Notable Outcomes and Trackable Events after Surgery: Evaluating an Uncomplicated Recovery after Radical Prostatectomy.

PURPOSE: A priority of MUSIC (Michigan Urological Surgery Improvement Collaborative) is to improve patient outcomes after radical prostatectomy. As part of these efforts we developed a novel system that uses unambiguous events to define an uncomplicated 30-day postoperative recovery and compares these outcomes across diverse urology practices. MATERIALS AND METHODS: MUSIC used a consensus approach to develop an uncomplicated recovery pathway comprising a set of precise perioperative events that are reliably measured and collectively reflect resource utilization, technical complications and coordination of care. Events that occurred outside the uncomplicated recovery pathway were considered deviations, including rectal injury, high blood loss, extended length of stay, prolonged drain or catheter placement, catheter replacement, hospital readmission or mortality. For men undergoing radical prostatectomy trained abstractors prospectively recorded clinical and perioperative data in an electronic registry. When a deviation from the NOTES (Notable Outcomes and Trackable Events after Surgery) pathway occurred, precipitating events were described by abstractors and we analyzed the events. RESULTS: From April 2014 through July 2015 a total of 2,245 radical prostatectomies were performed by 100 surgeons in a total of 37 diverse participating MUSIC practices. In the 29 practices in which 10 or more radical prostatectomies were performed during the interval analyzed the risk adjusted deviation rate ranged from 0.0% to 46.1% (p <0.0001). Anastomotic and gastrointestinal events were contributing factors in 50.2% of deviated cases. CONCLUSIONS: The novel NOTES system provides comparative data on unambiguous and actionable short-term outcomes after radical prostatectomy. The observed variation in outcomes across practices suggests opportunities for quality improvement initiatives. Decreasing anastomotic and gastrointestinal events represents a high impact opportunity for initial quality improvement efforts.

Use of Routine Home Health Care and Deviations From an Uncomplicated Recovery Pathway After Radical Prostatectomy.

OBJECTIVE: To evaluate the statistical association between routine home health use after prostatectomy, short-term surgical outcomes, and payments. METHODS: We identified all men who underwent a robotic radical prostatectomy from April 1, 2014, to October 31, 2015, in the Michigan Urological Surgery Improvement Collaborative (MUSIC) with insurance from Medicare or a large commercial payer. We calculated rates of "routine" home care use after prostatectomy by urology practice. We defined "routine" home care as home care initiated within 4 days of discharge among patients discharged without a pelvic drain. We then compared emergency department (ED) visits, readmissions, prolonged catheter use, catheter reinsertion rates, and 90-day episode payments, in unadjusted and using a propensity-adjusted analysis, for those who did and did not receive home care. RESULTS: We identified 647 patients, of whom 13% received routine home health care. At the practice level, the use of routine home care after prostatectomy varied from 0% to 53% (P = .05) (mean: 3.6%, median: 0%). Unadjusted, patients with routine home care had increased ED visits within 16 days (15.5% vs 6.9%, P <.01), similar rates of catheter duration for >16 days (3.6% vs 3.0%, P = .79) and need for catheter replacement (1.2% vs 2.5%, P = .46), and a trend toward decreased readmissions (0% vs 4.1%, P = .06). Only the increased ED visits remained significant in adjusted analyses (P <.01). Home health had an average payment of $1000 per episode. CONCLUSION: Thirteen percent of patients received routine home health care after prostatectomy, without improved outcomes. These findings suggest that patients do not routinely require home health care to improve short-term outcomes following radical prostatectomy, however, the appropriate use of home health care should be evaluated further.

A Retrospective Comparative Outcomes and Cost Analysis of Office Based, Ultrasound Guided Renal Mass Biopsy Performed by Urologists and Standard Hospital Biopsies for Small Renal Masses.

INTRODUCTION: Renal mass biopsy is useful in the evaluation of small renal masses. We have previously reported that office based, ultrasound guided renal mass biopsy is safe, effective and feasible when performed by urologists. This study compares office based, ultrasound guided renal mass biopsy performed by urologists and hospital based renal mass biopsy. METHODS: We retrospectively studied 70 patients who underwent office based, ultrasound guided renal mass biopsy and 155 who underwent hospital based, ultrasound or computerized tomography guided renal mass biopsy for evaluation of a small renal mass (4.0 cm or less) between January 2010 and February 2016. RESULTS: A total of 70 patients underwent office based, ultrasound guided renal mass biopsy. Median age in this group was 69.5 years, median body mass index was 29.5 kg/m2 and 61.4% of the patients (43) were male. A total of 103 patients underwent hospital based, ultrasound guided biopsy. Median age in this group was 68.0 years, median body mass index was 29.3 kg/m2 and 53.4% of the patients (55) were male. Finally, 52 patients underwent hospital based, computerized tomography guided biopsy. Median age in this group was 69 years, median body mass index was 30.1 kg/m2 and 51.9% of the patients (27) were male. Median tumor size was 2.7 cm in patients undergoing office based, ultrasound guided renal mass biopsy, 2.2 cm in those undergoing hospital based, ultrasound guided biopsy and 2.1 cm in those undergoing hospital based, computerized tomography guided biopsy (p = 0.001). Renal cell carcinoma was found in 43 of 70 (61.4%), 74 of 103 (71.8%) and 33 of 52 (63.5%) respective biopsies. Respective diagnostic rates were 81.4% (57 of 70 cases), 88.3% (91 of 103) and 86.5% (45 of 52, p = 0.434). Concordance with surgical pathology was 97.7% (42 of 43 cases), 100% (35 of 35) and 100% (15 of 15), respectively. Complication rates were 4.3% (3 of 70 patients), 13.6% (14 of 103) and 13.5% (7 of 52), respectively (p = 0.096). Cost analysis revealed that when available, office based, ultrasound guided renal mass biopsy provides the health care system a total savings of approximately $46,011 yearly. CONCLUSIONS: Office based, ultrasound guided renal mass biopsy for small renal masses is a safe and efficacious option for select patients, and potentially offers greater convenience and availability as well as decreased health care costs.

