Benjamin I. Chung

Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: a contemporary population-based analysis in the United States.

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

THE OUTCOME OF STOPPING PROPHYLACTIC ANTIBIOTICS IN OLDER CHILDREN WITH VESICOURETERAL REFLUX

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 (

Three differentiation states risk-stratify bladder cancer into distinct subtypes

6041 vs

The Use of Bowel for Ureteral Replacement for Complex Ureteral Reconstruction: Long-Term Results

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.

Perioperative Efficacy of Laparoscopic Partial Nephrectomy for Tumors Larger than 4 cm

PURPOSE Accepted management of vesicoureteral reflux includes surgical correction or prophylactic antibiotics with the hope for resolution as the child grows. The physician must consider surgery when reflux does not resolve despite uneventful years on prophylactic antibiotics. An alternative is cessation of the antibiotics. We report on the outcome of children taken off antibiotics with persistent reflux. MATERIALS AND METHODS During a 14-year period 51 children with documented reflux were taken off antibiotic prophylaxis. Selection criteria included children who were old enough to verbalize the symptoms of a urinary tract infection, and had normal voiding patterns, a minor history of infections and minimal or no renal scarring. Routine followup included nuclear cystography and renal sonography. RESULTS A total of 40 girls and 11 boys maintained on antibiotics for a mean of 4.8 years were taken off prophylaxis and followed for an average of 3.7 years. Mean patient age when prophylactic antibiotics were stopped was 8.6 years. Reflux resolved in 10 children (19.6%). A urinary tract infection developed in 5 girls and 1 boy (11.8%) (mean age 11) an average of 2.3 years (range 4 months to 9.4 years) after antibiotic discontinuation. One child had symptoms consistent with cystitis and 5 had febrile urinary tract infections. All were treated with oral antibiotics and 5 had subsequent operations. No new renal scars developed. CONCLUSIONS The majority of children did well following cessation of antibiotic prophylaxis despite persistent vesicoureteral reflux. Cessation of antibiotic prophylaxis is a reasonable option in a highly select patient population with reflux.

Expression of the proto-oncogene Axl in renal cell carcinoma.

Current clinical judgment in bladder cancer (BC) relies primarily on pathological stage and grade. We investigated whether a molecular classification of tumor cell differentiation, based on a developmental biology approach, can provide additional prognostic information. Exploiting large preexisting gene-expression databases, we developed a biologically supervised computational model to predict markers that correspond with BC differentiation. To provide mechanistic insight, we assessed relative tumorigenicity and differentiation potential via xenotransplantation. We then correlated the prognostic utility of the identified markers to outcomes within gene expression and formalin-fixed paraffin-embedded (FFPE) tissue datasets. Our data indicate that BC can be subclassified into three subtypes, on the basis of their differentiation states: basal, intermediate, and differentiated, where only the most primitive tumor cell subpopulation within each subtype is capable of generating xenograft tumors and recapitulating downstream populations. We found that keratin 14 (KRT14) marks the most primitive differentiation state that precedes KRT5 and KRT20 expression. Furthermore, KRT14 expression is consistently associated with worse prognosis in both univariate and multivariate analyses. We identify here three distinct BC subtypes on the basis of their differentiation states, each harboring a unique tumor-initiating population.

National Trends of Perioperative Outcomes and Costs for Open, Laparoscopic and Robotic Pediatric Pyeloplasty

PURPOSE Ileal and intestinal ureteral replacement remains a useful procedure for complex ureteral reconstruction. We examined the long-term safety and efficacy of this procedure, especially in regard to maintaining preoperative renal function and the avoidance of major complications. MATERIALS AND METHODS A total of 56 patients underwent intestinal ureteral substitution at our institution between 1979 and 2003, including 52 with an ileal ureteral replacement, 2 with colonic replacement alone and 2 with bilateral ureteral replacement, necessitating ileum and colon for 1 ureter each. The factors reviewed were indications for surgery, type of ureteral replacement, and the presence and type of complications. Followup data included excretory urogram or equivalent imaging results, and measurement of serum chloride, bicarbonate and creatinine before and after the procedure. RESULTS Overall the complication rate remained low. Mean followup was 6.04 years (median 3.2). Most postoperative complications, which occurred in 10 patients (17.9%), were minor in nature, including pyelonephritis, fever of unknown origin, neuroma, hernia, recurrent urolithiasis and deep venous thrombosis. Major complications occurred in 6 patients (10.5%), including anastomotic stricture, ileal graft obstruction, wound dehiscence and chronic renal failure. Overall patients did not experience worsening renal function after the procedure with equivalent median creatinine before and after the procedure (1.0 mg/dl). CONCLUSIONS During long-term followup major complications are rare and renal function remains preserved. Ileal and intestinal ureteral substitution remains a safe and efficacious procedure in patients with complex and difficult ureteral issues not amenable to more conservative measures.

Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era

BACKGROUND Laparoscopic partial nephrectomy (LPN) is typically reserved for kidney tumors < or = 4 cm in size. The use of LPN in patients with larger tumors (> 4 cm) has not been systematically evaluated. OBJECTIVE To examine technical feasibility and perioperative safety and efficacy of LPN for clinical stage pT1b-T2 tumors > 4 cm. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective review of data from an Institutional Review Board-approved, prospectively maintained database of 425 LPN procedures over a 6-yr period (September 1999 through December 2005). Patients were grouped according to tumor size: control group 1: < 2 cm (n=89; 21% of patients); control group 2: 2-4 cm (n=278; 65% of patients); and study group 3: > 4 cm (n=58; 14% of patients). INTERVENTION Retroperitoneal and transperitoneal LPN. MEASUREMENTS Serum creatinine levels, estimated glomerular filtration rates. RESULTS AND LIMITATIONS For groups 1, 2, and 3, mean tumor size was 1.5 cm, 2.9 cm, and 6 cm in diameter, respectively (p<0.001). Study group 3 patients more often had an American Society of Anesthesiologists score > or = 3 (p<0.05), central tumors (p<0.001), pelvicalyceal repair (p=0.004), and heminephrectomy (p<0.001). Total operative time, estimated blood loss, and duration of hospital stay were equivalent. Mean warm ischemia time was 30 min, 32 min, and 38 min in groups 1, 2, and 3, respectively (p=0.007). Tumor size > 4 cm did not increase significant risk for positive tumor margins, intraoperative complications, or postoperative genitourinary complications. In each group preoperative stage > or = 3 chronic kidney disease (CKD) was present in 31%, 35%, and 44% of patients in groups 1, 2, and 3, respectively (p=0.15); postoperatively, stage 3-5 CKD incidence increased to 52%, 52%, and 63% in groups 1, 2, and 3, respectively (p=0.20). Patients with tumor size > 4 cm and preoperative stage 3-5 CKD had an 8-fold increase in risk for CKD stage progression. Limitations of the study include retrospective analysis and a relatively low number of patients in group 3. CONCLUSIONS Given laparoscopic expertise and appropriate patient selection, LPN is feasible and efficacious for kidney tumors > 4 cm. Indications for LPN should be expanded to include patients with amenable tumors > 4 cm in order to maximally preserve kidney function in these patients.

The impact of robotic surgery on the surgical management of prostate cancer in the USA

In this investigation, we examined the role of the Axl proto-oncogene in renal cell carcinoma (RCC). Axl is a tyrosine kinase receptor implicated in myeloid leukogenesis, and has been found to be overexpressed in lung cancers and breast cancers. Axl has been described to act as a mitogenic factor along with its ligand Gas-6. Axl has also shown to have a role in apoptosis, cell adhesion, and chemotaxis. The differential expression of the Axl RNA transcript was examined in 20 pairs of matched normal kidney and clear cell RCC patient samples. We found that there was a significant increase in the steady-state levels of Axl mRNA in the RCC compared with the normal kidney pair (Students paired t-test P < 0.001). There was also a significant increase in Axl expression overall in RCC compared to normal kidney (P < 0.03). Western blotting was utilized to determine Axl protein levels in six out of the 20 pairs of the normal/RCC matched pairs. Overall, the level of expression was not significantly different between the paired normal kidneys and kidney tumors, but the detected Axl protein appeared to be at slightly different molecular weights. Primers were constructed for the two known Axl variant, RT-PCR performed, but no differences were observed in the expression of each variant. Next, we performed a gene silencing experiment utilizing double-stranded RNA constructed to silence the Axl gene in the 293 transformed kidney cell line. There was a 50% decrease in Axl gene expression in the RNAi transfected over control cells. In addition, flow cytometry performed to determine DNA content showed a 30% increase in G1/G0 cells, which were transfected with axl RNAi compared to control. Altogether, these findings suggest an overexpression of Axl as part of a proliferative phenotype in RCC.

Impact of surgeon volume on the morbidity and costs of radical cystectomy in the USA: a contemporary population‐based analysis

PURPOSE We performed a population based study comparing trends in perioperative outcomes and costs for open, laparoscopic and robotic pediatric pyeloplasty. Specific billing items contributing to cost were also investigated. MATERIALS AND METHODS Using the Perspective database (Premier, Inc., Charlotte, North Carolina), we identified 12,662 pediatric patients who underwent open, laparoscopic and robotic pyeloplasty (ICD-9 55.87) in the United States from 2003 to 2010. Univariate and multivariate statistics were used to evaluate perioperative outcomes, complications and costs for the competing surgical approaches. Propensity weighting was used to minimize selection bias. Sampling weights were used to yield a nationally representative sample. RESULTS A decrease in open pyeloplasty and an increase in minimally invasive pyeloplasty were observed. All procedures had low complication rates. Compared to open pyeloplasty, laparoscopic and robotic pyeloplasty had longer median operative times (240 minutes, p <0.0001 and 270 minutes, p <0.0001, respectively). There was no difference in median length of stay. Median total cost was lower among patients undergoing open vs robotic pyeloplasty (