Resident Trainees Increase Surgical Time: A Comparison of Obstetric and Gynaecologic Procedures in Academic Versus Community Hospitals.

OBJECTIVE: The impact of resident involvement in the operating room for common procedures in obstetrics and gynaecology can shed light on the resource demands of teaching. The objective of this study was to quantify the increased surgical time associated with teaching obstetrics and gynaecology resident trainees across a range of procedures known to require surgical assistance. METHODS: This population-based retrospective cohort study compared surgical duration between academic (teaching) hospitals and community (non-teaching) hospitals. The cohort was made up of adult residents of Ontario between fiscal years 2002 and 2013 who were undergoing commonly performed obstetrics and gynaecologic procedures. The most commonly billed procedures requiring surgical assistance were included: cesarean section, anterior or posterior repair, anterior and posterior repair, salpingo-oophorectomy, myomectomy, ectopic pregnancy, total or subtotal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy. Linked administrative databases held at the Institute of Clinical Evaluative Sciences (ICES) were used to define patient-, surgeon-, institution-, and procedure-related variables to limit confounding. Surgical duration, determined by anaesthetic billing records, was analyzed using a negative binomial regression. RESULTS: The total cohort included 337 389 surgical procedures. Of these procedures, 28% (94 203 procedures) were conducted in academic settings. The mean surgical duration of the procedures of interest (excluding vaginal hysterectomy) was significantly longer in academic hospitals compared with community hospitals. With many controls for case variability, this time differential reflects the burden of teaching resident trainees and other learners in the academic environment. The operating time increased between 6% and 20% for cases completed in academic centres versus in the community. As an example, the mean surgical duration of cesarean sections was 20.6 minutes (19%) longer in academic centres. Furthermore, the data highlighted a trend of increased teaching time for laparoscopic procedures compared with open procedures. The time ratio was the greatest for salpingo-oophortectomy and surgical management of ectopic pregnancies. The additional cost of carrying out these nine procedures in academic centres during the study period was $16.3 million. CONCLUSION: The cost of teaching resident trainees is increased operative time. This increased surgical cost in a publicly funded system must be considered as funding models evolve.

Hysterectomy in Ontario: A Population-Based Study of Outcomes and Complications in Minimally Invasive Compared with Abdominal Approaches.

OBJECTIVE: As quality-based procedures (QBPs) are being established across the province of Ontario, it is important to identify reliable quality indicators (QIs) to ensure that compensation coincides with quality. Hysterectomy is the most commonly performed gynaecologic procedure and as such is a care process for which a QBP is being developed. The aim of this study was to evaluate the technicity index (TI) as a QI for hysterectomy by defining it in the context of specific surgical outcomes and complications. METHODS: This population-based, retrospective cohort study included all women who underwent hysterectomy from April 2003 to October 2014 in the province of Ontario. Unadjusted and adjusted generalized linear models were created to assess the effect of a minimally invasive hysterectomy (MIH) approach on the primary outcome measure: all hysterectomy-associated complications (Canadian Task Force Classification II-2). RESULTS: Of the procedures meeting the study's inclusion criteria, 56.8% were performed using an abdominal hysterectomy approach, whereas 43.2% were performed using an MIH approach. Over the study period, TI improved significantly from 33.23% in 2003 to 58.47% in 2014. During this time span, the overall incidence of all hysterectomy-associated complications was 13.1%. CONCLUSION: The composite risk of all hysterectomy-associated complications was reduced by 46% with an MIH approach. The uptake of MIH improved significantly in Ontario from 2003 to 2014 and is adequately assessed by the TI. The TI is an appropriate QI for hysterectomy that can be used to track patients' outcomes and direct hysterectomy funding.

The Burden of Repeat Prescribing Medications after a Related Adverse Drug Event.

The use of medications such as glyburide, neuroleptics and benzodiazepines is potentially dangerous in the elderly, as they are linked to adverse drug events such as hypoglycemia and serious falls. We used administrative data from the province of Ontario to determine how often these medications are continued after a patient experiences one of these adverse events. Over a 12-year period, we identified 31,262 patients who had a hospital presentation with hypoglycemia or a fall within three months of starting the previously listed medications. Re-dispensing of these high-risk medications occurred in 55% of patients within six months of the adverse drug event. Among patients with re-dispensed therapies, about 10% had a repeat adverse drug event. These results highlight a common problem that could potentially be addressed with better medication reconciliation and health policies directed at reducing re-dispensing of high-risk medications.

