Gandaglia G, Sun M, Popa I, Schiffmann J, Trudeau V, Shariat SF, Trinh Q-D, Graefen M, Widmer H, Saad F, et al. Cardiovascular mortality in patients with metastatic prostate cancer exposed to androgen deprivation therapy: a population-based study. Clin Genitourin Cancer. 2015;13 (3) :e123-30.Abstract
INTRODUCTION: The aim of our study was to reexamine the prevalence of baseline cardiovascular (CV) morbidity and the rates of CV mortality in a contemporary cohort of patients with prostate cancer (PCa) exposed to androgen deprivation therapy (ADT). MATERIALS AND METHODS: Records of patients aged 65 years and older with metastatic PCa who received ADT were abstracted from the Surveillance, Epidemiology, and End Results-Medicare database between 1991 and 2009. The primary end points comprised 5-year CV mortality rates. Survival rates were stratified according to age and Charlson comorbidity index (CCI). Competing-risks Poisson regression methodologies were performed. RESULTS: Overall, 9596 patients with metastatic PCa treated with ADT were identified. At baseline, 3049 patients (31.8%) had preexisting CV disease. The 5-year CV mortality rates were 9.8% and 14.8% in the overall population and in patients with preexisting CV disease, respectively. The 5-year CV mortality rates increased with advanced age and higher CCI score. In multivariate competing-risks regression analyses, age, year of diagnosis, CV comorbidities, CCI, and marital status represented independent predictors of CV mortality, after accounting for the risk of dying from other causes (all P ≤ .04). Of those, preexisting CV disease contributed to the highest risk of CV mortality. Our study is limited by its retrospective nature. CONCLUSION: CV mortality represents a common event in patients with metastatic PCa treated with ADT. Preexisting CV disease represented the strongest risk factor.
Hanske J, Sanchez A, Schmid M, Meyer CP, Abdollah F, Feldman AS, Kibel AS, Sammon JD, Menon M, Eswara JR, et al. A Comparison of 30-Day Perioperative Outcomes in Open Versus Minimally Invasive Nephroureterectomy for Upper Tract Urothelial Carcinoma: Analysis of 896 Patients from the American College of Surgeons-National Surgical Quality Improvement Program Database. J Endourol. 2015.Abstract
BACKGROUND AND PURPOSE: Minimally invasive surgery for nephroureterectomy (MINU) in patients with upper tract urothelial carcinoma (UTUC) is increasingly used among urologists with reported equivalent oncologic outcomes compared with open nephroureterectomy (ONU). Population-level data comparing perioperative outcomes between these approaches remain limited, however. We sought to compare perioperative outcomes between MINU and ONU in a prospectively collected national cohort of patients. METHODS: Between 2006 and 2012, patients who underwent nephroureterectomy for UTUC within the American College of Surgeons-National Surgical Quality Improvement Program database were categorized into MINU or ONU. Our primary outcome of interest was 30-day perioperative complications. Secondary outcomes included use of lymph node dissection (LND), transfusion, reintervention and readmission rate, operative time, length of stay (LOS), and perioperative mortality. Multivariable logistic regression analyses were used to examine the association between outcomes and surgical approach. RESULTS: A total of 599 (66.9%) and 297 (33.1%) patients underwent MINU and ONU, respectively. Overall, 12.7% of patients experienced a complication within 30 days postoperatively, and the rate did not differ among surgical approaches. Patients in the MINU group, however, had a decreased LOS (P<0.001). On multivariable analysis, patients receiving MINU were less likely to undergo a LND (OR 0.13; P<0.001), had decreased risk of thromboembolic complications (odds ratio [OR] 0.13; P=0.018), decreased need for transfusion (OR 0.39; P=0.001), and decreased need for operative reintervention (OR 0.24; P=0.024). CONCLUSIONS: Patients receiving MINU have similar overall complication rates compared with ONU. MINU, however, was associated with a decreased risk of blood transfusions, thromboembolic events, reintervention, and overall LOS compared with ONU. MINU should be considered as a primary approach in select groups of patients with UTUC.
