Trudeau V, Becker A, Roghmann F, Shariat SF, Kluth LA, Hanna N, Abdo A'a, Gandaglia G, Tian Z, Perrotte P, et al. Local tumor destruction in renal cell carcinoma--an inpatient population-based study. Urol Oncol. 2014;32 (1) :54.e1-7.Abstract
OBJECTIVES: Local tumor destruction (LTD) is a recommended therapy alternative for localized T1 renal cell carcinoma for patients who are unfit for surgery. We examined patterns of use and complication rates of LTD in a large population-based cohort. MATERIALS AND METHODS: Overall, data for 5,285 patients undergoing LTD for renal cell carcinoma were extracted from the Nationwide Inpatient Sample database from 2006 to 2010. We assessed patient and hospital characteristics, as well as postoperative complications, using International Classification of Diseases, Ninth Revision codes. The effect of patient and hospital characteristics on peri-interventional complications (overall or specific) was tested using univariable or multivariable logistic regression models. RESULTS: Most patients were male (61.2%), aged 71 to 80 years (34.9%), and had 3 or more comorbidities (30.6%). Most LTDs were performed at urban (93.5%), teaching (57.7%), and low-volume (75.7%) hospitals. Overall complications were recorded in 15.4% of patients. In multivariable analyses adjusted for clustering, overall complications occurred more frequently in older, sicker patients who were treated at low-volume hospitals (all P<0.05). Similar results were recorded when each complication category was addressed individually. CONCLUSIONS: In the current population-based cohort, complications of LTD occurred in 1 of 6 patients and were more frequent in individuals with advanced age or multiple comorbidities, or both, especially if LTDs were performed at lower-volume hospitals.
Hansen J, Gandaglia G, Bianchi M, Sun M, Rink M, Tian Z, Meskawi M, Trinh Q-D, Shariat SF, Perrotte P, et al. Re-assessment of 30-, 60- and 90-day mortality rates in non-metastatic prostate cancer patients treated either with radical prostatectomy or radiation therapy. Can Urol Assoc J. 2014;8 (1-2) :E75-80.Abstract
INTRODUCTION: It is customary to consider deaths that occur within 90 days of surgery as caused by that surgery. However, such practice may overestimate the true short-term mortality rates after radical prostatectomy (RP). Indeed, treatment-unrelated events might affect short-term mortality rates. We assess RP-specific excess short-term mortality. METHODS: We performed a retrospective analysis of a population-based cohort of 59 010 patients (RP = 28 281 and external beam radiation therapy [EBRT] as reference group, n = 30 729) who were treated between 1998 and 2005 for non-metastatic prostate cancer. Using univariate and multivariate logistic regression analyses, we assessed the rates of 30-, 60- and 90-day mortality after either RP or EBRT. RESULTS: Within the cohort, 30-, 60- and 90-day mortality rates were 0.2, 0.5 and 0.6%, and 0.1, 0.4 and 0.6% for RP and EBRT patients, respectively. This resulted in overall 30-, 60, and 90- day mortality differences of 0.1, 0.1 and 0%, respectively. After stratification according to age and Charlson comorbidity index (CCI), the magnitude of these differences increased up to 3.2% in favour of EBRT in patients aged >75 years with CCI ≥2. In multivariable analysis, rates of 30-, 60- and 90- day mortality were 5.2-, 1.8- and 1.3-fold higher after RP than EBRT, respectively. Our study is limited by its non-randomized design. CONCLUSION: Overall, absolute short-term mortality rates after RP are comparable to those of EBRT. The difference decreases over time: 90 days <60 days <30 days. Nonetheless, their magnitude is far from trivial in the elderly and sickest patients.
