Mark D. Tyson

Association Between Radiation Therapy, Surgery, or Observation for Localized Prostate Cancer and Patient-Reported Outcomes After 3 Years

Importance Understanding the adverse effects of contemporary approaches to localized prostate cancer treatment could inform shared decision making. Objective To compare functional outcomes and adverse effects associated with radical prostatectomy, external beam radiation therapy (EBRT), and active surveillance. Design, Setting, and Participants Prospective, population-based, cohort study involving 2550 men (⩽80 years) diagnosed in 2011-2012 with clinical stage cT1-2, localized prostate cancer, with prostate-specific antigen levels less than 50 ng/mL, and enrolled within 6 months of diagnosis. Exposures Treatment with radical prostatectomy, EBRT, or active surveillance was ascertained within 1 year of diagnosis. Main Outcomes and Measures Patient-reported function on the 26-item Expanded Prostate Cancer Index Composite (EPIC) 36 months after enrollment. Higher domain scores (range, 0-100) indicate better function. Minimum clinically important difference was defined as 10 to 12 points for sexual function, 6 for urinary incontinence, 5 for urinary irritative symptoms, 5 for bowel function, and 4 for hormonal function. Results The cohort included 2550 men (mean age, 63.8 years; 74% white, 55% had intermediate- or high-risk disease), of whom 1523 (59.7%) underwent radical prostatectomy, 598 (23.5%) EBRT, and 429 (16.8%) active surveillance. Men in the EBRT group were older (mean age, 68.1 years vs 61.5 years, P < .001) and had worse baseline sexual function (mean score, 52.3 vs 65.2, P < .001) than men in the radical prostatectomy group. At 3 years, the adjusted mean sexual domain score for radical prostatectomy decreased more than for EBRT (mean difference, −11.9 points; 95% CI, −15.1 to −8.7). The decline in sexual domain scores between EBRT and active surveillance was not clinically significant (−4.3 points; 95% CI, −9.2 to 0.7). Radical prostatectomy was associated with worse urinary incontinence than EBRT (−18.0 points; 95% CI, −20.5 to −15.4) and active surveillance (−12.7 points; 95% CI, −16.0 to −9.3) but was associated with better urinary irritative symptoms than active surveillance (5.2 points; 95% CI, 3.2 to 7.2). No clinically significant differences for bowel or hormone function were noted beyond 12 months. No differences in health-related quality of life or disease-specific survival (3 deaths) were noted (99.7%-100%). Conclusions and Relevance In this cohort of men with localized prostate cancer, radical prostatectomy was associated with a greater decrease in sexual function and urinary incontinence than either EBRT or active surveillance after 3 years and was associated with fewer urinary irritative symptoms than active surveillance; however, no meaningful differences existed in either bowel or hormonal function beyond 12 months or in in other domains of health-related quality-of-life measures. These findings may facilitate counseling regarding the comparative harms of contemporary treatments for prostate cancer.

Safety of Holmium Laser Enucleation of the Prostate in Anticoagulated Patients

PURPOSE Oral anticoagulation (OA) is considered a strict contraindication to transurethral resection of the prostate (TURP). In recent years, however, safe and effective surgical alternatives such as holmium laser enucleation of the prostate (HoLEP) have emerged. Evidence from randomized trials has revealed that HoLEP has fewer bleeding complications than TURP, suggesting that HoLEP in anticoagulated patients is safer than TURP. However, published data evaluating bleeding complications in anticoagulated patients undergoing HoLEP are incomplete. Using a retrospective design, this is the first study to compare the bleeding complication rates of anticoagulated patients undergoing HoLEP to patients not on OA. MATERIALS AND METHODS We reviewed the electronic medical records of the first 76 HoLEP patients treated by a single urologist in two New England hospitals from May 2002 to September 2007. RESULTS Thirty-nine were on OA, and 37 were controls. Thirteen patients were on coumadin (mean international normalized ratio [INR] 1.5), and 25 were on aspirin at the time of their surgery. Among the patients on OA, 8% (n = 2) had intraoperative hematuria compared to 14% (n = 5) of controls (p = 0.25). No patients in either group required blood transfusions. Stratifying the OA population revealed no statistical differences in bleeding complication rates between the coumadin, aspirin, and control groups (p = 0.34). Additionally, there were no differences in standard postoperative outcomes. CONCLUSION These findings suggest that HoLEP has excellent hemostatic properties in high-risk patients and is a safe surgical alternative to TURP in patients on OA.

Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes

CONTEXT Enhanced recovery after surgery (ERAS) protocols aim to improve surgical outcomes by reducing variation in perioperative best practices. However, among published studies, results show a striking variation in the effect of ERAS pathways on perioperative outcomes after cystectomy. OBJECTIVE To perform a systematic review of the literature and a meta-analysis comparing the effectiveness of ERAS versus standard care on perioperative outcomes after cystectomy. EVIDENCE ACQUISITION We performed a literature search of PubMed, EMBASE, Web of Science, Google Scholar, the Cochrane Library, and the health-related grey literature in February 2016 according to the Preferred Reporting Items for Systematic Review and Meta-analysis and the Cochrane Handbook. Studies were reviewed according to criteria from the Oxford Centre for Evidence-Based Medicine. Thirteen studies (1493 total patients) met the inclusion criteria (ERAS: 801, standard care: 692). A pooled meta-analysis of all comparative studies was performed using inverse-weighted, fixed-effects models, and random-effects models. Publication bias was graphically assessed using contour-enhanced funnel plots and was formally tested using the Harbord modification of the Egger test. EVIDENCE SYNTHESIS Pooled data showed a lower overall complication rate (risk ratio [RR]: 0.85, 95% confidence interval [CI]: 0.74-0.97, p = 0.017, I2=35.6%), a shorter length of stay (standardized mean difference:-0.87, 95% CI: -1.31 to -0.42, p=0.001, I2=92.8%), and a faster return of bowel function (standardized mean difference: -1.02, 95% CI: -1.69 to -0.34, p=0.003, I2=92.2%) in the ERAS group. No difference was noted for the overall readmission rates (RR: 0.74, 95% CI: 0.39-1.41, p=0.36, I2=51.4%), although a stratified analysis showed a lower 30-d readmission rate in the ERAS group (RR: 0.39, 95% CI: 0.19-0.83, p=0.015, I2=0%). CONCLUSIONS ERAS protocols reduce the length of stay, time-to-bowel function, and rate of complications after cystectomy. PATIENT SUMMARY Enhanced recovery after surgery pathways for cystectomy reduce complications and the amount of time patients spend in the hospital.

Childbearing and Pregnancy Characteristics of Female Orthopaedic Surgeons

BACKGROUND The number of women entering orthopaedic surgery is steadily increasing. Information regarding pregnancy and childbearing is important to understand as it increasingly affects residency programs, clinical practices, and the female surgeons and their offspring. METHODS One thousand and twenty-one female surgeons completed an anonymous, voluntary, 199-item online survey distributed via individual female surgeon interest groups and word of mouth in nine specialties: general surgery, gynecology, neurosurgery, ophthalmology, orthopaedics, otolaryngology, plastic surgery, podiatry, and urology. Two hundred and twenty-three survey responses from orthopaedic surgeons were compared with those of the other surgical specialists as well as American Pregnancy Association national data to assess differences, if any, in pregnancy characteristics, demographics, and satisfaction. RESULTS The overall reported complication rate for all pregnancies among orthopaedic surgeons was significantly higher than the rate in the general American population (31.2% [eighty-two of 263] compared with 14.5%). There was an increased risk of preterm delivery among orthopaedic surgeons compared with a cohort of the general U.S. population matched according to age, race, health, and socioeconomic status (risk ratio, 2.5; 95% confidence interval [CI], 1.3 to 4.6). There was an increased risk of preterm labor and preterm delivery among women who reported working more than sixty hours per week (odds ratio, 4.95; 95% CI, 1.4 to 36.6). Female orthopaedic surgeons took shorter maternity leave during training than during clinical practice (median, four compared with seven weeks). The mean duration of breastfeeding was significantly shorter during training than during clinical practice (4.7 compared with 8.3 months, p = 0.03). CONCLUSIONS Female orthopaedic surgeons had an increased risk of pregnancy complications, particularly preterm delivery, compared with the general U.S. population. We found an increased risk of increased risk of preterm labor and delivery in surgeons working more than sixty hours per week during pregnancy.