Office-based Ultrasound-guided Renal Core Biopsy Is Safe and Efficacious in the Management of Small Renal Masses.

OBJECTIVE: To evaluate the safety and efficacy of ultrasound (US)-guided percutaneous renal mass biopsy (RMB) performed in the office setting by urologists. MATERIALS AND METHODS: This is a retrospective study involving patients who underwent office-based US-guided percutaneous RMB between April 2010 and October 2015. Baseline vital signs and US were performed prior to the procedure. Patients were then observed for 1 hour after the procedure and repeat vital signs and US were performed. Hemodynamically stable patients who did not develop hematoma were discharged. RESULTS: In 108 patients, 70 (64.8%) were male, median age was 69.5 years, and median mass size was 3.3 cm (interquartile range: 2.5-4.6). Biopsy yield was as follows: 72 (66.7%) had renal cell carcinoma, 14 (13.0%) had benign renal parenchyma, 11 (10.2%) had oncocytoma, 6 (5.6%) had angiomyolipoma, 2 (1.9%) had lymphoma, and 3 (2.8%) had other disease. The initial nondiagnostic rate was 14 of 108 (13.0%). There were 28 of 108 (25.9%) patients observed whereas 79 of 108 (73.2%) received surgery or ablative therapy. Final pathology was concordant with biopsy results in 66 of 68 (97.1%) cases. Three patients experienced a grade I Clavien-Dindo surgical complication, all of which were managed conservatively. CONCLUSION: Office-based US-guided RMB is safe and efficacious in the management of appropriately selected SRM. It potentially offers improved dynamic characterization of solid renal mass, greater convenience to patients, as well as cost savings. Further studies are needed to evaluate this promising technique.

One-year monitoring of an oligonucleotide fluorescence in situ hybridization probe panel laboratory-developed test for bladder cancer detection.

BACKGROUND: Previously, we had developed and manufactured an oligonucleotide fluorescence in situ hybridization (OligoFISH) probe panel based on the most clinically sensitive chromosomes found in a reference set of bladder carcinoma cases. The panel was clinically validated for use as a diagnostic and monitoring assay for bladder cancer, reaching 100% correlation with the results of the UroVysion test. After 1 year of using this probe panel, we present here the comparison of cytology, cystoscopy, and pathology findings to the OligoFISH probe panel results to calculate its clinical performance. MATERIALS AND METHODS: In order to calculate clinical performance, we compared the OligoFISH results to the cytology and cystoscopy/pathology findings for 147 initial diagnoses and 399 recurrence monitorings. Finally, we compared clinical performance to published values for the UroVysion test, including both low- and high-grade tumors. RESULTS: Chromosomes 3, 6, 7, and 20 were highly involved in bladder carcinoma aneuploidy. At the initial diagnosis, we obtained 90.5% (95% confidence interval [CI]: 84.5%-94.7%) accuracy, 96.8% sensitivity (95% CI: 91.0%-99.3%), 79.2% specificity (95% CI: 65.9%-87.8%), 89.2% positive predictive value (PPV; 95% CI: 81.5%-94.5%), and 93.3% negative predictive value (NPV; 95% CI: 81.7%-97.3%). When monitoring for recurrence, we obtained 85.2% accuracy (95% CI: 81.3%-88.5%), 82.0% sensitivity (95% CI: 76.0%-87.1%), 88.4% specificity (95% CI: 83.2%-92.5%), 87.7% PPV (95% CI: 82.1%-92.0%), and 83.0% NPV (95% CI: 77.3%-87.8%). When looking at low- and high-grade tumors, the test showed 100% sensitivity for high-grade tumors (95% CI: 92.5%-100%) and 87.5% sensitivity (95% CI: 68.8%-95.5%) for low-grade tumors. All the clinical parameters for the OligoFISH panel were higher than the UroVysion test's published performance. We found significantly higher clinical sensitivity and NPV at initial diagnosis and significantly higher specificity and PPV for recurrence. CONCLUSION: The OligoFISH probe panel is a fast, easy, and reproducible test for bladder cancer diagnosis and monitoring, with excellent clinical performance and utility.