Gender Disparity in Cystectomy Postoperative Outcomes: Propensity Score Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: While female gender is considered a protective determinant in the majority of cancers, outcomes in women diagnosed with bladder cancer have continued to show disproportional mortality when compared with men. OBJECTIVE: The aim of this retrospective propensity score-matched analysis was to evaluate the intra- and postoperative differences among genders, as well as to evaluate reproductive organ-preserving radical cystectomy (ROPRC) as compared with radical cystectomy (RC) as a potential confounder in female cystectomy patients. DESIGN, SETTING, AND PARTICIPANTS: Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), men and women undergoing a cystectomy between 2011 and 2017 were analyzed. In addition, females undergoing ROPRC and RC were analyzed for immediate postoperative outcomes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Men and women undergoing a cystectomy were evaluated through propensity score matching (PSM) for baseline differences using a 1:1 caliper width of 0.2 to the nearest neighbor. Using multivariable logistic regression analysis, we evaluated differences in the risk of readmission, complications, and reoperation in the immediate postsurgical period in males and females. Similarly, differences were assessed in ROPRC and RC groups. RESULTS AND LIMITATIONS: We achieved a balance between males and females after PSM: 1263 males and 1263 females treated with cystectomy. The risks of readmission (adjusted odds ratio [aOR] 1.228 [1.005-1.510], p=0.045), superficial surgical site infection (aOR 1.507 [1.095-2.086], p=0.012), and transfusion (aOR 2.031 [1.713-2.411], p<0.001) were increased in females undergoing a cystectomy compared with males. No differences were observed in surgical outcomes in ovarian sparing/RC cohort. CONCLUSIONS: Using the 2011-2017 NSQIP database, we were able to demonstrate an increased rate of postoperative transfusion, readmission rate, and surgical site infection in females who underwent cystectomy. Our findings suggest that females experience an increased rate of complications in the immediate postoperative period. This may ultimately lead to worse oncologic outcomes in females after an RC. Lastly, we did not find any increased rate of complications in ROPRC as compared with RC. PATIENT SUMMARY: This study highlights differences in immediate postoperative outcomes between males and females undergoing cystectomy for bladder cancer. Some of these potential differences include higher risk of infection, transfusion, and readmission. These differences may predispose females to worse long-term outcomes. In addition, due to potential benefits of ovarian preservation in the recent literature, we also evaluated the risks and complications of ovarian sparing cystectomy. We found ovarian preservation to be a safe and feasible procedure in a highly selected group of patients.

Direct Cost Savings Analysis of Nurse Practitioner for Inpatient Urology Practice.

INTRODUCTION: A 2015 survey of members of the American Urological Association found the majority of urologists (62.7%) work with an advanced practice provider. The aim of this study was to analyze direct cost savings of inpatient advanced practice provider hiring focusing on direct cost, length of stay, readmission rate and discharge planning. METHODS: Data from a single tertiary care referral center was collected between 2015 Q (quarter) 1 to 2018 Q2. Seven quarters before inpatient advanced practice provider implementation (2015 Q1 to 2016 Q3) were compared to 7 subsequent quarters after initiation of inpatient nurse practitioner program (2016 Q4 to 2018 Q2). A total of 1,190 major urological cases were performed during this time (178 cystectomies, 663 nephrectomies, 349 prostatectomies). Factors influenced by inpatient advanced practice provider such as length of stay, discharge before 11 a.m. and total direct cost were analyzed before advanced practice provider and after advanced practice provider. Mann-Whitney U and chi-square tests were used for continuous and categorical data, respectively. RESULTS: Advanced practice provider inclusion as part of a urology health care team showed an overall decreased length of stay (p=0.042) with an increase in discharges before 11 a.m. (p <0.001). There was no significant change in direct cost (p=0.89) combined for all 3 groups, but direct cost in the cystectomy group was significantly lower (p=0.048). There was a statistically significant improvement in discharge time for nephrectomy (p=0.039) and cystectomy (p=0.02) after advanced practice provider program initiation. CONCLUSIONS: Inclusion of an advanced practice provider within inpatient setting was shown to consistently improve length of stay and direct cost for cystectomy care.