Holmium Laser Applications of the Prostate

The high-powered holmium laser is an excellent tool for the surgical treatment of benign prostatic hyperplasia. This article discusses the background of holmium use in the prostate and describes the surgical techniques of holmium laser ablation of the prostate and holmium laser enucleation of the prostate. Operative challenges are reviewed with suggestions as to how to avoid these problems or deal with them when they arise. Surgical outcomes and a thorough literature review are both presented.

Living Donor Kidney Transplantation With Multiple Renal Arteries in the Laparoscopic Era

OBJECTIVES To compare the postoperative complications and survival metrics after multiple renal arteries (MRA) and single renal artery (SRA) laparoscopically procured living donor kidney transplantation (LLDKT). MRA are the most frequently encountered anatomic variation during kidney transplantation. The long-term outcomes of LLDKT with MRA are not well characterized. METHODS A retrospective review of our institutions LLDKT database was performed. All surgeries were performed at a single tertiary care academic center between June 1999 and September 2008. Patients were divided into 2 cohorts (MRA vs SRA), and analysis was limited to patients with at least 1-year follow-up. RESULTS Of 584 LLDKTs, 510 had at least 1-year follow-up (median: 36 months). A total of 393 grafts had an SRA, whereas 117 (23%) had MRA. When complications were stratified by the Clavien classification system, no differences were noted between groups (P = .5). Furthermore, rates of vascular (P = .2) and urological (P = .9) complications were similar between groups. There was, however, a higher incidence of slow graft function in the MRA group (P = .01), despite similar rates of delayed graft function (P = .9) and acute rejection (P = .4). Furthermore, allograft survival was similar between both groups with 76% of MRA and 81% of SRA grafts functioning at 5 years (P = .49). Patient overall survival was likewise similar between groups with 88% of MRA and 86% of SRA recipients surviving at 5 years (P = .76). CONCLUSIONS Despite a higher incidence slow graft function, MRA in LLDKT does not adversely affect long-term allograft and patient overall survival.

Racial Disparities in Survival for Patients With Clinically Localized Prostate Cancer Adjusted for Treatment Effects

OBJECTIVE To examine whether racial disparities in survival exist among black, Hispanic, and Asian patients compared with white patients with clinically localized prostate cancer (CLPC) after adjustment for the effects of treatment. PATIENTS AND METHODS We performed a retrospective cohort study of patients with CLPC diagnosed from January 1, 1995, through December 31, 2003, as documented in the Surveillance, Epidemiology, and End Results registry. Treatment-stratified, risk-adjusted Cox proportional hazards models were constructed. RESULTS During the study period, CLPC was diagnosed in 294,160 patients. Of these patients, 123,850 (42.1%) underwent surgery and 101,627 (34.5%) underwent radiotherapy, whereas 68,683 (23.3%) received no treatment. Overall 5-year and 10-year survival rates for Asians (85.6% and 67.6%, respectively), Hispanics (85.9% and 69.0%, respectively), and whites (83.9% and 65.7%, respectively) were higher than for blacks (81.5% and 61.7%, respectively) (P<.001). Prostate cancer-specific survival also varied significantly by race (P<.001). A risk-adjusted model stratified by primary treatment modality revealed that blacks had worse overall survival than whites (hazard ratio, 1.37; 95% CI, 1.33-1.41; P<.001), whereas Asians had better survival compared with whites (hazard ratio, 0.79; 95% CI, 0.76-0.83; P<.001). After the effects of treatment were accounted for, Hispanics had similar overall survival compared with whites (hazard ratio, 0.97; 95% CI, 0.94-1.01; P=.10). CONCLUSION Blacks with CLPC have poorer survival than whites, whereas Asians have better survival, even after risk adjustment and stratification by treatment. These data may be relevant to US regions with large underserved populations that have limited access to health care.