Ghani KR, Trinh Q-D, Jeong W, Friedman A, Lakshmanan Y, Omenon M, Elder JS. Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe. Int Braz J Urol. 2014;40 (1) :125-6; discussion 126.Abstract
INTRODUCTION: The treatment of large renal stones in children can be challenging often requiring combination therapy and multiple procedures. The purpose of this video is to describe our technique of robotic nephrolithotomy and pyelolithotomy for complex renal stone disease in children, and to demonstrate the utility of the robotic ultrasound probe to aid with stone localization. MATERIALS AND METHODS: Robotic nephrolithotomy/pyelolithotomy was carried out in four consecutive patients. A robotic ultrasound probe (Hitachi-Aloka, Tokyo, Japan) under console surgeon control was used in all cases. RESULTS: Two patients underwent robotic pyelolithotomy, one patient underwent robotic nephrolithotomy, whilst the fourth patient underwent robotic pyelolithotomy and nephrolithotomy along with Y-V pyeloplasty for concurrent ureteropelvic junction obstruction. Mean operative time, blood loss and hospital stay was 216 minutes, 37.5 mL and 2 days, respectively. The robotic ultrasound probe aided identification of calculi within the kidney in all cases. For nephroli¬thotomy it was helpful in planning the incision for nephrotomy. After nephrotomy or pyelotomy, stones were removed using a combination of robotic Maryland forceps, fenestrated grasper or Prograsp. Antegrade nephroscopy introduced through a laparoscopic port was used in all patients for confirmation of residual stone status. Two patients did not require a ureteral stent in the post-operative period. One patient had a minor complication (Clavien Grade 2 - dislodged malecot catheter). All patients were stone free at last follow-up. CONCLUSIONS: Robotic nephrolithotomy and pyelolithotomy with utilization of the robotic ultrasound probe offers a one-stop solution for complex renal stones with excellent stone-free rates.
Ben-Zvi T, Hueber P-A, Valdivieso R, Azzizi M, Tholomier C, Bienz M, Bhojani N, Trinh Q-D, Zorn KC. Urological resident exposure to transurethral surgical options for BPH management in 2012-2013: A pan-Canadian survey. Can Urol Assoc J. 2014;8 (1-2) :54-60.
Trinh VQ, Karakiewicz PI, Sammon J, Sun M, Sukumar S, Gervais M-K, Shariat SF, Tian Z, Kim SP, Kowalczyk KJ, et al. Venous thromboembolism after major cancer surgery: temporal trends and patterns of care. JAMA Surg. 2014;149 (1) :43-9.Abstract
IMPORTANCE: There is limited data on the prevalence and mortality of venous thromboembolism (VTE) following oncologic surgery. OBJECTIVE: To evaluate the trends, factors, and mortality of VTE following major cancer surgery. DESIGN, SETTING, AND PARTICIPANTS: Patients undergoing colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, or prostatectomy were identified retrospectively using the Nationwide Inpatient Sample between January 1, 1999, and December 30, 2009, resulting in a weighted estimate of 2,508,916 patients. MAIN OUTCOMES AND MEASURES: Venous thromboembolism following major cancer surgery was assessed according to date, patient, and hospital characteristics. The determinants of in-hospital VTE were evaluated using logistic regression analysis. RESULTS: Venous thromboembolism showed an estimated annual percentage increase of 4.0% (95% CI, 2.9% to 5.1%), which contrasts with a 2.4% (95% CI, -4.3% to -0.5%) annual decrease in mortality in VTE after major cancer surgery. In multivariate logistic regression analysis, older age (odds ratio [OR], 1.03; P < .001), female sex (OR, 1.25; P < .001), black race (vs white; OR, 1.56; P < .001), Charlson comorbidity index score of 3 or more (OR, 1.85; P < .001), and Medicaid (vs private insurance; OR, 2.04; P < .001), Medicare (OR, 1.39; P < .001), and uninsured (OR, 1.49; P < .001) status were associated with an increased risk of VTE. Conversely, other (nonwhite and nonblack) race (OR, 0.75; P < .001) was associated with a lower risk of VTE. Among hospital characteristics, urban location (OR, 1.32; P < .001) and teaching status (OR, 1.08; P = .01) were associated with greater odds of VTE. Patients with vs without VTE experienced 5.3-fold greater odds of mortality. CONCLUSIONS AND RELEVANCE: During our study period, VTE events following major cancer surgery increased in frequency; however, associated VTE mortality decreased. Changing VTE detection guidelines and better management of this condition may explain our findings.
