Major Urologic Cancer Surgery Research Articles

Prognostic Impact of Each Item of the SARC-F Questionnaire in Patients Undergoing Major Surgery for Urologic Cancer.

We aimed to evaluate the association between scores on each item of the SARC-F questionnaire and life expectancy in patients undergoing major surgery for urologic cancer. This retrospective study included 1018 patients undergoing elective major urologic cancer surgery. All patients completed the SARC-F questionnaire preoperatively. Demographic and clinical data were collected. The primary endpoint was an association between SARC-F scores and overall survival (OS). Of the 1018 patients, the median age was 72 years and 920 (90%) were male. Multivariate analysis revealed four factors significantly and independently associated with shorter OS: assistance with walking score ≥1 (Hazard ratio: HR=2.18, P=0.044), cancer stages ≥ III (HR=7.98, P<0.001), high blood loss ≥78 ml or blood transfusion during surgery (HR=4.53, P=0.007 and HR=2.41, P=0.037, respectively). This study found that among the items of the SARC-F questionnaire, assistance with walking was a strong predictor of life expectancy. Incorporating such a simple screening tool into the preoperative assessment would help to ensure more appropriate perioperative care for urologic cancer patients.

Editorial Comment on “Teaching Hospitals and Textbook Outcomes After Major Urologic Cancer Surgery”

Editorial Comment on “Teaching Hospitals and Textbook Outcomes After Major Urologic Cancer Surgery”

Teaching Hospitals and Textbook Outcomes After Major Urologic Cancer Surgery

ObjectivesTo assess textbook outcomes by hospital teaching status follow major surgery for genitourinary malignancies. MethodsWe used 100% national Medicare Provider Analysis and Review files from 2017-2020 to assess rates of textbook outcomes in undergoing bladder (i.e., radical cystectomy), kidney (i.e., radical or partial nephrectomy), and prostate (i.e., radical prostatectomy) surgery for genitourinary malignancies. The extent of integration of learners into each hospital’s workforce—defined as major, minor and non- teaching—was the primary exposure. A textbook outcome, measured at the patient level, was defined as the absence of in-hospital mortality and mortality within 30 days of surgery, no readmission 30 days following discharge, no postoperative complication, and no prolonged length of stay. ResultsTextbook outcomes were achieved in 51% (8,564/16,786) of patients after bladder cancer surgery, 70% (39,938/57,300) of patients after kidney cancer surgery, and 82% (50,408/61,385) of patients after prostate cancer surgery. After adjusting for patient- and hospital-level characteristics, teaching hospitals had higher rates of textbook outcomes in those undergoing bladder (50.7% vs 44.0%; p = 0.001), kidney (72.0% vs 69.7%; p = 0.02), and prostate (85.3% vs 81.0%; p < 0.001) surgery. This effect was attenuated, but not eliminated, by surgical volume in additional sensitivity analyses for bladder (OR: 1.20, 95% CI: 1.00 -1.42; p = 0.04) and prostate (OR: 1.15, 95% CI: 1.00-1.32; p = 0.04) surgery. There were no significant differences in kidney cancer surgery outcomes after adjusting for hospital volume (OR: 1.03, 95% CI: 0.93 – 1.14; p = 0.6). ConclusionsUndergoing major cancer surgery at a teaching hospital was associated with an increased likelihood of receiving a textbook outcome. This effect was attenuated by volume but persisted for bladder and prostate surgery.

Value of Flemish Version of the Triage Risk Screening Tool in Predicting Unfavorable Outcomes after Elective Cancer Surgery: A Propensity Score-Matched Retrospective Cohort Study

Introduction: The Flemish version of the Triage Risk Screening Tool (fTRST), derived from the Triage Risk Screening Tool for assessing risk of readmission to the emergency department, is increasingly used as a simple screening tool in oncology. This study aimed to evaluate the utility of the fTRST in the context of elective surgical treatment for urologic cancer patients. Methods: We included 886 patients who underwent major urologic cancer surgery at our institution between 2020 and 2022 and underwent preoperative screening, including fTRST. We set the fTRST cutoff at 2 and used propensity score matching and multivariate regression analysis to assess how fTRST affected two postoperative outcomes: ambulation failure and delirium. Results: Of the 886 patients, 693 (78%) had an fTRST score <2, and 193 (22%) had an fTRST score ≥2 (high likelihood of frailty). After matching the groups by propensity scores, we compared the outcomes of 131 patients in each group. We found that the group with fTRST ≥2 had significantly higher rates of ambulation failure (15 vs. 11%, p = 0.03) and delirium (16 vs. 11%, p = 0.008) than the group with fTRST <2. Multivariate logistic regression analysis showed that fTRST score ≥2 was an independent risk factor for postoperative ambulation failure (odds ratio [OR] = 4.05, p = 0.02), along with age ≥75 years (OR = 6.62, p = 0.02), preoperative benzodiazepine medications (OR = 5.12, p = 0.01), and receiving radical cystectomy (OR = 9.30, p = 0.02). Similarly, for delirium, fTRST score ≥2 was an independent risk factor (OR = 2.88, p = 0.03), along with preoperative benzodiazepine medications (OR = 4.38, p = 0.002). Conclusion: The fTRST might be a screening tool with great potential for identifying patients at high risk for unfavorable postoperative outcomes in elective urologic cancer surgery.

