Tarun Jindal

An Evaluation of the Timing of Surgical Complications Following Radical Cystectomy: Data From the American College of Surgeons National Surgical Quality Improvement Program

OBJECTIVE To examine time-to-event data for 19 common postoperative complications within 30 days following radical cystectomy (RC). METHODS Patients undergoing RC were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011). The primary end point was time-to-complication; secondary end points included length of stay (LOS), reintervention, readmission, and 30-day mortality. Further, the complications were stratified into pre- and postdischarge, and the predictors were identified. Lastly, the effect of time-to-complication on secondary outcomes was evaluated. RESULTS Overall, 1118 patients underwent RC. The overall complication rate was 52.1%; the median LOS was 8 days. The vast majority of complications (85.2%) were contained within the first 2 weeks of surgery with a median time-to-complication of 8.5 days; 31.4% of the complications occurred post discharge. In adjusted analyses, increasing age (odds ratio [OR] = 1.02, P < .001), black race (OR = 1.67, P = .001), and creatinine ≥1.2 mg/dL (OR = 1.26, P = .002) were significant predictors of predischarge complications, whereas diabetes (OR = 1.40, P < .001), cardiopulmonary disease (OR = 1.27, P = .005), neoadjuvant therapy (OR = 1.35, P = .007), and continent diversions (OR = 1.30, P = .004) were significant predictors of postdischarge complications. A body mass index of ≥30 was associated with increased odds of pre- as well as postdischarge complications (P < .01). For a given complication, timing did not affect the mortality odds (P = .310), but the risk of reintervention, readmission, and prolonged LOS varied. CONCLUSION One in 2 patients suffers a complication within 30 days of undergoing RC. A vast majority of complications occur early on postoperatively, either pre- or post discharge, highlighting the need for rigorous inpatient as well as outpatient surveillance during this period-knowledge regarding the time-to-complications, the effect of time-to-complications, and risk factors may facilitate improved patient-physician communication and allow patient-tailored follow-up.

Impact of travel distance to the treatment facility on overall mortality in US patients with prostate cancer

The objective of this study was to investigate the impact of travel distance to the treating facility on the risk of overall mortality (OM) among US patients with prostate cancer (PCa).

Racial differences in prostate-specific antigen–based prostate cancer screening: State-by-state and region-by-region analyses☆

OBJECTIVE Black men are more prone to harbor prostate cancer. They are more likely to succumb to this tumor than their White counterparts and may benefit from early detection and treatment. In this study, we assess the nationwide and regional disparity in prostate-specific antigen (PSA) screening for prostate cancer between Black men and non-Hispanic Whites (NHWs). METHODS A total of 247,079 (weighted 55,185,102) men, aged 40 to 99 years, who responded to the 2012 and 2014 behavioral risk factor surveillance system surveys were used for our analysis. End points consisted of self-reported PSA screening and self-reported nonrecommended PSA screening within 12 months of the interview. The latter was defined as screening in men with <10-year life expectancy. Available sociodemographic variables were used to predict these end points. The independent predictors from multivariate models were used to calculate the adjusted prevalence of PSA screening and nonrecommended PSA screening on a nationwide and regional level. These numbers were calculated for Blacks and NHWs separately and were compared between the 2 groups. RESULTS Prevalence of PSA screening was 30.7% in NHWs vs. 28.1% in Blacks (P<0.001). On a region-based analysis, New England, Middle Atlantic, South Atlantic, East North Central, East South Central, West South Central, and Mountain showed a significantly higher rate of PSA screening in NHWs as compared to Blacks (all P<0.001). Middle Atlantic had a significantly higher prevalence of nonrecommended screening in NHWs as compared to Blacks, whereas South Atlantic, West South Central, and Pacific had a significantly higher prevalence of nonrecommended screening in Blacks as compared to NHWs (all P<0.001). Overall, 43 states performed screening more frequently to NHWs, whereas only 8 states performed it more frequently to Black men. The nonrecommended screening was performed more frequently to NHWs in 19 states, whereas 24 states performed it more frequently to Black men. CONCLUSION Our study demonstrates that on a regional-level (and state-level), there are significant racial differences in overall and nonrecommended PSA screening across the United States. Further research is necessary to identify the reasons for the differences and help overcoming it.

