The impact of resident training on robotic operative times: is there a July Effect?

It is unknown whether the July Effect (a theory that medical errors and organizational inefficiencies increase during the influx of new surgical residents) exists in urologic robotic-assisted surgery. The aim of this study was to investigate the impact of urology resident training on robotic operative times at the beginning of the academic year. A retrospective chart review was conducted for urologic robotic surgeries performed at a single institution between 2008 and 2019. Univariate and multivariate mix model analyses were performed to determine the association between operative time and patient age, estimated blood loss, case complexity, robotic surgical system (Si or Xi), and time of the academic year. Differences in surgery time and non-surgery time were assessed with/without resident presence. Operative time intervals were included in the analysis. Resident presence correlated with increased surgery time (38.6 min (p < 0.001)) and decreased non-surgery time (4.6 min (p < 0.001)). Surgery time involving residents decreased by 8.7 min after 4 months into the academic year (July-October), and by an additional 5.1 min after the next 4 months (p = 0.027, < 0.001). When compared across case types stratified by complexity, surgery time for cases with residents significantly varied. Cases without residents did not demonstrate such variability. Resident presence was associated with prolonged surgery time, with the largest effect occurring in the first 4 months and shortening later in the year. However, resident presence was associated with significantly reduced non-surgery time. These results help to understand how new trainees impact operating room times.

Right Colectomy for an Inflammatory Mass in the Cecum Later Found to Be Tuberculosis.

Gastrointestinal tuberculosis (TB) is a rare manifestation of extra-pulmonary TB that is known to mimic many different gastrointestinal diseases. We present a case of an 85-year-old male patient with delayed diagnosis of gastrointestinal TB who underwent colonic resection for a cecal mass that was initially suspected to be malignant. Acid-fast staining of the surgical specimen later revealed acid-fast bacilli and multiple lymph nodes with necrotizing granulomas. The purpose of this study is to stress the importance of including gastrointestinal TB as a differential diagnosis for patients with suspected colorectal malignancy, especially when initial biopsy results do not reveal malignant features.

Gender, BMI, Patient Comorbidities, and Hospital Characteristics Influence 30-Day Readmission Following Vertical Sleeve Gastrectomy.

PURPOSE: Obesity impacts 300 million people worldwide and the number continues to increase. Laparoscopic sleeve gastrectomy (LSG) is one of several bariatric procedures offered to help these individuals achieve a healthier life. Here, we report 30-day readmission rates and risk factors for readmission after gastrectomy. MATERIALS AND METHODS: We used the US Healthcare Utilization Project's Nationwide Readmission Database (NRD) from 2016 to 2019 for patients who underwent laparoscopic gastrectomy and evaluated 30-day readmission rates, comparing readmitted patients to non-readmitted patients. Confounder adjusted and unadjusted analysis were proceeded to the potential factors. RESULTS: The study population consisted of 235,563 patients, with a 3.0% readmission rate. Factors associated with a higher readmission rate included older age, male gender, higher BMI, Medicare as the primary payer, longer length of stay, higher total charge, higher Charlson Comorbidity Index, higher Elixhauser-Comorbidity Index, lower household income, non-elective admission type, and non-routine disposition. Additionally, larger hospital bed size, and private, invest-own hospital ownership were associated with higher readmission rates. After adjusting for confounders, several comorbidities and complications were found to be significantly associated with readmission, including ileus, abnormal weight loss, postprocedural complications of digestive system, acute posthemorrhagic anemia, and history of pulmonary embolism (all p < 0.001). CONCLUSIONS: Patient characteristics including age, BMI, and payment source, as well as hospital characteristics, can impact the 30-day readmission after LSG. Such factors should be considered by CMS when deciding on penalties related to readmission.

Trends in Racial and Gender Diversity Among Complex General Surgical Oncology Fellowship Trainees.

