Racial Disparities at Mixed-Race and Minority Hospitals : Treatment of African American Males With High-Grade Splenic Injuries.

INTRODUCTION: Racial and socioeconomic disparities in health access and outcomes for many conditions is well known. However, for time-sensitive high-acuity diseases such as traumatic injuries, disparities in access and outcomes should be significantly diminished. Our primary objective was to characterize racial disparities across majority, mixed-race, and minority hospitals for African American ([AA] vs White) males with high-grade splenic injuries. METHODS: Data from the National Trauma Data Bank were utilized from 2007 to 2015; 24 855 AA or White males with high-grade splenic injuries were included. Multilevel mixed-effects regression analysis was used to evaluate disparities in outcomes and resource allocation. RESULTS: Mortality was significantly higher for AA males at mixed-race (OR 1.6; 95% CI 1.3-2.1; P < .001) and minority (OR 2.1; 95% CI 1.5-3.0; P < .001) hospitals, but not at majority hospitals. At minority hospitals, AA males were significantly less likely to be admitted to the intensive care unit (OR 0.7; 95% CI, 0.49-0.97; P = .04) and experienced a significantly longer time to surgery (IRR 1.5; P = .02). Minority hospitals were significantly more likely to have failures from angiographic embolization requiring operative intervention (OR 2.2, P = .009). At both types of nonmajority hospitals, AA males with penetrating injuries were more likely to be managed with angiography (mixed-race hospitals: OR 1.7; P = .046 vs minority hospitals: OR 1.6; P = .08). DISCUSSION: While multiple studies have shown that minority hospitals have increased mortality compared to majority hospitals, this study found this disparity only existed for AAs.

Thirty-day clinical outcomes of the Evolut PRO self-expanding transcatheter aortic valve: the international FORWARD PRO study.

AIMS: The Evolut PRO is a new transcatheter heart valve with an outer pericardial wrap intended to reduce paravalvular leak and facilitate tissue ingrowth. We aimed to evaluate the clinical performance and safety of the Evolut PRO valve in standard practice. METHODS AND RESULTS: FORWARD PRO is a prospective, multinational, multicentre observational study. Transcatheter aortic valve implantation with the Evolut PRO valve (23, 26, or 29 mm) was attempted in 629 non-consecutive patients from 39 centres from February 2018 to January 2019. The primary endpoint was the rate of all-cause mortality at 30 days compared to a pre-specified performance goal. An independent clinical events committee adjudicated safety endpoints based on VARC-2 definitions. All echocardiograms were centrally assessed by an independent core laboratory (Mayo Clinic, Rochester, MN, USA). Baseline characteristics included mean age 81.7±6.1 years, 61.8% female, STS score 4.7±3.3%, and 33.6% were frail. All-cause mortality at 30 days was 3.2%, which was lower than the pre-specified performance goal of 5.5% (p=0.004). Greater than mild AR was present in 1.8% of patients at discharge. CONCLUSIONS: The FORWARD PRO study confirmed the safety and efficacy of the Evolut PRO transcatheter aortic valve system with an external pericardial wrap. ClinicalTrials.gov Identifier: NCT03417011

Racial Disparities at Mixed-Race and Minority Hospitals: Treatment of African American Males With High-Grade Splenic Injuries.

INTRODUCTION: Racial and socioeconomic disparities in health access and outcomes for many conditions are well known. However, for time-sensitive high-acuity diseases such as traumatic injuries, disparities in access and outcomes should be significantly diminished. Our primary objective was to characterize racial disparities across majority, mixed-race, and minority hospitals for African American (AA) versus white males with high-grade splenic injuries. METHODS: Data from the National Trauma Data Bank was utilized from 2007 to 2015. A total of 24 855 AA or white males with high-grade splenic injuries were included. Multilevel mixed effects regression analysis was used to evaluate disparities in outcomes and resource allocation. RESULTS: Mortality was significantly higher for AA males at mixed-race (odds ratio [OR] 1.6; 95% CI 1.3-2.1; P < .001) and minority (OR 2.1; 95% CI 1.5-3.0; P < .001) hospitals, but not at majority hospitals. At minority hospitals, AA males were significantly less likely to be admitted to the intensive care unit (OR 0.7; 95% CI 0.49-0.97; P = .04) and experienced a significantly longer time to surgery (IRR 1.5; P = .02). Minority hospitals were significantly more likely to have failures from angiographic embolization requiring operative intervention (OR 2.2; P = .009). At both types of nonmajority hospitals, AA males with penetrating injuries were more likely to be managed with angiography (mixed-race hospitals: OR 1.7; P = .046 vs minority hospitals: OR 1.6; P = .08). DISCUSSION: While multiple studies have shown that minority hospitals have increased mortality compared to majority hospitals, this study found this disparity only existed for AAs.

