Urologic Cancer Surgery Research Articles

413 INPATIENT UROLOGIC CARE IN CRITICAL ACCESS HOSPITALS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness III1 Apr 2012413 INPATIENT UROLOGIC CARE IN CRITICAL ACCESS HOSPITALS Adam J. Gadzinski, Justin B. Dimick, Zaojun Ye, and David C. Miller Adam J. GadzinskiAdam J. Gadzinski Ann Arbor, MI More articles by this author , Justin B. DimickJustin B. Dimick Ann Arbor, MI More articles by this author , Zaojun YeZaojun Ye Ann Arbor, MI More articles by this author , and David C. MillerDavid C. Miller Ann Arbor, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.479AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Critical Access Hospitals (CAHs) comprise over 25% of acute care hospitals in the United States. As evidenced by their unique cost-based reimbursement, policymakers view CAHs as essential healthcare providers for rural communities and other underserved populations. In order to better understand their role in urologic care delivery, we examined utilization patterns for inpatient urological procedures at CAHs and non-CAH hospitals. METHODS We used data from the American Hospital Association (AHA) survey to identify all CAHs in the United States. After linking AHA data with the Nationwide Inpatient Sample (NIS), we used Clinical Classification Software to identify all patients who underwent at least one urological procedure during an inpatient stay at a CAH or non-CAH hospital. We classified each procedure as major (i.e., requiring an operating room) or minor, and assigned it to one of seven clinical categories (Figure). We then examined and compared the type and distribution of urological procedures performed at CAH versus non-CAH centers. RESULTS Among the 1,292 CAHs and 3,760 non-CAHs reporting data to the AHA, 35% and 36%, respectively, had at least one year of data in the NIS. From 2005 through 2009, these centers performed 1,013,762 urological procedures (49% major) during 702,116 admissions. CAHs performed only 1% of all procedures. Additionally, the proportion of CAHs performing any (65%) or major urological procedures (55%) was significantly lower than for non-CAH facilities (98% and 96%, respectively, both p-values<0.01). The distribution of both minor and major procedures also differed for CAH vs non-CAH centers (p<0.01). For major procedures, urologic cancer surgery is comparatively rare at CAHs (Figure). Instead, anti-incontinence surgeries represent the most common major inpatient urological procedures. CONCLUSIONS Two-thirds of CAHs perform inpatient urological procedures; however, only half provide access to major urologic surgery. The profile of major procedures is also different than for non-CAH facilities, with a greater emphasis on treatment of urinary incontinence and other benign urological conditions. These data inform ongoing efforts to enhance access and quality of urological care for rural communities and other underserved populations. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e169 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adam J. Gadzinski Ann Arbor, MI More articles by this author Justin B. Dimick Ann Arbor, MI More articles by this author Zaojun Ye Ann Arbor, MI More articles by this author David C. Miller Ann Arbor, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

412 IDENTIFICATION OF UNDERSERVED AREAS FOR UROLOGIC CANCER CARE

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness III1 Apr 2012412 IDENTIFICATION OF UNDERSERVED AREAS FOR UROLOGIC CANCER CARE John Gore, Jonathan Wright, Jason Izard, Jonathan Harper, and Michael Porter John GoreJohn Gore Seattle, WA More articles by this author , Jonathan WrightJonathan Wright Seattle, WA More articles by this author , Jason IzardJason Izard Seattle, WA More articles by this author , Jonathan HarperJonathan Harper Seattle, WA More articles by this author , and Michael PorterMichael Porter Seattle, WA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.478AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Geographic delineation of the delivery of urologic care would aid regional quality improvement initiatives intended to maximize health outcomes for urologic patients. We sought to define patterns of care for patients requiring urologic cancer surgery based on their region of residence. METHODS We accessed the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) for the years 2003-2007 and examined the ZIP code of residence for patients undergoing radical prostatectomy (RP), radical nephrectomy (RN), partial nephrectomy (PN), radical cystectomy (RC), and transurethral resection of the prostate (TURP). Through linkage of patient residential ZIP codes with the Dartmouth Atlas Hospital Service Area (HSA) and Hospital Referral Region (HRR) designations, we identified geographical areas where most patients get their local hospital care (65 exclusive HSAs in Washington) and their complex surgical care (6 exclusive HRRs in Washington), respectively. We compared care out of HSA and out of HRR for each urological oncology procedure with patients undergoing TURP. RESULTS Patients did not receive surgical treatment of their cancer in their HSA in 46% of RP cases, 45% of RN cases, 47% of PN cases, and 53% of RC cases compared with 30% of TURP cases (p<0.001 for all). Patients underwent surgery outside their HRR in 17% of RP cases, 15% of RN cases, 19% of PN cases, and 24% of RC cases, compared with 7% of TURPs (p<0.001 for all). More than half of patients traveled out of HRR for surgery in 7 HSAs for RP (11%), 3 HSAs for RN (5%), 10 HSAs for PN (15%), and 14 HSAs for RC (22%) compared with none for TURP. CONCLUSIONS Higher levels of surgical complexity mandate a larger burden of travel on patients to access care. Although patients could access TURP regardless of their HSA, many patients had to travel to different HSAs and even different HRRs to access urologic cancer care. RC remains most burdensome, consistent with prior reports of the urbanization of RC care. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e168-e169 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Gore Seattle, WA More articles by this author Jonathan Wright Seattle, WA More articles by this author Jason Izard Seattle, WA More articles by this author Jonathan Harper Seattle, WA More articles by this author Michael Porter Seattle, WA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Hospital Volume is a Determinant of Postoperative Complications, Blood Transfusion and Length of Stay After Radical or Partial Nephrectomy

