Daniel T. Oberlin

Contemporary Surgical Trends in the Management of Upper Tract Calculi

PURPOSE Upper tract nephrolithiasis is a common surgical condition that is treated with multiple surgical techniques, including shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. We analyzed case logs submitted to the ABU by candidates for initial certification and recertification to help elucidate the trends in management of upper tract urinary calculi. MATERIALS AND METHODS Annualized case logs from 2003 to 2012 were analyzed. We used logistic regression models to assess how surgeon specific attributes affected the way that upper tract stones were treated. Cases were identified by the CPT code of the corresponding procedure. RESULTS A total of 6,620 urologists in 3 certification groups recorded case logs, including 2,275 for initial certification, 2,381 for first recertification and 1,964 for second recertification. A total of 441,162 procedures were logged, of which 54.2% were ureteroscopy, 41.3% were shock wave lithotripsy and 4.5% were percutaneous nephrolithotomy. From 2003 to 2013 there was an increase in ureteroscopy from 40.9% to 59.6% and a corresponding decrease in shock wave lithotripsy from 54% to 36.3%. For new urologists ureteroscopy increased from 47.6% to 70.9% of all stones cases logged and for senior clinicians ureteroscopy increased from 40% to 55%. Endourologists performed a significantly higher proportion of percutaneous nephrolithotomies than nonendourologists (10.6% vs 3.69%, p <0.0001) and a significantly smaller proportion of shock wave lithotripsies (34.2% vs 42.2%, p = 0.001). CONCLUSIONS Junior and senior clinicians showed a dramatic adoption of endoscopic techniques. Treatment of upper tract calculi is an evolving field and provider specific attributes affect how these stones are treated.

The effect of minimally invasive prostatectomy on practice patterns of American urologists

INTRODUCTION AND OBJECTIVES To determine how robotic prostatectomy affects practice patterns of urologists, we examined the case volume characteristics among certifying urologists for the surgical treatment of prostate cancer. We hypothesized that the utilization of open and robotic prostatectomy as well as lymph node dissection changed dynamically over the last 10 years. METHODS A total of 6-month case log data of certifying urologists from 2003 to 2013 were obtained for the American Board of Urology. Cases were identified using Current Procedural Terminology codes for open radical prostatectomy (ORP) and laparoscopic or robotic-assisted laparoscopic prostatectomy (RALP) with a corresponding diagnosis of prostate cancer as defined by ICD-9 code 185.0. RESULTS OBTAINED A total of 6,563 urologists submitted case logs, of which 68% (4,470/6,563) reported performing at least one radical prostatectomy (RP), totaling 46,030 RPs logged. There was a 376% increase in the performance of RALP over the study period with robotic volume increasing from 22% of all RP in 2003 to 85% in 2013. Among surgeons performing ORP, the median number performed was 2; of surgeons who performed RALP, the median number performed was 8 (P<0.001). Overall, 39% of surgeons logging ORP performed 2 or fewer RP, whereas 19% of surgeons who performed RALP performed 2 or less RP (P<0.001). The highest volume robotic surgeons (top 10% surgical volume) performed 41% of all RALP with the highest performing robotic surgeon recording 658 prostatectomies over 6 months. Oncologists represented 4.1% of all surgeons performing RP and performed 15.1% of all RP (P<0.001); general urologists performed the majority of RP (57.8%). When performed open, there was no influence of surgeon specialty on the performance of lymph node dissection (LND); if performed robotically, oncologists were significantly more likely to perform LND compared with general surgeons (47% vs. 25.9%, respectively, P<0.001). CONCLUSIONS Robotic prostatectomies are performed 5 times more commonly than open prostatectomy and represent 85% of all RP performed by board-certified urologists in 2013. Compared to RALP, ORP are significantly more likely to be performed by lower volume surgeons. Oncologists perform a higher relative percentage of RPs and are significantly more likely to perform LND if performed robotically when compared with general urologists.

