Daniel Pucheril

Morbidity and mortality after benign prostatic hyperplasia surgery: data from the American College of Surgeons national surgical quality improvement program.

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.

Short-term perioperative outcomes of patients treated with radical cystectomy for bladder cancer included in the National Surgical Quality Improvement Program (NSQIP) database

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.

Contemporary Nationwide Patterns of Self-reported Prostate-Specific Antigen Screening

Funding/Support: Dr Smith is supported by National Institutes of Health/ National Heart, Lung, and Blood Institute training grant T32HL076139. Dr Weiss is supported by National Institutes of Health/National Heart, Lung, and Blood Institute grant K23HL118139 and a grant from the Parker B. Francis Fellowship Program. Dr Wunderink is supported in part by Centers for Disease Control and Prevention grant 1U18IP000490.

Patterns of Declining Use and the Adverse Effect of Primary Androgen Deprivation on All-cause Mortality in Elderly Men with Prostate Cancer

BACKGROUND Primary androgen deprivation therapy (pADT) is commonly used to treat elderly men diagnosed with localized prostate cancer (CaP), despite the lack of evidence supporting its use. OBJECTIVE To examine the effect of pADT on mortality and to assess contemporary trends of pADT use in elderly men with CaP. DESIGN, SETTING, AND PARTICIPANTS Men older than 65 yr residing in Surveillance, Epidemiology, and End Results (SEER) registry areas diagnosed with localized or locally advanced CaP between 1992 and 2009 and not receiving definitive therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Propensity score (PS)-weighted Cox proportional hazards models were used to estimate the effect of pADT use on overall survival among patients receiving pADT. The interaction between comorbidity-adjusted life expectancy (LE) and pADT use was assessed within the Cox and PS-weighted models. Contemporary (2004-2009) trends for pADT use were analyzed by linear regression. RESULTS AND LIMITATIONS The primary cohort included 46 376 men, of whom 17 873 received pADT (39%). Patients with >10 yr LE had lower pADT utilization rates than patients with short LE. Between 2004 and 2009, the use of pADT in men with localized CaP decreased by 14% (from 36% to 22%). Relative to observation, pADT was associated with a survival disadvantage, with a hazard ratio for all-cause mortality of 1.37 (95% confidence interval 1.20-1.56). Limitations included biases not accounted for by the PS-weighted model, changes in CaP staging over the study period, the absence of prostate-specific antigen (PSA) data prior to 2004, and the limits of retrospective analysis to demonstrate causality. CONCLUSIONS The use of pADT in elderly men with localized CaP has decreased over time. For men forgoing primary definitive therapy, the use of pADT is not associated with a survival benefit compared to observation, and denies men an opportunity for cure with definitive therapy. The deleterious effect of pADT is most pronounced in men with prolonged LE. PATIENT SUMMARY In this report, we assessed the effect of primary androgen deprivation (pADT) on prostate cancer mortality and determined current trends in the use of pADT. We showed that use of pADT in men aged >65 yr with localized prostate cancer has decreased over time. We also found that pADT is detrimental to men with localized prostate cancer, and particularly men with longer life expectancy. Therefore, we conclude that ADT should not be used as a primary treatment for men with prostate cancer that has not spread beyond the prostate.

Contemporary nationwide patterns of self-reported prostate-specific antigen screening in US veterans.

