Goutham Vemana

The second “time-out”: a surgical safety checklist for lengthy robotic surgeries

Robotic surgeries of long duration are associated with both increased risks to patients as well as distinct challenges for care providers. We propose a surgical checklist, to be completed during a second “time-out”, aimed at reducing peri-operative complications and addressing obstacles presented by lengthy robotic surgeries. A review of the literature was performed to identify the most common complications of robotic surgeries with extended operative times. A surgical checklist was developed with the goal of addressing these issues and maximizing patient safety. Extended operative times during robotic surgery increase patient risk for position-related complications and other adverse events. These cases also raise concerns for surgical, anesthesia, and nursing staff which are less common in shorter, non-robotic operations. Key elements of the checklist were designed to coordinate operative staff in verifying patient safety while addressing the unique concerns within each specialty. As robotic surgery is increasingly utilized, operations with long surgical times may become more common due to increased case complexity and surgeons overcoming the learning curve. A standardized surgical checklist, conducted three to four hours after the start of surgery, may enhance perioperative patient safety and quality of care.

Magnetic resonance imaging-targeted vs. conventional transrectal ultrasound-guided prostate biopsy: Single-institution, matched cohort comparison

OBJECTIVES To compare magnetic resonance imaging-targeted biopsy (MRITB) and conventional transrectal ultrasound-guided biopsy (TRUSGB) in the detection of prostate cancer (PCa) at our institution. METHODS Our prospective registry of patients undergoing prostate MRITB from December 2010 to July 2013 was analyzed. Patients were matched one-to-one to patients who underwent TRUSGB based on the following characteristics: age, prostate-specific antigen level, prostate volume, race, family history of PCa, initial digital rectal examination (DRE), prior use of 5-alpha reductase inhibitor, and prior diagnosis of PCa. MRITB was performed using a TargetScan system with the patient under general anesthesia. Magnetic resonance imaging suspicious regions (MSRs) were targeted with cognitive registration, and a full TargetScan template biopsy (TSTB) was also performed. RESULTS In total, 34 MRITB patients were matched individually to 34 TRUSGB patients. As compared with TRUSGB, patients who underwent MRITB had a greater overall rate of PCa detection (76% vs. 56%, P = 0.12) and a significantly higher number with Gleason score≥7 (41% vs. 15%, P = 0.03), whereas the rates of Gleason score 6 PCa detection were similar between MRITB and TRUSGB (35% vs. 41%, P = 0.80). As compared with the TSTB, magnetic resonance imaging suspicious regions-directed biopsies during MRITB had a significantly higher overall PCa detection (54% vs. 24%, P<0.01) and Gleason score≥7 PCa detection (25% vs. 8%, P<0.01). When compared with TSTB, TRUSGB had similar detection rates for benign prostate tissue (76% vs. 79%, P = 0.64), Gleason score 6 PCa (16% vs. 14%, P = 0.49), and Gleason score ≥7 PCa detection (8% vs. 7%, P = 1.0). CONCLUSIONS Cognitive registration MRITB significantly improves the detection of Gleason score≥7 PCa as compared with conventional TRUSGB.

Chemoprevention of Prostate Cancer

Large prospective randomized trials, such as the Prostate Cancer Prevention Trial (PCPT), Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial, and Selenium and Vitamin E Cancer Prevention Trial (SELECT), have provided practitioners with considerable data regarding methods of treatment and prevention of prostate cancer. The best-studied medications for prevention are 5 alpha-reductase inhibitors. Their efficacy and side effects are well characterized. Other medications, dietary nutrients, and supplements have not been as well studied and generally do not demonstrate efficacy for disease prevention with an acceptable level of evidence.

Camera-Port Site Metastasis of a Renal-Cell Carcinoma After Robot-Assisted Partial Nephrectomy

BACKGROUND AND PURPOSE Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis-in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN. PATIENT AND METHODS A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed. RESULTS Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction. CONCLUSION PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.