We examined the impact of hospital volume on short-term outcomes after nephrectomy for nonmetastatic renal cell carcinoma. Using the Nationwide Inpatient Sample we identified 48,172 patients with nonmetastatic renal cell carcinoma treated with nephrectomy (1998 to 2007). Postoperative complications, blood transfusions, prolonged length of stay and in-hospital mortality were examined. Stratification was performed according to teaching status, nephrectomy type (partial vs radical nephrectomy) and surgical approach (open vs laparoscopic). Multivariable logistic regression models were fitted. Patients treated at high volume centers were younger and healthier at nephrectomy. High hospital volume predicted lower blood transfusion rates (8.5% vs 9.7% vs 11.8%), postoperative complications (14.4% vs 16.6% vs 17.2%) and shorter length of stay (43.1% vs 49.8% vs 54.0%, all p <0.001). In multivariable analyses stratified according to teaching status, nephrectomy type and surgical approach, high hospital volume was an independent predictor of lower rates of postoperative complications (OR 0.73-0.88), blood transfusions (OR 0.71-0.78) and prolonged length of stay (OR 0.76-0.89, all p <0.001). Exceptions were postoperative complications at nonteaching centers (OR 0.94, p >0.05) and blood transfusions in nephrectomies performed laparoscopically (OR 0.68, p >0.05). On average, high hospital volume results in more favorable outcomes during hospitalization after nephrectomy.

Incidence, Risk Profile and Morphological Pattern of Lower Extremity Venous Thromboembolism After Urological Cancer Surgery

We examined the incidence of asymptomatic and symptomatic lower extremity venous thromboembolism in patients who underwent urological surgery for cancer, and identified preoperative and operative risk factors predictive of the thromboembolism. A cohort of 583 consecutive patients undergoing urological cancer surgery was prospectively assessed using complete lower limb ultrasound at postoperative day 7 from January 2005 to July 2009. In all patients heparin and mechanical thromboprophylaxis were prescribed until complete ambulation. Potential variables predictive of venous thrombosis were analyzed. Complete data were available in 538 patients (463 male and 75 female), of whom 177 underwent nephrectomy, 86 radical cystectomy and 275 radical prostatectomy. A total of 40 deep venous thrombosis cases were found (7.4%), most of which were asymptomatic (92%) and limited to deep calf veins (80%). Of those asymptomatic deep venous thrombosis cases 86% were limited to deep calf veins. In all, 12 pulmonary embolisms were diagnosed, of which 4 were lethal. On multivariate analysis history of venous thromboembolism (OR 5.16, p = 0.02) and radical cystectomy (OR 3.47, p = 0.002) were independently associated with venous thromboembolism. Lower extremity venous thromboembolism has a high rate of occurrence after urological surgery for cancer despite the recommended venous thromboembolism prophylaxis. Most cases are asymptomatic and limited to deep calf veins. Our results suggest that complete lower limb ultrasound should be performed early after radical cystectomy and in patients with a personal history of venous thromboembolism.

The role of religion and spirituality in psychological distress prior to surgery for urologic cancer.