Sammon JD, Kaczmarek BF, Ravi P, Sun M, Roghmann F, Sukumar S, Ghani K, Sharma P, Karakiewicz PI, Peabody JO, et al. Effect of metastatic site on emergency department disposition in men with metastatic prostate cancer. Can J Urol. 2013;20 (6) :7008-14.Abstract
INTRODUCTION: Though the prevalence of metastatic prostate cancer is decreasing, the rate of admission from the emergency department (ED) is increasing. Little is known about the implications of metastatic site on a patient's ED course and admission. MATERIALS AND METHODS: A weighted estimate of 15,367 patients with metastatic prostate cancer who presented to the ED between January 1, 2006 and December 31, 2009 was abstracted from the Nationwide Emergency Department Sample (NEDS). Descriptive statistics were used to elaborate patient and hospital characteristics of the metastatic prostate cancer population and logistic regression models were fitted to identify predictors of admission. RESULTS: The most common site of metastasis in patients with metastatic prostate cancer presenting to the ED was bone (80.6%), followed by liver (13.2%), lung (9.3) and other genitourinary sites (8.1%). Over the study period, there was an increase in prevalence of the four commonest metastatic sites, and admission rates varied between metastatic sites (83.2% for bone to 95.2% for nodal metastasis). Substantial variability in the rate of inpatient mortality was noted. Increasing age, Northeast region, increased comorbidity burden, and the presence of nodal metastases and other urinary metastases were shown to be independent predictors of hospital admission. CONCLUSIONS: The commonest metastatic site in patients presenting to United States EDs with metastatic prostate cancer between 2006 and 2009 was bone. Patients presenting with nodal metastases were most likely to be admitted. Independent predictors of hospitalization included age, Northeast region, increased comorbidities, nodal metastases and other urinary metastases.
Kaczmarek BF, Tanagho YS, Hillyer SP, Mullins JK, Diaz M, Trinh Q-D, Bhayani SB, Allaf ME, Stifelman MD, Kaouk JH, et al. Off-clamp robot-assisted partial nephrectomy preserves renal function: a multi-institutional propensity score analysis. Eur Urol. 2013;64 (6) :988-93.Abstract
BACKGROUND: Ongoing efforts are focused on minimizing or eliminating renal ischemia during robot-assisted partial nephrectomy (RPN). Although various techniques allowing the elimination of renal hilar clamping have been described, large multi-institutional studies assessing perioperative and functional outcomes of this approach are lacking. OBJECTIVE: To evaluate perioperative and functional outcomes of RPN without hilar clamping and to assess comparative effectiveness relative to clamped RPN. DESIGN, SETTING, AND PARTICIPANTS: A multi-institutional data analysis of prospectively collected records of 886 RPNs performed by high-volume surgeons across five academic institutions between 2007 and 2011 was carried out. A total of 66 patients who underwent RPN without hilar clamping were identified. After the exclusion of 17 patients, perioperative results of 49 patients were compared against propensity score matched clamped controls. INTERVENTION: RPN without hilar clamping. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics and propensity score matching. RESULTS AND LIMITATIONS: Patients undergoing off-clamp RPN had a mean tumor size of 2.5 cm (standard deviation [SD]: ± 2.1) and a mean RENAL nephrometry score of 5.3 (SD: ± 1.5). The mean preoperative estimated glomerular filtration rate (eGFR) was 81 (SD: ± 29). The mean estimated blood loss (EBL) was 210 ml (SD: ± 212), and the mean operative time was 155 min (SD: ± 46). No Clavien 3-5 complications were recorded. The mean postoperative change in eGFR was 3% at first follow-up (1-3 mo), and no patient required postoperative dialysis. The positive surgical margin rate was 3% (n=2), with no disease recurrence reported at a mean follow-up of 21 mo. In propensity score matched analyses, the off-clamp RPN patients had a significantly shorter mean operative time (156 min compared with 185 min, p<0.001), a higher EBL (228 ml compared with 157 ml, p=0.009), and a smaller decrease in eGFR (2% compared with -6%, p=0.008). The retrospective analysis was the main limitation of this study. CONCLUSIONS: With appropriately selected patients and adequate surgeon experience, off-clamp RPN is safe and feasible. Off-clamp RPN was associated with higher EBL, shorter operative times, and smaller decrease in renal function.