Muralidhar V, Dinh KT, Mahal BA, Ziehr DR, Chen Y-W, Viswanathan VB, Nezolosky MD, Choueiri TK, Hoffman KE, Hu JC, et al. Differential post-prostatectomy cancer-specific survival of occult T3 vs. clinical T3 prostate cancer: Implications for managing patients upstaged on prostate magnetic resonance imaging. Urol Oncol. 2015;33 (7) :330.e19-25.Abstract
PURPOSE/OBJECTIVE: Long-term androgen deprivation therapy (ADT) was proven in randomized trials to be superior to short-term ADT for radiation-managed patients who have clinical T3 (cT3) disease, but it is unknown whether patients with T3 disease seen only on magnetic resonance imaging require similarly aggressive treatment. We attempted to study this issue by analogy by comparing the long-term post-prostatectomy survival of patients with cT3 disease versus cT1/T2 disease upstaged to pathologic T3 disease. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 60,165 men diagnosed with prostate adenocarcinoma between 1995 and 2002 who underwent prostatectomy. Prostate cancer-specific mortality (PCSM) was evaluated by stage after adjusting for grade, marital status, race, sex, year of diagnosis, and age. RESULTS: The median follow-up was 10.5 years. Patients with cT1/T2 but pathologic T3a disease had significantly better 10-year PCSM than men with cT3 disease had (3.0% vs. 9.9%, adjusted hazard ratio [AHR] = 0.420, P<0.001), but they had worse PCSM than men with pathologic T2 disease had (3.0% vs. 0.91%, AHR = 2.53, P<0.001). Of patients with occult T3a disease, those with low-grade/intermediate-grade disease (Gleason score 7 or less) had a slightly higher 10-year PCSM when compared with those with pathologic T2 disease (1.34% vs. 0.91%, AHR = 1.69, P<0.001). Patients with cT1/T2 and pathologic T3b disease had similar PCSM as men presenting with cT3 disease (11.0% vs. 9.86%, AHR = 1.14 [0.862, 1.52], P = 0.353). CONCLUSIONS: Patients with occult T3a disease had less than half the risk of PCSM as those with cT3 disease, and a subset of those men had similar risk as patients with pathologic T2 disease. Therefore, it is possible that radiation-managed patients with low-grade/intermediate-grade T3a disease by magnetic resonance imaging only might not require long-term ADT. However, patients with occult T3b or high-grade occult T3a disease have similar PCSM as that of those presenting with cT3 disease, so they should be treated as aggressively, including long-course ADT when managed by radiation.
Schmid M, Sammon JD, Reznor G, Kapoor V, Speed JM, Abdollah FA, Sood A, Chun FK-H, Kibel AS, Menon M, et al. Dose-dependent effect of androgen deprivation therapy for localized prostate cancer on adverse cardiac events. BJU Int. 2015.Abstract
OBJECTIVES: To investigate the dose-dependent effect of androgen deprivation therapy (ADT) on adverse cardiac events in elderly men with non-metastatic prostate cancer (PCa) stratified according to life expectancy. PATIENTS AND METHODS: A total of 50 384 men diagnosed with localized PCa between 1992 and 2007 were identified within the Surveillance, Epidemiology, and End Results registry areas. We compared those who received ADT within 2 years of PCa diagnosis with those who did not, calculated as monthly equivalent doses of GnRH agonists (<8, ≥8 doses), or orchiectomy. Men were further stratified according to life expectancy (<5 years, 5-10 years and >10 years). Adjusted Cox hazard models assessed the risk of new-onset coronary heart disease (CHD), acute myocardial infarction (AMI), sudden cardiac death (SCD) and cardiac-related interventions, as well as any of these events. RESULTS: Overall, patients receiving GnRH agonists were more likely to experience a cardiac event, with the most pronounced effect among those receiving ≥8 doses (hazard ratio [HR] <8 doses: 1.13, 95% confidence interval [CI] 1.09-1.16, and HR ≥8 doses: 1.18, 95% CI 1.14-1.22; both P < 0.001). The effect of prolonged (≥8 doses) GnRH agonist use on cardiac events was sustained across all strata of life expectancy; however, there was no effect among men with a life expectancy of <5 years and when use of GnRH agonists was limited to <8 doses (HR 0.99, 95% CI 0.67-1.46; P = 0.964). The use of GnRH agonists was associated with a higher risk of CHD (HR <8 doses: 1.13, 95% CI 1.09-1.17 and HR ≥8 doses: 1.17, 95% CI 1.13-1.21; both P < 0.001). Conversely, the use of GnRH was generally not associated with an increased risk of AMI or SCD, except for men who received ≥8 doses of GnRH agonists and had a life expectancy of ≥5 years, who were at a significantly higher risk of SCD (HR for life expectancy 5-10 years: 1.19, 95% CI 1.06-1.33; P = 0.003 and HR for life expectancy >10 years: 1.16, 95% CI 1.04-1.29; P = 0.006). Finally, orchiectomy was not associated with overall cardiac events, AMI or SCD, and was protective with regard to cardiac-related interventions (HR 0.78, 95% CI 0.68-0.90, P = 0.001). CONCLUSION: Exposure to ADT with GnRH agonists is associated with an increased risk of cardiac events in elderly men with localized PCa and a decent life expectancy. Clinicians should carefully weigh the risks and benefits of ADT in patients with a prolonged life expectancy. Routine screening and lifestyle interventions are warranted in at-risk subpopulations treated with ADT.
