Heather Schultz

Robotic Radical Cystectomy for Bladder Cancer: Surgical and Pathological Outcomes in 100 Consecutive Cases

PURPOSE Radical cystectomy remains the most effective treatment for patients with localized, invasive bladder cancer and recurrent noninvasive disease. Recently some surgeons have begun to describe outcomes associated with less invasive surgical approaches to this disease such as laparoscopic or robotic assisted techniques. We report our maturing experience with 100 consecutive cases of robotic assisted laparoscopic radical cystectomy with regard to perioperative results, pathological outcomes and surgical complications. MATERIALS AND METHODS A total of 100 consecutive patients (73 male and 27 female) underwent robotic radical cystectomy and urinary diversion at our institution from January 2006 to January 2009 for clinically localized bladder cancer. Outcome measures evaluated included operative variables, hospital recovery, pathological outcomes and complication rate. RESULTS Mean age of this cohort was 65.5 years (range 33 to 86). Of the patients 61 underwent ileal conduit diversion, 38 received a neobladder and 1 had no urinary diversion (renal failure). Mean operating room time for all patients was 4.6 hours (median 4.3) and mean surgical blood loss was 271 ml (median 250). On surgical pathology 40% of the cases were pT1 or less disease, 27% were pT2, 13% were pT3/T4 disease and 20% were node positive. Mean number of lymph nodes removed was 19 (range 8 to 40). In no case was there a positive surgical margin. Mean days to flatus were 2.1, bowel movement 2.8 and discharge home 4.9. There were 41 postoperative complications in 36 patients with 8% having a major complication (Clavien grade 3 or higher) and 11% being readmitted within 30 days of surgery. At a mean followup of 21 months 15 patients had disease recurrence and 6 died of disease. CONCLUSIONS We report a relatively large and maturing experience with robotic radical cystectomy for the treatment of bladder cancer providing acceptable surgical and pathological outcomes. These results support continued efforts to refine the surgical management of high risk bladder cancer.

A phase II trial of neoadjuvant erlotinib in patients with muscle-invasive bladder cancer undergoing radical cystectomy: Clinical and pathological results

Study Type – Therapy (cohort)
Level of Evidence 2b

The impact of obesity on the diagnosis of prostate cancer using a modern extended biopsy scheme.

PURPOSE The effect of obesity on prostate cancer detection and behavior remains uncertain. We evaluated the impact of obesity, as measured by body mass index, in a case series of 500 consecutive men who underwent a modern 10 to 12 core biopsy approach. MATERIALS AND METHODS We retrospectively reviewed the records of a consecutive series of 500 men who underwent transrectal ultrasound guided prostate biopsy using a 10 to 12 core biopsy scheme. Variables, including patient age, prostate specific antigen, prostate specific antigen density, digital rectal examination findings, transrectal ultrasound prostate volume and biopsy outcome, including grade, were compared to anthropometric measures, including body mass index. RESULTS Of the men 26% were obese according to body mass index (greater than 30 kg/m(2)). A total of 223 men (45%) had a positive biopsy. Obese men were younger (62.0 vs 63.8 years), had a larger prostate (57.7 vs 47.8 cc) and were less likely to have any abnormality on digital rectal examination (19.6% vs 30.8%). Obese men were also less likely to have a positive biopsy based on chi-square analysis (38.8% vs 46.2%). On statistical modeling for the OR in nonobese vs obese men there was a trend toward lower detection based on crude and age adjusted ORs but not on multivariate OR controlling for age, prostate specific antigen and prostate volume. In addition, when examining for high grade disease (Gleason 4 + 3 or greater), no differences were observed on OR modeling. In men with negative biopsies those who were obese vs nonobese had a larger prostate volume and trended toward a higher median prostate specific antigen and age. These differences and trends were not observed in obese men with positive biopsies. CONCLUSIONS Of men undergoing prostate biopsy using a modern extended biopsy scheme obese men were younger, had a larger prostate and were less likely to have abnormal digital rectal examinations. Although some trends toward a lower detection rate in obese men were observed, such differences were not observed on multivariate analysis, nor were any differences observed in the incidence of higher grade tumors, thus questioning the effect of obesity on prostate cancer detection and behavior in our cases series.

Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles

Introduction: Projections suggest a significant shortage of urologists coupled with an increasing burden of urological disease due to an aging population. To meet this need, urologists have increasingly partnered with advanced practice providers. However, to this point the advanced practice provider workforce has not been comprehensively evaluated. Understanding the impact of advanced practice providers on the urology workforce is essential to maximize collaborative care as we strive for value and quality in evolving delivery models. Methods: A 29‐item, web based survey was administered to advanced practice providers identified by the AUA (American Urological Association), UAPA (Urological Association of Physician Assistants) and SUNA (Society of Urologic Nurses and Associates), querying many aspects of their practice. Results: A total of 296 advanced practice providers completed the survey. Advanced practice nurses comprised 62% of respondents while physician assistants comprised the remaining 38%. More than two‐thirds of the respondents were female and median age was 46 years. Only 6% reported having participated in formal postgraduate urological training. Advanced practice providers were evenly divided between institutional and private practice settings, and overwhelmingly in urban or suburban environments. The majority of advanced practice providers practice in the ambulatory setting (74%) and characterize their practice as general urology (72%). Overall 81% reported performing procedures independently, with 63% performing some procedures considered to be of moderate or high complexity. Conclusions: Advanced practice providers are active in the provision of urological care in many roles, including complex procedures. Given future workforce needs, advanced practice providers will likely assume additional responsibilities. As roles shift we must ensure we have the necessary educational and training opportunities to equip this vital part of our workforce.

