Mahal BA, Ziehr DR, Aizer AA, Hyatt AS, Sammon JD, Schmid M, Choueiri TK, Hu JC, Sweeney CJ, Beard CJ, et al. Getting back to equal: The influence of insurance status on racial disparities in the treatment of African American men with high-risk prostate cancer. Urol Oncol. 2014;32 (8) :1285-91.Abstract
OBJECTIVES: Treating high-risk prostate cancer (CaP) with definitive therapy improves survival. We evaluated whether having health insurance reduces racial disparities in the use of definitive therapy for high-risk CaP. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results Program was used to identify 70,006 men with localized high-risk CaP (prostate-specific antigen level > 20 ng/ml or Gleason score 8-10 or stage > cT3a) diagnosed from 2007 to 2010. We used multivariable logistic regression to analyze the 64,277 patients with complete data to determine the factors associated with receipt of definitive therapy. RESULTS: Compared with white men, African American (AA) men were significantly less likely to receive definitive treatment (adjusted odds ratio [AOR] = 0.60; 95% CI: 0.56-0.64; P < 0.001) after adjusting for sociodemographics and known CaP prognostic factors. There was a significant interaction between race and insurance status (P interaction = 0.01) such that insurance coverage was associated with a reduction in racial disparity between AA and white patients regarding receipt of definitive therapy. Specifically, the AOR for definitive treatment for AA vs. white was 0.38 (95% CI: 0.27-0.54, P < 0.001) among uninsured men, whereas the AOR was 0.62 (95% CI: 0.57-0.66, P < 0.001) among insured men. CONCLUSIONS: AA men with high-risk CaP were significantly less likely to receive potentially life-saving definitive treatment when compared with white men. Having health insurance was associated with a reduction in this racial treatment disparity, suggesting that expansion of health insurance coverage may help reduce racial disparities in the management of aggressive cancers.
Ravi P, Karakiewicz PI, Roghmann F, Gandaglia G, Choueiri TK, Menon M, McKay RR, Nguyen PL, Sammon JD, Sukumar S, et al. Mental health outcomes in elderly men with prostate cancer. Urol Oncol. 2014;32 (8) :1333-40.Abstract
OBJECTIVE: To examine the burden of mental health issues (MHI), namely anxiety, depressive disorders, and suicide, in a population-based cohort of older men with localized prostate cancer and to evaluate associations with primary treatment modality. PATIENTS AND METHODS: A total of 50,856 men, who were 65 years of age or older with clinically localized prostate cancer diagnosed between 1992 and 2005 and without a diagnosis of mental illness at baseline, were abstracted from the Surveillance, Epidemiology, and End Results-Medicare database. The primary outcome of interest was the development of MHI (anxiety, major depressive disorder, depressive disorder not elsewhere classified, neurotic depression, adjustment disorder with depressed mood, and suicide) after the diagnosis of prostate cancer. RESULTS: A total of 10,389 men (20.4%) developed MHI during the study period. Independent risk factors for MHI included age ≥ 75 years (hazard ratio [HR] = 1.29); higher comorbidity (Charlson comorbidity index ≥ 3, HR = 1.63); rural hospital location (HR = 1.14); being single, divorced, or widowed (HR = 1.12); later year of diagnosis (HR = 1.05); and urinary incontinence (HR = 1.47). Black race (HR = 0.79), very high-income status (HR = 0.87), and definitive treatment (radical prostatectomy [RP], HR = 0.79; radiotherapy [RT], HR= 0.85, all P<0.001) predicted a lower risk of MHI. The rates of MHI at 10 years were 29.7%, 29.0%, and 22.6% in men undergoing watchful waiting (WW), RT, and RP, respectively. CONCLUSION: Older men with localized prostate cancer had a significant burden of MHI. Men treated with RP or RT were at a lower risk of developing MHI, compared with those undergoing WW, with median time to development of MHI being significantly greater in those undergoing RP compared with those undergoing RT or WW.
Gandaglia G, Trinh Q-D. Models of assessment of comparative outcomes of robot-assisted surgery: best evidence regarding the superiority or inferiority of robot-assisted radical prostatectomy. Urol Clin North Am. 2014;41 (4) :597-606.Abstract
The widespread dissemination of robot-assisted radical prostatectomy (RARP) occurred despite the absence of high-level evidence supporting its safety and efficacy in patients with clinically localized prostate cancer. This study aims at systematically evaluating the models adopted in scientific reports assessing the comparative effectiveness of RARP versus open radical prostatectomy (ORP). Although several retrospective observational studies have assessed the comparative effectiveness of RARP and ORP, currently no published randomized data are available to comprehensively evaluate this issue. Furthermore, well-designed prospective investigations are needed to ultimately assess the benefits of RARP compared with other treatment modalities in patients with clinically localized prostate cancer.