The present study examined the associations between religion and spirituality (R/S), presurgical distress, and other psychosocial factors such as engagement coping, avoidant coping, and social support. Participants were 115 men scheduled for surgery for urologic cancer. Before surgery, participants completed scales measuring intrinsic religiosity, organized religious activity, and nonorganized religious activity (IR, ORA, NORA); social support (Medical Outcomes Study Social Support Survey); and distress (Impact of Event Scale [IES], Perceived Stress Scale [PSS], Brief Symptom Inventory-18 [BSI-18], and Profile of Mood States [POMS]). R/S was positively associated with engagement coping. Social support was positively associated with engagement coping and inversely associated with POMS and PSS scores. Engagement coping was positively associated with IES and BSI scores, and avoidant coping was positively associated with all distress measures. R/S moderated the association between engagement coping and IES scores, such that the association between engagement coping and IES was not significant for men with high R/S scores (greater religious belief). R/S moderated the association between social support and distress; the inverse association between social support and PSS and POMS scores was only significant for men who scored high on R/S. This study replicated findings from previous studies suggesting that engagement and avoidant types of coping can lead to increased distress prior to surgery. Although R/S was associated with engagement coping, it was not associated with any of the distress measures. The finding that R/S moderated the associations between engagement coping and distress and social support and distress suggests that the association between R/S, coping style, social support, and adjustment to stressful life situations is not simplistic, and indirect associations should be explored.

Hospital‐level variation in the quality of urologic cancer surgery

Unexplained variation in outcomes after common surgeries raises concerns about the quality and appropriateness of surgical care. Understanding variation in surgical outcomes may identify processes that could affect the quality of surgical and postoperative care. The authors of this report examined hospital-level variation in outcomes after inpatient urologic oncology procedures. Patients who underwent radical cystectomy, radical nephrectomy, and radical prostatectomy were identified from the Washington State Comprehensive Hospital Abstract Reporting System for the years 2003 through 2007. The postoperative length of stay (LOS) was measured, and LOS that exceeded the 75th percentile was classified as prolonged. The occurrence of Agency for Healthcare Quality patient safety indicators (PSIs), readmissions, and deaths also were measured. Analyses were adjusted for patient age and comorbidity in random effects, multilevel, multivariable models that assessed hospital-level outcomes. The authors identified 853 patients from 37 hospitals who underwent cystectomy, 3018 patients who underwent nephrectomy from 51 hospitals, and 8228 patients who underwent prostatectomy from 51 hospitals. Complications captured by PSIs were rare. Hospital-level variation was most profound for LOS outcomes after nephrectomy and prostatectomy (variance in prolonged LOS, 8.1% and 26.7%, respectively), thromboembolic events after nephrectomy (8% of variance), and mortality after cystectomy (7.1% of variance). Hospital-level variation confounds the care of urologic cancer patients in the state of Washington. The authors concluded that transparent reporting of surgical outcomes and local quality-improvement initiatives should be considered to ameliorate the observed variation and improve the quality of cystectomy, nephrectomy, and prostatectomy care.

Impact of Hospital Provider Volume on Outcome for Radical Urological Cancer Surgery in England

Introduction: Complex surgical procedures are associated with higher mortality and morbidity. There is a paucity of data supporting a volume-outcome relationship in the United Kingdom. We analysed Hospital Episode Statistics (HES) to contemplate the association of hospital provider volume and short-term outcomes (mortality rate and hospital stay) for 3 radical urological procedures in England. Materials and Methods: The HES database was extracted for radical prostatectomy (RP), radical cystectomy (RC) and radical nephrectomy (RN) using ICD-10 and OPCS-4 codes for 7 years. Hospitals were divided into quartiles depending on the annual hospital volume. The impact of hospital provider volume was analysed for outcomes. Results: Overall 43,946 patients were included in the study. RP patients had the lowest mortality rate (0.2%) and shorter in-patient stay (7 days). Mortality from RC and RN were 475 (5.3%) and 537 (2.6%), respectively. There was no significant difference for mortality following RP in four volume groups (p = 0.76). The mortality rate for RC decreased from 6.9% in the very low-volume group to 4.1% in the high-volume group (p < 0.001) without change in the in-hospital stay. The proportion of patients treated at high-volume centres for RP, RC and RN has increased from 0 to 42, 22 to 35 and 10 to 38%, respectively, over a 7-year study period. Conclusion: In England, hospital provider volume has a significant impact on outcome measures for radical pelvic urological procedures with a lower mortality (RC) and shorter in-patient stay (RP). Thus HES data from England support the hospital volume-outcome relationship and emphasise the centralisation of care for radical urological procedures.