Association between day of the week of elective surgery and postoperative mortality.

BACKGROUND: In prior studies, higher mortality was observed among patients who had elective surgery on a Friday rather than earlier in the week. We investigated whether mortality after elective surgery was associated with day of the week of surgery in a Canadian population and whether the association was influenced by surgeon experience and volume. METHODS: We conducted a population-based retrospective cohort study in the province of Ontario, Canada. We included adults who underwent 1 of 12 elective daytime surgical procedures from Apr. 1, 2002, to Dec. 31, 2012. The primary outcome was 30-day mortality. We used generalized estimating equations to compare outcomes for surgeries performed on different days of the week, adjusting for patient and surgeon factors. RESULTS: A total of 402 899 procedures performed by 1691 surgeons met our inclusion criteria. The median length of hospital stay was 6 (interquartile range 5-8) days. Surgeon experience varied significantly by day of week (p < 0.001), with surgeons operating on Fridays having the least experience. Nearly all of the patients who had their procedure on a Friday had postoperative care on the weekend, as compared with 49.1% of those whose surgery was on a Monday (p < 0.001). We found no difference in the 30-day mortality between procedures performed on Fridays and those performed on Mondays (adjusted odds ratio 1.08, 95% confidence interval 0.97-1.21). INTERPRETATION: Although surgeon experience differed across days of the week, the risk of 30-day mortality after elective surgery was similar regardless of which day of the week the procedure took place.

Urinary tract infections, urologic surgery, and renal dysfunction in a contemporary cohort of traumatic spinal cord injured patients.

AIMS: The objective of this study was to measure the incidence of urinary tract infections (UTIs), urologic reconstruction/urinary diversion, and renal dysfunction after a traumatic spinal cord injury (TSCI). METHODS: Retrospective cohort study using administrative data from Ontario, Canada. All incident adult TSCI patients (2002-2013) admitted to a rehabilitation center were included. The impact of lesion level on each outcome was assessed. The rate of outcomes was further compared to an age and sex matched sample from the general population. RESULTS: A total of 2,023 incident TSCI patients were identified (median follow-up of 4.8 years). Most patients (73%) were male and median age was 50 years. Lesion level included cervical (39%), thoracolumbar (44%), and unknown (17%). The incidence of serious UTIs (requiring emergency room visit or hospital admission) was 40%. Thoracolumbar lesion TSCI patients had significantly greater risk of serious UTIs (HR 1.3, 95%CI 1.1-1.7, P < 0.01) compared to those with a cervical lesion. Urologic reconstruction/urinary diversion was carried out on 2.4% of patients. New onset renal dysfunction was identified in 4.2% (84) TSCI patients. The rate ratios for serious UTIs (10.59, 95%CI 8.71-12.89), urologic reconstruction/urinary diversion (6.48, 95%CI 3.07-13.68), and renal dysfunction (2.55, 95%CI 1.70-3.83) were significantly increased among TSCI patients compared to matched controls. CONCLUSIONS: Urologic disease is still an important source of morbidity for contemporary TSCI patients, and is more common compared to the general population. Neurourol. Urodynam. 36:640-647, 2017. © 2016 Wiley Periodicals, Inc.

Cardiac Surgeons after Vacation: Refreshed or Rusty?

Introduction: Many surgeons describe feeling a bit out of practice when they return from a vacation. There have been no studies assessing the impact of surgeon vacation on patient outcomes. Methods: We used administrative data from the province of Ontario to identify patients who underwent a coronary artery bypass grafting. Using a propensity score, we matched patients who underwent their procedure immediately after their surgeon returned from vacation of at least 7 days (n = 1,161) to patients who were not operated immediately before or after a vacation period (n = 2,138). Results: There was no significant difference in patient mortality (odds ratio: 1.23, p = 0.52), length of operation (relative risk [RR]: 1.00 p = 0.58), or intensive care unit/ hospital stay (RR: 0.97 p = 0.66/RR: 0.98 p = 0.54, respectively). Conclusion: There was not a significant change in risk of death, operative length, or hospital stay after a surgeon vacation.