Hueber P-A, Liberman D, Ben-Zvi T, Woo H, Hai MA, Te AE, Chughtai B, Lee R, Rutman M, Gonzalez RR, et al. 180 W vs 120 W lithium triborate photoselective vaporization of the prostate for benign prostatic hyperplasia: a global, multicenter comparative analysis of perioperative treatment parameters. Urology. 2013;82 (5) :1108-13.Abstract
OBJECTIVE: To evaluate the surgical performance of the new Greenlight XPS-180 W laser system (American Medical Systems, Minnetonka, MI) and the effect of prostate volume (PV), in comparison with the former HPS-120 W system, for the treatment of benign prostatic hyperplasia by photo-selective vaporization of the prostate. METHODS: Between July 2007 and March 2012, 1809 patients underwent laser photo-selective vaporization of the prostate (1187 patients with the use of HPS-120 W and 622 patients with the use of XPS-180 W) at 7 international centers. All data were collected prospectively. Comparative analysis was performed between XPS and HPS according to PV measured by transrectal ultrasound. RESULTS: The XPS compared with HPS, allowed significantly reduced laser and operative time (29.6 minutes vs 65.8 minutes and 53 minutes vs 80 minutes, respectively; P <.01 for both). The number of fiber used during the procedures was significantly reduced with the XPS system (1.11 vs 2.28; P <.01), whereas total energy delivered was lower (250.2 kJ vs 267.7 kJ; P = .043). Overall, the mean operative time, mean laser time, and mean energy were all significantly increased according to PV >80 mL vs <80 mL. However, when stratified according to PV, XPS demonstrates significant advantages compared with HPS, regardless of prostate size in all operative parameters (P <.01). CONCLUSION: The new XPS-180 W system exhibits significant advantages in all surgical parameters compared with the HPS-120 W system. Overall, with XPS-180 W and HPS-120 W, mean operative time, laser time, and energy usage increased according to PV. This suggests that preoperative evaluation of PV by transrectal ultrasound should be mandatory.
Roghmann F, Ghani KR, Kowalczyk KJ, Bhojani N, Sammon JD, Gandaglia G, Trudeau V, Becker A, Sukumar S, Menon M, et al. Incidence and treatment patterns in males presenting with lower urinary tract symptoms to the emergency department in the United States. J Urol. 2013;190 (5) :1798-804.Abstract
PURPOSE: Due to varying clinical definitions of lower urinary tract symptoms, it has been difficult to determine comparable prevalence and incidence rates of lower urinary tract symptoms and their treatment modalities. We assessed the incidence of emergency department visits in men with lower urinary tract symptoms who presented to emergency departments in the United States and factors associated with an increased likelihood of hospitalization. MATERIALS AND METHODS: Emergency department visits from 2006 to 2009 associated with a primary diagnosis of lower urinary tract symptoms using established criteria were abstracted from the Nationwide Emergency Department Sample. Age adjusted incidence rates of emergency department visits and charges were calculated. We performed multivariable analysis to examine patient and hospital characteristics of those hospitalized and those with benign prostatic hyperplasia related adverse events. RESULTS: A weighted estimate of 1,178,423 emergency department visits for lower urinary tract symptoms was recorded with a national incidence of 197.6/100,000 males per year. A total of 112,288 visits (9.5%) resulted in hospitalization. Adverse events were identified in 734,269 patients (62.3%). The most common adverse events were catheterization in 44.6% of cases, infection in 17.4%, hematuria in 9.6%, bladder stones in 1.7%, hydronephrosis in 1.2% and acute renal failure in 0.1%. On multivariable analysis independent predictors of hospital admission included comorbidities, socioeconomic status, hospital characteristics and adverse events such as sepsis, acute renal failure and hydronephrosis. Independent predictors of adverse events included patient age, year of visit, socioeconomic status, hospital characteristics and concomitant neurological disease. In 2009 total emergency department charges for lower urinary tract symptoms were $494,981,922. CONCLUSIONS: The number of men with lower urinary tract symptoms who visit the emergency department has remained stable, while emergency department charges have increased by 40%. The rate of adverse events increased during the study period. These findings might suggest over reliance on medical and conservative therapy in the contemporary era.
Roghmann F, Becker A, Sammon JD, Ouerghi M, Sun M, Sukumar S, Djahangirian O, Zorn KC, Ghani KR, Gandaglia G, et al. Incidence of priapism in emergency departments in the United States. J Urol. 2013;190 (4) :1275-80.Abstract
PURPOSE: Priapism is a complex medical emergency that often requires prompt management. In this study, we examine the incidence of this condition in a United States population based setting, and assess patient and emergency department attributes associated with an increased likelihood of hospitalization. MATERIALS AND METHODS: Emergency department visits with a primary diagnosis of priapism between 2006 and 2009 were abstracted from the Nationwide Emergency Department Sample. Univariable and multivariable analyses were performed of patient and hospital characteristics of those admitted with priapism. RESULTS: Between 2006 and 2009 a weighted estimate of 32,462 visits to the emergency department for priapism was recorded in the United States, which represents a national incidence of 5.34 per 100,000 male subjects per year. The incidence of emergency department visits increased by 31.4% during the summer compared to the winter months. Overall 4,320 visits (13.3%) resulted in hospitalization/admission for further management. On multivariable analyses independent predictors of admission included Charlson comorbidity index score 3 or greater (OR 5.67, p <0.001), insurance status (Medicaid vs private OR 1.60, p = 0.001), hospital location (rural vs urban nonteaching OR 0.32, p <0.001), median ZIP code income (very high OR 0.65, p = 0.005), emergency department volume (very high vs very low OR 1.61, p = 0.004), sickle cell disease (OR 2.22, p <0.001) and drug abuse (OR 5.47, p <0.001). CONCLUSIONS: Emergency department visits for priapism are relatively uncommon and occur more frequently during the summer months. The majority of patients are treated and released expediently. Predictors of hospital admission included comorbidity profile, insurance, hospital location and emergency department volume.