The Expanding Role of Advanced Practice Providers in Urologic Procedural Care

OBJECTIVE To understand the role of Advanced Practice Providers (APPs) in urologic procedural care and its change over time. As the population ages and the urologic workforce struggles to meet patient access demands, the role of APPs in the provision of all aspects of urologic care is increasing. However, little is currently known about their role in procedural care. MATERIALS AND METHODS Commonly performed urologic procedures were linked to Current Procedural Terminology (CPT) codes from 1994 to 2012. National Medicare Part B beneficiary claims frequency was identified using Physician Supplier Procedure Summary Master Files. Trends were studied for APPs, urologists, and all other providers nationally across numerous procedures spanning complexity, acuity, and technical skill set requirements. RESULTS Between 1994 and 2012, annual Medicare claims for urologic procedures by APPs increased dramatically. Cystoscopy increased from 24 to 1820 (+7483%), transrectal prostate biopsy from 17 to 834 (+4806%), complex Foley catheter placement from 471 to 2929 (+522%), urodynamics testing from 41 to 9358 (+22,727%), and renal ultrasound from 18 to 4500 (+24,900%) CONCLUSION: We found dramatic growth in the provision of urologic procedural care by APPs over the past 2 decades. These data reinforce the known expansion of the APP role in urology and support the timeliness of ongoing collaborative multidisciplinary educational efforts to address unmet needs in education, training, and guideline formation to maximize access to urologic procedural services.

OUTCOMES AND IMPLICATIONS OF FOLLOW-UP BIOPSIES OF MEN ON ACTIVE SURVEILLANCE FOR LOW-RISK PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: Active surveillance (AS) is an important strategy for many men with low-risk prostate cancer. As part of the AS program, many chave advocated the use of follow-up biopsies (bx) to help monitor the disease. We evaluated the outcomes and implications of follow-up prostate bx in men in an AS program. METHODS: The AS program at our institution includes followup PSA, DRE, and a 12-core prostate needle bx at 6-12 months after diagnosis and every 1-2 years thereafter. The selected interval chosen was dependent on a variety of factors including patient age, health status, PSA level and dynamic, DRE, and qualitative elements of patient or physician concern. Demographic and clinical characteristics, biopsy outcomes, and clinical follow-up of these men are described. Biochemical, pathological, and clinical follow-up are described in this cohort. RESULTS: 71 men underwent initial bx and at least 1 follow-up bx as part of their AS program. Entry characteristics were as follows: mean age 63.5 years (53-82 yrs), mean PSA = 6.1 (1.3 23). 65/71 (92%) had Gleason 3+3 disease, 4 (6%) men had 3+4, 2 (3%) men had 4+3. 67 men were cT1c and 4 were cT2. On repeat (2nd) bx, negative bx rate was 41% (29/71) and the positive bx rate was 59% (42/71). No differences were observed with regard to pre-treatment PSA, original grade, stage, age, or race between those with negative vs. positive 2nd bx. Cancer core length appears to be associated with a positive 2nd bx: Of patients with negative 2nd bx, 27/29 (93%) had 1 mm and 2/29 (7%) had 2mm with no pt with 3mm or more on their original bx. Of those with positive 2nd bx, 12/42 (29%) had 1mm, 15/42 (36%) had 2 mm, and 15 (36%) had >=3mm on cores on original biopsies. Of those with a positive 2nd bx, 28 had no upgrading and 14 were upgraded. Of the 14 who had upgrading at 2nd bx, 10 had definitive treatment (6 RP, 4 XRT) and 4 were lost to FU. Of the 29 who had negative 2nd bx, none have undergone treatment. Of the 28 who had positive repeat (but no upgrading), 2 underwent treatment (1 RP and 1 brachy). Four patients with 2nd negative bx had a 3rd bx, and all were negative. 10 patients with positive 2nd bx had 3rd bx and all were positive. The PSAV trended higher in patients with negative vs. positive (no upgrade) vs. positive (upgrade) (-0.753 vs. 0.011 vs. 0.555 ng/ml/yr) CONCLUSIONS: The study helps characterize the outcomes and implications of repeat prostate bx in patients on AS. These results suggest that repeat biopsies are important in characterizing the volume, grade, and eventually decisions for treatment in men on active surveillance.

Procedures for the Nurse Practitioner in Urology

Objectives 1. Describe indications for specific office-based procedure appropriate to the urology patient. 2. Review both provider and patient preparation. 3. Discuss necessary post-procedure monitoring and follow-up.