National Practice Patterns of Treatment of Erectile Dysfunction with Penile Prosthesis Implantation

PURPOSE The increase in medical options to manage erectile dysfunction has changed how urologists approach erectile dysfunction. We reviewed contemporary trends in penile prosthesis implantation in the United States with an emphasis on practice patterns, demographics and temporal changes. MATERIALS AND METHODS Annualized case log data of penile prosthesis surgeries from certifying and recertifying urologists from 2003 to 2012 were obtained from the American Board of Urology. CPT code 54400 was used to identify malleable prosthesis surgeries and CPT codes 54401 and 54405 were used to identify inflatable prosthesis surgeries. To evaluate the association between surgeon characteristics and practice patterns we used the chi-square test. RESULTS The surgical cohort included 6,615 urologists who placed a total of 9,558 penile prostheses during the study period. Only 23.9% of urologists reported performing a penile prosthesis operation. Of the prostheses 75% were placed by surgeons who completed 4 or fewer such operations per year. Of urologists who recorded logs 1.5% considered themselves to be specialists in andrology and yet they were responsible for a disproportionate 10% of all prostheses implanted (OR 5.9, p <0.0001). The proportion of inflatable penile prostheses compared to malleable prostheses increased twelvefold in 10 years. The number of logged prosthesis surgeries was skewed toward more implants placed by the most experienced urologists than by new urologists (OR 1.92, p <0.0001). CONCLUSIONS Although specialists and high volume surgeons perform a disproportionate number of implant surgeries, low volume surgeons place most penile prostheses in the United States. Additional research is needed to determine best practices to achieve optimal patient outcomes in penile prosthesis surgery.

Practice Patterns in the Treatment of Urethral Stricture Among American Urologists: A Paradigm Change?

OBJECTIVE To examine surgical case volume characteristics among certifying urologists associated with treatment of urethral stricture to compare practice patterns of recent graduates to recertifying attending urologists and trends over time. MATERIALS AND METHODS Six-month case log data of certifying and recertifying urologists (2003-2013) were obtained from the American Board of Urology. Cases specifying a CPT code for urethral dilation, direct vision internal urethrotomy (DVIU), urethroplasty, and graft harvest in males ≥18 years were analyzed for surgeon-specific variables. RESULTS Among 6320 urologists logging at least one reconstructive urology procedure, 95,747 (86.2%) urethral dilations, 10,986 (10.0%) DVIU, and 4349 (3.9%) urethroplasties were identified, with 99 (0.9%) using graft and 405 (9.3%) staged procedures. Overall ratio of urethral dilation/DVIU to urethroplasty was 24.5:1. More recent log year and new certification correlated with a decrease in ratio of dilation/DVIU to urethroplasty, but stable use of graft. The ratio of dilation/DVIU to urethroplasty for new certification was much lower (7.9:1), compared to first (24.4:1), second (63.3:1), and third recertification cycles (99.5:1), wherein urethroplasty was increasingly rare. Newly certifying urologists performed urethroplasty 4.5 times more often than those recertifying. Academically affiliated urologists were 8 times more likely to perform urethroplasty. CONCLUSION Most urethral strictures are treated with dilation/DVIU, but a changing paradigm favoring urethroplasty is evident. Most urethroplasties are performed by a small number of urologists with high volume, academic affiliation, recent residency graduation, and residence in a state with a reconstructive urology fellowship.

The effect of surgical duration of transurethral resection of bladder tumors on postoperative complications: An analysis of ACS NSQIP data.