Sood A, Abdollah F, Sammon JD, Majumder K, Schmid M, Peabody JO, Preston MA, Kibel AS, Menon M, Trinh Q-D. The Effect of Body Mass Index on Perioperative Outcomes After Major Surgery: Results from the National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2011. World J Surg. 2015.Abstract
BACKGROUND: Obesity is associated with poor surgical outcomes and disparity in access-to-care. There is a lack of quality data on the effect of body mass index (BMI) on perioperative outcomes. Accordingly, we sought to determine the procedure specific, independent-effect of BMI on 30-day perioperative outcomes in patients undergoing major surgery. METHODS: Participants included individuals undergoing one of 16 major surgery (cardiovascular, orthopedic, oncologic; n = 141,802) recorded in the ACS-NSQIP (2005-2011). Outcomes evaluated included complications, blood transfusion, length-of-stay (LOS), re-intervention, readmission, and perioperative mortality. Multivariable-regression models assessed the independent-effect of BMI on outcomes. RESULTS: Nearly, 74  % of patients had a BMI disturbance; the majority being overweight (35.3  %) or obese (29.8  %). Morbidly obese patients constituted a small but significant proportion of the patients (5.7 %; n = 8067). In adjusted-analyses, morbidly obese patients had significantly increased odds of wound complications in 15 of the examined procedures, of renal complications after 6-procedures, of thromboembolism after 5-procedures, of pulmonary, septic and UTI complications after 2-procedures, and of cardiovascular complications after CABG. Conversely, obese/overweight patients, except for increased odds of wound complications after select procedures, had significantly decreased odds of perioperative mortality, prolonged-LOS and blood transfusion relative to normal BMI patients after 4, 8, and 9 of the examined procedures. CONCLUSIONS: The prevalence of BMI derangements in surgical patients is high. The effect of BMI on outcomes is procedure specific. Patients with BMI between 18.5 and 40-kg/m(2) at time of surgery fare equally well with regard to complications and mortality. However, morbidly obese patients are at-risk for postsurgical complications and targeted preoperative-optimization may improve outcomes and attenuate disparity in access-to-care.
Mahal BA, Cooperberg MR, Aizer AA, Ziehr DR, Hyatt AS, Choueiri TK, Hu JC, Sweeney CJ, Beard CJ, D'Amico AV, et al. Who bears the greatest burden of aggressive treatment of indolent prostate cancer?. Am J Med. 2015;128 (6) :609-16.Abstract
PURPOSE: The long-term prostate cancer-specific survival for patients initially managed with active surveillance for low-risk prostate cancer ranges from 97% to 100%. We characterized factors that are associated with aggressive treatment with radical prostatectomy or radiation for indolent prostate cancer (defined as screening-detected, low-risk disease). METHODS: The Surveillance, Epidemiology, and End Results Program was used to extract a cohort of 39,803 men diagnosed with prostate-specific antigen-detected, low-risk prostate cancer (clinical category T1c, Gleason score ≤6, and prostate-specific antigen <10) from 2004 to 2010. After socioeconomic profiles were generated from county-linked education and income data, multivariable logistic regression was used to determine whether there were any factors associated with high rates of aggressive treatment. RESULTS: The rate of aggressive treatment among all men with indolent prostate cancer was 64.3%. Greater rates of aggressive treatment were experienced by men with high socioeconomic status, Caucasian men, and married men (P < .001 for all cases). The increased adjusted odds for receipt of aggressive therapy were 1.25 (95% confidence interval [CI], 1.17-1.32; P < .001), 1.26 (95% CI, 1.21-1.32; P < .001), and 1.88 (95% CI, 1.80-1.97; P < .001) for men with high socioeconomic status, Caucasian men, and married men, respectively, compared with men with low socioeconomic status, non-Caucasian men, and unmarried men, respectively. CONCLUSIONS: Although men with high socioeconomic status, Caucasian men, and married men often receive the highest quality health care and have the best outcomes for many cancers, it seems that they are most at risk for the avoidable potential harms of aggressive treatment of indolent prostate cancer. Future policy should encourage more stringent guidelines for deferred treatment and culturally and sociodemographically competent counseling of active surveillance.
