David I. Chu

Annual Incidence of Nephrolithiasis among Children and Adults in South Carolina from 1997 to 2012

BACKGROUND AND OBJECTIVES The prevalence of nephrolithiasis in the United States has increased substantially, but recent changes in incidence with respect to age, sex, and race are not well characterized. This study examined temporal trends in the annual incidence and cumulative risk of nephrolithiasis among children and adults living in South Carolina over a 16-year period. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a population-based, repeated cross-sectional study using the US Census and South Carolina Medical Encounter data, which capture all emergency department visits, surgeries, and admissions in the state. The annual incidence of nephrolithiasis in South Carolina from 1997 to 2012 was estimated, and linear mixed models were used to estimate incidence rate ratios for age, sex, and racial groups. The cumulative risk of nephrolithiasis during childhood and over the lifetime was estimated for males and females in 1997 and 2012. RESULTS Among an at-risk population of 4,625,364 people, 152,925 unique patients received emergency, inpatient, or surgical care for nephrolithiasis. Between 1997 and 2012, the mean annual incidence of nephrolithiasis increased 1% annually from 206 to 239 per 100,000 persons. Among age groups, the greatest increase was observed among 15-19 year olds, in whom incidence increased 26% per 5 years (incidence rate ratio, 1.26; 95% confidence interval, 1.22 to 1.29). Adjusting for age and race, incidence increased 15% per 5 years among females (incidence rate ratio, 1.15; 95% confidence interval, 1.14 to 1.16) but remained stable for males. The incidence among blacks increased 15% more per 5 years compared with whites (incidence rate ratio, 1.15; 95% confidence interval, 1.14 to 1.17). These changes in incidence resulted in doubling of the risk of nephrolithiasis during childhood and a 45% increase in the lifetime risk of nephrolithiasis for women over the study period. CONCLUSIONS The incidence of kidney stones has increased among young patients, particularly women, and blacks.

Effect of race and socioeconomic status on surgical margins and biochemical outcomes in an equal-access health care setting: Results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database

The impact of race and socioeconomic status (SES) in prostate cancer (CaP) outcomes has been well‐studied, but controversy remains. The associations of race/SES with intermediate CaP outcomes, including positive surgical margin (PSM) and biochemical recurrence (BCR), were explored in an equal‐access setting.

Predictive value of digital rectal examination for prostate cancer detection is modified by obesity.

The American Cancer Societys updated screening guidelines for prostate cancer (CaP) render digital rectal examination (DRE) optional. We investigated the impact of DRE on CaP detection among obese men. Data from 2794 men undergoing initial prostate biopsy at three centers were analyzed to assess CaP risk attributed to abnormal DRE across body mass index (BMI) categories. Predictive accuracies of a combination of PSA, age, race, center and biopsy year including or excluding DRE findings were compared by areas under the receiver-operating characteristics curves. In all cohorts, obese men were less likely to have abnormal DREs diagnosed than non-obese men. As BMI category increased, abnormal DREs became stronger predictors for overall CaP in individual (P-trends⩽0.05) and combined (P-trend<0.001) cohorts, and for high-grade CaP in the Italian (P-trend=0.03) and combined (P-trend=0.03) cohorts. DRE inclusion improved the predictive accuracy for overall and high-grade CaP detection among all obese men (P⩽0.032) but not normal-weight men (P⩾0.198). DRE inclusion also near-significantly improved overall CaP detection in obese men with PSA<4 ng ml–1 (P=0.081). In conclusion, the predictive value of DRE is dependent on obesity and is significantly higher among obese men than normal-weight men.

