Richard S. Matulewicz

Contemporary Surgical Trends in the Management of Upper Tract Calculi

PURPOSE Upper tract nephrolithiasis is a common surgical condition that is treated with multiple surgical techniques, including shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. We analyzed case logs submitted to the ABU by candidates for initial certification and recertification to help elucidate the trends in management of upper tract urinary calculi. MATERIALS AND METHODS Annualized case logs from 2003 to 2012 were analyzed. We used logistic regression models to assess how surgeon specific attributes affected the way that upper tract stones were treated. Cases were identified by the CPT code of the corresponding procedure. RESULTS A total of 6,620 urologists in 3 certification groups recorded case logs, including 2,275 for initial certification, 2,381 for first recertification and 1,964 for second recertification. A total of 441,162 procedures were logged, of which 54.2% were ureteroscopy, 41.3% were shock wave lithotripsy and 4.5% were percutaneous nephrolithotomy. From 2003 to 2013 there was an increase in ureteroscopy from 40.9% to 59.6% and a corresponding decrease in shock wave lithotripsy from 54% to 36.3%. For new urologists ureteroscopy increased from 47.6% to 70.9% of all stones cases logged and for senior clinicians ureteroscopy increased from 40% to 55%. Endourologists performed a significantly higher proportion of percutaneous nephrolithotomies than nonendourologists (10.6% vs 3.69%, p <0.0001) and a significantly smaller proportion of shock wave lithotripsies (34.2% vs 42.2%, p = 0.001). CONCLUSIONS Junior and senior clinicians showed a dramatic adoption of endoscopic techniques. Treatment of upper tract calculi is an evolving field and provider specific attributes affect how these stones are treated.

Increasing incidence of metastatic prostate cancer in the United States (2004–2013)

Background:Changes in prostate cancer screening practices in the United States have led to recent declines in overall incidence, but it is unknown whether relaxed screening has led to changes in the incidence of advanced and metastatic prostate cancer at diagnosis.Methods:We identified all men diagnosed with prostate cancer in the National Cancer Data Base (2004–2013) at 1089 different health-care facilities in the United States. Joinpoint regressions were used to model annual percentage changes (APCs) in the incidence of prostate cancer based on stage relative to that of 2004.Results:The annual incidence of metastatic prostate cancer increased from 2007 to 2013 (Joinpoint regression: APC: 7.1%, P<0.05) and in 2013 was 72% more than that of 2004. The incidence of low-risk prostate cancer decreased from years 2007 to 2013 (APC: −9.3%, P<0.05) to 37% less than that of 2004. The greatest increase in metastatic prostate cancer was seen in men aged 55–69 years (92% increase from 2004 to 2013).Conclusions:Beginning in 2007, the incidence of metastatic prostate cancer has increased especially among men in the age group thought most likely to benefit from definitive treatment for prostate cancer. These data highlight the continued need for nationwide refinements in prostate cancer screening and treatment.

Impact of resident involvement on urological surgery outcomes: An analysis of 40,000 patients from the ACS NSQIP database

PURPOSE In addition to excellent patient care, the focus of academic medicine has traditionally been resident training. The changing landscape of health care has placed increased focus on objective outcomes. As a result, the surgical training process has come under scrutiny for its influence on patient care. We elucidated the effect of resident involvement on patient outcomes. MATERIALS AND METHODS We retrospectively analyzed data from the 2005 to 2011 NSQIP® participant use database. Patients were separated into 2 cohorts by resident participation vs no participation. The cohorts were compared based on preoperative comorbidities, demographic characteristics and intraoperative factors. Confounders were adjusted for by propensity score modification and complications were analyzed using perioperative variables as predictors. RESULTS A total of 40,001 patients met study inclusion criteria. Raw data analysis revealed that cases with resident participation had a higher rate of overall complications. However, after propensity score modification there was no significant difference in overall, medical or surgical complications in cases with resident participation. Resident participation was associated with decreased odds of overall complications (0.85). Operative time was significantly longer in cases with resident participation (159 vs 98 minutes). CONCLUSIONS Urology resident involvement is not associated with increased overall and surgical complications. It may even be protective when adjusted for appropriate factors such as case mix, complexity and operative time.