BACKGROUND: This study examines trends in racial and gender diversity of trainees within Complex General Surgical Oncology Fellowships, and compares the racial and gender proportions of trainees across different fields to assess potential barriers to increasing diversity within surgical oncology training programs. METHODS: Accredited Council for Graduate Medical Education (ACGME) data were queried to identify surgical trainees between 2013 and 2021. Trainees were identified based on self-reported race and gender and were stratified based on residency type and fellowship program type if applicable. Chi-square tests were used to assess differences between groups and trends. RESULTS: A significantly lower proportion of individuals who are underrepresented in medicine (URMs) trained in surgical oncology fellowships (8.9%) compared with both the overall trainee pool (12.8%) and general surgery residency programs (13.1%) [p < 0.05]. There was no significant increase in URM representation in surgical oncology fellowships across the study period. Furthermore, there was a significantly lower proportion of females training in surgical oncology fellowships (38.6%) compared with the overall trainee pool (45.6%) [p < 0.05]. Despite a significant increase in female representation in general surgery residency and other surgical fellowships, there was no significant increase in female representation in surgical oncology fellowships across the study period. CONCLUSIONS: This study identifies disparities in gender and racial minority representation within ACGME-accredited Complex General Surgical Oncology Fellowship training programs. While steps have been taken to expand diversity, more needs to be done to combat the systemic barriers that both racial minorities and women face during their training.

The effect of preoperative endoscopic tattooing on lymph node retrieval in colorectal cancer: a systematic review and meta-analysis.

PURPOSE: The effect of preoperative endoscopic tattooing (ET) on accurate colorectal cancer localization and resection has been well established. However, its effect on lymph node (LN) retrieval remains unclear. The purpose of this study was to systematically compare LN retrieval between patients with colorectal cancer who underwent preoperative ET and those who did not. METHODS: A systematic search for relevant studies was conducted using the following databases: PubMed, Embase, and Web of Science. Studies that compared LN retrieval in patients with colorectal cancer with and without preoperative ET were included. Weighted pooled odds ratio (OR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) for all outcomes using the random-effects model were calculated. RESULTS: 10 studies, including 2231 patients with colorectal cancer were included. Six studies reported total LN yield and showed significantly higher LN yield in the tattooed group (MD:2.61; 95% CI:1.01-4.21, P=0.001). Seven studies reported the number of patients with adequate LN retrieval and showed a significantly higher number of patients with adequate LN retrieval in the tattooed group (OR:1.89, 95% CI:1.08-3.32, P=0.03). However, subgroup analysis revealed that both outcomes were only statistically significant in patients with rectal cancer, and not in patients with colon cancer. CONCLUSIONS: Our results suggest that preoperative ET is associated with increased LN retrieval in patients with rectal cancer, but not in colon cancer. Further large-scale randomized control trials are necessary to validate our findings.

Small Bowel Evisceration Through a Perforated Stercoral Ulcer.

Stercoral ulcers are localized areas of loss of colonic mucosal integrity. They result from pressure necrosis of the colonic mucosa, secondary to chronic constipation and fecal inspissation. These ulcers are rare and, are associated with serious complications, including bleeding and perforation. We present the case of a 50-year-old woman who presented with small bowel evisceration through the anal canal secondary to extraperitoneal perforation of the rectum. The patient underwent emergent exploratory laparotomy with reduction of the bowel, followed by second look laparotomy in 24 hours. A full thickness defect in the rectum was identified and Hartmann's procedure was performed. The patient's postoperative course was uneventful. Extraperitoneal perforation and evisceration of bowel is a rare clinical entity. These cases are diagnosed early due to the obvious clinical presentation and however may be misdiagnosed as prolapse. They necessitate urgent and careful surgical planning, to ensure preservation of bowel and complete recovery.

Predictive Value of Voiding Efficiency After Active Void Trial in Men Undergoing BPH Surgery.