Age-period-cohort Analysis of Renal Cell Carcinoma in United States Adults

OBJECTIVE To determine the extent to which the year of diagnosis, year of birth, and age at diagnosis influence the incidence trends of kidney cancer in the United States. METHODS Cancer registry data from the National Cancer Institutes Surveillance, Epidemiology, and End-Results (SEER) program were obtained for 64,041 patients with kidney cancer diagnosed between 1973 and 2008. Overall and age-specific incidence rates were calculated and adjustments were made for birth cohort and period effects. Results were stratified by race and sex. Age-period-cohort analysis was used to examine the effects of age, year of diagnosis (period), and year of birth (cohort) on incidence trends. RESULTS The overall age-standardized annual incidence per 100,000 increased during the study period (1973 to 2008) by race, from 6.75 (95% confidence interval, 6.18-7.36) to 19.56 (18.85-20.20) among whites, from 5.31 (3.50-7.71) to 25.38 (23.00-27.92) among blacks, and from 5.61 (3.50-8.50) to 13.98 (12.41-15.71) among other races; and by sex, from 9.44 (8.49-10.47) to 26.48 (25.39-27.60) among men and from 4.21 (3.65-4.84) to 13.38 (12.64-14.11) among women. Age-period-cohort analysis revealed a strong influence from period and cohort effects. The 1983 birth cohort, for example, had a 2-fold increase in kidney cancer (incidence rate ratio, 1.93 [1.63-2.25]) compared with the referent 1948 cohort. CONCLUSION From 1973 to 2008, the incidence rate of kidney cancer increased for each sex and race across all age groups. Age-period-cohort models revealed that period-related factors, although significant, cannot alone account for these unfavorable temporal trends.

Bladder capacity on preoperative urodynamics may impact outcomes on transobturator male slings.

Stress incontinence is frequently seen after prostate surgery. We sought to evaluate preoperative urodynamic (UDS) parameters on functional outcomes after transobturator male sling placement.

Stress incontinence during the learning curve of holmium laser enucleation of the prostate.

BACKGROUND AND PURPOSE Holmium laser enucleation of the prostate (HoLEP) is an excellent surgical treatment for patients with benign prostatic hyperplasia, but surgical complications are not well described. We set out to determine the predictors of stress incontinence (SUI) after HoLEP during the learning curve. PATIENTS AND METHODS A retrospective review of our institutions HoLEP database was performed. Patients were divided into two groups: No pads at 3 months (group 1); SUI and/or mixed incontinence necessitating ≥ one pad at 3 months (group 2). RESULTS Seventy-seven patients underwent HoLEP at our institution. Nine (12%) were excluded for pure urge symptoms and two (3%) were lost to follow-up, leaving 66 total patients. No differences were noted as regards age (P = 0.54), operating room time (P = 0.18), prostate size (P = 0.85), prostate-specific antigen level (P = 0.96), or International Prostate Symptom Score (P = 0.11). The number of days between cases, however, was higher in group 2 (44.5 vs 18.1, P = 0.02) and was associated with SUI in simple logistic regression models (odds ratio [OR] 1.25; 95% confidence interval [CI]: 1.04-1.51; P = 0.019). As the interval time between cases increased from 1, 3, and 5 weeks, the strength of the association increased (1 week: OR 2.75; 95% CI: 0.78-9.66; P = 0.12; 3 weeks: OR 2.86; 95% CI: 0.92-8.91; P = 0.07; 5 weeks: OR 4.69; 95% CI: 1.21-18.26; P = 0.026). SUI resolved in all but two patients by 1 year. CONCLUSIONS The major associated risk for SUI, a complication presumably related to surgical technique, was prolonged duration between cases. During the learning curve, surgeons should schedule patients frequently to enhance learning and decrease time to mastery of the technique, thereby reducing SUI.