Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery.

PURPOSE: We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery. MATERIALS AND METHODS: The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications. RESULTS: A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively. CONCLUSIONS: Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Contemporary treatment patterns and outcomes of sarcomatoid bladder cancer.

PURPOSE: To characterize the treatment patterns and survival outcomes of sarcomatoid bladder cancer, a rare urothelial variant histology using a large population level cancer database. METHODS: The National Cancer Database was queried for all cases of sarcomatoid bladder cancer using International Classification of Disease-O-3 morphologic code 8122 between 2004 and 2014. Primary outcome was overall survival. RESULTS: A total of 489 patients met our inclusion criteria and were included in our analysis. Average age at diagnosis was 70.4 years. The majority of the population was male (61.8%) and Caucasian (92.2%). Tumor characteristics included 23.7% cT1, 41.1% cT2 and 15.3% cT3 or above. Median overall survival was 18.4 months (95% CI 13.3-23.6). On multivariate Cox proportional analysis, radical cystectomy alone or with multimodal therapy (chemotherapy or radiotherapy) resulted in a statistically significant reduction in the risk of death as compared to bladder preservation surgery alone. Survival in the radical cystectomy group did not differ between radical cystectomy alone and those receiving either neoadjuvant or adjuvant chemotherapy. CONCLUSIONS: Sarcomatoid bladder cancer has poor prognosis with 18.4-month median overall survival. While our data suggest that aggressive treatment improves outcomes, the role of multimodal therapy is unclear. Future study should continue to focus on multi-institutional collaboration to determine the most effective therapy.

Risk Factors for Priapism Readmission.

INTRODUCTION: Priapism is a urologic emergency with a tendency to recur in some patients. The frequency of, time to, and risk factors for priapism recurrence have not been well characterized. AIM: To identify predictors of priapism readmission. METHODS: We used the New York Statewide Planning and Research Cooperative System database to identify patients presenting to emergency departments with priapism from 2005 through 2014. Patients were tracked up to 12 months after initial presentation. Proportional hazards regression was used to identify risk factors for priapism readmission. MAIN OUTCOME MEASURES: Readmissions for priapism. RESULTS: The analytic cohort included 3,372 men with a diagnosis of priapism. The average age at first presentation was 39 ± 18 years and 40% were black. Within 1 year, 24% of patients were readmitted for recurrent priapism, 68% of whom were readmitted within 60 days. On multivariate analysis, sickle cell disease (hazard ratio [HR] = 2.5, 95% CI = 2.0-3.0), drug abuse or psychiatric disease (HR = 1.9, 95% CI = 1.6-2.2), erectile dysfunction history (HR = 1.9, 95% CI = 1.5-2.3), other than commercial medical insurance (HR = 1.2, 95% CI = 1.0-1.4), and inpatient admission for initial priapism event (HR = 0.5, 95% CI = 0.4-0.6) were significant risk factors for readmission. CONCLUSION: Nearly one fourth of patients with priapism were readmitted for recurrent priapism within 1 year of initial presentation. Most readmissions were within 60 days. Future research should focus on strategies to decrease recurrences in high-risk patients.

Perioperative blood transfusion predicts short term morbidity after nephrectomy.

INTRODUCTION: To assess 30-day morbidity and mortality following partial nephrectomy (PN) and radical nephrectomy (RN) with relation to the administration of perioperative blood transfusions PBT). MATERIALS AND METHODS: The National Surgical Quality Improvement Program was queried for patients with malignant renal tumors (International Classification of Diseases Ninth Revision codes 189-189.2) who underwent RN (Current Procedure Terminology codes 50220, 50225, 50230, 50234, 50236, 50545, 50546, 50548) or PN (50240, 50543) between 2005-2013. Patients were stratified by transfusion status and assessed for postoperative outcomes both separately and in composite, including morbidity, mortality, infectious complications, and pulmonary complications. Univariate and multivariate analyses were performed to identify significant independent predictors of these composite outcomes. RESULTS: The overall transfusion rates were 15.8% and 8.2% for RN and PN, respectively. On multivariate analysis, PBT was associated with increased morbidity (RN: OR 2.147, 95% CI 1.687-2.733; PN: OR 2.081, 95% CI 1.434-3.022), mortality (RN: OR 2.308, 95% CI 1.159-4.598; PN: OR 5.166, 95% CI 1.207-22.12), infectious complications (RN: OR 1.656, 95% CI 1.151-2.383; PN: OR 1.945, 95% CI 1.128-3.354) and pulmonary complications (RN: OR 3.040, 95% CI 2.125-4.349; OR 3.771, 95% CI 2.108-6.746). CONCLUSIONS: For patients undergoing RN or PN there is a significant association between receipt of PBT and 30-day postoperative outcomes, specifically overall morbidity, mortality, infectious complications, and pulmonary complications. The mechanism that underlies these effects has not been elucidated, but it most likely involves immunomodulation and acute lung injury. Future research should focus on formulating comprehensive transfusion guidelines for oncologic-related nephrectomies.

