Maxwell B. James

Impact of Surgeon Case Volume on Reoperation Rates after Inflatable Penile Prosthesis Surgery

Purpose: We investigated the impact of surgeon annual case volume on reoperation rates after inflatable penile prosthesis surgery. Materials and Methods: The New York Statewide Planning and Research Cooperative System database was queried for inflatable penile prosthesis cases from 1995 to 2014. Multivariate proportional hazards regression was performed to estimate the impact of surgeon annual case volume on inflatable penile prosthesis reoperation rates. We stratified our analysis by indication for reoperation to determine if surgeon volume had a similar effect on infectious and noninfectious complications. Results: A total of 14,969 men underwent inflatable penile prosthesis insertion. Median followup was 95.1 months (range 0.5 to 226.7) from the time of implant. The rates of overall reoperation, reoperation for infection and reoperation for noninfectious complications were 6.4%, 2.5% and 3.9%, respectively. Implants placed by lower volume implanters were more likely to require reoperation for infection but not for noninfectious complications. Multivariable analysis demonstrated that compared with patients treated by surgeons in the highest quartile of annual case volume (more than 31 cases per year), patients treated by surgeons in the lowest (0 to 2 cases per year), second (3 to 7 cases per year) and third (8 to 31 cases per year) annual case volume quartiles were 2.5 (p <0.001), 2.4 (p <0.001) and 2.1 (p=0.01) times more likely to require reoperation for inflatable penile prosthesis infection, respectively. Conclusions: Patients treated by higher volume implanters are less likely to require reoperation after inflatable penile prosthesis insertion than those treated by lower volume surgeons. This trend appears to be driven by associations between surgeon volume and the risk of prosthesis infection.

Micropapillary Bladder Cancer: Insights from the National Cancer Database

Introduction: Micropapillary bladder cancer (MPBC) is a variant histology of urothelial carcinoma (UC) that is associated with poor outcomes however given its rarity, little is known outside of institutional reports. We sought to use a population-level cancer database to assess survival outcomes in patients treated with surgery, radiation therapy and/or chemotherapy. Materials and Methods: The National Cancer Database (NCDB) was queried for all cases of MPBC and UC using International Classification of Disease-O-3 morphologic codes between 2004–2014. Primary outcome was survival outcomes stratified by treatment modality. Treatments included radical cystectomy (RC) with or without neoadjuvant chemotherapy (NAC) or adjuvant chemotherapy (AC). Results: Overall 869 patients with MPBC and 389,603 patients with UC met the inclusion criteria. Median age of the MPBC cohort was 69.9 years (58.9–80.9) with the majority of the cohort presenting with high-grade (89.3%) and muscle invasive or locally advanced disease (47.6%). For cT1 MPBC, outcomes of RC and BPS were not statistically different. For≥cT2 disease, NAC showed a survival benefit compared with RC alone for UC but not for MPBC. On multivariable analysis, MPBC histology independently predicted worse increased risk of death. On subanalysis of the MPBC RC patients, NAC did not improve survival outcomes compared with RC alone. Conclusions: Neoadjuvant chemotherapy utilization and early cystectomy did not show a survival benefit in patients with MPBC. This histology independently predicts decreased survival and prognosis is poor regardless of treatment modality. Further research should focus on developing better treatment options for this rare disease.

Timing and Predictors of Early Urologic and Infectious Complications After Renal Transplant: An Analysis of a New York Statewide Database

OBJECTIVES The most common complications after renal transplant are urologic and are a cause of significant morbidity in a vulnerable population. We sought to characterize the timing and predictors of urologic complications after renal transplant using a statewide database. MATERIALS AND METHODS We queried the New York Statewide Planning and Research Cooperative System database to identify patients who underwent renal transplant from 2005 to 2013. Postoperative complications included hydronephrosis, ureteral stricture, vesicoureteral reflux, nephrolithiasis, and urinary tract infections. Cox proportional hazards model was used to assess independent predictors of urologic complications. RESULTS In total, 9038 patients were included in the analyses. Urologic complications occurred in 11.3% of patients and included hydronephrosis (12.0%), nephrolithiasis (2.8%), ureteral stricture (2.4%), and vesicoureteral reflux (1.5%). We found that 23% experienced at least one urinary tract infection. On multivariate analysis, predictors of urologic complications included medicare insurance, hypertension, and prior urinary tract infection. Graft recipients from living donors were less likely to experience urologic complications than deceased-donor kidney recipients (P < .001). CONCLUSIONS Urologic complications occur in a significant proportion of renal transplants. Further study is needed to identify risk factors for complications after renal transplantation to decrease morbidity in this vulnerable population.