Meyer CP, Rios Diaz AJ, Dalela D, Hanske J, Pucheril D, Schmid M, Trinh VQ, Sammon JD, Menon M, Chun FKH, et al. Wound dehiscence in a sample of 1 776 cystectomies: identification of predictors and implications for outcomes. BJU Int. 2015.Abstract
OBJECTIVE: To investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy (RC). PATIENTS AND METHODS: In all, 1 776 patient records with Current Procedural Terminology (CPT) codes for radical cystectomy (RC) were extracted from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) between 2005 and 2012. Stratification was made based on the occurrence of postoperative wound dehiscence, defined as loss of integrity of fascial closure. Descriptive and logistic regression models were used to identify predictors of postoperative wound dehiscence. The implications of wound dehiscence on peri- and postoperative outcomes such as complications, mortality, prolonged length of stay (>11 days), and prolonged operative time (>411 min), were assessed. RESULTS: Of 1 776 patients analysed, 57 (3.2%) had a documented wound dehiscence. In multivariable analyses, chronic obstructive pulmonary disease (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.0-4.0; P = 0.03) and high body mass index (OR 2.3, 95% CI 1.3-4.4; P = 0.008) were significant predictors of wound dehiscence. While female gender had significantly lower proportions of wound dehiscence, multivariable analyses did not confirm this (OR 0.4, 95% CI 0.4-1.4; P = 0.75). CONCLUSIONS: Our study is the first to identify predictors of wound dehiscence after RC in a large, contemporary multi-institutional cohort. Identifying patients at risk of postoperative wound complications may guide the use of preventative measures at the time of surgery.
Lucca I, Rouprêt M, Kluth L, Rink M, Tilki D, Fajkovic H, Kassouf W, Hofbauer SL, de Martino M, Karakiewicz PI, et al. Adjuvant cisplatin-based combined chemotherapy for lymph node (LN)-positive urothelial carcinoma of the bladder (UCB) after radical cystectomy (RC): a retrospective international study of >1500 patients. BJU Int. 2015;115 (5) :722-7.Abstract
OBJECTIVE: To compare outcomes of patients with lymph node (LN)-positive urothelial carcinoma of the bladder (UCB) treated with or without cisplatin-based combined adjuvant chemotherapy (AC) after radical cystectomy (RC). PATIENTS AND METHODS: We retrospectively analysed 1523 patients with LN-positive UCB, who underwent RC with bilateral pelvic LN dissection. All patients had no evidence of disease after RC. AC was administered within 3 months. Competing-risks models were applied to compare UCB-related mortality. RESULTS: Of the 1523 patients, 874 (57.4%) received AC. The cumulative 1-, 2- and 5-year UCB-related mortality rates for all patients were 16%, 36% and 56%, respectively. Administration of AC was associated with an 18% relative reduction in the risk of UCB-related death (subhazard ratio 0.82, P = 0.005). The absolute reduction in mortality was 3.5% at 5 years. The positive effect of AC was detectable in patients aged ≤70 years, in women, in pT3-4 disease, and in those with a higher LN density and lymphovascular invasion. This study is limited by its retrospective and non-randomised design, selection bias, the absence of central pathological review and lack in standardisation of LN dissection and cisplatin-based protocols. CONCLUSION: AC seems to reduce UCB-related mortality in patients with LN-positive UCB after RC. Younger patients, women and those with high-risk features such as pT3-4 disease, a higher LN density and lymphovascular invasion appear to benefit most. Appropriately powered prospective randomised trials are necessary to confirm these findings.
Trinh Q-D, Nguyen PL, Leow JJ, Dalela D, Chao GF, Mahal BA, Nayak M, Schmid M, Choueiri TK, Aizer AA. Cancer-specific mortality of Asian Americans diagnosed with cancer: a nationwide population-based assessment. J Natl Cancer Inst. 2015;107 (6) :djv054.Abstract
BACKGROUND: Racial disparities in cancer survival outcomes have been primarily attributed to underlying biologic mechanisms and the quality of cancer care received. Because prior literature shows little difference exists in the socioeconomic status of non-Hispanic whites and Asian Americans, any difference in cancer survival is less likely to be attributable to inequalities of care. We sought to examine differences in cancer-specific survival between whites and Asian Americans. METHODS: The Surveillance, Epidemiology, and End Results Program was used to identify patients with lung (n = 130 852 [16.9%]), breast (n = 313 977 [40.4%]), prostate (n = 166 529 [21.4%]), or colorectal (n = 165 140 [21.3%]) cancer (the three leading causes of cancer-related mortality within each sex) diagnosed between 1991 and 2007. Fine and Gray's competing risks regression compared the cancer-specific mortality (CSM) of eight Asian American groups (Chinese, Filipino, Hawaiian/Pacific Islander, Japanese, Korean, other Asian, South Asian [Indian/Pakistani], and Vietnamese) to non-Hispanic white patients. All P values were two-sided. RESULTS: In competing risks regression, the receipt of definitive treatment was an independent predictor of CSM (hazard ratio [HR] = 0.37, 95% confidence interval [CI] = 0.35 to 0.40; HR = 0.55, 95% CI = 0.53 to 0.58; HR = 0.61, 95% CI = 0.60 to 0.62; and HR = 0.27, 95% CI = 0.25 to 0.29) for prostate, breast, lung, and colorectal cancers respectively, all P < .001). In adjusted analyses, most Asian subgroups (except Hawaiians and Koreans) had lower CSM relative to white patients, with hazard ratios ranging from 0.54 (95% CI = 0.38 to 0.78) to 0.88 (95% CI = 0.84 to 0.93) for Japanese patients with prostate and Chinese patients with lung cancer, respectively. CONCLUSIONS: Despite adjustment for potential confounders, including the receipt of definitive treatment and tumor characteristics, most Asian subgroups had better CSM than non-Hispanic white patients. These findings suggest that underlying genetic/biological differences, along with potential cultural variations, may impact survival in Asian American cancer patients.