Abdollah F, Klett DE, Sood A, Sammon JD, Pucheril D, Dalela D, Diaz M, Peabody JO, Trinh Q-D, Menon M. Predicting pathological outcomes in patients undergoing robot-assisted radical prostatectomy for high-risk prostate cancer: a preoperative nomogram. BJU Int. 2014.Abstract
OBJECTIVE: To identify which high-risk patients with prostate cancer may harbour favourable pathological outcomes at radical prostatectomy (RP). PATIENTS AND METHODS: We evaluated 810 patients with high-risk prostate cancer, defined as having one or more of the following: PSA level of >20 ng/mL, Gleason score ≥8, clinical stage ≥T2c. Patients underwent robot-assisted RP (RARP) with pelvic lymph node dissection, between 2003 and 2012, in one centre. Only 1.6% (13/810) of patients received any adjuvant treatment. Favourable pathological outcome was defined as specimen-confined disease (SCD; pT2-T3a, node negative, and negative surgical margins) at RARP-specimen. Logistic regression models were used to test the relationship among all available predicators and harbouring SCD. A logistic regression coefficient-based nomogram was constructed and internally validated using 200 bootstrap resamples. Kaplan-Meier method estimated biochemical recurrence (BCR)-free and cancer-specific mortality (CSM)-free survival rates, after stratification according to pathological disease status. RESULTS: Overall, 55.2% patients harboured SCD at RARP. At multivariable analysis, PSA level, clinical stage, primary/secondary Gleason scores, and maximum percentage tumour quartiles were all independent predictors of SCD (all P < 0.04). A nomogram based on these variables showed 76% discrimination accuracy in predicting SCD, and very favourable calibration characteristics. Patients with SCD had significantly higher 8-year BCR- (72.7% vs 31.7%, P < 0.001) and CSM-free survival rates (100% vs 86.9%, P < 0.001) than patients with non-SCD. CONCLUSIONS: We developed a novel nomogram predicting SCD at RARP. Patients with SCD achieved favourable long-term BCR- and CSM-free survival rates after RARP. The nomogram may be used to support clinical decision-making, and aid in selection of patients with high-risk prostate cancer most likely to benefit from RARP.
Schmid M, Abd-El-Barr A-E-R, Gandaglia G, Sood A, Olugbade K, Ruhotina N, Sammon JD, Varda B, Chang SL, Kibel AS, et al. Predictors of 30-day acute kidney injury following radical and partial nephrectomy for renal cell carcinoma. Urol Oncol. 2014;32 (8) :1259-66.Abstract
INTRODUCTION: Patients with renal cell carcinoma who were treated with radical nephrectomy (RN) or partial nephrectomy (PN) are at risk of postoperative acute kidney injury (AKI), and in consequence, short- and long-term adverse outcomes. We sought to identify independent predictors of 30-day AKI in patients undergoing RN or PN. MATERIALS AND METHODS: Between 2005 and 2011, patients who underwent RN or PN for renal cell carcinoma within the National Surgical Quality Improvement Program data set were identified. Patients with preexisting severe renal failure, defined as a preoperative estimated glomerular filtration rate<30 ml/min/1.73 m(2), were excluded from the analyses. AKI was defined as an elevation of serum creatinine>2mg/dl above baseline or the need for dialysis within 30 days of surgery. Univariable and multivariable logistic regression analyses were used to examine the association between preoperative factors and the risk of postoperative AKI. RESULTS: Overall, 1,944 (58.6%) and 1,376 (41.4%) patients underwent RN and PN, respectively. Overall, 1.8% of the patients included in the study experienced AKI within an average of 5.4 days after RN or PN. Independent predictors for AKI included obesity (odds ratio [OR] = 2.24, P = 0.04), history of neurovascular disease (OR = 5.29, P<0.001), and a preoperative chronic kidney disease stage II (OR = 10.00, P = 0.03) or stage III (OR = 26.49, P = 0.02). Furthermore, RN (OR = 2.87, P = 0.02) or the open approach (OR = 2.18, P = 0.04) was significantly associated with postoperative AKI. AKI was significantly associated with adverse postoperative outcomes, such as prolonged length of stay, occurrence of any complication, and mortality (all P <0.001). CONCLUSIONS: The assessment of preoperative kidney function and comorbidity status is essential to identify patients at risk of postoperative AKI. In addition to preoperative chronic kidney disease stages II and III, neurovascular disease, obesity, and surgical approach (RN or open) represent predictors of 30-day AKI. Careful patient selection as well as preoperative planning may help reduce this unfavorable postoperative outcome.