Disparities in Bladder Cancer Treatment and Survival Amongst Elderly Patients with a Pre-existing Mental Illness.

BACKGROUND: Pre-existing mental illness is known to adversely impact cancer care and outcomes, but this is yet to be assessed in the bladder cancer setting. OBJECTIVE: To characterize the patterns of care and survival of elderly patients with a pre-existing mental illness diagnosed with bladder cancer. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective analysis of patients enrolled in Surveillance, Epidemiology, and End Results (SEER)-Medicare. A population-based sample was considered. Elderly patients (≥68 yr old) with localized bladder cancer from 2004 to 2011 were stratified by the presence of a pre-existing mental illness at the time of cancer diagnosis: severe mental illness (consisting of bipolar disorder, schizophrenia, and other psychotic disorders), anxiety, and/or depression. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We performed multivariable logistic regression analyses to compare the stage of presentation and receipt of guideline-concordant therapies (radical cystectomy for muscle-invasive disease). Survival between patients with a pre-existing mental disorder and those without were compared using Kaplan-Meier analyses with log-rank tests. RESULTS AND LIMITATIONS: Of 66 476 cases included for analysis, 6.7% (n=4468) had a pre-existing mental health disorder at the time of cancer diagnosis. These patients were significantly more likely to present with muscle-invasive disease than those with no psychiatric diagnosis (23.0% vs 19.4%, p-<0.01). In patients with muscle-invasive disease, those with severe mental illness (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.37-0.81) and depression only (OR 0.71, 95% CI 0.58-0.88) were significantly less likely to undergo radical cystectomy or trimodality therapy. Patients in this subgroup who underwent radical cystectomy had significantly superior overall (hazard ratio [HR] 0.54, 95% CI 0.43-0.67) and disease-specific survival (HR 0.76, 95% CI 0.58-0.99) compared with those who did not receive curative treatment. CONCLUSIONS: Elderly patients with muscle-invasive bladder cancer and a pre-existing mental disorder were less likely to receive guideline-concordant management, which led to poor overall and disease-specific survival. PATIENT SUMMARY: Patients with severe mental illness and depression were only significantly less likely to undergo radical cystectomy for muscle-invasive disease, that is, to receive guideline-concordant treatment. Overall survival and disease-specific survival were inferior in patients with a pre-existing mental disorder, and were especially low in those who did not receive guideline-concordant care.

Persistent muscle-invasive bladder cancer after neoadjuvant chemotherapy: an analysis of Surveillance, Epidemiology and End Results-Medicare data.

OBJECTIVES: To evaluate whether patients with persistent muscle-invasive bladder cancer (MIBC) after undergoing neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) have worse overall survival (OS) and cancer-specific survival (CSS) than patients with similar pathology who undergo RC alone. MATERIALS AND METHODS: Using the Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified the records of patients with pT2-4N0M0 disease who underwent RC, with and without NAC, for MIBC between 2004 and 2011. To evaluate survival outcomes in those with MIBC after NAC vs patients with MIBC who underwent RC alone, we used Kaplan-Meier time-to-event analysis and Cox proportional hazard regression modelling. Landmark analysis was conducted to mitigate immortal time bias. Propensity scoring was used to decrease the risk of selection bias. RESULTS: Of the 1 886 patients with persistent pT2-4 disease at the time of RC, 1505 underwent RC alone and 381 received NAC + RC. After adjusting for confounders, the propensity-weighted risk of death from bladder cancer after diagnosis did not differ between the groups (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.72-1.08; P = 0.23); however, the risk of death from all causes was worse in the RC-alone group (HR 0.79, 95% CI0.67-0.94; P = 0.006). CONCLUSIONS: Patients who had persistent MIBC after platinum-based NAC + RC vs RC alone derived an OS benefit but not a CSS benefit from NAC. This may represent a selection bias favouring patients who were selected for NAC; however, the OS benefit was not evident in patients with persistent pT3-T4N0M0 disease. This study underscores the importance of future research investigating methods to identify patients who will respond to NAC for bladder cancer. It also highlights the need to consider adjuvant therapy in patients who have persistent MIBC after NAC.