Perioperative blood transfusion in radical cystectomy: Analysis of the National Surgical Quality Improvement Program database.

OBJECTIVES: To determine whether perioperative blood transfusion is associated with worse 30-day postoperative outcomes in radical cystectomy patients. METHODS: Utilizing the National Surgical Quality Improvement Program database, we identified 2934 patients diagnosed with bladder cancer (International Classification of Diseases Ninth Revision codes 188-188.9) who underwent radical cystectomy (Current Procedure Terminology codes 51570, 51575, 51580, 51585, 51590, 51595, 51596) between 2005 and 2013. Patients were stratified by transfusion status and assessed based on four composite postoperative outcomes: morbidity, surgical site infection, mortality and readmission. Multivariate regression models were used to determine significant independent predictors of the composite outcomes. RESULTS: Overall, 40.1% of patients received a transfusion, and there were significant differences in baseline variables such as age, sex, body mass index, smoking history and comorbidities. Transfusion was associated with increased morbidity, surgical site infection, readmission, operative time and length of stay on unadjusted analyses. On multivariate regression, transfusion was associated with increased morbidity (OR 1.361, 95% CI 1.131-1.638) and surgical site infection (OR 1.371, 95% CI 1.070-1.757). CONCLUSIONS: Perioperative blood transfusion is associated with increased risk of postoperative infection and morbidity. Previous work in this area has focused on negative long-term oncological outcomes, but this is the first study to examine short-term postoperative outcomes. Future research should focus on the immunosuppressive mechanism of perioperative blood transfusion and on restrictive transfusion guidelines for oncology patients.

Testosterone replacement therapy and erectile dysfunction.

Testosterone (T) deficiency and erectile dysfunction (ED) are independently functionally and socially impairing, and their concurrence in men can be challenging to treat. Successful management requires an understanding of the mechanisms through which T underlies normal erectile function. While the literature elucidating some of these mechanisms is vast (e.g., androgen regulation of the activity of nitric oxygen synthase and phosphodiesterase type 5) for others it is scarce (e.g., catalysts of castration-induced corporal fibrosis). The randomized controlled trial data for the efficacy of T replacement as mono- or combination therapy to treat ED has been conflicting. Positive results were frequently not clinically meaningful. Meta-analyses have been helpful in illuminating trends that seem to be promising. Consensus is still lacking in several areas, such as the threshold of low T severity for which replacement therapy is most beneficial; the timing for initiating combination therapy; and the duration of treatment.

Beyond Curvature: Prevalence and Characteristics of Penile Volume-Loss Deformities in Men With Peyronie's Disease.