Mahal BA, Aizer AA, Ziehr DR, Hyatt AS, Choueiri TK, Hu JC, Hoffman KE, Sweeney CJ, Beard CJ, D'Amico AV, et al. Racial disparities in prostate cancer-specific mortality in men with low-risk prostate cancer. Clin Genitourin Cancer. 2014;12 (5) :e189-95.Abstract
BACKGROUND: Men with low-risk prostate cancer (CaP) are considered unlikely to die of CaP and have the option of active surveillance. This study evaluated whether African American (AA) men who present with low-risk disease are at higher risk for death from CaP than white men. PATIENTS AND METHODS: The authors identified 56,045 men with low-risk CaP (T1-T2a, Gleason score ≤ 6, prostate-specific antigen ≤ 10 ng/mL) diagnosed between 2004 and 2009 using the Surveillance, Epidemiology, and End Results (SEER) database. Fine-Gray competing-risks regression analyses were used to analyze the effect of race on prostate cancer-specific mortality (PCSM) after adjusting for known prognostic and sociodemographic factors in 51,315 men (43,792 white; 7523 AA) with clinical follow-up information available. RESULTS: After a median follow-up of 46 months, 258 patients (209 [0.48%] white and 49 [0.65%] AA men) died from CaP. Both AA race (adjusted hazard ratio [AHR], 1.45; 95% CI, 1.03-2.05; P = .032) and noncurative management (AHR, 1.49; 95% CI, 1.15-1.95; P = .003) were significantly associated with an increased risk of PCSM. When analyzing only patients who underwent curative treatment, AA race (AHR, 1.62; 95% CI, 1.04-2.53; P = .034) remained significantly associated with increased PCSM. CONCLUSION: Among men with low-risk prostate cancer, AA race compared with white race was associated with a higher risk of PCSM, raising the possibility that clinicians may need to exercise caution when recommending active surveillance for AA men with low-risk disease. Further studies are needed to ultimately determine whether guidelines for active surveillance should take race into account.
Leow JJ, Gandaglia G, Sood A, Ruhotina N, Klett DE, Sammon JD, Schmid M, Sun M, Chang SL, Kibel AS, et al. Readmissions after major urologic cancer surgery. Can J Urol. 2014;21 (6) :7537-46.Abstract
INTRODUCTION: We examine the incidence and predictors of readmission after major urologic cancer surgery using a national, prospective-maintained database specifically developed to assess quality of surgical care. MATERIALS AND METHODS: Patients undergoing major urologic cancer surgery (radical prostatectomy [RP], radical nephrectomy [RNx], partial nephrectomy [PNx]), radical cystectomy [RC]) in 2011 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) using Current Procedural Terminology (CPT) codes. Those readmitted within 30 days after surgery were identified. Multivariable logistic regression models examined the association between patient characteristics and the odds of readmission. RESULTS: Overall, we identified 5356 RP, 1301 RNx, 918 PNx and 623 RC patients, of which 206 (3.8%), 533 (6.8%), 348 (6.3%) and 129 (20.7%) were readmitted within 30 days respectively. Independent predictors of readmission for RP included age (Odds Ratio [OR]: 1.02, p = 0.02), American Society of Anesthesiology (ASA) score 3-5 (versus 1-2, OR: 1.35, p = 0.04), smoking status (OR: 1.53, p = 0.04), and the occurrence of wound complications (OR: 9.31, p < 0.001), thromboembolic (OR: 14.7, p < 0.001), and renal failure (OR: 1.62, p = 0.01) complications during the index hospitalization. For RC patients, the only predictor of readmission was age (OR: 0.98, p = 0.04). Predictors of readmission for RNx included higher ASA score (OR: 1.77, p = 0.03), and the presence of any complications during the index hospitalization (OR: 2.21, p = 0.03). CONCLUSIONS: Several patient characteristics have a significant impact on the risk of 30 day readmission after major urologic cancer surgery. Our data suggests that improving prevention and management of complications during the index hospitalization may lead to a substantial decrease in readmission rates.
