Population-based trends in urinary diversion among patients undergoing radical cystectomy for bladder cancer.

UNLABELLED: What's known on the subject? and what does the study add?: Variations in the type of urinary diversion exist for patients undergoing radical cystectomy. Although its use has been increasing from 2001 to 2008, patients who are older, female, and primary insured by Medicaid are less likely to receive continent diversions. Furthermore, patients treated surgically at high-volume and teaching hospitals are more likely to receive continent diversions. OBJECTIVE: To describe the contemporary trends in urinary diversion among patients undergoing radical cystectomy (RC) for bladder cancer; and elucidate whether socioeconomic disparities persist in the type of diversion performed in the USA from a population-based cohort. PATIENTS AND METHODS: Using the Nationwide Inpatient Sample, we identified patients who underwent RC for bladder cancer between 2001 and 2008. Multivariable regression models were used to identify patient and hospital covariates associated with continent urinary diversion and enumerate predicted probabilities for statistically significant variables over time. RESULTS: Overall, 55635 (92%) patients undergoing RC for bladder cancer received incontinent urinary diversion, while 4552 (8%) patients received continent diversion from 2001 to 2008. Receipt of continent urinary diversion increased from 6.6% in 2001-2002 to 9.4% in 2007-2008 (P < 0.001 for trend). Patients who were older (odds ratio [OR] 0.93; P < 0.001), female (OR 0.52; P < 0.001) and insured by Medicaid (OR 0.54; P = 0.002) were less likely to receive continent urinary diversion. However, patients treated at teaching (OR 2.14; P < 0.001) and high-volume hospitals (OR 2.39; P = 0.04) had higher odds of continent urinary diversion. Predicted probabilities of continent diversion remained lower for female patients, Medicaid insurance status, and non-teaching and medium/low-volume hospitals over time. CONCLUSIONS: In this nationally representative sample of hospitals from 2001 to 2008, the use of continent diversion in RC gradually increased. Although variations in urinary diversion exist by hospital teaching status, case volume, patient gender and primary health insurance, increased attention in expanding the use of continent diversions may help reduce these disparities for patients undergoing RC for bladder cancer.

Iatrogenic splenectomy during nephrectomy for renal tumors.

OBJECTIVES: To evaluate risk factors associated with iatrogenic splenectomy during nephrectomy and to assess outcomes among patients undergoing nephrectomy for renal tumors. METHODS: Of 4323 patients who underwent nephrectomy at Mayo Clinic between 1992 and 2008, 33 (0.8%) had an iatrogenic/unplanned splenectomy. In a case-control study design, controls without splenectomy were matched 1:3 based on age, sex, surgical date, side of the renal tumor, surgical approach and surgeon. Perioperative features and survival were evaluated using conditional logistic and Cox regression. RESULTS: Among the 33 iatrogenic splenectomy patients, the majority (94%) underwent radical, open and left-sided nephrectomy. Primary tumor classification ≥T3 was the only clinicopathological risk factor significantly associated with splenectomy (odds ratio 3.4; P = 0.02). Compared with controls, patients with an iatrogenic splenectomy were more likely to have longer operative time (205 vs 171 min; P = 0.02), higher estimated blood loss (1.3 vs 0.3 L; P = 0.001), longer length of stay (median 7 vs 5 days; P = 0.03) and a higher likelihood for postoperative complications (odds ratio 5.3; P = 0.002). With a median of 9.8 years of follow up, splenectomy patients tended to have greater all-cause mortality (hazard ratio 1.6; P = 0.07), although this difference approached statistical significance. CONCLUSIONS: Iatrogenic splenectomy is a rare complication during nephrectomy and is associated with locally advanced tumors (≥pT3). It also carries prognostic significance for adverse perioperative outcomes and possibly diminished survival, although this warrants further study.

Outcomes following radical cystectomy for micropapillary bladder cancer versus pure urothelial carcinoma: a matched cohort analysis.