Bianchi M, Becker A, Abdollah F, Trinh Q-D, Hansen J, Tian Z, Shariat SF, Perrotte P, Karakiewicz PI, Sun M. Rates of open versus laparoscopic and partial versus radical nephrectomy for T1a renal cell carcinoma: a population-based evaluation. Int J Urol. 2013;20 (11) :1064-71.Abstract
OBJECTIVES: To examine the trends of open and laparoscopic partial nephrectomy and radical nephrectomy according to sociodemographic and tumor characteristics. METHODS: Using the Surveillance, Epidemiology, and End Results Medicare-linked database, 6024 patients diagnosed with T1a renal cell carcinoma were abstracted. Multivariable logistic regression analyses were used for prediction of open radical nephrectomy, open partial nephrectomy, laparoscopic radical nephrectomy and laparoscopic partial nephrectomy. Covariates comprised of patient age, baseline comorbidity status, sex, race, marital status, socioeconomic status, population density, Surveillance, Epidemiology and End Results registry, tumor size, and year of diagnosis. RESULTS: Open radical nephrectomy decreased from 89% in 1988 to 66% in 2005 (P < 0.001), whereas open partial nephrectomy increased from 7% to 29% (P < 0.001). Meanwhile, utilization of either laparoscopic radical nephrectomy or laparoscopic partial nephrectomy remained low. Treatment utilization differed according to Surveillance, Epidemiology, and End Results registries (P < 0.001). Increasing patient age, female sex, low socioeconomic status and unmarried status (all P ≤ 0.003) were predictors of open radical nephrectomy. The utilization rates of laparoscopic radical nephrectomy or laparoscopic partial nephrectomy varied minimally according to the examined characteristics. Older patients or women were significantly more likely to undergo laparoscopic radical nephrectomy, even after adjustment for all covariates (both P ≤ 0.02). CONCLUSIONS: The rising utilization rates of radical nephrectomy are encouraging. Nevertheless, disparities of treatment type still exist. It is of concern that older and female patients are less likely to undergo nephron-sparing surgery, and to have a radical nephrectomy by the laparoscopic approach instead.
Abd-El-Barr A-E-RM, Sukumar S, Trinh Q-D, Roghmann F, Sun M. Re: Surgeon variation in patient quality of life after radical prostatectomy: A. Hartz, T. He, S. Strope, D. R. Cutler, G. Andriole and C. Dechet J Urol 2013; 189: 1295-1301. J Urol. 2013;190 (4) :1441-2.
Sun M, Karakiewicz PI, Trinh Q-D. Reply to Hiten D. Patel and Mohamad E. Allaf's letter to the editor re: Maxine Sun, Andreas Becker, Zhe Tian, et al. Management of localized kidney cancer: calculating cancer-specific mortality and competing risks of death for surgery and nonsurgical mana. Eur Urol. 2013;64 (5) :e107-8.