Teaching surgery takes time: the impact of surgical education on time in the operating room.

BACKGROUND: It is generally accepted that surgical training is associated with increased surgical duration. The purpose of this study was to determine the magnitude of this increase for common surgical procedures by comparing surgery duration in teaching and nonteaching hospitals. METHODS: This retrospective population-based cohort study included all adult residents of Ontario, Canada, who underwent 1 of 14 surgical procedures between 2002 and 2012. We used several linked administrative databases to identify the study cohort in addition to patient-, surgeon- and procedure-related variables. We determined surgery duration using anesthesiology billing records. Negative binomial regression was used to model the association between teaching versus nonteaching hospital status and surgery duration. RESULTS: Of the 713 573 surgical cases included in this study, 20.8% were performed in a teaching hospital. For each procedure, the mean surgery duration was significantly longer for teaching hospitals, with differences ranging from 5 to 62 minutes across individual procedures in unadjusted analyses (all p < 0.001). In regression analysis, procedures performed in teaching hospitals were associated with an overall 22% (95% confidence interval 20%-24%) increase in surgery duration, adjusting for patient-, surgeon- and procedure-related variables as well as the clustering of patients within surgeons and hospitals. CONCLUSION: Our results show that a wide range of surgical procedures require significantly more time to perform in teaching than nonteaching hospitals. Given the magnitude of this difference, the impact of surgical training on health care costs and clinical outcomes should be a priority for future studies.

CONTEXTE: Il est généralement admis que la formation chirurgicale est associée à des interventions plus longues. L'objectif de la présente étude était de déterminer l'ampleur de cette augmentation pour les chirurgies courantes en comparant la durée des interventions dans les hôpitaux universitaires et les autres hôpitaux. MÉTHODES: Dans le cadre d'une étude de cohorte rétrospective basée sur la population, nous avons recensé tous les résidents adultes de l'Ontario (Canada) qui ont subi une intervention chirurgicale parmi une liste de 14 entre 2002 et 2012. À l'aide de plusieurs bases de données administratives reliées, nous avons constitué la cohorte de l'étude et recueilli des variables associées aux patients, aux chirurgiens et aux interventions. Nous avons déterminé la durée des opérations à partir des dossiers de facturation d'anesthésiologie. Une régression binomiale négative a été utilisée pour modéliser le lien entre le statut des hôpitaux ­ universitaires ou non ­ et la durée. RÉSULTANTS: Des 713 573 chirurgies à l'étude, 20,8 % ont eu lieu dans un hôpital universitaire. Dans tous les cas, la durée moyenne était significativement plus longue dans les hôpitaux universitaires, les écarts variant de 5 à 62 minutes pour chaque intervention dans les analyses non corrigées (p < 0,001 dans tous les cas). Selon l'analyse de régression, les chirurgies effectuées dans les hôpitaux universitaires étaient associées à une augmentation globale de la durée de 22 % (intervalle de confiance à 95 %, 20 %­24 %), après ajustement pour les variables liées aux patients, aux chirurgiens et aux interventions ainsi que pour la densité de patients pris en charge par les chirurgiens et les hôpitaux. CONCLUSION: Nos résultats montrent que de nombreuses interventions chirurgicales durent considérablement plus longtemps dans les hôpitaux universitaires que dans les autres hôpitaux. Étant donné l'ampleur de cet écart, l'étude de l'incidence de la formation chirurgicale sur les coûts des soins de santé et les résultats cliniques devrait être une priorité pour les recherches futures.