An exploratory study on the heterogeneity of postoperative delirium: Preoperative cognitive screening does not detect hallucinatory delirium risk

IntroductionThis study compared the clinical characteristics of patients who had hallucinations and those who did not during delirium after elective cancer surgery. Materials and methodsThis study retrospectively observed 1137 consecutive patients who had preoperative screening by a trained nurse before elective major urologic cancer surgery in our department. We compared the patient characteristics, including mini-cognitive assessment instrument (Mini-Cog) and Geriatric-8 (G8) scores, between those who developed postoperative delirium and those who did not, and also between those who had hallucinations and those who did not during delirium. ResultsOut of 1137 patients, 68 developed postoperative delirium, and 12 of them had hallucinations. A hierarchical cluster analysis based on the G8 and Mini-Cog scores divided the patients into two groups: one with high G8 and cognitive function (36 patients) and one with low G8 and cognitive function (32 patients). Hallucinations during delirium were more frequent in the high G8 and cognitive function group (11 out of 36 patients) than in the low G8 and cognitive function group (one out of 32 patients). Patients who had hallucinations during delirium also had higher preoperative Mini-Cog scores (P = 0.002) and G8 scores (P = 0.03) than those who did not, indicating better cognitive function and less frailty. DiscussionsWe identified a patient population that is prone to hallucinations that preoperative screening tools cannot detect. This suggests the heterogeneity of postoperative delirium and the need for further research.

In-Hospital Venous Thromboembolism and Pulmonary Embolism After Major Urologic Cancer Surgery

BackgroundThis study aimed to test for temporal trends of in-hospital venous thromboembolism (VTE) and pulmonary embolism (PE) after major urologic cancer surgery (MUCS).MethodsIn the Nationwide Inpatient Sample (NIS) database (2010–2019), this study identified non-metastatic radical cystectomy (RC), radical prostatectomy (RP), radical nephrectomy (RN), and partial nephrectomy (PN) patients. Temporal trends of VTE and PE and multivariable logistic regression analyses (MLR) addressing VTE or PE, and mortality with VTE or PE were performed.ResultsOf 196,915 patients, 1180 (1.0%) exhibited VTE and 583 (0.3%) exhibited PE. The VTE rates increased from 0.6 to 0.7% (estimated annual percentage change [EAPC] + 4.0%; p = 0.01). Conversely, the PE rates decreased from 0.4 to 0.2% (EAPC − 4.5%; p = 0.01). No difference was observed in mortality with VTE (EAPC − 2.1%; p = 0.7) or with PE (EAPC − 1.2%; p = 0.8). In MLR relative to RP, RC (odds ratio [OR] 5.1), RN (OR 4.5), and PN (OR 3.6) were associated with higher VTE risk (all p < 0.001). Similarly in MLR relative to RP, RC (OR 4.6), RN (OR 3.3), and PN (OR 3.9) were associated with higher PE risk (all p < 0.001). In MLR, the risk of mortality was higher when VTE or PE was present in RC (VTE: OR 3.7, PE: OR 4.8; both p < 0.001) and RN (VTE: OR 5.2, PE: OR 8.3; both p < 0.001).ConclusionsRC, RN, and PN predisposes to a higher VTE and PE rates than RP. Moreover, among RC and RN patients with either VTE or PE, mortality is substantially higher than among their VTE or PE-free counterparts.

The significance of SARC-F scores in predicting postoperative outcomes of older adults undergoing elective major surgery for urologic cancer