PURPOSE: Micropapillary (MP) bladder cancer is a rare variant of urothelial carcinoma (UC) which has been associated with an aggressive natural history. We sought to report the outcomes of patients with MP bladder cancer treated with radical cystectomy (RC) and compare survival to patients with pure UC of the bladder. METHODS: We identified 73 patients with MP bladder cancer and 748 patients with pure UC who underwent RC at our institution with median postoperative follow-up of 9.6 years. MP patients were stage-matched 1:2 to patients with pure UC. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test. RESULTS: MP cancers were associated with a high rate of adverse pathologic features, as 48/73 patients (66 %) had pT3/4 tumors and 37 (50 %) had pN+ disease. Ten-year cancer-specific survival in MP patients was 31 %, compared with 53 % in the overall cohort with pure UC (p = 0.001). When patients with MP bladder cancer were then stage-matched to those with pure UC, no significant differences between the groups were noted with regard to 10-year local recurrence-free survival (62 vs. 69 %; p = 0.87), distant metastasis-free survival (44 vs. 56 %; p = 0.54), or cancer-specific survival (31 vs. 40 %; p = 0.41). CONCLUSION: MP cancers are associated with a higher rate of locally advanced disease. However, when matched to patients with pure UC, patients with MP tumors did not have increased local/distant recurrence or adverse cancer-specific survival following RC.

Anatomic mechanisms for splenic injury during colorectal surgery.

Intraoperative iatrogenic splenic injury during colorectal surgery is rare but may cause significant morbidity. We aimed to describe the anatomic mechanisms of iatrogenic injury to the spleen during colonic surgery. All adult surgical patients who sustained a splenic injury during colectomy at our institution from 1992 to 2007 were retrospectively identified. The operative and pathologic reports were reviewed, and anatomic details of the injuries were collected. Results are reported as a proportion or median, with range reported in brackets. Of 13,897 colectomies, 71 splenic injuries among 58 patients were identified. Splenic flexure colonic mobilization occurred in 53 (91%) of these patients. The median number of tears was 1 (1-3). The average length of tear was 4.59 cm. The distribution of injury location on the spleen was 24 (34%) inferior, 14 (20%) hilar, 3 (4%) posterior, 2 (3%) lateral, and 1 (1%) superior. Three (4%) patients suffered from splenic rupture. The location of 24 (34%) injuries was not described. Capsular tears were the cause of splenic injury in 55 (95%) patients. Intraoperative splenic injury ultimately resulted in splenectomy in 44 (76%) patients. Splenic injury was a delayed finding requiring reoperation in 4 (7%) patients. The primary mechanism of intraoperative splenic injury during colectomy is capsular tears and lacerations secondary to misplaced traction and tension on the spleen during colonic mobilization. Techniques to lessen these forces may decrease the number of injuries and subsequent splenectomy.

Comparative effectiveness research in urology.

BACKGROUND: Comparative effectiveness research (CER) has come to remain at the forefront of political and scientific debates of health care. The aim of this article is to describe the attributes of CER and implications to the field of urology. METHODS: The authors reviewed the published urology literature and recent CER publications including the Institute of Medicine reports. RESULTS: CER is defined as the evaluation of the relative efficacy of diagnostic tests, treatments, and health care services against the current standards of care, with the goal of reducing health care costs while simultaneously improving quality. Significant government funds were recently devoted to CER efforts. The Institute of Medicine identified 25 of the most urgently needed areas for research of which three pertain to Urology: screening for prostate cancer, comparing effectiveness of treatments for localized prostate cancer, and use of imaging in diagnosing, staging, and monitoring cancer patients. Some of the important required strategies to formulate successful CER include involving health care stakeholders to aid in selecting appropriate topics, utilizing study populations that represent real life practice, and the development of large-scale national databases and registries. CONCLUSION: Several topics of urologic care have already been identified in the first quartile of CER priorities, and many others need to be added. Following the proposed research, designs for CER should be done while abiding by robust methodology, maintaining transparency, and effectively translating research into clinical practice.

Risk factors for splenic injury during colectomy: a matched case-control study.