The effect of pelvic factures on future stress incontinence and pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Pelvic fractures in women significantly disrupt the pelvic floor, which may cause stress urinary incontinence (SUI) or pelvic organ prolapse (POP). Our objective was to assess the incidence of operative treatment for SUI and POP after pelvic fracture. METHODS: We used administrative data from Ontario, Canada, to conduct a retrospective cohort study. Female patients who underwent operative repair of a pelvic fracture between 2002 and 2010 were identified. The primary outcomes were the subsequent surgical treatment of SUI or POP. To compare the incidence with that of the general population, patients who had operative repair of a pelvic fracture were matched (1:2) to a person in the general population (with a propensity score to account for measurable potential confounders). Our primary analysis was a Cox proportional hazards model to compare hazard ratios (HR) in subjects with a pelvic facture and those without. RESULTS: We identified 390 female patients with a median age of 47 (IQR 30-67) years. Our median follow-up period was 5.9 (4.1-8.3) years. The absolute risk of SUI surgery after pelvic fracture was 3.3 % (13 out of 390) compared with 1.0 % (8 out of 769) in the matched general population sample. The HR for SUI surgery was 5.8 (95 % CI 2.2-15.1). The absolute risk of POP surgery after pelvic fracture was 1.8 % (7 out of 390) compared with 0.9 % (7 out of 769) in the matched general population. The HR for POP surgery was 2.3 (95 % CI 0.9-5.8). CONCLUSIONS: Among patients who had a pelvic fracture requiring operative repair, there appears to be a significantly increased chance of surgery for SUI, but not for POP.

The Impact of Common Urologic Complications on the Risk of a Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic infections after total hip arthroplasty (THA) or total knee arthroplasty (TKA) are substantial complications, and there are conflicting reports of their association with urologic complications. Our objective was to determine whether urinary tract infection (UTI) and acute urinary retention (AUR) are significant risk factors for joint infections after THA or TKA. METHODS: We performed a population-based, retrospective cohort study of patients who were ≥66 years old when they underwent an initial THA or TKA between April 2003 and March 2013. Investigated exposures included a UTI presenting for treatment within 2 years after joint replacement, as well as AUR within 30 days after THA or TKA. The primary outcome was joint infection requiring hospital admission following THA or TKA (which had to occur within 2.25 years after THA or TKA for the UTI exposure or 120 days for the AUR exposure). RESULTS: A total of 113,061 patients met the inclusion criteria and had arthroplasties (44,495 THAs and 68,566 TKAs) during the study period. The median age was 74 years (interquartile range [IQR], 70 to 79 years). Of those patients, 28,256 (25.0%) had at least 1 UTI and they were more likely to be older and female; to have had previous antibiotic exposure, cystoscopy, or urinary retention; and to have atrial fibrillation. Most of those UTIs were coded as nonspecific UTI, and the patient was seen for outpatient treatment in a non-emergency department setting. A total of 2,516 patients (2.2%) had AUR within 30 days of the procedure. Those patients were more likely to be older and male, to have medical comorbidities, to have had previous transurethral procedures or cystoscopy and previous urology visits, and to have received a general anesthetic during their procedure. A total of 1,262 patients (1.1%) had joint infection requiring hospital admission. In multivariate Cox regression analysis, UTI was associated with an increased risk of joint infection (hazard ratio [HR], 1.21 [95% confidence interval (CI), 1.14 to 1.28]; p < 0.01). However multivariate analysis did not demonstrate an association between AUR and joint infection (HR, 0.99 [95% CI, 0.60 to 1.64]; p = 0.98). CONCLUSIONS: UTI was associated with increased risk of hip or knee periprosthetic joint infection, whereas AUR was not a significant risk factor. Timely and appropriate treatment of symptomatic UTIs in this patient population may be important to prevent periprosthetic joint infection. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Population-Based Cohort Study of the Impact of Infectious Complications Requiring Hospitalization after Prostate Biopsy on Radical Prostatectomy Surgical Outcomes.