Recently, the strength, assistance with walking, rise from a chair, climb stairs, and falls (SARC-F) questionnaire has been developed to screen patients with signs of sarcopenia. However, its clinical benefit remains uncertain in elderly patients undergoing elective major surgeries. This study aimed to explore the role of the SARC-F questionnaire as a screening tool for patients who plan to undergo elective major surgery for urologic cancer and to also evaluate correlations of SARC-F scores with established indicators of sarcopenia. This retrospective observational study enrolled 815 patients over 40 years of age undergoing elective major surgery for urologic cancer and who were screened with the SARC-F questionnaire, preoperatively. The primary endpoint was an association between SARC-F scores and postoperative ambulation failure. Here we define postoperative ambulation failure as a condition where a patient is unable to walk independently within 2 days after surgery and required physical rehabilitation or was transferred to other hospitals in a bedridden state. The secondary endpoint was an association between SARC-F scores and overall survival (OS). Psoas muscle density (PMD) and psoas muscle index (PMI) were calculated from abdominal computed tomography images, and their correlations with SARC-F scores grouped by sex. Of the 815 patients, 738 (91%) were male and the median age was 72 years. Although SARC-F scores weakly correlated with PMD in males and moderately correlated in females (ρ=-0.222 and ρ=-0.474, respectively), their correlation with PMI was negligible (ρ=-0.179 and ρ=-0.084, respectively). SARC-F scores successfully discriminate postoperative ambulation failure in both males and females with the respective area under the receiver operating characteristic curve of 0.856 and 0.813. Multivariate analysis also showed that SARC-F scores greater than 4 are an independent risk factor of postoperative ambulation failure along with older age, lower PMD, and poor performance status. SARC-F scores greater than 4 were significantly associated with a shorter OS in the whole cohort (P<0.001) and a subgroup of patients undergoing radical cystectomy (P=0.03; median follow-up of 515 days). The SARC-F questionnaire might be applicable to identify elderly patients at a higher risk of unfavourable outcomes after major urologic cancer surgery. A randomised controlled trial is necessary to confirm this finding.

Changes in Urologic Cancer Surgical Volume and Length of Stay During the COVID-19 Pandemic in Pennsylvania

Disruptions in cancer surgery during the COVID-19 pandemic led to widespread deferrals and cancellations, creating a surgical backlog that presents a challenge for health care institutions moving into the recovery phase of the pandemic. To describe patterns in surgical volume and postoperative length of stay for major urologic cancer surgery during the COVID-19 pandemic. This cohort study identified 24 001 patients 18 years or older from the Pennsylvania Health Care Cost Containment Council database with kidney cancer, prostate cancer, or bladder cancer who received a radical nephrectomy, partial nephrectomy, radical prostatectomy, or radical cystectomy between the first quarter (Q1) of 2016 and Q2 of 2021. Postoperative length of stay and adjusted surgical volumes were compared before and during the COVID-19 pandemic. The primary outcome was adjusted surgical volume for radical and partial nephrectomy, radical prostatectomy, and radical cystectomy during the COVID-19 pandemic. The secondary outcome was postoperative length of stay. A total of 24 001 patients (mean [SD] age, 63.1 [9.4] years; 3522 women [15%], 19 845 White patients [83%], 17 896 living in urban areas [75%]) received major urologic cancer surgery between Q1 of 2016 and Q2 of 2021. Of these, 4896 radical nephrectomy, 3508 partial nephrectomy, 13 327 radical prostatectomy, and 2270 radical cystectomy surgical procedures were performed. There were no statistically significant differences in patient age, sex, race, ethnicity, insurance status, urban or rural status, or Elixhauser Comorbidity Index scores between patients who received surgery before and patients who received surgery during the pandemic. For partial nephrectomy, a baseline of 168 surgeries per quarter decreased to 137 surgeries per quarter in Q2 and Q3 of 2020. For radical prostatectomy, a baseline of 644 surgeries per quarter decreased to 527 surgeries per quarter in Q2 and Q3 of 2020. However, the likelihood of receiving radical nephrectomy (odds ratio [OR], 1.00; 95% CI, 0.78-1.28), partial nephrectomy (OR, 0.99; 95% CI, 0.77-1.27), radical prostatectomy (OR, 0.85; 95% CI, 0.22-3.22), or radical cystectomy (OR, 0.69; 95% CI, 0.31-1.53) was unchanged. Length of stay for partial nephrectomy decreased from baseline by a mean of 0.7 days (95% CI, -1.2 to -0.2 days) during the pandemic. This cohort study suggests that partial nephrectomy and radical prostatectomy surgical volume decreased during the peak waves of COVID-19, as did postoperative length of stay for partial nephrectomy.