OBJECTIVES: To determine the predictive value of voiding efficiency on acute urinary retention after discharge from BPH surgery. MATERIALS AND METHODS: We performed a prospective observational cohort study of three surgeons' practices from 2019 to present. All men included underwent trial of void on post-operative day one after transurethral resection of prostate or Holmium enucleation of prostate . Active filling void trials were performed on all patients and voiding efficiency (percent of bladder volume emptied) was calculated. Multivariable logistic regression was performed to determine predictors of developing acute urinary retention. RESULTS: During the study period, 188 men met inclusion criteria. 110 (59%) men underwent Holmium enucleation of prostate , and 78 (41%) underwent transurethral resection of prostate. The median age of our cohort was 70 (IQR 65-75). The median prostate size was 100g (IQR 61-138g). Nineteen patients (10%) returned after discharge with acute urinary retention requiring catheterization. On post-operative day one, the median voiding efficiency was 75% (IQR 55%-94%). On multivariable analysis, patients with a voiding efficiency less than 50% were 3.8 times more likely (95% confidence interval 1.1-12.8) to develop subsequent retention compared to a voiding efficiency of greater than 75%. Increasing pre-operative prostate size was associated with lower risk of urinary retention after discharge (aOR 0.8, 95%CI 0.6-0.9). CONCLUSIONS: Voiding efficiency after an active void trial helps stratify risk of urinary retention in patients undergoing benign prostate surgery. High-risk patients include those with voiding efficiencies less than 50% and smaller pre-operative prostate sizes (<80g).

Robotic versus Laparoscopic Sigmoid Colectomy: Analysis of Healthcare Cost and Utilization Project Database.

Minimally invasive sigmoid colectomy via the laparoscopic approach (LA) has numerous benefits. We seek to compare outcomes between laparoscopic and robotic sigmoid colectomies. We analyzed the data using the National Inpatient Sample database between 2008 and 2014. Utilization and outcome measures were compared. The seven-year average number of patients who underwent elective sigmoid colectomy in the United States from 2008 to 2014 was estimated to be 197,053. Of these, 95.1 per cent were conducted using the LA. The mean age was 58.33 + 13.6 years and 58.23 + 12.8 years in laparoscopic and robotic approaches, respectively. No significant differences existed in respect to morbidities. Postoperative complications were comparable with respect to other complications. Length of hospital stay was statistically significantly shorter in the robot-assisted approach compared with the LA (mean 4.8 + 4 vs 5.7 + 5 days, respectively, P < 0.001). Patients who underwent robotic surgery had significantly higher total hospital charges than those who underwent laparoscopic surgery (median $45,057 vs $57,871 USD, P < 0.001). The advent of robot-assisted surgery has provided more options for patients and surgeons. Compared with laparoscopy, robot-assisted sigmoid colectomy has no clinical advantages in morbidity and mortality. However, the robotic approach has a significantly higher total charge to the patient.

Outcomes of an Integrated Urology-Palliative Care Clinic for Patients With Advanced Urological Cancers: Maintenance of Quality of Life and Satisfaction and High Rate of Hospice Utilization Through End of Life.

INTRODUCTION: Systematic integration of palliative care in a surgical setting is important, but has yet to be achieved. Despite evidence of early palliative care improving patients' quality of life, hospice utilization remains low. Through an integrated palliative care-urology clinic, we aim to assess the effect of early outpatient palliative care on hospice utilization, health-related quality of life (HRQOL) and satisfaction in patients with advanced urological cancers. METHODS: Participants were recruited from 2012 through 2016 in the Greater Los Angeles Veterans Affairs Hospital. We partnered with palliative care clinicians to develop an integrated urology-palliative care clinic, where participants were seen by the palliative care team on the same day as their urological visit. The 12-item Short-Form Survey, Patient Satisfaction Questionnaire Short-Form, Patient Health Questionnaire, and Brief Pain Inventory were administered at initial and subsequent visits. Follow-up questionnaire results were compared between baseline and the 2 follow-up visits, and hospice utilization rates were assessed. RESULTS: Fifty-three participants completed baseline questionnaires. Of those 22 (42%) patients completed at least one follow-up assessment. The median time for the first and second follow-up visits was 2.9 and 7.8 months, respectively. There were no significant differences in HRQOL and satisfaction between baseline and subsequent follow-up visits. A total of 36 (68%) of 53 participants who were enrolled at the start of the study were deceased. Of those, 29 (81%) expired within a home or inpatient hospice. CONCLUSIONS: Rates of hospice use were high in an integrated palliative care-urology model. Health-related quality of life and satisfaction did not worsen over time.