INTRODUCTION Transurethral resection of bladder tumor (TURBT) is a common procedure used in the diagnosis and treatment of bladder cancer. Despite how often it is performed, not much is known about the risk factors for complications. Traditional surgery has an increase in morbidity and mortality with increasing operative duration. We assess the effect of operative duration on TURBT complications. METHODS The years 2006 to 2012 of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were queried for patients undergoing TURBT. We separated patients into 4 groups based on operative time: 0 to 30 minutes, 30.1 to 60 minutes, 60.1 to 90 minutes, and greater than 90 minutes. Standard statistical analysis including multivariate regression was performed to determine predictors of complications. RESULTS A total of 10,599 TURBTs were included in our analysis. The overall complication rate for TURBT was 5.8% and there was an increase in the rate of complications seen as operative duration increased, which remained after controlling for age, comorbidities, tumor size, and American Society of Anesthesiology classification. Increased operative duration was associated with a greater risk of postoperative urinary tract infection, sepsis or septic shock, pulmonary embolism/deep venous thrombosis, reintubation or failure to wean, myocardial infarction, and death. Larger tumors were related to an increased odds of requiring blood transfusions. CONCLUSIONS Using a contemporary multicenter cohort of TURBTs from the ACS NSQIP database, we demonstrate that increased operative duration is associated with serious postoperative complications. This association was found to persist even after adjusting for patient age, comorbidities, tumor size, and functional status.

Male Sling and Artificial Urethral Sphincter for Male Stress Urinary Incontinence Among Certifying American Urologists

OBJECTIVE To examine case volume characteristics among certifying urologists performing male sling and artificial urinary sphincter (AUS) procedures to evaluate practice patterns in male stress urinary incontinence (SUI). MATERIALS AND METHODS Six-month case log data of certifying urologists (2003-2013) were obtained from the American Board of Urology. Cases specifying Current Procedural Terminology code for male sling, AUS, and removal or revision of either procedure in males ≥18 years were analyzed. RESULTS Among 1615 urologists (568 certifying and 1047 recertifying) logging at least 1 male incontinence procedure, 2109 (48% of all procedures) male sling and 2284 (52%) AUS cases were identified. The mean age of patients undergoing AUS was 74.9 years and the mean age of patients undergoing sling procedures was 67.3 years (P <.001). An increase in male incontinence procedures from 2003 to 2013 was demonstrated. The rate of male sling procedure increased from 32.7% of incontinence surgeries in 2004 to 45.5% in 2013 (P <.001). Academically affiliated urologists are 1.5 times more likely to perform AUS than male sling for SUI (P <.001). Median number of slings performed was 2 (range 1-40), with 32.7% placing slings exclusively. A small group of certifying urologists (3.4%) accounted for 22% of all male slings placed. This same cohort logged 10.2% of all AUS performed. Surgical management of male SUI varies widely across states (P <.001), with slings performed between 21% and 70% of the time. CONCLUSION Overall the number of male incontinence procedures has increased over time, with a growing proportion of male slings. Most slings and AUS cases are performed by a small number of high-volume surgeons.

Genomic characterization of high-risk non-muscle invasive bladder cancer.

The genetic mechanisms associated with progression of high-risk non-muscle-invasive bladder cancer (HR-NMIBC) have not been described. We conducted selective next-generation sequencing (NGS) of HR-NMIBC and compared the genomic profiles of cancers that responded to intravesical therapy and those that progressed to muscle-invasive or advanced disease. DNA was extracted from paraffin-embedded sections from 25 HR-NMIBCs (22 with T1HG; 3 with TaHG with or without carcinoma in situ). Ten patients with HR-NMIBC developed progression (pT2+ or N+) (“progressors”). Fifteen patients had no progression (“non-progressors”). Tissue from 11 patients with metastatic bladder cancer (BC) were analyzed for comparison. We found no difference in frequency of mutations of TP53, PIK3CA, or KMT2D between the primary tumors of progressors compared to non-progressors and metastatic tumors. An increased frequency of deletions of CDKN2A/B was identified in tumors at progression (37%) compared to non-progressors (6%) (p = 0.10). We found a significant decrease in total mutational burden (TMB) that has been associated with immunotherapy response comparing non-progressors, progressors and metastatic tumors at 15, 10.1 and 5.1 mutations/MB respectively (p = 0.02). This association suggests more advanced tumors have decreased neoantigen burden and may explain the mechanism of BCG response in non-progressors. We found no novel genetic drivers in progressors and HR-NMIBC had many genetic features similar to metastatic BC. Loss of CDKN2A/B may occur late during invasion of BC and may represent an important step in progression. Further research is necessary to evaluate TMB and loss of CDKN2A/B locus as a biomarker for progression of NMIBC.