INTRODUCTION: Non-curvature penile deformities associated with loss of erect penile volume are often overlooked and have not been thoroughly investigated. AIM: To describe the prevalence and functional impact of penile volume-loss deformities in our cohort of men with Peyronie's disease (PD). METHODS: We retrospectively examined medical records of patients with PD consecutively evaluated by a specialized urologist from December 2012 to June 2016. We excluded patients with prior surgical correction of PD, prior penile prosthesis, and inadequate erection during office examination. All patients underwent deformity assessment of the erect penis after intracavernosal injection. The assessment included measurement of penile curvature; evaluation for hourglass deformities, indentations, and distal tapering; and application of axial force to assess for penile buckling. Prior to the deformity assessment, each patient completed the Male Sexual Health Questionnaire and was asked if he experienced psychological distress and functional impairment related to his penile deformity. MAIN OUTCOME MEASURE: The primary clinical parameters that we evaluated were presence or absence of axial instability, functional impairment, psychological distress, penile pain, erectile dysfunction, ejaculatory dysfunction, sexual dissatisfaction, decreased sexual activity, and decreased sexual desire. RESULTS: 128 patients met criteria for inclusion. 83 patients (65%) had volume-loss deformities. Unilateral indentations, hourglass deformities, and distal tapering were present in 50 (39%), 30 (23%), and 16 (13%) patients, respectively. Penile curvature <10° degrees was present in 115 patients (90%). After controlling for angle of curvature, patients with volume-loss deformities had significantly higher rates of axial instability (odds ratio [OR] = 3.5, P = .01) and psychological distress (OR = 2.6, P = .03), as well as decreased sexual activity (OR = 2.7, P = .02), than patients with non-volume-loss deformities. CONCLUSION: Volume-loss penile deformities are highly prevalent in men with PD. These deformities are associated with penile axial instability and psychological distress, which may contribute to decreased frequency of sexual activity. Margolin EJ, Pagano MJ, Aisen CM, et al. Beyond curvature: prevalence and characteristics of penile volume-loss deformities in men with Peyronie's disease. Sex Med 2018;6:309-315.

Timing and Predictors of Early Urologic and Infectious Complications After Renal Transplant: An Analysis of a New York Statewide Database.

OBJECTIVES: The most common complications after renal transplant are urologic and are a cause of significant morbidity in a vulnerable population. We sought to characterize the timing and predictors of urologic complications after renal transplant using a statewide database. MATERIALS AND METHODS: We queried the New York Statewide Planning and Research Cooperative System database to identify patients who underwent renal transplant from 2005 to 2013. Postoperative complications included hydronephrosis, ureteral stricture, vesicoureteral reflux, nephrolithiasis, and urinary tract infections. Cox proportional hazards model was used to assess independent predictors of urologic complications. RESULTS: In total, 9038 patients were included in the analyses. Urologic complications occurred in 11.3% of patients and included hydronephrosis (12.0%), nephrolithiasis (2.8%), ureteral stricture (2.4%), and vesicoureteral reflux (1.5%). We found that 23% experienced at least one urinary tract infection. On multivariate analysis, predictors of urologic complications included medicare insurance, hypertension, and prior urinary tract infection. Graft recipients from living donors were less likely to experience urologic complications than deceased-donor kidney recipients (P < .001). CONCLUSIONS: Urologic complications occur in a significant proportion of renal transplants. Further study is needed to identify risk factors for complications after renal transplantation to decrease morbidity in this vulnerable population.

Collecting duct carcinoma of the kidney: Disease characteristics and treatment outcomes from the National Cancer Database.

OBJECTIVE: To use a large population-level database to assess survival outcomes for collecting duct renal cell carcinoma (CDRCC). MATERIALS AND METHODS: The National Cancer Database was queried for all cases of CDRCC and clear cell renal cell carcinoma (CCRCC) from 2004 to 2013. After removing patients with other cancer diagnoses, the analytic cohort was composed of 201,686 CCRCC and 577 CDRCC cases. Kaplan-Meier and cox proportional hazards analysis were employed to model survival. RESULTS: Compared to CCRCC, patients with CDRCC presented with higher grade and stage, node positive, and metastatic disease (70.7% vs. 30.0% with metastasis; P<0.001). Overall median survival for CDRCC was 13.2 months (95% CI: 11.0-15.5) compared to the 122.5 months (95% CI: 121.0-123.9) for CCRCC. On multivariate analysis of the CDRCC cohort, increasing T stage, high-grade disease, and metastasis were predictors of mortality. Of 184 patients with metastatic CDRCC, 113 underwent cytoreductive nephrectomy (CNx) whereas the rest were treated with chemo/radiation or observed. Survival outcomes were improved in patients who received both CNx with chemo/radiation compared to CNx alone (hazard ratio = 0.51, 95% CI: 0.32-0.79) or chemo/radiation alone (hazard ratio = 0.57, 95% CI: 0.37-0.89) on multivariate analysis. CONCLUSION: CDRCC is an aggressive subtype of renal cell carcinoma. Median survival is 13 months after diagnosis, drastically lower than for CCRCC. More than 70% of patients have metastatic disease at diagnosis. Chemo/radiation in addition to CNx is associated with a survival benefit over single mode therapy.