Efficacy of Systemic Chemotherapy Plus Radical Nephroureterectomy for Metastatic Upper Tract Urothelial Carcinoma

Given the growing body of evidence supporting the benefit of primary tumor control for a wide range of metastatic malignancies, we hypothesized that chemotherapy plus radical nephroureterectomy (RNU) is associated with an overall survival (OS) benefit compared to chemotherapy alone for metastatic upper tract urothelial carcinoma (mUTUC). Within the National Cancer Data Base (2004-2012), we identified 398 (38.4%) and 637 (61.6%) patients who received chemotherapy plus RNU and chemotherapy alone, respectively. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier curves showed that 3-yr OS was 16.2% (95% confidence interval [CI] 12.1-20.3) for chemotherapy plus RNU and 6.4% (95%CI 4.1-8.7) for chemotherapy alone (p<0.001). In IPTW-adjusted Cox regression analysis, chemotherapy plus RNU was associated with a significant OS benefit (hazard ratio 0.70, 95% CI 0.61-0.80; p<0.001). Despite the usual biases related to the observational study design, our findings show a net OS benefit for fit patients who received chemotherapy plus RNU for mUTUC relative to their counterparts treated with chemotherapy alone. PATIENT SUMMARY We examined the role of radical nephroureterectomy in addition to systemic chemotherapy for metastatic upper tract urothelial carcinoma. We found that such treatment may be associated with an overall survival benefit compared to chemotherapy alone in fit patients.

Small renal masses in the elderly: Contemporary treatment approaches and comparative oncological outcomes of nonsurgical and surgical strategies

Over the last decades, there has been a significant stage migration in renal cell carcinoma and especially older patients are getting diagnosed more frequently with low stage disease, such as small renal masses ≤4 cm of size. Considering the particular risk profile of an older population, often presenting with a nonnegligible comorbidity profile and progressive renal dysfunction, treatment approaches beyond aggressive radical surgical procedures have come to the fore. We sought to give a contemporary overview of the available different treatment strategies for incidental small renal masses in an elderly population with the focus on comparative oncological outcomes of nonsurgical and surgical modalities.

Surgical Training in the Robotic Surgery Era: The Importance of Structured Programs

Our generation is witnessing a technological evolution taking place in surgical practice in general and in the field of urology in particular. The introduction of robotic surgery has been an important advancement that is now widely accepted by patients as well by surgeons. The need of the hour is for optimally trained urologists who can effectively operate on the robotic platform. In this issue of the European Urology Focus, Lovegrove et al. addressed the very pertinent issue of training and assessment in robotic surgery [1]. They evaluated the validity, impact, effectiveness, and acceptability of various training modules available for robotic surgery. As with any new skill acquisition, robotic surgery has a learning curve that every surgeon will go through during the training period before becoming proficient in the technique. Several reports have demonstrated that increased experience and higher surgical volumes are associated with more favorable outcomes, such us lower postoperative complications, shorter operation time, minimal blood loss, lower readmission rates, lower costs, and better cancer control [2,3]. Another way in which this can be interpreted is that less experienced surgeons with lower surgical volumes have suboptimal outcomes. Mentoring new surgeons during the early phase of their learning curve is of the utmost importance to ensure patient safety, which is the most important factor and eventually determines the medicolegal sustainability of the technique. Traditionally, the method of training has been a mentored surgical apprenticeship; however, the system of presuming that skill acquisition is based on time spent under apprenticeship and subjective evaluation of skill acquisition has been challenged [4]. The contemporary

Efficacy of Local Treatment in Prostate Cancer Patients with Clinically Pelvic Lymph Node-positive Disease at Initial Diagnosis

BACKGROUND There is limited evidence supporting the use of local treatment (LT) for prostate cancer (PCa) patients with clinically pelvic lymph node-positive (cN1) disease. OBJECTIVE To examine the efficacy of any form of LT±androgen deprivation therapy (ADT) in treating these individuals. DESIGN, SETTING, AND PARTICIPANTS Using the National Cancer Database (2003-2011), we retrospectively identified 2967 individuals who received LT±ADT versus ADT alone for cN1 PCa. Only radical prostatectomy (RP) and radiation therapy (RT) were considered as definitive LT. INTERVENTION LT±ADT versus ADT alone. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Instrumental variable analyses (IVA) were performed using a two-stage residual inclusion approach to compare overall mortality (OM)-free survival between patients who received LT±ADT versus ADT alone. The same methodology was used to further compare OM-free survival between patients who received RP±ADT versus RT±ADT. RESULTS AND LIMITATIONS Overall, 1987 (67%) and 980 (33%) patients received LT±ADT and ADT alone, respectively. In the LT±ADT group, 751 (37.8%) and 1236 (62.2%) patients received RP±ADT and RT±ADT, respectively. In IVA, LT±ADT was associated with a significant OM-free survival benefit (hazard ratio=0.31, 95% confidence interval [CI]=0.13-0.74, p=0.007), when compared with ADT alone. At 5 yr, OM-free survival was 78.8% (95% CI: 74.1-83.9%) versus 49.2% (95% CI: 33.9-71.4%) in the LT±ADT versus ADT alone groups. When comparing RP±ADT versus RT±ADT, IVA showed no significant difference in OM-free survival between the two treatment modalities (hazard ratio=0.54, 95% CI=0.19-1.52, p=0.2). Despite the use of an IVA, our study may be limited by residual unmeasured confounding. CONCLUSIONS Our findings show that PCa patients with clinically pelvic lymph node-positive disease may benefit from any form of LT±ADT over ADT alone. While not necessarily curative by itself, the use of RP or RT could be the first step in a multi-modality approach aiming at providing the best cancer control outcomes for these individuals. PATIENTS SUMMARY We examined the role of local treatment for clinically pelvic lymph node-positive prostate cancer. We found that the delivery of radical prostatectomy or radiation therapy may be associated with an overall mortality-free survival benefit compared with androgen deprivation therapy alone.

