Kristin Baldea

The July Effect in Urologic Surgery: Myth or Reality?

Introduction: The July effect is the widely held belief that medical care is compromised at the beginning of the academic year due to transitioning medical trainees. We determined its impact on surgical outcomes in urological surgery. Methods: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database and State Emergency Department Database for California were used for the years 2007 to 2011. Patients were identified who underwent surgery in July, August, April and May, and separated into early (July and August) and late (April and May) cohorts. Surgical outcomes for early vs late surgery were compared for academic centers. Adjusted multivariate models were fit to determine the effect of early surgery as a predictor of adverse outcomes. Results: For major urological surgery July/August timing had no impact on length of stay, 30-day readmission, 30-day emergency room visits, never events, perioperative complications or mortality (all values p >0.05). Similarly, for stone, groin, bladder outlet and cystoscopic bladder procedures, July/August surgery had no impact on rates of urinary retention, emergency room visits within 30 days, clot evacuations within 30 days, perioperative complications or 30-day readmissions (all values p >0.05). At the end of the year cystectomies had increased odds of intraoperative complications (OR 0.63, 95% CI 0.4–0.97) while nephrectomies had higher odds of major complications (OR 0.69, 95% CI 0.53–0.89). Conclusions: Surgical outcomes are not compromised by having surgery at the beginning of the academic year, despite resident turnover, representing appropriate oversight during this potentially vulnerable time.

Antepartum nephrolithiasis and the risk of preterm delivery

Antepartum nephrolithiasis presents a complex clinical scenario which often requires an intervention such as ureteral stent or percutaneous nephrostomy tube (PCNT) placement, especially in the setting of urinary tract infection (UTI). We assess the risk of UTI and preterm labor in the setting of antepartum nephrolithiasis. A retrospective review of an administrative dataset for California and Florida was performed, which included pregnant women admitted for a delivery between 2008 and 2011. Antepartum nephrolithiasis admissions were identified, as were urological intervention (ureteral stent/ureteroscopy) or PCNT placement. Descriptive statistics were performed, as was multivariable logistic regression to identify predictors of UTI and preterm delivery. Of the 2,750,776 deliveries included in this dataset, 3904 (0.14%) were complicated by antepartum nephrolithiasis. 71.4% of these patients were managed conservatively, while 20.6% (n = 803) underwent urological intervention and 8.0% (n = 312) underwent PCNT placement. Preterm delivery rates increased from a baseline of 7.0% for patients without a stone to 9.1% for patients with stones managed conservatively, 11.2% for those undergoing a urologic intervention, and 19.6% for patients who had PCNT placement. On multivariable analysis, conservative management (adjusted odds ratio, aOR 1.3), urologic intervention (aOR 1.5), and PCNT (aOR 2.3) placement each independently increased the risk of preterm delivery (all p < 0.001). Antepartum nephrolithiasis is a condition that affects 1 in 714 women and has been correlated with increased risk of UTI and preterm labor. Intervention with ureteral stent or PCNT placement independently increase these risks, however, receipt of a nephrostomy tube confers the greatest risk of UTI and preterm delivery to the antepartum nephrolithiasis patient.

Metabolic Syndrome Increases Risk of Postoperative Myocardial Infarction Following Percutaneous Nephrolithotomy

INTRODUCTION Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for upper tract stone burdens greater than 2 cm. Metabolic syndrome (MetS) is a constellation of conditions (diabetes mellitus, hypertension, dyslipidemia, and obesity) and is a risk factor for nephrolithiasis. Our objective was to investigate adverse cardiovascular outcomes of PCNL in patients with comorbid MetS diagnoses. MATERIALS AND METHODS Data from the Healthcare Cost and Utilization Project State Inpatient Database for Florida and California were used to identify PCNL patients (ICD9: 55.03, 55.04) between 2007 and 2011. Patients were categorized having 0, 1-2, or 3-4 components of MetS. Postoperative myocardial infarction (MI) and inhospital mortality rate outcomes were identified. Multivariate logistic regression was used to control for patient characteristics (age, race, and primary insurance provider) and medical comorbidities. RESULTS PCNL was performed on 39,868 patients, of whom 17,932 (45.0%) had no MetS conditions, 19,268 (48.3%) had 1-2 MetS conditions, and 2668 (6.7%) had 3-4 MetS conditions. With increasing MetS conditions, patients had increased incidence of postoperative MI (0: 0.6%; 1-2: 1.0%; 3-4: 1.8%, p < 0.001). On multivariate analysis, the presence of 3-4 MetS comorbidities increased the odds of a postoperative MI (1-2: odds ratio [OR] 1.2, 95% confidence interval [CI] 0.94-1.53, p = 0.147; 3-4: OR 2.2, 95% CI 1.54-3.15, p < 0.001). CONCLUSIONS MetS patients have an increased risk of MI following PCNL given their pre-existing comorbidities. Routine preoperative cardiac testing may benefit this population before PCNL.