Guidelines for Reporting of Statistics for Clinical Research in Urology.

Investigators submitting clinical research to European Urology are encouraged to follow guidelines for the reporting of statistics. Adoption of the guidelines will not only increase the quality of published papers, but also improve statistical knowledge in urology in general.

Guidelines for reporting of statistics for clinical research in urology.

In an effort to improve the quality of statistics in the clinical urology literature, statisticians at European Urology, The Journal of Urology, Urology and BJU International came together to develop a set of guidelines to address common errors of statistical analysis, reporting, and interpretation. Authors should 'break any of the guidelines if it makes scientific sense to do so', but would need to provide a clear justification. Adoption of the guidelines will in our view not only increase the quality of published papers in our journals but improve statistical knowledge in our field in general.

Finasteride does not prevent bladder cancer: A secondary analysis of the Medical Therapy for Prostatic Symptoms Study.

BACKGROUND: Preclinical models have demonstrated that androgen receptor modulation can influence bladder carcinogenesis with an inverse association observed between serum androgen levels and bladder cancer (BC) incidence. It is still unclear whether 5α-reductase inhibitors, by preventing the conversion of testosterone to dihydrotestosterone, have a similar effect. This study aims to evaluate whether dihydrotestosterone-mediated androgen activity has an impact on BC incidence in a cohort of men included in a clinical trial of finasteride vs. placebo with rigorous compliance monitoring. METHODS: A secondary analysis was performed on all patients enrolled in the Medical Therapy for Prostatic Symptoms (MTOPS) Study and included in the biopsy substudy. Men were stratified into groups based on receiving finasteride and the incidence of BC compared between the groups. RESULTS: After exclusions for poor finasteride compliance (n = 338) and missing serum hormone results (n = 9), 2,700 men were eligible for analysis. In total, 0.8% (n = 18) of the cohort was diagnosed with BC during the trial period. There was no difference in the incidence of BC between men who received finasteride and those who did not (0.74% [n = 9] vs. 0.61% [n = 9], P = 0.67). Neither serum testosterone levels, prostate cancer diagnosis nor urinary bother (measured by International Prostate Symptom Score) demonstrated an association with BC diagnosis. These relationships were consistent in the subgroup of men in the biopsy substudy. CONCLUSION: There was no observable relationship between decreased dihydrotestosterone levels and BC diagnosis.

Racial Disparities in Surgical Outcomes Among Males Following Major Urologic Cancer Surgery.

INTRODUCTION: Disparities in healthcare outcomes between races have been extensively described; however, studies fail to characterize the contribution of differences in distribution of covariates between groups and the impact of discrimination. This study aims to characterize the degree to which clinicodemographic factors and unmeasured confounders are contributing to any observed disparities between non-Hispanic white and black males on surgical outcomes after major urologic cancer surgery. METHODS: Non-Hispanic white and black males undergoing radical cystectomy, nephrectomy, or prostatectomy for cancer in the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016 were included in this analysis. The outcome of interest was Clavien III-V complications. Analysis was conducted in 2017 using the Peters-Belson method to compare the disparity in outcomes while adjusting for 13 important demographic and clinical characteristics. RESULTS: Of the 15,693 cases included with complete data, 13.0% (n=2,040) were black. There was a significantly increased rate of unadjusted Clavien III and V complications between white versus black males for radical cystectomy (21.9% vs 10.1%, p=0.005); nephrectomy (6.4% vs 3.9%, p=0.028); and radical prostatectomy (2.3% vs 1.6%, p=0.046). Adjusting for differences in age, BMI, American Society of Anesthesiologists score, functional status, smoking history, and comorbidities including diabetes, chronic obstructive pulmonary disease, heart failure, renal failure, bleeding disorder, steroid use, unintentional weight loss, and hypertension between the groups could not explain the disparity in complications after radical cystectomy; the unexplained discrepancy was an absolute excess of 11.8% (p=0.01) in black males. There was an unexplained excess of complications in black males undergoing radical prostatectomy and nephrectomy but neither reached statistical significance. CONCLUSIONS: Black males undergoing radical cystectomy for cancer experienced higher complication rates than white males. Unexplained differences between the black and white males significantly contributed to the disparity in outcomes, which suggests that unmeasured factors, such as the quality of surgical or perioperative care, are playing a considerable role in the observed inequality. SUPPLEMENT INFORMATION: This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Health System Affiliation and 30-Day Readmission After Heart Attack in Black Men.