Collecting duct carcinoma of the kidney: Disease characteristics and treatment outcomes from the National Cancer Database

OBJECTIVE To use a large population-level database to assess survival outcomes for collecting duct renal cell carcinoma (CDRCC). MATERIALS AND METHODS The National Cancer Database was queried for all cases of CDRCC and clear cell renal cell carcinoma (CCRCC) from 2004 to 2013. After removing patients with other cancer diagnoses, the analytic cohort was composed of 201,686 CCRCC and 577 CDRCC cases. Kaplan-Meier and cox proportional hazards analysis were employed to model survival. RESULTS Compared to CCRCC, patients with CDRCC presented with higher grade and stage, node positive, and metastatic disease (70.7% vs. 30.0% with metastasis; P<0.001). Overall median survival for CDRCC was 13.2 months (95% CI: 11.0-15.5) compared to the 122.5 months (95% CI: 121.0-123.9) for CCRCC. On multivariate analysis of the CDRCC cohort, increasing T stage, high-grade disease, and metastasis were predictors of mortality. Of 184 patients with metastatic CDRCC, 113 underwent cytoreductive nephrectomy (CNx) whereas the rest were treated with chemo/radiation or observed. Survival outcomes were improved in patients who received both CNx with chemo/radiation compared to CNx alone (hazard ratio = 0.51, 95% CI: 0.32-0.79) or chemo/radiation alone (hazard ratio = 0.57, 95% CI: 0.37-0.89) on multivariate analysis. CONCLUSION CDRCC is an aggressive subtype of renal cell carcinoma. Median survival is 13 months after diagnosis, drastically lower than for CCRCC. More than 70% of patients have metastatic disease at diagnosis. Chemo/radiation in addition to CNx is associated with a survival benefit over single mode therapy.

Sling Procedures for the Treatment of Stress Urinary Incontinence: Comparison of National Practice Patterns between Urologists and Gynecologists

Purpose: Sling procedures, which have become the dominant method of surgical management of stress urinary incontinence, are frequently performed by urologists and gynecologists. Few studies investigating trends in surgical management have focused on differences in provision of care between the specialties. In this study we compared national practice patterns of sling procedures by provider type. Materials and Methods: We analyzed the 2006 to 2013 ACS (American College of Surgeons) NSQIP (National Surgical Quality Improvement Program) database. CPT‐4 codes were used to identify patients who underwent sling procedures and any concomitant pelvic floor procedures. Patient and operative characteristics were compared between urologists and gynecologists using bivariate and multivariate analysis. Results: Our analytical cohort included 22,192 sling procedures, of which 5,718 (25.8%) and 16,474 (74.2%) were performed by urologists and gynecologists, respectively. Urologists performed a greater percent of autologous fascial sling procedures than gynecologists (1.16% vs 0.06%, p <0.001). Concomitant prolapse repair was performed in 8,664 patients (44.1%), including 954 (16.7%) of urologists and 7,710 (46.8%) of gynecologists. On multivariable analysis urology patients were less likely to undergo concomitant prolapse repair or hysterectomy. Urology patients were more likely to have hypertension and be older, have a higher ASA® (American Society of Anesthesiologists®) class and be current smokers. Conclusions: Gynecologists perform the majority of sling procedures for stress urinary incontinence. While gynecologists perform more concomitant procedures, urologists tend to operate on older patients with more comorbidities. Urologists also perform a greater proportion of autologous fascial sling procedures. These findings demonstrate that, although gynecologists perform a greater number of surgeries, urologists treat a unique population of patients who require operative management of stress urinary incontinence.

Safety of Mesh for Vaginal Cystocele Repair: Analysis of National Patient Characteristics and Complications

Purpose: The use of mesh in vaginal cystocele repair has decreased. We analyzed the ACS NSQIP® (American College of Surgeons National Surgical Quality Improvement Project) database to compare outcomes of repairs with and without mesh. Materials and Methods: CPT was used to identify patients who underwent cystocele repair with and without mesh from 2006 to 2013. Patient characteristics and complications were analyzed. Results: We identified 6,849 patients, of whom 5,667 (82.5%) underwent native tissue repair and 1,182 (17.5%) underwent repair with mesh. Patients who received mesh were older (mean ± SD age 64 ± 11 vs 60 ± 12 years, p <0.001) and more had comorbidities (56% vs 47%, p <0.001). Mean mesh vs nonmesh operative time (97 ± 67 vs 95 ± 53 minutes, p = 0.2) and mean length of stay (1.3 ± 2.4 vs 1.4 ± 1.3 days, p = 0.2) were similar in the 2 groups. Urinary tract infection was the most common complication in cases without vs with mesh (3.8% vs 3.5%). Mesh procedure rates of mortality (0% vs 0.3%, p = 0.04) and overall surgical complications (1.8% vs 3.9% p <0.001) were higher. On multivariate analysis ASA® class 3 or greater (OR 1.4, p = 0.01), longer operative time (OR 1.004, p <0.001) and mesh (OR 1.32, p = 0.05) were associated with greater morbidity. Patient comorbidities, surgeon specialty and concomitant procedures did not confer an increased risk of complications. Conclusions: Native tissue repair is performed more commonly than mesh repair. ASA class, operative time and mesh use are associated with an increased risk of postoperative morbidity. These results suggest an increased risk of complications when using mesh in vaginal anterior repair, although the overall risk in each procedure was low.