Intermediate-Term Followup of Proximal Hypospadias Repair Reveals High Complication Rate

Purpose: Results following distal hypospadias repair are favorable. Grouping proximal and distal hypospadias repair artificially increases the perceived success rate of proximal hypospadias. We identified our complication rate of proximal hypospadias repair and hypothesized a higher complication rate for 1‐stage repair. Materials and Methods: We retrospectively reviewed the records of consecutive boys who underwent proximal hypospadias from 2007 to 2014. Proximal hypospadias was defined as a urethral meatus location at or more proximal than the penoscrotal junction after penile degloving. We further stratified boys into those with planned 1‐stage vs 2‐stage repair. Univariate and Cox regression analyses were performed to assess associations with covariates and compare time to the first complication, respectively. Results: A total of 167 boys met study inclusion criteria. Median followup was 31.7 months for 1‐stage repair in 86 patients and staged repair in 81. The overall complication rate was 56%. Complications developed in 53 of 86 1‐stage (62%) vs 40 of 81 staged (49%) repairs (p = 0.11). The number of unplanned procedures per patient was higher in the 1‐stage than in the staged group (0.99 vs 0.69, p = 0.06), as was the number of patients who had at least 2 complications (29 of 86 or 33% vs 13 of 81 or 16%, p = 0.03). Cox regression showed no difference in time to the first complication for staged compared to 1‐stage repair (HR 0.77, 95% CI 0.43–1.39). Conclusions: Our 56% complication rate of proximal hypospadias warrants further long‐term patient followup. More patients in the 1‐stage group experienced at least 2 complications. However, when complications developed, they developed no differently in the 2 groups.

Metabolic risk factors in prostate cancer.

The biology of prostate cancer is influenced by the metabolic profile of each individual. We examine the evidence available interlinking prostate cancer with obesity, diabetes, and other metabolic syndrome components.

Prostate cancer: Socioeconomic status and disparities in treatment patterns

Disparities in prostate cancer treatment patterns have been traced to differences in socioeconomic status. These results have implications for quality of care imparted by health-care providers. until randomized clinical trials establish standards of care, physicians must be wary of unconscious bias and strive to support, not dictate, the decision-making process.

Experience with Glycerin for Antegrade Continence Enema in Patients with Neurogenic Bowel

PURPOSE Malone antegrade continence enemas are used in the management of neurogenic bowel to attain fecal continence. Several different irrigation solutions have been described but glycerin, an osmotic laxative that promotes peristalsis, has rarely been mentioned or studied. We assessed clinical outcomes in our patients with a Malone antegrade continence enema using glycerin based irrigation. MATERIALS AND METHODS We retrospectively reviewed patients with neurogenic bowel who underwent a Malone antegrade continence enema procedure between 1997 and 2011. Glycerin diluted with tap water followed by a tap water flush is our preferred irrigation protocol. Bowel regimen outcomes examined included fecal continence, emptying time, leakage from stoma, enema volume, frequency and independence. RESULTS Of the 23 patients with followup greater than 6 months 19 used glycerin based irrigation. Average age at surgery was 8.8 years. Patients using glycerin instilled a median of 30 ml (mean 29) glycerin and 50 ml (131) tap water. Fecal continence rate was 95% and stoma leakage rate was 16%, and only 16% of patients required daily irrigation. CONCLUSIONS Glycerin is a viable and effective alternative irrigant for antegrade enemas of neurogenic bowel, with an excellent fecal continence rate. The volume of irrigant needed is typically less than 90 ml, which is much less than in published reports using tap water alone.

Variation in use of nephron-sparing surgery among children with renal tumors

OBJECTIVE Given the negative long-term effects of renal insufficiency, nephron-sparing surgery (NSS) is increasingly discussed for the treatment of pediatric renal tumors. We sought to examine variation in practice patterns of NSS among children with renal tumors. MATERIALS AND METHODS We performed a retrospective cohort analysis of claims data for pediatric inpatient admissions captured by the Kids Inpatient Database (1997-2009). We identified children with renal tumors who underwent surgery, including radical nephrectomy (RN) and NSS. We used multivariable logistic regression to assess the relationship between use of NSS and various clinical, demographic, and geographic predictors of interest. RESULTS We identified 10,108 pediatric inpatient admissions for renal tumors. Of these, 1657 were surgical admissions, with 1501 patients (90.5%) undergoing RN and 156 (9.5%) undergoing NSS. On multivariable analysis, NSS was associated only with a concomitant diagnosis of renal insufficiency (relative ratio [RR] 3.37, p = 0.01) and surgery in the Northeastern USA (RR 3.07, p = 0.03). Race/ethnicity, age, payer type, procedure year, and other non-clinical factors were not significantly associated with NSS. CONCLUSION In a large, nationwide pediatric cohort, RN remains the most common surgical intervention for renal tumors. NSS is significantly associated with a diagnosis of renal insufficiency, but not non-clinical factors such as patient gender or race.