OBJECTIVE: To compare radical prostatectomy outcomes in men with and without exposure to a major infectious event within 30-days of a prior TRUS-biopsy. MATERIALS AND METHODS: This retrospective cohort study included men who underwent radical prostatectomy from 2002 to 2013 in Ontario, Canada. Several linked administrative databases were used. Exposure was defined as hospitalization with evidence of a urinary tract infection or sepsis during the first 30-days after a prostate biopsy. The primary outcome was a composite of procedures indicative of a likely serious complication of radical prostectomy within the first 12 months after surgery. Secondary outcomes included oncological, functional, and hospital related events within 2 years of radical prostatectomy. RESULTS: A total of 26,254 patients were included in this study and 530 (2.02%) had a post-TRUS-biopsy infection. A similar proportion of patients with and without a post-TRUS-biopsy infectious event experienced the composite primary outcome (1.7% vs 1.1%; odds ratio [OR] 1.61, 95% confidence interval [CI] 0.82-3.14; P = .16). However, exposed patients had significantly higher odds of perioperative blood transfusion (OR 1.61, 95% CI 1.30-2.00; P <.001), bladder neck contracture (OR 1.35, 95% CI 1.12-1.63; P = .002), and 30-day hospital readmission (OR 2.08, 95% CI 1.47-2.95; P <.001), and a small but significant increase in length of hospital stay (P = 0.005). No other significant differences were observed. CONCLUSION: Although prior infectious events are associated with increased risk of blood transfusion, bladder neck contracture, and hospital readmission following radical prostatectomy, results from this study suggest that major surgical complications, are not adversely affected by TRUS-biopsy related infections.

The Impact of the Choosing Wisely Campaign in Urology.

OBJECTIVE: To determine if 3 of the Canadian Urological Association's Choosing Wisely recommendations (released in 2013-2014) related to urologic care altered physician and patient behavior. METHODS: Administrative data from Ontario, Canada between 2008 and 2017 was used. We identified 3 cohorts: First, we determined how many men >66 years of age had a serum testosterone level before starting testosterone therapy. Second, we determined how many boys undergoing an orchiopexy underwent abdominal imaging before their surgery. Third, we determined how many men with low risk prostate cancer underwent a Bone Scan after diagnosis. Piece-wise linear regression was used to evaluate for a significant change after Choosing Wisely. RESULTS: We identified 13,113 men who had their initial prescription for testosterone filled. Serum testosterone measurement increased over time, from approximately 43% to 68%. There were 9319 boys who underwent an orchiopexy. The use of pre-orchiopexy ultrasound was generally stable (approximately 55%). We identified 27,174 men with low risk prostate cancer. The use of bone scans after diagnosis decreased over time from approximately 24% to 20%. In all 3 of these groups, there was no significant change after Choosing Wisely (P = .74, P = .70, P = .72 respectively). CONCLUSION: In Ontario, there was no evidence of a significant change in 3 practice patterns that were featured in Choosing Wisely Urology recommendations. Further thought may be needed on how to translate these and future recommendations into behavior change.

Repair of congenital esophageal atresia with tracheoesophageal fistula repair in Ontario over the last 20years: Volume and outcomes.

BACKGROUND/PURPOSE: This study was designed to determine the volume, postoperative surgical outcomes and, if possible, the relationship between outcome and institutional / surgeon volume in neonates undergoing repair of esophageal atresia with tracheoesophageal fistula (EA-TEF) over the last 20years in Ontario. METHODS: Using administrative databases, a population based cohort study of patients undergoing EA-TEF repair in Ontario between 1993 and 2012 was conducted. RESULTS: 465 patients with the diagnosis of EA-TEF met inclusion criteria. The mean number of EA-TEF repairs per year per was 5.8. There was a significant difference in hospital annual volume between institutions (range 12.3-3.35: p<0.05). The average number of cases/surgeon for the last 10 study years ranged between 0.5 and 2 cases/year. Primary outcome revealed that repair of recurrent fistula or intestinal interposition was 5.3%, with no reportable difference between institutions. Secondary outcomes revealed that 45.6% underwent dilatation for esophageal strictures, and 19.8% underwent some type of drainage procedure of the chest. These rates were not significantly different between institutions. CONCLUSION: This study provides insight into the outcomes following EA-TEF repair in Ontario and the difficulty in determining surgeon or institution volume outcome relationships, as both primary and secondary outcome event rates are very low. LEVEL OF EVIDENCE: 2.

Postoperative Urinary Retention and Urinary Tract Infections Predict Midurethral Sling Mesh Complications.

