Comparison between complication rates of laser prostatectomy electrocautery transurethral resection of the prostate: A population-based study.

INTRODUCTION: We compare the complication rates and length of stay (LOS) of laser transurethral resection of the prostate (L-TURP) versus electrocautery transurethral resection of the prostate (E-TURP) in a population-based cohort. L-TURP has shown enhanced intraoperative safety and equivalent efficacy relative to E-TURP in several high volume centres. METHODS: Relying on the Florida Datafile as part of the Healthcare Cost and Utilization Project State Inpatient Databases (SID) between 2006 and 2008, we identified 8066 men with benign prostate hyperplasia who underwent L-TURP or E-TURP. Chi-square and Mann-Whitney tests were used to compare baseline characteristics. A multivariable linear regression model was used to analyze the effect of L-TURP versus E-TURP on complication rates and LOS. RESULTS: Overall complication rates did not differ significantly for L-TURP compared to E-TURP in univariable (8.8 vs. 7.4%, p = 0.1) and multivariable analyses (odds ratio [OR]: 1.06, confidence interval [CI]: 0.85-1.32, p = 0.6). Individuals undergoing E-TURP were less likely to experience a LOS in excess of 1 day (46.2 vs. 59.7%, p < 0.001). A lower risk to experience a LOS in excess of 1 day was confirmed for patients undergoing L-TURP after a multivariable linear regression model (OR: 0.37, CI: 0.23-0.58, p < 0.001), but not for a LOS in excess of 2 days (OR: 0.96, CI: 0.83-1.10, p = 0.2). CONCLUSIONS: Patient characteristics and perioperative safety were similar for L-TURP and E-TURP patients. However, LOS patterns demonstrated a modest benefit for L-TURP compared to E-TURP patients.

Laparoscopic radical nephrectomy vs laparoscopic or open partial nephrectomy for T1 renal cell carcinoma: comparison of complication rates in elderly patients during the initial phase of adoption.

OBJECTIVE: To assess postoperative complication profiles and 30-day mortality (30 dM) in older patients undergoing either laparoscopic radical nephrectomy (LRN) compared with open partial nephrectomy (OPN) or laparoscopic partial nephrectomy (LPN) for early stage renal cell carcinoma. METHODS: Using the Surveillance, Epidemiology, and End Results-Medicare linked database, 2277 patients aged>65 years with T1 renal cell carcinoma, who underwent LRN, OPN, or LPN were identified (1992-2005). Surgical and medical complications and 30 dM after nephrectomy were abstracted. Bivariate and multivariate logistic regression analyses were performed. RESULTS: Relative to LRN, the rate of surgical complications was higher for OPN (28% vs 20%; P<.001) and LPN (29% vs 20%; P=.01). These differences persisted after multivariate adjustment for patient and tumor characteristics (OPN: odds ratio, 1.6; 95% confidence interval, 1.28-1.91; P<.001; LPN: odds ratio, 1.6; 95% confidence interval, 1.13-2.39; P=.01). Specifically, relative to LRN, OPN was associated with a 7% higher rate of genitourinary complications (13% vs 20%; P<.001). Similarly, relative to LRN, LPN was associated with a 7% higher rate of genitourinary complications (13% vs 20%; P=.001) and with a 4% higher rate of hemorrhagic complications (8% vs 4%; P=.02). No statistically significant differences were recorded for all other surgical and/or medical complication types and 30 dM (all P≥.2). CONCLUSION: The complication and 30-dM rates were not different between LRN, OPN, and LPN groups. Exceptions include genitourinary complications that favor LRN relative to OPN and LPN and hemorrhagic complications that favor LRN relative to LPN. It is doubtful that these results should discourage the use of partial nephrectomy relative to LRN in older patients.

Management of localized kidney cancer: calculating cancer-specific mortality and competing risks of death for surgery and nonsurgical management.

BACKGROUND: For elderly individuals with localized renal cell carcinoma (RCC), surgical intervention remains the primary treatment option but may not benefit patients with limited life expectancy. OBJECTIVE: To calculate the trade-offs between surgical excision and nonsurgical management (NSM) with respect to competing causes of mortality. DESIGN, SETTING, AND PARTICIPANTS: Relying on a cohort of Medicare beneficiaries, all patients with nonmetastatic node-negative T1 RCC between 1988 and 2005 were abstracted. INTERVENTION: All patients were treated with partial nephrectomy (PN), radical nephrectomy (RN), or NSM. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cancer-specific mortality (CSM) and other-cause mortality (OCM) rates were modeled through competing-risks regression methodologies. Instrumental variable analysis was used to account for the potential biases associated with measured and unmeasured confounders. RESULTS AND LIMITATIONS: A total of 10 595 patients were identified. In instrumental variable analysis, patients treated with PN (hazard ratio [HR]: 0.45; 95% confidence interval [CI], 0.24-0.83; p=0.01) or RN (HR: 0.58; 95% CI, 0.35-0.96; p=0.03) had a significantly lower risk of CSM than those treated with NSM. In subanalyses restricted to patients ≥ 75 yr, the instrumental variable analysis failed to detect any statistically significant difference between PN (HR: 0.48; p=0.1) or RN (HR: 0.57; p=0.1) relative to NSM with respect to CSM. Similar trends were observed in T1a RCC only. CONCLUSIONS: PN or RN is associated with a reduction of CSM among older patients diagnosed with localized RCC, compared with NSM. The same benefit failed to reach statistical significance among patients ≥ 75 yr. The harms of surgery need to be weighed against the marginal survival benefit for some patients.

Survival after nephroureterectomy for upper tract urothelial carcinoma: a population-based competing-risks analysis.