Is there a benefit to additional neuroaxial anesthesia in open nephrectomy? A prospective NSQIP propensity score analysis.

INTRODUCTION: Neuroaxial (i.e., spinal, regional, epidural) anesthesia has been shown to be associated with reduced readmission rate, decreased hospital stay, and decreased overall complication rate in orthopedic and gynecologic surgery. Our aim was to identify differences in intra- and postoperative complications, length of stay and readmission rates in open nephrectomy patients managed with neuroaxial anesthesia. MATERIALS AND METHODS: Utilizing National Surgical Quality Inpatient Program (NSQIP) database, we identified patients who have undergone an open nephrectomy between 2014 and 2017. Patients were further subdivided based on anesthesia modality. We used the propensity score-matching (PSM) method to adjust for baseline differences among patients who received general anesthesia alone and those with additional neuroaxial anesthesia. Using step-wise multivariable logistic regression, we identified preoperative and intraoperative predictors associated with 30-day procedure-related readmission, complications, and postoperative length of stay. RESULTS: Out of 3,633 patients identified, 2346 patients met our inclusion and exclusion criteria. There was no difference in baseline characteristics after propensity score matching between general and additional neuroaxial anesthesia. Postoperative outcomes including: procedure-related readmission, rate of reoperation, operative time, all complications were similar between the groups. Adjuvant neuroaxial anesthesia group did experience a prolonged postoperative hospital stay that was statistically significant as compared to patients with general anesthesia alone [5.3 (3.5) days vs 4.8 (2.9) days, p = 0.007]. Compared to GA alone after multivariable logistic regression, neuroaxial anesthesia was not statistically significant for readmission (p = 0.909), any complication (p = 0.505), but did showed increased odds ratio of prolonged postoperative stay [aOR 1.107, 95% CI 1.042-1.176, p = 0.001] after adjusting for multiple factors. CONCLUSION: Using 2014-2017 NSQIP database, we were able to demonstrate no additional reduction in complication or readmission rate in patients with neuroaxial anesthesia as compared to general anesthesia alone. Furthermore, patients who did receive neuroaxial anesthesia experienced a longer postoperative course.

Standardized analysis of frequency and severity of complications after robot-assisted radical cystectomy.

BACKGROUND: Comprehensive and standardized reporting of adverse events after robot-assisted radical cystectomy (RARC) and urinary diversion for bladder cancer is necessary to evaluate the magnitude of morbidity for this complex operation. OBJECTIVE: To accurately identify and assess postoperative morbidity after RARC using a standardized reporting system. DESIGN, SETTING, AND PARTICIPANTS: A total of 241 consecutive patients underwent RARC, extended pelvic lymph node dissection, and urinary diversion between 2003 and 2011. In all, 196 patients consented to a prospective database, and they are the subject of this report. Continent diversions were performed in 68% of cases. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: All complications within 90 d of surgery were defined and categorized by a five-grade and 10-domain modification of the Clavien system. Univariable and multivariable logistic regression analyses were used to identify predictors of complications. Grade 1-2 complications were categorized as minor, and grade 3-5 complications were categorized as major. All blood transfusions were recorded as grade ≥2. RESULTS AND LIMITATIONS: Eighty percent of patients (156 of 196 patients) experienced a complication of any grade ≤90 d after surgery. A total of 475 adverse events (113 major) were recorded, with 365 adverse events (77%) occurring ≤30 d after surgery. Sixty-eight patients (35%) experienced a major complication within the first 90 d. Other than blood transfusions given (86 patients [43.9%]), infectious, gastrointestinal, and procedural complications were the most common, at 16.2%, 14.1%, and 10.3%, respectively. Age, comorbidity, preoperative hematocrit, estimated blood loss, and length of surgery were predictive of a complication of any grade, while comorbidity, preoperative hematocrit, and orthotopic diversion were predictive of major complications. The 90-d mortality rate was 4.1%. The main limitation is lack of a control group. CONCLUSIONS: Analysis of postoperative morbidity following RARC demonstrates a considerable complication rate, though the rate is comparable to contemporary open series that followed similar reporting guidelines. This finding reinforces the need for complete and standardized reporting when evaluating surgical techniques and comparing published series.