OBJECTIVE: To determine if postoperative urinary retention and urinary tract infections (UTIs) were predictors of future mesh complications requiring surgical intervention after midurethral sling (MUS). MATERIALS AND METHODS: Administrative data in Ontario, Canada, between 2002 and 2013 were used to identify all women who underwent a mesh-based MUS. The primary outcome was revision of the transvaginal mesh sling (including mesh removal/erosion/fistula, or urethrolysis). Two potential risk factors were analyzed: postoperative retention (within 30 days of procedure) and number of postoperative emergency room visits or hospital admissions for UTI symptoms. RESULTS: A total of 59,556 women had a MUS, of which 1598 (2.7%) required revision surgery. Of the 2025 women who presented to the emergency room or were admitted to hospital for postoperative retention, 212 (10.5%) required operative mesh revision. Of the 11,747 patients who had at least one postoperative UTI, 366 (3.1%) patients required operative mesh revision. In adjusted analysis, postoperative retention was significantly predictive of future reoperation (hazard ratio [HR] 3.46, 95% confidence interval [CI] 2.97-4.02), and this difference persisted when urethrolysis was excluded as a reason for sling revision (HR 3.08, 95% CI 2.62-3.63). Similarly, in adjusted analysis, each additional postoperative hospital visit for UTI symptoms increased the risk for surgical intervention for mesh complications (HR 1.74, 95% CI 1.61-1.87). CONCLUSION: Postoperative urinary retention and hospital presentation for UTI symptoms are associated with an increased risk of reoperation for MUS complications. These patients should be followed and investigated for mesh complications when appropriate.

Corticosteroid Usage Is Associated With Increased Artificial Urinary Sphincter Reoperation.

OBJECTIVE: To determine if oral corticosteroid use is associated with an increased risk of artificial urinary sphincter (AUS)-related reoperation. MATERIALS AND METHODS: Administrative data from Ontario were used to conduct a retrospective cohort study. Men >65 years of age who underwent implantation of an AUS between 2002 and 2013 were included. Prescriptions for oral corticosteroids were identified, and men were considered exposed from the date the prescription was dispensed to 180 days after the expected end of the prescription. The primary outcome was AUS reoperation. Data were analyzed using a Cox proportional hazards model with corticosteroid usage modeled as a time-varying covariate. RESULTS: We identified 747 men who met our inclusion criteria (median age of 71 years; interquartile range [IQR]: 68-75), of which 592 (79.3%) had a prior radical prostatectomy. The median duration of follow-up was 3.2 years (IQR: 1.3-5.9). One hundred seventy-five (23.4%) patients were exposed to corticosteroids during the study period (median duration of use was 21 days; IQR: 5-100). We identified an AUS reoperation in 176 men (23.6%). After adjusting for age, radiation exposure, and year of implantation, exposure to corticosteroids was significantly associated with the risk of AUS reoperation (hazard ratio: 1.68, 95% confidence interval: 1.03-2.75, P = .04). Radiation after AUS implantation was also significantly associated with AUS reoperation (hazard ratio: 2.07, 95% confidence interval: 1.06-4.07, P = .03). CONCLUSION: There is a significantly increased risk of AUS reoperation among men using oral corticosteroids.

The Impact of Multiple Prostate Biopsies on Risk for Major Complications Following Radical Prostatectomy: A Population-based Cohort Study.

OBJECTIVE: To evaluate the impact of multiple transrectal ultrasound-guided prostate biopsies (TRUS-Bx) before radical prostatectomy (RP) on surgical outcomes. MATERIALS AND METHODS: Administrative databases were used to identify all patients who had a RP performed in the province of Ontario from April 1, 2002, to March 31, 2013. TRUS-Bx prior to RP were identified and patients were categorized as having one or more than one prior TRUS-Bx. The primary end point was a composite index of serious surgical complications. Secondary outcomes included oncological interventions, functional-related events, and general health service-related outcomes. RESULTS: Among 27,637 patients, 4780 (17.3%) had ≥2 biopsies performed before RP. The proportion of patients who experienced the composite end point was similar between those with one TRUS-Bx compared to those with ≥2 TRUS-Bx (1.05% vs 1.19%, OR 1.14, 95% CI 0.85-1.52). Patients with ≥2 biopsies were more likely to have a perioperative blood transfusion compared to patients with only 1 biopsy (15.5% vs 12.8%, OR 1.25, 95% CI 1.15-1.37), while readmission rate and 30-day mortality were similar. The need for radiotherapy and androgen deprivation therapy within the first year after RP was higher in patients with a single biopsy. Patients with multiple TRUS-Bx were more likely to require post-RP urodynamic evaluation and bladder neck contracture-related interventions but were not at increased odds of surgery for incontinence or erectile dysfunction. CONCLUSION: Perioperative outcomes after RP are similar between men with single or multiple TRUS-Bx, although multiple TRUS-Bx were associated with an increased odds of perioperative blood transfusion.