Re: Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery

Re: Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery

Implementation and Assessment of No Opioid Prescription Strategy at Discharge After Major Urologic Cancer Surgery

Postoperative opioid prescriptions are associated with delayed recovery, perioperative complications, opioid use disorder, and diversion of overprescribed opioids, which places the community at risk of opioid misuse or addiction. To assess a protocol for eliminating postdischarge opioid prescriptions after major urologic cancer surgery. This cohort study of the no opioid prescriptions at discharge after surgery (NOPIOIDS) protocol was conducted between May 2017 and June 2021 at a tertiary referral center. Patients undergoing open or minimally invasive radical cystectomy, radical or partial nephrectomy, and radical prostatectomy were sorted into the control group (usual opioids), the lead-in group (reduced opioids), and the NOPIOIDS group (no opioid prescriptions). The NOPIOIDS group received a preadmission educational handout, postdischarge instructions for using nonopioid analgesics, and no routine opioid prescriptions. The lead-in group received a postdischarge instruction sheet and reduced opioid prescriptions at prescribers' discretion. The control group received opioid prescriptions at prescribers' discretion. Primary outcome measures included rate and dose of opioid prescriptions at discharge and for 30 days postdischarge. Additional outcome measures included patient-reported pain and satisfaction level, unplanned health care utilization, and postoperative complications. Of 647 opioid-naive patients (mean [SD] age, 63.6 [10.0] years; 478 [73.9%] male; 586 [90.6%] White), the rate of opioid prescriptions at discharge for the control, the lead-in, and the NOPIOIDS groups was 80.9% (157 of 194), 57.9% (55 of 95), and 2.2% (8 of 358) (Kruskal-Wallis test of medians: P < .001), and the overall median (IQR) tablets prescribed was 14 (10-20), 4 (0-5.3), and 0 (0-0) per patient in the control, lead-in, and NOPIOIDS groups, respectively (Kruskal-Wallis test of medians: P < .001). In the NOPIOIDS group, median and mean opioid dose was 0 tablets for all procedure types, with the exception of kidney procedures (mean [SD], 0.5 [1.7] tablets). Patient-reported pain surveys were received from 358 patients (72.6%) in the NOPIOIDS group, demonstrating low pain scores (mean [SD], 2.5 [0.86]) and high satisfaction scores (mean [SD], 86.6 [3.8]). There was no increase in postoperative complications in the group with no opioid prescriptions. This perioperative protocol, with emphasis on nonopioid alternatives and patient instructions, may be safe and effective in nearly eliminating the need for opioid prescriptions after major abdominopelvic cancer surgery without adversely affecting pain control, complications, or recovery.

Ability of clock drawing errors on Mini-Cog test to predict development of delirium after major urological cancer surgery

Abstract Background This study aimed to evaluate the impact of the clock drawing test (CDT) on postoperative delirium and compare the abilities of the mini-cognitive (Mini-Cog) test and the CDT for predicting postoperative delirium after major urological cancer surgery. Materials and methods In this single-center retrospective observational study, we collected the medical records of patients who underwent major urologic cancer surgery and preoperative cognitive screening based on the Mini-Cog test consisting of the CDT and the 3-word recall task at our department in 2020–2021 (n = 387). Univariate and multivariate logistic regression analyses were used to identify the clinical risk factors for postoperative delirium. We also compared the ability of the CDT alone and the Mini-Cog test consisting of the CDT and 3-word recall task to predict postoperative delirium. Results A total of 117 patients (30%) had abnormal CDT results. Postoperative delirium occurred in 29 patients (7%). On multivariate analysis, American Society of Anesthesiologists physical status ≥3 (odds ratio [OR], 5.0; p = 0.01), abnormal CDT (OR, 4.8; p &lt; 0.001), preoperative benzodiazepine use (OR, 4.9; p &lt; 0.001), and operative time ≥237 minutes (OR, 3.0; p = 0.01) were independent risk factors for postoperative delirium. The area under the curve for predicting postoperative delirium was 0.709 for CDT alone and 0.743 for the Mini-Cog test. No significant intergroup difference was observed (p = 0.43). Conclusions The CDT served as a formal but simple tool with adequate predictive power to identify the risk of postoperative delirium among patients undergoing major urological cancer surgery. Effective screening using the CDT might help provide optimal urological care for older patients.

Predictive value of the G8 and the IADL-modified G8 screening tools for postoperative delirium following major urological cancer surgery