Mahal BA, Aizer AA, Ziehr DR, Hyatt AS, Lago-Hernandez C, Chen Y-W, Choueiri TK, Hu JC, Sweeney CJ, Beard CJ, et al. The association between insurance status and prostate cancer outcomes: implications for the Affordable Care Act. Prostate Cancer Prostatic Dis. 2014;17 (3) :273-9.Abstract
BACKGROUND: The Affordable Care Act (ACA) aims to expand health insurance coverage to over 30 million previously uninsured Americans. To help evaluate the potential impact of the ACA on prostate cancer care, we examined the associations between insurance coverage and prostate cancer outcomes among men <65 years old who are not yet eligible for Medicare. METHODS: The Surveillance, Epidemiology and End Results Program was used to identify 85 203 men aged <65 years diagnosed with prostate cancer from 2007 to 2010. Multivariable logistic regression modeled the association between insurance status and stage at presentation. Among men with high-risk disease, the associations between insurance status and receipt of definitive therapy, prostate cancer-specific mortality (PCSM) and all-cause mortality were determined using multivariable logistic, Fine and Gray competing-risks and Cox regression models, respectively. RESULTS: Uninsured patients were more likely to be non-white and come from regions of rural residence, lower median household income and lower education level (P<0.001 for all cases). Insured men were less likely to present with metastatic disease (adjusted odds ratio (AOR) 0.23; 95% confidence interval (CI) 0.20-0.27; P<0.001). Among men with high-risk disease, insured men were more likely to receive definitive treatment (AOR 2.29; 95% CI 1.81-2.89; P<0.001), and had decreased PCSM (adjusted hazard ratio 0.56; 95% CI 0.31-0.98; P=0.04) and all-cause mortality (adjusted hazard ratio 0.60; 0.39-0.91; P=0.01). CONCLUSIONS: Insured men with prostate cancer are less likely to present with metastatic disease, more likely to be treated if they develop high-risk disease and are more likely to survive their cancer, suggesting that expanding health coverage under the ACA may significantly improve outcomes for men with prostate cancer who are not yet eligible for Medicare.
Gandaglia G, Ghani KR, Sood A, Meyers JR, Sammon JD, Schmid M, Varda B, Briganti A, Montorsi F, Sun M, et al. Effect of minimally invasive surgery on the risk for surgical site infections: results from the National Surgical Quality Improvement Program (NSQIP) Database. JAMA Surg. 2014;149 (10) :1039-44.Abstract
IMPORTANCE: Surgical site infection (SSI) represents the second most common cause of hospital-acquired infection and the most common type of infection in patients undergoing surgery. However, evidence is scarce regarding the effect of the surgical approach (open surgery vs minimally invasive surgery [MIS]) on the risk for SSIs. OBJECTIVE: To evaluate the role of the surgical approach on the risk for SSIs in a large contemporary cohort of patients undergoing surgery across different specialties. DESIGN, SETTING, AND PARTICIPANTS: The American College of Surgeons National Surgical Quality Improvement Program database is a national, prospective perioperative database specifically developed to assess quality of surgical care. We queried the database from January 1, 2005, through December 31, 2011, for patients undergoing appendectomy (n = 97,780), colectomy (n = 118,407), hysterectomy (n = 26,639), or radical prostatectomy (n = 11,183). EXPOSURES: Thirty-day SSIs. MAIN OUTCOMES AND MEASURES: We abstracted the data on 30-day SSIs and compared patients undergoing open procedures and MIS using propensity score matching. Logistic regression analyses of the matched cohorts tested the association between the surgical approach and risk for SSIs. RESULTS: The overall 30-day rates of SSIs were 5.4% for appendectomy, 12.1% for colectomy, 2.8% for hysterectomy, and 1.7% for prostatectomy. After propensity score matching, MIS was associated with lower rates of postoperative SSIs in patients undergoing MIS vs open procedures for appendectomy (3.8% vs 7.0%; P < .001), colectomy (9.3% vs 15.0%; P < .001), hysterectomy (1.8% vs 3.9%; P < .001), and radical prostatectomy (1.0% vs 2.4%; P < .001). In logistic regression analyses, MIS was associated with lower odds of SSIs in patients treated with appendectomy (odds ratio [OR], 0.52 [95% CI, 0.48-0.58]; P < .001), colectomy (OR, 0.58 [95% CI, 0.55-0.61]; P < .001), hysterectomy (OR, 0.44 [95% CI, 0.37-0.53]; P < .001), and radical prostatectomy (OR, 0.39 [95% CI, 0.25-0.61]; P < .001). CONCLUSIONS AND RELEVANCE: The proportion of patients developing SSIs within 30 days after surgery can be substantial and depends on the type of surgery. Minimally invasive surgery is significantly associated with reduced odds of SSIs. This advantage should be considered when assessing the overall benefits of minimally invasive techniques.