Repeat Surgical Intervention for Stress Urinary Incontinence after a Failed Mid Urethral Sling.

INTRODUCTION: We determined the incidence of stress urinary incontinence surgery performed after mid urethral sling procedures and the impact of physician volume on mid urethral sling failure. METHODS: Administrative data were used to identify all women who underwent a mid urethral sling procedure in Ontario, Canada between 2002 and 2013. The primary outcome was subsequent stress urinary incontinence surgery. The primary exposure was surgeon mid urethral sling case volume with high volume defined as greater than the 75th percentile. RESULTS: A total of 59,556 women with a median age of 52 years (IQR 45-63) received a mid urethral sling, of whom 3.3% underwent additional stress urinary incontinence operations. The most common secondary surgery was a repeat mid urethral sling in 78.3% of cases and a pubovaginal sling in 5.8%. The cumulative incidence of repeat stress urinary incontinence surgery at 10 years of followup was 5.2% (95% CI 4.9-5.5). On multivariable survival analysis the effect of surgeon mid urethral sling volume on subsequent stress urinary incontinence surgery was nonsignificant (HR 0.89, 95% CI 0.76-1.03). Younger patient age, lower comorbidity and simultaneous hysterectomy decreased the hazard of future stress urinary incontinence surgery. In this cohort 1,425 women (2.4%) required surgical revision or removal of the initial mid urethral sling, of whom 215 (15%) underwent a simultaneous or subsequent incontinence procedure. The most common procedure was still a mesh sling, which was placed in 159 women (74.0%). CONCLUSIONS: Secondary stress urinary incontinence surgery after mid urethral sling placement was observed in 3.3% of women. The majority of women with recurrent incontinence were treated with a repeat mid urethral sling. There is a nonsignificant trend toward higher mid urethral sling provider volume being correlated with a reduced risk of future stress urinary incontinence surgery.

Surgeon Experience and Complications of Transvaginal Prolapse Mesh.

OBJECTIVE: To measure the proportion of women with transvaginal prolapse mesh complications and their association with surgeon volume. METHODS: We conducted a retrospective, population-based cohort study of all women who underwent a mesh-based prolapse procedure using administrative data (hospital procedure and physician billing records) between 2002 and 2013 in Ontario, Canada. The primary outcome was surgical revision of the mesh. Primary exposure was surgeon volume: high (greater than the 75th percentile, requiring a median of five [interquartile range 5-6] procedures per year) and very high (greater than the 90th percentile, requiring a median of 13 [interquartile range 11-14] procedures per year) volume mesh implanters were identified each year. Primary analysis was an adjusted Cox proportional hazards model. RESULTS: A total of 5,488 women underwent mesh implantation by 1 of 368 unique surgeons. Median follow-up time was 5.4 (interquartile range 3.0-8.0) years. We found that 218 women (4.0%) underwent mesh reoperation a median of 1.17 (interquartile range 0.58-2.90) years after implantation. The hazard of reoperation for complications was only lower for patients of very high-volume surgeons (3.0% [145/3,001] compared with 4.8% [73/2,447], adjusted hazards ratio 0.59, 95% confidence interval 0.40-0.86). In multivariable modeling, younger age, concomitant hysterectomy, blood transfusion, and increased medical comorbidity were all associated with vaginal mesh reoperation. CONCLUSION: Approximately 5% of women who underwent mesh-based prolapse surgery required reoperation for a mesh complication within 10 years. The risk of reoperation was lowest for surgeons performing 14 or more procedures per year.

82-kDa choline acetyltransferase and SATB1 localize to ß-amyloid induced matrix attachment regions.