IntroductionThe purpose of this study was to evaluate whether the Geriatric-8 (G8) and the instrumental activities of daily living (IADL)-modified G8 are associated with the occurrence of postoperative delirium after major urological cancer surgery. Materials and MethodsWe retrospectively analyzed a total of 415 consecutive patients who underwent major urologic cancer surgery and were screened preoperatively using the G8 and the IADL-modified G8 at our institution between January 2020 and July 2021. For both the G8 and the IADL-modified G8, a cut-off value of 14 was used. All patients underwent perioperative management according to the Enhanced Recovery After Surgery protocol formulated at our institution. Delirium was diagnosed using the Confusion Assessment Method. The relationship between these screening tests and clinical variables was examined. Predictive accuracy was evaluated by the area under the receiver operating characteristic curve (AUC). To determine the risk factors for the occurrence of postoperative delirium, univariate and multivariate analyses were performed. ResultsOf the 415 patients, 160 (39%) were assigned to the low G8 (score ≤ 14) group and 166 (40%) to the low IADL-modified G8 (score ≤ 14) group. The median age of the patients was 72 years. Postoperative delirium occurred in 31 patients (7%). The AUC values for predicting postoperative delirium were 0.69 for the G8 and 0.71 for the IADL-modified G8. Multivariate analysis for the G8 showed that G8 ≤ 14 (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.2–6.0; P = 0.02), preoperative use of benzodiazepine (OR = 3.8; 95% CI = 1.6–8.6; P = 0.002), and operative time ≥ 237 min (OR = 3.3; 95% CI = 1.5–7.1; P = 0.003) were independent risk factors for postoperative delirium. Similarly, for the IADL-modified G8, IADL-modified G8 ≤ 14 (OR = 2.6; 95% CI = 1.1–5.8; P = 0.02), preoperative use of benzodiazepine (OR = 3.9; 95% CI = 1.7–8.8; P = 0.001), and operative time ≥ 237 min (OR = 3.3; 95% CI = 1.5–7.2; P = 0.003) were independent risk factors for postoperative delirium. DiscussionThe G8 and the IADL-modified G8 screening may allow for better identification of patients at risk of postoperative delirium.

The Mini-Cog: A simple screening tool for cognitive impairment useful in predicting the risk of delirium after major urological cancer surgery.

The purpose of this study was to evaluate the impact of the mini-cognitive assessment instrument (Mini-Cog) on postoperative delirium after major urological cancer surgery. In this single-center retrospective observational study, medical records were collected for patients who underwent major urologic cancer surgery at our department between 2020 and 2021, and underwent preoperative cognitive screening based on the Mini-Cog test (n=331). The probable cognitive impairment is defined as a Mini-Cog score of <3. Univariate and multivariate logistic regression analysis were used to identify the risk factors for postoperative delirium. Patients with probable cognitive impairment were 60 (18%). Postoperative delirium occurred in 26 patients (8%). Using multivariate analysis, the Mini-Cog score of <3 (odds ratio [OR]=12.7; P < 0.001), decline of instrumental activities of daily living (OR=3.0; P=0.04) and preoperative benzodiazepine use (OR=8.3; P < 0.001) were independent risk factors for postoperative delirium. For predicting postoperative delirium, Mini-Cog score with a cutoff value of <3 granting sensitivity of 69.2%, specificity of 86.2%, positive predictive value of 30.0% and negative predictive value of 97.1%. The Mini-Cog test is a simple screening tool with only two components (a delayed, three-word recall task and a clock drawing test): it is useful in identifying potential cases of cognitive decline and patients at risk for postoperative delirium along with other information routinely collected preoperatively. Effective screening using the Mini-Cog test opens the possibility to provide optimal urologic care for older patients Geriatr Gerontol Int 2022; 22: 319-324.

Racial Disparities in Surgical Outcomes Among Males Following Major Urologic Cancer Surgery

Disparities in healthcare outcomes between races have been extensively described; however, studies fail to characterize the contribution of differences in distribution of covariates between groups and the impact of discrimination. This study aims to characterize the degree to which clinicodemographic factors and unmeasured confounders are contributing to any observed disparities between non-Hispanic white and black males on surgical outcomes after major urologic cancer surgery. Non-Hispanic white and black males undergoing radical cystectomy, nephrectomy, or prostatectomy for cancer in the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2016 were included in this analysis. The outcome of interest was Clavien III-V complications. Analysis was conducted in 2017 using the Peters-Belson method to compare the disparity in outcomes while adjusting for 13 important demographic and clinical characteristics. Of the 15,693 cases included with complete data, 13.0% (n=2,040) were black. There was a significantly increased rate of unadjusted Clavien III and V complications between white versus black males for radical cystectomy (21.9% vs 10.1%, p=0.005); nephrectomy (6.4% vs 3.9%, p=0.028); and radical prostatectomy (2.3% vs 1.6%, p=0.046). Adjusting for differences in age, BMI, American Society of Anesthesiologists score, functional status, smoking history, and comorbidities including diabetes, chronic obstructive pulmonary disease, heart failure, renal failure, bleeding disorder, steroid use, unintentional weight loss, and hypertension between the groups could not explain the disparity in complications after radical cystectomy; the unexplained discrepancy was an absolute excess of 11.8% (p=0.01) in black males. There was an unexplained excess of complications in black males undergoing radical prostatectomy and nephrectomy but neither reached statistical significance. Black males undergoing radical cystectomy for cancer experienced higher complication rates than white males. Unexplained differences between the black and white males significantly contributed to the disparity in outcomes, which suggests that unmeasured factors, such as the quality of surgical or perioperative care, are playing a considerable role in the observed inequality. This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

Frailty and Greater Health Care Resource Utilization Following Major Urologic Oncology Surgery