112 HOSPITAL-LEVEL VARIATION IN DISPOSITION AND READMISSION AFTER SURGERY FOR UROLOGIC CANCERS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes III1 Apr 2010112 HOSPITAL-LEVEL VARIATION IN DISPOSITION AND READMISSION AFTER SURGERY FOR UROLOGIC CANCERS John L. Gore, Jonathan L. Wright, Hunter Wessells, and Michael P. Porter John L. GoreJohn L. Gore More articles by this author , Jonathan L. WrightJonathan L. Wright More articles by this author , Hunter WessellsHunter Wessells More articles by this author , and Michael P. PorterMichael P. Porter More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.162AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Unexplained variation in outcomes after common surgeries may subtend a quality of care concern. Evaluating and understanding variation in surgical outcomes may identify processes and policy measures that effect surgical quality improvement. We sought to examine hospital-level variation in outcomes after inpatient urologic oncology procedures in the state of Washington. METHODS We accessed Washington state hospital claims (Comprehensive Hospital Abstract Reporting System [CHARS] data) for the years 2003-2007. The CHARS database includes inpatient claims linked at the patient level such that all readmissions and subsequent inpatient procedures are captured. Using International Classification of Diseases, 9th Edition procedure codes, we identified subjects undergoing radical prostatectomy, radical nephrectomy, and radical cystectomy. We measured postoperative length of stay (LOS), death, readmissions, and Agency for Healthcare Quality Patient Safety Indicators (PSIs). We adjusted hospital-level outcomes by patient age and comorbidity. RESULTS We identified 8,228 men who underwent prostatectomy from 51 hospitals, 3,018 nephrectomy patients from 51 hospitals, and 853 cystectomy patients from 37 hospitals. The Table lists age- and comorbidity-adjusted length of stay, 30-day death rates and 1-year readmission rates by hospital volume quartile for each procedure (* indicates p<0.05 compared with volume quartile 4). Complications captured by PSIs were rare. Higher volume hospitals trended toward lower LOS and readmission rates compared with lower volume hospitals. Postoperative death was uncommon after prostatectomy and nephrectomy. Higher volume hospitals had lower 30-day death rates after radical cystectomy than lower volume hospitals, but this difference was not statistically significant. Table 1. Adjusted rates of readmission, alternate disposition, an d death after inpatient urologic oncology surgeries Procedure volume quartile 1 – lowest 2 3 4 - highest Radical prostatectomy LOS (days) 3.0⁎ 2.8⁎ 2.8⁎ 0.6 30-day death (%) 0.00 0.09 0.11 0.11 1-year readmission (no.) 0.17 0.18⁎ 0.14 0.00 Radical nephrectomy LOS (days) 5.0 4.5 4.7 4.5 30-day death (%) 1.8 1.2 1.1 1.1 1-year readmission (no.) 0.56 0.38 0.42 0.34 Radical cystectomy LOS (days) 9.6 10.6 9.9 9.8 30-day death (%) 4.5 4.2 3.4 0.48 1-year readmission (no.) 0.91 1.1 1.4 0.72 ⁎ p<0.05 for comparison with procedure volume quartile 4. CONCLUSIONS Hospital-level variation may confound the care of urologic cancer patients in the state of Washington. Hospitals with lower surgical volume had higher death and readmission rates than higher volume hospitals for radical prostatectomy, radical nephrectomy, and radical cystectomy. Transparent reporting of surgical outcomes and local quality improvement initiatives may ameliorate the variation documented. Seattle, WA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e46 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information John L. Gore More articles by this author Jonathan L. Wright More articles by this author Hunter Wessells More articles by this author Michael P. Porter More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robotic Distal Ureterectomy with Boari Flap Reconstruction for Distal Ureteral Urothelial Cancers: A Single Institutional Pilot Experience

Low-grade urothelial tumors of the distal ureter historically can be managed by open distal ureterectomy and ureteral reimplantation with or without bladder reconstruction. In recent years, the da Vinci surgical robotic system (DSRS) (Intuitive Surgical Inc., Sunnyvale, CA) has being increasingly used to perform complex urologic cancer surgeries. In this article, we report first on two consecutive patients undergoing robotic distal ureterectomy and Boari flap reconstruction (RDUBF) for distal ureteral cancer. Two consecutive patients underwent RDUBF, both with a diagnosis of low-grade papillary neoplasm of a distal ureter at our institution between August 2008 and November 2008. Perioperative parameters were prospectively collected and analyzed following institutional review board approval. Two patients, male and female (age, 70 and 71 years, respectively) were included in the study. In both the patients, RDUBF was completed transperitoneally without the need for open conversion. The operative time, estimated blood loss, time to hospital discharge, and time to stent removal for both patients were 270 and 220 minutes, 25 and 35 mL, and 2 days and 6 weeks, respectively. The percentage change in hematocrit following surgery was within 5% in all patients. There were no postoperative complications in both patients. Final pathology demonstrated low-grade carcinoma pT1NxMx and pTaNxMx papillary urothelial carcinoma with negative margins in both patients. A MAG3 (mercapto-acetyl-tri-glycine) renal scan at 3 months demonstrated prompt drainage in both patients. At a median follow-up of 6 months, the patients were alive with no signs of recurrent or metastatic disease on cystoscopic, cytologic, or radiologic follow-up. RDUBF reconstruction is technically feasible with using DSRS in select patients with distal ureteral cancer without disease recurrence in the short term. A larger cohort, with long-term follow-up, is necessary to validate our results.