Hanske J, Sanchez A, Schmid M, Meyer CP, Abdollah F, Roghmann F, Feldman AS, Kibel AS, Sammon JD, Noldus J, et al. Comparison of 30-day perioperative outcomes in adults undergoing open versus minimally invasive pyeloplasty for ureteropelvic junction obstruction: analysis of 593 patients in a prospective national database. World J Urol. 2015.Abstract
PURPOSE: The surgical correction of ureteropelvic junction obstruction (UPJO) is indicated to prevent progression to chronic renal insufficiency. Minimally invasive surgery (MIS) has become increasingly popular as an approach to UPJO correction. We compared the perioperative outcomes between minimally invasive (MIP) and open pyeloplasty (OP) in the adult population. METHODS: The current study was performed using the American College of Surgeons National Surgical Quality Improvement Program. Patients were identified using Current Procedural Terminology codes for pyeloplasty between 2005 and 2012, and were stratified according to either MIS or open approach. Patients with a diagnosis of malignant neoplasm of the kidney were excluded. Following exclusions, 593 patients remained for analysis. Primary outcomes of interest were overall perioperative complications, need for transfusions, re-intervention rate, prolonged operation time (pOT), prolonged length of stay (pLOS), readmission and mortality within 30 days of surgery. Multivariable logistic regression analyses were performed to examine the association between preoperative outcomes and surgical approach. RESULTS: In this study, 423 (71.3 %) patients underwent MIP and 170 (28.7 %) underwent OP. Patients who underwent MIP had a decreased risk of wound [Odds ratio (OR) 0.06, p < 0.009] and overall complications (OR 0.21, p < 0.001), transfusions (OR 0.04, p = 0.004) and pLOS [pLOS (OR 0.08, p < 0.001)]. Conversely, MIP was associated with an increased likelihood of pOT (OR 2.26, p = 0.002). CONCLUSION: Adults with UPJO undergoing MIP have a lower risk of overall complications, transfusions and pLOS compared to OP. Further studies are needed to determine whether these benefits offset the increase in expenditures, related to longer operative time and costs of disposables.
Ghatalia P, Morgan CJ, Je Y, Nguyen PL, Trinh Q-D, Choueiri TK, Sonpavde G. Congestive heart failure with vascular endothelial growth factor receptor tyrosine kinase inhibitors. Crit Rev Oncol Hematol. 2015;94 (2) :228-37.Abstract
A systematic review and meta-analysis was conducted to determine the relative risk (RR) of congestive heart failure (CHF) associated with approved multi-targeted vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKI). Eligible studies included randomized trials comparing arms with and without an FDA-approved VEGFR TKI. Statistical analyses calculated the relative risk (RR) and 95% confidence intervals (CI). A total of 10,647 patients from 16 phase III trials and 5 phase II trials were selected. All grade CHF occurred in 138 of 5752 (2.39%) patients receiving VEGFR TKIs and 37 of 4895 (0.75%) patients in the non-TKI group. High-grade CHF occurred in 17 of 1426 (1.19%) patients receiving VEGFR TKIs and 8 of 1232 (0.65%) patients in the non-TKI group. The RR of all grade and high-grade CHF for the TKI vs. no TKI arms was 2.69 (p<0.001; 95% CI: 1.86 to 3.87) and 1.65 (p=0.227, 95% CI: 0.73 to 3.70), respectively. The RR of relatively specific TKIs (axitinib) was similar to relatively non-specific TKIs (sunitinib, sorafenib, vandetanib, pazopanib).
