The "Rule of W" in Urology: Testing Surgical Dictum.

OBJECTIVE: To evaluate the timing and frequency of postoperative occurrences as described in the "Rule of W" mnemonic for modern urologic and general surgical cases. METHODS: Using data from the American College of Surgeons National Surgical Quality Improvement Program, patients who underwent a urologic or general surgery procedure and developed a postoperative pneumonia (PNA), urinary tract infection (UTI), surgical site infection, venous thromboembolic event, or myocardial infarction (MI) were included. Frequency and median days to complication were compared. RESULTS: A total of 445,639 general surgery and 57,963 urology patients were included. Median time to occurrence differed between the cohorts for PNA, UTI, superficial infection, organ space infection, and MI. MI occurred earliest on POD3 for both groups (P = .0438). PNA occurred second on POD4 and POD5 for general surgery and urology, respectively (P = .0034). Venous thromboembolic events occurred third with PE occurring on POD8 for both cohorts (P = .1225) and deep venous thrombosis occurring on POD10 and POD11 (P = .6879) for general surgery and urology, respectively. Wound-related complications occurred at days 9-12 for general surgery and 11-13 for urology. The final sequence yielded waves, wind, walking, water/wound for general surgery and waves, wind, walking, wound, water for urology. CONCLUSION: A different chronology of postoperative events was found for urology patients than that described in the original mnemonic. UTIs and wound-related complications represent the most frequent morbidities for the urologic and general surgical patient, respectively. As patient demographics and practice patterns evolve, the "Rule of W", and other teaching tools, will need to be continually and critically reviewed.

Radical prostatectomy and the effect of close surgical margins: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database.

OBJECTIVE: To evaluate biochemical recurrence (BCR) patterns amongst men undergoing radical prostatectomy (RP) with specimens having negative (NSM), positive (PSM), and close surgical margins (CSM) from the Shared Equal Access Regional Cancer Hospital (SEARCH) cohort, as PSM after RP are a significant predictor of biochemical failure and possible disease progression, with CSM representing a diagnostic challenge for surgeons. PATIENTS AND METHODS: Men undergoing RP between 1988 and 2015 with known final pathological margin status were evaluated. The cohort was divided into three groups based on margin status; NSM, PSM, and CSM. CSM were defined by distance of tumour ≤1 mm from the surgical margin. BCR was defined as a prostate-specific antigen (PSA) level of >0.2 ng/mL, two values at 0.2 ng/mL, or secondary treatment for an elevated PSA level. Predictors of BCR, metastases, and mortality were analysed using Cox proportional hazard models. RESULTS: Of 5515 men in the SEARCH database, 4337 (79%) men met criteria for inclusion in the analysis. Of these, 2063 (48%) had NSM, 1902 (44%) had PSM, and 372 (8%) had CSM. On multivariable analysis, relative to NSM, men with CSM had a higher risk of BCR (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.25-1.82; P < 0.001) but a decreased risk of BCR when compared to those men with PSM (HR 2.09, 95% CI 1.86-2.36; P < 0.001). Metastases, prostate cancer-specific mortality and all-cause mortality did not differ based on margin status alone. CONCLUSIONS: Management of men with CSM is a diagnostic challenge, with a disease course that is not entirely benign. The evaluation of other known risk factors probably provides greater prognostic value for these men and may ultimately better select those who may benefit from adjuvant therapy.