Gandaglia G, Popa I, Abdollah F, Schiffmann J, Shariat SF, Briganti A, Montorsi F, Trinh Q-D, Karakiewicz PI, Sun M. The effect of neoadjuvant chemotherapy on perioperative outcomes in patients who have bladder cancer treated with radical cystectomy: a population-based study. Eur Urol. 2014;66 (3) :561-8.Abstract
BACKGROUND: Although therapeutic guidelines recommend the use of neoadjuvant chemotherapy before radical cystectomy (RC) in patients who have muscle-invasive bladder cancer (MIBC), this approach remains largely underused. One of the main reasons for this phenomenon might reside in concerns regarding the risk of morbidity and mortality associated with neoadjuvant chemotherapy. OBJECTIVE: To compare perioperative outcomes between patients receiving neoadjuvant chemotherapy and those treated with RC alone. DESIGN, SETTING, AND PARTICIPANTS: Relying on the Surveillance Epidemiology and End Results-Medicare-linked database, 3760 patients diagnosed with MIBC between 2000 and 2009 were evaluated. INTERVENTION: RC alone or RC plus neoadjuvant chemotherapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Complications occurred within 30 and 90 d after surgery. Heterologous blood transfusions (HBTs), length of stay (LoS), readmission, and perioperative mortality were compared. To decrease the effect of unmeasured confounders associated with treatment selection, propensity score-matched analyses were performed. RESULTS AND LIMITATIONS: Overall, 416 (11.1%) of patients received neoadjuvant chemotherapy. Following propensity score matching, 416 (20%) and 1664 (80%) patients treated with RC plus neoadjuvant chemotherapy and RC alone remained, respectively. The 30-d complication, readmission, and mortality rates were 66.0%, 32.2%, and 5.3%, respectively. The 90-d complication, readmission, and mortality rates were 72.5%, 46.6%, and 8.2%, respectively. When patients were stratified according to neoadjuvant chemotherapy status, no significant differences were observed in the rates of complications, HBT, prolonged LoS, readmission, and mortality between the two groups (all p ≥ 0.1). These results were confirmed in multivariate analyses, where the use of neoadjuvant chemotherapy was not associated with higher risk of 30- and 90-d complications, HBT, prolonged LoS, readmission, and mortality (all p ≥ 0.1). Our study is limited by its retrospective nature. CONCLUSIONS: The use of neoadjuvant chemotherapy is not associated with higher perioperative morbidity or mortality. These results should encourage wider use of neoadjuvant chemotherapy when clinically indicated. PATIENT SUMMARY: Chemotherapy before radical cystectomy in patients with muscle-invasive bladder cancer does not increase the risk of complications or death. The use of chemotherapy should be strongly encouraged, as recommended by clinical guidelines, given its benefits.
Ruhotina N, Dagenais J, Gandaglia G, Sood A, Abdollah F, Chang SL, Leow JJ, Olugbade K, Rai A, Sammon JD, et al. The impact of resident involvement in minimally-invasive urologic oncology procedures. Can Urol Assoc J. 2014;8 (9-10) :334-40.Abstract
INTRODUCTION: Robotic and laparoscopic surgical training is an integral part of resident education in urology, yet the effect of resident involvement on outcomes of minimally-invasive urologic procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a large multi-institutional prospective database. METHODS: Relying on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant User Files (2005-2011), we abstracted the 3 most frequently performed minimally-invasive urologic oncology procedures. These included radical prostatectomy, radical nephrectomy and partial nephrectomy. Multivariable logistic regression models were constructed to assess the impact of trainee involvement (PGY 1-2: junior, PGY 3-4: senior, PGY ≥5: chief) versus attending-only on operative time, length-of-stay, 30-day complication, reoperation and readmission rates. RESULTS: A total of 5459 minimally-invasive radical prostatectomies, 1740 minimally-invasive radical nephrectomies and 786 minimally-invasive partial nephrectomies were performed during the study period, for which data on resident surgeon involvement was available. In multivariable analyses, resident involvement was not associated with increased odds of overall complications, reoperation, or readmission rates for minimally-invasive prostatectomy, radical and partial nephrectomy. However, operative time was prolonged when residents were involved irrespective of the type of procedure. Length-of-stay was decreased with senior resident involvement in minimally-invasive partial nephrectomies (odds ratio [OR] 0.49, p = 0.04) and prostatectomies (OR 0.68, p = 0.01). The major limitations of this study include its retrospective observational design, inability to adjust for the case complexity and surgeon/hospital characteristics, and the lack of information regarding the minimally-invasive approach utilized (whether robotic or laparoscopic). CONCLUSIONS: Resident involvement is associated with increased operative time in minimally-invasive urologic oncology procedures. However, it does not adversely affect the complication, reoperation or readmission rates, as well as length-of-stay.