BackgroundIn the setting of value-based care, it is critical to improve our understanding of surgical risk and greater health care resource utilization (HRU) as it relates to frailty. ObjectiveTo evaluate the impact of frailty on HRU and surgical morbidity in urologic oncology surgery using the five-item frailty index. Design, setting, and participantsA retrospective cohort study was conducted using subjects from the 2012–2016 American College of Surgeons National Surgical Quality Improvement Program who underwent radical cystectomy or minimally invasive or open radical prostatectomy, radical nephrectomy, or partial nephrectomy. Outcome measurements and statistical analysisMultivariable logistic regression was performed to determine the association between frailty index and any increase in HRU, which was defined as prolonged length of stay greater than the 75th percentile, discharge to continued care, or unplanned readmission within 30 d. Results and limitationsIn the overall cohort of 92 999 subjects and within each surgery type, increasing frailty score was associated with significant stepwise increases in HRU. Logistic regression adjusting for patient demographics revealed statistically significant odds ratios of 1.2 (95% confidence interval [CI] 1.2–1.3; p<0.001), 1.5 (95% CI 1.4–1.6; p<0.001), and 2.0 (95% CI 1.8–2.1; p<0.001) at frailty indices of 1, 2, and ≥3, respectively, for increased HRU relative to no frailty. In subanalyses, each categorical increase in frailty index was independently associated with prolonged length of stay, more discharges to continued care, and unplanned readmission. Increasing frailty score was associated with increasing rates of any complication and serious complications within each surgery type. The analysis is limited by the retrospective design and available data within a large hospital-based database. ConclusionsFrailty in major urologic oncology surgery is associated with greater HRU and surgical morbidity. Patient summaryWe assessed the impact of frailty on greater health care resource utilization and complications after major urologic cancer surgery in a large US population. With each increase in a frailty score, there was an increase in the likelihood of having complications, prolonged hospital stay, more discharges to continued care, and unplanned readmissions within 30 d.

Incidence and predictors of mortality following major urologic cancer surgery.

435 Background: Mortality following major urologic cancer surgery is a significant outcome to patients and providers. We utilized a population based cohort to test the hypothesis that the nature and number of perioperative complications impact the probability of mortality in major urologic surgery. Methods: Using the Premier Hospital Database we identified patients that underwent major urologic cancer surgery: radical prostatectomy (RP), radical nephrectomy (RN), or radical cystectomy (RC). Ninety-day complications were captured using ICD9 codes and complications were categorized according to the Agency for Healthcare Research and Quality Clinical Classification categories. The primary outcome was predicted probability of perioperative morality. Adjusted regression models were used and analyses were survey weighted. Models were adjusted for patient, hospital, and surgery characteristics, and we examined the predicted probability of mortality in three scenarios (no complication, index complication, or readmission complication). Results: From 2005-2013 we identified 630 828 RP, 306 532 RN, and 57 533 RC patients. At 90 days, 14.2% of RP patients had a complication, compared to 39% of RN patients and 68.3% of RC patients. Readmission rates at 90 days for RP were 1.9%, 5.9% for RN, and 19.9% for RC. For RN and RC the presence of a complication resulting in readmission compared to an index complication nearly doubled the predicted probability of mortality (RN 1.7% to 3.6%, and RC 3.9% to 6.8%). The number of complications during the index stay and on readmission compounded the impact on mortality. For RN and RC, 1 complication vs. 4 complications resulted in a nearly 3-fold increase in predicted probability of mortality. The nature of complications varied by incidence however, the three most common complications that resulted in the greatest increase in predicted probability of mortality across all three operations included pulmonary, cardiac, and renal complications. Conclusions: The number and nature of complications after major urologic cancer surgery impact the predicted probability of perioperative mortality and such data may be used to counsel patients when providing urologic cancer care.

The impact of readmission hospital on failure-to-rescue rates following major urologic cancer surgery

PurposePatients readmitted to secondary hospitals rather than the primary hospital where their surgery took place may be at risk for poorer outcomes. We sought to evaluate the effect of site of readmission on failure-to-rescue complication rates following urologic cancer surgery. Materials and methodsRetrospective review of major urologic cancer surgeries in the Washington State Comprehensive Hospital Abstract Reporting System between 1998 and 2013. Failure-to-rescue (FTR) rates, defined as inpatient death after a complication requiring hospital readmission, were compared between patients readmitted to their primary hospital with those readmitted to a secondary hospital. Multivariable logistic regression (MVA) models evaluated the association between readmission site and FTR. ResultsOf 31,498 eligible patients, 3,113 patients were readmitted to hospital within 90 days of surgery, of whom 29.2% were readmitted to a secondary hospital. The highest FTR rates were following cardiac (11.6%), respiratory (11.2%), and sepsis-related complications (10.0%). When limiting to patients who underwent surgery in a high-volume center, the odds of FTR were 4-fold higher when complications were managed in a secondary hospital (OR = 4.06, 95% CI: 1.67–9.89). ConclusionsThe institution where patients present for postoperative complications is associated with differential mortality outcomes. Upon validation in a large cohort, these findings may inform quality improvement initiatives that target postoperative readmissions, algorithm-based approaches to post-surgical management of complications, and guide clinical decision-making around hospital transfers.