Sammon JD, Trinh Q-D, Sukumar S, Ravi P, Friedman A, Sun M, Schmitges J, Jeldres C, Jeong W, Mander N, et al. Risk factors for biochemical recurrence following radical perineal prostatectomy in a large contemporary series: a detailed assessment of margin extent and location. Urol Oncol. 2013;31 (8) :1470-6.Abstract
OBJECTIVES: The implications of positive surgical margin (PSM) extent and location during radical perineal prostatectomy (RPP) have not been assessed in a contemporary series. We aimed to examine the incidence, location, and extent of PSM as well as their impact on biochemical recurrence (BCR) following RPP. MATERIALS AND METHODS: A total of 794 patients underwent RPP by a single surgeon between June 1993 and August 2010. Covariates included age, pathologic T stage, pathologic Gleason sum, preoperative PSA, prostate volume, PSM extent, and location. Life table, Kaplan-Meier, and Cox regression analyses assessed predictors of BCR following RPP. RESULTS: PSM were recorded in 162 patients (20.4%); of these, 83 (51.2%) were focal (≤ 1 mm) whereas 79 (48.8%) were broad (>1 mm). Location of PSM was anterior 10.5%, posterior or lateral 14.8%, bladder neck 23.5%, apical 32.1%, and multifocal 19.1%. At a median follow-up of 54 months, the 5-year BCR-free probability was 90.8% in patients with negative margins, 77.5% in patients with focal PSM, and 47.5% in patients with broad PSM. On multivariable analyses adjusted for age, pathologic T stage, pathologic Gleason sum, preoperative PSA, and prostate volume, broad PSM, (HR = 3.49, P < 0.001) as well as anterior (HR = 3.77, P = 0.003), bladder neck (HR = 2.25, P = 0.01) and multifocal (HR = 3.55, P < 0.001) PSM were independent predictors of BCR. CONCLUSIONS: In this study, we present oncologic outcomes following RPP in a large contemporary cohort of patients undergoing RPP. In adjusted analyses, broad and anterior PSM carried the highest risk of recurrence after RPP.
Trinh Q-D, Bjartell A, Freedland SJ, Hollenbeck BK, Hu JC, Shariat SF, Sun M, Vickers AJ. A systematic review of the volume-outcome relationship for radical prostatectomy. Eur Urol. 2013;64 (5) :786-98.Abstract
CONTEXT: Due to the complexity and challenging nature of radical prostatectomy (RP), it is likely that both short- and long-term outcomes strongly depend on the cumulative number of cases performed by the surgeon as well as by the hospital. OBJECTIVE: To review systematically the association between hospital and surgeon volume and perioperative, oncologic, and functional outcomes after RP. EVIDENCE ACQUISITION: A systematic review of the literature was performed, searching PubMed, Embase, and Scopus databases for original and review articles between January 1, 1995, and December 31, 2011. Inclusion and exclusion criteria comprised RP, hospital and/or surgeon volume reported as a predictor variable, a measurable end point, and a description of multiple hospitals or surgeons. EVIDENCE SYNTHESIS: Overall 45 publications fulfilled the inclusion criteria, where most data originated from retrospective institutional or population-based cohorts. Studies generally focused on hospital or surgeon volume separately. Although most of these analyses corroborated the impact of increasing volume with better outcomes, some failed to find any significant effect. Studies also differed with respect to the proposed volume cut-off for improved outcomes, as well as the statistical means of evaluating the volume-outcome relationship. Five studies simultaneously compared hospital and surgeon volume, where results suggest that the importance of either hospital or surgeon volume largely depends on the end point of interest. CONCLUSIONS: Undeniable evidence suggests that increasing volume improves outcomes. Although it would seem reasonable to refer RP patients to high-volume centers, such regionalization may not be entirely practical. As such, the implications of such a shift in practice have yet to be fully determined and warrant further exploration.
Kowalczyk KJ, Harbin AC, Choueiri TK, Hevelone ND, Lipsitz SR, Trinh Q-D, Tina Shih Y-C, Hu JC. Use of surveillance imaging following treatment of small renal masses. J Urol. 2013;190 (5) :1680-5.Abstract
PURPOSE: With the increasing incidence of small renal masses, there is greater use of ablation, nephron sparing surgery and surveillance compared to radical nephrectomy. However, patterns of care in the use of posttreatment imaging remain uncharacterized. The purpose of this study is to determine the rate of posttreatment imaging after various treatments for small renal mass. MATERIALS AND METHODS: Using SEER (Surveillance, Epidemiology and End Results)-Medicare data during 2005 to 2009, we identified 1,682 subjects diagnosed with small renal mass and treated with open partial nephrectomy (330), minimally invasive partial nephrectomy (160), open radical nephrectomy (404), minimally invasive radical nephrectomy (535), thermal ablation (212) and surveillance (42). Use of imaging was compared within 24 months of treatment and multivariate regression models were constructed to identify factors associated with increased imaging use. RESULTS: On adjusted analyses thermal ablation was associated with almost eightfold greater odds of surveillance imaging compared with open radical nephrectomy (OR 7.7, 95% CI 1.01-59.4). Specifically, thermal ablation was associated with increased computerized tomography (OR 5.28) and magnetic resonance imaging (OR 2.19) use and decreased ultrasound use (OR 0.59). Minimally invasive partial nephrectomy (OR 3.28) and open partial nephrectomy (OR 3.19) were also associated with increased computerized tomography use to a lesser extent. CONCLUSIONS: Subjects undergoing nephron sparing surgery undergo more posttreatment imaging compared to open radical nephrectomy. Although possibly associated with lower morbidity, thermal ablation is associated with significantly greater use of imaging compared to other small renal mass treatments. This may increase costs and radiation exposure, although further study is needed for confirmation.