PURPOSE: We assessed risk factors for splenic injury during colectomy and associated outcomes for a 15-year period at a single institution. METHODS: All adult general surgery patients who sustained a splenic injury during colectomy at our institution from 1992 to 2007 were retrospectively identified and matched 1:1 to controls without splenic injury. Putative risk factors were assessed using paired univariate analysis and conditional logistic regression. Differences in short- and long-term mortality were assessed using the log-rank test. Results are reported as a proportion, median, or odds ratio [OR (95% confidence intervals)]. RESULTS: A total of 118 patients were included: 59 patients with splenic injury and 59 control patients. Statistically significant risk factors for splenic injury during colectomy found on univariate analysis included: splenic flexure mobilization, OR 21.00 (2.82-156.12); Charlson comorbidity index≥5, OR 3.17 (1.26-7.93); ASA class≥3, OR 5.33 (1.55-18.3); and nonelective surgery, OR 5.00 (1.1-22.82). On multivariate analysis, only splenic flexure mobilization was independently associated with increased risk of splenic injury (OR 18.4 (2.1-161); p=0.0085). Splenic injured patients trended toward decrease survival both at 30 days (98 vs. 88%; p=0.06) and at 5 years (58 vs. 55%), with a hazard ratio of 1.6 (1.0, 2.6; p=0.05). CONCLUSIONS: Splenic flexure mobilization is the primary risk factor for splenic injury during colectomy, independent of other factors, such as higher ASA class, Charlson score, and nonelective surgery. Splenic injury during colectomy has an increased risk of death in both the short- and long-term.

The spleen as a target in severe acute respiratory syndrome.

It has been proposed that immune injury is the central mechanism of pathogenesis of the infectious disease, severe acute respiratory syndrome (SARS). To gain a better understanding of immune injury in the spleen, we investigated the number and distribution of various immune cell types in the spleens of SARS patients. We performed autopsies on six confirmed SARS cases, with six normal subjects as controls; spleen samples from these autopsies were examined with hematoxylin and eosin (H&E) sections, in situ hybridization for SARS virus genomic sequences, and immunohistochemistry with seven monoclonal antibodies to five cell types. The number and distribution of these cells were measured and analyzed using an image analysis system. SARS genomic sequences were detected in all SARS spleens. The SARS spleens all had severe damage to the white pulp and showed an alteration of the normal distribution of various cell types. Immunocytes in the red pulp were decreased by 68.0-90.7% except for CD68+ macrophages and human leukocyte antigen (HLA)-DR positive antigen-presenting cells (APC), which were decreased to a lesser degree. On average, CD68+ macrophages were increased in size by 2.21-fold. We hypothesize that the collapse of the splenic immune system plays a key role in the clinical outcome of these patients.

Non-O blood type is associated with an increased risk of venous thromboembolism after radical cystectomy.

OBJECTIVE: To evaluate the association of blood type (non-O vs O) with venous thromboembolism (VTE) risk after radical cystectomy (RC) for bladder cancer. METHODS: From 1980 to 2005, we identified 2076 consecutive patients with RC for whom blood type was available in 2008 (96.7%). We evaluated the association of blood type with postoperative VTE using logistic regression, controlling for patient age, tumor, and nodal stage, Eastern Cooperative Oncology Group (ECOG) performance status, body-mass index (BMI), and number of lymph nodes removed at surgery. RESULTS: A total of 865 of 2076 patients (41.7%) had O blood type, 1143 (55.0%) were non-O, and 68 (3.3%) were missing. Median follow-up was 11.1 years, during which time VTE developed in 216 patients (10.4%). No significant differences were noted between those with O vs non-O blood type regarding patient age (median 69 years vs 69, P = .87), ECOG (P = .69), BMI (median 27.5 vs 28.1, P = .12), tumor stage (P = .97), pN+ status (15.6% vs 15.2%, P = .79), or number of nodes removed (median 9 vs 8, P = .43). On multivariate analysis, non-O blood type was associated with a nearly two-fold increased risk of VTE (odds ratio [OR] = 1.85, P = .007). CONCLUSION: Non-O blood type was independently associated with an increased risk of VTE after RC. These patients should be counseled accordingly, and may benefit from increased perioperative prophylaxis.

High rate of pathologic upgrading at nephroureterectomy for upper tract urothelial carcinoma.