What's in a Number? Examining the Effect of a Dedicated Research Year on H-Index and Fellowship Decision-making.

OBJECTIVE: To assess the effect of a dedicated research year on the h-indices of residents and the pursuit of fellowship within a heterogeneous group of urology programs. We previously demonstrated that urology residents with a dedicated research year produce more than 2 times the number of publications than their counterparts in 5-year programs. However, we did not give consideration to the impact of these publications. MATERIALS AND METHODS: We obtained information on the publication output and pursuit of fellowship of graduates from the New York Section urology residency programs from 2009 to 2013. Data on peer-reviewed publications were obtained by PubMed query and h-index was documented from the Scopus database. RESULTS: During the 5-year study period, 148 individuals (116 M, 32 F) graduated from New York Section urology programs. The mean h-index was 4.6 for residents in 5-year programs compared with 8.1 for those in 6-year programs (P < .001). Residents with a dedicated research year were more likely to pursue fellowship training (79.3% vs 58.8%, P = .023) with no difference in the pursuit of accredited fellowship programs. Those residents who went on to fellowship training had a significantly higher h-index (6.2 vs 3.6, P = .001). CONCLUSION: Urology residents with a dedicated research year have almost 2 times the h-indices of their counterparts. Residents who pursue fellowship training also have higher h-indices. Residents who completed a dedicated research year were more likely to pursue fellowship training, although the accreditation status of these programs was variable.

Micropapillary Bladder Cancer: Insights from the National Cancer Database.

Introduction: Micropapillary bladder cancer (MPBC) is a variant histology of urothelial carcinoma (UC) that is associated with poor outcomes however given its rarity, little is known outside of institutional reports. We sought to use a population-level cancer database to assess survival outcomes in patients treated with surgery, radiation therapy and/or chemotherapy. Materials and Methods: The National Cancer Database (NCDB) was queried for all cases of MPBC and UC using International Classification of Disease-O-3 morphologic codes between 2004-2014. Primary outcome was survival outcomes stratified by treatment modality. Treatments included radical cystectomy (RC) with or without neoadjuvant chemotherapy (NAC) or adjuvant chemotherapy (AC). Results: Overall 869 patients with MPBC and 389,603 patients with UC met the inclusion criteria. Median age of the MPBC cohort was 69.9 years (58.9-80.9) with the majority of the cohort presenting with high-grade (89.3%) and muscle invasive or locally advanced disease (47.6%). For cT1 MPBC, outcomes of RC and BPS were not statistically different. For≥cT2 disease, NAC showed a survival benefit compared with RC alone for UC but not for MPBC. On multivariable analysis, MPBC histology independently predicted worse increased risk of death. On subanalysis of the MPBC RC patients, NAC did not improve survival outcomes compared with RC alone. Conclusions: Neoadjuvant chemotherapy utilization and early cystectomy did not show a survival benefit in patients with MPBC. This histology independently predicts decreased survival and prognosis is poor regardless of treatment modality. Further research should focus on developing better treatment options for this rare disease.

Utilization of Preoperative Laboratory Testing for Low-risk, Ambulatory Urologic Procedures.

OBJECTIVE: To determine the clinical significance of preoperative laboratory testing for low-risk ambulatory urologic procedures. MATERIALS AND METHODS: The National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2013 was queried for urethral sling procedures, cystoscopic procedures, and scrotal procedures. Multivariate analysis was used to assess for independent predictors of preoperative laboratory testing utilization and for postoperative complications. RESULTS: Overall, 7378 procedures were identified, with 73.9% undergoing 1 or more laboratory tests, including 37.9% who had no comorbidities. Patients who were tested were older, had a higher American Society of Anesthesiologists class, and had more preoperative comorbidities. Of these procedures, only 2.9% resulted in any complication. Most laboratory tests were drawn within 1 week of the procedure. On multivariate analysis of testing utilization, increasing age and medical comorbidities were predictive of testing. Multivariate analysis of postoperative outcomes showed that abnormal test laboratory findings were not predictive of postoperative complications in those with and without NSQIP-defined comorbidities. CONCLUSION: Abnormal preoperative laboratory testing was not a significant independent predictor of postoperative complications. Almost 40% of patients received preoperative testing despite having no NSQIP-detected comorbid conditions. A multidisciplinary approach should be taken to define procedures in which preoperative laboratory testing may be eliminated.