Aaron C. Weinberg

Venous thromboembolism after major urologic oncology surgery: a focus on the incidence and timing of thromboembolic events after 27,455 operations.

OBJECTIVEnTo investigate the incidence and timing of venous thromboembolism (VTE) and identify risk factors for venous thromboembolism among patients undergoing major surgery for urologic malignancies. VTE events are stratified by occurrence in the inpatient vs outpatient settings.nnnMATERIALS AND METHODSnThe National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Statistical Classification of Diseases, Ninth Revision codes to identify patients undergoing major surgery for urologic malignancies between 2005 and 2012. The incidence of overall 30-day VTE, postdischarge VTE, and post-VTE death was calculated for each surgical procedure. Logistic regression analysis was used to identify risk factors for VTE, adjusting for covariates including age, race, gender, smoking status, medical comorbidities, performance of pelvic lymph node dissection, and operative time.nnnRESULTSnThe study identified 27,455 patients who underwent an operation for malignancy--radical nephrectomy, partial nephrectomy, nephroureterectomy, radical prostatectomy, or radical cystectomy. The incidence and timing of VTE varied substantially across the procedures of interest. Overall, VTE occurred after radical cystectomy in 113 of 2065 of patients (5.5%), whereas only 19 of 2624 (0.7%) and 12 of 1690, respectively, of patients undergoing minimally invasive radical or partial nephrectomy procedures suffered a VTE event within 30-days of surgery. Among patients suffering a VTE after radical prostatectomy, 147 of 178 of venous thromboembolic events (82.6%) occurred after hospital discharge.nnnCONCLUSIONnThis study demonstrates the significant burden of VTE beyond the time of hospital discharge. Identification of high-risk patients should prompt consideration of extended-duration VTE prophylaxis in the outpatient setting.

Who Really Benefits From Nephron-sparing Surgery?

OBJECTIVEnTo analyze the influence of preoperative renal function on postoperative renal outcomes after radical nephrectomy (RN) and nephron-sparing surgery (NSS) for malignancy in patients stratified according to preoperative chronic kidney disease (CKD) stage and surgical extent (NSS vs RN).nnnPATIENTS AND METHODSnRetrospective review of patients undergoing renal surgery for localized renal masses stratified by surgical extent and preoperative CKD stage based on glomerular filtration rate (GFR) level: stage I (>90 mL/min/1.73 m(2)), stage II (60-89 mL/min/1.73 m(2)), and stage III (30-59 mL/min/1.73 m(2)). Survival analysis for significant renal impairment was based on freedom from the development of new-onset GFR <30 or <45 mL/min/1.73 m(2).nnnRESULTSnA total of 1306 patients were included in the analysis with preoperative CKD stage I (27.9%), II (52.1%), and III (20.1%); 41.3% and 58.7% underwent NSS and RN, respectively. NSS was associated with a lower annual rate of GFR decline in preoperative CKD stage-I (P = .028) and stage-II patients (P = .018), but not in CKD stage-III patients (P = .753). Overall, 5.0% and 15.0% developed new-onset GFR <30 mL/min/1.73 m(2) and <45 mL/min/1.73 m(2), respectively. There was no difference in the probability of developing significant renal impairment between NSS and RN in CKD stage-I or -III patients, whereas only in CKD stage-II patients was the surgical extent independently associated with development of significant renal impairment (RN: odds ratio, 9.0; P = .042 for GFR <30 mL/min/1.73 m(2) and odds ratio, 2.3; P = .003 for GFR <45 mL/min/1.73 m(2)).nnnCONCLUSIONnCompared with RN, NSS is associated with a lower rate of GFR decline for preoperative CKD stage-I and -II patients, but only CKD stage-II patients demonstrated a decreased risk of developing significant renal impairment.

Renal insufficiency is associated with an increased risk of papillary renal cell carcinoma histology.

PurposeEnd-stage renal disease (ESRD) and acquired renal cystic disease associated with dialysis are known risk factors of papillary renal cell carcinoma (pRCC); however, it is not known whether renal insufficiency alone is a risk factor for pRCC. Our aim was to test whether renal insufficiency is associated with an increased preponderance of pRCC.MethodsRetrospective review of institutional database to identify all patients who underwent extirpative renal surgery for renal cell carcinoma (RCC) with complete records from 1992 to 2012. We excluded those patients with preoperative ESRD as defined by GFRxa0<xa015xa0mL/min/1.73xa0m2. The dependent variable was histologic RCC subtype. Independent variables included demographic data, comorbidities, and renal functional data. Multivariate analysis by binary logistic regression was used to determine factors that independently were associated with pRCC development.ResultsA total of 1,226 patients met inclusion criteria, of which 15xa0% were pRCC. There was a positive association between likelihood of pRCC histology of RCC and increasing preoperative chronic kidney disease (CKD) stage (pxa0=xa00.021). Multivariate regression analysis indicated that male gender, race, and declining renal function categorized both by GFR and CKD stage were independently associated with a higher likelihood of pRCC histology as compared to other RCC histology.ConclusionsWithin a large cohort of patients with a diagnosis of RCC, declining renal function was independently associated with an increased likelihood of pRCC histology. This finding and the available molecular evidence indicating protein expression similarity between pRCC and resident stem cells, which appear to be upregulated with kidney damage, suggest a possible causal relationship between renal injury and pRCC.

Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery

Purpose: We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery. Materials and Methods: The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications. Results: A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively. Conclusions: Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Predicting Renal Parenchymal Loss after Nephron Sparing Surgery.

PURPOSEnWe analyze the relationship among various patient, operative and tumor characteristics to determine which factors correlate with renal parenchymal volume loss after nephron sparing surgery using a novel 3-dimensional volume assessment.nnnMATERIALS AND METHODSnWe conducted a retrospective review of an institutional database of patients who underwent nephron sparing surgery from 1992 to 2014 for a localized renal mass. Tumors were classified according to the R.E.N.A.L. nephrometry system. Using 3-dimensional reconstruction imaging software, preoperative and postoperative renal parenchymal volume was calculated for the ipsilateral and contralateral kidney.nnnRESULTSnA total of 158 patients were analyzed. Mean patient age was 58.7 years and mean followup was 40.1 months. Mean preoperative tumor volume was 34.0 cc and mean tumor dimension was 3.4 cm. Mean R.E.N.A.L. nephrometry score was 6.2, with 60.1%, 34.2% and 5.7% of tumors classified as low, medium and high complexity, respectively. Mean change in renal parenchymal volume after nephron sparing surgery was -15.3% for the ipsilateral kidney and -6.8% for total kidney volume. On univariate analysis ischemia time, tumor size, R.E.N.A.L. nephrometry score, complexity grouping and the individual nephrometry components of tumor size, percent exophytic, anterior/posterior, depth and tumor proximity to the renal artery or vein were associated with greater renal parenchymal volume loss. On multivariate analysis only ischemia time, tumor size, posterior location and percent exophytic were independently associated with more renal parenchymal volume loss.nnnCONCLUSIONSnUsing precise 3-dimensional volumetric analysis we found that ischemia time, tumor size and endophytic/exophytic properties of a localized renal mass are the most important determinants of renal parenchymal volume loss.

Nationwide practice patterns for the use of venous thromboembolism prophylaxis among men undergoing radical prostatectomy

PurposeTo examine the practice patterns and predictors of VTE prophylaxis following radical prostatectomy (RP).MethodsThis was a population-based observational study of 94,709 men with a diagnosis of prostate cancer (ICD-9 code 185) who underwent RP were identified from a hospital-based database from 2000 to 2010, including 68,244 (72.1xa0%) open RP (ORP) and 26,465 (27.9xa0%) robotic-assisted laparoscopic RP (RALP). VTE prophylaxis was classified as none, mechanical, pharmacologic, or combination.ResultsFollowing RP, 35,591 (52.2xa0%) received mechanical, 4,945 (7.2xa0%) pharmacologic, 7,720 (10.6xa0%) combination, and 20,438 (30.0xa0%) no VTE prophylaxis. A total of 245 VTE events (145 DVT, 114 PE) were identified, representing 0.25xa0% of all procedures. Men with >2 comorbidities (ORxa0=xa02.44; 95xa0% CI 1.78–3.35) and those who were black (ORxa0=xa01.44; 95xa0% CI 1.06–1.97) were more likely to have a VTE. Men who had RALP (ORxa0=xa00.61; 95xa0% CI 0.45–0.99), surgery at high-volume hospitals (ORxa0=xa00.45; 95xa0% CI 0.28–0.73), or received prophylaxis (ORxa0=xa00.67; 95xa0% CI 0.50–0.88) were less likely to develop a VTE.ConclusionDespite the observation that VTE prophylaxis reduces the risk of VTE by 40xa0%, VTE prophylaxis was not used in almost one-third of men who underwent radical prostatectomy.