Pandey A, Sood A, Sammon JD, Abdollah F, Gupta E, Golwala H, Bardia A, Kibel AS, Menon M, Trinh Q-D. Effect of preoperative angina pectoris on cardiac outcomes in patients with previous myocardial infarction undergoing major noncardiac surgery (data from ACS-NSQIP). Am J Cardiol. 2015;115 (8) :1080-4.Abstract
The impact of preoperative stable angina pectoris on postoperative cardiovascular outcomes in patients with previous myocardial infarction (MI) who underwent major noncardiac surgery is not well studied. We studied patients with previous MI who underwent elective major noncardiac surgeries within the American College of Surgeons-National Surgical Quality Improvement Program (2005 to 2011). Primary outcome was occurrence of an adverse cardiac event (MI and/or cardiac arrest). Multivariable logistic regression models evaluated the impact of stable angina on outcomes. Of 1,568 patients (median age 70 years; 35% women) with previous MI who underwent major noncardiac surgery, 5.5% had postoperative MI and/or cardiac arrest. Patients with history of preoperative angina had significantly greater incidence of primary outcome compared to those without anginal symptoms (8.4% vs 5%, p = 0.035). In secondary outcomes, reintervention rates (22.5% vs 11%, p <0.001) and length of stay (median 6-days vs 5-days; p <0.001) were also higher in patients with preoperative angina. In multivariable analyses, preoperative angina was a significant predictor for postoperative MI (odds ratio 2.49 [1.20 to 5.58]) and reintervention (odds ratio 2.40 [1.44 to 3.82]). In conclusion, our study indicates that preoperative angina is an independent predictor for adverse outcomes in patients with previous MI who underwent major noncardiac surgery, and cautions against overreliance on predictive tools, for example, the Revised Cardiac Risk Index, in these patients, which does not treat stable angina and previous MI as independent risk factors during risk prognostication.
Sood A, Abdollah F, Sammon JD, Kapoor V, Rogers CG, Jeong W, Klett DE, Hanske J, Meyer CP, Peabody JO, et al. An evaluation of the timing of surgical complications following nephrectomy: data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). World J Urol. 2015.Abstract
PURPOSE: The rates of complications following radical/partial nephrectomy (RN/PN) are well known; however, the data regarding timing are opaque. Accordingly, we sought to assess the median time-to-event for 19 principal postoperative complications within 30 days following surgery. METHODS: Patients undergoing RN/PN were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011). Primary endpoint was time-to-complication. Secondary endpoints included length-of-stay (LOS), re-intervention, re-admission and 30-day mortality. Multivariable regression models assessed the predictors for pre-/post-discharge complications and the effect of time-to-complication on secondary outcomes. RESULTS: Overall, 3820 patients underwent nephrectomy (RN = 63.6 %). The overall complication rate was 16.8 %, and the median LOS was 4 days. The majority of major complications (88.1 %), including bleeding/transfusion, renal, septic, deep venous thrombosis or pulmonary embolism, pulmonary, cardiac and neurologic, occurred prior to discharge. Conversely, the relatively minor complications, including wound and urinary tract infections, occurred predominantly post-discharge (70.7 %). The median time to major complications was 3 versus 13 days for minor complications. In multivariable analyses, age [odds ratio (OR) 1.02, p < 0.001], American Society of Anesthesiologists score ≥ 2 (p < 0.01) and PN (p < 0.001) were predictors of pre-discharge complications, while female gender (OR 1.67, p < 0.001), hypertension (OR 1.28, p = 0.007) and diabetes (OR 1.48, p < 0.001) were predictors of post-discharge complications. Creatinine ≥ 1.2 mg/dl and hematocrit < 30 increased (p < 0.01), whereas a minimally invasive approach decreased the odds (p < 0.05) for both pre-/post-discharge complications. For a given complication, time-to-complication did not affect the odds for mortality (p = 0.343) or re-intervention (p = 0.872). CONCLUSIONS: Approximately one in six patients suffers a complication following RN/PN; major complications tend to occur early with the majority occurring pre-discharge. Knowledge regarding the timing and risk factors for complications may facilitate improved patient-physician communication, both at admission and at discharge.