INTRODUCTION AND OBJECTIVES The quality of medical care to US veterans, as provided by the Veterans Health Administration, has recently been subjected to heightened scrutiny. We sought to report prostate-specific antigen screening (PSAS) in a contemporary cohort of veteran men (VM) vs. nonveteran men (NVM). We hypothesize that VM are less likely to receive age-appropriate PSAS compared with NVM. MATERIALS AND METHODS We identified VM and NVM aged 55 to 69 years without history of prostate cancer who underwent PSA testing in the year preceding that of the 2012 Behavioral Risk Factor and Surveillance System survey. The prevalence of PSAS among VM and NVM was determined in aggregate and on a state-by-state basis. Complex samples logistic regression models calculated the odds of PSAS based on veteran status, adjusted for patient/demographic characteristics. RESULTS In all, 56,962 responses were collected, yielding a weighted estimate of 23.7 million men, of which 30.5% were VM. Overall, 45.2% (CI: 43.9%-46.5%) of VM reported PSAS compared with only 37.5% (CI: 36.5%-38.5%) of NVM. VM were more likely to have health insurance (92.0%; CI: 91.3%-92.8% vs. 86.2%; CI: 85.4%-87.0%) and a regular health care provider (89.0%; CI: 88.2%-89.8% vs. 85.9%; CI: 85.1%-86.6%) compared with NVM. Unadjusted prevalence of PSAS varied widely across the United States for VM and NVM. In multivariable analyses, VM had higher odds for PSAS (odds ratio = 1.10, CI: 1.02%-1.18%). CONCLUSIONS Contrary to our initial hypothesis, our findings suggest a continued pattern of greater preventive health services use by veterans. VM were more likely to undergo PSAS than NVM. This is, in part, attributable to better access to primary care and health insurance. Nonetheless, heterogeneity in screening practices remained largely dependent on geography.

Predicting pathological outcomes in patients undergoing robot‐assisted radical prostatectomy for high‐risk prostate cancer: a preoperative nomogram

To identify which high‐risk patients with prostate cancer may harbour favourable pathological outcomes at radical prostatectomy (RP).

Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction.

The management options for ureteral obstruction are diverse, including retrograde ureteral stent insertion or antegrade nephrostomy placement, with or without eventual antegrade stent insertion. There is currently no consensus on the ideal treatment or treatment pathway for ureteral obstruction owing, in part, to the varied etiologies of obstruction and diversity of institutional practices. Additionally, different clinicians such as internists, urologists, oncologists and radiologists are often involved in the care of patients with ureteral obstruction and may have differing opinions concerning the best management strategy. The purpose of this manuscript was to review available literature that compares percutaneous nephrostomy placement vs ureteral stenting in the management of ureteral obstruction from both benign and malignant etiologies.

Wound dehiscence in a sample of 1 776 cystectomies: identification of predictors and implications for outcomes.

To investigate the incidence and predictors of wound dehiscence in patients undergoing radical cystectomy (RC).

Preventable mortality after common urological surgery: failing to rescue?

To assess in‐hospital mortality in patients undergoing many commonly performed urological surgeries in light of decreasing nationwide perioperative mortality over the past decade. This phenomenon has been attributed in part to a decline in ‘failure to rescue’ (FTR) rates, e.g. death after a complication that was potentially recognisable/preventable.

What is the hospital volume threshold to optimize inpatient complication rate after partial nephrectomy

OBJECTIVE To find a cutoff of hospital volume for elective partial nephrectomy (PN) for kidney cancer that can minimize the inpatient morbidity of this procedure. MATERIAL AND METHODS Analyzing the National Inpatient sample, from 2008 to 2011, we selected 8,753 records of adult patients undergoing elective PN for nonmetastatic kidney cancer, representing an estimated 43,178 partial nephrectomies performed in the United States during this period. Of these, 2,187 (estimated 10,848) PNs were performed via the robotic approach. International Classification of Diseases, Ninth Revision, diagnosis and procedure codes were used to define complications. Logistic regression within generalized estimating equation framework, with restricted cubic splines was used to identify the relationship of any inpatient complications and major inpatient complications with annual hospital PN volume, after adjusting for demographic characteristics, insurance status, location, and comorbidities. A similar analysis was done for a subset of patients undergoing robot-assisted PN. RESULTS Overall, rate of any inpatient complication and major inpatient complications was 1,801/8,753 (20.6%) and 839/8,753 (9.6%), respectively. Median annual hospital volume was 27 cases (interquartile range: 11-64). Restricted cubic spline analysis revealed a significant inverse nonlinear association between annual hospital volume and any inpatient complications (P<0.001). The odds of complications decreased with increasing annual hospital volume, with plateauing seen at 35 to 40 cases for both any inpatient complications and major inpatient complications. Analysis on a subset of robot-assisted PN revealed a similar inverse nonlinear relationship, with plateauing at 18 to 20 cases annually. CONCLUSION There is an inverse nonlinear relationship of hospital volume with morbidity of PN, with a plateauing seen at 35 to 40 cases annually overall, and at 18 to 20 cases for robot-assisted PN.