Gandaglia G, Trinh Q-D, Hu JC, Schiffmann J, Becker A, Roghmann F, Popa I, Tian Z, Perrotte P, Montorsi F, et al. The impact of robot-assisted radical prostatectomy on the use and extent of pelvic lymph node dissection in the "post-dissemination" period. Eur J Surg Oncol. 2014;40 (9) :1080-6.Abstract
INTRODUCTION: Previous series during the dissemination era of minimally invasive techniques for treatment of prostate cancer (PCa) showed a declining use of pelvic lymph node dissection (PLND). The aim of our study was to re-assess the impact of robot-assisted radical prostatectomy (RARP) on the utilization rate of PLND and its extent in the post-dissemination period. METHODS: Relying on the Surveillance Epidemiology and End Results (SEER) Medicare-linked database, 5804 patients with non-metastatic PCa undergoing open radical prostatectomy (ORP) or RARP between years 2008 and 2009 were identified. Uni- and multivariable logistic regression analyses tested the relationship between surgical approach (RARP vs. ORP) and: 1 - the rate of PLND (pNx vs. pN0-1); and 2 - the extent of PLND (limited vs. extended). RESULTS: Overall, 3357 (57.8%) patients underwent a PLND. The proportion of patients treated with PLND was significantly higher among ORP vs. RARP patients: 71.2 vs. 48.6%, respectively (P < 0.001). In addition, the median number of lymph nodes removed was significantly higher for patients treated with ORP vs. RARP: 5 vs. 4, respectively (P < 0.001). In multivariable analyses, ORP was associated with 2.7- and 1.3-fold higher odds of undergoing PLND and of receiving an extended PLND compared to RARP, respectively (both P ≤ 0.001). Stratified analyses according to disease risk classifications revealed similar trends. CONCLUSIONS: In the post-dissemination era, RARP remains associated with a decreased use of PLND and suboptimum extent. Efforts should be made to improve guideline adherence in performing a PLND whenever indicated according to tumor aggressiveness, despite surgical approach.
Trinh Q-D, Schrag D. Measuring the effectiveness of androgen-deprivation therapy for prostate cancer in the medicare population: adequate data are neither the same as nor the enemy of perfect data. JAMA Intern Med. 2014;174 (9) :1468-9.
Sood A, Trinh Q-D. Perioperative aspirin: to give or not to give?. BJU Int. 2014;114 (3) :318-9.
Leow JJ, Reese SW, Jiang W, Lipsitz SR, Bellmunt J, Trinh Q-D, Chung BI, Kibel AS, Chang SL. Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: a contemporary population-based analysis in the United States. Eur Urol. 2014;66 (3) :569-76.Abstract
BACKGROUND: Radical cystectomy (RC) is a morbid procedure associated with high costs. Limited population-based data exist on the complication profile and costs of robot-assisted RC (RARC) compared with open RC (ORC). OBJECTIVE: To evaluate morbidity and cost differences between ORC and RARC. DESIGN, SETTING, AND PARTICIPANTS: We conducted a population-based, retrospective cohort study of patients who underwent RC at 279 hospitals across the United States between 2004 and 2010. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariable logistic and median regression was performed to evaluate 90-d mortality, postoperative complications (Clavien classification), readmission rates, length of stay (LOS), and direct costs. To reduce selection bias, we used propensity weighting with survey weighting to obtain nationally representative estimates. RESULTS AND LIMITATIONS: The final weighted cohort included 34 672 ORC and 2101 RARC patients. RARC use increased from 0.6% in 2004 to 12.8% in 2010. Major complication rates (Clavien grade ≥ 3; 17.0% vs 19.8%, p = 0.2) were similar between ORC and RARC (odds ratio [OR]: 1.32; p = 0.42). RARC had 46% decreased odds of minor complications (Clavien grade 1-2; OR: 0.54; p = 0.03). RARC had $4326 higher adjusted 90-d median direct costs (p = 0.004). Although RARC had a significantly shorter LOS (11.8 d vs 10.2 d; p = 0.008), no significant differences in room and board costs existed (p = 0.20). Supply costs for RARC were significantly higher ($6041 vs $3638; p < 0.0001). Morbidity and cost differences were not present among the highest-volume surgeons (≥ 7 cases per year) and hospitals (≥ 19 cases per year). Limitations include use of an administrative database and lack of oncologic characteristics. CONCLUSIONS: The use of RARC has increased between 2004 and 2010. Compared with ORC, RARC was associated with decreased odds of minor but not major complications and with increased expenditures attributed primarily to higher supply costs. Centralization of ORC and RARC to high-volume providers may minimize these morbidity and cost differences. PATIENT SUMMARY: Using a US population-based cohort, we found that robotic surgery for bladder cancer decreased minor complications, had no impact on major complications and was more costly than open surgery.