Improved survival with local treatment of prostate cancer in men with metastatic disease: Look before you leap

TO THE EDITOR: In the recent report by Rusthoven et al that analyzed the overall survival (OS) outcomes for patients with metastatic prostate cancer (mPCa) treated with androgen deprivation therapy (ADT) alone versus prostate radiation therapy (RT) plus ADT, all data were derived from the National Cancer Data Base (NCDB) between 2004 and 2012. The authors found that prostate RT plus ADT is associated with significantly improved 5-year OS compared with ADT alone (49% v 33%; hazard ratio [HR], 0.67; P , .001) after accounting for available covariates. We recently performed a comprehensive analysis of the impact of local treatment (LT; radical prostatectomy [20%] or RT [80%]) versus no LT (defined as ADT alone [69%], watchful waiting [22%], or external-beam RT not targeted to the prostate [9%]) in men with mPCa recorded in the NCDB between 2004 and 2012 and noted an OS benefit in patients treated with LT versus no LT (3-year OS, 69% v 54%; HR, 0.60; P , .001) with no difference between radical prostatectomy and RTon OS. As such, Rusthoven et al corroborate these results. These findings highlight the growing and rapidly evolving paradigm for local treatment of mPCa, the mainstay of treatment of which has traditionally been ADT. However, some key areas in the analyses by Rusthoven et al need attention before the results of their study are generalized to the average patient with mPCa. Perhaps most importantly, Rusthoven et al did not incorporate baseline risk factors in quantitatively estimating the survival benefit of RT plus ADT. As we have shown, the impact of LT on OS in patients with mPCa is governed by preoperative tumor (biopsy; Gleason score; clinical T, N, and M stage) and patient characteristics (age, Charlson comorbidity index), and we created a novel risk calculator that is based on these factors to quantify the baseline risk of overall mortality (as shown in the data supplement of our article). Of note, for patients with a predicted mortality of. 70%, LT did not significantly improve OS. Although Rusthoven et al performed a classification and regression tree analysis, the latter creates distinct prognostic groups based on OS but does not quantify risk of mortality or provide a cutoff that demarcates when a patient will cease to benefit from LT. Furthermore, although the end point was OS (as opposed to PCa-specific survival), the authors did not include two important covariates: comorbidity status and M stage. These variables were included in our risk calculator and were the strongest predictors of OS in our analyses. The lack of adjustment for these variables can significantly limit the generalizability and clinical utility of the classification and regression tree model as proposed by Rusthoven et al because these variables represent an intrinsic part of the clinical assessment of patients presenting with mPCa and may be critical determinants of survival outcomes. Rusthoven et al also explored the effect of adding RT to ADT in treating patients with mPCa. Although a comparison of the effect of the addition of LT to the standard of care (ie, ADT) seems plausible, a significant proportion of patients with mPCa (31% in our analyses) may undergo watchful waiting for their disease or receive palliative RT for bony metastases. Why these patients were excluded in the study by Rusthoven et al is not entirely clear. Indeed, subgroup analyses would be useful in identifying which patients are likely to benefit the most from the addition of RT directed to the prostate and would increase the generalizability of the findings. Finally, the effect of the site of metastases was not quantified, which represents a key limitation of the study design. Contrary to the authors’ claim, the NCDB does record site of metastases at diagnosis through the Collaborative Staging system derived from the American Joint Committee on Cancer, 6th (2004 to 2009) and 7th (2010 to 2016) editions. In our analyses we observed that the majority of men with mPCa harbor M1b stage, which indicates bony metastases. Our Cox proportional hazards model showed M1a stage to be associated with a significantly lower risk of mortality (HR, 0.67; P , .001) compared with M1b disease. Conversely, there was no significant difference in mortality between M1c (HR, 1.08; P5 .3) and M1b stages. Furthermore, the CHAARTED (Chemohormonal Therapy Versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer) trial suggested that men with bony metastases might derive greater benefit from the addition of systemic chemotherapy to ADT (compared with other sites). Given these findings, it would have been interesting to study the survival benefit (if any) of RT plus ADT in patients with various sites of metastases or in those who receive chemotherapy with ADT. Such a study might provide further insight into the OS benefit of radiating the primary tumor site along with systemic ADT. The real impact of primary tumor control in patients with mPCa will be verified in ongoing randomized (clinical trial information: NCT02454543) and nonrandomized (clinical trial information: NCT02458716, NCT02138721) prospective studies. Although observational studies seem to support the beneficial role of LT for prostate cancer in such settings, physicians must identify the optimal candidates for such an approach.