Robotic Partial Cystectomy for Bladder Cancer: A Single-Institutional Pilot Study

Open partial cystectomy has been used as a curative option for select group of patients with bladder cancer. In recent years, the da Vinci Surgical Robotic System is being increasingly used to perform complex urologic cancer surgeries. We report first on a consecutive cohort of patients undergoing robotic partial cystectomy (RPC) for bladder cancer. Three consecutive patients underwent RPC, two with diagnosis of papillary neoplasm of bladder and one with urachal adenocarcinoma at our institution from July 2008 to January 2009. Perioperative parameters were prospectively collected and analyzed after Institutional Review Board approval. All three patients in the study were men with a median age of 50 years (range, 24-70 years). The RPC was completed transperitoneally in all three patients without the need for open conversion. The operative time, estimated blood loss, and time to hospital discharge for the three patients undergoing RPC were 185, 135, and 165 minutes; 25, 20, and 20 mL; and 5, 2, and 2 days, respectively. The percentage change in hematocrit after surgery was within 5% in all patients. There were no postoperative complications before discharge; however, one patient was readmitted and underwent small bowel resection secondary to bowel obstruction. Final pathology demonstrated high-grade carcinoma pT2bNxMx and pTaNxMx papillary urothelial carcinoma in two patients and invasive adenocarcinoma of the bladder pT3aNxMx in the remaining patient. The median follow-up was 6 months (range, 3-10 months). All three patients were alive with no signs of recurrent or metastatic disease on cystoscopic, cytological, or radiological follow-up. RPC is technically feasible using the da Vinci Surgical Robotic System in select patients with bladder cancer without disease recurrence in the short term. A larger cohort with long-term follow-up is necessary to validate our results.

Oncological Outcomes After Radical Cystectomy for Bladder Cancer: Open Versus Minimally Invasive Approaches

The number of centers performing robotic assisted radical cystectomy has recently increased, spurring greater concerns about oncological outcomes. In this review we summarize the most comprehensive articles published on the oncological outcomes of laparoscopic assisted, robotic assisted and open radical cystectomy. A MEDLINE/PubMed literature search was conducted in March 2009 to review English language articles published from 1998 onward. Of 217 selected articles on the 3 techniques 19 studies were selected for this review. The laparoscopic series reported recurrence-free survival rates in the range of 83% to 85% at 1 to 2 years and 60% to 77% at 2 to 3 years, while the robotic assisted studies reported recurrence-free survival rates of 86% to 91% at 1 to 2 years. Large open surgery studies showed 62% to 68% recurrence-free survival at 5 years and 50% to 60% at 10 years, with overall survival of 59% to 66% at 5 years and 37% to 43% at 10 years. Overall survival in the laparoscopic cohorts was 90% to 100% at 1 to 2 years and 50% to 87% at 2 to 3 years. Publications reporting robotic cases demonstrated a 90% to 96% overall survival in 1 to 2 years of followup. Despite the surge of centers adopting minimally invasive approaches for radical cystectomy, the long-term effectiveness of these techniques has not yet been proven. This review of recent and landmark articles on open and minimally invasive procedures emphasizes the need for prospective controlled studies and long-term followup data to determine the proper use of laparoscopic and robotic assisted techniques in bladder cancer surgery.

Editorial Comment

This article by Kawakami et al. presents the results of a survey on surgery for urological cancer performed in Japan in 2005. The authors divided this surgery into three types: laparoscopic surgery, minimum incision surgery and ordinary open surgery, and compared these three types with respect to numbers of operations performed, size of the incision, use of endoscopy, whether or not the surgeon's hand was inserted into the incision, complications and related factors.1 This article presents valuable data in terms of the progress made in surgical procedures, and also includes results that require consideration. One of these results was that in minimum incision prostatectomy, the hands of surgeons are inserted into the wound during surgery in more than 50% of operations and endoscopes are not used in more than 40%. I understand that this method is defined as an endoscopic surgery with the incision of about 7 cm where the hands are not inserted into the incision during the operation. It is classified as a different operation based only on the size of the incision and questions arise. Recently in Japan, special health insurance points have been set for minimum incision endoscopic prostatectomy.2 Therefore, the definition of the operative method should be clarified. The next considerable point was the result that ‘among laparoscopic surgery, minimum incision surgery and open surgery, no significant differences were found in complications attributable to the operative method.’ It has also been reported that there are no differences in pain between open and laparoscopic surgery in prostatectomy.3 If there are no benefits in terms of a reduction in complications and decrease in pain, what is the advantage of a 7-cm minimum incision over a 12-cm incision in prostatectomy? Conversely, will cancer lesion resection become insufficient with the smaller incision? I feel that the above points must be clarified in order for minimum incision prostatectomy to be considered as a better operative method.