Mahal BA, Ziehr DR, Aizer AA, Hyatt AS, Lago-Hernandez C, Choueiri TK, Elfiky AA, Hu JC, Sweeney CJ, Beard CJ, et al. Racial disparities in an aging population: the relationship between age and race in the management of African American men with high-risk prostate cancer. J Geriatr Oncol. 2014;5 (4) :352-8.Abstract
PURPOSE: To evaluate the relationship between age and race on the receipt of definitive therapy among men with high-risk prostate cancer (CaP). METHODS: We used the Surveillance, Epidemiology and End Results Program to identify 62,644 men with high-risk CaP (PSA >20 or Gleason 8-10 or stage ≥cT3a) diagnosed from 2004 to 2010. Multivariable logistic regression analysis modeled the interaction between age and race and its association with receipt of definitive therapy on 57,674 patients (47,879 white men; 9,795 African American [AA] men) with complete data on the covariates of interest. RESULTS: Among men age ≥70, AA men had a higher risk of CaP-specific mortality (PCSM) compared to white men after adjusting for sociodemographic and prostate cancer-specific factors (Adjusted HR 1.20; 95% CI 1.02-1.38; P=0.02). Nevertheless, a significant interaction between race and age was found (Pinteraction=0.01), such that the adjusted odds of receiving definitive treatment for AA vs. white was 0.67 (95% CI 0.62-0.73; P<0.001) among men age <70, but was 0.60 (95% CI 0.55-0.66; P<0.001) among men age ≥70, suggesting increased racial disparity in the receipt of definitive treatment among older men. CONCLUSION: AA men with high-risk CaP are less likely to receive definitive therapy than white men. This disparity is significantly larger among men age ≥70, despite excess PCSM among AA men in this group. With a rapidly expanding population of older minority men, this disparity should be urgently addressed to prevent increasing disparities in cancer care.
Gandaglia G, Varda B, Sood A, Pucheril D, Konijeti R, Sammon JD, Sukumar S, Menon M, Sun M, Chang SL, et al. Short-term perioperative outcomes of patients treated with radical cystectomy for bladder cancer included in the National Surgical Quality Improvement Program (NSQIP) database. Can Urol Assoc J. 2014;8 (9-10) :E681-7.Abstract
INTRODUCTION: We report the contemporary outcomes of radical cystectomy (RC) in patients with bladder cancer using a national, prospective perioperative database specifically developed to assess the quality of surgical care. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried from 2006 to 2011 for RC. Data on postoperative complications, operative time, length of stay, blood transfusions, readmission, and mortality within 30 days from surgery were abstracted. RESULTS: Overall, 1094 patients undergoing RC were identified. Rates of overall complications, transfusions, prolonged length of hospitalization, readmission, and perioperative mortality were 31.1%, 34.4%, 25.9%, 20.2%, and 2.7%, respectively. Body mass index represented an independent predictor of overall complications on multivariate analysis (p = 0.04). Baseline comorbidity status was associated with increased odds of postoperative complications, prolonged operative time, transfusion, prolonged hospitalization, and perioperative mortality. In particular, patients with cardiovascular comorbidities were 2.4 times more likely to die within 30 days following cystectomy compared to their healthier counterparts (p = 0.04). Men had lower odds of prolonged operative time and blood transfusions (p ≤ 0.03). Finally, the receipt of a continent urinary diversion was the only predictor of readmission (p = 0.02). Our results are limited by their retrospective nature and by the lack of adjustment for hospital and tumour volume. CONCLUSIONS: Complications, transfusions, readmission, and perioperative mortality remain relatively common events in patients undergoing RC for bladder cancer. In an era where many advocate the need for prospective multi-institutional data collection as a means of improving quality of care, our study provides data on short-term outcomes after RC from a national quality improvement initiative.
Schmid M, Ghani KR, Choueiri TK, Sood A, Kapoor V, Abdollah F, Chun FK, Leow JJ, Olugbade K, Sammon JD, et al. An evaluation of the 'weekend effect' in patients admitted with metastatic prostate cancer. BJU Int. 2014.Abstract
OBJECTIVES: To investigate whether mortality is increased for patients with metastatic prostate cancer (mCaP) admitted over the weekend. PATIENTS AND METHODS: Using the Nationwide Inpatient Sample (NIS) between 1998 and 2009, admitted patients with a diagnosis of prostate cancer and concomitant metastases were identified. Rates of in-hospital mortality, complications, use of imaging and procedures were assessed. Adjusted logistic regression models examined associations of mortality and complications. RESULTS: A weighted sample of 534 011 patients with mCaP was identified, including 81.7% weekday and 18.3% weekend admissions. Of these, 8.6% died after a weekday vs 10.9% after a weekend admission (P < 0.001). Patients admitted over the weekend were more likely to be treated at rural (17.8% vs 15.7%), non-teaching (57.6% vs 53.7%) and low-volume hospitals (53.4% vs 49.4%) (all P < 0.001) compared with weekday admissions. They presented higher rates of organ failure (25.2% vs 21.3%), and were less likely to undergo an interventional procedure (10.6% vs 11.4%) (all P < 0.001). More patients admitted over the weekend had pneumonia (12.2% vs 8.8%), pyelonephritis (18.3% vs 14.1%) and sepsis (4.5% vs. 3.5%) (all P < 0.001). In multivariate analysis, weekend admission was associated with an increased likelihood of complications (odds ratio [OR] 1.15, 95% confidence Interval [CI] 1.11-1.19) and mortality (OR 1.20, 95% CI 1.14-1.27). CONCLUSION: In patients with mCaP weekend admissions are associated with a significant increase in mortality and morbidity. Our findings suggest that weekend patients may present with more acute medical issues; alternatively, the quality of care over the weekend may be inferior.