A Case of an Invisible Ureteral Stent.

A 35-year-old female presented to the emergency department with fevers and flank pain and was found on computed tomography to have a retained ureteral stent that was placed during emergent ureteral repair eight years prior. The stent was only faintly visible on computed tomography and was completely radiolucent on fluoroscopy. We believe that the stent's radiopaque coating degraded and was lost after years of exposure to urine. This case suggests that a stent may become undetectable on standard imaging if left in place for a long enough period of time.

The Effect of Formal Robotic Residency Training on the Adoption of Minimally Invasive Surgery by Young Colorectal Surgeons.

OBJECTIVE: The minimally invasive approach to colorectal surgery is still underused. Only 50% to 60% of colectomies and 10% to 20% of rectal resections for cancer are performed laparoscopically. The increasing adoption of the robotic platform for colorectal surgery warrants re-evaluation of minimally invasive surgery (MIS) training techniques. Although considering lessons learned from past laparoscopic training, a standardized national robotic training program for colon and rectal surgery residents was developed and implemented in 2011. The objective of this study was to assess the effect of this program on the usage of MIS in practice following residency training. DESIGN: An internet-based 18 question survey was sent to all colon and rectal surgeons who graduated from ACGME-approved colon and rectal surgery residencies from 2013 to 2016. The survey questions were designed to determine MIS practice patterns for young colon and rectal surgeons after residency training for those who participated in the standardized national robotics training course when compared to those who did not participate. Grouped bar charts with error bars are presented along with summary statistics to offer a descriptive overview of training experiences by cohort. SETTING/PARTICIPANTS: This study is a survey of colon and rectal surgeons who completed colon and rectal surgery residencies to include all 52 programs across the United States. RESULTS: The overall survey response rate was 37.2% (109 of 293). Most (79.8%) of the colon and rectal surgery resident respondents participated in the formal robotic training course. The average respondent reported that 84% of colectomy cases and 74.8% of rectal resections done after residency training by all respondents were by the MIS approach. The laparoscopic approach was most prevalent for colectomies for both course participants (laparoscopic 55.1%, hand assisted lap 14.5%, and robotic 15.7%) and nonparticipants (laparoscopic 53.8%, hand assisted lap 12.3%, and robotic 15.9%). For rectal resections, the robotic approach was the preferred option for course participants (laparoscopic 24.5%, hand assist lap 14.0%, and robotic 39.2%) whereas laparoscopic and open approaches were used more often by nonparticipants (laparoscopic 36.8%, hand assist lap 8.0%, robotic 26.8%, and open 28.4%). Barriers to robotic implementation included lack of robotic mentors, inadequate robotic assistance, and the preference for the laparoscopic approach. CONCLUSION: The usage of MIS by young recently fellowship-trained colorectal surgeons is higher than previously reported. The proportion of rectal cases done robotically is higher compared to colon cases and with an apparent decrease in open rather than laparoscopic surgery, suggesting selective usage of robotic surgery for more challenging cases in the pelvis. Methods to more effectively increase the usage of minimally invasive approaches in colorectal surgery warrant further evaluation.

Advance Care Planning and Patient Preferences in a Feasibility Pilot Study to Improve End-of-Life Communication among Men with Metastatic Urological Malignancies.