INTRODUCTION: Black patients who experience acute myocardial infarction and receive care in high minority-serving hospitals have higher readmission rates. This study explores how hospital system affiliation (centralized versus decentralized/independent) impacts 30-day readmissions after acute myocardial infarction in black men. METHODS: In 2018, the Healthcare Cost and Utilization Project State Inpatient Database (2009-2013) was used to observe 30-day readmission for acute myocardial infarction by race, and data from the American Hospital Association Annual Survey of Hospitals (2009-2013) to determine hospital system affiliation for the states Arizona, California, North Carolina, and Wisconsin. A series of hierarchic logistic regressions were conducted to determine if hospital system affiliation mediates the relationship between race and 30-day readmission. RESULTS: Of 63,743 hospitalizations for acute myocardial infarction among men between 2009 and 2013, black men accounted for 7.1% of hospitalizations and 8.0% of readmissions. In both models, race significantly predicted 30-day readmission (unadjusted OR=1.25, 95% CI=1.14, 1.37, p<0.001; AOR=1.13, 95% CI=1.03, 1.25, p=0.046). After controlling for system type, black men were more likely to be readmitted after acute myocardial infarction than white men in both models (unadjusted OR=1.25, 95% CI=1.14, 1.38, p<0.001; AOR=1.14, 95% CI=1.03, 1.25). There was no difference in odds of being readmitted by race and hospital system type (unadjusted OR=0.88, 95% CI=0.25, 3.07, p=0.84, AOR=1.02, 95% CI=0.21, 5.10, p=0.98). CONCLUSIONS: Black men appear to be more likely to be readmitted after acute myocardial infarction. Centralization does not appear to mediate the relationship between race and 30-day readmissions for acute myocardial infarction. SUPPLEMENT INFORMATION: This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Racial and Geographic Disparities in Hepatocellular Carcinoma Outcomes.

INTRODUCTION: Hepatocellular carcinoma disproportionately affects minorities. Southern states have high proportions of black populations and prevalence of known risk factors. Further research is needed to understand the role of southern geography in hepatocellular carcinoma disparities. This paper examined racial disparities in hepatocellular carcinoma incidence, demographics, tumor characteristics, receipt of treatment, and all-cause mortality in southern and non-southern cancer registries. METHODS: Surveillance Epidemiology and End Results data were probed in 2015 to identify 43,868 patients diagnosed with hepatocellular carcinoma from 2000 to 2012 (5,455 in southern registries [Atlanta, Louisiana, and Rural and Greater Georgia]). RESULTS: Southern registries showed steeper increases of age-adjusted hepatocellular carcinoma incidence (from 2.89 to 5.29cases/100,000 people) versus non-southern areas (from 3.58 to 5.54cases/100,000 people). Blacks were over-concentrated in southern registries (32% vs 10%). Compared with whites, blacks were significantly younger at diagnosis, more likely diagnosed with metastasis, and less likely to receive surgical therapies in both registry groups. After adjustment, blacks had a significantly higher risk of all-cause mortality compared with whites in southern (hazard ratio=1.10, p=0.007) and non-southern areas (hazard ratio=1.08, p<0.001). For overall populations, southern registries had higher risk of all-cause mortality versus non-southern registries (hazard ratio=1.13, p<0.001). CONCLUSIONS: Age-adjusted incidence rates of hepatocellular carcinoma are plateauing overall, but are still rising in southern areas. Race and geography had independent associations with all-cause mortality excess risk among patients with hepatocellular carcinoma. Further studies are needed to understand the root causes of potential mortality risk excess among overall populations with hepatocellular carcinoma living in the South. SUPPLEMENT INFORMATION: This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Penetrating Colon Trauma Outcomes in Black and White Males.