Predictors of Readmission following Outpatient Urological Surgery

PURPOSE The Patient Protection and Affordable Care Act increases oversight of surgical outcomes and ties hospital readmissions to Medicare reimbursement. Given the increasing volume of outpatient urological procedures, to our knowledge this study provides the first multi-institutional multivariate analysis of patient factors that contribute to readmission. MATERIALS AND METHODS Using the 2011 National Surgical Quality Improvement Program database we identified 7,795 patients. Multiple logistic regression was used to predict 30-day unplanned hospital readmissions controlling for demographics, clinical characteristics and comorbidities. Readmission rates of the 5 most common procedures were calculated along with the rate of postoperative complications associated with readmission. RESULTS Outpatient urological surgery had an overall 3.7% readmission rate. The 5 most common procedures were cystourethroscopy and resection of bladder tumor (readmission rate 4.97%), laser prostatectomy (4.27%), transurethral resection of prostate (4.24%), hydrocele excision (1.92%) and sling surgery for urinary incontinence (0.85%). The most common comorbidities in readmitted patients were hypertension, diabetes and smoking. Risk adjusted multiple regression indicated that cancer history (OR 3.48), bleeding disorder (OR 2.03), male gender (OR 1.38), ASA(®) level 3 or 4 (OR 1.34) and age (OR 1.01) were significant predictors of readmission. Readmitted patients also had a higher 30-day complication rate. CONCLUSIONS Readmission after outpatient urological surgery occurs at a rate of 3.7%. A history of cancer, bleeding disorder, male gender, ASA level 3 or 4 and age were associated with readmission along with greater rates of medical and surgical complications. Our results may help guide risk reduction initiatives and prevent costly readmissions.

National Practice Patterns of Treatment of Erectile Dysfunction with Penile Prosthesis Implantation

PURPOSE The increase in medical options to manage erectile dysfunction has changed how urologists approach erectile dysfunction. We reviewed contemporary trends in penile prosthesis implantation in the United States with an emphasis on practice patterns, demographics and temporal changes. MATERIALS AND METHODS Annualized case log data of penile prosthesis surgeries from certifying and recertifying urologists from 2003 to 2012 were obtained from the American Board of Urology. CPT code 54400 was used to identify malleable prosthesis surgeries and CPT codes 54401 and 54405 were used to identify inflatable prosthesis surgeries. To evaluate the association between surgeon characteristics and practice patterns we used the chi-square test. RESULTS The surgical cohort included 6,615 urologists who placed a total of 9,558 penile prostheses during the study period. Only 23.9% of urologists reported performing a penile prosthesis operation. Of the prostheses 75% were placed by surgeons who completed 4 or fewer such operations per year. Of urologists who recorded logs 1.5% considered themselves to be specialists in andrology and yet they were responsible for a disproportionate 10% of all prostheses implanted (OR 5.9, p <0.0001). The proportion of inflatable penile prostheses compared to malleable prostheses increased twelvefold in 10 years. The number of logged prosthesis surgeries was skewed toward more implants placed by the most experienced urologists than by new urologists (OR 1.92, p <0.0001). CONCLUSIONS Although specialists and high volume surgeons perform a disproportionate number of implant surgeries, low volume surgeons place most penile prostheses in the United States. Additional research is needed to determine best practices to achieve optimal patient outcomes in penile prosthesis surgery.

Centralization of Penile Cancer Management in the United States: A Combined Analysis of the American Board of Urology and National Cancer Data Base

OBJECTIVE To assess the potential benefit of centralization of care in penile cancer. Centralization of care in other disease processes standardizes treatment and improves outcomes. Because penile cancer is a rare malignancy with unchanged mortality rates over the last two decades, we hypothesize that there may be a benefit to centralization. METHODS We identified surgeon, patient, and hospital characteristics captured by the National Cancer Data Base (1998-2012) and American Board of Urology case logs (2003-2013) for all penile cancer cases and procedures. Differences in patient demographics, stage of disease, referral patterns, and surgical quality indicators were assessed between academic and community hospitals. RESULTS Using case logs to evaluate the distribution of penile cancer care, we found that only 4.1% of urologists performed a penile surgery and 1.5% performed a lymph node dissection (LND). Academic centers treated higher-stage cancers and saw more cases/year than community centers, suggesting informal centralization. Two guideline-based quality indicators demonstrated no difference in use of penile-sparing surgery but a higher likelihood of having an LND performed at an academic center (48.4% vs 26.6%). The total lymph node yield was significantly greater at academic centers (18.5 vs 12.5). Regression modeling demonstrated a 2.29 increased odds of having an LND at an academic center. CONCLUSION Our data provide the first evidence for centralization of penile cancer in the US. At the time of diagnosis, equal number of patients is treated with penile-sparing surgery but there is greater use of LND and higher lymph node yield at academic centers. Ultimately, longer follow-up is necessary to determine if this improves survival of patients with penile cancer.

The effect of surgical duration of transurethral resection of bladder tumors on postoperative complications: An analysis of ACS NSQIP data.

INTRODUCTION Transurethral resection of bladder tumor (TURBT) is a common procedure used in the diagnosis and treatment of bladder cancer. Despite how often it is performed, not much is known about the risk factors for complications. Traditional surgery has an increase in morbidity and mortality with increasing operative duration. We assess the effect of operative duration on TURBT complications. METHODS The years 2006 to 2012 of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) were queried for patients undergoing TURBT. We separated patients into 4 groups based on operative time: 0 to 30 minutes, 30.1 to 60 minutes, 60.1 to 90 minutes, and greater than 90 minutes. Standard statistical analysis including multivariate regression was performed to determine predictors of complications. RESULTS A total of 10,599 TURBTs were included in our analysis. The overall complication rate for TURBT was 5.8% and there was an increase in the rate of complications seen as operative duration increased, which remained after controlling for age, comorbidities, tumor size, and American Society of Anesthesiology classification. Increased operative duration was associated with a greater risk of postoperative urinary tract infection, sepsis or septic shock, pulmonary embolism/deep venous thrombosis, reintubation or failure to wean, myocardial infarction, and death. Larger tumors were related to an increased odds of requiring blood transfusions. CONCLUSIONS Using a contemporary multicenter cohort of TURBTs from the ACS NSQIP database, we demonstrate that increased operative duration is associated with serious postoperative complications. This association was found to persist even after adjusting for patient age, comorbidities, tumor size, and functional status.