MP70-20 PREDICTORS AND UTILIZATION OF ABLATIVE THERAPIES IN NEW YORK STATE

INTRODUCTION AND OBJECTIVES: With the increased incidence of low-risk prostate and renal cancer, minimally invasive treatment options have become more desirable. In selected patients, focal ablative therapies offer less morbidity while achieving comparable outcomes to extirpative surgery. We describe patterns of usage of such therapies within a statewide database. METHODS: We queried the New York Statewide Planning and Research Cooperative System database to identify patients who underwent any focal ablative treatment for prostate or renal malignancy from 2001-2014 using CPT codes (55873, 53852, 53850, 50593, 50250, 50592, 50542), ICD-9-CM procedure codes (55325535, 6096, 6097), and ICD-9-CM diagnosis codes (185, 189.0, 189.1, 198.0). Medical comorbidities are also available. Hospital specific characteristics were obtained using available information from the New York Department of Health and the American Hospital Association. High volume centers were defined as the five highest volume hospitals according to number of ablative procedures. Logistic regression was performed to determine independent predictors of utilization. RESULTS: The final cohort included 1872 prostate ablations and 989 renal ablations. The five highest volume prostate and renal ablation centers performed 1173 (62.7%) and 376 (38.0%) cases, respectively. Demographic information is displayed in Table 1. On multivariate analysis, treatment with prostate ablation was associated with black race (OR 0.27, 95%CI 0.19-0.39, p<0.001), increasing age (OR 0.98, 95%CI 0.967-0.998, p1⁄40.03), teaching hospital status (OR 3.32, 95%CI 2.34-4.71, p<0.001), and number of beds (OR 1.002, 95%CI 1.001-1.002, p<0.001). For renal ablation, significant predictors on multivariate analysis were black race (OR 0.46, 95%CI 0.25-0.84, p1⁄40.012), other non-white race (OR 0.48, 95%CI 0.29-0.79, p1⁄40.004), number of beds (OR 1.001, 95%CI 1.000-1.001, p<0.001), and higher Elixhauser comorbidity index (OR 1.017, 95%CI 1.002-1.033, p1⁄40.025). CONCLUSIONS: In New York State, the use of ablative therapies is largely limited to academic institutions in urban areas, yet minority populations are significantly less likely to undergo such procedures. Future study should focus on identifying the barriers to treatment and what impact this might have on disease outcomes among different populations.

PD58-09 THE IMPACT OF A TEACHING HOSPITAL ON FUNDAMENTAL GENERAL UROLOGIC PROCEDURES: DO RESIDENTS HELP OR HURT?

(OCTAVE-Anas) score was created by combining PRO urinary function score changes at 3-months post-RARP, percentage of patients having a urethral catheter duration >16 days, percentage of patients readmitted, and blinded peer-review Global Evaluative Assessment of Robotic Skill (GEARS) scores of videos of the anastomosis technique. Similarly, for nerve sparing (NS), OCTAVENS score was created based on differences in erectile function at 6months post-RARP, percentage of organ-confined patients with positive margin, and GEARS assessment of NS technique. All component measures were standardized to represent number of standard deviations better (positive values) or worse (negative values) than population averages, and the OCTAVE score was calculated as the sum of these standardized values. RESULTS: From 4/2014 through 4/2016, 20 surgeons from 14 different practices (2,774 total patients) sent video clips of their surgical techniques and had at least 50% of their patients participating in MUSIC PRO. OCTAVE-Anas scores ranged from -6.4 to 3.5, while OCTAVENS scores ranged from -3.7 to 3.5. Construct validity was demonstrated with moderate correlation between OCTAVE and the video assessment scores (Anas r1⁄40.59, NS r1⁄40.56, Figure 1). CONCLUSIONS: OCTAVE successfully incorporates multidimensional assessments to reliably determine better performing surgeons for the anastomosis and nerve-sparing aspects of RARP. This method may be used to identify surgeons to provide peer surgical skill quality improvement, with the aim to advance care for prostate cancer patients in the state of Michigan.

Diagnostic yield of cystoscopy in the evaluation of recurrent urinary tract infection in women.

Due to a paucity of evidence‐based guidelines, anecdotal practice patterns often dictate clinical management of recurrent urinary tract infection (UTI) in women. Our aim was to identify pathologic findings of the urinary tract through cystoscopy and imaging in women with recurrent UTI, and to determine if specific risk factors are associated with a higher rate of abnormal findings.