Leow JJ, Reese S, Trinh Q-D, Bellmunt J, Chung BI, Kibel AS, Chang SL. Impact of surgeon volume on the morbidity and costs of radical cystectomy in the USA: a contemporary population-based analysis. BJU Int. 2015;115 (5) :713-21.Abstract
OBJECTIVES: To evaluate the relationship between surgeon volume of radical cystectomy (RC) and postoperative morbidity, and to assess the economic burden of bladder cancer in the USA. METHODS: We captured all patients who underwent RC (International Classification of Diseases, ninth revision, code 57.71) between 2003 and 2010, using a nationwide hospital discharge database. Patient, hospital and surgical characteristics were evaluated. The annual volume of RCs performed by the surgeons was divided into quintiles. Multivariable regression models were developed, adjusting for clustering and survey weighting, to evaluate the outcomes, including 90-day major complications (Clavien grade III-V) and direct patient costs. We adjusted for clustering and weighting to achieve a nationally representative analysis. RESULTS: The weighted cohort included 49,792 patients who underwent RC, with an overall 90-day major complication rate of 16.2%. Compared with surgeons performing one RC annually, surgeons performing ≥7 RCs each year had 45% lower odds of major complications (odds ratio [OR] 0.55; P < 0.001) and lower costs by $1690 (P = 0.02). Results were consistent when we analysed surgeon volume as a continuous variable and when we examined the surgeons with the highest volumes (≥28 cases annually), which showed markedly lower odds of major complications compared with the surgeons with the lowest volumes (OR 0.45, 95% CI 0.31-0.67; P < 0.001). Compared with patients who did not have any complications, those who had a major complication were associated with significantly higher 90-day median direct hospital costs ($43,965 vs $24,341; P < 0.001). CONCLUSIONS: We showed that there was an inverse relationship between surgeon volume and the development of postoperative 90-day major complication rates as well as direct hospital costs. Centralisation of RC to surgeons with higher volumes may reduce the development of postoperative major complications, thereby decreasing the burden of bladder cancer on the healthcare system.
Schmid M, Dalela D, Tahbaz R, Langetepe J, Randazzo M, Dahlem R, Fisch M, Trinh Q-D, Chun FK-H. Novel biomarkers of acute kidney injury: Evaluation and evidence in urologic surgery. World J Nephrol. 2015;4 (2) :160-8.Abstract
Patients undergoing urologic surgery are at risk of acute kidney injury (AKI) and consequently long-term deterioration in renal function. AKI is further associated with significantly higher odds of perioperative complications, prolonged hospital stay, higher mortality and costs. Therefore, better awareness and detection of AKI, as well as identification of AKI determinants in the urological surgery setting is warranted to pre-empt and mitigate further deterioration of renal function in patients at special risk. New consensus criteria provide precise definitions of diagnosis and description of the severity of AKI. However, they rely on serum creatinine (SCr), which is known to be an inaccurate marker of early changes in renal function. Therefore, several new urinary and serum biomarkers promise to address the gap associated with the use of SCr. Novel biomarkers may complement SCr measurement or most likely improve the diagnostic accuracy of AKI when used in combinations. However, novel biomarkers have to prove their clinical applicability, accuracy, and cost effectiveness prior to implementation into clinical practice. Most preferably, novel biomarkers should help to positively improve a patient's long-term renal functional outcomes. The purpose of this review is to discuss currently available biomarkers and to review their clinical evidence within urologic surgery settings.
Roghmann F, Ravi P, Hanske J, Meyer CP, Preston MA, Noldus J, Trinh Q-D. Perioperative outcomes after radical cystectomy at NCI-designated centres: Are they any better?. Can Urol Assoc J. 2015;9 (5-6) :207-12.Abstract
INTRODUCTION: In 1971, the National Cancer Institute (NCI) introduced a network of NCI-designated Cancer Centers (CC), which underwent a comprehensive approval process relying on research, education and prevention activities. In this study, we examine the effect of CC status on perioperative outcomes after radical cystectomy (RC). METHODS: Within the Nationwide Inpatient Sample, we focused on RC performed from 2006 to 2010. As all recognized centres were residency teaching institutions, we stratified according to teaching and CC-teaching status. We examined the rates of in-hospital mortality, intra- and postoperative complications, prolonged length of hospital stay, as well as blood transfusion. Multivariable logistic regression analyses were further adjusted for confounding factors. RESULTS: Overall, 22 840 RC patients (5451 at non-teaching, 10 857 at residency teaching, 6532 at CC-teaching institutions) were identified. Patients treated at residency teaching and CC-teaching institutions were younger, had less comorbidities, and more likely to have private insurance. In multivariable analyses, patients treated at residency and CC-teaching institutions were less likely to experience postoperative complications (odds ratio [OR] 0.73 and 0.66, respectively) and blood transfusions (OR 0.77 and 0.53, respectively) relative to patients treated at non-teaching institutions. In addition, CC patients were also less likely to experience in-hospital mortality (OR 0.61, all p < 0.001) as compared to non-teaching institutions. CONCLUSIONS: On average, patients treated at residency and CC-teaching institutions are less likely to experience unfavourable outcomes after RC. Moreover, patients treated at CC fared better than patients treated at residency teaching institutions. Our findings acknowledge the quality of RC care at accredited centres.