Kim SP, Tilburt JC, Karnes JR, Ziegenfuss JY, Han LC, Shah ND, Frank I, Smaldone MC, Gross CP, Yu JB, et al. Variation in treatment recommendations of adjuvant radiation therapy for high-risk prostate cancer by physician specialty. Urology. 2013;82 (4) :807-12.Abstract
OBJECTIVE: To assess the treatment recommendations from a nationally representative sample of radiation oncologists and urologists on adjuvant radiotherapy for patients with pathologically advanced prostate cancer after radical prostatectomy. METHODS: From a random sample of 1422 physicians (n = 711 radiation oncologists; n = 711 urologists) in the American Medical Association Masterfile, a mail survey queried treatment recommendations for adjuvant radiotherapy that varied by the following pathologic features: extraprostatic extension (pT3a) vs seminal vesicle invasion (pT3b), Gleason 7 vs Gleason 8-10, and margin negative (MN) vs margin positive (MP). Pearson chi-square and multivariable logistic regression were used to test for differences in treatment recommendations by physician specialty. RESULTS: Response rates for radiation oncologists and urologists were similar (44% vs 46%; P = .42). Radiation oncologists were more likely to recommend adjuvant radiotherapy than urologists for all the varying pathologic scenarios from pT3a, Gleason 7, and MN (42.5% vs 9.7%; adjusted odds ratio [OR]: 7.82, P <.001) to pT3b, Gleason 8-10, and MP disease (94.5% vs 89.1%, adjusted OR: 2.46, P <.001). Compared with radiation oncologists, urologists were more likely to recommend salvage radiotherapy pT3a, Gleason 7, and MN (90.3% vs 57.7%; adjusted OR: 7.72, P <.001) to pT3b, Gleason 8-10, and MP disease (10.9% vs 5.5%; adjusted OR: 2.22, P <.001). CONCLUSION: In this national survey, radiation oncologists and urologists have markedly different treatment recommendations for adjuvant and salvage radiotherapy. Patients with adverse pathologic features after radical prostatectomy should consult with both a urologist and radiation oncologist to hear a diversity of opinions to make the most informed decision possible.
Xylinas E, Kent M, Kluth L, Pycha A, Comploj E, Svatek RS, Lotan Y, Trinh Q-D, Karakiewicz PI, Holmang S, et al. Accuracy of the EORTC risk tables and of the CUETO scoring model to predict outcomes in non-muscle-invasive urothelial carcinoma of the bladder. Br J Cancer. 2013;109 (6) :1460-6.Abstract
BACKGROUND: The European Organization for Research and Treatment of Cancer (EORTC) risk tables and the Spanish Urological Club for Oncological Treatment (CUETO) scoring model are the two best-established predictive tools to help decision making for patients with non-muscle-invasive bladder cancer (NMIBC). The aim of the current study was to assess the performance of these predictive tools in a large multicentre cohort of NMIBC patients. METHODS: We performed a retrospective analysis of 4689 patients with NMIBC. To evaluate the discrimination of the models, we created Cox proportional hazard regression models for time to disease recurrence and progression. We incorporated the patients calculated risk score as a predictor into both of these models and then calculated their discrimination (concordance indexes). We compared the concordance index of our models with the concordance index reported for the models. RESULTS: With a median follow-up of 57 months, 2110 patients experienced disease recurrence and 591 patients experienced disease progression. Both tools exhibited a poor discrimination for disease recurrence and progression (0.597 and 0.662, and 0.523 and 0.616, respectively, for the EORTC and CUETO models). The EORTC tables overestimated the risk of disease recurrence and progression in high-risk patients. The discrimination of the EORTC tables was even lower in the subgroup of patients treated with BCG (0.554 and 0.576 for disease recurrence and progression, respectively). Conversely, the discrimination of the CUETO model increased in BCG-treated patients (0.597 and 0.645 for disease recurrence and progression, respectively). However, both models overestimated the risk of disease progression in high-risk patients. CONCLUSION: The EORTC risk tables and the CUETO scoring system exhibit a poor discrimination for both disease recurrence and progression in NMIBC patients. These models overestimated the risk of disease recurrence and progression in high-risk patients. These overestimations remained in BCG-treated patients, especially for the EORTC tables. These results underline the need for improving our current predictive tools. However, our study is limited by its retrospective and multi-institutional design.