Venous Thromboembolism Risk and Prophylaxis Practices in Surgical Patients with Active Cancer: Findings from the Global ENDORSE Survey.

Introduction : Cancer patients undergoing surgery have double the risk for VTE compared with non-cancer patients (Thromb Haemost 2003; 90:446–55). Current ACCP guidelines advocate the use of VTE prophylaxis in patients with active malignancy undergoing major surgical procedures. The recent ENDORSE survey reported that globally, 64% of patients admitted to surgical wards were at risk for VTE, and only 59% of these received ACCP-recommended prophylaxis (Lancet 2008; 371:387–94). In this subanalysis of ENDORSE, we evaluated the prevalence of VTE risk and prophylaxis practices in surgical patients with active malignancy.Methods: The ENDORSE study evaluated data from 30,827 patients admitted to surgical wards in 358 hospitals across 32 countries (Lancet 2008; 371:387–94). The influence of active malignancy on VTE risk and prophylaxis use was assessed in patients who had undergone abdominal, urological or gynecological surgery. Patient data were grouped and analyzed according to whether the surgery was related to a cancer diagnosis (surgery for cancer) or performed in patients without a cancer diagnosis (no cancer). Risk for VTE and use of appropriate prophylaxis was evaluated according to the 2004 ACCP-guidelines (Chest 2004; 126:338S–400S). Bleeding risk factors considered sufficient to present a contraindication to anticoagulant use included intracranial hemorrhage, bleeding at hospital admission, presence of a known bleeding disorder and clinically relevant hepatic impairment.Results: Of the 30,827 patients in surgical wards evaluated in ENDORSE, 18,461 had undergone major surgery as of the date of the survey, including 6172 patients who had abdominal, urological or gynecological operations and were considered at risk for VTE. All patients with a cancer diagnosis who underwent these types of surgery were considered at-risk for VTE, including 1767 patients whose surgical procedure was related to their diagnosis and 101 patients who underwent surgery unrelated to cancer. The proportion of patients receiving any ACCP-recommended prophylaxis ranged from 60% in patients undergoing surgery for urologic cancer to 86% in patients undergoing surgery for rectosigmoid cancer. Patients who had surgery related to their cancer had a higher rate of ACCP-recommended prophylaxis use, compared with patients who underwent surgery with no cancer diagnosis (Table). The proportion of patients considered to have bleeding risk sufficient to present a contraindication to anticoagulant use was 10.4% (surgery for cancer) and 10.9% (no cancer; Table). Fewer patients without a cancer diagnosis received anticoagulant prophylaxis, compared with those undergoing cancer-related surgery (Table).Table: VTE prophylaxis practice according to the presence of active malignancy.Surgery typeAt-risk receiving ACCP-recommendedprophylaxis n/N (%)Contrain-dications to anticoagulant use, n (%)Anticoagulant alone, n (%)Mechanical alone, n (%)Both, n (%)Surgery for cancer (N=1767)1295/1767 (73.3)183 (10.4)820 (46.4)136 (7.7)412 (23.3)No cancer (N=5097)2495/4304* (58.0)470 (10.9)1455 (33.8)426 (9.9)762 (17.7)*4304 of 5097 patients without a cancer diagnosis were considered at risk for VTEConclusion: The use of any type of ACCP-recommended VTE prophylaxis varied according to the type of cancer for which the surgery was performed. Although all cancer patients who undergo abdominal, urological or gynecological surgery are at risk for VTE, the results suggest that up to 30% of cancer patients where surgery is performed related to a cancer diagnosis do not receive ACCP-recommended prophylaxis. Less than 11% of patients who had surgery regardless of whether it was related to a cancer diagnosis had a bleeding risk sufficient to present a contraindication to anticoagulant use. These findings suggest that despite the existence of clear evidence-based guidelines, the use of VTE prophylaxis in cancer patients remains suboptimal.