INTRODUCTION: Racial disparities have been both published and disputed in trauma patient mortality, outcomes, and rehabilitation. In this study, the objective was to assess racial disparities in patients with penetrating colon trauma. METHODS: The National Trauma Data Bank was searched for males aged ≥14years from 2010 through 2014 who underwent operative intervention for penetrating colon trauma. The primary outcomes for this study were stoma formation and transfer to rehabilitation; secondary outcomes were postoperative morbidity and mortality. Analyses were performed in 2016-2018. RESULTS: There were 7,324 patients identified (4,916 black, 2,408 white). Black and white patients underwent fecal diversion with stoma formation at a similar rate (19.6% vs 18.5%, p=0.28). Black patients were more likely than white patients to be uninsured (self-pay; 37.1% vs 29.9%) and more likely to be injured by firearms (88.3% vs 70.2%, p<0.001), but had a lower overall postoperative morbidity rate (52.6% vs 55.3%, p=0.04). The odds of stoma formation (OR=0.92, 95% CI=0.78, 1.09, p=0.35) and the odds of transfer to rehabilitation (OR=1.03, 95% CI=0.82, 1.30, p=0.78) were similar for black versus white patients. CONCLUSIONS: Black patients experienced similar rates of stoma formation and transfer to rehabilitation as white patients with penetrating colon trauma. Multivariate analysis confirmed expected findings that trauma severity increased the odds of receiving an ostomy and rehabilitation placement. The protocol-based management approach to emergency trauma care potentially decreases the risk for the racial biases that could lead to healthcare disparities. SUPPLEMENT INFORMATION: This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Extended outpatient chemoprophylaxis reduces venous thromboembolism after radical cystectomy.

PURPOSE: Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism, is a common cause of morbidity and mortality after radical cystectomy. The purpose of our study was to evaluate the utility of extended outpatient chemoprophylaxis against VTE after radical cystectomy-with a focus on any reduction in the incidence of VTE, including DVT and pulmonary embolism. MATERIALS AND METHODS: Beginning in April 2013, we prospectively instituted a policy of extending inpatient VTE prophylaxis with subcutaneous heparin/enoxaparin for 30 days postoperatively. For this study, we reviewed the electronic medical records of all patients who underwent radical cystectomy at our institution from January 2012 through December 2015. The experimental group (n = 79) received extended outpatient chemoprophylaxis against VTE; the control group (n = 51) received no chemoprophylaxis after discharge. The primary outcome was the 90-day incidence of VTE. The secondary outcomes included the overall complication rate, the hemorrhagic complication rate, as well as the rate of readmission within 30 days of hospital discharge. RESULTS: The experimental group experienced a significantly lower rate of DVT (5.06%), assessed as of 90 days postoperatively, than the control group (17.6%): a relative risk reduction of 71.3% (P = 0.021). We found no significant differences in secondary outcomes between the 2 groups, including the overall complication rate (54.4% vs. 68.6%), the hemorrhagic complication rate (3.7% vs. 2.0%), and the readmission rate (21.5% vs. 29.4%). CONCLUSION: Extended outpatient chemoprophylaxis significantly reduced the incidence of VTE.

Decreased Use of Sphincter-Preserving Procedures Among African Americans with Rectal Cancer.