OBJECTIVE: To determine the association between endoscopic biopsy grade and the final pathologic characteristics at nephroureterectomy for upper tract urothelial carcinoma (UTUC). Endoscopic biopsy is an important tool for patients with UTUC because the results can influence the management decisions. METHODS: We identified 481 patients who had undergone nephroureterectomy for UTUC at the Mayo Clinic from 1995 to 2008. Of these patients, 184 underwent endoscopic cup or brush biopsy before nephroureterectomy. The biopsy tumor grade was then compared with the tumor grade and stage obtained at nephroureterectomy. RESULTS: Of the 184 patients, 27 (15%) had nondiagnostic biopsy results and 21 (11%) had positive biopsy results with no histologic grade. Of the 24 patients with grade 1 tumors on biopsy, 23 (96%) had the tumor upgraded on the final pathologic examination: 16 (67%) to grade 2 and 7 (29%) to grade 3. Similarly, 23 (40%) of 57 grade 2 tumors on biopsy were upgraded to grade 3 after nephrouretecomy. Only a few patients, 7 (4%) of 184, were found to have a lower histologic grade on the final pathologic examination. The number of patients with invasive UTUC for endoscopic grade 1, 2, and 3 tumors was 9 (38%) of 24, 31 (54%) of 57, and 47 (85%) of 55, respectively. CONCLUSION: In the context of patients selected for nephroureterectomy, we observed a greater than expected rate of tumor upgrading and invasive disease, particularly in those with low-grade tumors at biopsy. These findings should be considered when electing to use conservative or endoscopic management of low-grade UTUC.

Remnant torsion causing Budd-Chiari syndrome after right hepatectomy.

INTRODUCTION: Torsion or rotation of the remnant left liver after right hepatectomy is a potential cause of venous outflow obstruction. This can occur by external compression on the inferior vena cava or kinking of the left hepatic vein. DISCUSSION: We report a case of a young female who underwent right hepatectomy for stage IV colorectal metastases and suffered remnant left liver torsion causing acute Budd-Chiari syndrome. She was managed by placement of a metal stent across the area of stenosis which resolved her ascites and hyperbilirubinemia.

Incidental gallstones.

Gallstones develop in approximately 10% to 15% of the US population and represent one of the most common and most costly of all digestive diseases. Studies investigating gallstones' natural history have shown that gallstone-related complications arise at a rate of approximately 1% per year in asymptomatic patients and 2% per year in patients who already have symptoms. Patients can have any of multiple presentations with gallstone-related problems along a continuum of health threats from intermittent biliary colic to septic shock from ascending infections. In most clinical situations in which the patient's gallstone symptoms are either recurrent or have caused complications, cholecystectomy remains the procedure of choice. Laparoscopic cholecystectomy, first performed in the mid-1980s, has quickly become the gold standard in the US. For clinicians who perform abdominal procedures, the literature is consistent in advocating cholecystectomy for gallstones found incidentally during other abdominal procedures.

Splenic salvage after intraoperative splenic injury during colectomy.

OBJECTIVE: To determine the optimal surgical management of splenic injury encountered during colectomy. DESIGN: Retrospective review from 1992 to 2007. SETTING: Mayo Clinic in Rochester, Minnesota, a tertiary care center. PATIENTS: A cohort of patients who sustained splenic injury during colectomy from 1992 to 2007. MAIN OUTCOME MEASURES: Overall 30-day major morbidity and mortality and overall 5-year survival. RESULTS: Of 13,897 colectomies, we identified 59 splenic injuries (0.42%). Of these, 33 (56%) were in men; there was a median age of 68 years (range, 30-93 years) and a median body mass index of 25.5 (range, 15-54). Thirty-seven injuries (63%) occurred during elective surgery, 6 (10%) occurred without splenic flexure mobilization, and 5 (8.4%) occurred during minimally invasive surgery. Injury was successfully managed by primary repair in 10 (17%), splenorrhaphy in 4 (7%), and splenectomy in 45 cases (76%). Four injuries (7%) were unrecognized and resulted in reoperation and splenectomy. Multiple attempts at splenic salvage were performed in 30 (51%); of these, 21 (70%) required splenectomy. More than 2 attempts at salvage was associated with splenectomy (P = .03). The 30-day major morbidity and mortality rates were 34% and 17%, respectively. Sepsis was the most common complication, with no confirmed episodes of postsplenectomy sepsis. Median survival after splenic injury was 7.25 years. There was no significant association between the surgical management of splenic injuries and short- or long-term outcomes. CONCLUSIONS: Splenic injury is an infrequent but morbid complication. Splenic salvage is frequently unsuccessful; our data suggest that surgeons should not be reluctant to perform splenectomy when initial repair attempts fail.