Association Between Hospital and Surgeon Radical Prostatectomy Volume and Patient Outcomes: A Systematic Review

We examined the association between hospital and surgeon volume, and patient outcomes after radical prostatectomy. Databases were searched from 1980 to November 2007 to identify controlled studies published in English. Information on study design, hospital and surgeon annual radical prostatectomy volume, hospital status and patient outcome rates were abstracted using a standardized protocol. Data were pooled with random effects models. A total of 17 original investigations reported patient outcomes in categories of hospital and/or surgeon annual number of radical prostatectomies, and met inclusion criteria. Hospitals with volumes above the mean (43 radical prostatectomies per year) had lower surgery related mortality (rate of difference 0.62, 95% CI 0.47-0.81) and morbidity (rate difference -9.7%, 95% CI -15.8, -3.6). Teaching hospitals had an 18% (95% CI -26, -9) lower rate of surgery related complications. Surgeon volume was not significantly associated with surgery related mortality or positive surgical margins. However, the rate of late urinary complications was 2.4% lower (95% CI -5, -0.1) and the rate of long-term incontinence was 1.2% lower (95% CI -2.5, -0.1) for each 10 additional radical prostatectomies performed by the surgeon annually. Length of stay was lower, corresponding to surgeon volume. Higher provider volumes are associated with better outcomes after radical prostatectomy. Greater understanding of factors leading to this volume-outcome relationship, and the potential benefits and harms of increased regionalization is needed.

Radical Cystectomy for Carcinoma of the Bladder: 2,720 Consecutive Cases 5 Years Later

We performed a critical analysis of the results of radical cystectomy for invasive bladder carcinoma treated at 1 center. Between 1970 and 2000, 2,090 men and 630 women with invasive bladder cancer were treated with 1-stage radical cystectomy and urinary diversion. Followup ranged from 0 to 34.2 years with a mean of 5.5 +/- 5.7. Survival data were correlated to patient and tumor characteristics using univariate and multivariate analysis. Postoperative mortality was 2.6%. Squamous tumors accounted for 49.4% of cases, transitional cell carcinoma for 36.4% and adenocarcinoma for 9.6%. Regional lymph nodes were involved in 20.4% of cases. The 5 and 10-year disease-free survival rates were 55.5% and 50.03%, respectively. Evidence was provided that tumor stage, histological grade and lymph node status are the only independent variables which affect survival probability. Contemporary cystectomy can be performed with minimal mortality. Radical cystectomy for organ confined disease is followed by good therapeutic results and enhances the possibilities for functional restoration. With stage progression there is a stepwise reduction in survival probability. The radical operation can provide disease-free survival for an important subgroup of node positive cases (27.3%). Additional therapy is needed to improve the oncological outcome for advanced locoregional disease.

Mortality After Urologic Cancer Surgery: Impact of Non-index Case Volume

To quantify the degree to which overall urologic oncology volume either reduces or enhances the effect of single procedure volume on short-term outcomes after urologic oncology surgery. Urologic oncology procedures for prostate, kidney, and bladder cancer performed between 1988 and 2003 were identified in the Nationwide Inpatient Sample. Procedure-specific volume and urologic oncology volume (excluding the procedure of interest) were determined for each cancer and each hospital. Multivariable logistic regression models were constructed to measure the independent effect of urologic oncology volume (non-index procedures) on operative mortality after prostatectomy, cystectomy, and nephrectomy (index procedures) after adjusting for patient and hospital factors. Unadjusted operative mortality for prostatectomy, cystectomy, and nephrectomy was 0.2%, 2.8%, and 1.4%, respectively. For prostatectomy and cystectomy, the magnitude of the volume-mortality association was reduced after adjusting for non-index urologic oncology case volume. For example, the relationship between surgical volume and mortality was reduced by 20% for radical prostatectomy and 60% for radical cystectomy. The volume-outcome effect for index urologic oncology procedures is modified by experience with other non-index specialty-related procedures. Efforts to identify transferable, effective processes of care should focus on a subset of high-volume centers.

Effects of Hospital Procedure Volume and Resident Training on Clinical Outcomes and Resource Use in Radical Retropubic Prostatectomy Surgery in the Department of Veterans Affairs

In this retrospective cohort study we used data from the National Surgical Quality Improvement Program of the Veterans Health Administration to examine the effect of case volume and resident participation on radical retropubic prostatectomy outcomes. The study population included 5,736 patients who underwent radical retropubic prostatectomy in Veterans Administration hospitals between October 1, 2001 and September 30, 2004. Resource related outcomes included operative times and length of stay. Clinical outcomes included blood transfusion, complications, readmissions and reoperations. Hierarchical multivariate regression models were developed to predict outcomes. Risk adjustment was performed using patient chronic health factors and results of preoperative laboratory testing. A total of 5,070 radical retropubic prostatectomy surgeries met inclusion criteria. After adjustment for case mix, academic training institutions had longer operative times (3.2 vs 2.4 hours, p <0.01) but shorter length of stay (3.4 vs 4.2 days, p <0.01). Surgery at academic institutions was not associated with greater risk of transfusion (p = 0.36), reoperation (p = 0.93), complications (p = 0.53) or readmissions (p = 0.97). However, among the academic institutions low vs high hospital radical retropubic prostatectomy volume was associated with longer length of stay (3.7 vs 3.1 days, p = 0.02) and higher transfusion rate (29.6% vs 18.2%, p = 0.02). Substantial clustering of outcomes at the hospital level was observed. Within the Veterans Administration system academic training institutions have longer operative times for radical retropubic prostatectomy, but shorter length of stay. Among the same institutions, high volume hospitals tend to have lower transfusion rates and shorter length of stay. Clustering of outcomes at the hospital level suggests that unmeasured institutional factors are key determinants of clinical and resource related outcomes.