Emergency Department Utilization in Patients With Neurogenic Bladder: Contemporary Burden and National Trends in Prevalence, Inpatient Admission, and Associated Charges, 2006-2011

OBJECTIVE To quantify the national burden of neurogenic bladder disease, a chronic debilitating condition associated with frequent hospital visits, in the contemporary emergency care setting. METHODS Relying on the Nationwide Emergency Department Sample, 2006-2011, we abstracted patients presenting to the emergency department (ED) with neurogenic bladder utilizing International Classification of Diseases, Ninth Revision (ICD-9) codes. National trends in ED presentation, subsequent inpatient admission vs discharge, and associated charges were examined using the estimated annual percent change methodology. RESULTS Over the study period, a total of 875,066 patients with neurogenic bladder were seen in the ED, of which 538,532 (61.5%) were admitted. Total and median ED charges increased at an annual rate of 36.66% (P <.001) and 13.24% (P <.001), respectively, with total ED charges amounting to 87.48 million USD in the year 2011. Annual ED utilization also increased, although at a slower rate, 1.89% (P = .017). Inpatient admissions decreased at an annual rate of 3.67% (P <.001), whereas the use of long-term care facilities increased at 11.82% (P = .005). CONCLUSION Total ED charges are increasing at a dramatic rate, driven by the increasing utilization of the ED as an entry point to health care as well as the increasing per-visit charges. Encouragingly, the rates of inpatient admission are decreasing, likely secondary to improved triaging in the ED and increased utilization of long-term care facilities. It remains to be seen, however, whether the increased spending in the ED for better triaging and investment in long-term care facilities will translate into an overall economic benefit by reducing inpatient charges or not.

State-by-state Variation in Prostate-specific Antigen Screening Trends Following the 2011 United States Preventive Services Task Force Panel Update

OBJECTIVE To evaluate state-by-state trends in prostate-specific antigen (PSA) screening prevalence after the 2011 United States Preventive Services Task Force (USPSTF) recommendation against this practice. METHODS We included 222,475 men who responded to the Behavioral Risk Factor Surveillance System 2012 and 2014 surveys, corresponding to early and late post-USPSTF populations. Logistic regression was used to identify predictors of PSA screening and to calculate the adjusted and weighted state-by-state PSA screening prevalence and respective relative percent changes between 2012 and 2014. To account for unmeasured factors, the correlation between changes in PSA screening over time and changes in screening for colorectal and breast cancer were assessed. All analyses were conducted in 2016. RESULTS Overall, 38.9% (95% confidence interval [CI] = 38.6%-39.2%) reported receiving PSA screening in 2012 vs 35.8% (95% CI = 35.1%-36.2%) in 2014. State of residence, age, race, education, income, insurance, access to care, marital status, and smoking status were independent predictors of PSA screening in both years (all P <.001). In adjusted analyses, the nationwide PSA screening prevalence decreased by a relative 8.5% (95% CI = 6.4%-10.5%; P <.001) between 2012 and 2014. There was a vast state-by-state heterogeneity, ranging from a relative 26.6% decrease in Vermont to 10.2% increase in Hawaii. Overall, 81.5% and 84.0% of the observed changes were not accompanied by matching changes in respective colorectal and breast cancer screening utilization, for which there were no updates in USPSTF recommendations. CONCLUSION There is a significant state-by-state variation in PSA screening trends following the 2011 USPSTF recommendation. Further research is needed to elucidate the reasons for this heterogeneity in screening behavior among the states.