Russell Terry

Complications of Robot-Assisted Radical Prostatectomy

Robotic surgery represents a shift in the surgical paradigm and is consequently associated with a unique set of challenges and complications in comparison to open or conventional laparoscopic surgery. For the first time, the surgeon is not directly at the bedside but is rather directing an intermediary machine and a separate bedside team to perform the operation. This, in addition to the lack of tactile feedback, the greater reliance on visual anatomic clues when performing robotic surgery, and the inherent risk of malfunction or mechanical failure of robotic components may all contribute to complications noted during robot-assisted radical prostatectomy (RARP). In this chapter, we outline the risks and incidence of the more common complications associated with RARP and present methods to manage them.

Gender and Subspecialty of Urology Faculty in Department-based Leadership Roles

OBJECTIVE To characterize the current gender and subspecialty of those holding academic departmental administrative and educational leadership roles in urology. METHODS We conducted a cross-sectional observational study of U.S. Urology Residency Programs in 2016-2017. Inclusion criteria were participation in the Urology Residency Match Program and having a department of urology website. From June 1, 2016 to August 20, 2016, each departments website was queried. If information was missing or unclear, we reviewed faculty biographies and contacted residency program coordinators. RESULTS We queried 124 urology residency programs. For administrative leadership roles, women comprised 3.3% of chairs, 4.5% of vice chairs, and 7.9% of division directors. For educational leadership roles, women comprised 9.4% of fellowship directors, 8.1% of residency directors, and 27.4% of medical student clerkship directors. The most common subspecialties for chairs included oncology (49.2%), endourology (16.4%), and female urology (7.4%). Among division directors, female urology had the highest representation of women (27.8%) followed by pediatric urology (9.8%), reconstruction (5%), endourology (4.3%), and andrology (4%). CONCLUSION Overall, women are disproportionately underrepresented when it comes to educational and administrative positions of urology departmental leadership. There is also a wide yet narrowing gender gap as more women are pursuing careers in this field. Given this upward trend we may see more women in positions of leadership over time. Future efforts should be made to help promote the advancement of women to positions of leadership.

The Effect of Continued Low Dose Aspirin Therapy in Patients Undergoing Percutaneous Nephrolithotomy

Purpose Aspirin is often stopped prior to percutaneous nephrolithotomy due to concern about the surgical bleeding risk. There is evidence that discontinuing aspirin perioperatively increases thromboembolic events and continuing it may be safe. We assessed the effect of continuing low dose aspirin through percutaneous nephrolithotomy and its effect on surgical and safety outcomes. Materials and Methods We retrospectively reviewed the records of 285 consecutive percutaneous nephrolithotomies performed between 2012 and 2015 at our institution. We compared outcomes and complications in patients who continued 81 mg aspirin daily to those in patients not receiving aspirin. Results A total of 67 patients (24.5%) were maintained on low dose aspirin and 207 (75.5%) were not on aspirin. The aspirin group was older (66 vs 52 years), included more tobacco users (58.2% vs 31.4%) and had a higher ASA® (American Society of Anesthesiologists®) score (2.9 vs 2.5, all p <0.001). There was no difference in mean S.T.O.N.E. (size, topography [stone location], obstruction, number of stones and evaluation of HU) score (7.6 vs 7.7, p = 0.71) or blood loss (44 vs 54 ml, p = 0.151). There was no difference in residual stone fragment size, including 0 to 2 mm in 65.3% vs 61.4% of aspirin vs no aspirin cases, 3 to 4 mm in 19.4% vs 16.2% and greater than 4 mm in 15.3% vs 22.4% (p = 0.407). Length of stay and the change in hemoglobin, hematocrit and creatinine were similar. There was no difference in the readmission rate (14.9% vs 12.6%, p = 0.618) or the total complication rate (34.4% vs 26.6%, p = 0.221). There was also no difference in the number of major complications (10.4% vs 5.8%, p = 0.193), bleeding complications (3.0% vs 2.9%, p = 0.971) and the transfusion rate (1.5% vs 1.0%, p = 0.57). Conclusions Percutaneous nephrolithotomy appears effective and safe in patients who continue low dose aspirin perioperatively.