Kadlec AO, Ellimoottil C, Guo R, Trinh Q-D, Sun M, Turk TM. Contemporary volume-outcome relationships for percutaneous nephrolithotomy: results from the Nationwide Inpatient Sample. J Endourol. 2013;27 (9) :1107-13.Abstract
INTRODUCTION/OBJECTIVE: We sought to examine the contemporary relationship between case volume and outcome for percutaneous nephrolithotomy (PCNL) using a publically available administrative database. METHODS: A weighted sample of 7785 patients was obtained from the 2010 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS). ICD-9-CM diagnostic codes were used to identify patients with urolithiasis (592.0, 592.1, and 592.9) who underwent percutaneous nephrostomy with fragmentation (5504). Charlson Comorbidity Indices (CCI) were calculated based on diagnostic codes for all patients. Hospital case volume was quartile classified and we then compared key outcomes (the complication rate, transfusion rate, length of stay [LOS], and in-hospital mortality rate) by volume quartile. We then performed multivariate analysis to examine the effect of CCI, annual volume, and age on key outcomes. RESULTS: The overall complication rate was 17% in the weighted sample. In univariate analysis, statistically significant variation in the complication rate, CCI, transfusion rate, and in-hospital mortality was noted with regard to the hospital volume. The complication rate and transfusion rates varied by case volume, but in a nonlinear fashion, wherein rates were highest at the lowest and highest volume centers. CCI was strongly predictive (p<0.001) of complications and LOS in the multivariate analysis. Case volume was only predictive (p=0.042) of LOS in the multivariate analysis. CONCLUSION: Annual case volume of the treating center was associated with shorter LOS after PCNL, but case volume was not independently predictive of complication or transfusion in multivariate analysis. CCI was a strong independent predictor of complication and LOS.
Trinh Q-D, Bianchi M, Sun M, Sammon J, Schmitges J, Shariat SF, Sukumar S, Jeldres C, Zorn K, Perrotte P, et al. Discharge patterns after radical prostatectomy in the United States of America. Urol Oncol. 2013;31 (7) :1022-32.Abstract
OBJECTIVE: Discharge patterns, including prolonged length of stay (LOS) and adverse discharge disposition (ADD), are important clinical indicators of quality of care. We examined the effect of several indicators on discharge patterns after radical prostatectomy (RP). METHODS: Within the Nationwide Inpatient Sample, we focused on RPs performed between 2001 and 2007. Multivariable logistic regression analyses predicting the likelihood of prolonged LOS and ADD were performed. RESULTS: Overall, 89,883 eligible RPs were identified, yielding a weighted national estimate of 442,400 eligible RPs. The rates of prolonged LOS decreased from 28.9 in the early period (2001-2003) to 14.4% in the late period (2006-2007) (P < 0.001). Similarly, the rates of ADD decreased from 7.4 in the early period to 5.0% in the late period (P < 0.001). In multivariable analyses adjusted for clustering, both annual hospital caseload (AHC) and insurance status were independent predictors of prolonged LOS and ADD. For example, RP performed at low AHC hospitals were more frequently associated with prolonged LOS than intermediate (OR = 0.45, P < 0.001) and high (OR = 0.21, P < 0.001) AHC hospitals. Similarly, RP performed at low AHC hospitals were more frequently associated with ADD than intermediate (OR = 0.54, P < 0.001) and high (OR = 0.63, P < 0.001) AHC hospitals. CONCLUSIONS: An improving temporal trend in discharge patterns was recorded in patients undergoing RP, with significant reductions in the rates of prolonged LOS and ADD. Nonetheless, important disparities were recorded when discharge patterns were stratified according to insurance status and AHC. Specifically, shorter LOS and lower rates of ADD should be expected in patients with private insurance and/or treated at high AHC institutions.