Sub-Coronal Inflatable Penile Prosthesis Placement With Modified No-Touch Technique: A Step-by-Step Approach With Outcomes

INTRODUCTIONnThe surgical treatment of disorders of male sexual function requires specific exposure to correct the underlying problem safely and efficiently. Currently, sub-coronal exposure is used for treatment of phimosis, Peyronies disease plaque (PDP), and semirigid penile prosthesis insertion. Infra-pubic and scrotal incisions are used for inflatable penile prosthesis (IPP) placement. However, men who present with several disorders might require multiple procedures and surgical incisions.nnnAIMnTo report a prospective review of our surgical experience and outcomes with a single sub-coronal incision for IPP placement with a modified no-touch technique. This approach allows for access to the entire corporal body for multiple reconstructive procedures.nnnMETHODSnTwo hundred men had IPPs placed through a sub-coronal incision using our modified no-touch technique. The penis was degloved to the level of the penoscrotal junction and the dartos muscle was everted and secured to the drapes. This allowed exclusion of the scrotal and penile skin from the operative field. After artificial erection, the patients corpora were inspected for PDP and other abnormalities. Penoscrotal IPP models were placed in all cases with insertion proximal to the penoscrotal junction. After placement of the IPP, the abnormalities were repaired.nnnMAIN OUTCOME MEASURESnFeasibility of the procedure, operative times, complication rate, utilization of accessory, reconstructive procedures, and post-operative penile length.nnnRESULTSnOf the 200 men who had IPP placement, 92 had PDP that was treated, 106 (53%) consented to circumcision, 24 (12%) had their reservoir placed ectopically, and 31 (16%) had a prosthesis exchanged through the sub-coronal technique. Mean operative time was 73 minutes (39-161 minutes).nnnCONCLUSIONnSpecialists in the surgical treatment of disorders of male sexual function can perform multiple procedures safely and easily through a modified no-touch single sub-coronal incision. This approach allows access to the entire corporal body, providing excellent visibility and allowing the surgeon to perform multiple penile reconstructive surgeries through a single incision.

The Association Between Socioeconomic Status, Renal Cancer Presentation, and Survival in the United States: A Survival, Epidemiology, and End Results Analysis

OBJECTIVEnTo determine whether socioeconomic status (SES) predicts the size and local extent of tumors at presentation, and if this association leads to differences in survival.nnnMATERIALS AND METHODSnThe National Cancer Institutes Survival, Epidemiology, and End Results registry was queried for patients diagnosed with renal cancers between 2004 and 2010. Demographic, tumor, survival, and socioeconomic data were obtained. Cancers with T0 classification, nonrenal cell histology, or missing clinical or pathologic data were excluded. An SES measure was created from available metrics. Outcomes analyzed were tumor size, TNM classifications at diagnosis, tumor grade and histology subtype, and survival duration.nnnRESULTSnA total of 40,212 cases were identified. On regression modeling, lower SES was an independent risk factor for tumor size ≥ 4 cm (P = .003) and for T classification ≥ T2 (P = .040) at presentation, but did not predict histology subtype, positive lymph nodes, or metastasis. Lower SES predicted high-grade disease on univariate analysis (P = .012) but lost significance in the multivariate model. Lower SES was also independently predictive of shortened cancer-specific survival on multivariate analysis after adjusting for available cofactors (lowest vs highest SES quartile; P = .001).nnnCONCLUSIONnThis study suggests that low SES is correlated with poorer survival outcomes in renal cancer, and this may be related to a tendency toward larger and more locally advanced tumors at diagnosis. Additional investigation is needed to ascertain whether these effects could be mediated by relatively lower rates of incidental detection via abdominal imaging in disadvantaged populations.

Reliability and validity of the overactive bladder symptom score in spanish (OABSS-S)†‡

To validate the Spanish translation of the Overactive Bladder Symptom Score (OABSS) questionnaire.

Dorsal penile nerve block for robot-assisted radical prostatectomy catheter related pain: a randomized, double-blind, placebo-controlled trial

PurposeFollowing Robotic-Assisted Radical Prostatectomy (RARP) patients routinely have penile pain and urethral discomfort secondary to an indwelling urethral catheter. Our objective was to assess the effect of dorsal penile nerve block with bupivacaine on urethral catheter-related pain after RARP.MethodsFrom 2012–2013, 140 patients with organ-confined prostate cancer were enrolled in an IRB approved double-blinded, randomized control trial comparing a dorsal penile nerve block of bupivacaine versus placebo after RARP performed by a single-surgeon. Patients were asked to complete questionnaires using the Wong-Bakers FACES Pain Rating scale while hospitalized and for 9xa0days post-operatively, until the catheter was removed. The primary end-points were: catheter-related discomfort, abdominal (incisional) pain, and bladder spasm-related discomfort. Secondary end-points included narcotic and other analgesic usage.Results120 patients were randomized to placebo vs. bupivacaine dorsal penile nerve bock. The two arms (nu2009=u200956 bupivacaine and nu2009=u200960 placebo) did not differ in preoperative, perioperative, or pathological results. There was no difference in narcotic utilization between the two cohorts. Abdominal pain was slightly lower in the bupivacaine arm at 6xa0hours compared to the placebo arm, but there was no difference in abdominal pain at other time points, and there were no differences in reported catheter-related discomfort or bladder spasm-associated discomfort at any of the measured time points.ConclusionsThe data does not support the routine use of a dorsal penile nerve block with bupivacaine following RARP.