have increased. However, it is unclear if this change is due to increased diagnosis of adult ureteropelvic junction obstruction, a shift in management based on presumed efficacy, a desire to maximize robot use or some combination thereof. Therefore, we acquired and analyzed data on a national scale to determine the incidence of interventions to correct ureteropelvic junction obstruction in adults and to characterize trends in procedure selection. METHODS: Patients older than 18 years with ICD-9 procedure codes 55.87 (pyeloplasty) and 55.11 (endopyelotomy) were included in the study, with attention to those designated laparoscopic robotic assistance (17.42). Data were collected for the period from January 2000 through December 2012, and weighted to a national average using Nationwide Inpatient Sample guidelines. RESULTS: A total of 47,992 pyeloplasties were identified. Pyeloplasty rates exhibited a significant increase during this period [F(1,11)=41.38, p <0.01] and endopyelotomy rates exhibited a significant decrease [F(1,11)=64.7, p <0.01]. A higher percentage of pyeloplasties were performed robotically in 2012 vs 2009 (54% vs 44%, p <0.010). CONCLUSIONS: Rates of pyeloplasty appear to be increasing at the expense of endopyelotomy. The percentage of pyeloplasty cases performed robotically is increasing but it is unclear if this is due to superior results or a need for increased robot use.

NSQIP® Indexed Complications Following Transurethral Bladder Tumor Resection and Contemporary Financial Implications.

INTRODUCTION: We determined the incidence of NSQIP (National Surgical Quality Improvement Project) indexed complications by tumor size and investigated the related financial implications based on contemporary reimbursement schedules. METHODS: Transurethral bladder tumor resection procedures performed from 2010 to 2012 were identified and stratified by size specific CPT coding. Preoperative characteristics, surgical parameters and 30-day perioperative outcomes were compared using chi-square analysis and Student's t-test. Financial data for all inpatient transurethral bladder tumor resections performed during the most recent fiscal year at our institution were collected and analyzed, and a comparison was made using up-to-date Medicare reimbursement schedules. RESULTS: We identified 8,116 cases, including 3,533 coded as small (43.3%), 2,734 medium (33.5%) and 1,849 large (22.6%). Large resections required longer operative time (small-25.8 minutes, medium-33.0 minutes, large-49.0 minutes, p <0.01) and length of stay (small-0.67 days, medium-1.1 days, large-1.9 days, p <0.006), and had higher rates of transfusion (small-0.74%, medium-1.5%, large-3.7%, p <0.001), sepsis (small-0.23%, medium-0.44%, large-0.92%, p <0.05), renal insufficiency (small-0.17%, medium-0.15%, large-0.60%, p <0.01) and 30-day mortality (small-0.2%, medium-1%, large-1.8%, p <0.05) independent of preoperative parameters. Large resections were also associated with higher rates of 30-day readmission (small-4.3%, medium-6.3%, large-9.4%, p <0.001) and reoperation (small-2.1%, medium-2.7%, large-4.5%, p <0.001). Institutional data demonstrate that the most common Diagnosis Related Group classification results in an operating loss when treating Medicare beneficiaries. CONCLUSIONS: Urologist selected coding directly correlates with NSQIP indexed postoperative complications. Many cases of transurethral bladder tumor resection with associated complications may result in financial loss for the performing institutions. Efforts to improve quality of care and reimbursement seem warranted.

Robot-assisted ureteral reconstruction - current status and future directions.

Robotic surgery in the treatment in certain urological diseases has become a mainstay. With the increasing use of the robotic platform, some surgeries which were historically performed open have transitioned to a minimally invasive technique. Recently, the robotic approach has become more utilized for ureteral reconstruction. In this article, the authors review the surgical techniques for a number of major ureteral reconstuctive surgeries and briefly discuss the outcomes reported in the literature.

The Effect of Resident Involvement in Pelvic Prolapse Surgery: A Retrospective Study From a Nationwide Inpatient Sample.

OBJECTIVE: The primary aim of this study was to assess the effect of resident involvement on perioperative complication rates in pelvic organ prolapse surgery using the National Surgical Quality Improvement database. METHODS: All pelvic organ prolapse operations from 2006 to 2012 were identified and dichotomized by resident participation. Preoperative characteristics and 30-day perioperative outcomes were compared using χ and Student t test. To control for nonrandomization of cases, propensity scores representing the probability of resident involvement as a function of a case's comorbidities were calculated. They were then divided into quartiles, and because of equal probabilities for the first and second quartiles, 3 groups were created (Q1/2, Q3, and Q4), followed by substratification and analysis. As a control, complications of transurethral resection of prostate and nephrectomy were dichotomized by resident involvement. RESULTS: We identified 2637 cases. Resident involvement was associated with increased postoperative urinary tract infections, perioperative complications, and procedure length. After stratification by propensity scoring, the following unique findings occurred in each group: in the first group, resident involvement was associated with increased rates of readmission, pulmonary embolism, and sepsis; in the second and third groups, resident involvement was associated with increased rates of superficial surgical site infection. Resident involvement in nephrectomy observed increased perioperative complications and procedural length. In prostate resection, increased procedure lengths and decreased postoperative length of stay were observed. CONCLUSIONS: Resident involvement in pelvic organ prolapse surgery was associated with an increased risk of adverse outcomes. A similar effect was seen with nephrectomy but not with a more simple endoscopic urologic procedure.