Positive Surgical Margins in Soft Tissue Following Radical Cystectomy for Bladder Cancer and Cancer Specific Survival

We evaluated risk factors for positive soft tissue surgical margins and the impact of soft tissue surgical margins on metastatic progression and disease specific survival in patients treated with radical cystectomy for bladder cancer. A total of 1,589 patients who underwent radical cystectomy for primary urothelial cancer at our institution were included in the study. Several variables were analyzed including gender, age, use of perioperative chemotherapy, tumor stage, tumor grade, presence of carcinoma in situ, pathological vascular invasion, bladder pathology, status of soft tissue surgical margins, lymph node status, number of lymph nodes removed and number of positive lymph nodes. End points were freedom from progression to metastases and disease specific survival. Positive soft tissue surgical margins were detected in 67 patients (4.2%). Risk factors for positive soft tissue surgical margins were female gender (p = 0.04), pathological stage, vascular invasion in the radical cystectomy specimen, lymph node metastases (all p < or = 0.001) and median number of positive lymph nodes (p = 0.002). In addition, nonpure transitional cell carcinoma histology (p = 0.001) was associated with positive soft tissue surgical margins. In the 5 years after cystectomy, rates of disease specific survival for the negative and positive soft tissue surgical margin groups were 72% (95% CI 69-75) and 32% (95% CI 19-54), respectively. On multivariate analysis disease specific death was associated with tumor stage, positive soft tissue surgical margins, vascular invasion, presence of positive lymph nodes, number of nodes removed and number of positive nodes. Risk factors for positive soft tissue surgical margins are female gender, locally advanced cancer, presence of vascular invasion and mixed histology. Patients with positive soft tissue surgical margins have poor prognosis, and positive soft tissue surgical margins were found to be independently associated with disease specific death.

Radical cystectomy: defining the threshold for a surgeon to achieve optimum outcomes

Background: The reorganisation of cancer services in England will result in the creation of specialist high volume cancer surgery centres. Studies have suggested a relationship between increasing surgical volume and...

Complications of Laparoscopic Surgery for Urological Cancer: A Single Institution Analysis

We determined the incidence of and risk factors for perioperative complications associated with laparoscopic oncological surgery for urological malignancy. All records of patients undergoing laparoscopic surgery for urological malignancy at a tertiary care institution from April 1997 through January 2006 were reviewed. Relevant demographic and perioperative data during and within 6 weeks of surgery were evaluated retrospectively. Various factors were analyzed to estimate risk of a perioperative complication such as the Charlson Comorbidity Index, American Society of Anesthesiologists score, European Scoring System for laparoscopic urological operations and surgeon experience. Logistic regression was used to identify independent risk factors for perioperative complications. A total of 1,867 laparoscopic oncological surgeries were performed, including radical or partial nephrectomy, nephroureterectomy, radical prostatectomy and radical cystectomy. Perioperative complications occurred in 12.4% of patients, including 3.5% intraoperatively and 8.9% postoperatively. Intraoperative (2.3%) and postoperative hemorrhage (2.7%) accounted for 40% of all perioperative complications. All cause perioperative mortality occurred in 8 patients (0.4%). On multivariate analysis radical cystectomy (adjusted OR 4.9, p <0.001), partial nephrectomy (adjusted OR 2.4, p <0.001), length of surgery greater than 4 hours (adjusted OR 2.5, p <0.001) and preoperative serum creatinine greater than 1.5 mg/dl (adjusted OR 2.1, p = 0.04) were independent risk factors for perioperative complications. Comparing the periods of 1997 to 2000 vs 2001 to 2005, despite a significant increase in technical complexity of procedures (European Scoring System 9.8 vs 60.6, p <0.001), the incidence of complications tended to decrease (17.3% vs 12.5%, p = 0.3). In appropriately selected patients laparoscopic urological oncological surgery is safe. These data on perioperative complications could possibly serve as a reference benchmark for practicing urologists.