INTRODUCTION: Rates of advance care planning for patients with cancer are poor despite efforts to enhance discussions regarding goals of care. Good patient-physician communication is critical to providing quality end-of-life care and, thus, it is important to identify effective interventions to improve systems through which patient preferences are addressed. METHODS: To improve rates of advance care planning as well as examine patient preferences regarding end-of-life care, we developed an integrated urology-palliative care clinic. All patients with a new diagnosis of a metastatic urological malignancy or castration resistant prostate cancer seen in a urology clinic within the Veterans Affairs Greater Los Angeles Healthcare System were offered a palliative care referral to be performed immediately after their urology appointment. The primary outcome was completion of an advance directive or POLST (Physician Orders for Life-Sustaining Treatment) form and the secondary outcome was patient preference regarding end-of-life care. RESULTS: A total of 59 patients were enrolled in the study between February 2012 and October 2016, and no patients were lost or excluded. There were 25 eligible patients who declined enrollment. Overall 85% of patients completed an advance directive or POLST form, and 98% chose to withhold cardiopulmonary resuscitation, advanced cardiac life support and artificially administered nutrition. CONCLUSIONS: High levels of advance care planning are achievable in an integrated urology-palliative care clinic and the majority of patients with a terminal illness are averse to aggressive end-of-life care.

Engaging patients in complex clinical decision-making: Successes, pitfalls, and future directions.

BACKGROUND: By 2022, there will be 18 million predicted cancer survivors, which is an estimated 30% more than the number of survivors in 2012. In prostate cancer alone, the most common cancer in American men other than skin cancer, 1 in 7 men will be diagnosed during their lifetime. Nevertheless, only approximately 1 in 39 will actually die of the disease. Although life expectancy is often good, these men have multiple treatment management options to choose from, including active surveillance, surgery, or radiotherapy, each of which carries its own array of long-term adverse effects. The same applies to renal cancer where patient have to sift through information to decide among active surveillance, partial nephrectomy, racial nephrectomy, robotic vs. open surgery, and ablation. BASIC PROCEDURES: Ultimately, patient, providers, and stakeholders lack high-quality evidence to effectively guide treatment decisions, and these decisions become even harder to discern when considering end-of-life care, palliative care, and the ethics regarding the new End of Life Option Act. As of November 1, 2016, the number of open urologic cancer clinical trials listed on ClinicalTrials.gov was 843. MAIN FINDINGS: Although we continue to make tremendous strides in urologic cancer care, our options for choosing the best treatment from a patient and provider standpoint are seemingly growing murkier. We need to continue to understand how health-related quality of life varies from patient to patient, and ultimately, incorporate patient preferences and values into the treatment decision in order to make high-quality treatment decisions. CONCLUSIONS: The remained of this articles will focus on the significant strides made in urologic oncology regarding these difficult decisions from localized disease to end-of-life care and also will detail what needs to be done as we continue to pivot forward.

Patient-reported outcome measures in urology.

PURPOSE OF REVIEW: Many urologic treatments have similar clinical outcomes, necessitating alternative methods to discriminate between options. Patient-reported outcome measures (PROMs) have become the new standard for evaluating the patient experience, and their use has drastically increased over the past decade. The purpose of this review is to discuss the status of PROMs in urology, highlight commonly used tools and address their future direction. RECENT FINDINGS: An increasing number of urology-specific PROMs tools have been developed and validated. An increased focus on patient-centered care has provided an impetus for their rise in use. Implementation of PROMs has transitioned from being primarily descriptive in nature to producing actionable findings. Many PROMs are now implemented in daily clinical practice. The future of PROMs will involve new instrument development, integration into clinical practice and the use of PROMs as performance measures. SUMMARY: PROMs are effective tools for characterizing symptom burden and health-related quality of life. With increasing clinical implementation, PROMs are playing an increasing role in patients' clinical decision-making.