BACKGROUND: Improved multimodality rectal cancer treatment has increased the use of sphincter-preserving surgery. This study sought to determine whether African American (AA) patients with rectal cancer receive sphincter-preserving surgery at the same rate as non-AA patients. METHODS: The study used the Nationwide Inpatient Sample for years 1998-2012 to compare AA and non-AA patients with rectal cancer undergoing low anterior resection or abdominoperineal resection. The logistic regression model was used to adjust for age, gender, admission type, Elixhauser comorbidity index, and hospital factors such as size, location (urban vs.rural), teaching status, and procedure volume. RESULTS: The search identified 22,697 patients, 1600 of whom were identified as AA. After adjustment for age and gender, the analysis showed that AA patients were less likely to undergo sphincter-preserving surgery than non-AA patients [odds ratio (OR) 0.70; 95% confidence interval (CI) 0.63-0.78; p < 0.0001). After further adjustment for the Elixhauser comorbidity index, admission type, hospital-specific factors, and insurance status, the analysis showed that AA patients still were less likely to undergo sphincter-preserving surgery (OR 0.78; 95% CI 0.70-0.87; p < 0.0001). Although the proportion of non-AA patients undergoing sphincter-preserving surgery increased during the study period (p = 0.0003), this trend was not significant for the AA patients (p = 0.13). CONCLUSION: In this data analysis, the AA patients with rectal cancer had lower rates of sphincter-preserving surgery than the non-AA patients, even after adjustment for patient- and hospital-specific factors. Further work is required to elucidate why. Eliminating racial disparities in rectal cancer treatment should continue to be a priority for the surgical community.

Prevalence of Clostridium Difficile Infection in Patients After Radical Cystectomy and Neoadjuvant Chemotherapy.

BACKGROUND AND OBJECTIVES: Clostridium Difficile is the most common cause of nosocomial infectious diarrhea. This study evaluates the prevalence and predictors of Clostridium Difficile infections in patients undergoing radical cystectomy with or without neoadjuvant chemotherapy. METHODS: Retrospective chart review was performed of all patients undergoing cystectomy and urinary diversion at a single institution from 2011-2017. Infection was documented in all cases with testing for Clostridium Difficile polymerase chain reaction toxin B. Patient and disease related factors were compared for those who received neoadjuvant chemotherapy vs. those who did not in order to identify potential risk factors associated with C. Difficile infections. Chi squared test and logistic regression analysis were used to determine statistical significance. RESULTS: Of 350 patients who underwent cystectomy, 41 (11.7%) developed Clostridium Difficile in the 30 day post-operative period. The prevalence of C. Difficile infection was higher amongst the patients undergoing cystectomy compared to the non-cystectomy admissions at our hospital (11.7 vs. 2.9%). Incidence was not significantly different among those who underwent cystectomy for bladder cancer versus those who underwent the procedure for other reasons. Median time to diagnosis was 6 days (range 3-28 days). The prevalence of C. Diff infections was not significantly different among those who received neoadjuvant chemotherapy vs. those who did not (11% vs. 10.4% p = 0.72). A significant association between C. Difficile infection was not seen with proton pump inhibitor use (p = 0.48), patient BMI (p = 0.67), chemotherapeutic regimen (p = 0.94), individual surgeon (p = 0.54), type of urinary diversion (0.41), or peri-operative antibiotic redosing (p = 0.26). CONCLUSIONS: Clostridium Difficile infection has a higher prevalence in patients undergoing cystectomy. No significant association between prevalence and exposure to neoadjuvant chemotherapy was seen.

Urinary Diversion With vs Without Bowel Anastomosis in Patients With an Existing Colostomy: A Multi-institutional Study.

OBJECTIVE: To describe the short-term outcomes with the bowel anastomosis (BA) approach vs the no-bowel anastomosis (NBA) approach in adult patients undergoing urinary diversion. METHODS: A chart review was performed of adults undergoing urinary diversion from 2006 to 2015. Patients with a pre-existing colostomy were divided into NBA and BA groups. Postoperative complications were recorded per the Clavien-Dindo system. Variables were compared using the BA group as a control. A 2-tailed t test was used to compare means. RESULTS: A total of 43 patients were included: 33 in the BA group and 10 in the NBA. No significant differences were found between the 2 groups for the comorbidity index (P = .16), the body mass index (P = .54), or radiation history (P = .90). In the NBA and BA groups, the median blood loss was 250 and 300 mL (P = .11); the operative time was 550 and 480 minutes (P = .15); and the length of stay was 10 and 25 days (P = .38), respectively. The BA group had a higher rate of intraoperative (P = .04) and early (P = .02) overall complications. No significant difference was found in early bowel (P = .15) or ureteral obstruction (P = .08), in the overall stomal complications (P = .11), or in the rate of <90-day reoperation (P = .32). CONCLUSION: A lower rate of intraoperative and postoperative complications occurred in patients undergoing conversion of colostomy to a urinary diversion compared with patients with de novo urinary conduit creation. When possible, a BA should be avoided.