Transitioning from a Low Dose Rate to a High Dose Rate Prostate Brachytherapy Program: Comparing Initial Dosimetry and Improving Workflow Efficiency through Targeted Interventions

Purpose We transitioned from a low-dose-rate (LDR) to a high-dose-rate (HDR) prostate brachytherapy program. The objective of this study was to describe our experience developing a prostate HDR program, compare the LDR and HDR dosimetry, and identify the impact of several targeted interventions in the HDR workflow to improve efficiency. Methods and Materials We performed a retrospective cohort study of patients treated with LDR or HDR prostate brachytherapy. We used iodine-125 seeds (145 Gy as monotherapy, and 110 Gy as a boost) and preoperative planning for LDR. For HDR, we used iridium-192 (13.5 Gy × 2 as monotherapy and 15 Gy × 1 as a boost) and computed tomography–based planning. Over the first 18 months, we implemented several targeted interventions into our HDR workflow to improve efficiency. To evaluate the progress of the HDR program, we used linear mixed-effects models to compare LDR and HDR dosimetry and identify changes in the implant procedure and treatment planning durations over time. Results The study cohort consisted of 122 patients (51 who received LDR and 71 HDR). The mean D90 was similar between patients who received LDR and HDR (P = .28). HDR mean V100 and V95 were higher (P < .0001), but mean V200 and V150 were lower (P < .0001). HDR rectum V100 and D1cc were lower (P < .0001). The HDR mean for the implant procedure duration was shorter (54 vs 60 minutes; P = .02). The HDR mean for the treatment planning duration dramatically improved with the implementation of targeted workflow interventions (3.7 hours for the first quartile to 2.0 hours for the final quartile; P < .0001). Conclusions We successfully developed a prostate HDR brachytherapy program at our institution with comparable dosimetry to our historic LDR patients. We identified several targeted interventions that improved the efficiency of treatment planning. Our experience and workflow interventions may help other institutions develop similar HDR programs.

MP75-01 PARAVERTEBRAL BLOCK FOR PERCUTANEOUS NEPHROLITHOTOMY: A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND PLACEBO-CONTROLLED STUDY

INTRODUCTION AND OBJECTIVES: Renal transplantation in patients with lower urinary tract (LUT) dysfunction is a unique challenge, as they are at higher risk of urinary tract infection, sepsis, surgical complications, allograft dysfunction and graft loss. We opt to identify the impact of pre-transplant bladder cycling on the urological complications, graft function and lower urinary tract function. METHODS: The study included patients maintained on hemodialysis for more than 12 months with oliguria or anuria, reduced bladder capacity by ascending cystogram, poor compliance by cystometry, no history of lower urinary tract dysfunction and have no evidence of urological cause of renal failure. Patients were randomly allocated into two groups, group I received direct renal transplantation without bladder recycling. Group II received renal transplant after programmed bladder recycling throughbladder instillation of sterilewater in amount equal to the estimated bladder capacity to be gradually increased till patient can withstand filling the bladder with 200 cc for 2 hours. Standard renal transplantation was carried out with stented Leich Gregoir ureteroneocystostomy. Urological complications and graft functions were recorded at 3 months. Patients were assessed by IPSS, Cystogram as well as cystometry. To achieve a difference in mean cystometric capacity of 50 cc in favor of bladder training patients, 16 patients in each group are required to achieve a power of 80% and an a error of 0.05. RESULTS: A total of 22 patients were randomized so far including 11 patients in each group. All the cases underwent right iliac renal allotransplantation. Urinary leakage occurred in 2 cases (18%) in group I that was managed conservatively and subsided with prolongation of the internal stent and one case required percutaneous tube drainage. In group II urinary leakage occurred in one case (9%) that was managed by surgical exploration and redo ureterovesical reimplantation (p1⁄4 0.07 ). At 3 months, mean serum creatinine was 0.9 mg/dl and 1 mg/dl in both groups respectively (p1⁄4 0.4 ). Symptom score was 9 and 11 in both groups respectively (p 1⁄40.09 ). Mean cystometric capacity three months after transplant was 382 cc and 397 cc in both groups respectively (p1⁄4 0.1). CONCLUSIONS: Pretransplant programmed bladder recycling for patients with defunctionalized bladder provide no clinical advantage as regard postoperative urological complications, graft function, lower urinary tract symptoms and cystometric capacity.

Prostate Cancer in the Elderly Male: Diagnostic and Management Considerations

Purpose of ReviewAlong with an aging US population comes the growing need for clinical guidelines inclusive of and specific to this unique group. Prostate cancer (PCa) is increasingly recognized as a substantial cause of mortality and morbidity in the elderly. This review seeks to address the unmet need for standardized PCa screening and management protocols for geriatric men and to synthesize recommendations based on recent literature.Recent FindingsGuidelines regarding PCa screening in elderly men are still being optimized, with many organizations moving toward inclusion of pre-screening global health assessment. Physician compliance with screening and treatment of PCa in geriatric patients is suboptimal, despite advanced age being a predictor of advanced disease. Elderly patients may experience treatment-related side effects which differ from their younger counterparts.SummaryProviders treating older men are encouraged to utilize comprehensive health assessments which account for comorbidities, functional status, and global well-being, along with shared decision-making, in determining diagnostic and therapeutic pathways.