Becker A, Tennstedt P, Hansen J, Trinh Q-D, Kluth L, Atassi N, Schlomm T, Salomon G, Haese A, Budaeus L, et al. Functional and oncological outcomes of patients aged . BJU Int. 2014;114 (1) :38-45.Abstract
OBJECTIVE: To address the biochemical and functional outcomes after radical prostatectomy (RP) of men aged <50 years in a large European population. PATIENTS AND METHODS: Among 13,268 patients who underwent RP for clinically localised prostate cancer at our centre (1992-2011), 443 (3.3%) men aged <50 were identified. Biochemical recurrence (BCR) and functional outcomes (International Index of Erectile Function [IIEF-5], use of pads), were prospectively evaluated and compared between men aged <50 years and older patients. RESULTS: Men aged <50 years were more likely to harbour D'Amico low-risk (49.4 vs 34.9%, P < 0.001), organ-confined (82.6 vs 69.4%, P < 0.001) and low-grade tumours (Gleason score <7: 33.1 vs 28.7%, P < 0.001). Multivariate Cox regression analysis showed that age <50 years (hazard ratio 0.99; confidence interval 0.72-1.31; P = 0.9) was not a predictor of BCR. Urinary continence was more favourable in younger patients, resulting in continence rates of 97.4% vs 91.6% in most recent years (2009-2011) for patients aged <50 vs ≥50 years. After RP, a median IIEF-5 drop of 4 points in younger men vs 8 points in older patients was recorded (P < 0.001). Favourable recovery of urinary continence and erectile function in patients aged <50 years compared with their older counterparts was confirmed after multivariable adjustment. CONCLUSION: Men aged <50 years diagnosed with localised prostate cancer should not be discouraged from RP, as the postoperative rates of urinary incontinence and erectile dysfunction are low and probability of BCR-free survival at 2 and 5 years is high.
Bhojani N, Gandaglia G, Sood A, Rai A, Pucheril D, Chang SL, Karakiewicz PI, Menon M, Olugbade K, Ruhotina N, et al. Morbidity and mortality after benign prostatic hyperplasia surgery: data from the American College of Surgeons national surgical quality improvement program. J Endourol. 2014;28 (7) :831-40.Abstract
BACKGROUND AND PURPOSE: With the aging population, it is becoming increasingly important to identify patients at risk for postsurgical complications who might be more suited for conservative treatment. We sought to identify predictors of morbidity after surgical treatment of benign prostatic hyperplasia (BPH) using a large national contemporary population-based cohort. METHODS: Relying on the American College of Surgeons National Surgical-Quality Improvement Program (ACS-NSQIP; 2006-2011) database, we evaluated outcomes after transurethral resection of the prostate (TURP), laser vaporization of the prostate (LVP), and laser enucleation of the prostate (LEP). Outcomes included blood-transfusion rates, length of stay, complications, reintervention rates, and perioperative mortality. Multivariable logistic-regression analysis evaluated the predictors of perioperative morbidity and mortality. RESULTS: Overall, 4794 (65.2%), 2439 (33.1%), and 126 (1.7%) patients underwent TURP, LVP, and LEP, respectively. No significant difference in overall complications (P=0.3) or perioperative mortality (P=0.5) between the three surgical groups was found. LVP was found to be associated with decreased blood transfusions (odds ratio [OR]=0.21; P=0.001), length of stay (OR=0.12; P<0.001) and reintervention rates (OR=0.63; P=0.02). LEP was found to be associated with decreased prolonged length of stay (OR=0.35; P=0.01). Men with advanced age at surgery and non-Caucasians were at increased risk of morbidity and mortality. In contrast, normal preoperative albumin and higher preoperative hematocrit (>30%) levels were the only predictors of lower overall complications and perioperative mortality. CONCLUSIONS: All three surgical modalities for BPH management were found to be safe. Advanced age and non-Caucasian race were independent predictors of adverse outcomes after BPH surgery. In patients with these attributes, conservative treatment might be a reasonable alternative. Also, preoperative hematocrit and albumin levels represent reliable predictors of adverse outcomes, suggesting that these markers should be evaluated before BPH surgery.