Radical Cystectomy Perioperative Care Redesign

OBJECTIVE To present an evidence-based review of the perioperative management of the radical cystectomy (RC) patient in the context of a care redesign initiative. METHODS A comprehensive review of the key factors associated with perioperative management of the RC patient was completed. PubMed, Medline, and the Cochrane databases were queried via a computerized search. Specific topics were reviewed within the scope of the three major phases of perioperative management: preoperative, intraoperative, and postoperative. Preference was given to evidence from prospective randomized trials, meta-analyses, and systematic reviews. RESULTS Preoperative considerations to improve care in the RC patient should include multi-disciplinary medical optimization, patient education, and formal coordination of care. Efforts to mitigate the risk of malnutrition and reduce postoperative gastrointestinal complications may include carbohydrate loading, protein nutrition supplementation, and avoiding bowel preparation. Intraoperatively, a fluid and opioid sparing protocol may reduce fluid shifts and avoid complications from paralytic ileus. Finally, enhanced recovery protocols including novel medications, early feeding, and multi-modal analgesia approaches are associated with earlier postoperative convalescence. CONCLUSION RC is a complex and morbid procedure that may benefit from care redesign. Evidence based quality improvement is integral to this process. We hope that this review will help guide further improvement initiatives for RC.

The emerging role of homologous recombination repair and PARP inhibitors in genitourinary malignancies

As cells age and are exposed to genotoxic stress, preservation of the genomic code requires multiple DNA repair pathways to remove single‐strand or double‐strand breaks. Loss of function somatic genomic aberrations or germline deficiency in genes involved in DNA repair can result in acute cell death or, after a latency period, cellular transformation. Therapeutic exploitation of DNA repair by inhibition of poly (adenosine diphosphate [ADP]) ribose polymerases (PARP), a family of enzymes involved in the repair of single‐strand and in some cases double‐strand breaks, has become a novel cancer treatment. Although the application of PARP inhibitors (PARPis) initially focused on tumors with BRCA1 or BRCA2 deficiencies, synthetic susceptibilities to PARPis have been expanded due to the identification of tumors with mutations pathways involved in DNA damage repair, in particular those that repair double‐strand breaks using homologous recombination (HR). There is an increasing appreciation that genitourinary (GU) malignancies, including bladder cancer and especially prostate cancer, contain subsets of patients with germline and somatic alterations in HR genes that may reflect an increased response to PARPis. In this review, the authors describe the mechanisms and rationale of the use of PARPis in patients with GU cancers, summarize previously reported preclinical and clinical trials, and identify ongoing trials to determine how PARPis and strategies targeted at HR repair can have widespread application in patients with GU cancers. Cancer 2017;123:1912–1924.

The Evolving Management of Patients With Clinical Stage I Seminoma

OBJECTIVE To determine trends in management and factors associated with men receiving either chemotherapy or radiation therapy post orchiectomy for clinical stage I (CSI) seminoma in a contemporary setting. PATIENTS AND METHODS The National Cancer Data Base was queried for all patients with CSI seminoma from 1998 to 2012. Adjuvant treatment after orchiectomy was classified into 3 groups: surveillance, radiotherapy, and chemotherapy. Yearly trends in management are described. Subgroup analysis for the years 2010-2012 was completed using logistic regression to determine predictors of receiving treatment. RESULTS Of 80,385 patients with testicular cancer, 16,931 had CSI seminoma. There was a progressive decline in the use of post-orchiectomy treatment from 1998 to 2012. In the years 2010-2012 (n = 5816), 59.9% of patients chose surveillance compared with 25.1% receiving radiotherapy and 15.0% receiving chemotherapy. Regression modeling demonstrated that men aged 18-30 were less likely (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.69-1.00, P = .048) to receive treatment than those aged 31-37. Increasing pathologic stage was associated with a greater likelihood of treatment (OR 1.77, 95% CI 1.52-2.06), whereas patients treated at academic hospitals were less likely to receive adjuvant therapy (OR 0.77, 95% CI 0.62-0.94). CONCLUSION Despite a trend toward increased use of post-orchiectomy surveillance for patients with CSI seminoma, a significant portion of patients are still receiving treatment. Pathologic stage and treating hospital type have the strongest association with management decisions. Improved guideline adherence may reduce the potential for adverse effects after chemotherapy or radiation therapy for CSI seminoma.