Indocyanine Green (ICG) in Urologic Surgery.

Indocyanine green (ICG) is a dye used for fluorescent-guided surgery. This review article addresses the recent surge in reported uses of ICG in various surgical fields and provides a comprehensive and up to date review of the uses of ICG in urologic surgery.

Trends and Disparities in Cervical Spine Fusion Procedures Utilization in the New York State.

STUDY DESIGN: A retrospective review of the Statewide Planning and Research Cooperative System database of the New York State. OBJECTIVE: This study examined the rate of increase of cervical spine fusion procedures at low-, medium-, and high-volume hospitals, and analyzed racial and socioeconomic characteristics of the patient population treated at these three volume categories. SUMMARY OF BACKGROUND DATA: There has been a steady increase in spinal fusion procedures performed each year in the United States, especially cervical and lumbar fusion. Our study aims to analyze the rate of increase at low-, medium-, and high-volume hospitals, and socioeconomic characteristics of the patient populations at these three volume categories. METHODS: The New York State, Statewide Planning and Research Cooperative System (SPARCS) database was searched from 2005 to 2014 for the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Procedure Codes 81.01 (Fusion, atlas-axis), 81.02 (Fusion, anterior column, other cervical, anterior technique), and 81.03 (Fusion, posterior column, other cervical, posterior technique). Patients' primary diagnosis (ICD-9-CM), age, race/ethnicity, primary payment method, severity of illness, length of stay, hospital of operation were included. All 122 hospitals were categorized into high-, medium-, and low-volume. Trends in annual number of cervical spine fusion surgeries in each of the three hospital volume groups were reported using descriptive statistics. RESULTS: Low-volumes centers were more likely to be rural and non-teaching hospitals. African American patients comprised a greater portion of patients at low-volume hospitals, 15.1% versus 11.6% compared with high-volume hospitals. Medicaid and self-pay patients were also overrepresented at low-volume centers, 6.7% and 3.9% versus 2.6% and 1.7%, respectively. Compared with Caucasian patients, African American patients had higher rates of postoperative infection (P = 0.0020) and postoperative bleeding (P = 0.0044). Compared with privately insured patients, Medicaid patients had a higher rate of postoperative bleeding (P = 0.0266) and in-hospital mortality (P = 0.0031). CONCLUSION: Our results showed significant differences in hospital characteristics, racial distribution, and primary payments methods between the low- and high-volume categories. African American and Medicaid patients had higher rates of postoperative bleeding, despite similar rates between the three volume categories. This suggests racial and socioeconomic disparities remains problematic for disadvantaged populations, some of which may be attributed to accessibility to care at high-volume centers. LEVEL OF EVIDENCE: 3.

Modified frailty index associated with Clavien-Dindo IV complications in robot-assisted radical prostatectomies: A retrospective study.

OBJECTIVE: To determine the effect of frailty on patient outcomes including any complication, Clavien-Dindo IV (CDIV) (intensive care unit-level) complications, and 30-day mortality for robotic-assisted radical prostatectomies (RARP) patients in comparison to other predictive indices using the modified frailty index (mFI). MATERIAL AND METHODS: Patients undergoing RARP from 2008 to 2014 for a prostate cancer-related diagnosis were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The mFI was developed using the Canadian Study of Health and Aging Frailty Index as a model. The mFI was compared with other associative indices such as the American Society of Anesthesiology (ASA) classification and the Charlson comorbidity index (CCI). Rates of CDIV complications and 30-day mortality were analyzed based on mFI score using SAS version 9.22. RESULTS: A total of 23,104 patients undergoing RARP were queried. RARP patients with the highest frailty score (≥3) had an adjusted odds for CDIV complications of Odds ratio of 12.107 (CI: 2.800-52.351, P< 0.005) in comparison with nonfrail RARP patients. These odds were higher than the ASA and Charlson comorbidity index. Additionally, a variable combining mFI and ASA had fair sensitivity and specificity for predicting 30-day mortality in RARP patients (C-statistic = 0.7097, P<0.0001). CONCLUSION: Increasing mFI scores are associated with worsening outcomes for patients undergoing RARP. A combined mFI and ASA variable can be used to predict 30-day mortality for RARP patients better than mFI or ASA alone.

Utilization Trends and Short-term Outcomes of Robotic Versus Open Radical Cystectomy for Bladder Cancer.

OBJECTIVE: To compare utilization trends and short-term outcomes of robotic versus open radical cystectomy for bladder cancer since the introduction of the robotic modifier (ICD-9 17.4x). MATERIALS AND METHODS: Using the Statewide Planning and Research Cooperative System database, an all-payer administrative system on all hospital discharges in New York State, we identified patients undergoing radical cystectomy (57.71) with a diagnosis of bladder cancer (188.0-188.9, 233.7, 236.7) from October 2008 to December 2012. Primary outcomes were inpatient complications and mortality at index stay. RESULTS: Of the 2525 patients, 24.2% (610 of 2525) underwent robotic and 75.8% (1915 of 2525) underwent open radical cystectomy. The proportion of robotic cases increased from 19.9% (119 of 597) in 2009 to 28.9% (173 of 598) in 2012 (P < .05). From 2009 to 2012, the number of open surgeons decreased from 117 to 109, and that of robotic increased from 56 to 66. Robotic patients had lower approach-specific surgeon and hospital volume, and more likely underwent lymph node dissection, ileal conduit diversion, blood transfusion, and prolonged length of stay. On multivariate analysis, robotic approach conferred a reduced risk of blood transfusion (odds ratio: 0.600, 95% confidence interval: 0.492-0.732, P < .0005) but had no association with prolonged length of stay. There were no significant differences in inpatient complications or mortality at index stay, parenteral nutrition, length of stay, hospital charges, readmission rates up to 90 days, or mortality up to 90 days between the surgical approaches. CONCLUSION: Despite the rapid dissemination and more recent experience of robotic radical cystectomy, we report lower rates of blood transfusion and otherwise similar short-term outcomes with open radical cystectomy.