Penile fracture with associated urethral rupture.

Penile fracture of the erect penis is an uncommon but emergent urological trauma. Potential outcomes include erectile dysfunction, penile curvature, and urethral injury. Treatment is emergent surgical repair. We present the case of a 42-year-old man with a penile fracture complicated by a urethral rupture and subsequent repair. A discussion of the key aspects of this condition is presented.

Erectile dysfunction and sleep related disorders.

PURPOSE: There are reported links between erectile dysfunction and sleep disorders. We reviewed the physiology of penile erection during sleep and the possible links between the pathophysiology of erectile dysfunction and the most commonly diagnosed sleep disorders. MATERIALS AND METHODS: A MEDLINE search using the identifiers erectile dysfunction, sleep, sleep disorders, sleep apnea, insomnia and narcolepsy was performed to identify the current literature pertaining to erectile dysfunction and sleep disorders. The peer reviewed literature and relevant surveys from 1985 to 2006 were subsequently reviewed. RESULTS: An association between erectile dysfunction and sleep disorders appears to exist in survey studies relying on self-report and in small case series. Hormonal, neural and endothelial mechanisms have been implicated in linking sleep disorders with erectile dysfunction. Treatment of sleep disorders, specifically sleep apnea with continuous positive airway pressure, has been shown to improve patient erectile function. CONCLUSIONS: Clinicians should consider concomitant sleep disorders when evaluating patients with erectile dysfunction, especially in those refractory to routine therapy. Further studies are necessary to clearly define the causative link between sleep disorders and erectile dysfunction.

Current recommendations for imaging in the management of urologic traumas.

Three percent to 10% of trauma patients have genitourinary tract injuries. Radiologic imaging is essential for making the correct diagnosis and managing it appropriately. Which modality is appropriate is based on the mechanism of injury and patient presentation. Patients with pelvic injuries and gross hematuria should undergo either CT cystography or conventional cystography. Ultrasound is warranted in patients with scrotal trauma when physical exam is inconclusive. Patients with penetrating trauma to the external genitalia, who suffer blunt trauma to the penis, or who present with gross hematuria, blood at the meatus, inability to void, perineal/scrotal ecchymosis, or abnormal digital rectal exam should undergo retrograde urethrography. Using these criteria for imaging should lead to the proper diagnosis and minimize patient morbidity.

Holmium: yttrium-aluminum-garnet laser puncture of ureteroceles in neonatal period.

OBJECTIVES: The use of the holmium:yttrium-aluminum-garnet (YAG) laser to incise a ureterocele in children has been reported. However, its use to puncture ureteroceles in neonates has not. Therefore, we evaluated the effectiveness and safety of ureterocele puncture using a holmium-YAG laser in neonatal patients. METHODS: We reviewed our experience of all neonates (ie, children younger than 28 days old) who underwent transurethral puncture of a ureterocele. The preoperative data collected included age at presentation, mode of presentation, ureterocele location, and weight and age at the procedure. A holmium:YAG laser was used to incise the ureterocele, and a 200, 365, or 550-microm laser fiber was passed through a 6F or 7.5F cystoscope. RESULTS: A total of 4 neonates (2 boys and 2 girls) underwent transurethral holmium laser puncture of five ureteroceles. All patients were initially diagnosed with prenatal ultrasound findings confirmed after birth with additional imaging. The mean age at the initial puncture was 13.8 days, with a mean patient weight of 3.9 kg. The mean follow-up was 2.8 years (range 1.7 to 3.4). Four (80%) of five ureteroceles were adequately decompressed after one attempt. One patient required a second puncture of the ureterocele at 46 days of age because of incomplete decompression. None of the patients experienced an intraoperative or postoperative complication, including new vesicoureteral reflux after laser puncture. CONCLUSIONS: Holmium:YAG laser puncture of ureterocele is a safe, efficacious, and viable option for children in the neonatal period. However, this technique in these young children requires additional evaluation.