OBJECTIVES: To examine the rates of cancer-specific mortality, other-cause and bladder cancer mortality in patients with upper-tract urothelial carcinoma undergoing radical nephroureterectomy. METHODS: Relying on the Surveillance, Epidemiology, and End Results database, 9899 patients treated with radical nephroureterectomy were identified. A 20-strata graphical aid was constructed using age (<60, 60-69, 70-79, >79 years) and American Joint Committee on Cancer/TNM stage (pT1N0/x , pT2N0/x , pT3N0/x , pT4N0/x , pTany pN1₋3) as stratifying variables. The 5-year cancer-specific mortality, other-cause and bladder cancer mortality rates were generated through competing-risks Poisson regression methodologies. Multivariable competing-risks regression models were used to test the effect of age and stage on three different end-points: cancer-specific mortality, other-cause and bladder cancer mortality. RESULTS: Overall, 1797 (18.1%), 891 (9.1%) and 3090 (31.2%) patients died of cancer-specific mortality, other-cause and bladder cancer mortality, respectively. Following stratification according to age and stage, the proportion of patients who succumbed to cancer-specific mortality (11.7-21.9%) and other-cause mortality (8.9-30.4%) increased with age. In contrast, with increasing stage, the proportion of patients who died of cancer-specific mortality increased (7.2-37.5%), whereas the proportion of other-cause mortality remained stable (18.9-22.0%). The rate of bladder cancer mortality increased with advancing stage. At multivariable competing-risk regression model, besides age and stage, women, type of surgery, grade and location were associated with higher cancer-specific mortality. Furthermore, ureteral location, stage and grade were associated with bladder cancer mortality. CONCLUSIONS: The developed graphical aid for prediction of cancer-specific mortality, other-cause, and bladder cancer mortality according to age and stage in patients with upper-tract urothelial carcinoma undergoing radical nephroureterectomy can be useful for physicians and patients during clinical counseling.

Radical prostatectomy vs radiotherapy vs observation among older patients with clinically localized prostate cancer: a comparative effectiveness evaluation.

OBJECTIVE: To compare efficacy between radical prostatectomy (RP), radiotherapy and observation with respect to overall survival (OS) in patients with clinically localized prostate cancer (PCa). METHODS: Using data (1988-2005) from the Surveillance, Epidemiology, and End Results-Medicare linked database, 67 087 men with localized PCa were identified. The prevalence of the initial treatment strategy was quantified according to patients' life expectancy ([LE] <10 vs ≥10 years) at initial diagnosis and according to tumour stage. To reduce the unmeasured bias associated with treatment, we performed an instrumental variable analysis. Stratified (by stage and LE) Cox regression and competing-risks regression analyses were generated for the prediction of OS and cancer-specific mortality, respectively. RESULTS: Among patients with <10 years of LE, most were treated with radiotherapy (49%) or observation (47%). Among patients with ≥10 years of LE, most received radiotherapy (49%), followed by RP (26%). In men with <10 years of LE, RP and radiotherapy were not different with respect to OS (hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.45-1.48, P = 0.499). Conversely, in men with ≥10 years of LE, RP was associated with an improved OS compared with observation (HR: 0.59, 95% CI: 0.49-0.71, P < 0.001) and radiotherapy (HR: 0.66, 95% CI: 0.56-0.79, P < 0.001). Similar results were recorded in competing-risks regression analyses. CONCLUSION: In patients with an estimated LE ≥10 years at initial diagnosis, RP was associated with improved survival compared with radiotherapy and observation, regardless of disease stage.

Health care-associated infections after major cancer surgery: temporal trends, patterns of care, and effect on mortality.

BACKGROUND: Approximately 1.7 million individuals per year are affected with health care-associated infections (HAIs) in the United States. The authors examined trends in the incidence of HAI after major cancer surgery (MCS) and risk factors for HAI to describe the effects of HAI on mortality after MCS. METHODS: Patients undergoing 1 of 8 MCS procedures within the Nationwide Inpatient Sample between 1999 and 2009 were identified (n = 2,502,686). Generalized linear regression models were used to estimate the impact of the primary predictors (procedure type, age, sex, race, insurance status, Charlson comorbidity index, hospital volume, and hospital bed size) on the odds of HAI and in-hospital mortality. Trends in incidence were evaluated with linear regression. RESULTS: Overall, MCS-associated HAI incidence increased 2.7% per year (P < .001), whereas mortality decreased 1.3% per year (P < .001). Male gender (odds ratio [OR], 1.12, 95% confidence interval [CI], 1.10-1.14), advancing age (OR, 1.02; 95% CI, 1.02-1.02), black race (OR, 1.26; 95% CI, 1.21-1.31), ≥1 comorbidities (OR, from 1.08 [95% CI, 1.04-1.13] to 1.31 [95% CI, 1.27-1.35]), and nonprivate insurance (OR, from 1.18 [95% CI, 1.15-1.22] to 1.67 [95% CI, 1.59-1.76]) were associated with an increased odds of HAI on multivariable analysis. Conversely, increasing hospital volume was associated with lower odds of HAI (OR, 0.999; 95% CI, 0.99-0.99). Patients with MCS-associated HAI had increased odds of mortality (OR, 8.66; 95% CI, 8.51-8.82). CONCLUSIONS: Between 1999 and 2009, the incidence of MCS-associated HAI events increased; however, HAI-associated mortality decreased. That said, significant disparities exist in the hospital and demographic attributes associated with MCS-associated HAI, with attendant health policy implications. Moreover, HAI remains detrimentally linked to mortality during hospitalization.