Utilization trends and outcomes up to 3 months of open, laparoscopic, and robotic partial nephrectomy.

The aim of the study was to compare the utilization trends and short-term outcomes of open, laparoscopic, and robotic partial nephrectomy in New York State since the introduction of the robotic modifier in October 2008. The Statewide Planning and Research Cooperative System database is an all-payer, administrative database covering all hospital discharges within New York State. All patients who underwent partial nephrectomy (ICD-9 55.4) for kidney cancer (189.0) from October 2008 to December 2012 were identified. Patients with a minimally invasive modifier (54.21, 54.51) without the robotic modifier (17.4x) were categorized in the laparoscopic cohort. Logistic regression was performed to assess outcomes by surgical approach. Of the 5107 patients, 57.9% (2959/5107) underwent open, 12.1% (617/5107) laparoscopic, and 30.0% (1531/5107) robotic partial nephrectomy. From 2009 to 2012, the percentage of robotic cases increased from 17.7 to 39.8%. In comparison to open patients, those undergoing laparoscopic and robotic approaches, respectively, were less likely to receive blood transfusion (OR 0.54, p < 0.0005 and OR 0.45, p < 0.0005) and to experience a prolonged length of stay (OR 0.52, p < 0.0005 and OR 0.30, p < 0.0005). Patients undergoing robotic approach were also less likely to have an inpatient complication (OR 0.74, p = 0.004) and be readmitted within one (OR 0.73, p = 0.005) and 3 months (OR 0.69, p < 0.0005), but were at higher risk of excess hospital charges (OR 1.216, p = 0.01). Robotic partial nephrectomy is the predominant minimally invasive approach in New York State. Minimally invasive partial nephrectomy has multiple short-term advantages over open, with the costlier robotic approach having additional advantages with less inpatient complication and readmission risk.

Trends in Subspecialization Within Inpatient Urology From 1982 to 2012.

OBJECTIVE: To elucidate the evolving trends in subspecialization related to individual practice within inpatient urology over a 31-year period spanning from 1982 to 2012. METHODS: We conducted a retrospective cohort study by querying the centralized New York State data on partial nephrectomy, radical nephrectomy, radical prostatectomy, and radical cystectomy procedures for all inpatient encounters in the state of New York for the years 1982-2012 using the Statewide Planning and Research Cooperative System dataset. All encounters involving 1 of the procedures were identified and the AMA Masterfile was used to identify all physicians who have completed residencies in urology. We performed descriptive analyses to determine the quantity of cases, quantity of patients, and distribution of the cases among operating physicians. High-volume urologists, defined as the top 5% of urologists in terms of caseload, were identified, and the distributions of their procedures was analyzed. RESULTS: The proportion of procedures completed by high-volume urologists increased significantly for all procedures. The number of identified urologists involved in radical cystectomy and radical nephrectomy has declined since 1982, with the number of identified urologists involved in partial nephrectomy and radical prostatectomy beginning a continuous decline from 2004 to 1999, respectively. During the 31-year time period, the number of cases increased for all procedures. CONCLUSION: A smaller group of urologists is performing a larger proportion of cases for each studied procedure, reflecting a trend toward subspecialization.

A Medical Application to Bridge the Gap between Clinicians and Clinical Data.

There currently exists a gap between medical data and the clinicians who wish to use the data as the foundation for evidence-based medicine. The current disjointed workflow often requires statisticians to act as bridges in order to answer inquiries from clinicians. This can lead to suboptimal results as due to a gap between the fundamental understanding of clinical underpinnings and formal statistical interpretation of the data. To address this challenge, we have created a multi-platform application that allows clinicians to quickly and easily navigate and analyse the data. This application has been successfully implemented and tested within the Urology department at Mount Sinai Hospital for comprehensive analysis of complex urological data.

Spectrin alpha is important for rear polarization of the microtubule organizing center during migration and spindle pole assembly during division of neointimal smooth muscle cells.

Directed migration of smooth muscle cells (SMCs) from the media to the intima and their subsequent proliferation are key events in atherosclerosis as these cells contribute to the bulk and stability of atheromatous plaques. We showed previously that two cytoskeleton-associated proteins, RHAMM and ARPC5, play important roles in rear polarization of the microtubule organizing centre (MTOC), directed migration, and in maintaining cell division fidelity. These proteins were analyzed to predict additional potential interacting partners using the bioinformatics programs BLAST, ClustalW, and PPI Spider. We identified spectrin alpha, a protein with a known role in actin polymerization as part of the pathway. We show that in migrating SMCs spectrin alpha localizes at the nodes of the actin net, and it partially colocalizes with RHAMM in the perinuclear region. In dividing SMCs spectrin alpha is present at spindle poles and midbody. Moreover, we show that spectrin alpha and RHAMM interact in a complex. Using siRNA to knockdown spectrin disrupted SMC migration, MTOC polarization, and the assembly of a polygonal actin net dorsolateral of the nucleus. Spectrin alpha knockdown also disrupted the organization of the bipolar spindle, chromosome division, and cytokinesis during cell division. The identification of interacting partners such as spectrin alpha and the decoding of pathways involved in polarity regulation during the migration of smooth muscle cells in atherosclerosis is important for identifying atherosclerosis biomarkers and developing therapeutic agents to block atherosclerotic plaque formation.