Dinh KT, Mahal BA, Ziehr DR, Muralidhar V, Chen Y-W, Viswanathan VB, Nezolosky MD, Beard CJ, Choueiri TK, Martin NE, et al. Risk of prostate cancer mortality in men with a history of prior cancer. BJU Int. 2015.Abstract
OBJECTIVES: To describe outcomes of patients with prostate cancer diagnosed after another malignancy and identify factors associated with prostate cancer death in this population, as little is known about the clinical significance of prostate cancer as a subsequent malignancy. PATIENTS AND METHODS: We studied 18 225 men diagnosed with prostate cancer after another malignancy from 1973 to 2006. We compared demographic and clinical variables, and the proportion of death from prostate cancer vs prior malignancy with t-test and chi-squared analyses. Fine and Gray's regression was used to consider the effect of treatment on prostate cancer death. We then studied a second cohort of 88 013 men with prostate cancer as a first or second malignancy to describe current diagnostic and treatment patterns. RESULTS: One in seven men died from prostate cancer in our first cohort. More died from prostate cancer following colorectal cancer (16.8% vs 13.7%), melanoma (13.4% vs 7.56%), and oral cancer (19.1% vs 4.04%), but fewer following bladder cancer, kidney cancer, lung cancer, leukaemia and non-Hodgkin's lymphoma (all P < 0.001). Prostate cancer treatment was associated with a nearly 50% lower risk of death when high-grade or high-stage (adjusted hazard ratio 0.55, 95% confidence interval [CI] 0.47-0.64). Patients who died from prostate cancer had higher grade and stage disease, and received less treatment than patients who died from prior malignancy. The second cohort showed subsequent prostate cancer had more high-risk disease (36.3% vs 22.2%, P < 0.001) and less prostate cancer treatment (adjusted odds ratio 0.872, 95% CI 0.818-0.930) than primary prostate cancer. CONCLUSIONS: Prostate cancer remains a significant cause of mortality when diagnosed as a subsequent cancer. These results suggest prostate cancer treatment should be seriously considered in patients with prior malignancies, especially those with high-grade or locally advanced prostate cancer.
Wang EH, Yu JB, Gross CP, Abouassaly R, Cherullo EE, Smaldone MC, Shah ND, Kiechle J, Trinh Q-D, Sun M, et al. Association between surgeon and hospital characteristics and lymph node counts from radical prostatectomy and pelvic lymph node dissection. Urology. 2015;85 (4) :890-5.Abstract
OBJECTIVE: To assess whether surgical approach and hospital characteristics independently determine the number of lymph nodes (LNs) removed from prostate cancer patients undergoing radical prostatectomy (RP) and pelvic LN dissection (PLND). METHODS: Using the National Cancer Database, we identified all surgically treated patients diagnosed with pretreatment intermediate- or high-risk prostate cancer from 2010 to 2011. The primary outcome was the number of LNs retrieved at the time of RP. Generalized estimating equations were used to assess for differences in the adjusted number of LNs retrieved after accounting for patient and hospital characteristics and surgical approach. RESULTS: Overall, 35,876 patients were diagnosed with intermediate-risk (61.2%) and high-risk (38.8%) prostate cancer and underwent RP and PLND.On multivariate analysis, open RP and high-volume and academic hospitals were independently associated with greater LN counts compared with robotic-assisted RP and medium or low and community hospitals, respectively (all P <.001). After adjusting for patient and hospital variables, higher adjusted LN counts were observed for open RP compared with robotic-assisted RP (7.1 vs 6.1; P <.001). Adjusted counts were also higher for high-volume hospitals compared with medium- or low-volume hospitals (7.8 vs 5.9; P <.001), and academic compared with community hospitals (7.3 vs 5.6; P <.001). CONCLUSION: Among patients with aggressive prostate cancer treated with RP and PLND, retrieval of LN counts varied by surgical approach and hospital characteristics.
Sun M, Trinh Q-D. Diagnosis and staging of bladder cancer. Hematol Oncol Clin North Am. 2015;29 (2) :205-18, vii.Abstract
Bladder cancer (BCa) is a heterogeneous disease with a variable natural history. Most patients (70%) present with superficial tumors (stages Ta, T1, or carcinoma in situ). However, 3 out of 10 patients present with muscle-invasive disease (T2-4) with a high risk of death from distant metastases. Moreover, roughly between 50% and 70% of superficial tumors do recur, and approximately 10% to 20% of them progress to muscle-invasive disease. However, BCa has a relatively low ratio of mortality versus incidence of new cases. In consequence, there is the danger of overdiagnosis and overtreatment.
Sammon JD, Abdollah F, Klett DE, Pucheril D, Sood A, Trinh Q-D, Menon M. The diminishing returns of robotic diffusion: complications after robot-assisted radical prostatectomy. BJU Int. 2015.