Differentiation of Solid Renal Tumors with Multiparametric MR Imaging

Characterization of renal tumors is critical to determine the best therapeutic approach and improve overall patient survival. Because of increased use of high-resolution cross-sectional imaging in clinical practice, renal masses are being discovered with increased frequency. As a result, accurate imaging characterization of these lesions is more important than ever. However, because of the wide array of imaging features encountered as well as overlapping characteristics, identifying reliable imaging criteria for differentiating malignant from benign renal masses remains a challenge. Multiparametric magnetic resonance (MR) imaging based on various anatomic and functional parameters has an important role and adds diagnostic value in detection and characterization of renal masses. MR imaging may allow distinction of benign solid renal masses from several renal cell carcinoma (RCC) subtypes, potentially suggest the histologic grade of a neoplasm, and play an important role in ensuring appropriate patient management to avoid unnecessary surgery or other interventions. It is also a useful noninvasive imaging tool for patients who undergo active surveillance of renal masses and for follow-up after treatment of a renal mass. The purpose of this article is to review the characteristic MR imaging features of RCC and common benign renal masses and propose a diagnostic imaging approach to evaluation of solid renal masses using multiparametric MR imaging. ©RSNA, 2017.

Contemporary National Surgical Outcomes in the Treatment of Ureteropelvic Junction Obstruction

OBJECTIVE To evaluate contemporary national trends and outcomes of open pyeloplasty (OP) vs minimally invasive pyeloplasty (MIP) in the treatment of ureteropelvic junction obstruction using the National Surgical Quality Improvement Program database. METHODS Patients treated by OP or MIP between 2006 and 2011 were identified by The International Classification of Diseases, Ninth Revision, Clinical Modification codes corresponding to pyeloplasty as their primary operative procedure. Perioperative variables were analyzed using the chi-square and the Student t test. Multiple logistic regressions were used to identify morbidities and readmission risk factors. RESULTS Three hundred fifty-five patients were identified. Of them, 20.2% of cases were OP and 79.8% were MIP. There was a significant increase in MIP from 33% in 2006 to 83% in 2011 (P <.001). A total of 11.7% of patients in the MIP group underwent outpatient surgery (P = .002). Patients treated at a teaching hospital were over 3 times more likely to undergo MIP (odds ratio = 3.17; P = .001). There was significantly longer hospitalization in OP vs MIP (3.9 vs. 2.2 days; P = .001). OP was associated with significantly increased risk of reoperation or postoperative morbidity compared with MIP (11.1% vs. 4.2%; P = .02). Multivariate analysis confirmed a higher rate of overall morbidity in the OP cohort (P = .03). Male patients had significantly higher postoperative morbidity or reoperation rates (odds ratio = 4.38; P = .002). There was no significant difference in operative time between groups (P = .2). CONCLUSION Within the American College of Surgeons National Surgical Quality Improvement Program hospitals, MIP is associated with decreased reoperation and postoperative morbidity compared with OP.

Industry Ties in Medicine: Insight from the Open Payments Program

and the evidence supporting them are discussed in our article. Patients with NASH who have other indications for bariatric surgery can be referred for sur gical evaluation, but we cannot support recommending it as primary treatment for NASH at this time. The studies on this topic are predominantly retrospec tive, uncontrolled, or not randomized. The largest prospective trial to date was recently reported in Gastroenterology and revealed nearly 85% histologic res olution of NASH at 1 year after bariatric surgery. Despite these excellent re sults, the study authors pointed out that the trial was not randomized and that additional studies are indicated. Koch et al argue that it is “unlikely that a human studies subcommittee would permit randomization to sur gery vs no surgery [in this setting]” because of the obvious mortality benefit of bariatric surgery. We disagree and believe that the safety and benefit of this procedure in patients with NASHwho have no other indications for bariatric surgery has not been vigorously researched and de serves further investigation. Through additional studies, we may be able to improve patient selection and more clearly define the risks, benefits, and complications of these bariatric proce dures in the setting of liver disease, cirrhosis, and portal hypertension.