Race and 30-Day Morbidity in Pediatric Urologic Surgery.

BACKGROUND AND OBJECTIVE: Quality improvement in surgery involves identifying patients at high risk for postoperative complications. We sought to assess the impact of race and procedure type on 30-day surgical morbidity in pediatric urology. METHODS: The National Surgical Quality Improvement Program–Pediatrics (NSQIP-P) is a prospective registry of surgical cases from 50 and 56 pediatric hospitals in 2012 and 2013, respectively. We performed a cohort study of children followed in NSQIP-P who underwent urologic surgery. Forty unique operations were stratified into 6 clinically related procedure groups: ureteral, testicular, renal, urinary diversion, penile and urethral, or bladder procedures. Outcomes were 3 different composite measures of 30-day morbidity. Primary predictors were patient race and procedural group. Multivariate logistic regression was used to identify associations between race, procedure type, and postoperative morbidity. RESULTS: Of 114 395 patients in the NSQIP-P cohort, 11 791 underwent pediatric urologic procedures. Overall 30-day complication rate was 5.9% and was higher in bladder and urinary diversion procedures. On multivariate analyses, non-Hispanic black compared with non-Hispanic white children had higher odds of 30-day overall complications (odds ratio 1.34; 95% confidence interval, 1.03–1.74) and 30-day hospital-acquired infection (odds ratio 1.54; 95% confidence interval, 1.08–2.20). Bladder and urinary diversion procedures relative to testicular procedures had significantly higher odds of surgical morbidity across all composite outcome measures. CONCLUSIONS: Black race and bladder and urinary diversion operations were significantly associated with 30-day surgical morbidity. Future efforts should identify processes of care that decrease postoperative morbidity among children.

Mortality and Morbidity after Laparoscopic Surgery in Children with and without Congenital Heart Disease

Objectives To determine the risk of morbidity and mortality after laparoscopic surgery among children with congenital heart disease (CHD). Study design Cohort study using the 2013‐2014 National Surgical Quality Improvement Program‐Pediatrics, which prospectively collected data at 56 and 64 hospitals in 2013 and 2014, respectively. Primary exposure was CHD. Primary outcome was overall in‐hospital postoperative mortality. Secondary outcomes included 30‐day mortality and 30‐day morbidity (any nondeath adverse event). Among 34 543 children who underwent laparoscopic surgery, 1349, 1106, and 266 had minor, major, and severe CHD, respectively. After propensity score matching within each stratum of CHD severity, morbidity and mortality were compared between children with and without CHD. Results Children with severe CHD had higher overall mortality and 30‐day morbidity (OR 12.31, 95% CI 1.59‐95.01; OR 2.51, 95% CI 1.57‐4.01, respectively), compared with matched controls. Overall mortality and 30‐day morbidity were also higher among children with major CHD compared with children without CHD (OR 3.46, 95% CI 1.49‐8.06; OR 2.07, 95% CI 1.65‐2.61, respectively). Children with minor CHD had similar mortality outcomes, but had higher 30‐day morbidity compared with children without CHD (OR 1.71, 95% CI 1.37‐2.13). Conclusions Children with major or severe CHD have higher morbidity and mortality after laparoscopic surgery. Clinicians should consider the increased risks of laparoscopic surgery for these children during medical decision making.