Race and postoperative complications following urologic cancer surgery: An ACS-NSQIP analysis

PurposeRacial disparities in complication rates have been demonstrated for a variety of surgical procedures. We hypothesized that African American (AA) patients experience higher postoperative complication rates than whites following urologic oncology procedures. Materials and methodsPatients in American College of Surgeons National Surgical Quality Improvement Program who underwent radical prostatectomy (RP), radical or partial nephrectomy (RN/PN), and radical cystectomy (RC) between 2005 and 2013 were included. Complications were grouped as minor (Clavien I–II), major (Clavien III–IV), or death (Clavien V). A 30-day complication rates and disparities in preoperative comorbidity burden were compared by race. After adjustment for comorbidity burden, multivariable logistic regression was performed to test the association between race and risk of complication. ResultsOf 38,642 patients included in the analysis, 90% were white and 10% were AA. In unadjusted analysis, there were no significant differences in complication rates between AA and white patients for any Clavien grade in the procedures queried (RP: P = 0.07; RN/PN: P = 0.70; RC: P = 0.12). After controlling for a higher comorbidity burden among AA patients, AA race was again not independently associated with 30-day postoperative complications for RP (odds ratio [OR] = 1.08, 95% CI: 0.92–1.29), RN/PN (OR = 0.98, 95% CI: 0.84–1.13), or RC (OR = 1.10, 95% CI: 0.84–1.43). ConclusionDespite a higher comorbidity burden, AA patients in American College of Surgeons National Surgical Quality Improvement Program are not at increased risk of 30-day postoperative complications following major urologic cancer surgery. These findings suggest that comorbidity burden, as opposed to race, is most strongly associated with the risk of postoperative complications. To minimize perioperative risk, clinicians should strive to preoperatively optimize medical comorbidities in all patients undergoing urologic cancer surgery.