Defining the Potential of Neoadjuvant Chemotherapy Use as a Quality Indicator for Bladder Cancer Care

PURPOSE Despite known survival benefits, overall use of neoadjuvant chemotherapy before cystectomy is low, raising concerns about quality of care. However, not all patients undergoing cystectomy are eligible for this therapy. We establish the maximum proportion of patients expected to receive neoadjuvant chemotherapy if all those eligible had a consultation with medical oncology. MATERIALS AND METHODS From institutional data (January 2010 through December 2012) we identified 215 patients treated with radical cystectomy for bladder cancer. After excluding patients not eligible for neoadjuvant chemotherapy, we fit models assessing patient disease and health factors affecting referral to medical oncology and receipt of neoadjuvant chemotherapy. Expected use of chemotherapy was then determined for increasingly broad groups of patients treated with cystectomy after controlling for factors precluding the use of neoadjuvant chemotherapy. RESULTS Of the 215 patients identified 127 (59%) were eligible for neoadjuvant chemotherapy. After additional consideration of patient factors (patient refusal, health status and poor renal function), maximum receipt of neoadjuvant chemotherapy increased from 42% to 71% as more restrictive definitions for the eligible patient cohort were used. CONCLUSIONS Substantial variability exists in the proportion of patients eligible for neoadjuvant chemotherapy based on the population identified. While there is substantial underuse of neoadjuvant chemotherapy, the development of quality metrics for this essential therapy depends on correct identification of the cystectomy population being assessed. Even with referral of all appropriate patients for medical oncology evaluation, use of chemotherapy would likely not exceed 50% of patients in nationally representative cystectomy data.

Institutional Review Board approval and innovation in urology: current practice and safety issues.

To retrospectively review recent publications describing novel procedures/techniques, and describe the Institutional Review Board (IRB)/ethics approval process and potential ethical dilemmas in their reporting.

Survival Comparison Between Endoscopic and Surgical Management for Patients With Upper Tract Urothelial Cancer: A Matched Propensity Score Analysis Using Surveillance, Epidemiology and End Results-Medicare Data.

OBJECTIVE To determine survival differences among patients receiving endoscopic vs surgical management for upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS Using Surveillance, Epidemiology and End Results-Medicare data, patients diagnosed with nonmuscle-invasive, low-grade UTUC as their first cancer diagnosis between 2004 and 2009 were identified. Receipts of endoscopic and surgical interventions were assessed, and patients were separated into surgical or endoscopic management cohorts. Two-to-one propensity score analysis was performed to control for baseline characteristics between groups. RESULTS The endoscopic management (n = 151) and matched surgical management (n = 302) groups demonstrated no significant differences in age, gender, race, marital status, Charlson comorbidity index, or year of diagnosis. Endoscopic management was an independent and significant predictor of all-cause and cancer-specific mortality (hazard ratio 1.6 for overall survival [OS], hazard ratio 2.1 for cancer-specific survival [CSS]). Kaplan-Meier estimated survival was significantly lower for endoscopic management, with both OS and CSS curves diverging at approximately 24-36 months. A subset of patients initially receiving endoscopic management went on to receive surgical intervention (80/151 = 53%) at a median of 8.8 months from diagnosis. For these patients, Kaplan-Meier-estimated CSS was not significantly different from those who continued with only endoscopic management, and remained significantly lower than patients who received upfront surgery. CONCLUSION Although initial survival outcomes (first 24 months) are similar for endoscopic and surgical management of nonmuscle-invasive, low-grade UTUC, both CSS and OS are significantly inferior for the endoscopic management group in the longer term. Furthermore, transition from initial endoscopic management to surgical intervention appears to have limited impact on survival.