MP92-01 SAFETY AND EFFICACY OF POST-OPERATIVE EXTENDED-DURATION VENOUS THROMBOEMBOLISM PROPHYLAXIS IN HIGH-RISK UROLOGIC ONCOLOGY PATIENTS

INTRODUCTION AND OBJECTIVES: Patients undergoing major urologic oncology surgery are at risk for post-operative venous thromboembolic events (VTE). The development of VTE following surgery often presents clinically after discharge and is associated with potentially significant morbidity and mortality. At present there is little published data on the safety and efficacy of extended duration venous thromboembolism prophylaxis (EDVTP) beyond the time of hospital discharge in urologic oncology patients. In this study, we evaluate the use of EDVTP for post-operative high-risk urologic oncology patients. METHODS: All patients undergoing major urologic oncology surgery by a single surgeon at our institution from April 2015 to present were evaluated for their risk for VTE using the Caprini risk assessment model. Patients considered high-risk (Caprini score 5) were discharged on post-operative EDVTP according to 2012 ACCP guidelines. 28 days of postoperative subcutaneous enoxaparin was considered the standard of care in eligible patients. These patients were prospectively monitored for the development of clinically symptomatic VTE within 30 days postoperatively and for adverse effects of EDVTP. RESULTS: 150 patients who underwent major urologic oncology surgery were considered to be at high VTE risk based on Caprini score of 5. Average patient age was 63.3 years and 68% of the patients were male. Surgical procedures performed included 39% radical cystectomy, 29% nephrectomy, 16% partial nephrectomy and 16% other. Average Caprini score was 7. Of these, 75% were candidates to receive a 28 day course of enoxaparin EDVTP. The most common reasons for the 25% of patients not receiving standard enoxaparin EDVTP included renal insufficiency (31%), atrial fibrillation requiring oral anticoagulation (26%), and previously diagnosed VTE requiring therapeutic anticoagulation (16%). Adherence to guidelines was not associated with any VTE prophylaxis complications. There were also no noted complications from the use of enoxaparin. The rate of observed 30-day symptomatic VTE in this population was 0%, with an anticipated rate of >5% based upon Caprini score. CONCLUSIONS: Post-operative use of EDVTP appears to be a safe and effective way to decrease the risk of VTE in high-risk urologic oncology patients. Additional data from larger registries is needed to evaluate and confirm the benefit gained and need for use of EDVTP in this patient population.

PD21-11 PCNL IN GERIATRIC PATIENTS: AN EVALUATION OF OUTCOMES, COMPLICATIONS AND DISCHARGE NEEDS

INTRODUCTION AND OBJECTIVES: Growing numbers of geriatric patients present for definitive management of kidney stones. Geriatric patients with large stones may be candidates for percutaneous nephrostolithotomy (PCNL), however their care-related needs may differ from younger patients. We reviewed our PCNL experience in geriatric patients to better define surgical outcomes, complications, and discharge needs. METHODS: We retrospectively analyzed patients undergoing PCNL from 2012-2015 in our institution. Preoperative characteristics, surgical outcomes, complications, and discharge needs were compared between two groups: geriatric patients (aged 65 years) and nongeriatric patients (<65years). Statistical analysis was performed with students t-test and chi-squared test. RESULTS: We analyzed 287 consecutive patients: 89(31%) patients 65 years; 198(69%) patients <65 years (mean age 72 vs 48 years, p<0.001). The results can be seen in Table 1. Geriatric patients were more likely Caucasian (91% vs 73.7%, p1⁄40.001), had fewer positive preoperative urine cultures (27% vs 41.6%, p1⁄40.017), and had higher American Society of Anesthesiologist scores (mean 2.83 vs 2.55, p<0.001). OR time (mean 159 vs 185 minutes, p1⁄40.003) and estimated blood loss (41 vs 56 mL, p1⁄40.014) were less in the geriatric group. The residual stone fragment size was less after one procedure (0-2 mm: 72.9% vs 58.5%; 3-4 mm: 15.6% vs 17.5%; >4 mm: 11.5% vs 24%, p1⁄40.024) in the geriatric group. There were no differences in 30 day readmissions (12.4% vs 12.6%, p1⁄40.95), total complications (30.3% vs 27.3%, p1⁄40.594) or major complications (9.0% vs 5.6% Clavien III p1⁄40.279) between the geriatric and non-geriatric groups respectively. Length of stay (3.1 vs 3.2 days, p1⁄40.852) was similar between the groups, however the geriatric group was more often discharged with services to assist with nephrostomy tubes or wound dressings (21.3% vs 9.1%, p1⁄40.016). CONCLUSIONS: PCNL is an acceptable surgical option in appropriately selected geriatric patients. These patients require more home nursing care, but otherwise do well compared to younger patients. This information may be helpful for both patient counseling and discharge planning in the geriatric stone population. Source of Funding: None