MP32-08 READMISSIONS AFTER MAJOR UROLOGIC CANCER SURGERY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness IV1 Apr 2015MP32-08 READMISSIONS AFTER MAJOR UROLOGIC CANCER SURGERY Jeffrey Leow, Julian Hanske, Christian Meyer, Giorgio Gandaglia, Marianne Schmid, Jesse Sammon, Firas Abdollah, Mani Menon, Maxine Sun, Joachim Noldus, Adam Kibel, and Quoc-Dien Trinh Jeffrey LeowJeffrey Leow More articles by this author , Julian HanskeJulian Hanske More articles by this author , Christian MeyerChristian Meyer More articles by this author , Giorgio GandagliaGiorgio Gandaglia More articles by this author , Marianne SchmidMarianne Schmid More articles by this author , Jesse SammonJesse Sammon More articles by this author , Firas AbdollahFiras Abdollah More articles by this author , Mani MenonMani Menon More articles by this author , Maxine SunMaxine Sun More articles by this author , Joachim NoldusJoachim Noldus More articles by this author , Adam KibelAdam Kibel More articles by this author , and Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1404AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We examine the incidence and predictors of readmission after major urologic cancer surgery using a national, prospective-maintained database specifically developed to assess quality of surgical care. METHODS atients undergoing major urologic cancer surgery (radical prostatectomy [RP], radical nephrectomy [RNx], partial nephrectomy [PNx]), radical cystectomy [RC]) in 2011 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) using CPT codes. Those readmitted within 30-days after surgery were identified. Multivariable logistic regression models examined the association between patient characteristics and the odds of readmission. RESULTS Overall, we identified 5,356 RP, 1,301 RNx, 918 PNx and 623 RC patients, of which 206 (3.8%), 533 (6.8%), 348 (6.3%) and 129 (20.7%) were readmitted within 30-days respectively. Independent predictors of readmission for RP included age (Odds ratio [OR]: 1.02, p=0.02), ASA score 3-5 (vs. 1-2, OR: 1.35, p=0.04), smoking status (OR: 1.53, p=0.04), and the occurrence of wound (OR: 9.31, p<0.001), thromboembolic (OR: 14.7, p<0.001), and renal failure (OR: 1.62, p=0.01) complications during the index hospitalization. For RC patients, the only predictor of readmission was age (OR: 0.98, p=0.04). Predictors of readmission for RNx included higher ASA score (OR: 1.77, p=0.03), and the presence of any complications during the index hospitalization (OR: 2.21, p=0.03). CONCLUSIONS Several patient characteristics have a significant impact on the risk of 30-day readmission after major urologic cancer surgery. Our data suggests that improving prevention and management of complications during the index hospitalization may lead to a substantial decrease in readmission rates. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e367 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeffrey Leow More articles by this author Julian Hanske More articles by this author Christian Meyer More articles by this author Giorgio Gandaglia More articles by this author Marianne Schmid More articles by this author Jesse Sammon More articles by this author Firas Abdollah More articles by this author Mani Menon More articles by this author Maxine Sun More articles by this author Joachim Noldus More articles by this author Adam Kibel More articles by this author Quoc-Dien Trinh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP24-18 THE IMPACT OF READMISSIONS TO SECONDARY HOSPITALS ON FAILURE-TO-RESCUE RATES FOLLOWING MAJOR UROLOGIC CANCER SURGERY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness III1 Apr 2015MP24-18 THE IMPACT OF READMISSIONS TO SECONDARY HOSPITALS ON FAILURE-TO-RESCUE RATES FOLLOWING MAJOR UROLOGIC CANCER SURGERY Jasmir Nayak, Sarah Holt, Jonathan Wright, Atreya Dash, and John Gore Jasmir NayakJasmir Nayak More articles by this author , Sarah HoltSarah Holt More articles by this author , Jonathan WrightJonathan Wright More articles by this author , Atreya DashAtreya Dash More articles by this author , and John GoreJohn Gore More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1160AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urological cancer surgery is complex with some suggesting centralization of certain procedures in an effort to improve outcomes and reduce morbidity. Morbidity extends beyond the index surgery and can be further reduced by effective peri-operative complication management. Although outcomes vary among hospitals, part of this may be attributed to differences in the failure-to-rescue (FTR) complications. We examined FTR rates and compared those readmitted to their index surgery hospital with those readmitted to a secondary hospital. METHODS We accessed the Washington State Comprehensive Hospital Abstract Reporting System from 2009-2013. ICD-9 codes identified patients who underwent radical prostatectomy (RP), radical cystectomy (RC), partial nephrectomy (PN), radical nephrectomy (RN) and retroperitoneal lymph node dissection (RPLND) for malignancy. FTR in this analysis was defined as death following readmission within 90 days of the index surgery. Primary (PH) and secondary hospitals (SH) were defined using hospital identifiers linked to unique admissions. Multivariable logistic regression models were used to identify factors associated with FTR. RESULTS 11,536 patients underwent urologic cancer surgery, of whom 61% underwent RP, 22% RN, 10% PN, 6% RC and 1% RPLND. Overall, 10% (range: 6-37%) were readmitted within 90 days of surgery. 61% were readmitted to their PH, although this varied according to procedure type (57% readmitted to PH after RP, compared with 60% after RN, 65% after PN, 67% after RC and 83% after RPLND). The likelihood of readmission to the PH decreased with increasing hospital volume (p<0.0001). Overall FTR rate was 4%, ranging from 0% for RPLND to 6% for RN. The FTR rate when presenting to the PH was 1.5% compared with 6.6% at a SH (p=0.002). The most common readmission diagnoses were renal failure (24%), sepsis (10%), venothromboembolic event (9%) and pneumonia (8%). Controlling for age, sex, comorbidities and hospital volume, the readmission hospital was independently associated with FTR (OR 0.39, 95% CI 0.21-0.74 for PH versus SH). CONCLUSIONS Hospital readmissions within 90 days of major urologic cancer surgery are associated with a low FTR rate; however, patients readmitted to a SH experienced higher FTR than those readmitted to their original hospital. These findings may inform clinical decision-making around hospital transfers and aid future quality improvement initiatives to reduce the morbidity associated with complex urologic oncology surgeries. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byChappidi M, Kates M, Stimson C, Johnson M, Pierorazio P and Bivalacqua T (2018) Causes, Timing, Hospital Costs and Perioperative Outcomes of Index vs Nonindex Hospital Readmissions after Radical Cystectomy: Implications for Regionalization of CareJournal of Urology, VOL. 197, NO. 2, (296-301), Online publication date: 1-Feb-2017.Lenis A and Chamie K (2018) Regionalization of Cystectomy: Importance of Care Coordination, Bundled Payments and Surgical OwnershipJournal of Urology, VOL. 197, NO. 2, (278-279), Online publication date: 1-Feb-2017. Volume 193Issue 4SApril 2015Page: e283-e284 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jasmir Nayak More articles by this author Sarah Holt More articles by this author Jonathan Wright More articles by this author Atreya Dash More articles by this author John Gore More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...