Scarless Pyeloplasty in the Pediatric Population

OBJECTIVE To assess the outcomes of a modified technique for pediatric laparoscopic pyeloplasty (LP) performed without instrument trocars. METHODS A retrospective cohort study for all LPs performed without instrument trocars was performed. Patient demographics, surgical technique, complications, and clinical outcomes were reviewed. All patients undergoing this procedure had a single trocar placed to insufflate and introduce the laparoscope. Skin punctures were used without trocars to introduce 3-mm instrumentation for LP. RESULTS Nine patients with 10 procedures were identified. Median age was 8 months old (range 3-190). Median weight was 8.3 kg (range 5.9-70.5). Median operative time was 229 minutes (range 145-387). All procedures were performed without additional trocars. There were no open conversions. Median hospital stay was 1 day (range 1-4). Median narcotic use was 0.1 mg/kg/d of intravenous morphine equivalent. There were no intraoperative complications. Median follow-up was 36 months (range 18-45). Follow-up renal ultrasound evaluation has demonstrated improved hydronephrosis in all patients. No reoperative pyeloplasty was performed. Subjective assessment of cosmesis has shown excellent outcome with almost imperceptible evidence of operative intervention. CONCLUSION LP without instrument trocars can be safely and effectively performed without compromise of the surgical procedure, with minimal use of narcotics, and with a short hospital stay. Intermediate-term follow-up indicates encouraging results for achieving scarless surgery.

Bad Habits May Be Hard to Break

Prostate-specific antigen (PSA)–based screening for prostate cancer (PCa) is likely here to stay. This conclusion seems inescapable, notwithstanding two large random prospective trials that show either no benefits (Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial [PLCO]) or fairly modest benefits (European Randomized Study of Screening for Prostate Cancer) for reducing PCaspecific mortality [1,2]. The inevitability of PSA testing is supported by other observations including the behavior of the control group of the PLCO [3] and ‘‘popular opinion,’’ through which large segments of patients in the United States undergo frequent testing. This has been long recognized, and the age stratum most likely to be screened is the upper 70s [4]. Now the data from Nordstrom et al. [5] show a similar pattern emerging in Stockholm County, Sweden. These new data raise important questions: If PSA testing is inevitable, can it nonetheless be discouraged for the men who are least likely to benefit from it due to their age or comorbidity [6]? And can retesting be discouraged for men with very low initial PSA levels (eg, 1), namely, men who have a very low likelihood of future development of a clinically significant cancer [7,8]? It is difficult to make general suggestions on ways to reduce PSA testing among men with a low likelihood of benefiting from it. Perhaps a candid discussion of the reality that the presence of one comorbidity or more significantly lessens a man’s chance of dying from PCa [6] (and thus benefiting from diagnosis and treatment) would reduce a man’s preference for testing or at least motivate him to improve his overall lifestyle. Materials delineating the likelihood of overdiagnosis [9], which is very common among men who get screened, and that fairly represent the impact of subsequent overtreatment [10] may also be beneficial. However, once annual screening has begun, it can be quite difficult to change. There is an urgent need to educate patients and physicians about the best use of PSA. Unfortunately, the first 25 yr of the PSA era were marked by extensive overdiagnosis and overtreatment. Those are things we need to avoid during the next 25 yr.

Sources of Variation in Follow-up Expenditure after Radical Cystectomy

BACKGROUND Follow-up care after radical cystectomy is poorly defined, with extensive variation in practice patterns. We sought to determine sources of these variations in care as well as examine the economic effect of standardization of care to guideline-recommended care. METHODS Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1992 to 2007, we determined follow-up care expenditures (time and geography standardized) for 24 months after surgery. Accounted expenditures included office visits, imaging studies, urine tests, and blood work. A multilevel model was implemented to determine the effect of region, surgeon, and patient factors on care delivery. We then compared the actual expenditures on care in the Medicare system (interquartile range) with the expenditures if patients received care recommended by current clinical guidelines. RESULTS Expenditures over 24 months of follow-up were calculated per month and per patient. The mean and median total expenditures per patient were