The M-transcript of human choline acetyltransferase (ChAT) produces an 82-kDa protein (82-kDa ChAT) that concentrates in nuclei of cholinergic neurons. We assessed the effects of acute exposure to oligomeric amyloid-ß1-42 (Aß1-42) on 82-kDa ChAT disposition in SH-SY5Y neural cells, finding that acute exposure to Aß1-42 results in increased association of 82-kDa ChAT with chromatin and formation of 82-kDa ChAT aggregates in nuclei. When measured by chromatin immunoprecipitation with next-generation sequencing (ChIP-seq), we identified that Aß1-42-exposure increases 82-kDa ChAT association with gene promoters and introns. The Aß1-42-induced 82-kDa ChAT aggregates co-localize with special AT-rich binding protein 1 (SATB1), which anchors DNA to scaffolding/matrix attachment regions (S/MARs). SATB1 had a similar genomic association as 82-kDa ChAT, with both proteins associating with synapse and cell stress genes. After Aß1-42 -exposure, both SATB1 and 82-kDa ChAT are enriched at the same S/MAR on the APP gene, with 82-kDa ChAT expression attenuating an increase in an isoform-specific APP mRNA transcript. Finally, 82-kDa ChAT and SATB1 have patterned genomic association at regions enriched with S/MAR binding motifs. These results demonstrate that 82-kDa ChAT and SATB1 play critical roles in the response of neural cells to acute Aß-exposure.

The increasing incidence of gallbladder disease in children: A 20year perspective.

OBJECTIVE: The incidence of cholecystectomy in the pediatric population has increased over the last 20years but has not been described in a Canadian population. We conducted the first province-wide study to describe the incidence of cholecystectomy in children in Ontario. STUDY DESIGN: A population-based, retrospective cohort using administrative databases in Ontario, Canada, was conducted. We included patients less than 18years of age who underwent cholecystectomy from 1993 to 2012. Trends in rates of cholecystectomy were assessed with the Cochrane-Armitage test. RESULTS: There were a total of 6040 pediatric cholecystectomies performed over the study period in Ontario. The mean age was 14.3years, and 79.6% of patients were females. The crude incidence per 100,000 person-years increased from 8.8 to 13.0 (p<0.001) from 1993 96-2009-12, respectively. The sex-specific incidence showed a larger increase in the female population from 14.7 to 21.1 per 100,000 person-years (p<0.001). The vast majority (82%) of surgeries were performed in 13-17year olds and were largely performed in the community (>75%). CONCLUSIONS: There has been a significant rise in the incidence of pediatric cholecystectomy in Ontario over the last 20years. The majority of surgeries are performed in the community, and pediatricians will likely see an increase of gallbladder disease in practice.

The impact of teaching on the duration of common urological operations.

INTRODUCTION: The ability of academic (teaching) hospitals to offer the same level of efficiency as non-teaching hospitals in a publicly funded healthcare system is unknown. Our objective was to compare the operative duration of general urology procedures between teaching and non-teaching hospitals. METHODS: We used administrative data from the province of Ontario to conduct a retrospective cohort study of all adults who underwent a specified elective urology procedure (2002-2013). Primary outcome was duration of surgical procedure. Primary exposure was hospital type (academic or non-teaching). Negative binomial regression was used to adjust relative time estimates for age, comorbidity, obesity, anesthetic, and surgeon and hospital case volume. RESULTS: 114 225 procedures were included (circumcision n=12 280; hydrocelectomy n=7221; open radical prostatectomy n=22 951; transurethral prostatectomy n=56 066; or mid-urethral sling n=15 707). These procedures were performed in an academic hospital in 14.8%, 13.3%, 28.6%, 17.1%, and 21.3% of cases, respectively. The mean operative duration across all procedures was higher in academic centres; the additional operative time ranged from 8.3 minutes (circumcision) to 29.2 minutes (radical prostatectomy). In adjusted analysis, patients treated in academic hospitals were still found to have procedures that were significantly longer (by 10-21%). These results were similar in sensitivity analyses that accounted for the potential effect of more complex patients being referred to tertiary academic centres. CONCLUSIONS: Five common general urology operations take significantly longer to perform in academic hospitals. The reason for this may be due to the combined effect of teaching students and residents or due to inherent systematic inefficiencies within large academic hospitals.