The Impact of Age on Urethroplasty Success.

OBJECTIVE: To determine if age is an independent predictor of surgical success in patients undergoing urethroplasty. Urethroplasty performed by excision and primary anastomosis depends on vascular collateralization. Successful augmented urethroplasty depends on graft neovascularization. Older patients have more comorbid conditions including peripheral vascular disease associated with reduced penile blood flow. METHODS: This is a retrospective review of urethroplasties from 11 institutions. Primary outcome was functional success at 1 year from surgery, defined as freedom from post-urethroplasty procedures. Secondary outcome was freedom from cystoscopic evidence of stricture recurrence at 3 months. Study outcomes were compared between 2 age cohorts (<60 years old and ≥60 years old). Multivariable logistic regression analysis evaluated the influence of patient factors on our primary and secondary outcomes, using age as a continuous variable. RESULTS: Of 322 urethroplasties, 258 were performed in patients <60 years and 64 in patients ≥60 years. Median follow-up was 1.8 years. The following were not significantly different between groups: stricture length or location, smoking status, number of previous urethrotomies or dilations, and urethroplasty type. The following were more common in patients ≥60 years: diabetes, hypertension, hyperlipidemia, coronary artery and peripheral vascular disease, chronic obstructive pulmonary disease, and cancer. There was no difference in need for repeat procedures or anatomic recurrence between age groups or with increasing age. Stricture length was the only statistically significant clinical factor. CONCLUSION: Urethroplasty success may be affected by comorbidities but not age. Age alone should not be used as an absolute exclusion criterion for men needing urethral reconstruction.

Long-term Risk of Urinary Adverse Events in Curatively Treated Patients With Rectal Cancer: A Population-Based Analysis.

BACKGROUND: Treatment modalities for rectal cancer, including radiation, are associated with urinary adverse effects. OBJECTIVE: The purpose of this study was to determine the influence of surgery and radiation therapy for rectal cancer on long-term urinary complications. DESIGN: Using the Surveillance Epidemiology and End Results-Medicare data set from the United States, patients with rectal cancer older than 66 years of age who underwent rectal resection between 1992 and 2007 were stratified into treatment groups that accounted for surgical resection and the timing of radiation therapy, if used. A control group of patients who did not have rectal cancer were matched by age, sex, demographics, and comorbidities. The primary outcome was a urinary adverse event defined as a relevant urinary diagnosis with an associated procedure. Patients with rectal cancer in different treatment groups were compared with control patients using a propensity-adjusted, multivariable Cox regression analysis. SETTINGS: The study was conducted with the Surveillance Epidemiology and End Results-Medicare data set from the United States at our institution. RESULTS: Of the 11,068 patients with rectal cancer, 56.2% had surgical resection alone, 21.7% received preoperative radiation, and 22.1% received postoperative radiation. The median follow-up for all of the groups of patients was >2 years. All of the groups of patients with rectal cancer were more likely to develop a urinary adverse event compared with control subjects. Adjusted HRs were 2.28 (95% CI, 2.02-2.57) for abdominoperineal resection alone, 2.24 (95% CI, 1.79-2.80) for preoperative radiation and surgical resection, 2.04 (95% CI, 1.70-2.44) for surgical resection and postoperative radiation, and 1.69 (95% CI, 1.52-1.89) for low anterior resection alone. LIMITATIONS: Treatment patterns are somewhat outdated, with a large proportion of patients receiving postoperative radiation. The data did not allow for accurate assessment of urinary tract infections or mild urinary retention that is not managed with a procedure. CONCLUSIONS: Rectal cancer surgery with or without radiation is associated with a higher risk of urinary complications requiring procedures. Patients who undergo low anterior resection without radiation tend toward the lowest risk for a urinary adverse event.